CASE

PRESENTATION

ANU. M. PAUL
FINAL YEAR PART 1
A
 PERSONAL DATA

● Name : Leena
● Op No : 24731/19
● Age : 38
● Gender : Female
● Address : Omassery
● Occupation :Nurse
● Contact no:9744445917
CHIEF COMPLAINT

Patient complains of pain in the right lower back

tooth area since 2 months.
 HISTORY OF PRESENTING
ILLNESS
● Pt. complains of pain in the lower back tooth area. After
trans-alveolar extraction before 2 months there was no history
of pain for next 15 days. After 5 days removing the suture
pain gradually progressed in the right side of face at the level
of angle of mandible.
● Pain was of dull in nature which then progressed to throbbing
intermittent and radiating type over a period of past 1month.
● It is also associated with trismus and swelling in the right side
of face at the level of angle of mandible.
 PAST DENTAL HISTORY

● Patient had undergone uneventful extraction about 2 months

before.
 PAST MEDICAL HISTORY

● There is history of diabetes since 2 months.

● Pt. is under medication of Metformin 500 mg once daily.
 FAMILY HISTORY

● There is history of hypertension for mother for past 6yrs.

 PERSONAL HISTORY
● Diet : Mixed Diet

● Oral Hygiene : She brushes twice daily using tooth paste

and soft bristled toothbrush in horizontal and circular
direction.

● Habits : No deleterious habits reported

● Marital status : Married

● Sleep, appetite, micturition and bowel movements are normal

EXAMINATION OF THE
PATIENT
 GENERAL EXAMINATION
● Gait : Normal

● Built : Moderately built

● Nourishment : Moderately nourished

● Orientation : Well oriented to time, place, person

● Pallor , icterus , cyanosis , clubbing , oedema or lymphadenopathy

not present
VITAL SIGNS

● Temperature : Afebrile

● Blood Pressure : 110/80 mmHg

● Pulse : 72 beats per minute

● Respiratory rate : 17 breaths per minute

TMJ EXAMINATION

● Clicking Sound : No clicking sound

● Tenderness : No tenderness

● Deviation and deflection : No deviation and deflection

● Mouth Opening : 45mm

 INTRA ORAL EXAMINATION
SOFT TISSUE EXAMINATION
● Buccal mucosa : White raised branching striae with bluish black
discolouration is seen bilaterally on periphery and erosive areas in
the centre. Small tissue tag is also seen in right side near to lips.
● Lips and Labial mucosa : No abnormality detected
● Hard palate : No abnormality detected

● Floor of mouth : No abnormality detected

● Tonsillar fauces and
oropharynx : No abnormality detected
● Tongue : No abnormality detected
TISSUE EROSIVE
TAG LICHEN PLANUS
GINGIVA

● Colour : Pinkish red in colour

● Contour : Scalloped margin

with rounded interdental papillae
● Consistency : Soft and edematous

● Surface texture : Stippling absent

● Bleeding on probing : Present

Desquamative gingivitis
 HARD TISSUE EXAMINATION

M D M

17 16 15 14 13 12 11 21 22 23 24 25 26 27

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37

D D D

D-DECAY

M-MISSING
● Total number of teeth : 26
● Decayed teeth : 26, 36, 37, 46
● Restored teeth : Nil
● Missing teeth : 17, 27, 48
● Root stump : Nil
● Molar relation :Angle’s Class 1 molar relation
● Overjet : 2mm
● Overbite : 1.5mm
 ORAL HYGIENE STATUS

● Plaque : +

● Calculus: Nil

● Stains : ++
LOCAL EXAMINATION OF
BUCCAL MUCOSA
INSPECTION:

● On inspection white raised branching striae with bluish black

discolouration is seen on the periphery and erosive areas in
the center in both sides of buccal mucosa.
● A tissue tag is also seen on the right side of buccal mucosa .
EROSIVE LICHEN PLANUS
PALPATION

● On palpation lesion is non scrapable.

● It is associated with burning sensation.
● Non tender on palpation.
 PROVISIONAL DIAGNOSIS
● Oral Erosive Lichen Planus

● Dental caries i.r.t 26,36,37,47.

● Chronic desquamative gingivities.

● Partially edentulous area i.r.t 17,27.

 INVESTIGATION

OPG is taken.
● Bony fragments are seen in distal aspect of 47.

● Boundaries of inferior alveolar canal is not clearly seen.

 FINAL DIAGNOSIS

● Post extraction pain-Idiopathic.

● Oral erosive lichen planus.

● Chronic desquamative gingivties

● Dental caries i.r.t 26, 36, 37,47.

● Partially edentulous area i.r.t 17, 27.

 TREATMENT PLAN

Advise
● Surgical consultation.
● Topical steroids.
● Oral prophylaxis.
● Endodontic consultation i.r.t 26,36,37,47.
● Prosthetic rehabilitation i.r.t 17,27.
 DISCUSSION

ORAL EROSIVE LICHEN

PLANUS
LICHEN PLANUS
DEFINITION

● It is a common chronic immunological mucocutaneous

disorder that varies in appearance from keratotic to
erythematous and ulcerative.
● Affect either skin or mucosa.
● Cause bilateral white striations, papules or plaques on buccal
mucosa, tongue or gingiva.
ETIOLOGY

● It is a T cell mediated autoimmune disease.

● CD8+ T cells recognize antigen associated with MHC class I
on keratinocytes.
● CD8+ T cells trigger keratinocyte apoptosis.
● Activated CD8+ T cells release cytokines attract lymphocytes
into developing lesion.
● Expression or unmasking of lichen planus antigen is induced
by:
-Drugs,allergens contact in dental restorative materials
or toothpastes, mechanical trauma and viral infection.
CLINICAL FEATURES

● Site : Skin lesions :

Flexor surfaces of wrist
Inner aspect of thighs and knees
Trunk
● Oral lesions :
Buccal mucosa, tongue, gingiva, lips,
palate and floor of mouth
● Age : >40 yrs.

● Females>males
SKIN LESIONS

● Small, angular, flat toped papules few millimeters in

size.
● Discrete gradually coalesce into larger plaques
covered by fine glistening scale.
● Papules demarcated from surrounding skin.
● Early lesions are red in colour which gradually
become purple and violaceous hue.
● Latter lesions become dirty brownish colour.
● Center of papule is umbilicated and surface is
covered by fine greyish white lines known as
WICKHAM’S STRIAE.
ORAL MANIFESTATIONS

Oral lesions with no lesions elsewhere in the body are called

isolated lichen planus.
There are four types of lichen planus.
i) Reticular
ii) Erythematous
iii) Erosive
iv) Bulbuos
RETICULAR
● Most common and readily recognized one.
● Slightly elevated white or greyish velvety thread like
papules in lace like linear, annular, ring pattern .
● Lines are wavy and parallel.
● A tiny elevated dot like structure at intersection of white
lines is called STRIAE OF WICKHAM.
ERYTHEMATOUS
● Smooth, red, poorly defined erythematous areas with or
without peripheral striae.
● Keratotic changes combined with mucosal erythema.
● Associated with chronic desquamative gingivitis.
EROSIVE
● Pseudomembrane covered ulcerations with keratosis and
erythema.
● Severe form with extensive degeneration and sepaartion of
epithelium from connective tissue.
● Pain, burning sensation and bleeding may present.
BULLOUS
Vesiculobullous presentation combined with reticular or erosive
pattern.

OTHER TYPES
-Plaque type
-Hypertrophic type
-Pigmented type
DIFFERENTIAL DIAGNOSIS
-Lichenoid reaction
-Leukoplakia
-Frictional keratosis
-Discoid lupus erythematosus
-Chronic ulcerative stomatitis
-Erythema multiforme
-Pemphigus vulgaris
-Benign mucous membrane pemphigoid
INVESTIGATIONS
● BIOPSY should be done to confirm diagnosis.
● Erosive lichen planus may be examined histopathologically
to assess dysplastic changes.
TREATMENT
● Absolutely there is no treatment for OLP.
● If no symptoms no active treatment is needed except
reassurance, reviewed regularly.
CONSERVATIVE MANAGEMENT OF OLP
● Corticosteroids
● Griseofulvin
● Cyclosporin
● Retinoid
Corticosteroids
● Topical 0.1 % triamcinolone acetonide
● Potent preparation --- 0.1 % flucinolone acetonide and
0.05% fluocinonide.
● Orobase
● Elixir form --- dexamethasone
triamcinolone
clobetasol
THANK
YOU