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My BDS4 > OM - Lichen Planus > Flashcards

OM - Lichen Planus Flashcards

1
Q

Whos at risk of lichen planus?

A

30-50 year olds

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2
Q

What causes lichen planus? (8)

A
  • Idiopathic cause
  • Genetic predisposition – Not specifically HLA linked
  • Physical and emotional stress
  • Injury to the skin; lichen planus often appears where the skin has been scratched or after surgery (in susceptible patients)
  • Localized skin disease such as herpes zoster
  • Systemic viral infection, such as hepatitis C
  • Contact allergy – to metal fillings (amalgam)
  • Drugs – esp antihypertensives and Gold, Quinine
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3
Q

what is an isomorphic response (koebnerisation) in relation to LP?

A

where injury to the skin can cause lichen planus to appears (where the skin has been scratched or after surgery) in susceptible patients

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4
Q

Describe the histological appearance/characteristics of lichen planus. (5)

A

T cell infiltrate into the basement membrane area of CT = Lymphocytic band hugging the membrane (key diagnostic feature_

  • Chronic Inflammatory cell infiltrate
  • Saw tooth rete ridges
  • Basal cell damage
  • Patchy acanthosis
  • Parakeratosis
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5
Q

What does the histological appearance tell us about what occurs in lichen planus?

A

Lymphocytes are attracted to the area specifically to deal with a perceived threat – Langerhans cells in the epithelium present an antigen which activates an immune response.
The immune response attempts to remove the chronic irritation which causes the changes in the epithelium and the clinical appearance.

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6
Q

What are some of the types of LP? Describe (3)

A
  1. Reticular – lacey pattern on;
    Normal mucosa Or Erythematous mucosa
  2. Atrophic – where erythema (=atrophy) is the predominant feature
    Erosive = where atrophy results in no epithelial cover
  3. Ulcerative = where atrophy results in no epithelial cover
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7
Q

What are the symptoms of oral LP? (3)

A
  • Often none
  • Sensitive to hot/spicy food & Burning sensation in the mucosa
  • from thinning of the epithelium
  • Up to 50% patients have other areas of the body involved
  • Skin
  • Scalp
  • Genitals
  • hair
  • nails
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8
Q

Where else can LP present? (4)

A

Cutaneous - skin

Wrists:
- raised purple lesions with white striae (Wickems striae)

Scalp – area of hair loss were lesions present

Nails – characteristic ridging

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9
Q

Describe the sites where oral LP is commonly found. (5)

A
  • Buccal mucosa – most common site
  • Gingivae (Desquamative Gingivitis – when in isolation)
  • Tongue – lateral aspect, dorsum
  • Lips
  • Palate
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10
Q

Where is the most common site for oral LP?

A

Buccal mucosa

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11
Q

Where on the buccal mucosa can LP present? (3)

A
  • Anterior at commissure
  • Mid
  • Posterior around 3rd molar tooth
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12
Q

where is the most common site for incidental/asymptomatic finding of LP?

A

Buccal mucosa

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13
Q

How do we differentiate between desquamative gingivitis and pemphigoid and plasma cell gingivitis?

A

Biopsy - histological examination

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14
Q

What are the characteristics of gingival LP/desqamative gingivitis? (3)

A
  • patchy appearance
  • mostly erythematous however Some forms give a more ‘typical’ reticular lichenoid pattern
  • lesions can be found in isolation
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15
Q

What can gingival LP also be known as when the lesions only affect the gingival tissues?

A

Desquamative gingivitis

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16
Q

How do we manage gingival LP? (1)

A

Ensure there is plaque control as these lesions seem to be plaque driven (esp interdental plaque)

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17
Q

What are the risks of gingival biopsy (1) and what techniques help us to reduce these? (2)

A

– Risk of damaging the attachment/junctional area of the gingiva/tooth

– Must have a good clear margin between tooth and the lesion
– Ideally sample from high in the sulcus

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18
Q

What are the characteristics of LP on the dorsum of the tongue? (1)

A

Lesions on the dorsum = loss of papillae and smooth tongue surface

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19
Q

What commonly causes lichen planus on the dorsum of the tongue?

A

idiopathic

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20
Q

what usually causes lichen planus on the lateral aspect of the tongue? (2)

A

may have drug/amalgam trigger

  • Amalgam most likely if there is an ISOLATED lateral tongue lesion
  • Look at tongue position at REST to see if there is amalgam contact
21
Q

What are the general characteristics of lichen planus? (3)

A
  • More often WIDESPREAD lesions
  • Often BILATERAL and mirrored
  • Often poorly responsive to
    standard steroid treatment
22
Q

How do we describe an oral lichenoid lesion where the cause is know?

A

‘lichenoid reaction to..”

23
Q

What medications are associated with lichen planus? (5)

A

(antihypertensives)
- b-adrenergic blockers
- ace inhibitors

  • diuretics: Bendroflumethiazide, frusemide
  • NSAIDS
  • DMARDS (disease modifying antirheumatic drugs e.g. sulphasalazine)
  • Phenothiazines (rare)
24
Q

How do we manage lichenoid drug reactions? (3)

A

consider/assess;

Benefit of drug causing the reaction - Does the benefit of stopping the medical drug outweigh the risk to the patient’s health
Mild lichen symptoms – unlikely, Significant lichen symptoms – yes probably (Where maximum topical or systemic treatment likely needed to control the lichen symptoms)

If in doubt, discuss with the GP - Maybe medicine no longer needed or there is an easy change to an alternative

  • Risk of stopping drug
  • Discomfort from symptoms
25
Q

What is the suggested cause of amalgam causing lichenoid reactions?

A

not entirely sure

Old amalgams
possibly the corrosion products of amalgams

26
Q

How do we manage amalgam related lesions? (2)

A

No symptomatic = do nothing
(however, low risk that it could be a potentially malignant lesion)

symptoms = replace

27
Q

What are the problems associated with not treating an amalgam that is causing a lichenoid reaction?

A

very low risk that it Could be a potentially malignant lesion

28
Q

What are the problems associated with replacing an amalgam that is causing a lichenoid reaction? (2)

A
  • Replacing restoration will increase tooth damage
  • Cost to patient for amalgam removal
29
Q

If one amalgam is causing a lichenoid reaction should all other amalgams be replaced?

A

No routine need – reactions seem to be some caused by the change in the amalgam involved e.g. corrosion – the change is the only problematic amalgam.
Only replaced when in direct contact with the lichenoid lesions

30
Q

When should we completely avoid replacing amalgams causing ARL’s?

A

pregnancy

31
Q

What restorative tx should we avoid in a px with a history of lichenoid reactions and why? (1)

A

Avoid bonded crowns as palladium can be associated with Lichenoid reactions however the incidence is much lower

32
Q

What are the general management strategies for lichen planus? (3)

A
  1. Remove any cause:
    - Medicines
    - Dental restorations
  2. BIOPSY
    - Unless a good reason not to e.g. lichenoid, RAU
  3. Blood tests
    LP more symptomatic in px with haematinic deficiency
    - Haematinincs
    - FBC
33
Q

Why is a blood test relevant when diagnosing LP?

A

LP more symptomatic in px with haematinic deficiency

34
Q

How do we manage intermittent lichen planus? (2)

A
  • Topical OTC remedies
  • Chlorhexidene m/w
  • Benzdamine m/w
  • All patients to avoid SLS containing toothpaste (esp in gingival lesions)
  • Sensodyne Pronamel
  • Kingfisher
35
Q

How do we manage persistent lichen planus in the primary setting? (1)

A
  • Topical steroids (as for Oral Ulcers)
  • Beclomethasone MDI 0.5mg/puff – 2 puffs x 2-3 daily
  • Betamethasone rinse – 1mg/10ml/2mins/twice daily

Advise that during the lesion/symptom free period to stop using the drugs and then start using again once the lesions/symptoms appear

36
Q

How do we manage persistent lichen planus in a Hospital setting if primary care efforts are unsuccessful? (4)

A
  • Higher strength topical steroids
    – puffer or rinse
  • ‘Skin’ Steroid Cream – CLOBETASOL in a ‘veneer’ for gingival lesions
  • Topical tacrolimus – ointment or mouthwash
  • Hydroxychloroquine – cutaneous and oral LP
  • Systemic immunmodulators
  • Azathioprine
  • mycophenolate
37
Q

provide 2 examples of systemic immunomodulators.

A
  • Azathioprine
  • mycophenolate
38
Q

What causes GVHD? (2)

A

Bone marrow/stem cell transplant

39
Q

Describe what graft vs host disease is sing an example.

A

after a bone marrow transplant/ Stem cell transplant, the patient’s new bone marrow recognises a foreign host and is causing immunological damage to the mouth in order to reject the host = appearance of lichen like lesions

40
Q

Describe how GVHD presents in the mouth, how do we differentiate between this and lichen planus?

A

Lichen like lesion
- appears in unusual LP positions such as the hard palate

41
Q

Describe how GVHD appears histologically

A

Similar to LP
- has a lymphocytic band along the basement membrane and a change in the keratinized/prickle cell layers.

42
Q

What diseases can present in a similar manner to Lichen planus in the mouth? (2)

A

GVHD - graft vs host disease

Lupus (various types)

43
Q

For what lesions must we always consider lupus erythematosus in our differential diagnosis?

A

palatal lichen like lesions

44
Q

How can discoid lupus present in the mouth?
What other tests can be used to confirm this diagnosis?

A

Lichen like lesions that ONLY present in the mouth

  • no auto antibodies present on a blood test.
45
Q

How can systemic lupus present in the mouth?
What other tests can be used to confirm this diagnosis?

A

lichen like lesions present in the mouth and elsewhere

– autoantibodies ANA/Ro/dsDNA present in the blood sample

46
Q

What autoantibodies are present in systemic lupus (3)

A

anti-ANA
anti-Ro
anti-dsDNA

47
Q

Describe how lupus appears histologically.

A

Different appearance to lichen planus as the lymphocyte infiltration is much deeper in the connective tissue and away from the basement membrane

48
Q

How do we treat only oral lichen like (GVHD&Lupus) symptoms? (2)

A
  • Treat symptoms as Lichen Planus
  • Liaise with physician regarding oral lesions

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