Prevalence of desquamative gingivitis in dermatological lesions-A retrospective institution based study

Santosh Bala1, Herald J. Sherlin*2, Vivek Narayan3 1Saveetha Dental college and Hospitals, Saveetha Institute of Medical and Technical Sciences Saveetha University, Chennai 600 077, Tamil Nadu, India 2Department of Oral pathology, Saveetha Dental college and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600 077, Tamil Nadu, India 3Department of Oral Medicine, Saveetha Dental college and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600 077, Tamil Nadu, India


INTRODUCTION
The mouth or the oral cavity is always known to be a sentinel or early warning system, that is why it is often referred to as the mirror of health and disease (Scully and Porter, 1997;Sridharan et al., 2017). Most of the oral mucosa is derived embryologically from an invagination of the ectoderm (Squier and Brogden, 2010;Thangaraj et al., 2016). Thus due to similar ori ices, other disorders which are primarily associated with the skin are involved (Eisenberg and Krutchkoff, 1992;Gupta and Ramani, 2016;Jayaraj et al., 2015b).
Lichen planus is a chronic mucocutaneous disorder of the strati ied squamous epithelium that affects oral and genital mucous membranes (Boyd and Neldner, 1991;Sivaramakrishnan and Ramani, 2015;Shree et al., 2019). Oral lichen planus is considered to be nothing but the mucosal counterpart of cutaneous lichen planus (Mollaoglu, 2000;Viveka et al., 2016;Hannah et al., 2018). Pemphigus Vulgaris is an autoimmune intraepithelial blistering disease involving the skin and mucous membrane (Langan et al., 2008;Jangid et al., 2015). The condition is known to affect both sexes equally and is found to be more common in middle-aged and elderly patients (Becker and Gaspari, 1993;Jayaraj et al., 2015a).
Most patients present with oral lesions as their irst sign of pemphigus Vulgaris. The most common site of infection of these diseases is buccal mucosa, Palate then lingual and labial mucosa. The gingiva is not the site to be affected with pemphigus Vulgaris, but the most common oral manifestation preceding the lesion is desquamative gingivitis (Sridharan et al., 2019;López-Jornet and Bermejo-Fenoll, 2005). In many pemphigus Vulgaris patients, oral lesions are very commonly seen and often followed by the development of skin lesions (López-Jornet and Bermejo-Fenoll, 2005;Gheena and Ezhilarasan, 2019).
The term desquamation is derived from the Latin word, which translates scraping ish lakes (Swathy et al., 2015;Suresh, 2016;Sherlin et al., 2015). In medical terms, the word de ines loss of epithelium elements in small and large amounts. Desquamative gingiva is a clinical inding which progresses characteristic features like erosion, vesicular formation, atrophy, marginal and keratinised gingiva (Shklar, 1968;Jayaraj et al., 2015c). There has been insuficient research done to try associating dermatological lesions with desquamative gingiva. The current study tries to ind a correlation between dermatological lesions and desquamative gingiva to aid in an easier diagnosis and effective treatment plan. The aim of the present study is to ind the prevalence of desquamative gingiva in dermatological lesions.

MATERIALS AND METHODS
The present study is a correlation type study the setting used for data collection was the hospital typesetting.The parameters used in the present study are age, gender, duration of presenting illness, previous history, clinical appearance, presence of desquamative gingiva, clinical diagnosis, histopathological diagnosis and treatment. Data was collected using reviewed patient records and analysed the data of 86,000 patients between June 2019 and March 2020. This record is a patient management software to store and maintain patient details and patient history right from their irst visit to the last visit. All the cases report present in the software word cross-veri ied by the examiner and then uploaded. The data collected from the patient record was transferred to SPSS for further analysis. Chi-Square test was done to compare the proportion between various parameters, and p<0.05 were considered signi icant.

RESULTS AND DISCUSSION
A total of 24 patients with dermatological lesions were identi ied in the study. Among these 24 patients, 70% were females, 30% were males. The most commonly affected age group is from 50 to 60 years. The current study also showed that most of the patients, around 50%, showed a burning sensation in the mouth as their presenting illness. The most common presenting illness seen was burning sensation in patients diagnosed histopathologically as lichen planus. This was found to be statistically signi icant. Pearson's chi-square p=0.020 (Table 1). The clinical diagnosis showed 41% lichen planus, and histological diagnosis showed 75% lichen planus. The X-axis represents the various clinical diagnosis, and Y-axis represents the count of the histopathological diagnosis. The green bar represents that histopathological diagnosis of lichen planus and the blue bar represents that histopathological diagnosis that was not performed. Most of the lesions diagnosed clinically as different dermatological and gingival lesions were diagnosed histopathologically as lichen planus and pemphigus Vulgaris had been diagnosed clinically and not histopathologically. This was found to be statistically signi icant. Pearson's chi-square p<.001 (Figure 1). The correlation between clinical diagnosis and desquamative gingiva showed 91% likelihood and the correlation between these ram showing correlation between Histopathological diagnosis and Clinical Diagnosis.

Figure 1: Bar diagram depicting the correlation between Histopathological Diagnosis and Clinical diagnosis of oral manifestations in dermatological lesions
One such study shows that 72.9% of females are more frequent with oral manifestations and derma-

Figure 2: Bar chart depicting the correlation between Presence or absence of Desquamative Gingivitis and clinical diagnosis
tological lesions which is similar to our result of 70% female predilection (Hasan et al., 2012). The mean age group that's predominantly affected by oral lichen planus is 45 to 55 years. Previous studies show that the mean age of patients affected by oral lichen planus is 58 years.
Numerous diseases present as desquamative gingivitis, in the present study, lichen planus is the most common oral lesion 75%. The X-axis represents the various clinical diagnosis, and Y-axis represents the frequency of desquamative gingivitis. Blue bar represents the absence of desquamative gingiva, and the green bar represents the presence of desquamative gingiva. The incidence of desquamative gingiva in dermatological lesions like Oral Lichen planus and pemphigus Vulgaris was found to be remark-ably high and statistically signi icant. Pearson's chisquare p = 0.001 ( Figure 2). These indings are in contrast to those previously reported wherein pemphigus was the most common lesion associated with desquamative gingivitis. (Ahmed et al., 2006). This might be due to various reasons like the prevalence of Lichen planus compared to Pemphigus in the present population and other geographical and ethnic variations (Loue and Pike, 2007). The drawback in the present study was that histopathological was not carried out for 6 pemphigus Vulgaris patients who were evaluated only by clinical features. There was no signi icant association between Histopathological diagnosis and Desquamative gingivitis. Pearson's chi-square p = 0.070 (Table 2). Histopathological diagnosis enables dental practitioners to procure a more ef icient treatment planning as it is a more accurate approach.
Another study states that the prevalence of desquamative gingivitis is more commonly seen in mucous membrane pemphigoid, where the current study shows oral lichen planus (Scully and Muzio, 2008). The limitations to the following study might be due to the small sample size collected in a restricted population, and many other parameters are not taken into consideration such as genetic parameters, other organs affected and the MMP cannot be con irmed by immuno luorescence. However, the present study shows future scope with advanced histopathological procedures, further studies with larger populations. The knowledge obtained from the study aids dentists to understand better other oral conditions that are analogous to dermatological lesions. Histopathological diagnosis and clinical diagnosis are both equally important for arriving at an accurate diagnosis and ef icient treatment plan.

CONCLUSION
According to the current study population, dermatological lesions are the common cause of desquamative gingiva. The prevalence of oral lichen planus was higher and commonly seen along with desquamative gingiva.