| **THE UNIVERSITY OF** | | :---: | | **WESTERN** | | **AUSTRALIA** | **Allergies** **and immune** **mediated** **disease I -** **OLP** **Dr Agnieszka Frydrych**  #### Course Presentation Overview This session focuses on allergies and immune-mediated diseases, specifically addressing Oral Lichen Planus (OLP). #### Presenter Information - **Lecturer:** Dr Agnieszka Frydrych - **Institution:** The University of Western Australia A close-up medical photograph showing oral mucosal tissue with red, inflamed areas and white patches, indicative of oral lichen planus (OLP). The image is part of a presentation on allergies and immune-mediated diseases by Dr. Agnieszka Frydrych from The University of Western Australia. # **Lichen Planus** * **Chronic, systemic disease of established immune-mediated pathogenesis.**   Lichen planus is a chronic, systemic disease characterized by an established immune-mediated pathogenesis. Close-up photo of oral lichen planus showing white, lacy lesions on the gingiva and adjacent mucosa, with inflamed tissue around the teeth. Photo of the oral cavity displaying erythematous mucosa with white, reticular patterns characteristic of lichen planus, likely affecting the buccal mucosa. **Lichen Planus**   Lichen Planus Close-up intraoral photo showing the upper dental arch with lichen planus lesions on the gingiva, indicated by a black arrow pointing to a red, inflamed area near the teeth. Another close-up intraoral photo of the upper dental arch, displaying lichen planus lesions on the gingiva, with a black arrow highlighting the affected area. **Lichen Planus** **Lichen Planus**   Lichen Planus Close-up photograph of oral mucosa showing lichen planus lesions, with a black arrow pointing to a specific area of inflammation or lesion on the gingival tissue. Another close-up photograph of oral mucosa illustrating lichen planus, with a black arrow highlighting a lesion on the gingiva, likely indicating the presence of the condition. **Lichen Planus**   Lichen Planus A close-up photograph of a lichen growing on tree bark, illustrating the natural form of lichen, which is the namesake for the medical condition lichen planus. A clinical photograph showing oral lichen planus, characterized by white, lacy streaks on the red oral mucosa, demonstrating the condition's appearance in the mouth. # **Lichen Planus** **Clinical patterns** * $\rightarrow$ **Reticular** * $\rightarrow$ **Plaque-like** * $\rightarrow$ **Erythematous** * $\rightarrow$ **Erosive / ulcerative** * $\rightarrow$ **Papular** * $\rightarrow$ **Bullous** The clinical presentation of Lichen Planus manifests in several distinct patterns: - Reticular - Plaque-like - Erythematous - Erosive / ulcerative - Papular - Bullous **Lichen Planus** **Clinical patterns** $\rightarrow$ **Reticular**   #### Reticular Pattern - Reticular A close-up photo showing a reticular pattern of lichen planus on the oral mucosa, characterized by white, lace-like streaks on a reddish background. A photo depicting another clinical presentation of lichen planus, showing erythematous, inflamed oral tissue with a textured surface, likely representing a different stage or variant of the condition. **Lichen Planus** 🔊 * Clinical patterns * **Plaque-like**   #### Plaque-like Pattern - Plaque-like A close-up photo showing a plaque-like lesion of lichen planus on the oral mucosa, characterized by white, reticulated patterns on a reddish background. A smaller photo depicting a similar plaque-like lesion of lichen planus, illustrating the characteristic white, lacy pattern on the oral tissue. **Lichen Planus** *Clinical patterns* $\rightarrow$**Plaque-like**   #### Plaque-like Pattern - Plaque-like A close-up clinical photograph showing oral lichen planus (OLP) with white, lacy patterns on the oral mucosa, labeled as 'OLP'. A clinical photograph of leukoplakia in the oral cavity, characterized by white patches on the mucosal surface, labeled as 'Leukoplakia'. # **Lichen Planus** **Lichen Planus** * **Clinical patterns** * $\rightarrow$ **Erythematous** <img src="image.png" alt="Intraoral view showing an erythematous patch on the buccal mucosa, consistent with Oral Lichen Planus.">  #### Erythematous Pattern - Erythematous Intraoral view showing an erythematous patch on the buccal mucosa, consistent with Oral Lichen Planus. The image displays a red, inflamed area on the inner cheek, adjacent to teeth, illustrating the clinical presentation of the condition. **Lichen Planus** * Clinical patterns $\rightarrow$ **Erythematous**   #### Erythematous Pattern - Erythematous A close-up clinical photo showing erythematous lesions in the oral cavity, labeled with 'CIS' indicating a specific case or condition, under the heading 'Lichen Planus'. A clinical photo of the oral cavity displaying erythematous tissue, labeled with 'OLP' to denote Oral Lichen Planus, illustrating a typical presentation of the condition. **Lichen Planus** **Lichen Planus** $\bullet$Clinical patterns $\rightarrow$ **Erosive / ulcerative**   #### Erosive / Ulcerative Pattern - Erosive / ulcerative A close-up photo showing an erosive/ulcerative lesion in the oral cavity, with visible redness and tissue breakdown, illustrating a clinical pattern of lichen planus. A detailed photo of an erosive/ulcerative lesion in the mouth, highlighting inflamed tissue and ulceration, consistent with the clinical presentation of lichen planus. Lichen Planus **Lichen Planus** Clinical patterns **Papular**  #### Papular Pattern - Papular A close-up photo showing the oral cavity with a lesion consistent with lichen planus, characterized by white, lacy patterns on the mucosal surface. The image is labeled under the clinical pattern 'Papular' and is part of a presentation on lichen planus. **Lichen Planus** **Lichen Planus** -Clinical patterns $\rightarrow$**Bullous** 🔊 <br> <img src="image1.png" alt="Image showing two close-up photos of the mouth, likely illustrating Lichen Planus. The left image shows the front teeth and gums with some redness and a small, dark lesion on the gingiva. The right image shows a posterior tooth with a metal crown, and surrounding tissue that appears inflamed and possibly blistered or showing bulla formation, with dental instruments nearby.">   #### Bullous Pattern - Bullous Close-up photograph showing a dental patient's mouth with a metallic dental crown on a tooth, surrounded by inflamed and possibly blistered gingival tissue, illustrating a bullous clinical pattern of Lichen Planus. Close-up photograph of the anterior teeth and gingiva, displaying erythematous and inflamed tissue with a small dark lesion on the gingiva, representing a clinical manifestation of Lichen Planus. # **Lichen Planus** * **OLP affects people of all ethnic groups** (worldwide prevalence 2.2%). * **More frequently seen in women.** * **Typical age of presentation is between 30-60** years of age. Oral Lichen Planus (OLP) is a global condition with specific demographic trends: - **Global Prevalence**: OLP affects people of all ethnic groups with a worldwide prevalence of approximately 2.2%. - **Gender Distribution**: The condition is more frequently observed in women than in men. - **Age of Onset**: The typical age of presentation for patients is between 30 and 60 years of age. **Lichen Planus** * **OLP can occur in children (prevalence 0.03%).** **Photo: Gunashekhar M et al. Dermatology Online J. 2010;16:9.**  #### Pediatric Prevalence While primarily an adult condition, Oral Lichen Planus can occur in children, though it is significantly less common, with an estimated prevalence of 0.03%. A composite photo showing four clinical images of lichen planus in children, including lesions on the lips and oral mucosa. The images illustrate the characteristic appearance of the condition in pediatric patients, with a citation to Gunashekhar M et al. Dermatology Online J. 2010;16:9. **Lichen Planus** * **Commonly involves oral mucosa but can involve other sites:** * **→Skin** * **→Scalp** * **→Nails** * **→Genital mucosa** * **→Anal mucosa** * **→Oesophageal mucosa** * **→Pharyngeal mucosa** * **→Gastric mucosa** * **→Conjunctiva**  Lichen planus commonly involves the oral mucosa, but the condition can also manifest across various other anatomical sites, including: - **Dermatological and Appendageal Sites** - Skin - Scalp - Nails - **Mucosal Sites** - Genital mucosa - Anal mucosa - Oesophageal mucosa - Pharyngeal mucosa - Gastric mucosa - Conjunctiva A bulleted list diagram on a blue background, detailing the various sites affected by Lichen Planus. The text is organized into two columns, with green arrows pointing to each site, including skin, scalp, nails, genital mucosa, anal mucosa, oesophageal mucosa, pharyngeal mucosa, gastric mucosa, and conjunctiva. **Lichen Planus** <img src="image1.jpg" alt="Two images displaying patches of Lichen Planus on human skin. The left image shows lesions on a wrist, and the right image shows lesions on an arm/torso area.">   #### Clinical Presentation of Cutaneous Lesions Visual documentation illustrates the presentation of lichen planus lesions on the skin, specifically highlighting involvement of the wrist and the arm/torso areas. A close-up photograph showing patches of Lichen Planus on a person's wrist, characterized by small, reddish-purple, flat-topped papules. The image includes a date stamp '12 8'02' at the bottom right. A photograph displaying Lichen Planus lesions on the upper arm or torso area, with numerous small, red, itchy papules scattered across the skin. The image is set against a blue background with the title 'Lichen Planus' in yellow text. # **Lichen Planus** **Lichen Planus** Photos curtesy of Clinical Associate Professor Kurt Gebauer, Dermatology West, Perth WA.   #### Clinical Photography Credits Photographic documentation provided courtesy of Clinical Associate Professor Kurt Gebauer, Dermatology West, Perth WA. A close-up photo showing a skin lesion with a reticulated, reddish pattern, characteristic of lichen planus, with a visible navel and a body piercing. A photo displaying a cluster of small, red, raised papules on the skin, consistent with lichen planus, located near the navel area. **Lichen Planus** **Photo: Antonio JR et al. An Bras Dermatol 2014.**  #### Clinical Reference Photo source: Antonio JR et al. An Bras Dermatol 2014. A close-up photo of a scalp lesion consistent with lichen planus, showing a red, inflamed area surrounded by dark hair. The image is credited to Antonio JR et al., An Bras Dermatol 2014. **Lichen Planus** Photo: Podboy A et al. Aliment Pharmacol Ther 2017  #### Clinical Reference Photo source: Podboy A et al. Aliment Pharmacol Ther 2017. A photo showing an endoscopic view of the esophagus with lichen planus, characterized by white, lacy patterns and erythematous mucosa. The image is cited as being from Podboy A et al., Aliment Pharmacol Ther 2017. # **OLP – Aetiology and** # **Pathogenesis** * **Aetiology unknown** * **? Local / systemic inducers of cell-mediated hypersensitivity** * **? Stress** * **? Autoimmune response to epithelial antigens** * **? Microorganisms** * **Dominant type 1 (Th1) cell mediated immune response** While the exact aetiology of Oral Lichen Planus (OLP) remains unknown, several factors are considered potential triggers or contributors to the condition: #### Potential Etiological Factors - **Inducers of Hypersensitivity**: Local or systemic inducers of cell-mediated hypersensitivity may play a role. - **Psychological Factors**: Stress is frequently cited as a possible contributing factor. - **Autoimmune Response**: The condition may involve an autoimmune response directed against epithelial antigens. - **Microbial Influence**: The role of various microorganisms is under consideration. #### Immunopathogenesis - The disease is characterized by a dominant **Type 1 (Th1) cell-mediated immune response**. **OLP – Differential Diagnosis**     This section covers the differential diagnosis for Oral Lichen Planus (OLP). A close-up photo showing a red, inflamed lesion on the inner cheek with a dental restoration visible in the background. A photo of the oral cavity showing a tooth with a dark filling and a white, raised lesion on the adjacent mucosa. A photo displaying a white, raised lesion on the inner cheek, with a dental instrument and a tooth with a crown visible. A photo of the lower front teeth with a red, inflamed area along the gumline, indicating possible gingivitis or irritation. **OLP – Differential Diagnosis** $\rightarrow$**Lichenoid drug reactions** $\rightarrow$**Contact lichenoid reactions** $\rightarrow$**Chronic ulcerative stomatitis** $\rightarrow$**Linear IgA disease** $\rightarrow$**Mucous membrane pemphigoid** $\rightarrow$**Pemphigus vulgaris** $\rightarrow$**Lupus erythematosus** $\rightarrow$**Graft versus host disease** $\rightarrow$**Other**  The differential diagnosis for Oral Lichen Planus (OLP) includes the following conditions: - Lichenoid drug reactions - Contact lichenoid reactions - Chronic ulcerative stomatitis - Linear IgA disease - Mucous membrane pemphigoid - Pemphigus vulgaris - Lupus erythematosus - Graft versus host disease - Other related conditions The image displays a slide titled 'OLP – Differential Diagnosis' with a list of conditions arranged in two columns, each preceded by a green arrow. The left column includes 'Lichenoid drug reactions,' 'Contact lichenoid reactions,' 'Chronic ulcerative stomatitis,' 'Linear IgA disease,' and 'Mucous membrane pemphigoid.' The right column lists 'Pemphigus vulgaris,' 'Lupus erythematosus,' 'Graft versus host disease,' and 'Other.' This layout functions as a diagnostic checklist for distinguishing oral lichen planus from other similar conditions. **OLP – Differential Diagnosis** $\rightarrow$ **Lichenoid drug reactions** **Photos: Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia**  Clinical documentation and photographic evidence of Lichenoid Drug Reactions (LDR). *Source: Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia.* A close-up intraoral photograph showing lichenoid drug reactions on the oral mucosa, characterized by white, lacy patterns and erythematous areas, with a dental restoration visible in the lower right. The image is credited to Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia. **OLP – Differential Diagnosis** **$\rightarrow$Lichenoid drug reactions** **LDR** $\quad$ **OLP**   Comparative analysis between Lichenoid Drug Reactions (LDR) and Oral Lichen Planus (OLP). A close-up photograph of a patient's oral cavity showing lichenoid drug reactions (LDR), characterized by white, reticulated lesions on the buccal mucosa and tongue. A close-up photograph of a patient's oral cavity showing oral lichen planus (OLP), characterized by erythematous mucosa with white, lacy patterns, labeled as OLP. # **OLP – Differential Diagnosis** | Category | Medications | |---|---| | **Antibiotics** | • Tetracycline | | **Anticonvulsants** | • Carbamazepine | | | • Oxcarbazepine | | | • Phenytoin | | | • Valproate sodium | | **Antidiabetics** | • Chlorpropamide | | | • Glipizide | | | • Tolbutamide | | **Antidiarrheals** | • Bismuth | | **Antifungals** | • Amphotericin B | | | • Ketoconazole | | **Antihypertensives** | • Atenolol | | | • Enalapril | | | • Hydrochlorothiazide | | | • Methyldopa | | | • Metoprolol | | **Antimalarials** | • Chloroquine | | | • Hydroxychloroquine | | | • Quinidine | | | • Quinine | | **Antimycobacterials** | • Aminosalicylate sodium | | | • Isoniazid | | | • Rifampin | | | • Streptomycin | | **Antiretrovirals** | • Zidovudine | | **Chemotherapeutics** | • Dactinomycin | | | • Imatinib | | **Immunomodulatory drugs** | • Gold salts | | | • Interferon-a | | | • Penicillamine | | **NSAIDs** | • Aspirin | | | • Diflunisal | | | • Ibuprofen | | | • Indomethacin | | | • Naproxen | | | • Rofecoxib | | | • Sulindac | | **Psychiatric** | • Benzodiazepines | | | • Tricyclic antidepressants | | | • Lithium |  #### Medications Associated with Lichenoid Drug Reactions - **Antibiotics** - Tetracycline - **Anticonvulsants** - Carbamazepine - Oxcarbazepine - Phenytoin - Valproate sodium - **Antidiabetics** - Chlorpropamide - Glipizide - Tolbutamide - **Antidiarrheals** - Bismuth - **Antifungals** - Amphotericin B - Ketoconazole - **Antihypertensives** - Atenolol - Enalapril - Hydrochlorothiazide - Methyldopa - Metoprolol - **Antimalarials** - Chloroquine - Hydroxychloroquine - Quinidine - Quinine - **Antimycobacterials** - Aminosalicylate sodium - Isoniazid - Rifampin - Streptomycin - **Antiretrovirals** - Zidovudine - **Chemotherapeutics** - Dactinomycin - Imatinib - **Immunomodulatory drugs** - Gold salts - Interferon-a - Penicillamine - **NSAIDs** - Aspirin - Diflunisal - Ibuprofen - Indomethacin - Naproxen - Rofecoxib - Sulindac - **Psychiatric Medications** - Benzodiazepines - Tricyclic antidepressants - Lithium The image displays a table titled "OLP – Differential Diagnosis" that lists various medication categories and their associated drugs. The table is organized into columns with categories such as Antibiotics, Anticonvulsants, Antidiabetics, Antidiarrheals, Antifungals, Antihypertensives, Antimalarials, Antimycobacterials, Antiretrovirals, Chemotherapeutics, Immunomodulatory drugs, NSAIDs, and Psychiatric, each followed by specific drug examples. The text is presented in a clear, structured format against a blue background with yellow and white text for emphasis. **OLP – Differential Diagnosis** $\rightarrow$ **Contact lichenoid reactions (to mercury)**  Focus on contact lichenoid reactions specifically related to mercury exposure. A close-up photograph of a contact lichenoid reaction in the oral cavity, showing erythematous and ulcerated mucosa adjacent to a metallic dental restoration, likely indicating a reaction to mercury. The surrounding tissue appears inflamed with white patches and a glossy surface. # **OLP – Differential Diagnosis** **$\rightarrow$ Contact lichenoid reactions (to mercury)** <img src="image1.png" alt="Image showing two clinical photographs side-by-side comparing OLP and CLR on the buccal mucosa. The image on the left is labeled OLP and shows white, lacy, reticular lesions. The image on the right is labeled CLR and shows an ulcerative/erosive lesion with surrounding white areas, likely in contact with a metal restoration.">   #### Clinical Comparison: OLP vs. Contact Lichenoid Reaction (CLR) Clinical photographs compare the presentation of these two conditions on the buccal mucosa: - **OLP**: Characterized by white, lacy, reticular lesions. - **CLR**: Presents as an ulcerative/erosive lesion with surrounding white areas, typically in direct contact with a metal restoration. Clinical photograph showing oral lichen planus (OLP) on the buccal mucosa, characterized by white, lacy, reticular lesions with surrounding erythematous tissue. Clinical photograph illustrating contact lichenoid reaction (CLR) to mercury, displaying an ulcerative/erosive lesion with surrounding white areas, adjacent to a metallic dental restoration. # **OLP – Differential Diagnosis** | Dental adhesives | Dental restorative materials | Dental metals | Flavourings | |---|---|---|---| | • **Acrylate compounds** | • **Composite** | • **Beryllium** | • **Balsam of Peru** | | • **Eugenol** | • **Glass ionomer** | • **Cobalt** | • **Cinnamon, cinnamic aldehyde** | | | • **Porcelain** | • **Copper** | • **Eugenol** | | | | • **Chromium** | • **Menthol** | | | | • **Gold** | • **Peppermint** | | | | • **Mercury** | • **Vanillin** | | | | • **Nickel** | | | | | • **Palladium** | | | | | • **Silver** | | | | | • **Tin** | |  #### Categorization of Dental Allergens - **Dental Adhesives** - Acrylate compounds - Eugenol - **Dental Restorative Materials** - Composite - Glass ionomer - Porcelain - **Dental Metals** - Beryllium - Cobalt - Copper - Chromium - Gold - Mercury - Nickel - Palladium - Silver - Tin - **Flavourings** - Balsam of Peru - Cinnamon, cinnamic aldehyde - Eugenol - Menthol - Peppermint - Vanillin The image contains a table titled 'OLP – Differential Diagnosis' that lists various dental materials and substances categorized into four columns: Dental adhesives, Dental restorative materials, Dental metals, and Flavourings. The table provides a comprehensive list of potential allergens or irritants, including acrylate compounds, eugenol, composite, glass ionomer, porcelain, beryllium, cobalt, copper, chromium, gold, mercury, nickel, palladium, silver, tin, balsam of Peru, cinnamon, cinnamic aldehyde, menthol, peppermint, and vanillin. This table is used to aid in differential diagnosis for oral lichen planus (OLP) by identifying possible triggers. **OLP – Differential Diagnosis** | Dental adhesives | Dental restorative materials | Dental metals | Flavourings | |---|---|---|---| | • Acrylate compounds | • Composite | • Beryllium | • Balsam of Peru | | • Eugenol | • Glass ionomer | • Cobalt | • Cinnamon, cinnamic aldehyde | | | • Porcelain | • Copper | • Eugenol | | | | • Chromium | • Menthol | | | | • Gold | • Peppermint | | | | • **Mercury** | • Vanillin | | | | • Nickel | | | | | • Palladium | | | | | • Silver | | | | | • Tin | |  #### Common Allergens in Dental Materials - **Dental Adhesives**: Acrylate compounds, Eugenol - **Dental Restorative Materials**: Composite, Glass ionomer, Porcelain - **Dental Metals**: Beryllium, Cobalt, Copper, Chromium, Gold, Mercury, Nickel, Palladium, Silver, Tin - **Flavourings**: Balsam of Peru, Cinnamon/cinnamic aldehyde, Eugenol, Menthol, Peppermint, Vanillin A table titled 'OLP – Differential Diagnosis' listing various categories of potential allergens, including dental adhesives, dental restorative materials, dental metals, and flavourings. The table is organized into four columns with bullet points under each category, and 'Mercury' is highlighted with a red circle in the 'Dental metals' section. # **OLP – Differential Diagnosis** $\rightarrow$ **Contact lichenoid reactions** * **Skin patch testing useful but not absolute** <img src="image_description.png">   #### Diagnostic Considerations - Skin patch testing is a useful diagnostic tool for contact lichenoid reactions, though results are not absolute. A photo showing a skin patch test on a patient's back, with multiple patches labeled with numbers from 1 to 22, indicating a diagnostic procedure for contact lichenoid reactions. A close-up photo of a skin reaction after a patch test, showing a reddish area with handwritten notes indicating '20 mins' and 'Balsam of Peru', illustrating a positive reaction to a specific allergen. # **OLP – Differential Diagnosis** $\rightarrow$ **Chronic ulcerative stomatitis** Photo: Azzi L et al. Oral Dis 2019.  Clinical presentation of Chronic Ulcerative Stomatitis. *Source: Azzi L et al. Oral Dis 2019.* A clinical photo showing chronic ulcerative stomatitis, with visible oral lesions on the mucosal lining of the mouth. The image includes a dental prosthesis and a gloved hand, indicating a clinical examination setting. 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}\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ }\text{ } $$$$\text{ }$$\text{(CUS)}$$ are clinical images representing Oral Lichen Planus (OLP) and Chronic Ulcerative Stomatitis (CUS). The text provides the context for these images as part of a differential diagnosis for OLP. The source of the photos is cited at the bottom right: "Photo: Azzi L et al. Oral Dis 2019." **The text content is:** * **OLP – Differential Diagnosis** * $\rightarrow$ **Chronic ulcerative stomatitis** * **CUS** (Label on the left image) * **OLP** (Label on the right image) * **Photo: Azzi L et al. Oral Dis 2019.**   #### Clinical Comparison: CUS vs. OLP Clinical images represent the differences between Chronic Ulcerative Stomatitis (CUS) and Oral Lichen Planus (OLP). *Source: Azzi L et al. Oral Dis 2019.* A close-up photo of a patient's mouth showing chronic ulcerative stomatitis (CUS) with visible ulcers and lesions on the oral mucosa, labeled as 'CUS' in the image. A close-up photo of a patient's mouth showing oral lichen planus (OLP) with erythematous and erosive lesions, labeled as 'OLP' in the image. **OLP – Differential Diagnosis** $\rightarrow$ **Linear IgA disease** <img src="image1.png">  Clinical documentation regarding the presentation of Linear IgA disease in the context of OLP differential diagnosis. A close-up photo of the oral cavity showing erythematous and inflamed gingiva with a linear pattern of redness along the gumline, consistent with the presentation of Linear IgA disease as indicated by the text on the slide.   [Page intentionally left blank or contains no legible text content] Close-up photograph of a patient's upper teeth and gums, showing red, inflamed tissue along the gumline with the label 'Linear IgA Disease' at the bottom. The image is used to illustrate a clinical presentation of the condition. Close-up photograph of a patient's upper teeth and gums, showing red, inflamed tissue with visible dental restorations, including gold crowns and a metal clasp, labeled 'OLP' at the bottom. This image illustrates a clinical presentation of oral lichen planus. **OLP – Differential Diagnosis** $\rightarrow$ **Mucous membrane pemphigoid** <img src="image.png" alt="Image of oral mucosa showing an erythematous and potentially ulcerated or desquamative area adjacent to teeth."> **Photo: Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia.**  #### Clinical Presentation Clinical image of oral mucosa showing an erythematous and potentially ulcerated or desquamative area adjacent to teeth, characteristic of Mucous Membrane Pemphigoid. *Source: Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia.* A close-up photograph of the oral mucosa showing an erythematous and potentially ulcerated or desquamative area adjacent to teeth, illustrating a case of mucous membrane pemphigoid. The image is credited to Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia. **OLP – Differential Diagnosis** $\rightarrow$ **Mucous membrane pemphigoid**  Further clinical considerations for Mucous Membrane Pemphigoid as a differential for OLP. A clinical photograph showing two skin lesions on a patient's leg, consistent with mucous membrane pemphigoid, as indicated by the text. The lesions appear as erythematous, crusted, and ulcerated areas, illustrating the dermatological presentation of the condition. **OLP – Differential Diagnosis** $\rightarrow$ **Mucous membrane pemphigoid** <table> <tr> <td><strong>MMP</strong></td> <td><strong>OLP</strong></td> </tr> <tr> <td><img src="image1.jpg"></td> <td><img src="image2.jpg"></td> </tr> </table> **Photos: Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia**  #### Comparative Clinical Features Side-by-side clinical comparison between Mucous Membrane Pemphigoid (MMP) and Oral Lichen Planus (OLP). *Source: Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia.* Two clinical photos comparing mucous membrane pemphigoid (MMP) and oral lichen planus (OLP), showing oral lesions with erosions and ulcerations on the mucosal surfaces. The images are labeled and used for differential diagnosis, with the MMP photo on the left and the OLP photo on the right. **OLP – Differential Diagnosis** $\rightarrow$ **Mucous membrane pemphigoid**  Continued differential diagnosis details for Mucous Membrane Pemphigoid. A clinical photograph showing a case of bullous OLP (Oral Lichen Planus) with a blister-like lesion on the gingiva, labeled as 'Bullous OLP'. The image is part of a differential diagnosis slide for mucous membrane pemphigoid, highlighting the visual presentation of the condition. **OLP – Differential Diagnosis** $\rightarrow$ **Mucous membrane pemphigoid** Photos: DaCosta J. Clin Opthalmol 2012.   #### Ocular and Mucosal Involvement Clinical documentation of Mucous Membrane Pemphigoid. *Source: DaCosta J. Clin Opthalmol 2012.* A close-up photo of the oral mucosa showing erythematous and ulcerated lesions, illustrating a case of mucous membrane pemphigoid as part of a differential diagnosis for OLP. A close-up photo of an eye with conjunctival involvement, showing redness and inflammation, consistent with mucous membrane pemphigoid, referenced in the context of OLP differential diagnosis. # **OLP – Differential Diagnosis** **Pemphigus vulgaris**  Introduction to Pemphigus Vulgaris as a differential diagnosis. A clinical photograph showing oral lesions consistent with pemphigus vulgaris, characterized by erythematous mucosal surfaces with areas of erosion and blistering, located in the oral cavity. **OLP – Differential Diagnosis** $\rightarrow$ **Pemphigus vulgaris**   Clinical evaluation of Pemphigus Vulgaris in relation to OLP. A close-up photo of oral lesions labeled 'PV' (Pemphigus vulgaris), showing extensive erythematous and ulcerated mucosa with a prominent blister and surrounding inflammation. A close-up photo of oral lesions labeled 'OLP' (Oral Lichen Planus), displaying a white, reticulated pattern on the buccal mucosa with adjacent ulceration and a visible tooth. **OLP – Differential Diagnosis** $\rightarrow$ **Lupus erythematosus** **LE** **OLP** **LE** **Photo: Lourenco SV et al. J Cutan Pathol 2007**    #### Comparative Analysis: LE vs. OLP Clinical comparison between Lupus Erythematosus (LE) and Oral Lichen Planus (OLP). *Source: Lourenco SV et al. J Cutan Pathol 2007.* A close-up photo of a patient's mouth showing a lesion labeled 'LE' (Lupus erythematosus), with a visible ulcerated area on the gingiva and a dental restoration nearby. A photo of an oral lesion labeled 'OLP' (Oral Lichen Planus), displaying a red, inflamed area on the buccal mucosa with a dental instrument in the frame. A photo of a patient's mouth showing a widespread red and inflamed area on the gingiva, labeled 'LE' (Lupus erythematosus), with teeth and surrounding tissue affected. **OLP – Differential Diagnosis** $\rightarrow$ **Graft versus host disease**  Examination of Graft Versus Host Disease (GVHD) as a lichenoid-presenting condition. A close-up photo of an oral cavity showing red, inflamed mucosa with a visible graft versus host disease lesion. The image is part of a presentation on OLP - Differential Diagnosis, highlighting the condition's appearance in the mouth. # **OLP – Differential Diagnosis** **→ Graft versus host disease** GVHD   Clinical characteristics of Graft Versus Host Disease (GVHD). A close-up photograph of the oral cavity showing a patient with graft versus host disease (GVHD), characterized by red, inflamed mucosa and visible dental structures. The image is labeled 'GVHD' to indicate the condition. A close-up photograph of the oral mucosa displaying a lesion consistent with oral lichen planus (OLP), characterized by white, reticulated patterns on the mucosal surface. The image is labeled 'OLP' to identify the condition. # **OLP - Diagnosis** **OLP - Diagnosis** **“Never assume the obvious is true”** - William Safire  "Never assume the obvious is true" — William Safire A photograph of a clear glass filled with water, containing a pink plastic spoon that appears bent due to refraction, illustrating the concept of optical illusion. The image is framed within a blue presentation slide titled 'OLP - Diagnosis' and includes a quote by William Safire: 'Never assume the obvious is true,' emphasizing the theme of visual deception. # **OLP - Diagnosis** **Clinical criteria** * Presence of bilateral, more or less symmetric lesions * Presence of a lacelike network of slightly raised grey-white lines (reticular pattern) * Erosive, atrophic, bullous, and plaque-type lesions are only accepted as a subtype in the presence of reticular lesions elsewhere in the oral mucosa In all other lesions that resemble OLP but do not complete the aforementioned criteria, the term “clinically compatible with” should be used. **Histopathologic criteria** * Presence of a well-defined, band like zone of cellular infiltration that is confined to the superficial part of the connective tissue, consisting mainly of lymphocytes * Signs of liquefaction degeneration in the basal cell layer * Absence of epithelial dysplasia When the histopathologic features are less obvious, the term “histopathologically compatible with” should be used. To achieve a final diagnosis, clinical as well as histopathologic criteria should be included. **A diagnosis of OLP requires fulfilment of clinical and histopathologic criteria.** The term OLL will be used in the following conditions: 1. Clinically typical of OLP but histopathologically only compatible with OLP 2. Histopathologically typical of OLP but clinically only compatible with OLP 3. Clinically compatible with OLP and histopathologically compatible with OLP Van der Meij EH. J Oral Pathol Med 2003;32:507-12. #### Clinical Diagnostic Requirements - Presence of bilateral, more or less symmetric lesions. - Presence of a lacelike network of slightly raised grey-white lines (reticular pattern). - Erosive, atrophic, bullous, and plaque-type lesions are only accepted as a subtype in the presence of reticular lesions elsewhere in the oral mucosa. In all other lesions that resemble Oral Lichen Planus (OLP) but do not complete the aforementioned criteria, the term "clinically compatible with" should be used. #### Histopathologic Diagnostic Requirements - Presence of a well-defined, band-like zone of cellular infiltration that is confined to the superficial part of the connective tissue, consisting mainly of lymphocytes. - Signs of liquefaction degeneration in the basal cell layer. - Absence of epithelial dysplasia. When the histopathologic features are less obvious, the term "histopathologically compatible with" should be used. #### Final Diagnosis and Oral Lichenoid Lesions (OLL) To achieve a final diagnosis, clinical as well as histopathologic criteria should be included. A diagnosis of OLP requires fulfilment of both clinical and histopathologic criteria. The term OLL will be used in the following conditions: 1. Clinically typical of OLP but histopathologically only compatible with OLP. 2. Histopathologically typical of OLP but clinically only compatible with OLP. 3. Clinically compatible with OLP and histopathologically compatible with OLP. **OLP - Diagnosis** <table> <thead> <tr> <td>Modified WHO criteria</td> <td>Proposed criteria</td> </tr> </thead> <tbody> <tr> <td>Bilateral, more or less symmetric lesions</td> <td>Multifocal symmetric distribution</td> </tr> <tr> <td>- Erosive, atrophic, bullous, and plaque-type lesions are only accepted as a subtype in the presence of reticular lesions elsewhere in the oral mucosa</td> <td>White and red lesions exhibiting one or more of the following forms: <ul><li>Reticular/papular</li></ul></td> </tr> <tr> <td>- Lace-like network of slightly raised gray-white lines (reticular pattern)</td> <td><ul><li>Atrophic (erythematous)</li><li>Erosive (ulcerative)</li><li>Plaque</li><li>Bullous</li></ul></td> </tr> <tr> <td></td> <td>Lesions are not localized exclusively to the sites of smokeless tobacco placement</td> </tr> <tr> <td></td> <td>Lesions are not localized exclusively adjacent to and in contact with dental restorations</td> </tr> <tr> <td></td> <td>Lesion onset does not correlate with the start of a medication</td> </tr> <tr> <td></td> <td>Lesion onset does not correlate with the use of cinnamon-containing products</td> </tr> <tr> <td>Well-defined, band-like zone of cellular infiltration consisting mainly of lymphocytes and confined to the superficial lamina propria</td> <td>Band-like or patchy, predominately lymphocytic infiltrate in the lamina propria confined to the epithelium-lamina propria interface</td> </tr> <tr> <td>Liquefaction degeneration in the basal cell layer</td> <td>Basal cell liquefactive (hydropic) degeneration</td> </tr> <tr> <td>Absence of epithelial dysplasia</td> <td>Lymphocytic exocytosis</td> </tr> <tr> <td></td> <td>Absence of epithelial dysplasia</td> </tr> <tr> <td></td> <td>Absence of verrucous epithelial architectural change</td> </tr> </tbody> </table> **Cheng YSL et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2016;122:332-354**   #### Comparison of Modified WHO and Proposed Criteria | Modified WHO Criteria | Proposed Criteria | | :--- | :--- | | Bilateral, more or less symmetric lesions | Multifocal symmetric distribution | | Lace-like network of slightly raised gray-white lines (reticular pattern) | White and red lesions exhibiting one or more of the following forms: Reticular/papular, Atrophic (erythematous), Erosive (ulcerative), Plaque, Bullous | | Erosive, atrophic, bullous, and plaque-type lesions are only accepted as a subtype in the presence of reticular lesions elsewhere | Lesions are not localized exclusively to the sites of smokeless tobacco placement | | (N/A) | Lesions are not localized exclusively adjacent to and in contact with dental restorations | | (N/A) | Lesion onset does not correlate with the start of a medication | | (N/A) | Lesion onset does not correlate with the use of cinnamon-containing products | | Well-defined, band-like zone of cellular infiltration consisting mainly of lymphocytes and confined to the superficial lamina propria | Band-like or patchy, predominately lymphocytic infiltrate in the lamina propria confined to the epithelium-lamina propria interface | | Liquefaction degeneration in the basal cell layer | Basal cell liquefactive (hydropic) degeneration | | (N/A) | Lymphocytic exocytosis | | Absence of epithelial dysplasia | Absence of epithelial dysplasia | | (N/A) | Absence of verrucous epithelial architectural change | A comparative table outlining the 'Modified WHO criteria' and 'Proposed criteria' for diagnosing OLP (Oral Lichen Planus), detailing clinical and histopathological features such as lesion distribution, types, and absence of dysplasia. A table comparing histopathological features of OLP, including cellular infiltration patterns, basal cell degeneration, and absence of epithelial dysplasia, between the 'Modified WHO criteria' and 'Proposed criteria'. **OLP - Diagnosis** * **Should every case of OLP** **be biopsied?** #### Clinical Consideration - Should every case of OLP be biopsied? **OLP - Diagnosis**  A close-up clinical photograph of a patient's upper dental arch, showing teeth with visible restorations and gingival inflammation, under the heading 'OLP - Diagnosis'. **OLP - Diagnosis** **2018** **2013**  #### Chronological Review - 2013 - 2018 Two side-by-side photos showing dental conditions labeled '2013' and '2018', illustrating changes in the patient's teeth over time, with the title 'OLP - Diagnosis' at the top. **<font color="yellow">OLP - Diagnosis</font>**  A close-up intraoral photograph showing a patient's mouth with visible oral lesions, including white patches and red areas on the tongue and surrounding tissues, under the heading 'OLP - Diagnosis'. **OLP - Diagnosis**   Close-up intraoral photograph showing the upper dental arch with visible gingival inflammation and dental restorations, likely illustrating a case of oral lichen planus (OLP) as part of a diagnosis. Intraoral photograph of the lower dental arch displaying characteristic lesions of oral lichen planus, including white reticular patterns and erythematous areas on the gingiva, used for diagnostic purposes. **<font color="yellow">OLP - Diagnosis</font>** <img src="image1.png" alt="Intraoral photographs comparing Verrucous carcinoma and OLP"> **Verrucous carcinoma** | **OLP** --- | ---   #### Differential Diagnosis Comparison - Verrucous carcinoma - Oral Lichen Planus (OLP) Intraoral photograph showing a case of verrucous carcinoma, characterized by a white, wart-like lesion on the gingiva, with an arrow pointing to the affected area. Intraoral photograph illustrating oral lichen planus (OLP), displaying erythematous and white reticular lesions on the buccal mucosa, with an arrow indicating the site of interest. # **OLP - Diagnosis** * **Routine investigations:** * $\rightarrow$ **FBC** * $\rightarrow$ **B12** * $\rightarrow$ **Folate** * $\rightarrow$ **Iron studies** * $\rightarrow$ **other** <img src="image.png">  #### Laboratory Screening - Full Blood Count (FBC) - Vitamin B12 - Folate - Iron studies - Other relevant investigations A photograph showing three blood collection tubes with different colored caps (yellow, yellow, and purple) on a blue background. The tubes are labeled with patient information fields such as name, date of birth, and other clinical details, indicating their use for routine blood investigations. # **OLP - Diagnosis** <img src="image_of_oral_lesions.jpg" alt="Two images comparing oral lesions. Left image labeled Folate deficiency shows reticular white lesions on the palate. Right image labeled OLP shows white lacy patterns (Wickham's striae) on the hard palate."> **Photos: Dr. Jerry Bouquot, The Maxillofacial Center, Morgantown, West Virginia**   #### Comparative Clinical Presentation - **Folate deficiency**: Presentation of reticular white lesions on the palate. - **Oral Lichen Planus (OLP)**: Presentation of white lacy patterns (Wickham's striae) on the hard palate. A close-up photo of an oral lesion associated with folate deficiency, showing white, reticular patterns on the palate. The image is labeled 'Folate deficiency' and is part of a diagnostic comparison for OLP. A close-up photo of an oral lesion associated with OLP (Oral Lichen Planus), displaying white lacy patterns (Wickham's striae) on the hard palate. The image is labeled 'OLP' and is part of a diagnostic comparison with folate deficiency. # **OLP - Diagnosis** * **Routine investigations:** * $\rightarrow$**FBC** * $\rightarrow$**B12** * $\rightarrow$**Folate** * $\rightarrow$**Iron studies** * $\rightarrow$**other**  #### Laboratory Screening - Full Blood Count (FBC) - Vitamin B12 - Folate - Iron studies - Other relevant investigations A photo showing three blood collection tubes with different colored caps (yellow, yellow, and purple) labeled with patient information fields such as name, date, and time. The tubes are placed on a light blue surface, and the labels indicate they are BD Vacutainer brand tubes used for routine investigations. **OLP - Management** **OLP - Management** * **No cure available.** * **Treatment is supportive and palliative only.** * **Can be associated with reduced QOL.** <img src="image_of_oral_lesion.png">  - No cure available. - Treatment is supportive and palliative only. - Condition can be associated with reduced Quality of Life (QOL). A clinical photograph showing an oral lesion, likely related to OLP (Oral Lichen Planus), with erythematous and possibly erosive mucosa. The image is presented in the context of a slide discussing management options for OLP, where treatment is described as supportive and palliative. **OLP - Management** * Smooth sharp cusps. * Eliminate ill-fitting dental prosthesis. * Maintain meticulous oral hygiene. <img src="arrow_pointing_right" /> **<font color="orange">Koebner phenomenon</font>** <img src="speaker_icon" />   #### Physical Irritants and Oral Care - Smooth sharp cusps. - Eliminate ill-fitting dental prosthesis. - Maintain meticulous oral hygiene. #### Koebner Phenomenon The Koebner phenomenon (isomorphic response) is a relevant consideration in management where trauma can trigger new lesions. A pink arrow pointing to the right, indicating a directional flow or connection to the text 'Koebner phenomenon' in orange font. A speaker icon with sound waves emanating from it, symbolizing audio or sound output. **OLP - Management** Did you know that **DRINKING as LITTLE** as one Standard **DRINK a day** **INCREASES YOUR RISK** **OF MOUTH CANCER?**  #### Alcohol and Cancer Risk Drinking as little as one standard drink a day increases your risk of mouth cancer. A close-up photo of an oral cavity showing a lesion on the tongue, illustrating the risk of mouth cancer. The image is overlaid with text stating that drinking as little as one standard drink a day increases the risk of mouth cancer. **OLP - Management** The image is a slide presenting the Australian Alcohol Guidelines with information categorized into sections. | Section | Details | |---|---| | **Title** | Alcohol Guidelines: Australian guidelines to reduce health risks from drinking alcohol | | **Logo/Source** | BUILDING A HEALTHY AUSTRALIA (with NHMRC logo) | | **1: HEALTHY ADULTS** | Drink no more than **10** standard drinks a **week** AND no more than **4** standard drinks on **any one day**<br> to reduce the risk of harm from alcohol. The less you drink, the lower your risk of harm. | | **2: CHILDREN AND PEOPLE UNDER 18 YEARS OF AGE** | Should not drink alcohol to reduce the risk of harm from alcohol. | | **3: WOMEN WHO ARE PREGNANT OR BREASTFEEDING** | Should not drink alcohol to prevent harm from alcohol to their unborn child or baby. | | **Footer Link** | https://www.health.gov.au/news/australian-alcohol-guidelines-revised | | **Bottom Text** | www.nhmrc.gov.au/alcohol |  #### Australian Alcohol Guidelines (NHMRC) 1. **Healthy Adults**: Drink no more than 10 standard drinks a week AND no more than 4 standard drinks on any one day to reduce the risk of harm from alcohol. The less you drink, the lower your risk of harm. 2. **Children and People Under 18**: Should not drink alcohol to reduce the risk of harm. 3. **Women who are Pregnant or Breastfeeding**: Should not drink alcohol to prevent harm to their unborn child or baby. The image displays a four-quadrant infographic summarizing the Australian Alcohol Guidelines. The top-left quadrant provides an overview of the guidelines, while the top-right quadrant details recommendations for healthy adults, including limits of 10 standard drinks per week and 4 on any one day. The bottom-left quadrant advises that children and people under 18 should not drink alcohol, and the bottom-right quadrant states that women who are pregnant or breastfeeding should also abstain. Each section includes illustrative icons and text to convey the recommendations clearly. **OLP - Management** **OLP - Management** <div style="background-color: #000080; color: #FFFF00; padding: 10px;"> <h1>**OLP - Management**</h1> </div> # **What is a standard drink?** <div style="text-align: center;"> <img src="image_of_standard_drinks_chart" alt="Chart showing different types of alcoholic drinks and their standard drink sizes." style="max-width: 100%;"> </div> | Drink Type | Volume | Alcohol Content | Image | |---|---|---|---| | LIGHT BEER | 425 ml | 2.7% alc/vol | | | MID STRENGTH BEER | 375 ml | 3.5% alc/vol | | | FULL STRENGTH BEER | 285 ml | 4.9% alc/vol | | | REGULAR CIDER | 285 ml | 4.9% alc/vol | | | SPARKLING WINE | 100 ml | 13% alc/vol | | | WINE | 100 ml | 13% alc/vol | | | FORTIFIED WINE (e.g. sherry, port) | 60 ml | 20% alc/vol | | | SPIRITS (e.g. gin, rum, whiskey) | 30 ml | 40% alc/vol | | The standard drink is defined in the Australia and New Zealand Food Standards Code. <div style="display: flex; justify-content: space-between; align-items: center; padding: 10px; background-color: #ADD8E6;"> <div style="background-color: #4B0082; color: white; padding: 10px; border-radius: 50%;"> NHMRC </div> <div style="font-size: 1.2em; color: #000080;"> www.nhmrc.gov.au/alcohol </div> <div style="text-align: right; font-size: 0.9em; color: #000080;"> BUILDING<br>A HEALTHY<br>AUSTRALIA </div> <div> </div> </div>  #### Standard Drink Definitions A standard drink is defined in the Australia and New Zealand Food Standards Code. Examples include: - **Light Beer (2.7% alc/vol)**: 425 ml - **Mid Strength Beer (3.5% alc/vol)**: 375 ml - **Full Strength Beer (4.9% alc/vol)**: 285 ml - **Regular Cider (4.9% alc/vol)**: 285 ml - **Sparkling Wine (13% alc/vol)**: 100 ml - **Wine (13% alc/vol)**: 100 ml - **Fortified Wine (e.g., sherry, port) (20% alc/vol)**: 60 ml - **Spirits (e.g., gin, rum, whiskey) (40% alc/vol)**: 30 ml A chart titled 'What is a standard drink?' that illustrates various alcoholic beverages and their corresponding standard drink sizes. The chart includes icons for light beer (425 ml, 2.7% alc/vol), mid-strength beer (375 ml, 3.5% alc/vol), full-strength beer (285 ml, 4.9% alc/vol), regular cider (285 ml, 4.9% alc/vol), sparkling wine (100 ml, 13% alc/vol), wine (100 ml, 13% alc/vol), fortified wine (60 ml, 20% alc/vol), and spirits (30 ml, 40% alc/vol). The information is sourced from the Australia and New Zealand Food Standards Code. **OLP - Management** | | | |---|---| | **1 in 100** | Healthy adults drinking within the guideline recommendation have less than a 1 in 100 chance of dying from an alcohol-related condition. | | NHMRC Building A Healthy Australia | www.nhmrc.gov.au/alcohol | |---|---|  #### Risk Statistics Healthy adults drinking within the guideline recommendation have less than a 1 in 100 chance of dying from an alcohol-related condition. The figure is a visual representation showing that healthy adults drinking within the guideline recommendation have less than a 1 in 100 chance of dying from an alcohol-related condition. It features a large circle containing 100 small human figures, with one highlighted in blue to represent the 1 in 100 risk. The text and graphic are part of a public health message from NHMRC, emphasizing the low risk of alcohol-related death for those who drink within recommended limits. **OLP - Management** * **Associations with periodontal disease?**  #### Periodontal Associations Are there associations with periodontal disease? A close-up photograph of a patient's mouth showing the upper teeth and gums, with visible redness and inflammation in the gingival tissue, likely illustrating a case of periodontal disease. The image is used to discuss associations between OLP (Oral Lichen Planus) and periodontal disease. **OLP - Management** **OLP - Management** * Plaque control is important in the management of OLP.  #### Plaque Control Plaque control is important in the management of Oral Lichen Planus (OLP). A close-up photo of a patient's mouth showing oral lichen planus (OLP) with white, reticulated lesions on the gingiva and buccal mucosa. The image illustrates the clinical presentation of OLP, which is relevant to the management discussed in the slide text about plaque control. **OLP - Management** * **? Implants – implant loss does not appear to be** directly related to OLP  #### Dental Implants Implant loss does not appear to be directly related to OLP. A close-up photo of a patient's mouth showing a dental implant or prosthesis, with visible gums and teeth. The image is used to illustrate the topic of implants in the context of OLP management, where implant loss does not appear to be directly related to OLP. **OLP - Management** * **Medication**   Pharmacological management is a primary component of OLP treatment. Close-up intraoral photo showing a lesion on the oral mucosa, with surrounding redness and inflammation, likely related to OLP management under medication. Another intraoral photo displaying a more extensive area of oral lichen planus (OLP) with erosive lesions and white striae, illustrating the condition's appearance during management. # **OLP - Management** * **Corticosteroids** * $\rightarrow$ **Topical** * $\rightarrow$ Systemic * $\rightarrow$ Intralesional * **Calcineurin inhibitors** * $\rightarrow$ Cyclosporine * $\rightarrow$ Tacrolimus * **Other** <img src="image_of_oral_lesion_on_tongue">  #### Therapeutic Categories - **Corticosteroids** - Topical - Systemic - Intralesional - **Calcineurin inhibitors** - Cyclosporine - Tacrolimus - **Other agents** A close-up photograph of an oral lesion on the tongue, showing a pinkish, raised area with a slightly ulcerated surface, located near the base of the tongue. The image is part of a presentation slide on OLP (Oral Lichen Planus) management, illustrating a clinical example of the condition. # **OLP - Management** * **Topical corticosteroids** * $\rightarrow$ **Clobetasol propionate** * $\rightarrow$ **Fluocinonide** * $\rightarrow$ **Betamethasone dipropionate** * $\rightarrow$ **Beclomethasone dipropionate** * $\rightarrow$ **Fluocinonide acetonide** * $\rightarrow$ **Betamethasone valerate** * $\rightarrow$ **Triamcinolone acetonide** * $\rightarrow$ **Hydrocortisone** <br>  #### Common Topical Agents - Clobetasol propionate - Fluocinonide - Betamethasone dipropionate - Beclomethasone dipropionate - Fluocinonide acetonide - Betamethasone valerate - Triamcinolone acetonide - Hydrocortisone A bulleted list under the heading "Topical corticosteroids" that includes various corticosteroid medications such as Clobetasol propionate, Fluocinonide, Betamethasone dipropionate, Beclomethasone dipropionate, Fluocinonide acetonide, Betamethasone valerate, Triamcinolone acetonide, and Hydrocortisone, presented as a structured list with arrows pointing to each item. # **OLP - Management** * **Topical corticosteroids** * **$\rightarrow$Clobetasol propionate** * **$\rightarrow$Fluocinonide** * **$\rightarrow$Betamethasone dipropionate** * **$\rightarrow$Beclomethasone dipropionate** * **$\rightarrow$Fluocinonide acetonide** * **$\rightarrow$Betamethasone valerate** * **$\rightarrow$Triamcinolone acetonide** * **$\rightarrow$Hydrocortisone**  #### Corticosteroid Options - Clobetasol propionate - Fluocinonide - Betamethasone dipropionate - Beclomethasone dipropionate - Fluocinonide acetonide - Betamethasone valerate - Triamcinolone acetonide - Hydrocortisone A green, cone-shaped figure on a blue background, positioned to the right of a list of topical corticosteroids. The figure is a simple geometric shape without any labels or data, likely serving as a visual placeholder or design element. **OLP - Management** * **For biopsy proven** symptomatic OLP: **$\rightarrow$Betamethasone** **dipropionate** **0.05% ointment** **(Diprosone)** **2/day.**  #### Betamethasone Dipropionate For biopsy-proven symptomatic OLP: - **Agent**: Betamethasone dipropionate 0.05% ointment (Diprosone) - **Frequency**: 2 times per day A photo of a book cover titled 'Oral and Dental Version 3', featuring two clown figurines with exaggerated facial expressions. The image is positioned on the right side of a presentation slide about OLP management, with text on the left discussing treatment with Betamethasone dipropionate ointment. **OLP - Management** * **Beclomethasone dipropionate inhaler** **50-100mcg/dose up to 2 sprays,** **4/day.** <img>An image of a brown inhaler device is displayed against a white background, with a label on the top part.*  #### Beclomethasone Dipropionate - **Formulation**: Inhaler - **Dosage**: 50-100mcg/dose - **Frequency**: Up to 2 sprays, 4 times per day A photograph of a brown beclomethasone dipropionate inhaler, labeled with 'QVAR 50', displayed against a white background. The image is positioned next to text describing the medication's dosage as 50-100mcg per dose, up to 2 sprays, 4 times per day. **OLP - Management** * **Dexamethasone mouthwash** 0.5-1mg/5ml, up to 4/day.  #### Dexamethasone Mouthwash - **Dosage**: 0.5-1mg/5ml - **Frequency**: Up to 4 times per day A close-up photo of a mouth showing oral lesions, likely related to OLP (Oral Lichen Planus), with red, inflamed mucosa and white streaks. This image is presented in the context of OLP management using dexamethasone mouthwash. **<font color="yellow">OLP - Management</font>** <img src="image_of_dental_models_and_intraoral_photo.jpg" alt="Dental images showing models and a close-up of inflamed gums.">    Clinical application of topical formulations often involves dental models or trays to increase contact with inflamed gingival tissues. A dental model showing a clear aligner on a cast, illustrating the application of orthodontic treatment. The model is placed on a textured white surface, emphasizing the alignment of teeth. Another view of a dental model with a clear aligner, highlighting the fit and positioning on the teeth. The model is displayed on a white textured surface, similar to the first image. A close-up intraoral photo showing inflamed gums and teeth with a clear aligner. The gums appear red and swollen, indicating potential periodontal issues, while the aligner is visible on the upper teeth. **OLP - Management** * **Factors influencing effectiveness of TC:** * $\to$Drug potency * $\to$Contact time * $\to$Vehicle / formulation  The effectiveness of topical corticosteroids (TC) is influenced by: - Drug potency - Contact time - Vehicle / formulation A speaker icon with sound waves, likely used as a visual cue for audio in a presentation, located in the bottom right corner of the slide. # **OLP - Management** * **OLP - Management** * Causes of treatment failure: * $\rightarrow$ **Incorrect diagnosis.** * $\rightarrow$ **Superimposed candidal infection.** * $\rightarrow$ TC of inadequate potency. * $\rightarrow$ Poor patient compliance.  Common reasons for treatment failure include: - Incorrect diagnosis - Superimposed candidal infection - Topical corticosteroid (TC) of inadequate potency - Poor patient compliance A small speaker icon with sound waves, likely indicating audio or sound-related content, positioned in the bottom right corner of the slide. **OLP - Management** - **Local complications:** - $\rightarrow$ Oral candidiosis  #### Candidiasis - Oral candidiosis A clinical photograph showing oral candidiasis, characterized by white, creamy patches on the tongue and oral mucosa, consistent with a local complication of OLP (Oral Lichen Planus) management. **OLP - Management** * **Local complications:** $\rightarrow$ **Oral candidiosis**  #### Fungal Infection - Oral candidiosis A close-up photograph of the inside of a patient's mouth showing inflamed oral mucosa with white patches, consistent with oral candidiasis. The image is presented as an example of a local complication under the 'OLP - Management' section, with text indicating 'Oral candidiosis' as a related condition. # **OLP - Management** * **Local complications:** * $\rightarrow$ Oral candidiosis  #### Secondary Infection - Oral candidiosis A close-up clinical photograph showing oral candidiasis, characterized by red, inflamed mucosal tissue with visible white patches and lesions, illustrating a local complication of OLP management. **OLP - Management** **OLP - Management** $\rightarrow$**Oral candidiasis**    #### Oral Candidiasis - Development of oral candidiasis is a known local complication of topical steroid use. A photo of a Daktarin oral gel box, labeled as pharmacist-only medicine, with a blue and yellow design, containing 40g of gel and a measuring spoon. A photo of a Fungilin prescription-only medicine bottle, containing 20 lozenges with amphotericin B 10 mg, labeled for use as an antifungal treatment. A photo of a Nilstat oral drops box, labeled as pharmacist-only medicine, containing 24 mL of cherry-flavored oral drops with nystatin, for children and adults. **OLP - Management** $\rightarrow$**Oral candidiasis**    #### Fungal Complications - Oral candidiasis A photo of a white box labeled 'Nilstat Oral drops' with a red 'X' over it, indicating it is not recommended. The box is marked as 'PHARMACIST ONLY MEDICINE' and contains 24 mL of medication. A photo of a brown bottle labeled 'FUNGILIN', a prescription-only medicine containing amphotericin B. The bottle has a white cap and contains 20 lozenges, each with 10 mg of the active ingredient. A photo of a blue and red box labeled 'Daktarin Oral Gel', a pharmacist-only medicine with miconazole 20 mg/g. The packaging indicates it is a 40 g net product with a measuring spoon. **OLP - Management** **Local complications:** $\rightarrow$Oral candidosis $\rightarrow$Stomatopyrosis $\rightarrow$Hypogeusia $\rightarrow$Oral hairy leukoplakia #### Range of Local Effects - Oral candidosis - Stomatopyrosis (burning mouth) - Hypogeusia (reduced taste) - Oral hairy leukoplakia **OLP - Management** Systemic adverse effects: ►Changes in: →Mood →Weight →Blood pressure →Blood glucose →Plasma cortisol ►Insomnia ►Moon face ►Hirsutism  Systemic adverse effects may include: - **Changes in**: - Mood - Weight - Blood pressure - Blood glucose - Plasma cortisol - **Other effects**: - Insomnia - Moon face - Hirsutism A gray speaker icon with white sound waves emanating from it, located on the right side of the slide. This figure is a graphical representation of audio or sound, likely indicating an audio component or alert related to the content about OLP management and systemic adverse effects. **OLP - Management** * **OLP - Management** * Systemic prednisolone 0.5-1.0mg/kg/d.  #### Systemic Prednisolone - **Dosage**: 0.5-1.0 mg/kg/day A close-up clinical photo showing the oral cavity with visible lesions on the mucosal tissue, likely representing a case of OLP (Oral Lichen Planus). The image is presented under the heading 'OLP - Management' and is accompanied by text about systemic prednisolone treatment. **OLP - Management** * **Regular follow-up - at least annual.** SCC in OLP   #### Cancer Surveillance - Regular follow-up is required, at least annually. - Monitoring is essential due to the risk of Squamous Cell Carcinoma (SCC) developing in OLP. A photo of dental instruments, including a mirror and probe, placed inside a clear plastic container on a green surface, likely for use in oral examination. A close-up photo of the inside of a mouth showing a lesion on the tongue, highlighted with a black circle and labeled 'SCC in OLP', indicating a case of squamous cell carcinoma in oral lichen planus. **OLP - Management**   Ongoing clinical review is necessary for the long-term management of OLP patients. A close-up photograph of a patient's oral cavity showing a lesion on the tongue, highlighted by a black circle. The lesion appears as a raised, pinkish area with a slightly irregular surface, located on the lateral aspect of the tongue near the base. A detailed close-up photograph of the tongue's surface, showing a prominent, raised lesion with a rough, granular texture. The lesion is located on the dorsal surface of the tongue, with surrounding tissue appearing slightly inflamed and erythematous. **OLP - Summary** * Common, chronic, systemic, immunologically mediated disease. * Aetiology unknown. * Diagnosis is based on fulfilment of clinical and histopathological criteria. * Topical corticosteroids are the first line of treatment. * Regular follow-up is recommended.  Oral Lichen Planus (OLP) is characterized by the following key features: - **Nature of the Disease**: It is a common, chronic, systemic, and immunologically mediated condition. - **Aetiology**: The exact cause remains unknown. - **Diagnosis**: Identification is based on the fulfillment of both clinical and histopathological criteria. - **Management**: Topical corticosteroids serve as the first line of treatment. - **Monitoring**: Regular clinical follow-up is recommended for all patients. A clinical photograph showing the oral cavity of a patient with OLP (Oral Lichen Planus). The image displays white, lacy patterns on the buccal mucosa and gingiva, along with areas of erythema and ulceration, consistent with the disease's characteristic presentation. This visual evidence supports the summary text on the left, which describes OLP as a chronic, immunologically mediated condition. 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