OLP and lichenoid tissue reactions Flashcards
what is lichen planus
a common chronic immune mediated mucocutaneous disease
where can it commonly affect
- mucosa
-skin
-ano-genital mucosa
more rare
- pharynx
-conjunctiva
difference between OLP and OLL
- clinically look identical
- similar histopathological features
- OLP - no specific identifiable etiological factor
OLL- identifiable aetiological factor or manifestation of systemic disease
OLR ??
reaction - caused by drug or material
clinical problems associated with OLP and OLL
- very common
- often painful
- no cure
- can be a manifestation of systemic disease
- it has a 1% risk of malignant transformation over 10 years
epidemiology of OLP/OLL
- commonly presents between the ages of 30-65
- slight female predilection
- no racial predilection
genetics role in OLP/OLL
- association with HLA - which codes for how our immune system works
an association with genes encoded at Chromosome 6 (where MHC is encoded) and lichen planus
factors which increase OLP/OLL risk
- immune system - CD8 and 4
- genetic - HLA type
environment - trauma, stress, medication, restorative materials
immunopathogenesis of OLP
- dependent on adaptive immune responce
- CD8+ T cell mediated destruction of basal keratinocytes
- these cells activated in lymph node by antigen-presenting cells expressing MHC I
- they recognise an antigen presented on MHC I on basal keratinocytes
- upon recognition of antigen release of granzyme and perforin to disrupt the cell membrane leading to cell death
also release of TNF- alpha - influnce CD4+ T cells
risk factors for OLP/OLL
- stress
- genetics
- medications
- dental materials
- viral infection
- chronic trauma
- lupus - can present as a lichenoid lesion
- graft versus host disease
- diabetes
- hypertension
- autoimmune diseases
- nutritional deficiency - can exacerbate symptoms
- sodium lauryl sulphate - foaming agent in toothpaste
what things in social history increase malignancy risk
- smoking
- alcohol
-betel - low socioeconomic status
clinical features of OLP/OLL
white patch
- red patch - desquamative gingivitis
- erosion/ulcer
what are the types of OLP
what is reticular OLP
- reticular - net like pattern
-lacy appearance - asymptomatic
-spontaneously resolve
what is atrophic OLP
- red mucosa
- thinning of mucous membrane
- desquamative gingivitis
what is papular OLP
- multiple white papules
uncommon
what is erosive OLP
- erosions - similar appearance to an ulcer but resemble partial loss of epithelium
- if there is an ulcer in OLP/OLL it is still termed erosive
- symptomatic
- risk of malignant chance
- keep close eye
-irregular pattern
what is plaque like OLP
- thickened white plaque
- similar to white patches
what is bullous OLP
- uncommon
- superficial mucoceles
where is common in mouth for OLP/OLL
- bilateral/symmetrical
- buccal mucosa and tongue most common
- if OLTR - then might be near etiological factor
- if on palate and floor - consider lupus
differences in clinical features of OLP and OLTR
what to say to patient if diagnosed with OLP/OLL
- describe what it is
-non curable
-immune mediated - caused by - genetics, environment
- common
-range of TX - risk of malignant change
management of OLP and OLL
- clinical photos
- OHI and PMPR If desquamative
-change amalgam restorations - SLS free toothpaste
- refer
-symptomatic relief
when would you refer OLP/OLL
- symptomatic
- unilateral/non-symmetrical distribution
- any non-reticular lichen planus
- unclear diagnosis
- the patient has other risk factors for malignant change
- you think a biopsy is indicated
- on side of tongue lesion - always refer - high malignant potential
what is symptomatic relief for OLP/OLL
-benxydamine 0.15% MV or spray
- betamethasone MW 500mcg
if 1 highly localised lesion then beclomatasone 50 mcg inhaler
- hydrocortisone oromucosal tablet - 2.5mg
what is management of OLP/OLL in secondary care
- same as primary
- exclude systemic disease
- if symptomatic or erosive - FBC, haematinics , oral rinse to exclude final infection
risks of biopsy
- pain
-bleeding - swelling
- infection
-altered sensation
benefits of biopsy
- confirms diagnosis
- may identify dysplasia
- can exclude vesicuobullous
what are types of biopsy
- Incisional biopsy for H & e staining
- If wishing to exclude blistering disease also undertake incisional biopsy for Direct Immunofluorescence
- An incisional punch or free-hand ellipse is generally appropriate
what as histological features of OLP/OLL
- death of basal keratinocytes/liquefaction
- colloid bodies (sometimes called civatte bodies)
- band like lymphocytic infiltrate - almost exclusively T cells
- higher CD8+ T cell frequency
- acanthosis
- hyperparakeratosisi or hyperorthokeratosis
- saw tooth rete pegs
- epithelial atrophy or erosion
- ?features of dysplasia
management of OLP and OLL
- remove amalgam
- possible stop medication
- topical steroid
- potent topical steroid
-systemic steroids
-topical cacineurin inhibitors
-hydroxychloroquine
-azathioprine
-mycophenolate mofetil
what are names of some medications used for OLP and OLL
-topical steroids
-prednisolone (systemic steroid)
- potent topical steroids (cobetasol of flucocinolone)
- topical calcineurin inhibitors (tacrolimus)
- hydoxychloroquine
- azathioprine (DMARD)
what is considered in high risk groups of patients with OLP/OLL
hep C
if recent stem cell transplant what should be considered
GVHD
if palatal distribution of OLP and systemic features like joint pain and rash what should be considered
lupus
what blood tests can be done for lupus
- anti-nuclear antibodies
- biopsy
- anti-smith
- anti-dsDNA
- complement
- immunoglobulins and protein electrophoresis
what are white areas over skin lesions termed in LP
wickhams striae
risks of cancer in OLP/OLL
- increase in symptom severity
- new lesions
- new onset ulcers
- exophytic lesions
- erythema
- dysphagia
- lymphadenopathy
- erosive
-tongue lesions
