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Oral Medicine > Lichen Planus > Flashcards

Lichen Planus Flashcards

1
Q

What is Lichen planus?

A

Chronic inflammatory immune-mediated condition of unknown origin.

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2
Q

What are the possible causes of lichen planus?

A

Genetic predisposition.
Physical and emotional stress
Injury to the skin
Localised skin disease- i.e. herpes zoster
Systemic viral infection
Contact allergy
Drugs

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3
Q

Describe the pathogenesis of Lichen Planus.

A

A specific trigger causes an immune response, foreign object is presented to T-lymphocytes, either via a random encounter or during routine surveillance, which causes chronic activation of CD8 cytotoxic T cells.
Chronic over-reaction of the immune response to normal stimuli.
Stimuli not removed.
The CD8 cytotoxic T cells will kill basal keratinocytes.

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4
Q

What are the histological features of lichen planus?

A

T lymphocyte infiltration in a thick band a the basement membrane.
Saw tooth rete ridges
Basal cell destruction
Patchy acanthosis
Parakeratosis.
Civatte bodies- dead keratinocytes
Epithelial tropism

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5
Q

What are the extra-oral symptoms of Lichen Planus?

A

Wickham Striae
Ridging of nails
Hair loss in the scalp
Itchy skin

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6
Q

What are the intra-oral symptoms of Lichen Planus?

A

Often none
White lesion that cannot be rubbed off
Sensitivity to spicy/hot foods
Burning sensation in the mucosa.

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7
Q

What are the common Lichen Planus sites?

A

Buccal mucosa
Gingivae- desquamative gingivitis
Tongue
Lips
Palate

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8
Q

Where is Lichen Planus commonly found on the buccal mucosa?

A

Anterior at commissure
Mid
Posterior around 3rd molar.

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9
Q

What is gingival Lichen Planus?

A

Desquamative gingivitis.

Erythematous band of which extends all the way from the marginal gingivae to the sulcus depth.
Plaque driven in many patients.
Can be very patchy- some forms more typical reticular pattern.

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10
Q

What is tongue Lichen Planus?

A

Dorsum of the tongue usually idiopathic.
Lateral border can sometimes be drug induced or local reaction to amalgam.
- If it is localised LP, look to see if the amalgam matches up to this.

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11
Q

Which sites are easy to biopsy?

A

Buccal mucosa easiest
Tongue relatively easy but is painful to heal
Gingivae very difficult to biopsy- risk of damage to the attachment area of gingivae/tooth.

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12
Q

What is the difference between a Lichenoid reaction and Lichen Planus?

A

Lichenoid reactions are reactions that can be attributed to a cause, it can be local or systemic.

Lichen Planus is a chronic inflammatory condition that is immune-mediated with unknown origin.

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13
Q

What is a Lichenoid drug reaction?

A

Reaction to a drug, whereby, the lesion is bilateral and mirrored.
Widespread.

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14
Q

What drugs are commonly associated with lichenoid drug reactions?

A

ACE inhibitors
Beta blockers
Diuretics
NSAIDs
DMARDs
Penicillamone
Sulphasalazine
Gold

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15
Q

How would you manage lichenoid drug reactions?

A

Weight up risks and benefits of stopping the drug.
Weigh up the patient’s symptoms- are they getting discomfort from the lesion?
Discuss with GP to see if there is a suitable alternative drug the patient can use that won’t cause a lichenoid reaction.

If in doubt- discuss with the patient’s GP.

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16
Q

What is an amalgam-related lichenoid reaction?

A

Localised reaction caused by amalgam restorations.
Looks like LP.
Lesion will be in close proximity to the lesion.

17
Q

What factors would suggest the lichenoid reaction is caused by amalgam?

A

Lesion is in close proximity to the amalgam restoration when the patient is in occlusion.
Lesion is localised- not seen anywhere else in the oral cavity.
No systemic symptoms.

18
Q

What might you do if you suspect amalgam Lichenoid reaction?

A

Do nothing- make patient aware of the potentially malignant potential of the lesion.
Replace the amalgam restoration.
- patient would need to pay for this, tooth not symptomatic now but may be once you replace it, taking tooth tissue away when disease not present.
Patch test for skin allergy.

19
Q

If you were to replace the amalgam restoration, what material might you use to replace it?

A

Composite.
Glass
Gold
Onlay or inlay

20
Q

What investigations might you want to do if you suspect Lichen Planus?

A

Remove any cause- amalgam restorations, medications.
Patch test for allergy if amalgam reaction suspected.
Clinical Photographs
Biopsy
Blood tests- haematinics, FBC.
If Lupus suspected- autoantibody screen- ANA, Ro, dsDNA.

21
Q

What is the relationship between OLP/OLL and malignant transformation?

A

Main link is unknown but some papers have suggested that in som forms of OLP, you have dysplasia.
Increased risk of oral cancer is independent of the type of OLP and therapy administered.

Less than 1% of patients who present with OLP.

22
Q

What factors make it more likely that the lesions develop into oral cancer?

A

Patients risk factors already present- family history, smoker, alcohol use.

Site of lesion- lateral border of the tongue, FOM, soft palate.

23
Q

What would warrant a biopsy in these types of lesions?

A

Lesion is in a high risk site.
Patient has a lot of risk factors.
Lesion has changed in some way.
Patient is symptomatic.

24
Q

In mild, intermittent lesions, what might you advise the patient to take?

A

Avoid SLS- containing toothpaste.
Avoid hot/spicy foods.
Chlorhexidine gluconate mouthrinse- 0.2%, 300ml, 10 ml rinsed in the mouth for 1 minute twice a day.
Benzydamine mouthwash/spray- 0.15%.

25
Q

In persistent symptomatic lesions, what might you prescribe for the patient?

A

Beclometasone inhaler- 50 micrograms- 1 200 dose unit, 1-2 puffs directed at area twice daily.
Betamethosone soluble tablets- 500 micrograms, 100 tablets, dissolve one tablet in 10 mld of water and rinse 4 times a day.

26
Q

If steroid therapy is indicated, what must you advise the patient?

A

Risks- candidate infections, stinging and burning of mucosa, dermatitis with intense redness, sore throat, hoarse throat.

Advise patient not to use them in periods of remission.

27
Q

If previous treatments do not work, what treatments may be required in a secondary setting?

A

Higher strength topical steroids.
- Clobetasol cream with a gingival veneer.
Topical Tacrolimus- 0.1% applied to affected area twice per day.
Hydroxycloroquine.
Systemic immunomodulators- Azothioprine- immunosuppressive drug that disrupts purine synthesis to reduce proliferation of T and B cells.
Mycophenolate.

28
Q

What other explanation can be attributed to lichen plants-like reactions in the oral cavity?

A

Graft Vs Host disease
Lupus Erythematosis.

Oral Medicine (15 decks)

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