Lichen planus

1. ORAL LICHEN PLANUSORAL LICHEN PLANUS
Dr shabeel pn
ROYAL DENTAL COLLEGE

3. 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

4. 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

5. Lichenoid reactionsLichenoid reactions
Exhibits clinical and histological similarity
Distinguished 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

6. 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%

7. Etiology Etiology
Specific etiology is unknown
Psychological stress
No evident genetic bias or no uniform
etiologic factors
Abnormal recognition and expression of
basal keratinocytes of epithelium as
foreign antigens by langerhans cells

8. 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

9. Clinical FeaturesClinical Features
Age- middle aged or elderly people
mean age of onset- 5
th
decade of life
rarely in young adults and children
More in females ( 1.4:1 )
Site- both skin lesions and mucosal
lesions are present
Grinspan’s syndrome –OLP, DM & HP

10. 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

12. 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

13. 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

16. 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

17. 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

19. 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

21. 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

24. 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

27. 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

28. Differential DiagnosisDifferential Diagnosis
Lichenoid reactions
Leukoplakia
Candidiasis
Pemphigus
Cicatricial pemphigoid
Erythema multiforme
Syphilis
Recurrent aphthae
Lupus erythematosus
Squamous cell carcinoma

29. Malignant transformationMalignant transformation
Controversy
Increased risk of oral squamous cell
carcinoma
Frequency of transformation is low,
between 0.3% and 3%
Erosive and atrophic forms commonly
undergo transformation

31. 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

32. ReferencesReferences
Burket’s Oral Medicine – 10
th
Edition
 Shafer’s Oral Pathology – 5
th
Edition
Essentials of Oral Pathology
www.emedicine.com
www.medscape.com