**2. Materials and methods**

The present study was based on a retrospective review of 39 cases that were classified as MMP (25 patients) or PV (14 patients) at Nihon University, School of Dentistry at Matsudo, from 2001 to 2018. The protocol of this study was approved by an institutional review board (Ethics Committee Approval No. EC14-011-1). The summary of the 39 patients are shown in **Table 3**. Some of the 39 patients presented in this study have been previously reported [6, 10, 11, 14, 27, 28, 31]. All 39 patients described gingival lesions consistent with DG (**Figures 1** and **2**). The oral lesions were confined to the gingiva in 27 patients (69.2%), although other 12 patients (30.8%) also had extragingival involvements (the buccal mucosa, soft palate, or tongue). Eleven of the 39 patients (28.2%) confirmed the existence of extraoral involvements (nose, pharynx, larynx, ocular mucosa, or skin). Gingival biopsies were performed in all 39 patients. Patients were diagnosed with MMP or PV through clinical examination supported by histopathologic diagnosis and DIF testing for each patient (**Figures 3** and **4**). The current study examined the clinical records of each


*MMP = mucous membrane pemphigoid; PV = pemphigus vulgaris; DIF = direct immunofluorescence; BMZ = basement membrane zone; ISC = intercellular space.*

*\*After a diagnosis of MMP or PV, patients were advised to confirm the presence or absence of extraoral lesions by a dermatologist, an otorhinolaryngologist, and an ophthalmologist. \*\*Deposition of varying combinations of IgG, IgA, fibrinogen, and complement C3.*

**61**

**Figure 4.**

*Gingival Nikolsky's Sign: A Valuable Tool in Identifying Oral Manifestations of Mucous…*

*Desquamative gingivitis in mucous membrane pemphigoid. The intensity of the gingival erythema or erosion is* 

*Desquamative gingivitis in pemphigus vulgaris. The attached gingiva presents as friable nature of the tissue.* 

*Biopsy confirmation of mucous membrane pemphigoid. A subepithelial blister formation was found in hematoxylin-eosin-stained section. Direct immunofluorescence showed a linear deposition of IgG at the* 

*Biopsy confirmation of pemphigus vulgaris. Acantholysis and suprabasilar blister formation were recognized in hematoxylin-eosin-stained section. Direct immunofluorescence showed an intercellular deposition of IgG.*

*Bullae develop quickly and then rupture, leaving eroded painful surfaces with ragged borders.*

*DOI: http://dx.doi.org/10.5772/intechopen.82582*

*variable, and the involvement may be diffuse or patchy distribution.*

**Figure 1.**

**Figure 2.**

**Figure 3.**

*basement membrane zone.*

#### **Table 3.**

*Characteristics of 39 patients with autoimmune bullous diseases.*

*Gingival Nikolsky's Sign: A Valuable Tool in Identifying Oral Manifestations of Mucous… DOI: http://dx.doi.org/10.5772/intechopen.82582*

#### **Figure 1.**

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

The present study was based on a retrospective review of 39 cases that were classified as MMP (25 patients) or PV (14 patients) at Nihon University, School of Dentistry at Matsudo, from 2001 to 2018. The protocol of this study was approved by an institutional review board (Ethics Committee Approval No. EC14-011-1). The summary of the 39 patients are shown in **Table 3**. Some of the 39 patients presented in this study have been previously reported [6, 10, 11, 14, 27, 28, 31]. All 39 patients described gingival lesions consistent with DG (**Figures 1** and **2**). The oral lesions were confined to the gingiva in 27 patients (69.2%), although other 12 patients (30.8%) also had extragingival involvements (the buccal mucosa, soft palate, or tongue). Eleven of the 39 patients (28.2%) confirmed the existence of extraoral involvements (nose, pharynx, larynx, ocular mucosa, or skin). Gingival biopsies were performed in all 39 patients. Patients were diagnosed with MMP or PV through clinical examination supported by histopathologic diagnosis and DIF testing for each patient (**Figures 3** and **4**). The current study examined the clinical records of each

Mean (years) 65.8 46.9 59.0 Range (years) 36–80 24–73 24–80

Male 9 1 10 (25.6%) Female 16 13 29 (74.4%)

Desquamative gingivitis 25 14 39 (100%)

Restricted to the gingiva 18 9 27 (69.2%) Gingiva + extragingiva 7 5 12 (30.8%) Extraoral site involvement\* 8 3 11 (28.2%)

Subepithelial blisters 21 — Acantholysis and suprabasilar blisters — 14 Nonspecific 3 — Nondiagnostic 1 —

BMZ deposition\*\* 25 — ICS deposition\*\* — 14 *MMP = mucous membrane pemphigoid; PV = pemphigus vulgaris; DIF = direct immunofluorescence;* 

*\*After a diagnosis of MMP or PV, patients were advised to confirm the presence or absence of extraoral lesions by a* 

**MMP (n = 25) PV (n = 14) Total** 

**(n = 39)**

**2. Materials and methods**

**Age at diagnosis**

**Clinical findings**

**Biopsy findings**

DIF examination

Intraoral site involvement

Histopathological examination

*BMZ = basement membrane zone; ISC = intercellular space.*

*dermatologist, an otorhinolaryngologist, and an ophthalmologist.*

*Characteristics of 39 patients with autoimmune bullous diseases.*

*\*\*Deposition of varying combinations of IgG, IgA, fibrinogen, and complement C3.*

**Gender**

**60**

**Table 3.**

*Desquamative gingivitis in mucous membrane pemphigoid. The intensity of the gingival erythema or erosion is variable, and the involvement may be diffuse or patchy distribution.*

#### **Figure 2.**

*Desquamative gingivitis in pemphigus vulgaris. The attached gingiva presents as friable nature of the tissue. Bullae develop quickly and then rupture, leaving eroded painful surfaces with ragged borders.*

#### **Figure 3.**

*Biopsy confirmation of mucous membrane pemphigoid. A subepithelial blister formation was found in hematoxylin-eosin-stained section. Direct immunofluorescence showed a linear deposition of IgG at the basement membrane zone.*

#### **Figure 4.**

*Biopsy confirmation of pemphigus vulgaris. Acantholysis and suprabasilar blister formation were recognized in hematoxylin-eosin-stained section. Direct immunofluorescence showed an intercellular deposition of IgG.*

#### **Figure 5.**

*Nikolsky's sign in pemphigus vulgaris. The epithelium is dislodged by the application of a firm sliding force.*

**Figure 6.**

*Nikolsky's sign with bleeding in mucous membrane pemphigoid. Gingival bleeding can occur in some patients characterized by subepithelial blister formation.*

individual which provided information on each patient's gingival symptoms, gingival site involvement, and the presence of gingival epithelial desquamation based on a test for Nikolsky's sign. At the initial dental appointment, a test for Nikolsky's sign was performed in all 39 patients by a single examiner (HE) using the "marginal" method and the "direct" method (**Figures 5** and **6**) [32, 33]. Briefly, a positive gingival Nikolsky's sign described the extension of the erosion on the surrounding normal-appearing tissue by rubbing the edge of the affected area with a periodontal probe (the "marginal" method), or the ease of inducing erosion by rubbing apparently unaffected the gingiva distant from the lesions (the "direct" method). All 39 patients were evaluated using the "marginal" method. In addition, in some patients we also used the "direct" method. When a positive Nikolsky's sign was identified, the presence of gingival bleeding was also evaluated (**Figure 6**).
