Oral lichenoid reactions Flashcards
What is lichen planus?
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
What is a key diagnostic feature of lichen planus histologically?
Parakeratosis
Patchy acanthosis
Thick lymphocytic band hugging the basement membrane
Elongation rete ridges
Civate bodies
What is the difference between ORAL LICHEN PLANUS and ORAL LICHENOID REACTION?
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.
Although LP is idiopathic, what are some theories as to what causes it?
Genetic pre-disposition
Physical and emotional stress
Localised skin disease - herpes zoster
Injury to the skin
Systemic viral infection - hep C
Contact allergy
Drugs
What are symptoms of oral lichen planus?
Often none
Sensitive to hot/ spicy food
Burning sensation in the mucosa
Where is the most common site for oral lichen planus?
Buccal mucosa
What is OLP termed when it is ONLY found on the gingivae?
Desquamative gingivitis
NOTE - similar clinical appearance to gingival pemphigoid and plasma cell gingivitis - histology tells the difference
Explain the management for gingival lichen planus?
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
What occurs in tongue lichen planus?
Dorsum of tongue usually idiopathic - loss of papillae and smooth tongue surface
Lateral aspect may have drug/ amalgam trigger
Easy biopsy site but painful
What is the conventional treatment of OLP and OLL?
Main way of treating is removal of cause
What are some typical medications that may cause OLL?
Ace inhibitors
Beta-adrenergic blockers
Diuretics
NSAID’s
DMARDs
What are typical OTC remedies for INTERMITTENT OLL?
CHX
Benzydamine mouthwash (DIFFLAM) - removes pain. Side effect stinging or numbness
What is the PRIMARY CARE for persistent symptomatic OLP and OLL + doses?
Corticosteroids - beclomethasone inhaler 0.5mg/ puff, 2 puffs 3x per dat.
Betamethasone rinse - 1mg/ 10ml, 2mins twice a day
What is SECONDARY CARE for OLP and OLL?
Clobetasol cream (corticosteroid)
Topical tacrimolius ointment or mouthwash
DMARD (hydroxychloroquine) tablets
Systemic immunomodulators
Which DMARDs are specifically associated with oral lichenoid reactions?
Penicillamine
Gold
Sulphasalazine
Describe appearance of reticular lichen planus?
Fine white striae crossing each other in the lesion - lacy pattern
Background mucosa may be normal or erythematous.
At what point does atrophic LP transform to erosive?
Where the atrophy extends to the point of having no epithelium at all to the point of ULCERATION = erosive
What are the different forms of lichen planus?
Reticular
Atrophic
Bullous
Erosive
Ulcerative
Erythematous
(first 4 most common)
Describe atrophic lichen planus?
Areas of erythematous lesion surrounded by reticular tissue
Yellow fibrinous covering over base of CT
What type of OLL are poorly responsive to standard steroid treatment?
Lichenoid drug reaction
How do you manage drug-induced OLL?
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
How to manage an amalgam related OLL?
If ASYMPTOMATIC - DO NOTHING
If not, replace with other filling material.
What is general management for lichenoid lesions?
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
What antibody is largely associated with lupus/ SLE?
Anti-Ro antibody
What must be considered when palatal lichenoid lesions are found?
Lupus must always be considered
What is GVHD?
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.
How does lupus erythematosis appear histologically?
Intense lymphocytic infiltrate is much deeper in the CT and away from the basement membrane
What is lupus called when it is found only in the mouth?
Discoid lupus - no auto antibodies
Histological signs of lichen planus?
Drop-shaped rete pegs
Parakeratosis
