Lichen planus

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Lichen planus

  1. 1. ORAL LICHEN PLANUS Dr shabeel pn ROYAL DENTAL COLLEGE
  2. 3. Oral Lichen Planus <ul><li>Common mucocutaneous disease with varying clinical presentation </li></ul><ul><li>Wilson 1869 </li></ul><ul><li>Lichen Ruber planus </li></ul><ul><li>Premalignant condition </li></ul><ul><li>Involvement of oral mucosa is frequent along with or preceded by lesions on skin and genital mucous membrane </li></ul>
  3. 4. Definition <ul><li>OLP is a rather common chronic mucocutaneous disease which probably arises due to abnormal immunological reaction and the disease have some tendency to undergo malignant transformation </li></ul>
  4. 5. Lichenoid reactions <ul><li>Exhibits clinical and histological similarity </li></ul><ul><li>Distinguished from OLP on the basis of </li></ul><ul><li>1. association with administration of drug, contact with a metal, use of food flavors or systemic diseases </li></ul><ul><li>2. Resolution when the cause is eliminated or when disease is treated </li></ul>
  5. 6. Epidemiology <ul><li>Very common- 1% of population </li></ul><ul><li>In Indians 1.5%(average) </li></ul><ul><li>3.7% mixed oral habits </li></ul><ul><li>0.3% non users of tobacco </li></ul><ul><li>Risk more among who smoke and chew tobacco </li></ul><ul><li>cutaneous lesion alone 35% </li></ul><ul><li>mucosal lesion alone 25% </li></ul><ul><li>both together 40% </li></ul>
  6. 7. Etiology <ul><li>Specific etiology is unknown </li></ul><ul><li>Psychological stress </li></ul><ul><li>No evident genetic bias or no uniform etiologic factors </li></ul><ul><li>Abnormal recognition and expression of basal keratinocytes of epithelium as foreign antigens by langerhans cells </li></ul>
  7. 8. Pathogenesis <ul><li>CD8 + T cells trigger the apoptosis of oral epithelial cells </li></ul><ul><li>They recognize an antigen which is similar to an antigen associated with major histocompatability complex class 1 on keratinocytes </li></ul><ul><li>They release cytokinins that attract additional lymphocytes which accumulate in sub basilar connective tissue </li></ul><ul><li>Liquefaction degeneration of basal keratinocytes </li></ul>
  8. 9. Clinical Features <ul><li>Age- middle aged or elderly people </li></ul><ul><li>mean age of onset- 5 th decade of life </li></ul><ul><li>rarely in young adults and children </li></ul><ul><li>More in females ( 1.4:1 ) </li></ul><ul><li>Site- both skin lesions and mucosal lesions are present </li></ul><ul><li>Grinspan’s syndrome –OLP, DM & HP </li></ul>
  9. 10. Skin Lesions <ul><li>Purple, pruritic and polygonal papules </li></ul><ul><li>May be discreet or gradually coalesce into plaques each covered by fine glistering scale </li></ul><ul><li>Bilaterally symmetrical </li></ul><ul><li>Increase in size if subjected to any irritation </li></ul><ul><li>Usually self limiting unlike the oral lesions lasting only one year or less </li></ul><ul><li>Initially red > purple or violaceous hue > a dirty brownish color </li></ul><ul><li>Periods of regression and recurrence </li></ul><ul><li>“ Koebner’s phenomenon”- skin lesions extend along the areas of injury or irritation </li></ul><ul><li>Most often on wrist, forearms, knees, thighs and trunk </li></ul><ul><li>Face remains uninvolved </li></ul>
  10. 12. Mucosal Lesions <ul><li>Normally asymptomatic </li></ul><ul><li>Bilaterally symmetrical </li></ul><ul><li>Sometimes simultaneously have OSF, leukoplakia,etc. </li></ul><ul><li>Clinical types </li></ul><ul><li>1.reticular </li></ul><ul><li>2.atrophic </li></ul><ul><li>3.erosive </li></ul><ul><li>4.bullous </li></ul><ul><li>5. other types </li></ul>
  11. 13. Reticular type <ul><li>Most common and most readily recognized form </li></ul><ul><li>Slightly elevated fine whitish lines (Wickham’s striae) in lace like or annular pattern </li></ul><ul><li>Lines are wavy and parallel </li></ul><ul><li>A tiny elevated dot like structure at the point of intersection of lines </li></ul><ul><li>Commonly on buccal mucosa and buccal vestibule </li></ul><ul><li>Sometimes on tongue, gingiva, lips and floor of the mouth </li></ul>
  12. 16. Atrophic type <ul><li>Keratotic changes combined with mucosal erythema </li></ul><ul><li>smooth, poorly defined erythematus areas with or without peripheral striae </li></ul><ul><li>Usually associated with desquamative gingivitis </li></ul><ul><li>Pain and burning sensation </li></ul>
  13. 17. Erosive type <ul><li>Pseudo membrane covered ulcerations with keratosis and erythema </li></ul><ul><li>Severe form with extensive degeneration and separation of epithelium from connective tissue </li></ul><ul><li>Faint white zone resembling radiating striae seen at the junction with normal epithelium </li></ul><ul><li>Pain, burning sensation, bleeding, desquamative gingivitis </li></ul><ul><li>Commonly on buccal mucosa and vestibule </li></ul><ul><li>More dysplasia and malignant transformation </li></ul>
  14. 19. Bullous type <ul><li>Vesciculobullous presentation combined with reticular or erosive pattern </li></ul><ul><li>Rare form characterized by large vesicles or bullae (4mm to 2cm) </li></ul><ul><li>Lesions usually develop within an erythematus base, rupture immediately leaving painful ulcers </li></ul><ul><li>Usually have peripheral radiating striae and seen on posterior part of buccal mucosa </li></ul>
  15. 21. Other types <ul><li>Plaque type : flattened white areas </li></ul><ul><li>-dorsal surface of tongue </li></ul><ul><li>-often resemble leukoplakia </li></ul><ul><li>Hypertrophic type : well circumscribed, elevated white lesion resembling leukoplakia </li></ul><ul><li>-biopsy needed for diagnosis </li></ul><ul><li>Pigmented type : rarely erosive type can be associated with diffused </li></ul><ul><li>-usually on buccal mucosa and vestibule </li></ul><ul><li>-reticulated white patches with or without a red erosive component flanked brown macular foci </li></ul>
  16. 24. Histopathology <ul><li>Hyper orthokeratinisation or hyper parakeratinisation </li></ul><ul><li>Thickening of granular layer </li></ul><ul><li>Acanthosis of spinous layer </li></ul><ul><li>Intercellular oedema in spinous layer </li></ul><ul><li>“ Saw-tooth” rete pegs </li></ul><ul><li>Liquefaction necrosis of basal layer- Max Joseph spaces </li></ul><ul><li>Civatte ( hyaline or cytoid) bodies </li></ul><ul><li>Juxta epithelial band of inflammatory cells </li></ul>
  17. 27. Immunofluorescent Studies <ul><li>Band of fibrinogen in the basement membrane zone </li></ul><ul><li>Multiple IgM staining cytoid bodies in dermal papilla or peribasalar area </li></ul><ul><li>Highly suggestive of lichen planus if present in clusters </li></ul>
  18. 28. Differential Diagnosis <ul><li>Lichenoid reactions </li></ul><ul><li>Leukoplakia </li></ul><ul><li>Candidiasis </li></ul><ul><li>Pemphigus </li></ul><ul><li>Cicatricial pemphigoid </li></ul><ul><li>Erythema multiforme </li></ul><ul><li>Syphilis </li></ul><ul><li>Recurrent aphthae </li></ul><ul><li>Lupus erythematosus </li></ul><ul><li>Squamous cell carcinoma </li></ul>
  19. 29. Malignant transformation <ul><li>Controversy </li></ul><ul><li>Increased risk of oral squamous cell carcinoma </li></ul><ul><li>Frequency of transformation is low, between 0.3% and 3% </li></ul><ul><li>Erosive and atrophic forms commonly undergo transformation </li></ul>
  20. 31. Treatment <ul><li>No cure </li></ul><ul><li>Management of symptoms </li></ul><ul><li>Principal aims: resolution of painful symptoms, resolution of mucosal lesions, reduction of risk of cancer & maintenance of good oral hygiene </li></ul><ul><li>Corticosteroids: both systemic & topical </li></ul><ul><li>Topical: </li></ul><ul><li>0.05% fluocinonide ( Lidex) </li></ul><ul><li>0.05% clobetasol ( Temovate) </li></ul><ul><li>as pastes or gels </li></ul><ul><li>Candida overgrowth </li></ul>
  21. 32. References <ul><li>Burket’s Oral Medicine – 10 th Edition </li></ul><ul><li>Shafer’s Oral Pathology – 5 th Edition </li></ul><ul><li>Essentials of Oral Pathology </li></ul><ul><li>www.emedicine.com </li></ul><ul><li>www.medscape.com </li></ul>
  22. 33. THANK YOU CREATIVE SUPPORT BY PATRICK GEORGE

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