Note on Oral lichen planus

1. ORAL LICHEN PLANUS
IBRAHIM .A. ABU BAKR

2. INTRODUCTION
“Oral lichen planus is a chronic immunologic inflammatory
mucocutaneous disorder commonly found in oral cavity,
where it appears as white, reticular, plaque or erosive
lesions.”
Erasmus Wilson, 1869

3. ETIOLOGY IMMUNOLOGY
a. Due to cell mediated immune response
b. Due to auto-immunity
c. Immuno-deficiency
 GENETICS FACTORS
Reported in twins, families and husband and wife.
 INFECTIONS : Spirochaete
 DRUGS AND CHEMICALS
 PSYCHOGENIC FACTORS: stress,nervousness
 HABITS: chewers of tobacco,Betel nut chewers,smoking

4. CLINICAL FEATURESAGE: middle age and elderly(35-55yrs)
SEX: shows slight predilection for females
SITES: common sites are buccal mucosa and to lesser extent
tongue,lips,gingiva,floor of the mouth and palate.
 Patient may report with burning sensation of oral mucosa
 While taking hot or spicy food patient experienced discomfort
 Oral lesion is characterized by radiating white & gray velvety
thread like papules in linear,angular & retiform arrangement.
 Tiny white elevated dots are present on intersection of white
lines called “WICKHAM’S STRIAE”

5. CLINICAL FEATURES
Presents with various manifestation such as
‫٭‬ Reticular
‫٭‬ Papular
‫٭‬ Plaque
‫٭‬ Atrophic
‫٭‬ Ulcerative
‫٭‬ Bullous

6.  Most common
 Usually asymptomatic
 Usually consist of numerous
raised,thin,snowy-white lines,
which produce a lacework or a
reticular appearance.
 Commonly seen bilaterally in
buccal mucosa, tongue,
gingiva, mucobuccal fold or
multiple sites
Clinical features
RETICULAR PAPULAR PLAQUE ATROPHIC ULCERATIVE BULLOUS

7.  Whitish elevated lesions 0.5mm -
1mm in size, well seen on
keratinized areas of oral mucosa.
 Clinically characterized by small
pebbled white or gray.
 Most oftenly , papules are seen at
the periphery of reticular form
CLINICAL FEATURES
RETICULAR PAPULAR PLAQUE ATROPHIC ULCERAATIVE BULLOUS

8.  Seen as a homogenous well
demarcated white plaque
 Most common in smokers
 On cessation of smoking plaque
may disappear and convert to
reticular type
 Resemble homogenous oral
leukoplakia
 Dorsal surface of tongue is
mostly affected.
CLINICAL FEATURES
RETICULAR PAPULAR PLAQUE ATROPHIC ULCERATIVE BULLOUS

9.  Characterized by homogenous
red area on the oral mucosa
 Commonly affects the gingiva
or the buccal mucosa
 Commonly associated with
desquamative gingivitis
 Requires a histopathologic
examination in order to arrive
at diagnosis
CLINICAL FEATURES
RETICULAR PAPULAR PLAQUE ATROPHIC ULCERATIVE BULLOUS

10.  Most disabling of lichen planus
 Clinically – fibrin coated ulcers
surrounded by an erythematous
zone resembling radiating white
striae is frequently seen at the
junction where the erosive area
meets with the normal epithelium
 Sub epithelial inflammation -
most prominent at center of the
lesion
 Patient complain of severe pain
and burning sensation in the
mouth during food intake
CLINICAL FEATURES
RETICULAR PAPULAR PLAQUE ATROPHIC ULCERATIVE BULLOUS

11. CLINICAL FEATURES
RETICULAR PAPULAR PLAQUE ATROPHIC ULCERATIVE BULLOUS
 Rare form of lichen planus
 Small bullae or vesicles that rupture
easily, leaving painful, ulcerated
surface
 Usually have peripheral radiating
striae and these lesions are often
seen over the posterior part of the
buccal mucosa

12. DIFFERENTIAL DIAGNOSIS
LEUKOPLAKIA: men are more commonly
affected
Wickham’s striae are absent
CANDIDIASIS : pseudomembrane can be rubbed
off
PEMPHIGUS : acantholysis can be seen
histologically and LP striation are evident
LUPUS ERYTHEMATOUS :fleeky and feathery
appearance

13. DIAGNOSIS BASED ON CLINICAL FINDINGS
 LABORATORY DIAGNOSIS:
1.hyperkeratosis and hyperorthokeratosis
2.Acanthosis
3.Degeneration of basal cell layer
4.sawtooth appearance of rete pegs
5.presence of Civatte bodies
 IMMUNOFLUORESCENT STUDY: all forms of lichen
planus lesions are usually negative for IgG,IgA and
IgM antibodies but positive for fibrinogen.

14. MANAGEMENT
1.Removal of the cause
2.Chemotherapy
A. Steroids
In most patients steroids are commonly used
 Early Regimen
 1.Topical application of Triamcinolone acetonide
 2.Tabs prednisolone 5mg
 3.Inj methyl prednisolone 40mg

15. MANAGEMENT
 LATE REGIMEN
Earlier regimen is continued for 3 or more weeks.
Once a week intra-lesional injection of the following:
1. Tabs prednisolone 30mg/day for 1st week of 3weeks
2.Tabs prednisolone 15mg/day for 2nd week of 3weeks
3. Tabs prednisolone 5mg/day for 3rd week of 3weeks
B. Antifungal
1.Nystatin topical application
2. Ketoconazole TP
3. Clotrimazole oral troches 10mg 5times/day for 2wks

16. MANAGEMENT
C. Vitamin A analogue
Retinoids are useful in conjugation with topical
steroids because of their anti-keratinizing and
immuno-modulating effects.
D. Surgery
Indicated when conventional methods failed
E.Topical used of antiseptic mouthwashes should be
avoided.

17. TREATMENT PROTOCOL
Asymptomatic
Follow Up – 3 Month
SSYMPTOMATIC
follow up
RESPONSE RESPONSE
ANTIFUNGAL
THERAPY
no response
no response
POSITIVE
Check For Candidiasis
Biopsy
?
• Improve Oral
Hygiene
• Avoid Precipitating
Factors (Drugs,
Foods, Chemicals)
• Reassurance
TOPICAL STEROIDS
Triamcinolone acetonide
Betamethasone
Tacrolimus
Candida ve
follow up
Systemic Steroids
POSITIVE

18. PROGNOSIS
Malignant transformation ranges from 0.4% -
12.3%
Tobacco chewers are more prone to develop
malignant lesion