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Jc on oral lichen planus

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  • 1. Introduction  ORAL LICHEN PLANUS Latin- Flat Algae Like  “leichen ruber“- described by Hebra.  "lichen planus“- Erasmus Wilson (1869)  Wickham noted the punctuations and striae .  Age- 30-60 years  Females> males.  0.5-2% of the population.  It have premalignant potential and can progress to SCC(0.4%).  Resolves approximately in 1 year,  15% to 20% of cases follow a relapsing course Kaz, R.W., Brahim, J, and Travis,W.D.oral squamous cell carcinoma arising in a patient with long- standing lichen planus. Oral Surg Oral Med Oral Pathol 70: 282-285, 1990. Sarah A. Gary G. Systemic Treatment of Cutaneous Lichen Planus: An Update, Cutis. 2011;87:129-134.
  • 2.  Etiology  Cell-mediated immunologically induced degeneration of the basal cell layer of the epithelium.  Immunologically induced lichenoid lesion is the common denominator.  Stress, diabetes, hepatitis C, trauma, and hypersensitivity to drugs and metals  In response to a variety of agents (eg, drugs, chemicals, metals, and foods) “lichenoid” reactions to dental restorations,  Mouth rinses, antibiotics, gold injections for arthritis, and immunocompromised status such as graft-versus-host disease.
  • 3. Associated factors BaganJ, et al. Topical therapies for oral lichen planus management and their efficacy: a narrative review. Current Pharmaceutical Design, 2012, 18, 5470-5480.
  • 4. Clinical Features  Age- 5th decade  F>M  any oral mucosal site, mostly buccal mucosa.  Pain or discomfort, which interferes with function and with quality of life.  The prevalence rate 0.1 and 2.2%.  The frequency of malignant transformation ranges from 0.4% to 5.3% with the highest rate noted in erythematous and erosive lesions Rajendran R. Oral lichen planus. J Oral Maxillofac Pathol 2005;9(1):3-5
  • 5. Clinical Subtypes .  Reticular- lacelike keratotic mucosal configurations  Atrophic - keratotic changes combined with mucosal erythema  Erosive - pseudomembrane- covered ulcerations combined with keratosis and erythema  Bullous – rare- vesiculobullous presentation combined with reticular or erosive patterns  Reticular  Plaquelike  Erosive  Papular  Atrophic  Bullous  Papular form- Minute white papules which gradually enlarge and coalesce to form either a reticular, annular, or plaque pattern. Parashar P. Oral Lichen Planus. OtolaryngolClin N Am. 44 (2011) 89-107 Burkit’s oral medicine 11th edi
  • 6. Morphology Description Reticular Annular (a) Slightly elevated fine whitish lines (Wickham’s striae) lacelike pattern or a pattern of fine radiating lines or (b) Annular lesions- 'Ring-shaped' lesions, develop gradually from single small pigmented spots into circular groups of papules with clear, unaffected skin in the center.10% cases. Atrophic Inflamed areas of the oral mucosa covered by thinned red- appearing epithelium. Bullous Rare and may sometimes resemble a form of linear IgA disease. Ulcerative/ Erosive Complication of the atrophic process after trauma or ulceration. Symptomatic- mild burning to severe pain. Central area of erosion with yellowish fibrinous exudate surrounded by erythema. Burkit’s oral medicine 11th edi Paul C. Edward, oral lichen planus :clinical presentation and management,2002,68(8),494-99
  • 7. Differential diagnosis  Leukoplakia  Graft vs host ds  Discoid lupus erythematosus  Chronic candidiasis  Mucous membrane pemphigoid  Chronic cheek biting  Lichenoid reaction  Hypersensitivity mucositis  White sponge nevus  IgA reaction Paul C. Edward, oral lichen planus :clinical presentation and management,2002,68(8),494-99
  • 8. Treatment Many patients with oral lichen planus may not have any symptoms, in such cases there may be no need for active treatment except for reassurance and periodic check-ups. However, in many cases patients suffer from painful, erythematous, erosive or bullous lesions which have a slight predilection for transformation into oral squamous cell carcinoma. Thus, the principal aim of treating OLP would be to resolve the painful symptoms, the oral lesions and long-term follow-up to counter the chances of transformation into malignant lesions, especially for erosive and atrophic forms of OLP, which are more prone for transformation. G. Lodi,Current controvercies in OLP: report of an international consensus meeting, oral surg, oral path, oral med,2005;100:164-78
  • 9. Corticosteroids  The efficacy of corticosteroids for treatment of lichen planus is mainly attributed to its anti-inflammatory and immuno-suppressive. These can be used topically, intralesionally and systemically .  Topical corticosteroid therapy is usually the treatment of choice initially, as it can be effectively delivered to the lesion surface with minimal potential for systemic side effects.  flucocinonide,- 0.05%  clobetasol - 0.05% (Powercort cream, Clobenol cream),  Triamcinolone acetonide - 0.1% buccal paste form (Tess, Kenacort oral paste, Cortrima cream),
  • 10.  These agents are either applied topically or rinsed (if in the form of solution) 3-4 times/day after meal. Patients are advised not to eat or drink for 30 minutes thereafter.  Dexamethosone and betamethasone valverate. 0.05% gel,  They are prescribed as gels, creams, ointment with orabase (Kenalog in Orabase) or oral rinses.  Drugs which are available in orabase formulations are preferred because of their tenacity on the oral mucosa leading to better drug delivery. Carhere M, Gass E, Carranza M, et al. Systemic and topical corticosteroids treatment of oral lichen planus. J Oral Pathol Med 2003;32(6):323-29.
  • 11.  Intralesional corticosteroids are reserved for cases which do not respond to topical steroids.  10 to 20 mg of insoluble triamcinolone acetonide (Avcort injection, Comcort injection) is diluted with 0.5 ml saline or lidocaine 2% then injected into the lesion, which solubilize gradually and therefore have a prolonged duration of action. Silverman S Jr, Gorsky M, Lozda-Nur F. A prospective study of findings and management in 214 patients with oral lichen planus. Oral Surg Oral Med Oral Pathol 1991;72:665-70.
  • 12.  Systemic corticosteroids are indicated for short period when fail to respond to topical steroids.  Prednisone (Wysolone) 40 to 80 mg daily for less than10 days without tapering is advised  hydrocortisone 20 mg tab or triamcinolone 4 mg tab orally max 50 mg/day for five days.  If corticosteroids are used for prolonged therapy, they should not be stopped abruptly. If done so, it can flare up the underlying disease for which steroids were prescribed and cause acute adrenal insufficiency because of HPA axis suppression. Carhere M, Gass E, Carranza M, et al. Systemic and topical corticosteroids treatment of oral lichen planus. J Oral Pathol Med 2003;32(6):323-29.
  • 13.  combinations of more than one topical corticosteroid may be effective Systemic steroids and immunosuppressants prescribed for more severe cases would include:  Dexamethasone (Decadron) elixir 0.5 mg/5 ml Disp: 320 ml For 3 days, rinse with 1 tablespoonful (15 ml) qid and swallow. For 3 days, rinse with teaspoonful (5 ml) qid and swallow. For 3 days, rinse with 1 teaspoonful (5 ml) qid and swallow every other time. Rinse with 1 teaspoonful (5 ml) qid and expectorate. Or  Prednisone tablets 10 mg Disp: 26 tablets Take 4 tablets in the morning for 5 days, then decrease by 1 tablet on each successive day. 5days- 4 tab6th day 3 tab7th day 2tab8th day 1tab Or – Prednisone tablets 5 mg Disp: 40 tablets Take 5 tablets in the morning for 5 days, then 5 tablets in the morning every other day until gone. 5 days 5 tab7th, 9th, 11th day….
  • 14. Retinoids  Systemic and topical retinoids have been employed to treat OLP.  Retinoids have antikeratinizing and immunomodulating effects.  Retinoids include the natural compounds and synthetic derivatives of retinol that exhibit vitamin A activity.  Retinoids were synthesized by making minor structural changes.  First generation compounds include retinol, tretinoin and isotretinoin.  Second generation retinoids are synthetic analogs, which include etretinate and acitretin.  Third generation retinoids include arotinoids, which currently are in development.
  • 15.  As compared to systemic retinoids, topical retinoids are preferred and generally produce good Results.  Tretinoin is available in the form of 0.05% cream (Retino- A, Airol ).  Isoretinoin is available as 0.05% gels (Sotret, Acno). Buajeeb W, Kraivaphan P, Pobrurksa C. Efficacy of topical retinoic acid compared with topical flucinolone acetonide in the treatment of oral lichen planus. Oral Surg Oral Med Oral Pathol 1994;83:21-25.
  • 16. Cyclosporin  Cyclosporin is a very commonly used immunosuppressive drug which belongs to a family of cyclicpolypeptides derived from the fungus Tolypocladium inflatum.  It is basically used to prevent rejection in organ transplantation. It inhibits chronic inflammatory reactions by inhibiting T-cell activation and proliferation, also inhibits lymphokine production and release of interleukin-2.
  • 17.  Topical ciclosporin can be used either in the form of mouthwashes or in the form of adhesive base.  Patients are advised to swish and spit 5 ml of medication (l00 mg /ml) three times daily for 8 weeks or 0.025% cyclosporin in an adhesive base to apply four times daily, in some cases systemic cyclosporin has been suggested.  orally-administered formulation, (Neoral), is available as a solution and as soft gelatin capsules (10 mg, 25 mg, 50 mg and 100 mg).  (Immusol, Imusporin) 100 mg/ml oily solution (Katzung) and 100 mg/ml oral rinse (Sandimmune)  Systemic- 8mg/kg/day Buajeeb W, Kraivaphan P, Pobrurksa C. Efficacy of topical retinoic acid compared with topical flu. acetonide in the treatment of oral lichen planus. Oral Surg Oral Med Oral Pathol 1994;83:21-25.
  • 18. Levamisole Levamisole was developed in 1966 as an antihelmentic drug, but has immunoregulating properties. Mechanism of action of Levamisole has been found to Immunomodulate or immunopotentiate T-cell mediated immunity. Dose- Levamisole is administered at a dose of 50 mg three times/day for three consecutive days per week for 4 to 6 weeks. Levamisole (Ergamisol, Vermisol) is available as 50 mg,150 mg tab. Lu Sy, Chen WJ, Eng HL. Dramatic response to levimisole and low dose prednisolone in 23 patients with oral lichen planus. Oral Surg Oral Med Oral Pathol 1995;80:705-09.
  • 19. Azathioprine  Azathioprine is a purine antimetabolite.  It has anti-inflammatory properties and decreases antibody production.  Azathioprine is reserved for patients who do not respond to other treatment modalities. It can also be used in combination with corticosteroids and cyclosporin.  When used in combination with corticosteroids, azathioprine can effectively enhance corticosteroid immunosuppressive activity.  Thus, a lower dose of prednisone is required to achieve clinical efficacy and thereby diminishing adverse effects of corticosteroids.  Azathioprine (Imuran, Azoprin)- 50 mg tab. started at 50 mg/day and can be escalated up to 150 mg/day.
  • 20. Tacrolimus  Tacrolimus is a macrolide form of immunosuppressant derived from a type of bacterium, Strepto. tsukubaensis. It inhibits the transcription of interluekin-2 and transduction of signal to T-lymphocyte, and thus effectively causing immuno-suppresion.  Its systemic use is comparable to corticosteroids but topical applications of 0.1% tacrolimus is proved to be far superior in treating of symptoms of oral lichen planus than 0.05% clobetasol.  Recent studies by application of tacrolimus ointment 0.1% four times daily for 4 to 8 weeks resulted in faster resolving of symptoms in oral lichen planus as compared to topical corticosteroid application.  Topical- 0.1 to 0.3% (Tacroz Forte). Corrocher G, Di Lorenzo G, Martenelli N, et al. Comparative effect of tacrolimus 0.1% ointment and clobetasol 0.05% ointment in patients with oral lichen planus. J Clin Periodontol 2008;35:244-49.
  • 21. Dapsone  Dapsone should be considered in resistant cases of erosive OLP.  It has anti-inflammatory and immune-modulatory effects.  It is available as 5% gel (Acnesone) 25, 50 and 100 mg tab(Dapsone).  Dose - 100 mg orally in divided doses and may be increased at the rate of 50 mg/day per week to a maximum of 300 mg/ day. Giovanni Lodi, et al. Current controversies in oral lichen planus: Report of an international consensus meeting. (Part 2). Clinical management and malignant transformation. Oral Surg Oral MedOral Pathol Oral Radiol Endod 2005;100:164-78.
  • 22. Interferon  Topically applied gel preparation containing human fibroblast interferon and interferon-alpha have suggested to improve erosive OLP. Development and exacerbation of OLP during and after IFN- alpha therapy for HCV infection have been reported, although systemic IFN-alpha (3-10 million IU thrice weekly) is successfully used to treat OLP in patients with and without HCV infection.  It is available as vials (Roferon-A) and syringes (Intafla-PF)
  • 23. Mycophenolate Mofetil  It is an immunosuppressant used in treatment of patients with transplants.  It is available as 250 and 500 mg tablets (Baxmune) and 200 mg/ml suspension (Cellcept). Thalidomide  It has been documented to have anti-inflammatory action in cases of auto- immune disease  Use of thalidomide as a regular line of treatment is not recommended, unless all other treatment options have been exhausted. Its role in teratogenicity has to be remembered at all times.  Available as 100 mg capsules (Oncothal) Dalmau J, Puig L, Roé E, Peramiquel L, Campos M, Alomar A. Successful treatment of oral erosive lichen planus with mycophenolate mofetil. J Eur Acad Dermatol Venereol 2007;21(2):259-60. Macario-Barrel A, Balguerie X, Joly P. Treatment of erosive oral lichen planus with thalidomide (French). Ann Dermatol Venereol 2003;130:1109-12.
  • 24. PUVA Therapy  Photosensitizing psoralen drug and UVA  radiation was introduced as a new therapy for oral mucosal lesions in 1987 by Jansen et al.  Psoralens belong to the furocoumarin class of compounds, which are derived from fusion of a furan with a coumarin.  Four psoralens are used in PUVA therapy—psoralen, 5 methoxy psoralen (Bergapten), 8-methoxypsoralen (Methoxsalen) and 4, 5, 8-trimethyl psoralen (Trioxsalen). Ultraviolet irradiation in combination with psoralens modulates the function of the cells of the immune system.  Psoralen(topical or systemic sensitizer)+ UVA(320-400nm) exposure
  • 25. Nontherapeutic Options  Photodynamic Therapy  Photodynamic therapy is a technique that uses a photosensitizing compound activated at a specific wavelength of laser light to destroy the targeted cell via strong oxidizers, which cause cellular damage, membrane lysis and protein inactivation. It may have immunomodulatory effects and may induce apoptosis.  Methylene blue can be administered topically and orally and it may be a preferred choice for superficial lesions in skin and oral cavity. The fact that methylene blue has a strong absorption at wavelength longer than 620 nm, where light penetration into tissue is optimal, has led to the use of methylene blue as a promising candidate for PDT.
  • 26. Surgery and Lasers  Surgical excision, cryotherapy, CO2 laser and ND:YAG laser have all been used in the treatment of OLP.  In general, surgery is reserved to remove high-risk dysplastic areas.  Excimer 308 nm laser is an effective choice for treatment of OLP cases as it is well tolerated and painless when used.
  • 27. Maintainance  Avoidance of precipitating factors like spicy or acidic foods, tissue trauma, and xerostomia- inducing agents.  A "magic mouthwash" containing benadryl, kaopectate (or carafate), and milk of magnesia as a base to which nystatin and/or lidocaine may be added for maintenance therapy.  When pt is not responding to corticosteroid and triamcinolone CO2-LASER- lessens pain and burning sensation, no recurrence upto 1 yr. De magalhaes,, removal of OLP by CO2- LASER, Brazilian dent j.2011;22(6);522-6
  • 28. HEPATITIS C VIRUS INFECTION AND ORAL LICHEN PLANUS Hepatitis C Virus (HCV) may be an etiologic factor in OLP., The characteristic band like lymphocytic infiltrate might thus be directed toward HCV infected cells. Whether HCV infected patients have increased risk of developing OLP or patients with OLP have enhanced risk of developing HCV infection is yet to be answered. The putative pathogenetic link between OLP and HCV still remains controversial and needs a lot of prospective and interventional studies for a better understanding
  • 29. Sharma et al. Erosive Oral Lichen Planus and its Management: A Case Series, J Nepal Med Assoc 2008;47(170):86-90  Topical corticosteroids are the mainstay in treating mild to moderately symptomatic lesions, include 0.05% betamethasone valerate gel, 0.05% fluocinonide gel, and 0.1% triamcinolone acetonide ointment.  The prophylactic use of a 0.2% Chlorhexidine gluconate rinse may help reduce the incidence of fungal infection during corticosteroid therapy.  The depth of thermal damage for the CO2 laser extends from 50 to 100μm compared to 200 μm for Argon and 600 μm for the Nd: YAG laser.19 Therefore, one can expect a lower risk with CO2 laser to the periosteum and the underlying bone.
  • 30.  A double blind study of 28 pt with severe oral lichen plnus treated with etretinate(75 mg daily) or a placebo for 2 mths, showed that the retinoid had a marked beneficial effect. Kjell H. Hakan M. Severe oral lichen planus: treatment with an aromatic retinoid, BJD, 2006, 23(5), 121-26
  • 31. López J, Roselló Llabrés X, Cyclosporine A, an alternative to the oral lichen planus erosive treatment. Bull Group Int Rech Sci Stomatol Odontol.1995;38(1-2):33-8.  Presented a double-blind study in two groups afflicted with erosive oral lichen planus of long evolution and resistant to other treatments.  In the group A he used mouthwashes with a 5 ml Cyclosporine A solution to a 10% in olive oil of 0.4 degrees of acidity for 5 minutes, tds for 8 weeks.  In the control group he used acetonide of triamcinolone 01% in aqueous solution.  After 2 weeks, Patients in group A improved considerably in their symptomatology in a 90% against a 60% in group B.
  • 32. Neeta Misra, Efficacy of diode laser in the management of oral lichen planus, BMJ Case Reports 2013; doi:10.1136/bcr-2012-007609  The patient with OLP lesions was treated using diode laser (940 nm) for the symptomatic relief of pain and burning sensation.  The patient was assessed before, during and after the completion of the treatment weekly. The treatment was performed for 2 months and the patient showed complete remission of burning sensation and pain.  The follow-up was performed for 7 months and no recurrence of burning sensation was found.
  • 33. According to naturalnews.com Aloe vera  A controlled trial published in the British Journal of Dermatology confirmed empirical findings that aloe vera can effectively treat mouth ulcers associated with oral lichen planus.  Patients who were given aloe vera topical applications reported 50% improvement in symptoms and 33% of them reported that burning pain in the mouth disappeared. Sciencedaily.com also supports the use of aloe vera to alleviate the discomfort associated with oral lichen planus.  Aloe vera contains anthraquinones, chemical compounds that promote healing and arrest pain because of their anti-inflammatory nature.
  • 34. Bee Propolis  Bees use propolis, a natural resin found in young tree buds; remetabolize it with their own nectar secretions to make a sealant to build their hives. Bee propolis contains antimicrobial properties that are effective in killing bacteria. Extracts of propolis can inhibit the growth of bacteria, including Staphylococcus aureus, the cause of deadly infections in hospital.  It is not only effective in fighting cavities, gingivitis, periodontal disease, and reducing plaque buildup and bad breath, but it can also kill bacteria and bring relief to oral lichen planus sufferers.
  • 35. Petruzzi M, Lucchese A, Topical retinoids in oral lichen planus treatment: an overview. Dermatology. 2013;226(1):61-7.  Reviewed Sixteen studies (280 OLP patients topically treated with different classes of retinoids) and concluded that topical Isotretinoin was the most frequently employed retinoid in the treatment of OLP. Particularly keratotic form better responds than erosive form.
  • 36. G. Lodi,Current controvercies in OLP: report of an international consensus meeting,oral surg, oral path, oral med,2005;100:164-78
  • 37.
  • 38. 12 months) Atrophic Topical, flucocinonide,- 0.05% clobetasol - 0.05% (Powercort cream, Clobenol cream), Triamcinolone acetonide - 0.1% buccal paste form (Tess, Kenacort oral paste), 20-40mg Intralesional 10 to 20 mg triamcinolone acetonide (Avcort inj) + 0.5 ml saline or lidocaine 2% Asymptomatic-Lycopene retinoids Symptomatic- steroids Oral prednisone (recurrence) Dapsone (50-150 mg daily) Resistant -ciclosporine Azathioprine Levamisole Tacrolimus Interferon Not needed Avoidance of predisposing factors "magic mouthwash“ milk of magnesia + nystatin and/or lidocaine. Bullous Erosive Same as above Same as above PUVA Psycho- therapy Surgery, cryotherapy, LASER Same as above
  • 39. Antioxidents & follow up Symptomatic-Topical, flucocinonide,- 0.05% clobetasol - 0.05% (Powercort cream) Triamcinolone acetonide - 0.1% paste form (Tess, Kenacort oral paste), 20-40mg steroids Oral prednisone (recurrence) Dapsone (50-150 mg daily) without symptoms Intralesional 10 to 20 mg triamcinolone acetonide (Avcort inj) + 0.5 ml saline or lidocaine 2%Systemic- Steroids prednisone (recurrence) Dapsone (50-150 mg daily Resistant – ciclosporine Azathioprine Levamisole Tacrolimus Interferon PUVA Psychotherapy Surgery, cryotherapy, LASER Avoidance of predisposing factors "magic mouthwash“ milk of magnesia + nystatin and/or lidocaine Antioxidents & follow up With symptoms