A 71-year-old man presents with mucosal pain during tooth brushing and a “flabby” sensation in his gums. The symptoms have come on gradually over the past 7 to 8 months. The patient’s medical history was remarkable for hypertension and hypercholesterolemia, which were being monitored by his physician every 3 months. His medications included simvastatin(Drug information on simvastatin), atenolol, hydrochlorothiazide(Drug information on hydrochlorothiazide), fluticasone(Drug information on fluticasone)/salmeterol inhaler, fluticasone propionate, albuterol inhaler, guaifenesin, and loratadine(Drug information on loratadine). Doxycycline(Drug information on doxycycline) and tobramycin(Drug information on tobramycin)/dexamethasone eye ointment had been prescribed by his ophthalmologist for a recent eye “infection.” There was no known allergy, metal sensitivity, or history of tobacco use.
The patient appeared to be in no distress. Examination of the eyes revealed erythema of the eyelids and sclera; the eyelashes appeared wet (Figure 1). The salivary glands were slightly enlarged. The patient’s dentition was intact, although he had had extensive restorations. Moderate interdental plaque was noted. The gingiva displayed moderate to severe erythema, with an intermittent pattern extending on the free gingival margin to the alveolar mucosa (Figure 2). In a few areas, a pseudomembrane was evident (Figure 3). Limited erythema was seen on the lingual and palatal surfaces. Nikolsky sign was positive.
Immunofluorescence antibody stain of a biopsy specimen was positive for IgG, IgA, C3, and fibrinogen and negative for antibody to IgM. The positive staining was uniform and present along the basement membrane that separates the surface epithelium from the connective tissue. It was also present along the basal cell layer as shown in one of the fragments that represents completely detached epithelium.
The hematoxylin and eosin–stained frozen section showed elongated pieces of oral mucosa, some with intact underlying connective tissue and others with completely detached epithelium. The detached epithelium was keratinized, and the line of detachment was below the basal cell layer. The connective tissue was focally infiltrated by lymphocytes and a few plasma cells.
The findings suggested the following diagnostic possibilities:
• Ulcerative gingivitis
• Benign mucous membrane pemphigoid
• Bullous/erosive lichen planus
• Bullous pemphigoid
• Early erythema multiforme