 Hello everyone welcome back to another session on dentistry and most today's topic is oral lichen planus it is a immunological muco cutaneous lesions which can affect either skin or mucosa or both so it is not just confined to oral cavity it is present other parts of the body too what we are seeing about oral lichen planus in detail so now let's get into the details of oral lichen planus so oral lichen planus so lichen planus the word derived from the greek word lichen means trimose and also a latin word planus planus means flat so trimose or flat so it looks like a trimose and it is a flat lesion so that's why it got this name lichen planus it is a immunologically mediated muco cutaneous disease first described by wilson in 1869 it affects around 0.5 to 1 percentage of world population the condition can affect either the skin mucosa or both so it causes bilateral white striations papules or plaques on the buckle mucosa tongue and ginger so it is either papule or plaque or white striation can be seen on buckle mucosa tongue and ginger let's see it's a historical information that is it was first described by wilson in 1869 as a chronic disease affecting the skin scalp nails and mucosa with possible rare malignant degeneration and franco is henry reported the first oral lichen planus related cosinoma in 1910 and we come in 1895 described the characteristic appearance of whitish stray and punctuations that developed a flat surface papules so that is become stray which is a characteristic feature of oral lichen planus which was it was described first in 1895 so let's see the epidemiology of oral lichen planus so as I mentioned it was affecting around 1.5 population and the highest is 3.7 percent it is people with mixed oral habits and lowest is 0.3 percent in non users of tobacco okay so in mixed users it is around 3.7 and non users it is 0.3 percent so the annual age adjusted incidence rate was 2.12 2.5 among thousand men and women and the relative risk of oral lichen planus among smokers is 13.7 times greater than non smokers so smoking is a big contributing or predisposing factor for oral lichen planus so as per definition it is a common chronic immunological muco cutaneous disorder of striated squamous epithelium so etiological factors we don't know exact etiology but the most accepted and current data suggest it is a T cell mediated inflammatory disease in which there is a production of cytokines which leads to apoptosis apoptosis is nothing but cell death so T cell mediated problem there is cytokine production and it leads to apoptosis that is a etiology so other possible theories which includes genetic backgrounds where the weak association between HLA antigen and lichen planus so that also is there but it is commonly accepted one is T cell mediated cytokines apoptosis concept and allow to see the predisposing factors so genetic background could be a predisposing factor and infectious agents such as HPV virus that is human papilloma virus, epstein bar virus, human immunodeficiency that is HIV virus there are various habits which includes smoking, betel nut chewing and diabetes hypertension which are associated with oral lichen planus. Dental materials such as prostrate treatments in the oral cavity also identified as a triggering element of oral this lichenoid drug reaction okay and drugs this drug reaction may be triggered by systemic drugs including NSAIDs, beta blockers and sulfonyl urea so these are the predisposing factors of oral lichen planus now let's move on to the clinical features so clinical features oral lichen planus affects all racial groups and there is a female to male predilection that is 1.4 to 1 females having more diseases it is affecting oral cavity in a bilateral fashion it is always bilateral oral lesions usually involve the posterior buccal mucosa or less commonly the tongue and although any side can be involved palatal and sublingual lesions are very rare palatal and sublingual lesions age we can say middle aged or elderly people mean age is around fifth decade and it is rarely seen in young adults and children so lichen planus commonly affect 1 to 2 percentage of general population we discussed it already prevalence is around 0.5 to 2.2 percentage and the skin lesions so while coming to the skin lesions of lichen planus which appear as small angular flat topped papule flat topped papule only a few millimeter or diameter these may be discrete or gradually coalesce into large plaque so papule is different plaque is a correlated mass appearance plaque means hard surface so you know dental plaque so it is a hard tenacious appeared material so papule coalesce to form plaque each of which is covered by a fine glistening scale okay so the papules are sharply demarcated from the surrounding skin so early in the course of the disease the lesion appear as red but they soon take reddish purple or violet hue then later a dirty brownish color it will develop so the center of the papule may be slightly implicated so we know what is umbilical chord so the center of this papule it's like umbilical area it is slightly umbilicated its surface is covered by a characteristic very fine grayish white lines which is known as vicamstray so vicamstray is very very important it is a commonly asked question as a short note it is seen in oral lichen planus it is a white grayish white lines seen on the surface of this lesion and the lesion may occur anywhere on the skin surface but usually are distributed in a bilateral symmetrical pattern most often on the flexor surface of the wrist and forearms the inner aspect of knees and thighs and the trunk so i'm talking about the other parts lesions which is seen in the other parts not just in the oral cavity so in chronic cases hypertrophic plaques may develop especially over the shins and the primary symptom of lichen planus is severe pruritus that may be intolerable okay and in patients with oral lichen planus scalp involvement and nail involvement is rare actually so these are the clinical features so don't forget vicamstray okay now we are into oral manifestations so oral manifestation in the oral cavity the lesion consists of radiating white gray velvety thread like papules in a linear or annular and retiform arrangement forming a typical reticular patches rings and streaks so it is a tiny white elevated dot is present at the intersection of white lines which are vicamstray so when vicamstray is inter sector and these intersected areas will be little elevated dot so it is it could be linear annular or retiform arrangement and the most common site is buccal mucosa and it is usually asymptomatic and bilaterally symmetrical anywhere in the oral cavity so it can be seen mostly on buccal mucosa tongue lip ginjeva floor of the mouth palate and may appear weeks or months before the appearance of cutaneous lesion and in oral lichen planus we have various types that it is based on the clinical presentation so these are the clinical presentation types so we have basically six types one is reticular erosive atrophic plaque like popular and bullies oral lichen planus these are the clinical presentation different types of clinical presentation classification so let's see one by one first is a reticular type which is the most common type and commonly seen on posterior buccal mucosa and may not be seen on tongue less commonly in ginjeva and lips and even vermilion border they're usually bilaterally seen characteristic pattern of interlacing white lines that is vicamstray the stri often displays a peripheral erythematous zone which reflects the sub epithelial inflammation so there will be the vicamstrays associated with erythematous zone which indicate there is a sub epithelial inflammation and lines are wavy and parallel this is seen in reticular the name gives an idea reticular pattern we know what is how the reticular pattern of anything look like so this becomes stri the clinical presentation will be in a reticular fashion now we have erosive erosive are usually asymptomatic atrophic areas the erosion we know erosion or something is removed from the surface layer surface layer is getting removed so that is erosion so atrophic areas with central ulceration of varying degree periphery of these atrophic regions is usually bordered by fine white radiating stri and symptoms it could be if symptoms other it could be pain burning sensation bleeding and also d squammative ginjevatus so there will be a pseudo membrane covered covering ulceration with keratosis and erythema so there will be a pseudo membrane is covering on the erosive the third one is atrophic oral lichen planus it is characterized by a homogeneous red area smooth poorly defined erythematous area with or without peripheral stray okay the symptoms include pain and burning sensation and keratotic changes combined with mucosal erythema this could be with or without peripheral stray erosive has peripheral stray so when this atrophic oral lichen planus is present in buccal mucosa or in palate there will be peripheral stri present only on buccal mucosa and palate so always remember these stri are very common in reticular pattern because of the stri itself it's got this particular name reticular oral lichen planus now we have plaque type oral lichen planus which is homogeneous well demarcated white plaque seen but not always surrounded by stri which is very common in tobacco uses which could be single or multifocal plaques will be seen and the popular type so the popular type of oral lichen planus is usually present in the initial phase of the disease so it is clinically characterized by small white dots which in most occasions intermingle with the reticular form okay and sometimes these popular elements merge with stri as part of the natural course and the last one is bull's one vesicular bull's presentation combined with reticular or erosive pattern and rare form characterized by large vesicles or bull's and lesions usually develop with an erythematous base rupture immediately leaving a painful ulcer so this bulla will rupture and there will be a painful ulcer and usually these have peripheral radiating stray and are seen on posterior part of buccal mucosa and severe form of extensive degeneration and separation of epithelium from connective tissue also seen in bull's oral lichen planus so these are the six types of oral lichen planus what are they one is reticular erosive atrophic plaque like popular and bull's type most common one is reticular and the bull's is the very rare type so in histopathology so there are lots of features in histopathology the unique features the first one is hyper ortho keratosis or hyper parakeratosis can be seen in epithelium there will be thickening of granular layer there will be acanthosis of spinous layer there will be intercellular edema in spinous layer and there will be sore tooth retipics will be seen sore tooth retipics liquefaction necrosis of basal air that is max joseph clef space which is known as max joseph clef space and sevet bodies that is hyaline bodies or cytoid bodies are seen juxta epithelial band of inflammatory cells juxta epithelial band and an esophilic band may be seen just beneath the basement membrane and which represent fibrin covering of lamina propria so there are lots of histopathological features mainly sevet bodies or hyaline bodies sore tooth retipics max joseph clef space all are associated with oral lichen planus so let's move on to the management and treatment part of oral lichen planus so basically oral lichen planus the treatment goal or the management goal is to reduce the symptoms and speed healing promote the healing if symptoms are mild it may not need any treatment is a self-limiting disease so it will be over by around 8 to 12 months so mild cases we can use fluorinated topical steroids or it should include antihistamines medicines that calm down the immune system such as cyclosporin, lidocaine, mouth washes to namdana area and make the eating more comfortable topical corticosteroids can be applied like clobectosol or oral corticosteroids to reduce swelling and lower immune responses and vitamin a cream also can be applied and the we can use dressings over the skin to protect from scratching and ultraviolet therapy also is an option so pharmacological methods what we have seen and complication is what we are seeing is it could be become malignant that is all chances of oral cancer is there so let's summarize this by seven p's the letter p so it is a papillose squamous solution it is pruritic in nature it is plain topped it is polyangular it is purple colored it is papule and plaque formation and there will be pigmentation okay so oral lichen planus is an important question it will be asked in oral pathology and even oral medicine so you need to write maximum subcontent its introduction its histopathology clinical features oral manifestations the types the six types and its management its pharmacology etiology epidemiology and predisposing factors and all sub beddings you can include and don't forget few things which could be asked as short-term stress or toothed epics max Joseph cliff space and various types of lichen planus that is six types so i'll come over the new topic and industry thank you