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OMPR > Oral Lichen Planus > Flashcards

Oral Lichen Planus Flashcards

1
Q

Diff Dx when you see white striae

A 
Differential Diagnosis:
• Oral Lichen Planus
• Oral Lichenoid Reactions
    – Oral Lichenoid Contact Lesions
    – Oral Lichenoid Drug Reactions
   – Oral Lichenoid Lesions of Graft vs Host Disease
• Systemic or Discoid Lupus Erythematosis
• Hepatitis C Infections
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2
Q

Epidemiology of OLP

A
  • Prevalence 1-2%
  • Occurs in middle-age
  • Slight predominance in females
  • No racial predilection
  • Approximately 60% are symptomatic.
  • When symptomatic, it is a sensitivity to spicy foods or acidic foods, pain (i.e. annoyance) felt when brushing, not necessarily needing pain killers but bothersome

• Most patients have intermittent symptoms over time (exacerbation/remission)

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3
Q

Oral Lichen Planus: Features

A

• Characteristic lacy
appearance, with radiating lines, most often in a reticular
appearance (Wickham’s striae),
• can be punctate
• can be plaque-like lesions (mistaken as a leukoplakia but histopathology will show OLP)
• White changes with associated erythema, ulceration, or
occasionally bullae will result in symptoms of burning &
sensitivity to acidic/spicy foods.
• BILATERAL
• BUCCAL MUCOSA MOST COMMON (but can be anywhere)
• 25% show extra-oral lesions
• No causative factor evident in history

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4
Q

With OLP, changes in pigmentation are caused by…?

A

Some pigmented changes (post inflammatory pigmentation) caused by Melanocytes secreting more melanin in response to inflammation

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5
Q

Erosive OLP

A

Erosive form of lichen planus (gingival lichen planus) described as:

  • Lacy
  • Radiating
  • Reticular
  • Wickham’s striae
  • Bilateral
  • Erosive
  • Ulcerative
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6
Q

Ulcerative OLP

A

Inflammation so significant that epithelium deteriorates
And ulcerates; LOTS OF PAIN; difficulty eating or drinking

Described as:

  • Lacy
  • Radiating
  • Reticular
  • Wickham’s striae
  • Bilateral
  • Erosive
  • Ulcerative
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7
Q

Extra-oral lesions of OLP

A

Itchy papules particularly on the back of the hands associated with lichen planus

Vulval lichen planus

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8
Q

Diagnosis of Oral Lichen Planus

A
  • Incisional biopsy is mandated to confirm diagnosis of OLP, to differentiate between OLP and lichenoid reactions, and to rule out dysplasia or carcinoma
  • Biopsy white changes on non-keratinized mucosae, not red nor ulcerated areas
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9
Q

Histopathology of OLP

A

• Dense subepithelial lymphocytic infiltrate
• Band like layer of inflammatory lymphocytes
• Severe basal cell destruction
• Increase in the number of intraepithelial lymphocytes
• Degenerating basal keratinocytes form colloid or
Civatte bodies, which appear as homogenous
eosinophilic globules
• Hemidesmosomes are disrupted, resulting in microscopic clefts between the epithelium and the connective tissue

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10
Q

One histology difference between OLP and Lichenoid Mucositis

A

In lichenoid mucositis there may be a mixed infiltrate

with perivascular infiltration

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11
Q

Pathogenesis of OLP

A

OLP is a CD-8 T-cell mediated response

1) Antigen-specific CD8+ T cells are activated in the OLP epithelium.
2) Activated Antigen-specific CD8+ T cells (CTL) trigger keratinocyte apoptosis, possibly via TNF-a secretion
3) activated CTL undergo intralesional clonal expansion and release soluble mediators (cytokines/chemokines) which stimulate lymphocyte extravasation from the local microvasculature and migration towards the epithelium
4) Recruited lymphocytes secrete MMP-9, which causes epithelial basement membrane disruption
5) Epithelial basement membrane disruption (i) facilitates the passage of lymphocytes into the epithelium and (ii) denies keratinocytes a cell survival signal, resulting in further keratinocyte apoptosis.

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12
Q

Malignant Transformation in OLP Patients

A

Higher risk than general population but still low

In a systemic review with 16 studies, 1% of OLP patients/year with an average age 61, females>malesClose surveillance needed

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13
Q

Oral Lichenoid Reactions

A

• Oral lichenoid contact lesions
– Amalgam or other metal contact sensitivity
– Foods/ flavoring
• Oral lichenoid drug reactions

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14
Q

Large Medication group Contributing to Lichenoid Rxns

A

ANTIHYPERTENSIVES

  • Atenolol
  • Enalapril
  • Hydrochlorothiazide
  • Methyldopa
  • Metoprolol
  • Thiazide Diuretics
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15
Q

Lichenoid Reactions: Features

A

White changes indistinguishable to OLP by
appearance alone
• If lichenoid reaction has a systemic cause, lesions
may be widespread (including extra-orally)
• Skin lesions are more common in lichenoid reaction
to drugs.
• If lichenoid reaction has a local cause the lesion will
generally be found at the site(s) of contact.
• Causative factor is evident in history: medication
use, dental restorations, oral habits, and food intake
is important.
• Lichenoid reactions may develop after exposure to a
medication for periods of >1 year

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16
Q

Diagnosis of Oral Lichenoid Reactions

A

• Incisional biopsy is mandated to
differentiate between OLP. Perivascular
mixed inflammatory infiltrate often seen.
• Histopathologist may use the term
“lichenoid mucositis”
• Biopsy white changes on non-keratinized
mucosae, not red nor ulcerated areas
• Patch testing to mercury or amalgam (or
other metals) is usually positive in patients
with lesions in close proximity to an
amalgam or metal-containing restoration.

17
Q

Treatments for OLP (RCTs)

A
  • Corticosteroids
  • Calcineurin inhibitors
  • Retinoids
  • PUVA
  • Oral Hygiene
  • Other treatments

….there is insufficient evidence to support the superior effectiveness
of any specific treatment

18
Q

What we do for OLP patients?

A

Dexamethasone Elixir or Solution 0.5mg/5ml
• Indicated for multiple or difficult to reach
lesions
– Disp: variable volumes
– Label: swish and spit with 5-10 ml for 5
minutes up to 4 times a day and expectorate

• Fluocinonide 0.05% gel or ointment (creams
are contraindicated)
• Indicated for easily accessible lesions/only a few lesions
– Disp: variable volumes (15-30g tubes)
– Label: rub in a thin film over areas 3x/day
(after meals and at bedtime)
– Do not use for more than 2 weeks

More severe cases/ pt not responding:
Ultra-Potent Corticosteroids
• Clobetasol or halobetasol gel or ointment 0.05%
– Disp: 15g tube
– Label: apply a thin film over area twice a day
– Do not use for more than 2 weeks
• Clobetasol may also be compounded into 0.05%
solution (not covered by insurance)

19
Q

Topical tacrolimus

A 
•  Calcineurin inhibitor
• Prevents T-cell activation
• Same family as cyclosporine A
• Comes as an ointment (0.03 or 0.1%)
• Tacrolimus may also be compounded into a 0.5mg/5ml
solution (not covered by insurance)
20
Q

Systemic Agents

A
  • OTC (curcumin 1500mg twice a day)
  • Prednisone
  • Mycophenolate Mofetil
  • Azathioprine
  • Others

OMPR (8 decks)

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