OLP and OLTR

Question 1

What is OLP?

Answer 1

A common chronic immune-mediated mucocutaneous disease

Question 2

OLP sites?

Answer 2

Oral mucosa
Skin (Nails and scalp)
Ano-genital mucosa

Occasionally:
Pharynx
Esophagus
Conjunctiva

Question 3

Malignant transformation risk of OLP and OLRT?

Answer 3

1% risk over 10 years

Question 4

Genetic association of OLP

Answer 4

HLA (Human Leukocyte Antigen)
Genome Wide Association Studies (GWAS) on chromosome 6

Question 5

OLP Environmental triggers

Answer 5

Restorative materials
SLS
Stress
Trauma
Medical conditions
Medications

Question 6

Immune system associated with OLP

Answer 6

CD8+ T Cells
CD4+ T Cells
Local inflammatory response

Question 7

OLP Pathogenesis

Answer 7

1. CD8+T Cell mediated destruction of Basal keratinocytes
2. T Cell activated by antigen presenting cells, expressing MHC 1
3. T Cells recognize antigen on MHC 1 of basal keratinocytes
4. Upon recognition of antigen, release of GRANZYME and PERFORIN that disrupt cell membrane leading to death
5. Also release of TNF- Alpha and IL-6 (pro inflammatory cytokynes) which influence CD4+ T Cells.

Question 8

RF for OLP

Answer 8

Stress
Genetics
GvHD
Diabetes
A.I.D
SLS toothpaste
Dental material

Question 9

E/O Manifestations to look out for?

Answer 9

Skin/Scalp/Nail
Genitals
Eyes
Oesophagus

Question 10

Sites in mouth affected by OLP?

Answer 10

Tongue
Buccal mucosa
Gingiva
Unususal (Palate/ FOM)

Question 11

Clinical features of OLP?

Answer 11

White patch
Red patch
Erosion/ Ulcer

Question 12

Types of OLP

Answer 12

Reticular (asymptomatic)
Atrophic
Erosive
Papular
Plaque like
Bullous

Question 13

Atrophic OLP

Answer 13

Red mucosa
Due to thinning of mucous membrane
Desquamative gingivitis

Question 14

Erosive OLP

Answer 14

Parital loss of epithelium
High risk of malignant change
Irregular pattern
Lower threshold for biopsy
Persistent ulcer

Question 15

Bullous OLP

Answer 15

May be caused by superficial mucoceles
Need to exclude blistering disease

Question 16

OLP Vs. OLTR Sites

Answer 16

OLP is bilateral/ symmetrical
OLTR is unilateral/ near restoration
Buccal mucosa 80%
Tongue 65%
Lips 20%
Palate/ FOM <10%

Question 17

Management of OLP and OLTR in GDP?

Answer 17

1. Provide relevant info to pt
2. Symptomatic relief
3. Take clinical photos
4. Consider referral
5. PMPR & OHI for desquamative gingivitis
6. Consider changing restorations
7. SLS free toothpaste

Question 18

Reasons for referral to OM?

Answer 18

Symptomatic
Unilateral/ non-symmetrical
Non-reticular OLP
Unclear diagnosis
Pt has other RF
Biopsy indicated

Question 19

Symptomatic relief for OLP/OLTR

Answer 19

Benzydamine 0.15% MW
15ml every 30mins as required

Question 20

What to give if Difflam doesn’t work?

Answer 20

Betamethasone 500mcg
Dissolve 1 tablet in 10ml water
Rinse for 5 mins
Spit after rinse
DONT SWALLOW
Up to 4x daily

Question 21

If Difflam doesn’t work and HIGHLY LOCALISED?

Answer 21

Clenil Modulite Beclometasone 50mcg MDI
1-2 puffs
Unlicensed
(may be associated with fungal infection)

Question 22

Hydrocortisone Oromucosal tablet dosage?

Answer 22

2.5mg
1 tablet dissolved next to lesion 4x daily until healed

Question 23

Triggers to avoid?

Answer 23

SLS toothpaste
Avoid trigger foods

Question 24

What to include in referral?

Answer 24

1. Detailed hx
2. Clinical findings
3. Provisional diganosis
4. Why to be seen my specialist
5. Tx tried
6. Clinical photos
7. Refer to OM/OMFS

Question 25

Secondary care management of OLP?

Answer 25

1. Same as primary care 2. Consider biopsy 3. If erosive consider FBC, Haematinics, Oral rinse (to exclude fungal infection), skin antibody test 4. Manage symptoms 5. Patch testing, stop medications

Question 26

Types of Biopsy?

Answer 26

Incisional biopsy for H&E Staining Incisional biopsy for DI Incisional punch or Free hand ellipse

Question 27

Histological features of OLP/ OLTR?

Answer 27

1. Death of basal keratinocyte 2. Colloid bodies/ Civatte bodies 3. Band like lymphocytic infiltrate (CD8+ T Cell) 4. Acanthosis 5. Hyperparakeratosis / Hyperorthokeratosis 6. Saw tooth rete pegs 7. Epithelial atrophy or erosion

Question 28

Common drugs asssociated with OLP?

Answer 28

ACE inhibitors (ramipril) Beta-blockers (propanolol) DMARD (hydroxychloroquine) Diuretic (Furosemide) NSAIDs Hypoglycemics (Metformin) Biologics ( Infliximab) Allopurinol

Question 29

Other types of tx for OLP/ OLTR in secondary care?

Answer 29

1. Topical steroids 2. Systemic steroids ( Prednisolone) 3. Clobetasol/ Fluocinolone (with vacuum splint) 4. Tacrolimus ointment 5. Hydroxychloroquine 6. Azathioprine 7. Mycophenolate mofetil

Question 30

How to check patient for Lupus?

Answer 30

Anti-nuclear antibodies Biopsy Anti-Smith Anti-dsDNA Complement Immunoglobulins and protein eletrophoresis

Question 31

E/O OLP

Answer 31

Wickham's striae ( white areas over skin lesions

Question 32

Malignant change in OLP/ OLTR?

Answer 32

1% over 10 years More common on erosive lesions and tongue Gradual changes

Question 33

How to look out for malignant change?

Answer 33

Increase severity New lesions New onset ulcers Exophytic lesions Erythema Dysphagia Lymphadenopathy