Lichen planus clinical features and histopathology .pptx

lichen planus clinical features and pathological findings

1. Lichen planus

2. Lichen planus Licehn planus is derived from Greek word Leichen which means tree moss and Latin word planus which means flat It is immunologically mediated muco cutaneous disease First described by Wilson in 1869 It can involve both skin or mucosa or both

3. The overall prevalence of oral lichen planus among Indians is 1.5% Its highest in tobacco users with a relative risk of 13.7 Exact etiology is unknown It’s a T cell mediated inflammatory disease in which cytotoxic CD 8 T cells trigger apoptosis of oral epithelial cells Certain viruses like HPV, HIV and HCV have been implicated

4. Clinical features Female to male ratio 1.4 : 1 Affects oral cavity and skin Most commonly occurs in 5 th decade 40% patients have both oral and cutaneous lesions, 35% have cutaneous alone and another 25% have oral lesions alone

5. The skin lesions of lichen planus appear as small, angular, flat topped papules only a few millimeter in diameter. These may be discrete or gradually coalesce into larger plaques, each of which is covered by fine glistening scale Early in the course of the disease the lesions appear red, but they soon take a reddish, purple, violaceous hue The centre of papule may be slightly umbilicated. Its surface is covered by characteristic, very fine greyish white lines called Wickhams striae

6. Lesions are usually bilaterally symmetrical, most often on flexor aspects of wrist and forearm These lesions are extremely pruritic “Pruritic, purple, polygonal, planar papules, and plaques is classical description of lichen planus

7. Oral manifestations In oral cavity lesions consist of radiating white, grey velvety thread like papules in a linear, annular and retiform arrangement forming typically lacy, reticular patches, rings and streaks A tiny white elevated dot is present at the intersection of white lines known as wickham striae The lesions are asymptomatic bilaterally symmetrical Most commonly involve buccal mucosa, tongue, lips, gingiva, floor of mouth They may precede cutaneous lesions by weeks to months

8. Oral lesions Reticular Erosive Atrophic Plaque like Papular Bullous Reticular Plaque like

9. Histology Microscopically, lichen planus is a prototypical interface dermatitis, so called because the inflammation and damage are concentrated at the interface of the squamous epithelium and papillary dermis There is a dense, continuous infiltrate of lymphocytes along the dermoepidermal junction

10. The lymphocytes are intimately associated with basal keratinocytes, which often atrophy or become necrotic As a response to damage, the basal cells take on the appearance of the more mature cells of the stratum spinosum ( squamatization ) This pattern of inflammation causes the dermoepidermal interface to assume an angulated, zigzag contour ( sawtoothing ) Anucleate, necrotic basal cells are seen in the inflamed papillary dermis and are referred to as colloid bodies or Civatte bodies .

11. These changes bear some similarities to those in erythema multiforme (another type of interface dermatitis) However, Lichen planus shows well-developed changes of chronicity, like epidermal hyperplasia, hypergranulosis , and hyperkeratosis

12. Microscopic examination shows a bandlike infiltrate of lymphocytes along the dermoepidermal junction, hyperkeratosis, hypergranulosis , and pointed rete ridges (“ sawtoothing ”), which results from chronic injury of the basal cell layer

13. Closer view shows lymphocytes and melanophages in the papillary dermis, vacuolar alteration of the basal layer, necrotic keratinocytes ( Civatte bodies), and enlarged keratinocytes with eosinophilic cytoplasm

14. Oral lichen planus. Similar lichenoid inflammatory pattern as seen in the skin except for less hypergranulosis and confluent parakeratosis

15. Stomatitis

16. Stomatitis Stomatitis is an inflammation of mucous lining of the mouth which may involve the cheeks, gums, tongue, lips and roof or floor of mouth The word stomatitis literally means inflammation of the mouth It is a painful condition usually associated with redness, swelling and occasional bleeding from affected area Various factors can lead to stomatitis

17. Causes of stomatitis Chemotherapy Radiotherapy Loose fitting dental prosthetics Trauma Poor dental hygiene Smoking Infections(Viral, bacterial, fungal) Drugs

18. Symptoms Fever Blisters in mouth Swollen gums Drooling Dysphagia Foul smelling breath

19. Types of stomatitis Nutritional deficiency stomatitis Aphthous stomatitis Angular stomatitis Denture related stomatitis Allergic contact stomatitis Migratory stomatitis Herpetic gingivostomatitis

20. Nutritional deficiency Malnutrition (improper dietary intake) or Malabsorption ( poor absorption of nutrients in body) can lead to nutritional deficiency states Common deficiencies which lead to stomatitis are Iron Vit B2 (riboflavin) Vit B6 (Pyridoxine) Folic acid Vit B12 ( Cobalamine )

21. Aphthous stomatitis Aphthous stomatitis(Canker sores) is the recurrent appearance of mouth ulcers in otherwise healthy individuals The cause in not completely understood, but it is thought that it represents a T cell mediated immune response The individual ulcers recur periodically and heal completely

22. Angular stomatitis Inflammation of corners(angles) of lips is termed angular cheilitis or angular stomatitis More common in children Caused due to nutritional deficiency

23. Denture related stomatitis This is most common condition in denture wearers Mucosa beneath the denture appears reddened and is painful Can lead to secondary candida infection Antifungals, improved oral hygiene, removing dentures during sleep prevents this condition

24. Hereptic gingivostomatitis Painful stomatitis Multiple ulcers Caused by Herpes simplex virus

25. Leukoplakia

26. Leukoplakia is defined by the World Health Organization as “a white patch or plaque that cannot be off and cannot be characterized clinically or pathologically as any other disease Accordingly, white patches caused by obvious irritation or entities such as lichen planus and candidiasis are not considered leukoplakia Approximately 3% of the world’s population has leukoplakic lesions, of which 5% to 25% are dsyplastic and at risk for progression to squamous cell carcinoma.

27. Until proved otherwise by means of histologic evaluation, all leukoplakias must be considered precancerous They typically affect individuals between 40 and 70 years of age, with a 2:1 male predominance Tobacco use (cigarettes, pipes, cigars, and chewing tobacco) is the most common risk factor for leukoplakia Other causes include alcohol, sharp tooth, trauma etc

28. Sites of predilection Lateral and ventral tongue Floor of mouth Alveolar ridge mucosa Corner of mouth Less frequently soft palate and lip

29. Clinical forms Homogenous leukoplakia Non homogenous leukoplakia Proliferative verrucous leukoplakia Erythroleukoplakia Sub lingual keratosis Oral hairy leukoplakia Erythroluekoplakia Oral hairy luekoplakia

30. Histology On histologic examination leukoplakia and erythroplakia show Spectrum of epithelial changes ranging from hyperkeratosis overlying a thickened, acanthotic but orderly mucosal epithelium to lesions with markedly dysplastic changes sometimes merging into carcinoma in situ The most severe dysplastic changes are associated with erythroplakia , and more than 50% of these cases undergo malignant transformation With increasing dysplasia and anaplasia, a subjacent inflammatory cell infiltrate of lymphocytes and macrophages is often present

31. Histologic appearance of leukoplakia showing dysplasia, characterized by nuclear and cellular pleomorphism and loss of normal maturation

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