Download Periodontal Treatment of Benign Mucous Membrane Pemphigoid

Continuing Education
Course Number: 127.2
Periodontal Treatment of
Benign Mucous Membrane
Pemphigoid
Authored by Silvana R. P. Orrico, PhD; Cláudia M. Navarro, PhD;
Fabiana P. Rosa, PhD; Fábio A. Coelho Reis, DDS;
Daniela S. Salgado, MSc, PhD; and Mirian A. Onofre, PhD
Upon successful completion of this CE activity 1 CE credit hour may be awarded
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Continuing Education
Recommendations for Fluoride Varnish Use in Caries Management
Periodontal Treatment of Benign
Mucous Membrane Pemphigoid
Paulista, Departamento de Diagnóstico e Cirurgia, in Brazil.
She can be reached via e-mail at [email protected].
LEARNING OBJECTIVES:
INTRODUCTION
Disclosure: The authors report no conflicts of interest.
Benign mucous membrane pemphigoid (BMMP) is a
After reading this article, the individual will learn:
• The diagnosis, clinical presentation and treatment for
BMMP.
• The importance of effective bacterial plaque control in
improvement of BMMP lesions.
vesiculobullous/vesiculoerosive chronic disease, somewhat
rare, with an autoimmune etiology, that involves mainly the
oral cavity.1-6 However, it can also affect other mucous
membranes such as conjunctive, genital, esophageal, and
laryngeal.4,7,8 Although these lesions can be observed in
young individuals, the disease affects mainly middle-aged
and older individuals (aged 50 to 80 years), with higher
predilection for women in the proportion of 2:1, without
presenting geographic and ethnical differences.4,6,9,10
The diagnosis is made with regard to the history,
symptoms, clinical presentation, and histopathology. The
histopathological findings define epithelial splitting disease
which is more easily viewed and often confirmed with
immunofluorescence. Therefore, it is often necessary to
bisect the biopsy specimen and submit half for hematoxylin
and eosin, and half for immunofluorescence. Furthermore,
the “Siegel” technique can be utilized, in which the surgeon
generates a positive Nikolsky’s sign and teases off the
epithelial layer for histopathologic submission with
immunofluorescence. BMMP is often noted for a positive
Nikolsky’s sign. A positive Nikolsky’s sign refers to blistering
upon light pressure to adjacent epithelial tissue. The
differential diagnosis includes other oral autoimmune
vesiculoerosive disease such as oral lichen planus, discoid
lupus, pemphigus vulgaris, and erythema multiforme major,
and other oral inflammatory disease such as oral
candidiasis. Once the diagnosis is made, it is important for
the dentist to refer the patient to an ophthalmologist for the
evaluation of degenerative ocular disease.1-5,11
The sites of higher involvement in oral mucosa are gingiva,
buccal and alveolar mucosa, palate, tongue, and inferior
lip,5,8,12-14 with manifestations that vary from erythema to
vesicles/blister formations that break and expose the subjacent
conjunctive tissue (erosion/ulceration). The individual with
BMMP may be completely free from any symptoms or may
ABOUT THE AUTHORS
Dr. Orrico is an associate professor of
Periodontics at the Faculdade de Odontologia, UNESP-University, Estadual
Paulista, Departamento de Diagnóstico
e Cirurgia, in Brazil. She can be
reached at [email protected].
Dr. Navarro is an assistant professor of Oral Diagnosis at the
Faculdade de Odontologia, UNESP-University, Estadual
Paulista, Departamento de Diagnóstico e Cirurgia, in Brazil.
She can be reached via e-mail at the address
[email protected].
Dr. Rosa is an associate professor in the Department of
Biointeraction at the Institute of Health Sciences, Federal
University of Bahia, in Brazil. She can be reached via e-mail
at [email protected].
Dr. Reis is a clinical periodontist. He can be reached at
[email protected].
Dr. Salgado is a student in Periodontics at the Faculdade
de Odontologia, UNESP-University, Estadual Paulista,
Departamento de Diagnóstico e Cirurgia, in Brazil. She can
be reached at [email protected].
Dr. Onofre is an associate professor of Oral Diagnosis at the
Faculdade de Odontologia, UNESP-University, Estadual
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Continuing Education
Periodontal Treatment of Benign Mucous Membrane Pemphigoid
complain about a burning sensation,8 accompanied or not by
pain symptoms, depending on the degree of superficial
desquamation.9,12 The manifestations described above
frequently involve both free and attached gingival margin,
embracing the predominance of different forms, from erythema
with few areas of desquamation to extensive ulcerated areas
that can be denominated as desquamative gingivitis. This
condition results in the formation of subepithelial blisters, which
can result in detached epithelium even with minimal
manipulation of gingival tissue (positive Nikolsky’s sign), thus
promoting bleeding and pain in the reddish surfaces.6,8,12
Intact blisters are rarely observed, and the presence of a
pseudomembrane, easily detached and that exposes the
subjacent conjunctive tissue when removed, is common.9,15
As BMMP is a chronic condition, the control of the
clinical situation requires adequate treatment. Therapy for
autoimmune vesiculoerosive disease is directed to control
disease rather than cure disease. Such treatment is
variable, individual, and requests a multidisciplinary
approach that includes dentists, dermatologists, and
ophthalmologists. The therapeutic use of systemic
corticosteroids is dependent on the degree of involvement
of oral and other mucous membranes.5,6,13 However, when
lesions are restricted to the oral cavity, the administration of
topical corticosteroids is the treatment of choice, promoting
good results and reducing collateral effects.2
In conjunction with corticosteroid therapy, the elimination of
trauma and infection is beneficial for patients with BMMP with
oral manifestations. In this context, nonsurgical periodontal
therapy consisting of scaling and root planing, effective
bacterial plaque control, and the elimination of factors that can
directly damage the tissue can represent an important
approach for the control of lesions.
A case report is described that demonstrates the
importance of periodontal support therapy with effective
bacterial plaque control in improvement and stabilization of
gingival manifestations of BMMP.
Figure 1.
Free and attached
gingiva from the buccal
aspect showing
erythema, bleeding, and
desquamation.
Figure 2.
Bleeding blister at right
inferior alveolar ridge.
Figure 3.
Partial improvement in
clinical features of free
and attached gingiva
from the buccal aspect,
after treatment with
topical corticosteroids.
hypertension. Lesions had been present for 4 years and
showed intense bleeding during tooth brushing. The patient
had been examined previously by 3 periodontists, but no
definitive diagnosis was obtained. Clinical examination
revealed erythema and bleeding in free and attached gingiva
(Figure 1), with the presence of bleeding blisters in the distal
region of the maxillary left second molar and mandibular right
alveolar ridge (Figure 2). A biopsy was performed on the
mandibular alveolar edge and confirmed the hypothetical
diagnosis of BMMP.
After evaluation of oral hygiene condition by plaque
index,15 treatment was initiated, consisting of 0.05%
beclomethasone (dipropionate) spray and nonsurgical
periodontal therapy consisting of scaling and root planing,
and tooth polishing with nonabrasive toothpaste. The tooth
brushing method prescribed was the modified Stillman with
CASE REPORT
A male patient, aged 60 years, presented with a complaint of
a bleeding gingival blister formation with rupture of the
blisters. He was a former smoker with controlled
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Continuing Education
Periodontal Treatment of Benign Mucous Membrane Pemphigoid
Figure 4.
Persistence of
erythematous areas in
mandibular anterior
lingual gingiva after
corticosteroid therapy.
Note the presence of
calculus in the lingual
and interproximal
regions of affected
teeth, indicating the
difficulty in bacterial
plaque control.
the same toothpaste used during polishing. After 15 days, a
partial improvement in clinical condition was observed, with
approximately 50% reduction of blisters and erosive areas
associated with a decrease of bacterial plaque surfaces.
However, the interproximal regions presented desquamation and erosion (Figure 3) related to the difficulty in
controlling bacterial plaque (Figure 4). Oral hygiene
instruction was reinforced with the use of an interdental
toothbrush that resulted in improvement of the clinical
condition. In this phase, due to the continuous use of
topical corticosteroids, an antifungal drug (20 mg of
miconazol, oral gel) was prescribed.
After 90 days from the beginning of treatment, the patient
reported a worsening of the condition that was related to stress
episodes (Figure 5). The periodontal support and bacterial
plaque removal were intensified on a weekly basis, and an
alcohol-free 0.12% chlorhexidine solution was prescribed and
applied in regions with higher plaque accumulation.The topical
corticosteroids and antifungal drugs were discontinued. A 90%
improvement in lesions was observed 160 days after
beginning the treatment (Figure 6). The support periodontal
therapy was evaluated every 3 months for a 5-year period, and
no exacerbation of the clinical condition was observed.
Figure 5.
Exacerbation of lesions
associated with stress,
within 90 days of
initiating treatment.
Figure 6.
Improvement of 90% of
lesions after 5 months
of periodontal treatment.
DISCUSSION
The BMMP diagnosis is not always easily defined, and
many times the inflammatory feature of gingival lesions can
mimic periodontal disease.16 In this context, it is important
to consider periodontal disease not only in the differential
diagnosis, but also in the treatment of BMMP.
Oral hygiene maintenance is beneficial for patients with
autoimmune vesiculoerosive disease. Inflammation
secondary to bacterial plaque tends to increase both the
frequency and severity of BMMP and other autoimmune
disease entities.17,18
Even though tooth brushing may be associated with pain
and possible blister ruptures,3 excellent oral hygiene is
fundamental to bacterial plaque control.2 Inflamed gingiva
tends to be painful; therefore plaque control tends to be more
difficult. It is not unexpected that patients with BMMP tend to
have higher levels of gingival inflammation than control
patients.19 Oral hygiene must be evaluated by an appropriate
and reproducible index to verify the necessity of altering
hygiene procedures and to evaluate the results of treatment. In
the present case, the Silness-Löe plaque index20 was used.
Avoiding trauma, pain, and discomfort during tooth
brushing is also essential for BMMP patients. Thus, in the
case presented, the patient was advised to use the
modified Stillman technique, preventing the insertion of
toothbrush bristles in the marginal gingiva. The careful use
of dental floss was also recommended. The type of
toothbrush is also of importance, and in the cases of BMMP
it must be extra-soft. It is suggested to utilize toothpastes
which are low-abrasive and free from whitening agents
and/or inhibitors of bacterial plaque and dental calculus
formation.21,22 Mouthwashes containing alcohol, hydrogen
peroxide, cetylpyridinium chloride, thymol, or menthol may
exacerbate the clinical condition and must be avoided.15
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Continuing Education
Periodontal Treatment of Benign Mucous Membrane Pemphigoid
The use of chlorhexidine digluconate, although it has an unquestionable effect on bacterial plaque control, must be
avoided during acute manifestation of lesions, but it can be
applied after the improvement of clinical condition in a nonalcoholic formulation.
In the case presented, the plaque control performed by a
professional and the application of 0.12% chlorhexidine
digluconate resulted in 90% improvement of lesion conditions,
demonstrating the importance of bacterial plaque control for
the treatment of BMMP.
Scaling and root planing must be carefully and delicately
accomplished in order to prevent tissue dilacerations,
particularly in patients with a positive Nikolsky’s sign. During
polishing, a rubber cup and low-abrasive prophylaxis paste in
controlled speed must be used, thus avoiding injuries to
gingival tissue. As a complementary procedure, areas with
bacterial plaque retention, which make control of lesions
more difficult, must be corrected; caries lesions must be
restored and faulty prostheses and other restorations must
be corrected. Agents that cause direct injuries to tissue must
also be removed.1
Lesions should be considered for re-evaluation monthly
and, after clinical stabilization, every 3 months. Professional
plaque control and oral hygiene instruction should be
considered weekly until improvement in the clinical condition
is observed, and then intervals should be determined based
on the requirements of each patient.
Possible surgical interventions for aesthetic reasons or
complementary treatment as needed may be considered
after the described periodontal treatment for BMMP, but only
if BMMP-related lesions are in the remission phase, which
permits adequate tissue manipulation. However, there is the
possibility that the trauma of surgery will result in a flare-up
of the BMMP condition. There are controversies concerning
the maintenance of local corticosteroids during the postoperative phase, because these medications can retard
cicatrization.23,24
The present case demonstrated that the periodontal
treatment described was effective in reducing the gingival
manifestations of BMMP in our patient and represents a
complementary treatment to the use of corticosteroids with
the aim of improving lesion conditions. This successful
therapeutic result corroborates with the report by Damoulis
and Gagari,23 which proposed a combined treatment of
topical corticosteroids with periodontal therapy in patients
with BMMP, highlighting the importance of frequent
periodontal support visits.
CONCLUSION
A case has been presented which demonstrates that
nonsurgical periodontal treatment with effective support
therapy and plaque control was effective in improving and
stabilizing the gingival manifestations of BMMP.
REFERENCES
1. Antonelli JR, Bachiman R, Scherer W. Mucous
membrane pemphigoid: a disease of the elderly. Spec
Care Dentist. 1991;11:143-147.
2. Bagan J, Lo Muzio L, Scully C. Mucosal disease series.
Number III. Mucous membrane pemphigoid. Oral Dis.
2005;11:197-218.
3. Darling MR, Daley T. Blistering mucocutaneous
diseases of the oral mucosa—a review: part 1. Mucous
membrane pemphigoid. J Can Dent Assoc.
2005;71:851-854.
4. Scully C, Carrozzo M, Gandolfo S, et al. Update on
mucous membrane pemphigoid: a heterogeneous
immune-mediated subepithelial blistering entity. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
1999;88:56-68.
5. Chan LS, Ahmed AR, Anhalt GJ, et al. The first
international consensus on mucous membrane
pemphigoid: definition, diagnostic criteria, pathogenic
factors, medical treatment, and prognostic indicators.
Arch Dermatol. 2002;138:370-379.
6. Position paper: oral features of mucocutaneous
disorders. J Periodontol. 2003;74:1545-1556.
7. Vincent SD, Lilly GE, Baker KA. Clinical, historic, and
therapeutic features of cicatricial pemphigoid. A
literature review and open therapeutic trial with
corticosteroids. Oral Surg Oral Med Oral Pathol.
1993;76:453-459.
8. Weinberg MA, Insler MS, Campen RB. Mucocutaneous
features of autoimmune blistering diseases. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 1997;84:517-534.
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Continuing Education
Periodontal Treatment of Benign Mucous Membrane Pemphigoid
18. Ramón-Fluixá C, Bagán-Sebastián J, Milián-Masanet
M, et al. Periodontal status in patients with oral lichen
planus: a study of 90 cases. Oral Dis. 1999;5:303-306.
9. Carrozzo M, Broccoletti R, Carbone M, et al.
Pemphigoid of the mucous membranes. The clinical,
histopathological and immunological aspects and
current therapeutic concepts [in Italian]. Minerva
Stomatol. 1996;45:455-463.
19. Tricamo MB, Rees TD, Hallmon WW, et al. Periodontal
status in patients with gingival mucous membrane
pemphigoid. J Periodontol. 2006;77:398-405.
10. Nally F. Diagnosis of mouth lesions. Practitioner.
1992;236:488-493.
20. Silness J, Löe H. Periodontal disease in pregnancy. II.
Correlation between oral hygiene and periodontal
condition. Acta Odontol Scand. 1964;22:121-135.
11. Siegel MA. Intraoral biopsy technique for direct
immunofluorescence studies. Oral Surg Oral Med Oral
Pathol. 1991;72:681-684.
21. Skaare A, Kjaerheime V, Barkvoll P, et al. Skin
reactions and irritation potential of four commercial
toothpastes. Acta Odontol Scand. 1997;55:133-136.
12. Siegel MA, Balciunas BA, Kelly M, et al. Diagnosis and
management of commonly occurring oral
vesiculoerosive disorders. Cutis. 1991;47:39-43.
22. Kowitz G, Jacobson J, Meng Z, et al. The effects of
tartar-control toothpaste on the oral soft tissues. Oral
Surg Oral Med Oral Pathol. 1990;70:529-536.
13. Mutasim DF. Autoimmune bullous dermatoses in the
elderly. Drugs Aging. 2003;20:663-681.
23. Damoulis PD, Gagari E. Combined treatment of
periodontal disease and benign mucous membrane
pemphigoid. Case report with 8 years maintenance.
J Periodontol. 2000;71:1620-1629.
14. Stoopler ET, Sollecito TP, DeRossi SS. Desquamative
gingivitis: early presenting symptom of mucocutaneous
disease. Quintessence Int. 2003;34:582-586.
15. Castellanos Suárez JL. Enfermedades gingivales de
origen inmune. Medicina Oral. 2002;7:271-283.
24. Lorenzana ER, Rees TD, Hallmon WW. Esthetic
management of multiple recession defects in a
patient with cicatricial pemphigoid. J Periodontol.
2001;72:230-237.
16. Lynch DP, Heaton BW, Jacobi JA. Periodontal
manifestations of mucocutaneous disease: diagnosis
and treatment. Tex Dent J. 1984;101:18-23.
17. Holmstrup P, Schiøtz AW, Westergaard J. Effect of
dental plaque control on gingival lichen planus. Oral
Surg Oral Med Oral Pathol. 1990;69:585-590.
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Continuing Education
Periodontal Treatment of Benign Mucous Membrane Pemphigoid
2. Which of the following is NOT one related to diagnosis of
BMMP:
a. Histopathological findings.
b. Clinical presentation.
c. Periodontal therapy.
d. Symptomatology.
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3. The differential diagnosis of BMMP includes:
a. Oral lichen planus.
b. Periodontitis.
c. Oral leukoplakia.
d. Both a and b.
4. In relation to desquamative gingivitis, the following is
NOT correct:
a. This clinical sign is always present in individuals with
BMMP.
b. Results in the formation of subepithelial blisters and
detached epithelium.
c. Promotes bleeding and pain.
d. Is characterized by extensive ulcerated areas.
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5. The adequate treatment of BMMP with gingival
manifestation requires:
a. Only topical corticosteroids therapy.
b. Systemic and topical corticosteroids therapy.
c. Corticosteroid and nonsurgical periodontal therapy.
d. Only fungal therapy.
6. In relation to oral hygiene of individuals with gingival
lesions of BMMP:
a. Dental floss is not recommended.
b. The type of toothbrush is not significant.
c. Mouthwashes containing alcohol are recommended.
d. Low-abrasive toothpastes are recommended.
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7. The bacterial plaque control of patients with BMMP is:
a. Effective in reducing the gingival manifestations.
b. Not beneficial for patients with autoimmune diseases such
as BMMP.
c. Associated with pain and should not be performed.
d. Recommended for patients without gingival lesions.
POST EXAMINATION QUESTIONS
1. Benign mucous membrane pemphigoid (BMMP) is:
a. A chronic disease with a bacterial etiology, that affects
mucous membranes.
b. An autoimmune disease with higher predilection for men in
proportion of 2:1.
c. A vesiculobullous/vesiculoerosive disease that involves only
the oral cavity.
d. A chronic disease that affects mainly middle-aged and
older individuals.
8. A positive Nikolsky’s sign refers to:
a. Blanching of adjacent epithelial tissue.
b. Blistering upon light pressure to adjacent epithelial tissue.
c. Inflammation of adjacent epithelial tissue.
d. None of the above.
6
Continuing Education
Periodontal Treatment of Benign Mucous Membrane Pemphigoid
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