Oral lichenoid reactions

Question 1

What is lichen planus?

Answer 1

Ongoing inflammatory condition that affects the mucous membrane in the mouth. Lymphocyte activation that are attracted to the area to deal with a PERCEIVED threat.d
UNKOWN CAUSE

Question 2

What is a key diagnostic feature of lichen planus histologically?

Answer 2

Parakeratosis
Patchy acanthosis
Thick lymphocytic band hugging the basement membrane
Elongation rete ridges
Civate bodies

Question 3

What is the difference between ORAL LICHEN PLANUS and ORAL LICHENOID REACTION?

Answer 3

Clinically and histo-pathologically similar BUT
OLP - consequence of T cell mediated auto-inflammatory process to an UNKOWN antigen
OLR - caused by drugs, dental materials or dental plaque - KNOWN CAUSE.

Question 4

Although LP is idiopathic, what are some theories as to what causes it?

Answer 4

Genetic pre-disposition
Physical and emotional stress
Localised skin disease - herpes zoster
Injury to the skin
Systemic viral infection - hep C
Contact allergy
Drugs

Question 5

What are symptoms of oral lichen planus?

Answer 5

Often none

Sensitive to hot/ spicy food
Burning sensation in the mucosa

Question 6

Where is the most common site for oral lichen planus?

Answer 6

Buccal mucosa

Question 7

What is OLP termed when it is ONLY found on the gingivae?

Answer 7

Desquamative gingivitis

NOTE - similar clinical appearance to gingival pemphigoid and plasma cell gingivitis - histology tells the difference

Question 8

Explain the management for gingival lichen planus?

Answer 8

OH very important in settling the lesion - especially interdental.

Biopsy can be difficult for gingival lesions - risk of damaging attachment area of gingiva/ tooth.
Adherent attached mucosa may be damaged lifting from the bone

Question 9

What occurs in tongue lichen planus?

Answer 9

Dorsum of tongue usually idiopathic - loss of papillae and smooth tongue surface

Lateral aspect may have drug/ amalgam trigger

Easy biopsy site but painful

Question 10

What is the conventional treatment of OLP and OLL?

Answer 10

Main way of treating is removal of cause

Question 11

What are some typical medications that may cause OLL?

Answer 11

Ace inhibitors
Beta-adrenergic blockers
Diuretics
NSAID’s
DMARDs

Question 12

What are typical OTC remedies for INTERMITTENT OLL?

Answer 12

CHX
Benzydamine mouthwash (DIFFLAM) - removes pain. Side effect stinging or numbness

Question 13

What is the PRIMARY CARE for persistent symptomatic OLP and OLL + doses?

Answer 13

Corticosteroids - beclomethasone inhaler 0.5mg/ puff, 2 puffs 3x per dat.

Betamethasone rinse - 1mg/ 10ml, 2mins twice a day

Question 14

What is SECONDARY CARE for OLP and OLL?

Answer 14

Clobetasol cream (corticosteroid)
Topical tacrimolius ointment or mouthwash
DMARD (hydroxychloroquine) tablets
Systemic immunomodulators

Question 15

Which DMARDs are specifically associated with oral lichenoid reactions?

Answer 15

Penicillamine
Gold
Sulphasalazine

Question 16

Describe appearance of reticular lichen planus?

Answer 16

Fine white striae crossing each other in the lesion - lacy pattern
Background mucosa may be normal or erythematous.

Question 17

At what point does atrophic LP transform to erosive?

Answer 17

Where the atrophy extends to the point of having no epithelium at all to the point of ULCERATION = erosive

Question 18

What are the different forms of lichen planus?

Answer 18

Reticular
Atrophic
Bullous
Erosive
Ulcerative
Erythematous

(first 4 most common)

Question 19

Describe atrophic lichen planus?

Answer 19

Areas of erythematous lesion surrounded by reticular tissue
Yellow fibrinous covering over base of CT

Question 20

What type of OLL are poorly responsive to standard steroid treatment?

Answer 20

Lichenoid drug reaction

Question 21

How do you manage drug-induced OLL?

Answer 21

Need to assess benefit vs risk of stopping the drug - does benefit of stopping drug outweigh the risk to patient’s health
And the discomfort of symptoms

Question 22

How to manage an amalgam related OLL?

Answer 22

If ASYMPTOMATIC - DO NOTHING

If not, replace with other filling material.

Question 23

What is general management for lichenoid lesions?

Answer 23

Remove the cause - medication, restorations etc.
BIOPSY - essential if unclear if lesion is lichenoid

Blood tests - haematinics, FBC- note - associations between OLP and low haematinics

Symptomatic relief

Question 24

What antibody is largely associated with lupus/ SLE?

Answer 24

Anti-Ro antibody

Question 25

What must be considered when palatal lichenoid lesions are found?

Answer 25

Lupus must always be considered

Question 26

What is GVHD?

Answer 26

A systemic disorder that occurs when the graft’s immune cells recognize the host as foreign and attack the recipient’s body cells. Causes immunological damage in order to try and reject the host.
“Graft” refers to transplanted, or donated tissuee.g. bone marrow, and “host” refers to the tissues of the recipient.

Question 27

How does lupus erythematosis appear histologically?

Answer 27

Intense lymphocytic infiltrate is much deeper in the CT and away from the basement membrane

Question 28

What is lupus called when it is found only in the mouth?

Answer 28

Discoid lupus - no auto antibodies

Question 29

Histological signs of lichen planus?

Answer 29

Drop-shaped rete pegs
Parakeratosis