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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.81 no.3 Rio de Janeiro June 2006
Topical occlusive corticosteroid for the treatment of gingival manifestations of vesicobullous autoimmune diseases*
Ana Carolina Fragoso MottaI; Marilena Chinali KomesuII; Márcio Fernando de Moraes GrisiIII; Cacilda da Silva SouzaIV; Ana Maria Ferreira RoselinoV; Dante Antonio MigliariVI
IDentist, Ph.D. in Oral Diagnosis,
School of Dentistry, Universidade de São Paulo USP - São Paulo
IIAssociate Professor, Dept. of Morphology, Stomatology, and Physiology of the School of Dentistry of Ribeirão Preto da Universidade de São Paulo USP - Ribeirão Preto (SP), Brazil
IIIAssociate Professor, Dept. of Orthognatic Surgery, Traumatology, and Periodontics of the School of Dentistry of Ribeirão Preto da Universidade de São Paulo - USP - Ribeirão Preto (SP), Brazil
IVM.D., Professor, Dept of Clinical Medicine, Division of Dermatology, School of Medicine of Ribeirão Preto da Universidade de São Paulo - USP - Ribeirão Preto (SP), Brazil
VAssociate Professor, Dept of Clinical Medicine, Division of Dermatology, School of Medicine of Ribeirão Preto da Universidade de São Paulo - USP - Ribeirão Preto (SP), Brazil
VIAssociate Professor, Dept. of Stomatology, School of Dentistry, Universidade de São Paulo - USP - São Paulo (SP), Brazil
Management of gingival lesions of vesicobullous autoimmune diseases is one the main challenges to oral medicine, primarily because of their chronic nature. Systemic therapy is required in most severe lesions, however, whenever feasible, topic corticosteroid therapy is preferred. This article describes a technique to provide topical occlusive corticotherapy that has shown to be effective in controlling these lesions, especially in patients exclusively with gingival lesions.
Keywords: Adrenal cortex hormones; Autoimmune diseases; Gingiva; Oral manifestations; Skin diseases, vesiculobullous
Management of gingival lesions of vesicobullous autoimmune diseases is one the main challenges to oral medicine, primarily because of their chronic nature.1-3 Treatment of these lesions usually requires topical corticosteroids, or other anti-inflammatory drugs. Systemic therapy is required in most severe lesions, especially in pemphigus. However, whenever feasible, topical corticosteroid is preferred, because of adverse effects of systemic treatment.4-6 Some studies reported good outcomes of patients with oral lesions treated with a topical corticosteroids mouthwash,4 and ointment with or without an adherent vehicle.5-8 However, it can be difficult to apply and maintain the corticosteroid on the entire lesional surface in patients with extensive or deep gingival lesions. In addition, normal mouth movements can rapidly displace the corticosteroid from its initial localization, reducing the contact time between drug and lesions. The use of a tray with ointment provides a solution for this problem, because it secures the corticosteroid, and provides an occlusive therapy.9,10
This article describes a technique of topical occlusive corticotherapy in a 36-year-old woman that was presented to Oral Diagnosis Clinics of Dentistry School of Ribeirão Preto at University of São Paulo for evaluation of painful, ulcerated, desquamative gingival lesions that had developed 12 years before. These had been unresponsive to all forms of treatment. A medical history of the patient was taken and revealed no unusual findings. Upon physical examination, she presented a good aspect, with no evidence of other lesions in her body. Intraoral examination revealed diffuse gingival inflammation with mild edema and evidence of intact bulla, involving mainly the vestibular gingival surfaces (Figure 1).
The patient was referred to University Hospital of Medical School of Ribeirão Preto at University of São Paulo, Division of Dermatology for a baseline evaluation of possible involvement in other sites. There were no ocular, skin or genital lesions and the patient remains free of such involvement to the present day.
A biopsy specimen of gingival lesion was then obtained for light microscopy and direct immunofluorescence analysis. Histopathologic examination showed subepithelial vesicle formation separating the surface epithelium from the underlying connective tissue at the level of the basement membrane. A mild infiltration of chronic inflammatory cells was noticed subjacent to the cleavage sites. Direct immunofluorescence revealed deposition of IgG in the linear band at the level of the basement membrane. After a review of all findings, diagnosis was of mucous membrane pemphigoid.
Firstly, periodontal treatment was carried out because the patient presented gingivitis, and it consisted of plaque control and standard scaling and crown planning. After periodontal treatment, a topical corticosteroid therapy was instituted using soft maxillary and mandibular trays of silicone plates fabricated on study models (Figure 2A, B, C and D) similar to those described by Aufdemorte et al.10
The patient was instructed to coat all internal surfaces with clobetasol propionate 0.05% ointment and to insert the trays three times a day (after breakfast, after lunch and after dinner), 20 minutes each time, after the oral hygiene. The patient was advised to expectorate excess saliva after the application and not to swallow for at least 1 hour.
All areas of ulceration were healing after 2 weeks (Figure 3). The corticosteroid was gradually tapered off over the next week and then discontinued. The patient was advised to continue applying the corticosteroid ointment (3-week cycle) whenever necessary.
Close follow-up of the patient was carried out, starting on a monthly basis for three months and every three months, thereafter.
This paper describes an occlusive technique for treatment of gingival lesions of vesicobullous autoimmune diseases. Due to the localized nature of involvement in this patient presented here, topical occlusive corticosteroid therapy was considered the treatment of choice. The use of a tray with a potent topical corticosteroid, as clobetasol propionate that was used in this study, has been promised to improve disease control since it maintains a greater contact time between the ointment and all the gingival lesion.10 Special emphasis should be placed to oral hygiene, because dental plaque often aggravates the symptoms of the lesions. Hence the need for proper oral physiotherapy should constantly be reinforced to the patient and periodontal treatment should be instituted whenever necessary.9,10
In conclusion, we emphasize that patients with gingival lesions of vesicobullous diseases require interdisciplinary care, and that the technique here described can be used for patients exclusively with gingival lesions, and can be an adjunct to systemic treatment in patients with oral and skin lesions.
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Ana Carolina Fragoso Motta
Rua Padre Anchieta, 2050 - Jardim Antártica
14051-220 - Ribeirão Preto - SP
Fax: +55 (16) 3633-6720
Received on May 18, 2004.
Approved by the Consultive Council and accepted for publication on April 03, 2006.
Conflict of interest: None
*Work done at School of Dentistry of
Universidade de São Paulo - USP (Campi São Paulo and Ribeirão
Preto); Hospital das Clínicas School of Medicine of Ribeirão
Preto - Universidade de São Paulo - USP - São Paulo (SP), Brazil.
Clob x, Galderma Brazil Ltda., São Paulo, SP