Three women had a diagnosis of oral lichen planus OLP , which was made on the basis of clinical and histologic features. All three had persistent burning pain associated with large mucosal lesions. Changes in the color red, red and white, white , configuration, and severity of the lesions were unpredictable and did not correlate well with topical corticosteroid therapy. Only one patient used tobacco cigarettes --this patient had recurrent oral candidiasis and was receiving multiple medications.
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Lichenoid Dysplasia LD is often regarded as lichen planus with dysplastic features, as it mimics lichen planus clinically and histologically. Although it has been confirmed that these two entities are entirely different with not so similar etiopathogenesis, yet the confusion still exists. The separation between the two is of utmost importance as each of them has their own prognosis and treatment plan.
We report one such case, where a year-old male with excessive burning sensation had similar clinical picture as that of lichen planus but was histologically diagnosed as LD. A year-old male patient reported to the Dental Outpatient Department with a chief complaint of excessive burning sensation upon eating spicy food since two months.
Since then, the severity of burning sensation has progressively increased. He got an amalgam restoration done in the tooth 37 around ten years back and did not change any tooth powder or paste recently. Medical history did not reveal any significant finding. As the patient did not notice any lesion before, so any change in the lesion could not be commented. The lesion had irregular margins with slightly raised surface and measured around 1. The oral mucosa elsewhere was clinically normal.
Clinically, a provisional diagnosis of lichen planus and leukoplakia was made. Histopathological examination revealed hyperparakeratinized hyperplastic epithelium with saw tooth shaped rete ridges and juxta epithelial band of chronic inflammatory cells chiefly lymphocytes.
After correlating the clinical findings with the histological features, a final diagnosis of lichenoid dysplasia was made. After five years of periodic follow up and postsurgical excision, no sign of recurrence was observed. Intraoral photograph revealing grayish white lace like lesion on left buccal mucosa, measuring around 1. Photomicrograph revealing hyperparakeratinized hyperplastic epithelium with saw tooth shaped rete ridges black arrows and juxta epithelial band of chronic inflammatory cells blue arrow H and E, 40X.
Photomicrograph showing an area of transformation of saw tooth shaped rete ridges into drop shaped rete ridges black arrows H and E, 40X. In the present case, the lesion diagnosed as lichen planus clinically came out to be LD histologically. In other words, this term is to be used when there are lichen planus like histological features in dysplastic epithelium.
It does not imply dysplastic changes in lichen planus. It is neither a variant nor a transitional form of lichen planus. The pathogenesis of these two lesions is entirely different - in lichen planus the lichenoid infiltrate represents cell mediated immune response incited by different antigens whereas in LD, it represents immune surveillance mechanism against atypical epithelial cells [ 2 ]. Clinically these two appear similar, but LD is usually unilateral as seen in our case report and is more frequently seen on cancer prone sites like floor of the mouth, tongue, mandibular lingual alveolar ridge, soft palate, tonsillar pillar and uvula.
Although the incidence of LD is far less than lichen planus, but when present its distinction from the latter is often difficult. The malignant potential of oral lichen planus is questioned in the recent past. Numerous studies have disclosed the fact that most of the previously reported cases of malignant transformation were either a Lichenoid Lesion LL or LD misdiagnosed as lichen planus.
Thus LDs and LLs have propensity for transformation, but not the lichen planus and hence the differentiation between these comparably similar entities is very important [ 3 - 5 ].
In addition to these four categories, Kumar S et al. Lichenoid reaction associated with amalgam or other dental restorations can be differentiated clinically on the basis of its unilateral presentation and its topographical relation with the amalgam restoration. Histologically, lymphoid follicle formation chiefly comprised of neutrophils and plasma cell is seen.
Drug related LL is considered as a different form of delayed hypersensitivity reaction, wherein drug or its metabolite acts as haptens. A history of drug usage in the recent past helps in making the clinical diagnosis.
Histologically, the inflammatory infiltrate with predominant eosinophils is more widely spread deep into the connective tissue. Histopathologically, subepithelial vesiculation, minimal lymphocytic infiltrate and perivascular cuffing of inflammatory cells distinguishes GVHD lesion from characteristic lichen planus. At times, oral lesions in discoid lupus erythematosus reveal lichen planus like white striae. Clinically, such lesions are usually unilateral and have a predilection for vermillion area, palate and buccal mucosa.
Histologically, a characteristic Periodic Acid Schiff PAS stained positive material is seen along the basement membrane and around the blood vessels. In addition, hyperkeratosis with plugging, perivascular infiltration and more deeply spread inflammatory infiltrate into the stroma are other significant differences [ 2 , 8 ].
In erythema multiforme in absence of skin lesions , the histopathological resemblance with lichen planus can be ruled out clinically more efficiently. Lesions in erythema multiforme are more common in anterior part of the oral cavity; blood crusted ulceration on lips are almost exclusively seen in erythema multiforme.
A definite history of exposure to known drugs inciting the hypersensitivity reaction or a recent herpes virus infection makes clinical correlation more valuable in clinching the diagnosis [ 9 , 10 ].
Kamath VB et al. In case of LLs for which a distinct cause can be found warrants the removal of associated causative agent like drug, amalgam restoration. In view of malignant transformation, biopsy is mandatory for LD and erosive and atrophic forms of lichen planus. Three month review following the treatment for the first year and biannually for the next two years is recommended. Repeated biopsies to be done when recurrence, change or spread is detected.
This case was clinically diagnosed as lichen planus but was confirmed to be LD histologically. The malignant potential of a lichen planus has been a matter of debate from ages, whereas LD is definitely premalignant, thus the distinction between the two entities is important.
National Center for Biotechnology Information , U. J Clin Diagn Res. Published online May 1. Patil , 3 and Shekhar Kapoor 4. Find articles by Kumud Mittal. Find articles by Mihir Jha. Roopa S. Find articles by Roopa S. Find articles by Shekhar Kapoor. Author information Article notes Copyright and License information Disclaimer. Corresponding author. E-mail: moc. Abstract Lichenoid Dysplasia LD is often regarded as lichen planus with dysplastic features, as it mimics lichen planus clinically and histologically.
Keywords: Lichen planus, Lichenoid reaction, Squamous cell carcinoma. Case Report A year-old male patient reported to the Dental Outpatient Department with a chief complaint of excessive burning sensation upon eating spicy food since two months.
Open in a separate window. Discussion In the present case, the lesion diagnosed as lichen planus clinically came out to be LD histologically. Conclusion This case was clinically diagnosed as lichen planus but was confirmed to be LD histologically. Lichenoid lesions of oral mucosa. Diagnostic criteria and there importance in the alleged relationship to oral cancer.
Oral lichenoid lesions: Clinico-pathological mimicry and its diagnostic implications. J Dent Res. Oral lichen planus: Progress in understanding its malignant potential and the implications for clinical management. Current controversies in oral lichen planus. Report of an international consensus meeting part 2: Clinical management and malignant transformation. Oral lichen planus: Controversies surrounding malignant transformation. Oral Dis. Oral lichen planus and oral lichenoid lesions; A critical appraisal with emphasis on the diagnostic aspects.
Oral Lichenoid Dysplasia: A Clinicopathologic Analysis
The question about premalignant potential of OLP has been mired by controversy. OLP and other lichenoid dysplysia of oral mucosa occur commonly, and yet they are poorly understood. Furthermore, the role of Histochemical markers, Quantitative cytology and Morphometry as prognostic tools in evaluation of OLP has been proved beyond doubt. In the present study nuclear and cytoplasmic volume of basal cells, Spinous cell maximum diameter in OLP, normal mucosa and oral carcinoma are measured on Hematoxylin and Eosin stained sections using image analysis software.
Lichenoid Dysplasia–A Case Report with a Review of Differential Diagnosis