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Mucosal “Peeling” Biopsy Technique for the Immunopathologic Evaluation of Desquamative Gingivitis–Associated Mucous Membrane Pemphigoid

Carlos Ricotti, MD; John Kowalczyk, BBA; Anthony Fernandez, MD, PhD; Carlos H. Nousari, MD
Arch Dermatol. 2008;144(11):1538. doi:10.1001/archderm.144.11.1538.
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Desquamative gingivitis can result from various pathogenetic factors, including mucous membrane pemphigoid (MMP).1 Adequate gingival sampling for immunopathologic evaluation is mandatory for the diagnosis of MMP. The gingival mucosal “peeling” biopsy technique (Figure 1) yields sufficient epithelium samples for histologic analysis and direct immunofluorescence (DIF).2 Hemidesmosomal proteins (BPAG1-2 and α6β4-integrin) are the most common MMP autoantigens, resulting in a “capping hemidesmosomal” linear IgG DIF pattern on the gingival epithelial undersurface (Figure 2). To circumvent false-negative DIF results, related to less common, deeper basement membrane zone autoantigens (laminin5/6 and collagenVII), serologic evaluation for anti–basement membrane zone autoantibodies (eg, indirect immuno-fluorescence and enzyme-linked immunosorbent assay) should be performed. If the findings of DIF and serologic studies are nondiagnostic and a high index of clinical suspicion for MMP remains, an appropriate mucosal punch or incisional biopsy should be performed. Gingival lesions in patients with MMP may deter clinicians from performing sampling owing to technical difficulty. Mucosal peeling can provide adequate immunopathologic samples for the diagnosis of desquamative gingivitis–associated MMP.

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Figure 2.

Routine hematoxylin-eosin staining of mucous membrane pemphigoid–associated desquamative gingivitis shows the detached epithelium of a subepithelial blister with a smooth epithelial undersurface and no dyskeratosis or acantholysis. These features mitigate against interface or lichenoid mucositis–associated subepithelial blistering disorders or autoimmune pemphigus. Inset, Direct immunofluorescence of mucous membrane pemphigoid–associated desquamative gingivitis shows thin, linear IgG deposition along the basilar poles of basal epithelial cells, giving a characteristic “hemidesmosomal capping” pattern (original magnification ×20).

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Figure 1.

Mucosal peeling technique for the immunopathologic evaluation of desquamative gingivitis–associated mucous membrane pemphigoid. A and B, Induce gingival epithelium detachment with a cotton-tipped applicator in an area close to an erosion where there is attached epithelium overlying an erythematous base (often no local anesthesia is required). C, Gently pull and retract the detached epithelium from the gingival surface using toothless surgical tissue forceps. D, After an adequate sample is visualized, cut the detached and retraced epithelium with surgical scissors or a No. 15 blade scalpel. Then, place the detached tissue sample in immunofluorescence transport solution for processing at an appropriate laboratory.

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