CASE

PRESENTATION
Resource faculties:
Prof. Dr. Jyotsna Rimal (HoD)
Presenter :
Dr. Iccha Kumar Maharjan (Associate Prof.)
Sagar Adhikari
Dr. Pragya Regmee (Assistant Prof.) JR- II

Department of Oral Medicine and Radiology

 Demographic Details

• Name: Goma Rai Marital status: Married

• Age/ Gender: 35 years/ Patient ID number: 3190228
Female
Phone number: 9861783845
• Address: Dharan-16, Sunsari
SES: Upper middle
• Occupation: House wife
• Religion: Hindu
2
• Date: 25th February, 2019
 Chief complain

• Complain of roughness in right side of cheek in inner aspect since 3

months.

3
History of Presenting Illness
• Apparently well 3 months back when she noticed roughness in right
side of cheek in inner aspect.
• Associated with burning sensation (NRS=7/10) which was insidious in
onset, gradually progressive, intermittent, aggravated on consumption
of hot and spicy food with no radiation and shifting.
• No known history of trauma/ cheek bite.
• No history of any discharge
• No history of similar areas present in other parts of oral cavity.
• No history of similar areas present in other parts of body(skin). 4

• No history of itching sensation anywhere else in the body.

• No known history of allergy to any food items, medications.
• No recent change in toothpaste.
• No recent use of any medications.
• No history of fever.

5
Medical History: No relevant medical history reported.

Family History: No history of similar illness in other members of family

Past Dental History: History of cleaning of teeth at a local dental clinic 6

months back which was uneventful.
No history of any filling done in teeth.

6
Personal History:
• Diet history: Mixed diet, 2 major (rice, pulses, vegetables) + 2 minor
(tea, snacks) meals/day.
• Sleep: Unaltered
• Bowel/bladder: Unaltered
• Menstrual: Normal with cycle of 30 days
• Oral hygiene: Brushes twice daily with medium bristle toothbrush and
fluoridated toothpaste for 3-4 minutes in vertical/horizontal stroke
motion. Changes her toothbrush every 2-3 months. Occasional use of
tooth pick.
7
• Deleterious habit: Not present
General examination
Vitals: Peripheral Signs:
• Pulse: 74 beats/minute, measured in Pallor
right wrist (radial artery)
Icterus
• Respiratory rate: 18 cycles/ minute,
thoracoabdominal Cyanosis Absent

• Blood pressure: 130/ 80 mmHg in right Clubbing

arm in supine position Edema
• Temperature: Afebrile to touch Dehydration
8
• Height: 5 feet 2 inch (as said by patient)
• Weight:61 kg
• Body mass index: 24.6 kg/m2 (Normal)

9
Extraoral examination:
No abnormality detected in:
Face
Skin
Hair
Eyes
Ears
Nose
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Neck
 Temporomandibular Joint (TMJ)
• Inspection:
Bilateral pre-auricular area appeared symmetrical.
• Palpation:
• Extra-auricular: Bilateral well coordinated synchronous movement
of condyle felt. No tenderness present at rest, occlusion, right/left
lateral excursion, protrusion and inter-incisal opening.
No joint noise felt
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Auscultation: No joint noise heard.

Range of motion: Interincisal opening: 44mm

• Right/left lateral excursion: 10mm
• Protrusion: 8mm,
• No deflection/deviation present.

12
 Muscles of Mastication
• Primary muscles of mastication: Bilateral masseter and
temporalis appeared symmetrical with adequate bulk of masseter
and non-tender on palpation. Bilateral lateral and medial
pterygoid were non-tender on functional and non-functional
manipulation.

• Accessory muscles of mastication: Bilateral digastric, 13

sternocleidomastoid and trapezius appear clinically normal.
Lymph Node:
• Submental, bilateral submandibular and cervical nodes not palpable

Cranial Nerve Examination:

• No abnormality detected in bilateral trigeminal and facial nerve
examination.

14
Local examination
Inspection: Right buccal mucosa

Ill defined white radiating and interlacing

striae on erythematous background,
irregular shaped, on right buccal mucosa
with respect to 18,17 and retromolar
area, size approximately 4X2 cm2
extending 5mm posterior to
pterygomandibular raphe.
Adjacent mucosa appears normal.
15
Inspection: Right buccal mucosa

Linear white striae with peripheral

hyperpigmentation on buccal mucosa
with respect to 43, 44, 45 and 46.
Adjacent mucosa appears normal.

16
Local examination
Inspection: Left buccal mucosa

White radiating linear striae on

erythematous background on left
buccal mucosa, extending from mesial
aspect of 36 to distal aspect of 38
approximately 3 cm in length. Adjacent
mucosa appears normal.

17
Local examination
Palpation: Right buccal mucosa

All inspectory findings were confirmed.

Non scrapable , with well defined
irregular border, size of 4.5X2.5 cm2
measured with divider and scale, soft
on consistency, rough textured, non
tender on palpation.
No any discharge associated.
No any induration appreciated
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Local examination
Palpation: Right buccal mucosa
All inspectory findings were
confirmed.
Non scrapable, soft on consistency,
smooth textured, non tender on
palpation.
No any discharge associated.
No any induration appreciated

19
Local examination
Palpation: Left buccal mucosa
All inspectory findings were confirmed.
Non scrapable , linear of length 3.5 cm
measured with divider and scale, soft on
consistency, smooth textured, non tender
on palpation.
No any discharge associated.
No any induration appreciated

20
Gingiva:
• Color: Pink with generalized diffused pigmentation of attached
gingiva
• Contour: scalloping margin, knife edged marginal gingiva ,
triangular shaped interdental papilla
• Consistency: firm
• Size: not enlarged
• Stippling: present
• Bleeding on probing: present on lingual aspect of 32, 31, 41, 42
• Position: At CEJ
• Periodontal pocket: Absent
• Furcation involvement : Absent 21
 Hard tissue
• Generalized plaque, calculus Molar relation: Bilateral Angle’s Class I
and stains deposits. Canine relation: Bilateral class I
• Attrition: 11,21, 33, 32, 31, 41,
42, 43
• Pit caries with respect to 26
• Overjet: 2mm
• Overbite: 2mm
22
 Case summary
• A 30 year old female visited Department of Oral Medicine and
Radiology with chief complain of roughness in right side of cheek
in inner aspect since 3 months.
• Apparently well 3 months back when she noticed roughness in
right side of cheek in inner aspect. Associated with burning
sensation (NRS=7/10) which was insidious in onset, gradually
progressive, intermittent, aggravated on consumption of hot and
spicy food with no radiation and shifting.
• No any other relevant history of presenting illness.
23
Inspection:
Right buccal mucosa
• Ill defined white radiating and interlacing striae on erythematous
background, irregular shaped, on right buccal mucosa with respect to
18,17 and retromolar area, size approximately 4X2 cm2 extending
5mm posterior to pterygomandibular raphe. Adjacent mucosa appears
normal.
• Linear white striae with peripheral hyperpigmentation on buccal
mucosa with respect to 43, 44, 45 and 46. Adjacent mucosa appears
normal.
Left buccal mucosa
• White radiating linear striae on erythematous background on left
buccal mucosa, extending from mesial aspect of 36 to distal aspect of
38. Adjacent mucosa appears normal. 24
Palpation:
Right buccal mucosa
• All inspectory findings were confirmed. Non scrapable , with well
defined irregular border, size of 4.5X2.5 cm2 measured with divider and
scale, soft on consistency, rough textured, non tender on palpation. No
any discharge associated. No any induration appreciated
Left buccal mucosa
• All inspectory findings were confirmed.
• Non scrapable , linear of length 3.5 cm measured with divider and
scale, soft on consistency, smooth textured, non tender on palpation.
No any discharge associated. No any induration appreciated 25
 Chairside Investigations

White light Violet light Amber light

Identafi ® and Loss of auto fluorescence:

Negative 26
Toluidine Blue Stain
Vascularity: Negative
Toluidine
Toluidine blue stain: Negative
blue stain
Provisional diagnosis
Reticular form of oral lichen planus with respect to right and left
buccal mucosa.

27
 Differential diagnosis: Oral lichen planus
Disease Points for Points against

Lichenoid drug Similar appearance (whitish No any history of use of drugs,

reactions radiating striae in Bilateral
erythematous background)

Lichenoid contact Similar appearance (whitish No associated dental materials

eruptions radiating striae in
erythematous background),
Site(buccal mucosa)
Discoid lupus Similar appearance(whitish Absence of more prominient striae
erythematosus radiating striae) Age, ending in sharp demarcation.
site(buccal mucosa), non
scrappable white lesion

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 Prescription
Rx,
1. Tantum Mouthwash 10 ml TIDX 7 days

29
Investigations:
SN Parameters Values Reference range
1 Hemoglobin 16.4 gm/dL 11-16
2 TLC 8000 cells/mm cube 4000-11000
3 DLC N 63, L 19, M 5, E 13 N 40-75, L 20-45, M 2-10,
E 1-6
4 Platelets 249000 cells/ mm cube 150000- 400000
5 International 1, 14 sec 1, 14-16 sec
Normalized Ratio,
Prothrombin time
6. Activated partial 29 sec 25-30
thromboplastin time
7. Bleeding time 3 min 2-5
30
8. Clotting time 7 min 3-6
7 Random Blood 90mg/dL < 140
Sugar
8. Serology HIV, HBsAg, HCV
(Negative)

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Procedure
• Incisional biopsy under local anesthesia with 6mm punch
from right buccal mucosa.

32
Histopathology Date: April 18, 2019

33

4x 10x Oral Lichen Planus

Final Diagnosis
• Oral Lichen Planus (Reticular form, Bilateral buccal mucosa)

34
 Treatment plan
Systemic phase:
• Not required
Initial phase:
• Oral prophylaxis and oral hygiene instructions (Dept. of Periodontology
and Oral Implantology)
Corrective phase:
Restoration of carious 26 (Dept. of Conservative Dentistry and
Endodontics)
Maintenance phase:
35
• Maintain good oral hygiene, follow up on 15 days.
 Prescription
Rx,
1. KENACORT oral paste LA XTID for 15 days
(Triamcinolone acetonide 0.1%)
2. Cap LYCOVINO SG BD for 15 days.
(Lycopene 5000mcg, Lutein 2000mcg, Beta Carotene 5.17 mg, Zinc
sulphate 27.45mg, Selenium dioxide 70 mcg, Grape seed extract 10 mg)
3. Mouthwash TANTUM 10ml X SOS/TID
(Benzydamine 0.15%)
36
Follow up after 15 days(2 nd May)

37
Second Follow up (28 th may)

38
Third Follow up after 1 month( 4 th June)

39
Fourth Follow up after 45 days ( 19th June)

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 Discussion: Oral lichen planus

• A common chronic inflammatory mucocutaneous disorder that

typically affects the oral mucosa and additionally, in some
cases the skin.
• Can affect other non-oral mucosal surfaces such as the
genitals, anus and pharynx.
• Conjunctival and oesophageal involvement may rarely occur.

41

Guidelines for the Management of Oral Lichen Planus In Secondary Care , The British Society for Oral Medicine- October 2010
Etiology and Pathogensis
• The etiology of OLP is not known.
• During many years, it has become evident that the immune system has a
primary role in the development of this disease.
• Expression of the cell-mediated arm of the immune system being involved in
the pathogenesis of OLP through T-lymphocyte cytotoxicity directed against
antigens expressed by the basal cell layer.
• Stress is considered as an aggravating factor.
• During recent years, an association between OLP and hepatitis C virus
(HCV) has been described in populations from Japan and some
Mediterranean countries.
42

Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

Epidemiology
• Prevalence: 0.5-2.2%
• Female> Male
• Mean Age: 55 years

43

Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

Clinical Findings:
• OLP may contain both red and white elements and provide, together
with the different textures, the basis for the clinical classification of this
disorder.
• The white and red components of the lesion can be a part of the
following clinical types:
• Reticular
• Papular
• Plaque-like
• Bullous
44
• Erythematous
• Ulcerative
Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015
Reticular form of OLP:
• Characterized by fine white lines or striae.
• The striae may form a network but can
also show annular (circular) patterns.
• Often display a peripheral erythematous
zone, which reflects a subepithelial
inflammation.
• Most frequently is observed bilaterally in the buccal mucosa and
rarely on the mucosal side of the lips.
45
• Can sometimes be observed at the vermilion border.
Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015
Papular type of OLP
• Usually present in the initial phase of the
disease
• Clinically characterized by small white
dots, which in most occasions intermingle
with the reticular form.
• Sometimes the papular elements merge
with striae as part of the natural course.

46

Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

Plaque-type OLP
• Shows a homogeneous well-demarcated
white plaque that occurs in conjunction with
striae
• May clinically be very similar to homogeneous
oral leukoplakias.
• The difference between these two mucosal
disorders is the presence of reticular or
papular structures in the case of plaque-like
OLP.
• Most often encountered in smokers, and
following cessation, the plaque may disappear 47
and convert into the reticular type of OLP.
Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015
Erythematous (atrophic) OLP
• Characterized by a homogeneous red
area.
• When present in the buccal mucosa or in
the palate, striae are frequently seen in the
periphery of the lesion.
• Some patients may display erythematous
OLP exclusively affecting attached gingiva
• This form of lesion may occur without any
papules or striae and presents as
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desquamative gingivitis.
Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015
Ulcerative lesions
• The most disabling form of OLP
• Clinically, the fibrin-coated ulcers are
surrounded by an erythematous zone with
white striae in the periphery
• Patients complain of a smarting sensation
in conjunction with food intake.

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Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

Bullous lesions
• This rare presentation manifests as small
vesicles or bullae within the white patches
• Rupture to form ulcers

50

Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

• Cutaneous lesions may be encountered in approximately 15% of
patients with OLP.
• Classic appearance of skin lesions consists of pruritic erythematous
to violaceous papules that are flat topped.

51

Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

• The predilection sites are the trunk and flexor surfaces of arms and
legs.
• The papules may be discrete or coalesce to form plaques.
• The patients report relief following intense scratching of the lesions,
but trauma may aggravate the disease, which is referred to as a
Koebner phenomenon.
• The most frequent extra-oral mucosal site involved is the genital
mucosa.
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Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

 DIAGNOSIS

• The diagnostic criteria of oral lichen planus – defined by the World

Health Organization – are precise and describe both clinical and
histopathological features

53
 54
Rad M, Hashemipoor MA, Mojtahedi A, Zarei MR, Chamani G, Kakoei S, Izadi N. Correlation between clinical and
histopathologic diagnoses of oral lichen planus based on modified WHO diagnostic criteria. Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology and Endodontics. 2009 Jun 1;107(6):796-800.
 Management
• Several topical drugs have been suggested, including steroids,
calcineurin inhibitors (tacrolimus), retinoids, and ultraviolet
phototherapy.
• Among these, topical steroids are widely used and accepted as the
primary treatment of choice.
• Some reports have advocated very potent steroids as clobetasol
propionate in favor of intermediate steroids such as triamcinolone
acetonide.
55

Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

 • Topical application of cyclosporine, tacrolimus, and retinoids has
been suggested as a second-line therapy for OLP.
• Topical tacrolimus 0.1% ointment has been reported to have a
better initial therapeutic response than triamcinolone acetonide
0.1% ointment.
• However, this drug has been labeled with the US Food and Drug
Administration’s Black Box Warning: “Possibility of increased risk of
malignancy (squamous cell carcinoma and lymphoma) in patients
using topical tacrolimus/pimecrolimus for cutaneous psoriasis.
56

Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015

Q. What is the efficacy of clobetasole compared to
triamcenolone in the treatment of oral lichen planus?
Problem Intervention Comparison Outcome

Question Oral Lichen Clobetasol Triamcenolone Efficacy

Planus

MeSH Lichen Clobetasol Triamcenolone Efficacy

Planus Oral

57
58
59
 • Group I -10 patients with clinically and histologically confirmed OLP
subjects were recruited to receive topical triamcinolone acetonide
0.1% for 6 weeks
• Group II -10 patients with clinically and histologically confirmed OLP
subjects were recruited to receive topical clobetasol propionate
0.05% for 6 weeks
• Group III -10 patients with clinically and histologically confirmed OLP
subjects were recruited to receive topical tacrolimus 0.03% for 6
weeks.
60
➢Sivaraman, Shivakumar, et al. "A randomized triple-blind clinical trial to compare the effectiveness of topical triamcinolone
acetonate (0.1%), clobetasol propionate (0.05%), and tacrolimus orabase (0.03%) in the management of oral lichen
planus." Journal of pharmacy & bioallied sciences 8.Suppl 1 (2016): S86.
• All the three groups were instructed to apply the topical ointments on
the lesional site. Topical agent is applied 4 times a day for 6 weeks
and subjects were checked at 1st, 3rd, and 6th week for the remission
lesion. Subjects were also checked after 3 months as follow-up.

61
 Result:
• The overall treatment response was significant better in the Group B
(clobetasol 0.05%).
• No recurrence was observed in any of the three groups at the end of
3 months.
Conclusion:
• It was concluded that clobetasol propionate 0.05% ointment has
higher efficacy when compared to triamcinolone acetonide 0.1%
ointment and tacrolimus ointment 0.03% in the management of OLP.
• It was also inferred that triamcinolone 0.1% has better effects than
tacrolimus 0.03%. 62
➢Sivaraman, Shivakumar, et al. "A randomized triple-blind clinical trial to compare the effectiveness of topical triamcinolone
acetonate (0.1%), clobetasol propionate (0.05%), and tacrolimus orabase (0.03%) in the management of oral lichen
planus." Journal of pharmacy & bioallied sciences 8.Suppl 1 (2016): S86.
Comparative study of the efficacy of Lycopene versus
Prednisolone in the management of Oral Lichen Planus: A
double blind, Randomized Clinical Trial
• This was a double-blind randomized comparative study in which
clinically and histopathologically proven symptomatic OLP patients
were enrolled and divided into two groups.
• Lycopene group received oral lycopene 4 mg/day (n=13) and
prednisolone group received oral prednisolone 40 mg/day (n=15) for
eight consecutive weeks.
• Assessments were made at baseline and after 2, 4, 6 and 8 weeks of
treatment, based on the Numerical Rating Scale (NRS) and the
Piboonniyom REU (Reticular, Erythematous and Ulceration) severity
score. 63

Kushwaha RP, Rauniar GP, Rimal J. Comparative study of the efficacy of lycopene versus prednisolone in the
management of oral lichen planus-a randomized, double blind clinical trial.
• REU severity scores were decreased by 74% (p=0.005) and 91%
(p=0.001) in lycopene and prednisolone groups respectively.
• Complete remission (EI=100%) of lesion was observed in two
(15.4%) patients treated with lycopene and ten (66.7%) patients
treated with prednisolone.
• However, the overall treatment response was higher in the
prednisolone group as compared to the lycopene group.
• In conclusions, prednisolone was found to be more effective than
lycopene in the treatment of OLP.
64
 Conclusion
➢Definitive diagnosis and management of symptomatic OLP remain
challenging. Importantly, there is no uniform approach for treating OLP,
and management will vary from individual to individual.

➢ The most commonly used treatment for oral lichen planus is topical
corticosteroids. For severe disease, systemic medications may be
warranted including corticosteroid.
65
 References
➢ Jontell and Holmstrup. Red and white lesions of the oral mucosa. In: Glick M. Burket’s Oral Medicine. 12th
edition. Connecticut: PMPH, 2015
➢ Neville B., Damm DD , Allen CM , Bouquot J and Neville BW. Epithelial pathology. In: Oral And Maxillofacial
Pathology. 3rd edition. United Kingdom: Saunders Elsevier, 2009
➢ Rajendran R. Benign and malignant tumors of oral cavity. In: Shafer’s textbook of Oral Pathology. 6th edition.
Delhi: Elsevier, 2010
➢ Wood and Goaz. White lesions of the Oral Mucosa. In: Differential diagnosis of oral and maxillofacial lesions.
5th edition. St Louis: Mosby, 2007
➢ Guidelines for the Management of Oral Lichen Planus In Secondary Care , The British Society for Oral
Medicine- October 2010
➢ Di DS, Guida A, Salerno C, Contaldo M, Esposito V, Laino L, Serpico R, Lucchese A. Oral lichen planus: a
narrative review. Frontiers in bioscience (Elite edition). 2014;6:370-6.
➢ Rad M, Hashemipoor MA, Mojtahedi A, Zarei MR, Chamani G, Kakoei S, Izadi N. Correlation between clinical
and histopathologic diagnoses of oral lichen planus based on modified WHO diagnostic criteria. Oral Surgery, 66
Oral Medicine, Oral Pathology, Oral Radiology and Endodontics. 2009 Jun 1;107(6):796-800.
 References
➢ Sivaraman, Shivakumar, et al. "A randomized triple-blind clinical trial to compare the effectiveness of topical
triamcinolone acetonate (0.1%), clobetasol propionate (0.05%), and tacrolimus orabase (0.03%) in the
management of oral lichen planus." Journal of pharmacy & bioallied sciences 8.Suppl 1 (2016): S86.
➢ Thongprasom K. Oral lichen planus: Challenge and management. Oral diseases. 2018 Mar 1;24(1-2):172-3.
➢ Lavanya N, Jayanthi P, Rao UK, Ranganathan K. Oral lichen planus: An update on pathogenesis and
treatment. Journal of oral and maxillofacial pathology: JOMFP. 2011 May;15(2):127.
➢ Alrashdan MS, Cirillo N, McCullough M. Oral lichen planus: a literature review and update. Archives of
dermatological research. 2016 Oct 1;308(8):539-51.
➢ Kushwaha RP, Rauniar GP, Rimal J. Comparative study of the efficacy of lycopene versus prednisolone in
the management of oral lichen planus-a randomized, double blind clinical trial.

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Thank you
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