Oral lichen planus (OLP) is a chronic inflammatory disease that causes bilateral papules, striations or plaques in the mouth. It predominantly affects adults over 40 years old and has a female to male ratio of 1.4:1. There are several types of OLP lesions including reticular, erosive, and plaque-like lesions. A T-cell mediated immune response triggers keratinocyte apoptosis in OLP lesions. Histological examination of biopsy samples is used to diagnose and differentiate OLP from other conditions. Treatment aims to reduce symptoms and involves topical corticosteroids, systemic steroids, or immunosuppressants like tacrolimus ointment.

1. ORAL LICHEN
PLANUS
Presented by-
Ishita Singhal
(Intern)

2. INTRODUCTION
• Oral Lichen Planus
A chr onic inf lammat or y disease t hat causes
bilat eral papules, st riat ions or plaques
May cause eryt hema, erosions and blist er s
Found on buccal mucosa, t ongue and gingiva
Female: Male r at io: 1.4:1
Pr edominant ly seen in adult s over 40 year s.
0.5% t o 2% of gener al populat ion
Af f ect s all et hnicit ies

3. Plaque-like OLP Reticular OLP
Erosive OLP Reticular OLP

4. PATHOGENESIS OF
RETICULAR L.P.
Or al Lichen planus is a pur ely T cell mediat ed
inf lammat or y r esponse. Ther e are no B cells, plasma
cells and no deposit s of immunoglobulin or
complement .
The t r igger f or ker at inocyt e apopt osis in OLP is,
f or t he most part , unknown. However, t he
lymphocyt ic inf ilt rat e in OLP is composed almost
exclusively of T cells, and t he maj or it y of T cells
wit hin t he epit helium and adj acent t o damaged basal
ker at inocyt es are act ivat ed CD8+ lymphocyt es.
Ther ef ore, it is very pr obable t hat cyt ot oxic T cells
t r igger ker at inocyt e apopt osis in OLP.

5. PROPOSED
IMMUNOPATHOGENESIS
OF OLP
A lichen planus-specif ic ant igen is expr essed in
conj unct ion wit h MHC class 1 molecules on ker at inocyt es
at t he OLP lesion sit e.
Ant igen specif ic CD8+ T cells ar e act ivat ed in t he ar ea.
Act ivat ed ant igen-specif ic CD8+ cyt ot oxic T
lymphocyt es t r igger ker at inocyt e apopt osis, possibly by
secr et ed TNF-α.
The act ivat ed T lymphocyt es under go int r a-lesion clonal
expansion and r elease soluble mediat or s (cyt okines and
chemokines), which r ecr uit lymphocyt es f r om t he local
micr ovasculat ur e and cause migr at ion t owar d t he
epit helium.

6. This hypot hesis predict s t hat t he maj orit y of
lymphocyt es recruit ed t o t he OLPlesion sit e are not
specif ic f or t he lichen planus-specif ic ant igen. However,
t hey may cont ribut e t o t he pat hogenesis of OLPby
secret ing MMP-9, which leads t o epit helial basement
membrane disrupt ion.
Epit helial basement membrane disrupt ion allows f or t he
passage of lymphocyt es int o t he epit helium and denies
kerat inocyt es a cell survival signal, result ing in f urt her
kerat inocyt e apopt osis.
This hypot hesis predict s t hat t he earliest event s in OLP
lesion f ormat ion are conf ined t o t he epit helium and t hat
basement membrane and connect ive t issue changes occur
secondarily.

7. CLINICAL
PRESENTATION
Or al lesions-mor e persist ent and r esist ant t o
t r eat ment t han skin lesions
30-50% of pt s also have cut aneous lesions
Thr ee common t ypes
 Ret icular
 Er osive
 Plaque
Var iant s of Plaque and Erosive t ypes
 At r ophic
 Bullous

8. CLINICAL
PRESENTATION
Ret icular lesions
Most common t ype
I nt erlacing whit e kerot ot ic lines wit h
eryt hemat ous border s (Wickham’s st riae)
Typically bilat erally on buccal mucosa,
mucobuccal f old and gingiva
Less common on t ongue, palat e and lips
Asympt omat ic

9. Erosive lesions
2nd
most common t ype
Mix of er yt hemat ous and ulcer at ed ar eas
surr ounded by radiat ing ker ot ot ic st r iae
Similar appearance t o candidiasis, pemphigus and
lupus
Lesions t end t o migrat e and of t en mult if ocal
Most ly buccal mucosa and vest ibule
Symptomatic:
 Sore mout h sensit ive t o heat , cold, spices, and alcohol
 Pain and bleeding on t ouch
Plaque lesions
Resemble f ocal leukoplakias
Var y f rom smoot h f lat ar eas t o r aised ir r egular
plaques
Of t en mult if ocal
Dorsum of t ongue and buccal mucosa

10. Variants of Erosive and Plaque lesions
Atrophic
 Dif f use, eryt hemat ous pat ches
 Causes signif icant discomf ort
 Gingiva and buccal mucosa
Bullous
 I nt raoral bullae on buccal mucosa and lat eral surf ace
of t ongue
 Rupt ure soon af t er appearance result ing in classic
appearance of erosive lesions

11. DIAGNOSTIC TESTS
Clinical exam: f or r et icular LP wit h
char act erist ic appear ance of Wickham’s st r iae or
annular pat t er n on eryt hemat ous backgr ound
Histological and Direct Immunofluorescent
examinations: f or plaque and er osive LP because
t hey can r esemble ot her mucosal lesions including
malignancy

12. Histological exam
Requires biopsy
Varies based on t he t ype of lesion
Typically: epit helial hyperplasia, ort ho and para
kerat osis, acant hosis, at rophic areas wit h loss of ret e-
pegs, dense accumulat ion of T-lymphocyt es in t he basilar
cell layer
Direct Immunofluorescent examination
Requires biopsy
Dif f erent iat es bet ween ot her aut oimmune condit ions
Det ect s shaggy deposit ion of f ibrinogen along t he
basement membrane

13. HISTOLOGY:
RETICULAR LICHEN
PLANUS
Consist s of local areas of epit helial hyperplasia in which t he
surf ace cont ains a t hick layer of ort hokerat in or parakerat in.
The spinous cell layer may be t hickened (acant hosis) wit h
short ened and point ed ret e pegs(Wickham’s st riae).
 Bet ween t hese areas t he epit helium is t hinned (at rophic),
wit h loss of ret e peg f ormat ion.
The adj acent cont ains a t hin, dense accumulat ion of T
lymphocyt es t hat move t hrough t he basement membrane and
are observed in t he basilar and parabasilar cell layers of t he
epit helium.

14. HISTOLOGY:
EROSIVE LICHEN
PLANUS
Exhibit an ext ensively t hinned epit helium wit h areas of
complet e loss of ret e peg f ormat ion and a dense inf ilt rat e of
T lymphocyt es.
This T lymphocyt e inf ilt rat e obscures t he basement
membrane and ext ends well int o t he middle and upper levels
of t he epit helium.
Liquef act ion of t he basement membrane and dest ruct ion of
t he basal cells is present in most areas.
 Occasionally, sub epit helial separat ion will be present .
Of t en, t he epit helium is lost , exposing t he underlying
connect ive t issue.
 The lymphocyt es are conf ined t o a narrow zone in t he upper
layers of t he connect ive t issue.

15. HISTOLOGY: PLAQUE
LICHEN PLANUS
Plaque LP resembles t he hist ology of ret icular LP because of
t he st riae pat t ern but it lacks t he int ermit t ent at rophic
areas of t he epit helium.
 I t consist s of generalized hyperort hokerat osis or
hyperparakerat osis combined wit h acant hosis.
There may be loss of ret e pegs at t he epit helial and
connect ive t issue int erf ace or alt erat ion of t heir shape int o
a “saw-t oot h” pat t ern.
 The basement membrane is not iceably t hickened.
 The band of T lymphocyt es present in t he superf icial
connect ive t issue is more sparse t han I n ret icular LP, wit h
only occasional cells f ound in t he lower levels of t he
epit helium.

16. TREATMENT OF OLP
No t reat ment f or OLP is curat ive
Goal:
Reduce painf ul sympt oms
Resolut ion of oral mucosal lesions
Reduce risk of oral squamous cell carcinoma
I mprove oral hygiene
Eliminate exacerbating factors:
Repair def ect ive rest orat ions or prost hesis
Remove of f ending mat erial causing allergy
Diet:
Eliminat e smoking and alcohol consumpt ion
Eat f resh f ruit and veget ables (but avoid t omat oes and nut s)
Reduce St ress

17. Medicat ion
Topical cort icost eroids
 0.05% clobet asol proprionat e gel
 0.1% or 0.05% bet amet hasone valerat e gel
 0.05% f luocinonide gel
 0.05% clobet asol but yrat e oint ment
 0.1% t riamcinolone acet onide oint ment
Can be applied direct ly or mixed wit h Orabase

18. Medicat ion
Syst emic St er oid Ther apy
 Prednisone (f or 70kg adult )
• 10-20mg/ day f or moderat ely severe cases
• As high as 35 mg/ day f or severe cases
• Should be t aken in t he morning t o avoid insomnia
• Should be t aken wit h f ood t o avoid pept ic ulcerat ion
 Azat hioprine (I muran) – I nhibit s synt hesis of DNA
• 1mg/ kg/ d f or 6-8 weeks
 Met hylprednisolone (Medrol Dosepak)
• t o reduce pain and inf lammat ion
Prophylact ic use of 0.12% chlorhexidine gluconat e may
help reduce f ungal inf ect ion during cort icost eroid
t herapy

19. ALTERNATIVE
TREATMENT OF OLP
0.1% t opical t acr olimus oint ment 2x/ day
Tacr olimus: immunosuppressive macr olide
Suppr esses T-cell act ivat ion
I nt raoral ulcer at ion resolved af t er 3 mont hs of
daily applicat ion
Remission f or 1 year wit hout maint enance

20. THANKYOU