Lichen planus

ORAL LICHEN PLANUSORAL LICHEN PLANUS

Dr shabeel pn

ROYAL DENTAL COLLEGE

Oral Lichen PlanusOral Lichen Planus

Common mucocutaneous disease with varying clinical presentation

Wilson 1869 Lichen Ruber planus Premalignant condition Involvement of oral mucosa is frequent along

with or preceded by lesions on skin and genital mucous membrane

DefinitionDefinition

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

Lichenoid reactionsLichenoid reactions

Exhibits clinical and histological similarityDistinguished from OLP on the basis of

1. association with administration of drug, contact with a metal, use of food flavors or systemic diseases

2. Resolution when the cause is eliminated or when disease is treated

Epidemiology Epidemiology

Very common- 1% of population In Indians 1.5%(average)

3.7% mixed oral habits

0.3% non users of tobacco Risk more among who smoke and chew tobacco

cutaneous lesion alone 35%

mucosal lesion alone 25%

both together 40%

Etiology Etiology

Specific etiology is unknownPsychological stressNo evident genetic bias or no uniform

etiologic factorsAbnormal recognition and expression of

basal keratinocytes of epithelium as foreign antigens by langerhans cells

PathogenesisPathogenesis

CD8 + T cells trigger the apoptosis of oral epithelial cells

They recognize an antigen which is similar to an antigen associated with major histocompatability complex class 1 on keratinocytes

They release cytokinins that attract additional lymphocytes which accumulate in sub basilar connective tissue

Liquefaction degeneration of basal keratinocytes

Clinical FeaturesClinical Features

Age- middle aged or elderly people

mean age of onset- 5th decade of life

rarely in young adults and childrenMore in females ( 1.4:1 )Site- both skin lesions and mucosal

lesions are presentGrinspan’s syndrome –OLP, DM & HP

Skin LesionsSkin Lesions Purple, pruritic and polygonal papules May be discreet or gradually coalesce into plaques each

covered by fine glistering scale Bilaterally symmetrical Increase in size if subjected to any irritation Usually self limiting unlike the oral lesions lasting only one

year or less Initially red > purple or violaceous hue > a dirty brownish

color Periods of regression and recurrence “Koebner’s phenomenon”- skin lesions extend along the areas

of injury or irritation Most often on wrist, forearms, knees, thighs and trunk Face remains uninvolved

Mucosal LesionsMucosal Lesions

Normally asymptomatic Bilaterally symmetrical Sometimes simultaneously have OSF, leukoplakia,etc. Clinical types 1.reticular 2.atrophic 3.erosive 4.bullous 5. other types

Reticular typeReticular type

Most common and most readily recognized form

Slightly elevated fine whitish lines (Wickham’s striae) in lace like or annular pattern

Lines are wavy and parallel A tiny elevated dot like structure at the point of

intersection of lines Commonly on buccal mucosa and buccal

vestibule Sometimes on tongue, gingiva, lips and floor of

the mouth

Atrophic typeAtrophic type

Keratotic changes combined with mucosal erythema

smooth, poorly defined erythematus areas with or without peripheral striae

Usually associated with desquamative gingivitis

Pain and burning sensation

Erosive typeErosive type

Pseudo membrane covered ulcerations with keratosis and erythema

Severe form with extensive degeneration and separation of epithelium from connective tissue

Faint white zone resembling radiating striae seen at the junction with normal epithelium

Pain, burning sensation, bleeding, desquamative gingivitis

Commonly on buccal mucosa and vestibule More dysplasia and malignant transformation

Bullous typeBullous type

Vesciculobullous presentation combined with reticular or erosive pattern

Rare form characterized by large vesicles or bullae (4mm to 2cm)

Lesions usually develop within an erythematus base, rupture immediately leaving painful ulcers

Usually have peripheral radiating striae and seen on posterior part of buccal mucosa

Other typesOther types

Plaque type: flattened white areas -dorsal surface of tongue -often resemble leukoplakia

Hypertrophic type: well circumscribed, elevated white lesion resembling leukoplakia

-biopsy needed for diagnosis

Pigmented type: rarely erosive type can be associated with diffused

-usually on buccal mucosa and vestibule -reticulated white patches with or without a red erosive

component flanked brown macular foci

HistopathologyHistopathology

Hyper orthokeratinisation or hyper parakeratinisation

Thickening of granular layer Acanthosis of spinous layer Intercellular oedema in spinous layer “Saw-tooth” rete pegs Liquefaction necrosis of basal layer- Max

Joseph spaces Civatte ( hyaline or cytoid) bodies Juxta epithelial band of inflammatory cells

Immunofluorescent StudiesImmunofluorescent Studies

Band of fibrinogen in the basement membrane zone

Multiple IgM staining cytoid bodies in dermal papilla or peribasalar area

Highly suggestive of lichen planus if present in clusters

Differential DiagnosisDifferential Diagnosis

Lichenoid reactions Leukoplakia Candidiasis Pemphigus Cicatricial pemphigoid Erythema multiforme Syphilis Recurrent aphthae Lupus erythematosus Squamous cell carcinoma

Malignant transformationMalignant transformation

ControversyIncreased risk of oral squamous cell

carcinomaFrequency of transformation is low,

between 0.3% and 3%Erosive and atrophic forms commonly

undergo transformation

TreatmentTreatment

No cure Management of symptoms Principal aims: resolution of painful symptoms,

resolution of mucosal lesions, reduction of risk of cancer & maintenance of good oral hygiene

Corticosteroids: both systemic & topical Topical: 0.05% fluocinonide ( Lidex) 0.05% clobetasol ( Temovate) as pastes or gels Candida overgrowth

ReferencesReferences

Burket’s Oral Medicine – 10th Edition Shafer’s Oral Pathology – 5th EditionEssentials of Oral Pathology www.emedicine.comwww.medscape.com