Oral Lichen planus and Lichenoid tissue reactions

Question 1

What is lichen Planus?

Answer 1

a common chronic immune mediated mucocutaneous disease

Question 2

Lichen Planus can commonly effect…

Answer 2

oral mucosa
skin
- including nails and scalp
ano-genital mucosa

Question 3

lichen planus can occasionally affect…

Answer 3

pharynx
oesophagus
conjunctiva

Question 4

Similarities between lichen planus and oral lichenoid lesions

Answer 4

clinical lesions will look identical
very similar histopathological features

Question 5

how do oral lichenoid lesions and oral lichen planus differ?

Answer 5

oral lichen planus: no specific identifiable aetiological factor

oral lichenoid lesions: an identifiable aetiological factor OR a manifestation of a systemic disease

Question 6

clinical problems associated with OLP and oral lichenoid lesions

Answer 6

very common
often painful
no cure
can be a manifestation of systemic disease
1% risk of malignant transformation over 10 years

Question 7

epidemiology of OLP/OLL

Answer 7

1% disease prevalence
- likely under-reported
slightly more common in females
no racial predilection

Question 8

OLP and OLL genetic links

Answer 8

associated with some HLA(human leukocyte antigen subtypes

Question 9

risk factors for OLP and OLL

Answer 9

stress
dental materials
SLS
medical conditions
medication
nutritional deficiency
chronic trauma
hypertension

Question 10

conditions which are associated with an increased OLP or OLL risk

Answer 10

graft versus host disease
diabetes
lupus
auto-immune diseases

Question 11

oral lichen planus immunopathogeneis

Answer 11

CD8+ T cell mediated destruction of basal keratinocytes

Question 12

OLP and OLL - social history risk factors

Answer 12

smoking increases risk of malignant change
alcohol - high alcohol associated with increased risk of malignancy
- betel nut
diet
- fruit and veg intake
low SES

Question 13

Dental history and OLP/OLL

Answer 13

regular attendee
does toothpaste contain SLS
denture use
plaque - can exacerbate symptoms

Question 14

clinical presentaion of OLP and OLL

Answer 14

can present as
- white patch
- red patch
- erosion/ulcer
often combination of these

Question 15

types of lesions seen in OLP/OLL

Answer 15

reticular
atrophic
papular
erosive
plaque like
bullous

Question 16

reticular lichen planus/ OLL - clinical features

Answer 16

from latin ‘reticulum’ = small net
net like or network like pattern or lacy appearance
- white lines = striae
more likely to asymptomatic than other forms
more likely to spontaneously resolve

Question 17

Atrophic OLP/OLL clinical features

Answer 17

red mucosa
- due to thinning of mucous membrane
desquamative gingivitis can be classed as atrophic

Question 18

papular lichen planus clinical features

Answer 18

multiple white papules
uncommon

Question 19

erosive lichen planus clinical features

Answer 19

erosion - similar appearance to an ulcer but resemble partial loss of the epithelium
- still termed erosive if here is an ulcer in OLP/OLL
more likely to be symptomatic
higher risk of malignant change
ulcers will be persistent
irregular pattern
lower biopsy threshold

Question 20

plaque like lichen planus clinical features

Answer 20

a thickened white plaque/white patch

Question 21

bullous lichen planus clinical features

Answer 21

uncommon
may be caused by superficial mucoceles
need to exclude blistering diseases as a cause of appearance

Question 22

Where in oral mucosa is affected by oLP/OLL

Answer 22

OLP more likely to be bilateral/symmetrical
OLTR may be unilateral or disturbed near aetiological factor e.g. amalgam restorations
- variation if drug induced

buccal mucosa 80%
tongue 65%
palate and floor of mouth <10%
- rare
- consider underlying medical condition particularly Lupus
gingiva = presents as desquamative gingivitis

Question 23

management of OLP and OLL in general practice

Answer 23

provide relevant information of the condition - if you are confident in diagnosis
provide symptomatic relief if needed
take clinical photographs
consider referral
PMPR and OHI - especially for desquamative gingivitis
consider changing amalgam restorations if in direct contact with isolated lesion
advise SLS free toothpaste
avoid trigger foods

Question 24

OLP and OLL - reasons for referral

Answer 24

symptomatic
unilateral/non-symmetrical distribution
any non-reticular lichen planus
unclear diagnosis
patient has other risk factors for malignant change
biopsy may be indicated

Question 25

OLP and OLL symptomatic relief

Answer 25

0.15% Benzydamine (Difflam) mouthwash or spray - mouthwash for generalised - spray for localised lesions rinse or gargle every 1 1/2 hours as required - usually for no more than 7 days

Question 26

OLP and OLL symptomatic relief - if benzydamine doesn't work

Answer 26

betamethasone 500 mcg soluble tablets - fully dissolve tablet in 10ml water - rinse for 5 minutes - spit after rinsing - do not swallow - repeat up to 4x daily no significant risks or interactions - little systemic absorption may be associated with oral fungal infection

Question 27

what is required in a referral for OLP/OLL?

Answer 27

detailed history clinical findings provisional diagnosis a reason why it needs seen in specialist care details of treatments tried excellent clinical photos referral; to oral medicine or local oral and maxillofacial surgery unit

Question 28

OLP and OLL secondary care management

Answer 28

initially same as primary care excellent history and examination development of provisional and differential diagnosis explanation to patient of the condition biopsy consideration clinical photos if erosive or symptomatic: - consider FBC, haematinics, oral rinse to rule out fungal infection - skin antibody tests to exclude blistering disease exclude systemic disease manage symptoms consider patch testing/stopping medications/changing restorations

Question 29

biopsy - risks

Answer 29

pain bleeding bruising infection altered sensation - temp or permanent sutures

Question 30

diseases linked to OLP/OLL and management

Answer 30

hepatitis C - consider in high risk groups of patients with OLP and OLL - readily treatable lupus - consider investigating for lupus if palatal distribution and systemic features consistent with lupus e.g. joint pain, fatigue, malar/butterfly rash - biopsy - anti-nuclear antibodies - complement - anti-dsDNA graft versus host disease - recent stem cell transplant

Question 31

biopsy - benefits

Answer 31

confirms the diagnosis - not always needed may identify dysplasia - highlighting a patient with increased risk of malignant transformation can exclude vesiculobullous disorders

Question 32

types of biopsy

Answer 32

incisional biopsy for H and E staining incisional biopsy for direct immunofluorescence - if wishing to exclude blistering disease an incisional punch or free hand ellipse is generally appropriate

Question 33

Histological features of OLP/OLL

Answer 33

keratosis hyperplastic epithelium lymphocytes in epithelium basal cell destruction band-like lymphocytic infiltrate epithelial atrophy or erosion

Question 34

Dental materials that can be linked to lichenoid contact reaction

Answer 34

mercury nickel palladium gold silver tin acrylics GI composite chromium

Question 35

drug treatments for OLP/OLL in secondary care

Answer 35

topical steroids - always first line systemic steroids e.g. prednisolone - to bring severe disease under control quickly potent topical steroids topical calcineurin inhibitors hydroxychloroquine azathioprine - increased risk of infection mycophenolate mofetil - increased infection risk

Question 36

diseases linked to OLP/OLL and management

Answer 36

hepatitis C - consider in high risk groups of patients with OLP and OLL - readily treatable lupus - consider investigating for lupus if palatal distribution and systemic features consistent with lupus e.g. joint pain, fatigue, malar/butterfly rash - biopsy - anti-nuclear antibodies - complement - anti-dsDNA graft versus host disease - recent stem cell transplant

Question 37

malignant change in OLP - risk

Answer 37

1% over 10 years more common in erosive lesions more common on lesions on tongue debate if OLL more likely to transform than OLP likely a gradual change

Question 38

OLP malignant change - red flags to be aware of

Answer 38

- increased severity - new lesions - new onset ulcers - erythema - lymphadenopathy - dysphagia - exophytic (outward growth) lesions

Question 39

extra oral lichen planus - management

Answer 39

advise patient to see GP

Question 40

OLP/OLL histological features

Answer 40