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.