oral lichen planus presentation

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oral lichen planus presentation

  1. 1.  Lichen planus (LP) is derived from the Greek leichen meaning tree moss and the Latin planus meaning flat  Lichens are primitive plants composed of symbiotic algae and fungi  Planus in Latin for flat.  Term suggests flat fungal condition  Current evidence indicates –Immunologicaly mediated mucocutaneous disorder. Text book of oral medicine and radiology –ongole first edition
  2. 2. Erasmus Wilson first described LP in 1869, as a chronic disease affecting the skin, scalp, nails, and mucosa, with possible rare malignant degeneration. And is thought to affect 0.5 to 1% of the worlds population.  Francois Henri Hallopeau reported the first oral lichen planus (OLP)–related carcinoma in 1910. Thibierge first described the oral lesions symmetrically in 1893 Text book of oral medicine and radiology –ongole first edition
  3. 3.  WICKHAM 1895 described the characteristic appearance of whitish striae and punctuations that develop atop the flat surfaced papules Text book of oral medicine and radiology –ongole first edition cont.....
  4. 4. Definition Oral lichen planus (OLP) is defined as a common chronic immunological mucocutaneous disorder that varies in appearnce from keratotic to erythematous and ulcerative Lichen planus is relatively common disorder of the stratified squamous epithelia Wilson 1896 Duske and frick,1982: skully and El-kom1985
  5. 5.  Eisen D 2005 defined oral lichen planus as a relatively common chronic inflammatory disorder affecting the statified squamous epithelia  Lichen planus (LP) is a common disorder in which auto-cytotoxic T lymphocytes trigger apoptosis of epithelial cells leading to chronic inflammation. Oral LP (OLP) can be a source of severe morbidity and has a small potential to be malignant. Crispian Scully 2007 Text book of oral medicine and radiology –ongole first edition
  6. 6.  Inspite of extensive research ,exact etiology is still unknown  The most accepted and current data suggests that OLP is a T cell mediated inflammatory disease (Regezi et al., 1978) (Gilhar et al., 1989), (Porter et al., 1997) (Sugerman et al., 2002) in which there is a production of cytokines which leads to apoptosis  Auto cytotoxic CD8 and Tcells trigger apoptosis of oral epithelial cells.(eversole 1997 porter et al 1997 Abnormal recognition and expression of basal keratinocytes of epithelium as foreign antigens by langerhans cells Text book of oral medicine and radiology –ongole first edition
  7. 7.  Other possible theories include the genetic background ,where the weak association between HLA antigen and lichen planus was found by POWELL et al 1986 and roston 1994  Vincent et al 1990 ,soto araya et al 2004 reported the strong association of psychological factors like higher level of anxiety, greater depression and psychic disorders in patients with erosive lichen planus. Text book of oral medicine and radiology –ongole first edition
  8. 8. PREDISPOSING FACTORS  GENETIC BACKGROUND  AUTO IMMUNITY –ASSOCIATED WITH OTHER AUTO IMMUNE DISEASE  IMMUNODEFICIENCY  DRUGS  DENTAL MATERIALS  STRESS  HABITS pathogenesis of oral lichen planus j oral pathol med 2010 19;729_734
  9. 9. 1 •ANTIGEN SPECIFIC CELL MEDIATED MECHANISM 2 •NON SPECIFIC MECHANISM 3 •AUTOIMMUNE RESPONSE 4 •HUMORAL IMMUNITY PATHOGENESIS OF OLP The various mechanisms hypothesized to be involved in the immunopathogenesis are:
  10. 10. 1 •THE EPITHELIAL BASEMENT MEMBRANE 2 •MATRIX METALLOPROTENINASES 3 •CHEMOKINES 4 •MAST CELLS NON SPECIFIC MECHANISMS pathogenesis of oral lichen planus j oral pathol med 2010 19;729_734
  11. 11. Sugerman PB, Savage NW. Oral lichen planus: causes,diagnosis and management. Aust Dent J. 2002 ; 47:290-7
  12. 12. EPIDEMIOLOGY •Very common- 1% of population •In Indians 1.5%(average) •3.7% mixed oral habits •0.3% non users of tobacco •Risk more among who smoke and chew tobacco RACE Oral lichen planus affects all racial groups. SEX The female-to-male ratio for oral lichen planus is 1.4:1 Text book of oral medicine-burkete‟s 11th edition
  13. 13.  Oral lichen planus is invariably a disease that affects regions of the oral cavity bilaterally.  Oral lesions usually involve the posterior buccal mucosa, or less commonly the tongue and although any site can be involved palatal and sublingual lesions are not common
  14. 14. AGE- middle aged or elderly people MEAN AGE OF ONSET- 5 th decade of life rarely in young adults and children Lichen planus commonly affects 1-2% of the general population ,prevalance rate being 0.5to 2.2% 40% lesions occur on both oral and cutaneous surfaces, 35% occur on cutaneous surfaces alone,and 25% occur on oral mucosa alone Text book of oral medicine-burkete‟s 11th edition
  15. 15.  Cutaneous lesions of lichen planus (LP) are self-limiting and cause itching.  Appears as purple, pruritic ,polygonal, flat topped –flexor surfaces  Fine lace like network of white lines (whikam s striae) Text book of oral medicine-burkete‟s 11th edition
  16. 16. Louis frederic wickham described the presence of fine white or grey lines or dots seen on the top of the pruritic rash on the skin in lichen planus . These striae are popularly referred to as “WICKHAMS STRIAE or HONITON LACE” Text book of oral medicine and radiology –ongole first edition
  17. 17. CLINICAL MANIFESTATIONS SKIN LESIONS •Purple, pruritic and polygonal papules •May be discrete or gradually coalesce into plaques each covered by fine glistering scale •Bilaterally symmetrical •Increase in size if subjected to any irritation •Usually self limiting unlike the oral lesions lasting only one year or less Text book of oral medicine-burkete‟s 11th edition
  18. 18. •Initially red > purple or violaceous hue > a dirty brownish color •Periods of regression and recurrence •“ Koebner’s phenomenon”- skin lesions extend along the areas of injury or irritation (ISOMORPHIC RESPONSE) •Most often on wrist, forearms, knees, thighs and trunk •Face remains uninvolved
  19. 19. TYPES OF CUTANEOUS LICHEN PLANUS HYPERTROPHIC PLAQUES VESICULAR LICHEN PLANUS LICHEN PLANUS PEMPHIGOIDES
  20. 20. LICHEN PLANUS OF NAILS LICHEN PLANOPILARIS ACTINIC KERATOSIS (ON ARM)
  21. 21. ULCERATIVE LICHEN PLANUS OVERLAP SYNDROME
  22. 22. TYPES OF ORAL LICHEN PLANUS: The lichen planus can manifest in various clinical forms ANDREASENS 1968 have described the clinical types. They may be appearing as:  RETICULAR  PAPULES  PLAQUE LIKE  ATROPHIC  EROSIVE  BULLOUS Text book of oral medicine and radiology –ongole first edition
  23. 23.  Most common and most readily recognized form  Mostly on posterior buccal mucosa.  May not be seen on tongue ,less commonly in gingiva &lips  They are usually bilaterally seen.  Characteristic pattern of interlacing white lines (whikam s striae)  The striae often displays a peripheral erythematous zone ,which reflects the subepithelial inflammation • Lines are wavy and parallel • Reticular olp can sometimes be observed at the vermillion border 92% Text book of oral medicine-burkete‟s 11th edition
  24. 24.  The papular type of olp is usually present in the initial phase of the disease.  It is clinically characterized by small white dots,which in most occasions intermingle with the reticular form.  Sometimes the papular elements merge with striae as part of the natural course.  SIZE 0.5MM 11% Text book of oral medicine-burkete‟s 11th edition
  25. 25.  Plaque type olp shows a homogenous well demarcated white plaque often, but not always surrounded by striae.  Plaque type lesions may clinically be very similar to homogenous leukoplakia  Common in tobacco users  Single / multi focal 36% Text book of oral medicine-burkete‟s 11th edition
  26. 26. It is characterized by a homogenous red area.  smooth, poorly defined erythematus areas with or without peripheral striae Usually associated with Desquamative gingivitis ATROPHIC TYPE Text book of oral medicine-burkete‟s 11th edition 44%
  27. 27. Pain and burning sensation Keratotic changes combined with mucosal erythema Erythematous OLP requires a histopathologic examination in order to arrive at a correct When this type of lp is present in the buccal mucosa or in the palate striae are frequently seen in the periphery ATROPHIC TYPE Text book of oral medicine-burkete‟s 11th edition
  28. 28.  More significant for the patient because the lesions are usually symptomatic.  Atrophic areas with central ulceration of varying degree  Periphery of the atrophic regions is usually bordered by fine ,white radiating striae  Atrophy and ulceration are –gingival mucosa • Pain, burning sensation, bleeding, desquamative gingivitis • Pseudo membrane covered ulcerations with keratosis and erythema Text book of oral medicine-burkete‟s 11th edition 9%
  29. 29. BULLOUS TYPE Vesciculobullous presentation combined with reticular or erosive pattern Rare form characterized by large vesicles or bullae (4mm to 2cm) Lesions usually develop within an erythematus base, rupture immediately leaving painful ulcers Usually have peripheral radiating striae and seen on posterior part of buccal mucosa 1% Text book of oral medicine-burkete‟s 11th edition
  30. 30. Severe form with extensive degeneration and separation of epithelium from connective tissue Faint white zone resembling radiating striae seen at the junction with normal epithelium Commonly on buccal mucosa and vestibule More dysplasia and malignant transformation Text book of oral medicine-burkete‟s 11th edition
  31. 31.  They are the most disabling form of oral lichen planus  Clinically ,the fibrin coated ulcers are surrounded by an erythematous zone frequently displaying radiating white striae.  This appearance may reflect a gradient of the intensity of sub epithelial inflammation that is most prominent at the centre of the lesion. Text book of oral medicine-burkete‟s 11th edition
  32. 32. Buccal mucosa 80% Tongue 65% Lips 20% Gingiva,floor of mouth& palate 10% Text book of oral medicine-burkete‟s 11th edition
  33. 33.  Histopathology FIRST DESCRIBED BY DUBRENILL 1906 later revised by Shklar in 1972 ◦Hyper orthokeratinisation or hyper parakeratinisation ◦Thickening of granular layer ◦Acanthosis of spinous layer ◦Intercellular oedema in spinous layer ◦“ Saw-tooth” rete pegs ◦Liquefaction necrosis of basal layer- Max Joseph spaces ◦Civatte ( hyaline or cytoid) bodies ◦Juxta epithelial band of inflammatory cells ◦An eosinophilic band may be seen just beneath the basement membrane and represent fibrin covering lamina propria Text book of oral medicine-burkete‟s 11th edition
  34. 34. HISTOLOGICAL PICTURES Oral Lichen PlanusPallavi Parashar, BDS, DDS
  35. 35. Oral Lichen PlanusPallavi Parashar, BDS, DDS
  36. 36. World Health Organization diagnostic criteria (1978) of oral lichen planus (OLP) CLINICAL CRITERIA Presence of white papule, reticular, annular, plaque-type lesions,gray-white lines radiating from the papules Presence of a lace-like network of slightly raised gray-whitelines (reticular pattern) Presence of atrophic lesions with or without erosion, may also Bullae Correlation between clinical and histopathologic diagnoses of oral lichen planus based on modified WHO diagnostic criteria -Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:796-800)
  37. 37. HISTOPATHOLOGIC CRITERIA Presence of thickened ortho or parakeratinized layer in sites with normally keratinized, and if site normally non keratinized this layer may be very thin Presence of Civatte bodies in basal layer, epithelium and superficial part of the connective tissue Presence of a well-defined band like zone of cellular infiltration that is confined to the superficial part of the connective tissue,consisting mainly of lymphocytes Signs of „liquefaction degeneration‟ in the basal cell layer Correlation between clinical and histopathologic diagnoses of oral lichen planus based on modified WHO diagnostic criteria -Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:796-800)
  38. 38. Modified World Health Organization diagnostic criteria of OLP and OLL CLINICAL CRITERIA Presence of bilateral, more or less symmetrical lesions Presence of a lacelike network of slightly raised gray- white lines(reticular pattern) Erosive, atrophic, bullous and plaque-type lesions are accepted only as a subtype in the presence of reticular lesion else where in the oral mucosa In all other lesions that resemble OLP but do not complete the aforemented criteria, the term “clinically compatible with”should be used
  39. 39. HISOPATHOLOGIC CRITERIA Presence of a well-defined bandlike zone of cellular infiltrationthat is confined to the superficial part of the connective tissue,consisting mainly of lymphocytes Signs of liquefaction degeneration in the basal cell layer Absence of epithelial dysplasia When the histopathologic features are less obvious, the term“histopathologically compatible with” should be used
  40. 40. FINAL DIAGNOSIS FOR OLP OR OLL To achieve a final diagnosis, clinical as well as histopathologic criteria should be included OLP A diagnosis of OLP requires fulfillment of both clinical and histopathologic criteria The term OLL will be used under the following conditions: 1- Clinically typical of OLP but histopathologically only compatible with OLP 2- Histopathologically typical of OLP but clinically only compatible with OLP 3- Clinically compatible with OLP and histopathologically compatible with OLP
  41. 41.  CD8+ T cells are activated in OLP andCD8+ T cells co-localize with apoptotic keratinocytes  in OLP lesions. CD8+ cytotoxic T cells are known to trigger apoptosis of virally infected cells.  Herpes simplexvirus (HSV: human herpesviruses types 1 and 2) causes an acute gingivostomatitis, herpes labialis (cold sores)and recurrent intra-oral herpes. Oral lichen planus: Causes, diagnosis and managementAustralian Dental Journal 2002;47:(4):290-297
  42. 42. Varicella-zoster virus (VZV) human herpes virus 3causes chicken pox with oral ulceration in children and shingles with pain and oral ulceration in adults. Epstein-Barr virus (EBV) Human herpes virus 4 causes glandular fever (infectious mononucleosis) with associated sore throat and petechiae on the soft palate Oral lichen planus: Causes, diagnosis and managementAustralian Dental Journal 2002;47:(4):290-297
  43. 43. Cytomegalovirus (CMV: Human herpes virus is associated with aphthous-type oral ulceration Human papillomavirus (HPV) 6 and 11 It cause oral warts (squamous papilloma) and condyloma accuminatum whereas HPV 16 and 18 are associated with some oral squamous cell carcinomas The coxsackie RNA viruses may also infect the oral mucosa. Coxsackie A4 causes herpangina, coxsackieA10 causes acute lympho reticular pharyngitis and coxsackie A16 causes hand, foot and mouth disease
  44. 44.  Lichen planus is often associated with immune mediated diseases like  Alopecia areata  Dermatomyositis  Lichen sclerosis et atrophicus  Morphea  Myasthenia gravis  Ulcerative colitis  Primary biliary sclerosis Text book of oral medicine and radiology –ongole first edition
  45. 45.  GRINSPAN SYNDROME is the association of OLP with diabetes and hypertension.  GRAHAM LITTLE SYNDROME and VULVO- VAGINO- GINGIVAL SYNDROME are other syndromes associated with ORAL LICHEN PLANUS, in which there is mucosal involvement of gingival and genital region, usually of erosive type. Text book of oral medicine and radiology –ongole first edition
  46. 46.  OLP is considered a pre-malignant condition  The reported transformation rates vary from 0 .5 to 2%. Over a period of 5 years 1.Increased risk of oral squamous cell carcinoma 2.Frequency of transformation is low, between 0.3% an3% 3.Erosive and atrophic forms commonly undergo transformation Holmpstrup et al 1998
  47. 47. COMPLICATIONS  Oral lichen planus and its treatment may predispose people to oral C albicans super infection Patients with oral lichen planus may have a slightly increased risk of oral cancer,  Oral SCC in patients with oral lichen planus is a feared complication an controversial issue. Oral Lichen PlanusJ:ournal of Dental Sciences & Research 2:1: Pages 62-87
  48. 48.  Clinical aspect  Histopathological features  3 essential features 1. Hyperortho or para keratosis 2. Saw tooth rete pegs 3. Basal cell liquefaction degeneration  Additional features 1. T lymphocyte infilterate 2. Civatte or colloid bodies 3. Artificial tearing b/t epithelium and connective tissue.
  49. 49. Oral Lichen Planus is a diagnosis that demands careful correlation of the clinical setting with the results of routine biopsy examination.
  50. 50.  Lichenoid reaction  Oral leukoplakia  Frictional keratosis  Discoid Lupus Erythematosus  Chronic Ulcerative Stomatitis  Erythema multiformae  Pemphigus Vulgaris  Benign Mucous Membrane Pemphigoid DD for Oral Maxillofacial Lesions-Wood&Goaz
  51. 51. 1. LEUKOPLAKIA  known irritant factor  Clinical appearance  Histopathology
  52. 52. 2. LICHENOID LESION  Clinical appearance contact with restoration  Unilateral  Histopathology  Lesion resolve after withdrawal of agent.
  53. 53. 3.LUPUS ERYHTEMATOSUS  Well demarcated cutaneous lesions with round or oval erythematous plaques with scales and follicular plugging  Histopathology  Direct immunofluorescence  Butterfly like rashes over the cheeks and nose known as malar rash.
  54. 54. 4.PEMPHIGUS VULGARIS Nikolsky sign positive in pemphigus vulgaris Patient gives the recurrence history of bullae and vesicle formation
  55. 55. 5.BENIGN MUCOUS MEMBRANE PEMPHIGOID Eye involvement Mucosal blistering, ulceration, subsequent scaring Desquamative gingivitis is the most common manifestation and may be the only manifestation of the disease appearing bright red
  56. 56. It is typically clinically characterized by a white lesion without any red elements The lesion is observed in areas of the oral mucosa subjected to increased friction, or trauma caused by ,for example food intake. Lesion is non symptomatic
  57. 57. 7.ERYTHEMA MULTIFORMAE Bullae and vesicle formation Appear as a target or iris lesion More severe form of erythema multiformae is STEVEN JOHNSON SYNDROME Course of lesion is acute
  58. 58. 8.CHRONIC ULCERATIVE STOMATITIS Painful, exacerbating and remitting oral erosions, and ulcerations
  59. 59.  Biopsy of the lesion should be done to confirm the diagnosis  Erosive lichen planus may be examined histopathologically to assess for dysplastic features  Hypertrophic form of lichen planus resembles homogenous leukoplakia  In order to differentiate this condition from leukoplakia the lesion can be biopsied. Text book of oral medicine and radiology –ongole first edition
  60. 60. DIAGNOSTIC TESTS Direct immunofluorescence is useful in distinguishing OLP from other lesions, especially vesiculobullous lesions such as PV BMMP and linear immunoglobulin A (IgA) bullous dermatitis Direct immunofluoresence demonstates a shaggy band of fibrinogen in the basement membrane zone is 90 to 100 % cases Specimens for immunofluoresence should be stored in MICHEL”S BOUINS SOLUTION or normal saline and then sent to histopathology Indirect immunofluorescence studies are not useful in the clinical diagnosis of OLP. Serum test is negative Text book of oral medicine and radiology –ongole first edition
  61. 61. Periodic acid-Schiff (PAS)staining of biopsy specimens and candidal cultures or smears may be performed. Other Tests Skin patch testing may be helpful in identifying a contact allergy in some patients with oral lichen planus. Oral Lichen PlanusJ:ournal of Dental Sciences & Research 2:1: Pages 62-87
  62. 62.  Oral lichen planus is a chronic inflammatory disease.  The lesions of cutaneous lichen planus typically resolve within1-2 years, whereas the lesions of oral lichen planus are long lasting and persist for 20 years  Resolution of the white striations, plaques, or papules is rare.  Current immunosuppressiv etherapies usually control oral mucosal erythema, ulceration,and symptoms in patients with oral lichen planus with minimal adverse effects. Oral Lichen PlanusJ:ournal of Dental Sciences & Research 2:1: Pages 62-87
  63. 63.  Advise patients that oral lichen planus lesions may persist for many years with periods of exacerbation and quiescence  In the context of appropriate medical care, the prognosis for most patients with oral lichen planus is excellent. Oral Lichen PlanusJ:ournal of Dental Sciences & Research 2:1: Pages 62-87
  64. 64. PATIENT EDUCATION IN ORAL LICHEN PLANUS The importance of patient education in OLP has been reported.  The chronicity of oral lichen planus and the expected periods of exacerbation and quiescence  The aims of treatment,specifically the elimination of mucosal erythema, ulceration,pain, and sensitivity The possibility that several treatments may need to be tried  The potentially increased risk of oral cancer The possibility of reducing the risk of oral cancer . Oral Lichen PlanusJ:ournal of Dental Sciences & Research 2:1: Pages 62-87
  65. 65. Lichen planus like eruptions were first reported in military personnel in World War II who had been prescribed anti-malarial drugs. Since that time, a wide variety of drugs have been associated with precipitating lichen planus – like eruptions and this phenomenon has been termed lichenoid drug reaction. Lichenoid lesions may be unilateral, asymmetric and occur in uncommon sites and tend to be erosive. Histological examination may show a more diffuse lymphocytic infiltrate and more colloid bodies than in classic LP ORAL LICHENOID REACTION (OLR):
  66. 66.  Lichenoid reaction is a term used for lesions that resemble OLP clinically and histologically, but have an identifiable aetiology.  Precipitants include chronic graft verses host disease (cGVHD), some dental materials and a range of drugs  They may be a manifestation of disease like lupus erythematosus. Oral mucosal disease;British Journal of Oral and Maxillofacial Surgery 46 (2008) 15–21
  67. 67. Lichenoid reaction to the amalgam restoration on the buccal aspect of the molar tooth. This is an isolated response without the symmetrical distribution seen in typical OLP. Oral lichen planus: Causes, diagnosis and managementAustralian Dental
  68. 68. treatment
  69. 69.  General consideration  Achieve specific goal  Eliminate atrophic and ulcerated lesions  Allevate symptoms  Avoid mechanical trauma and irritation
  70. 70.  Absolutely there is no treatment for OLP  If no symptoms – no active treatment is needed except reassurance ,reviewed regularly.
  71. 71.  Corticosteroids  Retinoid  Grisofulvin  Cyclosporin
  72. 72.  More useful in management of OLP Topical corticosteriods  Systemic steroids are contraindicated or the patient refuses intralesional injections  Safer , long-term use needs follow up  Causes adrenal suppression  Secondary candidiasis
  73. 73.  These have great value when there is acute exacerbation of symptoms  Used in combinations with topical steroids  Adverse effects-GI upset, polyurea , insomnia Retinoids  First used for the treatment of asymptomatic reticulated lichenplanus  Tretinoin is the available Vit A 0.1% (applied locally).
  74. 74.  RETINOIDS  TOPICAL – 0.1% vit A  Rapid elimination but with relapse  0.1% isotretenoin gel  Tretenoin ointment – burning sensation and irritation  Systemic --- Etretinate 25 - 75 mg/day relapse after discontinuatuon
  75. 75. CYCLOSPORIN  Immunosuppressant reduces lymphokines  Reduces the proliferation and function of T- lymphocytes  Renal dysfunction GRISEOFULVIN  In treatment of erosive Lp when steroid is contraindicated or  When lesion is resistant to steroids.
  76. 76.  Its appropriate to use topical with intralesional preparations  Causes atrophy of tissues and secondary candidiasis
  77. 77.  DRUG THERAPY  Optimal dose, duration and true efficacy remain variable.  Corticosteroids  Topical 0.1% triamcinolone acetonide  Potent preparation --- 0.1% fluocinolone acetonide --- 0.05% fluocinonide  Orobase  Elixir form --- dexamethasome ---- triamcinolone ---- clobetasol
  78. 78.  SYSTEMIC STEROIDS  Reserved for recalcitrant LP  Daily dose of prednisone 40-80mg for initial 5-7 days – gradually withdrawal over 2-4 weeks  Alternate day administration.
  79. 79.  TACROLIMUS  Immunosuppressive – inhibit T cell activation  Tacrolimus ointment 0.1% - - penetrate oral mucosa  Local irritation  Relapse common  Potential carcinogen
  80. 80.  CYCLOSPORIN  Suppress T cell cytokine production  Solution of 100mg/ml --- bad taste, burningsensation , high cost  Alternative for initial control
  81. 81.  MISCELLANEOUS 1. ANTIFUNGAL  Topical clotrimazole 2. ANTIBIOTIC  2% auromycin mouth wash  Tetracycline mouth wash
  82. 82. Surgery Surgical excision, cryotherapy, CO2 laser, andND:YAG laser have all been used in the treatment of OLP.  In general, surgery is reserved to remove high-risk dysplastic areas. management of oral lichen planus Arch Iranian Med 2005; 8 (4): 252 – 256
  83. 83. Laser The 308 nm excimer laser has been used as a possible and additional method in the treatment of OLP.  Treatments are painless and well tolerated. Clinical improvement has been achieved in most patients. Excimer 308 nm lasers could be an effective choice in treating symptomatic OLP management of oral lichen planus Arch Iranian Med 2005; 8 (4): 252 – 256
  84. 84. PHOTOCHEMOTHERAPY In this method, clinician uses ultraviolet A(UVA) with wavelengths ranging from the 320 –400 nm, after the injection of psoralen. The use of PUVA therapy in OLP waits further evaluation in large controlled trails. In two studies ,UVA was applied to lesions, 2 hours after theinjection of psoralen. After 2 months, most of thelesions had been notably improved and the remission times ranged from 2 to 17 months One potential draw back of PUVA therapy is the risk of the squamous cell carcinoma (SCC) development in a condition with premalignant potential, management of oral lichen planus Arch Iranian Med 2005; 8 (4): 252 – 256
  85. 85. CONCLUSION OLP is a chronic condition that is immune mediated and is characterized by episodic exacerbations and remissions. It is known to be a T cell–mediated condition with predominantly cytotoxic CD8 T cells. A definite diagnosis of OLP is based ona combination of clinical and histologic findings. The cause of OLP remains elusive,and therefore the treatment goals are directed at alleviating related signs and symptoms Topical steroids are the first line of treatment of symptomatic OLP Regular and long-term follow-up of patients with OLP is recommended to evaluate for changes in the lesion and to screen for malignancies.
  86. 86.  Text Book of Oral Medicine-Burkete‟s 11th Edition  Text Book of Oral Pathology-Shafer-4th Edition  Text book of oral & maxillofacial pathology –Neville 3rd Edition  TEXT BOOK OF ORAL MEDICINE AND RADIOLOGY-ONGOLE  CAWSONS ORAL PATHOLOGY AND ORAL MEDICINE  TEXT BOOK OF ORAL PATHOLOGY .REGEZZI  SUGERMAN PB, SAVAGE NW. ORAL LICHEN PLANUS: CAUSES,DIAGNOSIS AND MANAGEMENT. AUST DENT J. 2002 ; 47:290-7  ORAL LICHEN PLANUS –REVIEW MOLLAOGLU .N BOMFS 2000  ORAL LICHEN PLANUS –REVIEW PETER JUNGELL 1990 JOPM
  87. 87. PATHOGENESIS OF ORAL LICHEN PLANUS J ORAL PATHOL MED 2010 VOL 39 729-734 CORRELATION BETWEEN CLINICAL AND HISTOPATHOLOGIC DIAGNOSES OFORAL LICHEN PLANUS BASED ON MODIFIED WHO DIAGNOSTIC CRITERIA -ORAL SURG ORAL MED ORAL PATHOL ORAL RADIOL ENDOD 2009;107:796-800) ORAL LICHEN PLANUS: CAUSES, DIAGNOSIS AND MANAGEMENTAUSTRALIAN DENTAL JOURNAL 2002;47:(4):290-297 ORAL MUCOSAL DISEASE;BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY 46 (2008) 15–21 ORAL LICHEN PLANUS: CLINICAL FEATURES, ETIOLOGY, TREATMENT AND MANAGEMENT; A REVIEW OF LITERATURE JODDD, VOL. 4, NO. 1 WINTER 2010
  88. 88. LICHEN PLANUS IS A DISEASE THAT IS NOT “CURED” IN THE USUAL SENSE OF THE WORD BUT MERELY “CONTROLLED”
  89. 89. THANK YOU

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