Main complaint and medical history

A 43 year old male patient presented to the oral medicine clinic with the complaint of painful burning gums. His symptoms began around 2 months prior to his initial presentation and he had visited a dentist who prescribed Corsodyl mouthrinse, Augmentin and anti-inflammatory medications. At the same visit, tooth 45 was extracted. He reported no allergies to medications and rarely used medications of any kind. He was also a non-smoker and consumed no alcohol. An interesting aspect of his medical history included the appearance of skin lesions in his early 20s. These “itchy” lesions resolved after a doctor in his native country (Bangladesh) gave him a series of injections and have never recurred. Further questioning of his current complaints also revealed that his lower left leg occasionally burns and the overlying skin itches.

Clinical examination:

Extra oral examination revealed no abnormalities to the head and neck although lesions were detected on lower legs with the left shin and ankle presenting the greater density of lesions. The skin lesions presented as multiple purple/brown dry scaly macules with prominent distended and tortuous varicose veins below the skin. The patient indicated that these lesions have developed slowly over the years as he spends a lot of time standing behind the till at his shop.

Intra- oral examination revealed poor plaque control with visible calculus and a healing extraction socket of of 45. Localised areas of the posterior buccal gingiva presented clinically as desquamative gingivitis due to their erythematous frail and eroded appearance. The vestibular mucosa appeared erythematous with numerous radiating lacy white striations extending into the alveolar mucosa and areas of attached gingiva. Lesions were present bilaterally in maxillary and mandibular vestibules with small patches of buccal mucosa affected. Pain remained limited to posterior gingiva and vestibules (Figures 1 and 2).

Figure 1: Frontal view in occlusion

Figure 2: Right and left lateral views (patient did not occlude posteriorly)

Figure 3: Closer examination of the maxillary vestibule reveals the striated pattern

Figure 4: Maxillary (left) and mandibular (Right) occlusal views

Figure 5: initial panoramic radiograph following extraction of tooth 45

Figure 1: Frontal view in occlusion

Figure 2: Right and left lateral views (patient did not occlude posteriorly)

Figure 3: Closer examination of the maxillary vestibule reveals the striated pattern

Figure 4: Maxillary (left) and mandibular (Right) occlusal views

Periodontal charting:

Periodontal diagnosis:

  • Mild generalized chronic periodontitis
  • Superimposed Desquamative gingivitis secondary to contact allergy or autoimmune condition
  • Localised gingival recession
  • Caries
  • Individual tooth prognosis was good with the exception of tooth 18.


Systemic phase:

Patient was instructed to stop all medications including multivitamins and herbal remedies even though he assured me that he was not consuming any. Dietary modification included the removal of all spices and processed foods for the next three weeks until his review appointment. Further instruction into oral hygiene included the cessation of using his current toothpaste until the review. Paroex gel was provided and instructed to use as a toothpaste replacement until the next oral medicine follow up. An appointment was also set for dermatology which was booked 2 months in future.

Initial phase therapy:

Oral hygiene instructions and demonstration included brushing and flossing techniques and the use of interdental brushes. Full mouth SRP with chlorhexidine intra-pocket irrigation, completed according to the full mouth disinfection protocols. Paroex gel prescribed for long term use. An incisional biopsy was taken from left maxillary vestibule at an area with intact epithelium and sent for histopathologic examination. A shortfall in retrospect is that a tissue biopsy for immunofluorescence should have been taken at that time in order to exclude othe immunologic entities. The patient was recalled in three weeks to assess the lesions and present the histologic findings.

Figure 6: Histopathology report demonstrates histological features typical of lichen planus but required exclusion of similar entities

Follow up visits:

At 3 weeks post biopsy: The biopsy site had healed well, plaque and gingival indices were improved (pockets were not measured) and the lesions appeared less erythematous. However, the pain and discomfort persisted. Betamethosone, 0,5mg dissolved in 10ml water was prescribed as a rinse and spit for 1 week (medium potency)

2 weeks post betamethasone prescription: The patient was then followed up two weeks after prescribing the betamethasone rinse and resolution of desquamative gingivitis was noted. Mild symptoms persisted at vestibular sites but were manageable. The patient was instructed to continue on the bland diet. The dermatologist had indicated the skin lesions to be a result of the underlying varicose veins and so referred the patient to a vascular surgeon for further assessment. The dermatologist acknowledged the possibility of lichen planus and prescribed Dovate (Clobetasol Propionate – 2.5Mg/5G) cream. As the oral lesions were very mildly symptomatic, no further oral medications were given.

Periodontal re-evaluation (8 weeks after initial phase therapy)

Desquamative areas were healed and the patient was comfortable. The vascular surgeon has prescribed the use of compressive stockings for the early management of the varicose veins. The patient had reported the itching and burning of the legs has dramatically improved. Oral hygiene at interproximal and lingual sites required further improvement. As periodontal indices had improved and pockets detected remained shallow, non- durgical maintenance was scheduled every 3 months.

Periodontal risk asessment:

Figure 7: PRA