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\def\RunningAuthor{Herald J Sherlin et al.}
\firstPage{1259}
\articleType{Original Article}
\receivedDate{28 Aug 2020}
\acceptedDate{01 Oct 2020}
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\title{\textbf{Prevalence of desquamative gingivitis in dermatological lesions - A retrospective institution based study}}
\author{Santosh~Bala\textsuperscript{1},  
            Herald~J~Sherlin\textsuperscript{*}\textsuperscript{2}, 
            Vivek~Narayan\textsuperscript{3}~\\[5pt]{\textsuperscript{1}Saveetha Dental college and Hospitals, Saveetha Institute of Medical and Technical Sciences Saveetha University, Chennai - 600 077, Tamil Nadu, India}~\\{\textsuperscript{2}Department of Oral pathology, Saveetha Dental college and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai - 600 077, Tamil Nadu, India}~\\{\textsuperscript{3}Department of Oral Medicine, Saveetha Dental college and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai - 600 077, Tamil Nadu, India}}

\begin{abstract}
The oral cavity is considered to be the window to your body because oral manifestations accompany many systemic diseases. In many instances, oral involvement precedes the appearance of other symptoms or lesions at other locations. The aim of this study is to find the correlation of these formative gingiva along with dermatological lesions. Details of patients reported with dermatological lesions to the dental hospital with oral manifestations were obtained from a detailed patient record. The data collected is tabulated graphically via SPSS for statistical analysis. 24 patients were reported with various dermatological lesions. 70\% of female predilection was observed, and maximum patients carried the lesion for about 12 months. Out of the 24 patients, 70\% show the presence of desquamative gingiva clinically. Histopathological diagnosis shows that 75\% of the dermatological lesions present in the oral cavity is lichen planus. 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.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Desquamative gingiva,\newline Dermatological lesions,\newline Oral Lichen planus,\newline pemphigus
\end{keywords}
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Herald~J~Sherlin~\\ Phone:\ ~\\  Email:\ sherlin@saveetha.com
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\section{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 \unskip~\citep{891736:20381193,891736:20381179}. Most of the oral mucosa is derived embryologically from an invagination of the ectoderm \unskip~\citep{891736:20381183,891736:20381201}. Thus due to similar orifices, other disorders which are primarily associated with the skin are involved \unskip~\citep{891736:20381184,891736:20381199,891736:20381185}. 

Lichen planus is a chronic mucocutaneous disorder of the stratified squamous epithelium that affects oral and genital mucous membranes \unskip~\citep{891736:20381202,891736:20381191,891736:20381180}. Oral lichen planus is considered to be nothing but the mucosal counterpart of cutaneous lichen planus \unskip~\citep{891736:20381194,891736:20381195,891736:20381203}. Pemphigus Vulgaris is an autoimmune intraepithelial blistering disease involving the skin and mucous membrane \unskip~\citep{891736:20381189,891736:20381181}. The condition is known to affect both sexes equally and is found to be more common in middle-aged and elderly patients \unskip~\citep{891736:20381182,891736:20381196}. 

Most patients present with oral lesions as their first 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 \unskip~\citep{891736:20381200,891736:20381206}. In many pemphigus Vulgaris patients, oral lesions are very commonly seen and often followed by the development of skin lesions \unskip~\citep{891736:20381206,891736:20381198}. 

The term desquamation is derived from the Latin word, which translates scraping fish flakes \unskip~\citep{891736:20381205,891736:20381178,891736:20381190}. In medical terms, the word defines loss of epithelium elements in small and large amounts. Desquamative gingiva is a clinical finding which progresses characteristic features like erosion, vesicular formation, atrophy, marginal and keratinised gingiva \unskip~\citep{891736:20381186,891736:20381197}. There has been insufficient research done to try associating dermatological lesions with desquamative gingiva. The current study tries to find 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 find the prevalence of desquamative gingiva in dermatological lesions.
    
\section{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 first visit to the last visit. All the cases report present in the software word cross-verified 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{\textless}0.05 were considered significant. 
    
\section{Results and Discussion}
A total of 24 patients with dermatological lesions were identified 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 significant. Pearson's chi-square p=0.020 (Table~\ref{tw-bbd772fe59e5}). 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 significant. Pearson's chi-square p{\textless}.001 (Figure~\ref{f-8641b500bcde}). 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. 


\begin{table*}[!htbp]
\caption{\boldmath {Cross Tabulation showing the relationship between histopathological diagnosis and presenting illness} }
\label{tw-bbd772fe59e5}
\def\arraystretch{1.1}
\ignorespaces 
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\begin{tabulary}{\linewidth}{p{\dimexpr.19019999999999996\linewidth-2\tabcolsep}p{\dimexpr.15919999999999998\linewidth-2\tabcolsep}p{\dimexpr.12330000000000002\linewidth-2\tabcolsep}p{\dimexpr.06799999999999999\linewidth-2\tabcolsep}p{\dimexpr.20299999999999997\linewidth-2\tabcolsep}p{\dimexpr.15160000000000002\linewidth-2\tabcolsep}p{\dimexpr.10469999999999999\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Histopathological Diagnosis & \cAlignHack Asymptomatic & \cAlignHack Burning Sensation & \cAlignHack Pain & \cAlignHack Pain and Burning sensation & \cAlignHack Blisters/ulcers & \cAlignHack White patches\\
\tblmidrule 
\cAlignHack No biopsy &
  \cAlignHack 0 &
  \cAlignHack 0 &
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  \cAlignHack 0 &
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\cAlignHack OralLichen Planus &
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  \cAlignHack 11 &
  \cAlignHack 3 &
  \cAlignHack 1 &
  \cAlignHack 1 &
  \cAlignHack 1\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Cross Tabulation depicting the relationship between Histopathological Diagnosis and Presence or absence of Desquamative Gingivitis} }
\label{tw-b1a9264adc7f}
\def\arraystretch{1.1}
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\begin{tabulary}{\linewidth}{p{\dimexpr.3345\linewidth-2\tabcolsep}p{\dimexpr.3255\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Histopathological Diagnosis & \cAlignHack Desquamative Gingiva  \mbox{}\protect\newline Absent & \cAlignHack Desquamative Gingiva  \mbox{}\protect\newline Present\\
\tblmidrule 
\cAlignHack No biopsy &
  \cAlignHack 0 &
  \cAlignHack 6\\
\cAlignHack Oral Lichen Planus &
  \cAlignHack 7 &
  \cAlignHack 11\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

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\caption{\boldmath {Bar diagram depicting the correlation between Histopathological Diagnosis and Clinical diagnosis of oral manifestations in dermatological lesions}}
\label{f-8641b500bcde}
\end{figure}
\egroup

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\caption{\boldmath {Bar chart depicting the correlation between Presence or absence of Desquamative Gingivitis and clinical diagnosis}}
\label{f-66974a7705c3}
\end{figure}
\egroup
One such study shows that 72.9\% of females are more frequent with oral manifestations and dermatological lesions which is similar to our result of 70\% female predilection \unskip~\citep{891736:20381192}. 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 remarkably high and statistically significant. Pearson's chi-square p = 0.001 (Figure~\ref{f-66974a7705c3}). These findings are in contrast to those previously reported wherein pemphigus was the most common lesion associated with desquamative gingivitis. \unskip~\citep{891736:20381204}. 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 \unskip~\citep{891736:20381188}. 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 significant association between Histopathological diagnosis and Desquamative gingivitis. Pearson's chi-square p = 0.070 (Table~\ref{tw-b1a9264adc7f}). Histopathological diagnosis enables dental practitioners to procure a more efficient 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 \unskip~\citep{891736:20381187}. 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 confirmed by immunofluorescence. 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 efficient treatment plan. 
    
\section{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. 

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.
    

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