Lichenoid Lesions of the Oral Cavityhandouts.uscap.org/2016_LC01_Mull_1P.pdf · 2016-03-02 ·...
Transcript of Lichenoid Lesions of the Oral Cavityhandouts.uscap.org/2016_LC01_Mull_1P.pdf · 2016-03-02 ·...
ACCME/DisclosuresThe USCAP requires that anyone in a position to influence or control the content of CME disclose
any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their
spouse/partner have, or have had, within the past 12 months, which relates to the content of
this educational activity and creates a conflict of interest.
Dr. Susan Müller declares she has no conflict(s) of interest to disclose.
Oral Lichenoid Lesions: Distinguishing the benign from the deadly
Susan Müller, DMD, MS Professor Emeritus
Emory University School of Medicine
Goals
Understand the clinical and histologic presentation of oral lichen planus
How to distinguish some of the common clinical and histologic mimics of oral lichen planus
Differentiate dysplastic lesions that may mimic oral lichen planus
Oral Lichen Planus
Precise etiology unknown T cell-mediated immune dysregulation in which
autocytotoxic CD8+ T cells trigger apoptosis of epithelial cells
Often seen without cutaneous or other mucosal involvement (35% of patients)
Reticular form Most common asymptomatic Wickham’s striae Bilat BM, tongue,
gingiva, palate, vermilion border
Plaque form Dorsal tongue
Erosive OLP: ◦ less common ◦symptomatic ◦Atrophic erythematous areas with central ulceration ◦bordered by fine, white radiating striae
Lichen Planus is a bilateral and/or multifocal disease!
Oral Lichen Planus
Shaggy deposits of fibrin
Oral Lichen Planus: Differential Diagnosis Oral lichenoid drug reactions to systemic
drugs Oral lichenoid contact-sensitivity Chronic graft-versus-host disease “Lichenoid dysplasia” Proliferative Verrucous Leukoplakia
Oral Lichenoid Drug Reaction (OLDR)
Commonly associated drugs include: NSAIDS Antihypertensives Antimalarials Sulfonylureas Misc: gold, allopurinol, penicillamine
Müller S. Oral manifestations of dermatologic disease: a focus on lichenoid lesions.
Head Neck Pathol. 2011 Mar;5(1):36-40.
Drug Rxn To Antihypertensive
OLDR
Mixed inflammatory infiltrate
Oral Lichenoid Contact Reactions
Can be triggered by various contact allergens: Dental amalgam Flavoring agents – particularly cinnamon Acrylic resin monomer
Relevant contact sensitivities in patients with the diagnosis of lichen planus. J Am Acad Dermatol 2000;42:177-82.
Amalgam Reaction
Contact reaction to dental amalgam
Lichenoid Reaction to Amalgam Tertiary lymphoid follicles can form Perivascular inflammation usually present
Cinnamon Reaction Contact reaction to
cinnamon flavoring found in gum, candy, toothpaste, mouthwash, dental floss, soft drinks.
Can see thickened white areas as well as red, sore areas.
Lichen Planus
Is Lichen Planus a premalignant lesion?
Controversial: reported frequency of 0.4% to 5% over observation period of .5 to > 20 yrs.
Most occur in sites of atrophic or erosive LP In some reported cases, LP diagnosis made only on
clinical observation.
Risk of oral squamous cell carcinoma in 402 patients with oral lichen planus: a follow-up study in an Italian population. Oral Oncol, 40 (2004)
The clinical manifestations and treatment of oral lichen planus. Dermatologic Clinics, 21;January 2003.
Dysplasia should NOT be present in lichen planus
Oral Lichenoid Dysplasia
Low-power microscopic features of a band-like inflammatory cell infiltrate can mimic lichen planus
Budding of the epithelial rete and cytologic atypia can be seen
Oral lichenoid lesions that do not have the typical clinical and histologic features of oral lichen planus have a higher malignant transformation rate than lichen planus
Should we make the diagnosis of lichenoid dysplasia?
•The term may cause confusion
•May result in inadequate patient management
Proliferative Verrucous Leukoplakia
First described in 1985, it is a clinical mimic of OLP
Patients are often older females with no EtOH or tobacco history
Multifocal lesions with a propensity for the gingiva, palate, tongue, and buccal mucosa
PVL Histology
Verruciform epithelial hyperkeratosis with a focal area of interface mucositis is noted in an early stage PVL
Atypical Epithelial Hyperplasia
PVL Histology
A 56M – biopsy submitted as rule out lichen planus
A 56M – biopsy submitted as rule out lichen planus
Proliferative Verrucous Leukoplakia
5 weeks later…..
Conclusions Oral lichenoid lesions can be a diagnostic challenge for the pathologist
due to the tremendous overlap in the clinical and pathologic presentation of many inflammatory, reactive, and immune-mediated disorders than commonly involve the oral mucosa.
Ideally good clinical information will accompany the biopsy specimen including site, presentation and other relevant information as an accurate diagnosis cannot be made in a vacuum. It is critical that dysplastic changes in lichenoid lesions not be overlooked to ensure appropriate treatment for the patient.