Oral Lichen planus and Lichenoid tissue reactions Flashcards
What is lichen Planus?
a common chronic immune mediated mucocutaneous disease
Lichen Planus can commonly effect…
oral mucosa
skin
- including nails and scalp
ano-genital mucosa
lichen planus can occasionally affect…
pharynx
oesophagus
conjunctiva
Similarities between lichen planus and oral lichenoid lesions
clinical lesions will look identical
very similar histopathological features
how do oral lichenoid lesions and oral lichen planus differ?
oral lichen planus: no specific identifiable aetiological factor
oral lichenoid lesions: an identifiable aetiological factor OR a manifestation of a systemic disease
clinical problems associated with OLP and oral lichenoid lesions
very common
often painful
no cure
can be a manifestation of systemic disease
1% risk of malignant transformation over 10 years
epidemiology of OLP/OLL
1% disease prevalence
- likely under-reported
slightly more common in females
no racial predilection
OLP and OLL genetic links
associated with some HLA(human leukocyte antigen subtypes
risk factors for OLP and OLL
stress
dental materials
SLS
medical conditions
medication
nutritional deficiency
chronic trauma
hypertension
conditions which are associated with an increased OLP or OLL risk
graft versus host disease
diabetes
lupus
auto-immune diseases
oral lichen planus immunopathogeneis
CD8+ T cell mediated destruction of basal keratinocytes
OLP and OLL - social history risk factors
smoking increases risk of malignant change
alcohol - high alcohol associated with increased risk of malignancy
- betel nut
diet
- fruit and veg intake
low SES
Dental history and OLP/OLL
regular attendee
does toothpaste contain SLS
denture use
plaque - can exacerbate symptoms
clinical presentaion of OLP and OLL
can present as
- white patch
- red patch
- erosion/ulcer
often combination of these
types of lesions seen in OLP/OLL
reticular
atrophic
papular
erosive
plaque like
bullous
reticular lichen planus/ OLL - clinical features
from latin ‘reticulum’ = small net
net like or network like pattern or lacy appearance
- white lines = striae
more likely to asymptomatic than other forms
more likely to spontaneously resolve
Atrophic OLP/OLL clinical features
red mucosa
- due to thinning of mucous membrane
desquamative gingivitis can be classed as atrophic
papular lichen planus clinical features
multiple white papules
uncommon
erosive lichen planus clinical features
erosion - similar appearance to an ulcer but resemble partial loss of the epithelium
- still termed erosive if here is an ulcer in OLP/OLL
more likely to be symptomatic
higher risk of malignant change
ulcers will be persistent
irregular pattern
lower biopsy threshold
plaque like lichen planus clinical features
a thickened white plaque/white patch
bullous lichen planus clinical features
uncommon
may be caused by superficial mucoceles
need to exclude blistering diseases as a cause of appearance
Where in oral mucosa is affected by oLP/OLL
OLP more likely to be bilateral/symmetrical
OLTR may be unilateral or disturbed near aetiological factor e.g. amalgam restorations
- variation if drug induced
buccal mucosa 80%
tongue 65%
palate and floor of mouth <10%
- rare
- consider underlying medical condition particularly Lupus
gingiva = presents as desquamative gingivitis
management of OLP and OLL in general practice
provide relevant information of the condition - if you are confident in diagnosis
provide symptomatic relief if needed
take clinical photographs
consider referral
PMPR and OHI - especially for desquamative gingivitis
consider changing amalgam restorations if in direct contact with isolated lesion
advise SLS free toothpaste
avoid trigger foods
OLP and OLL - reasons for referral
symptomatic
unilateral/non-symmetrical distribution
any non-reticular lichen planus
unclear diagnosis
patient has other risk factors for malignant change
biopsy may be indicated
OLP and OLL symptomatic relief
0.15% Benzydamine (Difflam) mouthwash or spray
- mouthwash for generalised
- spray for localised lesions
rinse or gargle every 1 1/2 hours as required
- usually for no more than 7 days
OLP and OLL symptomatic relief - if benzydamine doesn’t work
betamethasone 500 mcg soluble tablets
- fully dissolve tablet in 10ml water
- rinse for 5 minutes
- spit after rinsing
- do not swallow
- repeat up to 4x daily
no significant risks or interactions - little systemic absorption
may be associated with oral fungal infection
what is required in a referral for OLP/OLL?
detailed history
clinical findings
provisional diagnosis
a reason why it needs seen in specialist care
details of treatments tried
excellent clinical photos
referral; to oral medicine or local oral and maxillofacial surgery unit
OLP and OLL secondary care management
initially same as primary care
excellent history and examination
development of provisional and differential diagnosis
explanation to patient of the condition
biopsy consideration
clinical photos
if erosive or symptomatic:
- consider FBC, haematinics, oral rinse to rule out fungal infection
- skin antibody tests to exclude blistering disease
exclude systemic disease
manage symptoms
consider patch testing/stopping medications/changing restorations
biopsy - risks
pain
bleeding
bruising
infection
altered sensation
- temp or permanent
sutures
diseases linked to OLP/OLL and management
hepatitis C
- consider in high risk groups of patients with OLP and OLL
- readily treatable
lupus
- consider investigating for lupus if palatal distribution and systemic features consistent with lupus e.g. joint pain, fatigue, malar/butterfly rash
- biopsy
- anti-nuclear antibodies
- complement
- anti-dsDNA
graft versus host disease
- recent stem cell transplant
biopsy - benefits
confirms the diagnosis
- not always needed
may identify dysplasia
- highlighting a patient with increased risk of malignant transformation
can exclude vesiculobullous disorders
types of biopsy
incisional biopsy for H and E staining
incisional biopsy for direct immunofluorescence
- if wishing to exclude blistering disease
an incisional punch or free hand ellipse is generally appropriate
Histological features of OLP/OLL
keratosis
hyperplastic epithelium
lymphocytes in epithelium
basal cell destruction
band-like lymphocytic infiltrate
epithelial atrophy or erosion
Dental materials that can be linked to lichenoid contact reaction
mercury
nickel
palladium
gold
silver
tin
acrylics
GI
composite
chromium
drug treatments for OLP/OLL in secondary care
topical steroids - always first line
systemic steroids e.g. prednisolone
- to bring severe disease under control quickly
potent topical steroids
topical calcineurin inhibitors
hydroxychloroquine
azathioprine
- increased risk of infection
mycophenolate mofetil - increased infection risk
diseases linked to OLP/OLL and management
hepatitis C
- consider in high risk groups of patients with OLP and OLL
- readily treatable
lupus
- consider investigating for lupus if palatal distribution and systemic features consistent with lupus e.g. joint pain, fatigue, malar/butterfly rash
- biopsy
- anti-nuclear antibodies
- complement
- anti-dsDNA
graft versus host disease
- recent stem cell transplant
malignant change in OLP - risk
1% over 10 years
more common in erosive lesions
more common on lesions on tongue
debate if OLL more likely to transform than OLP
likely a gradual change
OLP malignant change - red flags to be aware of
- increased severity
- new lesions
- new onset ulcers
- erythema
- lymphadenopathy
- dysphagia
- exophytic (outward growth) lesions
extra oral lichen planus - management
advise patient to see GP
OLP/OLL histological features
