Oral Lichen planus and Lichenoid tissue reactions

Question 1

What is lichen Planus?

Answer 1

a common chronic immune mediated mucocutaneous disease
commonly affects
- oral mucosa
- skin - including nails and scalp
- ano-genital mucosa

can occasionally affect
- pharynx
- oesophagus
- conjucnctiva

Question 2

clinical problems associated with OLP and oral lichenoid lesions

Answer 2

very common
often painful
no cure
can be a manifestation of systemic disease
1% risk of malignant transformation over 10 years

Question 3

epidemiology of OLP/OLL

Answer 3

1% disease prevalence
- likely under-reported
slightly more common in females
no racial predilection

Question 4

OLP and OLL genetic links

Answer 4

associated with some HLA(human leukocyte antigen subtypes

Question 5

risk factors for OLP and OLL

Answer 5

stress
genetics
medication
dental materials
viral infections
chronic trauma
lupus
graft versus host disease
diabetes
hypertension
auto-immune diseases
nutritional defiency
sodium lauryl sulphate
- foaming agent in toothpaste

Question 6

OLP and OLL - social history risk factors

Answer 6

smoking increases risk of malignant change
alcohol - high alcohol associated with increased risk of malignancy
- betel nut
diet
- fruit and veg intake
low SES

Question 7

Dental history and OLP/OLL

Answer 7

regular attendee
does toothpaste contain SLS
denture use
plaque - can exacerbate symptoms

Question 8

clinical features of OLP and OLL

Answer 8

can present as
- white patch
- red patch
- erosion/ulcer
often combination of these

Question 9

types of lesions seen in OLP/OLL

Answer 9

reticular
atrophic
papular
erosive
plaque like
bullous

Question 10

reticular lichen planus/ OLL - clinical features

Answer 10

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

Question 11

Atrophic OLP/OLL clinical features

Answer 11

red mucosa
- due to thinning of mucous membrane
desquamative gingivitis can be classed as atrophic

Question 12

papular lichen planus clinical features

Answer 12

multiple white papules
uncommon

Question 13

erosive lichen planus clinical features

Answer 13

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

Question 14

plaque like lichen planus clinical features

Answer 14

a thickened white plaque

Question 15

bulbous lichen planus clinical features

Answer 15

uncommon
may be caused by superficial mucoceles
need to exclude blistering diseases as a cause of appearance

Question 16

Where in oral mucosa is affected by oLP/OLL

Answer 16

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

Question 17

management of OLP and OLL in general practice

Answer 17

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

Question 18

OLP and OLL - reasons for referral

Answer 18

symptomatic
unilateral/non-symmetrical distribution
any non-reticular lichen planus
unclear diagnosis
patient has other risk factors for malignant change
biopsy may be indicated

Question 19

OLP and OLL symptomatic relief

Answer 19

0.15% Benzydamine (Difflam) mouthwash or spray
- mouthwash for generalised
- spray for localised lesions

rinse or gargle every 16 hours as required
- usually for no more than 7 days

Question 20

OLP and OLL symptomatic relief - if benzydamine doesn’t work

Answer 20

bethamethasone 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

Question 21

what is required in a referral for OLP/OLL?

Answer 21

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

Question 22

OLP and OLL secondary care management

Answer 22

initially sam 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

Question 23

biopsy - risks

Answer 23

pain
bleeding
bruising
infection
altered sensation
- temp or permanent
sutures

Question 24

biopsy - benefits

Answer 24

confirms the diagnosis
- not always needed
may identify dysplasia
- highlighting a patient with increased risk of malignant transformation
can exclude vesiculobullous disorders

Question 25

types of biopsy

Answer 25

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

Question 26

Histological features of OLP/OLL

Answer 26

keratosis
hyperplastic epithelium
lymphocytes in epithelium
basal cell destruction
band-like lymphocytic infiltrate
epithelial atrophy or erosion

Question 27

Dental materials that can be linked to lichenoid contact reaction

Answer 27

mercury
nickel
palladium
gold
silver
tin
acrylics
GI
composite
chromium

Question 28

drug treatments for OLP/OLL in secondary care

Answer 28

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

Question 29

diseases linked to OLP/OLL and management

Answer 29

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

Question 30

malignant change in OLP - risk

Answer 30

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
be aware of
- increased severity
- new lesions
- new onset ulcers
- erythema
- lymphadenopathy
- dysphagia
- exophytic (outward growth) lesions