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Oral Disease - Soft tissue > Lichen Planus > Flashcards

Lichen Planus Flashcards

1
Q

What is lichen planus?

A

Chronic, inflammatory mucocutaneous disease of unknown aetiology

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2
Q

What is the likely aetiology of lichen planus?

A

Cell mediated immunological reaction within affected tissues due to an unknown trigger

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3
Q

Epidemiology of lichen planus

A

Common (0.5-2% of adult population)
Female predilection 2:1
Age of onset around 30-60

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4
Q

Why is lichen planus likely to be a cell mediated immunological reaction?

A

There is an accumulation of T cells within the epithelium along with macrophages, langerhans cells and local production of cytokines

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5
Q

Why is lichen planus likely to be an autoimmune disease?

A

Females > males and it is associated with other AI diseases e.g. primary billary cirrhosis

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6
Q

What type of lichen planus has a known HLA association?

A

VVG variant (vulvovaginal-gingival)

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7
Q

What are the cutaneous features of lichen planus?

A

4 Ps - polygonal, purititc, purple papules commonly found on the flexors of the wrists, lumbar region, anterior leg (shins) and genitalia

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8
Q

What are the features of the vulvovaginal gingival variant of lichen planus?

A

Lesions affecting the vulva, vagina and gingiva

Scarring type is associated with lacrimal duct scarring, perforated eat drugs, hoarse voice and difficulty swallowing

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9
Q

How long do cutaneous LP lesions last?

A

Around 2 years (shorter duration than oral LP)

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10
Q

What are the phenotypes of oral lichen planus?

A
  • Reticular
  • Papular
  • Erosive
  • Atrophic
  • Plaque type
  • Bullous
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11
Q

List the oral features of lichen planus

A 
Bilateral, symmetrical lesions commonly on the buccal mucosa, labial mucosa, dorsal tongue, gingiva 
Striations 
Papules 
Atrophic areas 
Erosions 
Plaques
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12
Q

What are striations?

A

Sharply defined and white
May appear lacy, starry or annular
Can be firmer than the surrounding mucosa

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13
Q

What are papules?

A

Pinpoint, flat topped papules (can be white, red or purple) which may be interspersed with the striate

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14
Q

Describe atrophic lichen planus lesions

A

Red areas of mucosal thinning, may be associated with striate

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15
Q

Describe erosion lichen planus lesions

A

Shallow and irregular areas of epithelial destruction which may be covered in a slightly raised, yellow fibrin layer
Margins may be depressed due to fibrosis and healing at the periphery

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16
Q

Describe plaque-like lichen planus lesions

A

Dense thickening of the mucosal tissue (tends to be white)

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17
Q

What % of oral LP have it confined to the gingiva only?

A

10%

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18
Q

What is oral postinflammatory hyperpigmentation?

A

Brown or black pigmentation of the mucosa following the lichenoid lesion distribution as a result of an inflammatory response

19
Q

Describe the disease course of lichen planus

A

Periods of relapse and remission

20
Q

What type of lichen planus is more persistent?

A

Plaque like lesions

21
Q

Common CO for lichen planus

A
  • Slight stiffness of mucosa
  • Soreness or oral discomfort (esp with atrophic or erosive types) - difficult to eat
  • May be asymptomatic due to insidious onset
22
Q

Describe oral lichen planus that is confined to the gingiva only

A

Lesions tend to be atrophic and the gingiva is shiny, inflamed and smooth (desquamative)
Straie are uncommon
Plaque accumulation present due to difficulty cleaning

23
Q

Histological signs of lichen planus

A
  • Compact, dense band of lymphocytic infiltrate under the epithelio-mesenchymal junction, or partially disrupting the epithelium
  • Saw tooth profile and rete ridges
  • Hyperkeratosis and acanthosis
  • Apoptotic body (liquefaction degradation)
  • Widening of basement membrane
  • Melanin drop outs
24
Q

Special IX for lichen planus

A
  • Biopsy for histopatholology

- Immunoflouresence to rule out mmp, pv and dle

25
Q

Management pathway for lichen planus

A
  • Diagnosis
  • Supportive - not infectious
  • Topical agents +/- systemic depending on severity
  • Maintainence
  • Monitoring
26
Q

What topical agents are used for lichen planus

A

Difflam or lidocaine

27
Q

What topical therapies are used for lichen planus

A

Corticosteroids**, fluticasone, mometasone or calcineurin inhibitors

28
Q

What systemic therapies are used for lichen planus

A

Corticosteroids***, hydroquinone, azathioprine or methotrexate

29
Q

Treatment of gingval lichen planus

A
  • Difficult
  • Triamcinolone paste (corticosteroid)
  • Tacrolimus mouthwash if unresponsive
30
Q

Differential diagnosis of oral lichen planus

A
  • Lichenoid reaction
  • Frictional keratosis
  • Leukoplakia
  • If erythematous LP then erythematous candidiasis
  • Lupus
  • Pemphius and MMP
31
Q

Referral for oral lichen planus

A
  • Unsure of diagnosis
  • Speckled lesion - suspicious
  • Unresponsive to steroids
32
Q

What is the oral disease severity score?

A

Categories OLP as mild, moderate and severe based on site score, activity score and pain score

33
Q

What type of OLP tends to have the highest severity score?

A

Ulcerative oral lichen planus

34
Q

What are oral lichenoid lesions?

A

Lichen-planus like lesions that are caused wither by systemic drug treatment, or those where the histological picture is not diagnostic for LP

35
Q

Describe the clinical appearance of oral lichenoid lesions due to amalgam

A
  • Small, unilateral lesions localised around amalgam restorations
36
Q

Describe the clinical appearance of oral lichenoid lesions due to drug therapy

A
  • Widespread lesions in the mouth and skin associated with the onset of a drug
  • Asymmetrical
37
Q

What drugs are associated with oral lichenoid lesions

A
  • Colloidal golds
  • Antihypertensives
  • Oral hypoglyceamics
  • NSAIDs - naproxen
  • Penecillamine
  • Tricyclic antidepressants
  • Antimalarials
  • Biologics
38
Q

What dental materials are associated with oral lichenoid lesions

A

Amalgam, composite, acrylic, cobalt and nickel

39
Q

Describe the pathology of OLL due to dental materials

A

Contact hypersensitivity (delayed = type IV) due to alteration in antigenicity of basal keratinocytes by the release of dental materials

40
Q

When is the diagnosis ‘oral lichenoid lesion’ made?

A
  • Histopathology not diagnostic of lichen planus
  • Histopathology is diagnostic of OLP but clinically doesn’t match
  • Clinical and histology indicates OLL
41
Q

What is the malignant potential of oral lichen planus

A

Reports suggest 1-4% change over 10 years (however this is controversial and may be considered as <1%)

42
Q

List risk factors for increased risk of malignant change in OLP lesions

A
  • Smokers
  • Females
  • Lesions on the tongue
  • Atypical lesions
  • Red lesions
43
Q

What is desquamative gingivitis?

A

A clinical description of erythematous gingiva, desquamation and erosion of the gingival epithelium and blister formation - usually affecting whole width of the attached gingiva around teeth

44
Q

What is desquamative gingivitis associated with?

A
  • Lichen planus (most common)
  • MMP
  • Pemphigus vulgaris

Oral Disease - Soft tissue (12 decks)

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