management of lichen planus Flashcards
3 contributing factor groups to lichen planus
Most are IDIOPATHIC – no known cause
Some related to MEDICATION (particularly anti-hypertensive)
Some related to AMALGAM restorations
if cause of lesion is known the reaction is referred to as
lichenoid reaction to…..
dx and managed as LP and cause removed
v little difference histologically between attirbutable cause reaction adn idiopathic LP
3 common medication classes which can cause LP
antihypertensives
* ACE inhibitors
* beta-adrenergic blockers
* diuretics - bendroflumethiazide, frusemide
NSAIDs
DMARDs disease modifying anti-rheumatic drugs
* pencillamine
* gold
* sulphasalazine (most common)
rare - phenothiazines
lichenoid drug reactions appearance
More often WIDESPREAD lesions
Often BILATERAL and mirrored
Often poorly responsive to standard steroid treatment
management of lichenoid drug reactions
risk/benefit analysis
* Does the benefit of stopping the medical drug outweigh the risk to the patient’s health
* Mild lichen symptoms – unlikely
* Significant lichen symptoms – probably
* Where maximum topical or systemic treatment likely needed to control the lichen symptoms
Discomfort from symptoms and degree of tx necessary with immune modulators to get lichenoid lesions under control
if in doubt discuss with pt’s GP
* may no longer need medication
* maybe an easy change of medication e.g. ACE inhibitor to AT2 blocker (same affect on blood pressure, but don’t seem to be associated with lichenoid reactions)
lichenoid reactions to amalgam dx
amalgam restoration in close proximity - either at rest or in function
not clear what exactly triggers LP - amalgam, mercury, something else
*patch (skin) test to amalgam/mercury sometimes carried out *
options for managing amalgam lichenoid reactions
If NOT symptomatic do nothing?
Potentially malignant lesion – is this sensible (low malignant transformation risk)
* Replacing restoration will increase tooth damage
* Cost to patient – DPB will fund composite when Patient pays for ‘new amalgam’
Should other amalgams be replaced?
* No routine need – amalgam restoration should only be removed if in direct contact with lichenoid lesion
4 materials for replacing amalgam
Composite common
Glass
Gold – low Palladium Alloy (PMA), where full coverage necessary
* Palladium has some association with lichenoid reactions – only not used when there is an evidence of previous lichenoid change
Bonded crown?
how to remove amalgam?
ideally:
* rubber dam
* high volume suction
* PPE
avoid risk of mercury vapour being released
avoid during pregnancy
6 tests that can be used in management of lichen planus
Remove any cause:
* Medicines
* Dental restorations
BIOPSY
* Unless a good reason not to
Blood tests
Haematinincs – more symptomatic if def
FBC
*If lupus suspected autoantibody screen (ANA, Ro, dsDNA)
how to manage mild intermittend lesions of lichen planus
2
Topical OTC remedies
* Chlorhexidene m/w
* Benzdamine m/w
Avoid SLS containing toothpaste driver in many cases, particularly gingival lesions
* Sensodyne Pronamel
* Kingfisher
good for occasional mild symp lesions
how to manage mild intermittend lesions of lichen planus
2
Topical OTC remedies
* Chlorhexidene m/w
* Benzdamine m/w
Avoid SLS containing toothpaste driver in many cases, particularly gingival lesions
* Sensodyne Pronamel
* Kingfisher
good for occasional mild symp lesions
primary care management of persistent symptomatic lichen planus
Topical steroids (SDCEP as for Oral Ulcers)
* Beclomethasone MDI 0.5mg/puff – 2 puffs x 2-3 daily
* Betamethasone rinse – 1mg/10ml/2mins/twice daily
As and when pt needs
* Active and quiescence periods – advise pt that during good times there maybe no need for medication use, and should restart the topical steroid as soon as lesion starts to become symptomatic
beclomethasone MDI for oral ulceration/lichen planus
0.5mg/puff - 2 puffs x 2-3 daily
topical steroid, use in active periods
betamethasone rinse for oral ulceration/lichen planus
1mg/10ml for 2mins twice daily
topical steroid, use in active periods
hospital management of persisting symptomatic lichen planus
when simple tx have not proven effective in controlling pt symptoms
Higher strength topical steroids to the lesion (more active ingredient directed at it), can prevent need for systemic tx
Cream can be applied in a ‘veneer’ for gingival lesions using vacuum formed device to hold steroid cream for longer period, hard for it to adhere to
* ‘Skin’ Steroid Cream – CLOBETASOL or Synalar gel
* Topical tacrolimus – ointment or mouthwash
Hydroxychloroquine
* Effective immune modulator for both cutaneous and oral lichen planus
Systemic immunmodulators – needed for some cases, others not work
* Azathioprine, mycophenolate
what is the cause of this widespread lichenoid reaction
systemic
graft versus host disease (GVHD)
* pt had bone marrow transplant, transplant recognised host as foreign trying to reject – causing immunological damage
histologically
* similar to LP – lymphocytic band presenting along the BM and change in keratinisation and prickle cell layers
important to consider GVHD as systemic disease – presentation in mouth will be seen in other body tissues and organs and these can be harder to investigate – see pts on bone marrow transplant clinic assessed regularly by dental team to check for evidence of GVHD
* may need tx with systemic immune suppressants to tx and settle the disease - can result in oral lesions becoming quiescent and more reticular rather than disappearing altogether
if find palatal lichen planus lesions always consider
Lupus Erythematosis
discoids lupus when
solitary lesion present in oral mucosa
lupus LP lesion associated with systemic autoantibodies
systemic lupus erythematosus
* appears different from LP histologically – imp distinction that is found by biopsy
* Intense lymphocytic infiltrate is deeper in connective tissue and away from BM
management of a lichen-like lesion
Underlying disease needs consideration
* Oral disease may be asymptomatic
GVHD common after stem-cell transplant/bone marrow transplant
Lupus lesions can be: can be first presentation
* ONLY in the mouth (discoid lupus – no auto antibodies)
* Mouth and elsewhere (systemic lupus – ANA/Ro/dsDNA antibodies in the blood)
If ONLY oral symptoms
* Treat symptomatically as Lichen Planus (local tx alone may be necessary)
Liaise with physician regarding oral lesions in terms of overall context of pt health
* May persist even if systemic disease controlled
if only oral lichen lesions found
Treat symptomatically as Lichen Planus (local tx alone may be necessary)
Liaise with physician regarding oral lesions in terms of overall context of pt health
* May persist even if systemic disease controlled
