**Author details**

*Gingival Disease - A Professional Approach for Treatment and Prevention*

dental hygiene products.

ment outcome.

**5. Conclusions**

excessive or improper oral hygiene practices or by hypersensitivity reactions to oral hygiene products such as toothpaste or mouth rinses may mimic positive Nikolsky's sign elicited by autoimmune bullous diseases (**Figure 9**) [45–47]. Biopsy may provide histopathologic evidence supporting the diagnosis, but DIF is often not indicated because it is routinely negative since intact epithelium may be required to validate the diagnosis. Eliminating causative agents leads to disappearance of gingival involvement in most patients with hypersensitivity reactions to dental or

After the diagnosis of MMP or PV, patients often require an extraoral examination by medical specialists including a dermatologist, an ophthalmologist, and an otolaryngologist. All patients with extraoral involvement should be managed by medical specialists using systemic treatment with or without hospitalization. Patients with exclusively oral lesions may be managed using moderate to very-highpotency topical corticosteroid therapy often combined with effective dental plaque control. The therapeutic goal for DG lesions is the remission or suppression of the clinical signs and symptoms such as gingival soreness, bleeding, and swelling as shown in **Table 4**. Response to therapy can be assessed to determine whether or not the patient exhibits a positive Nikolsky's sign or other evidence of ongoing disease. The disappearance of lesions and of Nikolsky's sign may indicate a favorable treat-

Nikolsky's sign is a simple nondiagnostic test that may suggest a need for biopsy diagnosis of autoimmune or other diseases in the oral mucosa. The gingiva is often a preferable site for performing the test for Nikolsky's sign especially if DG is present. A positive reaction of this sign is the basis for suspecting autoimmune bullous diseases such as MMP and PV. In that case, it is critical to conduct DIF testing in conjunction with histopathological examination to establish the final diagnosis. It is also important to remember that DG is a general descriptive term rather than a diagnosis. Oral healthcare providers have a great responsibility to remain suspicious of unexplained oral manifestations of systemic or unusual intraoral diseases and disorders. The presence of a positive oral Nikolsky's sign serves as a warning that careful evaluation is needed in search of the etiology of the sign. Once other causes have been eliminated, the clinician must remain aware that biopsy or referral for biopsy may be necessary to determine the current diagnosis. It is important to remember, however, that biopsy of tissue sites that feature Nikolsky's sign is not indicated because a positive Nikolsky's sign is indicative of friable epithelium and proper diagnosis is predicated on obtaining a biopsy from a site with intact epithelial surfaces. Nonetheless, this simple test for Nikolsky's sign may serve as a valuable indicator of underlying autoimmune or other diseases and lead to obtaining a correct diagnosis. In many instances patients with diseases or disorders featuring gingival Nikolsky's sign may require appropriate referral to other dental or medical specialists after identifying suspicious lesions. For the early diagnosis of autoimmune bullous disorders, oral healthcare providers should consider the use of this test that may ultimately lead to the early diagnosis of MMP

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and PV or other diseases or disorders.

The authors report no conflicts of interest related to this study.

**Conflict of interest**

Hiroyasu Endo1 \*, Terry D. Rees2 , Hideo Niwa<sup>3</sup> , Kayo Kuyama4 , Maya Oshima5 , Tae Serizawa5 , Shigeo Tanaka5 , Morio Iijima6 , Masamichi Komiya<sup>5</sup> and Takanori Ito1

1 Department of Oral Diagnosis, Nihon University School of Dentistry at Matsudo, Japan

2 Department of Periodontics, Texas A&M College of Dentistry, Dallas, TX, USA

3 Department of Head and Neck Surgery, Nihon University School of Dentistry at Matsudo, Japan

4 Department of Pathology, Nihon University School of Dentistry at Matsudo, Japan

5 Department of Oral Surgery, Nihon University School of Dentistry at Matsudo, Japan

6 Department of Removable Prosthodontics, Nihon University School of Dentistry at Matsudo, Japan

\*Address all correspondence to: endo.hiroyasu@nihon-u.ac.jp

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
