lichen planus and lichenoid reaction 4 .ppt

oral lichen planus and lichenoid reaction

1. Oral Lichen Planus

2. •Lichenplanus(LP)isderivedfromtheGreekLeichen
meaningTreeMossandtheLatinPlanusmeaningflat
•Lichen’sareprimitiveplantscomposedofsymbioticalgae
andfungi
•Termsuggestsflatfungalcondition

3. Definition
•Lichenplanus(LP)isacommondisorderinwhichauto-
cytotoxicTlymphocytestriggerapoptosisofepithelialcells
leadingtochronicinflammation.OralLP(OLP)canbea
sourceofseveremorbidityandhasasmallpotentialtobe
malignant.
-CrispianScully2007

4. •Commonskindisorderwhichaffects0.5–1%ofworld
population(Prevalanceinindianpopulation:1.5%)
•MucocutaneousSkinDisease:CanaffectSkinandOral
mucousmembrane
•Orallesionsarefrequentandmanytimesprecedethe
appearanceoflesionsonskinandgenitalmucousmembrane

5. Etiology
•Thecauseofthediseaseisunknown.
•CurrentevidenceindicatesImmunologicallyMediated
mucocutaneousdisorder
•IncitingfactorsthathavebeennotedarePsychosomatic
FactorsandLichenoidDrugReactions

6. Predisposing Factors
1.GENETIC BACKGROUND
2.AUTO IMMUNITY –ASSOCIATED WITH OTHER
AUTO IMMUNE DISEASE
3.IMMUNODEFICIENCY
4.DRUGS
5.DENTAL MATERIALS
6.STRESS
7.ADVERSE HABITS

7. Pathogenesis of Oral Lichen Planus
•Thevariousmechanismshypothesizedtobeinvolvedinthe
immunopathogenesisare:
1.ANTIGEN SPECIFIC CELL MEDIATED
MECHANISM
2.NONSPECIFICMECHANISM
3.AUTOIMMUNE RESPONSE
4.HUMORAL IMMUNITYPATHOGENESISOFOLP

8. NON SPECIFIC MECHANISM
•EpithelialBasementMembraneInteractions
•MatrixMetalloproteninasesMediated
•ChemokineMediated
•MastCellsMediated

9. Immunologic Mechanisms

10. Expression of an Unknown antigen associated with MHC class-I on
basal keratinocytesonly at the lesion site
(Self-peptide , Lichen Planusantigen)
Influx of Antigen specific CD8+ T-cell due to either:
(i)Encountering the keratinocyteantigen by chance on routine
surveillance in the epithelium (“Chance Encounter” hypothesis)
OR
(ii)Attracted to the epithelium by keratinocyte-derived chemokines
(“Directed Migration” hypothesis).

11. Activated CD8+ T-cells (and possibly keratinocytes) release
chemokines that attract additional lymphocytes and other
immune cells into the developing OLP lesion
CD8+ cytotoxic T-cells in OLP secrete TNF-αthat triggers
keratinocyte apoptosis via TNF-R1.

12. Keratinocyteantigenexpressionatthedevelopinglesionsite
couldbeinducedby:
–Systemicdrugs(lichenoiddrugreaction),
–Contactallergensindentalrestorativematerialsor
toothpastes(contacthypersensitivityreaction),
–Mechanicaltrauma(Koebnerphenomenon),
–BacterialorViralinfection,or
–AnUnidentifiedagent.
Subsequently,intra-epithelialCD8+cytotoxicT-cells
recognizethelichenplanusantigenassociatedwithMHC
class-Ionlesionalkeratinocytesandtriggerkeratinocyte
apoptosis.

13. Lichenoid Drug Reaction
Some of the drugs commonly associated with Lichenoid
reactions are:-
1.Anti –malarials
2.NSAIDs
3.Diuretics
4.Antihypertensives
5.Antibiotics
6.Heavy metals.

14. Alternate Immunologic Mechanism

15. Langerhan’s Cells or basal keratinocytes may present antigen
associated with MHC class-II to CD4+ helper T-cells that are
stimulated to secrete the Th1 cytokines IL-2 and IFN-γ
Activation of CD8+ cytotoxic T-cells
Trigger basal keratinocyte apoptosis
(Local production of IFN-γmaintains keratinocyte MHC class-II
expression, thereby contributing to disease chronicity)

16. Psychosomatic Factor
•Stress,anxietyandemotionalchangesmaytriggerLichen
planus
•Provenfactthatpatientswitherosiveandatrophiclesions
exhibitsgreateranxietyandotherpsychologicdisorders.
•Difficulttodeterminecauseandeffectrelationbetween
psychologicdisordersandoralLichenplanus.
(Psychologicdisorderscouldbeaconsequenceoforal
Lichenplanusanditslesions)

17. General Clinical features
•AGE-middle aged or elderly people
•MEAN AGE OF ONSET -5 th decade of life
•Rarely in young adults and children
•Female : Male = 3 : 2
•Lichen planus commonly affects 1-2% of the general
population , prevalence rate being 0.5to 2.2%
•40% lesions occur on both oral and cutaneous surfaces,
35% occur on cutaneous surfaces alone, and 25% occur
on oral mucosa alone

18. •Theskinlesionsaresmall,angular,flattoppedpapulesonly
afewmillimetersindiameterbilaterallydistributedon
FlexorSurfaces
•Discretelesionswhichgraduallycoalesceintolarge
plaques.Thecentreofthepapule/plaquemaybeslightly
umblicatedwithaglisteningscalecoveringit.
•Characteristic,veryfine,grayish–whiteradiatinglines
called“Wickham’sstriae”seen.Alsocalled“HonitonLace”
•TheprimarysymptomofLichenplanusis“Severe
Pruritis”.

19. •Selflimitingdiseasewithperiodsofregressionand
recurrence
•InitiallyRed-->PurpleorViolaceoushue-->adirty
Brownishcolor
•GrinspanSyndrome=LichenPlanus+Hypertension+
DiabetesMellitus
•“Koebner’sphenomenon”-skinlesionsextendalongthe
areasofinjuryorirritation(ISOMORPHICRESPONSE)

24. Oral Manifestations
PatientCommonlyPresentswithBurningsensationoforal
mucosawhenhehasfood.SometimesPainmaybefelt
TypesofOralLichenPlanus:
1.Reticular
2.Papular
3.Plaquelike
4.Atrophic
5.Erosive
6.Bullous
7.Ulcerative

25. Distribution of Oral Lesions
1.Buccal mucosa = 80%
2.Tongue = 65%
3.Lips = 20%
4.Gingiva, Floor or mouth & Palate = 10%

26. Reticular Lichen Planus
•Most common type
generallyseenbilaterallyon
posteriorBuccalmucosa
•OuterradiatingWickham
striaeseenwhichoften
displaysaperipheral
erythematouszone,which
reflectsthesubepithelial
inflammation

27. Papular Type
•Usuallypresentinthe
initialphaseofthedisease.
•Characterizedbysmall
whitedots,whichusually
interminglewiththe
reticularform.
•Sizeapprox.0.5mm

28. Plaque Type
•Showsahomogenouswell
demarcatedwhiteplaque
withWickhamstriae
•Plaquetypelesionsmay
clinicallybeverysimilarto
homogenousleukoplakia
•Commonintobaccousers

29. Atrophic Type
•Characterized by a
homogenousredareawhichis
smooth,poorlydefinedwith
peripheralstriae
•Usuallyassociatedwith
Desquamativegingivitis
•Pain&Burningsensation
•Histopathologicexamination
mandatory toconfirm
diagnosis

31. Erosive Type
•SymptomaticLesions=Pain,
Burningsensation,bleeding,
desquamativegingivitis
•Atrophicareaswithcentral
ulcerationofvaryingdegree
•Peripheryshowsstriae
•Pseudomembranecovered
ulcerationswithkeratosisand
erythema

32. Bullous Type
•Vesciculobullouspresentationcombinedwithreticularor
erosivepattern
•Rareformcharacterizedbylargevesiclesorbullae(4mm
to2cm)
•Lesionsusuallydevelopwithinanerythematusbase,
ruptureimmediatelyleavingpainfululcers
•Usuallyhaveperipheralradiatingstriaeandseenon
posteriorpartofbuccalmucosa

35. Ulcerative Type WHO 1972
•Theyarethemostdisablingformoforallichenplanus
•Clinicallythefibrincoatedulcersaresurroundedbyan
erythematouszonefrequentlydisplayingradiatingwhite
striae.
•Thisappearancemayreflectagradientoftheintensityof
subepithelialinflammationthatismostprominentatthe
centreofthelesion.

37. Oral Lichen Planus
Investigations

38. •Histopathology
•Immunoflourescentstudies
•ImmunoglobulinAssay
•PASstaining
•SkinPatchtesting

39. •Hyperorthokeratinisationorhyperparakeratinisation
•Thickeningofgranularlayer
•Acanthosisofspinouslayer
•Intercellularoedemainspinouslayer
•“Saw-tooth”retepegs
•Liquefactionnecrosisofbasallayer-MaxJosephspaces
Histopathology

40. •Civatte(hyalineorcytoid)bodies
•Aneosinophilicbandmaybeseenjustbeneaththebasement
membraneandrepresentfibrincoveringlaminapropria
•Juxta-epithelialwell-definedbandlikezoneofcellular
infiltrationthatisconfinedtothesuperficialpartofthe
connectivetissue,consistingmainlyoflymphocytes

42. Max Joseph spaces: Sub-epithelial clefts formed by acantholysis or
hydropic degeneration of basal cells.

43. Civattebodies:
(Hyaline/Cytoid/Colloid/Sabouraud/Keratin)
–SeeninBasallayer&upperPapillarydermis,
individuallyorinclumps
–Apoptotickeratinocytes
–Containsofintracellularfilamentsofdead
keratinocytes,andmayentrapimmunoglobulinor
fibrin
–Slightlysmallerthanbasalkeratinocytes,Rounded,
Eosinophilic,Hyaline,Anucleatestructures

46. •DirectimmunofluorescenceisusefulindistinguishingOLP
fromotherlesionsanddemonstratesaSHAGGYBANDOF
FIBRINOGENinthebasementmembranezonein90to100
%cases
•MultipleIgMstainingcytoidbodiesindermalpapillaor
peribasalarareacanalsobeseen.Highlysuggestiveof
lichenplanusifpresentinclusters
•Indirectimmunofluorescencenotusefulinthediagnosisof
OLP
Immunoflourescence studies

48. •Periodicacid-Schiff(PAS)stainingofbiopsyspecimensand
candidalculturesorsmearsmaybeperformed.
•SkinpatchtestingmaybehelpfulinidentifyingContact
Allergyinpatientstodifferentiateorallichenplanusand
lichenoidreaction

49. Malignant Transformation
•OLPisconsideredapre-malignantcondition
•Thereportedtransformationratesvaryfrom0.4to5.3%.
Overaperiodof5years
1.IncreasedriskofOralSquamousCellCarcinomain
OLPpatientswhoalsoshowTobaccoAbuse
2.EROSIVEandATROPHIC formscommonly
undergotransformation

50. Microbes in Oral Lichen Planus
•IncreasedprevalenceofCandidaspeciesinboth
mycologicalandhistologicalstudiesoforallichenplanus
•LPmoreprevalentInHIV+vepatients
•HepatitisCVirusinfectionandconcomitantoccurrenceof
orallichenplanushasbeenobserved

51. Syndromes Associated with Oral Lichen Planus
•GRINSPANSYNDROME istheassociationofOLPwithDiabetes
andHypertension
•GRAHAM LITTLESYNDROME andVULVO-VAGINO-
GINGIVALSYNDROME areothersyndromesassociatedwith
OLPinwhichthereismucosalinvolvementofgingivalandgenital
region,usuallyoferosivetype

52. Oral Lichenoid Reaction
•Lichenoidreactionsandlichenplanusareofdifferent
etiologyyetexhibitsimilarclinicalandhistopathologic
features
•Lichenoidreactionsdiffersfromlichenplanusastheyoccur
followingexposuretospecificagents
•Suchagentsarebelievetoexposethelichenspecificantigen
onkeratinocytes.

53. •OralLichenoidreactionscanbegroupedas:
1.LichenoidDrugReactions
2.LichenoidcontactReactions
3.LichenoidreactionsofGraftversushostdisease

54. Lichenoid Drug Reaction
•FirstreportedinmilitarypersonnelinWorldWarIIwho
hadbeenprescribedanti-malarialdrugsandsincethena
widevarietyofdrugshavebeenassociatedwith
precipitatingLichenoidDrugReactions
•DrugsthathavebeenimplicatedincludeNSAIDS,ACE-
inhibitorsandbeta-blockers.

55. •Lichenoidlesionsmaybeunilateral,asymmetricandoccur
inuncommonsitesandtendtobeerosive.
•Histologicalexaminationmayshowamorediffuse
lymphocyticinfiltrateandmorecolloidbodiesthaninclassic
Lichenplanus

57. Lichenoid Contact Reaction
•Followingtheplacementofadentalrestorationorprovisionofa
denture
•Theselichenoidreactionsareusuallytheresultofacontact
sensitivityorirritationtoanyrestorationoradenturecomponent
incloseproximitytotheoralmucosa
•Alsofollowingexposuretoflavorings,especiallycinnamatesin
toothpaste

59. Lichenoid Reactions of Graft Vs Host disease
•Oralmucosallichenoidlesionsarealsoseenwithinthe
spectrumofchronicgraft-versus-hostdiseasefollowing
allogenicbonemarrowtransplantation.