Lichen Planus Webcast with Dr. James Sciubba

Welcome to another live webcast of the International oral lichen planus support group I’m your moderator, Art Upton and I’m joined in the studio today by co-founders of our group Dr. Terry Rees and Dr. Nancy Burkhard Texas A&M University Baylor College of Dentistry. Our special guest today will be joining us live via Skype from his home in Baltimore Maryland. He’s Dr. James J. Sciubba professor retired of the Johns Hopkins School of Medicine, the Milton J Dance Head and Neck Center, Greater Baltimore Medical Center. Dr. Rees will be introducing you a little bit more to Dr. Sciubba in just a moment, but first for the inevitable housekeeping segment. You will be able to ask questions today and our guest and our hosts will answer as many as possible during the discussion portion of the program after our guest’s Presentation. You may enter your questions in the chat window just to the right of this viewing window. After our guest’s presentation he and Dr. Rees and Dr. Burkhardt will, as I mentioned a moment ago, be answering as many of your questions as possible during the session. If for some reason you do not have your concerns addressed today your list of
00:01:25,609 –>00:01:25,619 questions will remain on this page along with the recording of the webcast for about a month and one of the doctors will provide answers during that time. The chat questions will appear after the webcast is over as comments below the viewer window. Don’t forget our web address after the 30 day period. You will be able to find this webcast even after that on our website and our new website address will have backup on the screen at the end of the session now. When you go to our website, we just want to be sure that you notice that
00:02:07,679 –>00:02:07,689 on every page you will notice a give today button. Please be as generous as you can to help us keep this service available to you and free for everyone The involved production crew, guests, everyone donate their services for free but there are expenses involved in producing and Recording and in publishing these webcasts for you so please visit our site, click the gear button and follow me on $STREET on-screen instructions for sending us a donation regardless of how small and please be sure to designate that you want your donation to go to the Oral Lichen Planus Support Group. With that said, I’ll turn the rest of the webcast over to our hosts Dr. Terry Rees and Dr. Nancy Burkhardt the Co-founders of the Oral Lichen Planus Support
Group. They will have a few words for you and then we’ll introduce our guest for a brief presentation followed by discussion and answering some of your Questions. Dr. Rees- Thank you Art. We want to welcome all of you to another chat session. It’s hard to believe that it’s been almost 17 years since we started doing these from time to time and we grew up first using the computers and trying to answer questions that people asked us on the computers and that was very labor-intensive. Today we’ve gotten a little more sophisticated, no a lot more Sophisticated. We’re very honored to have Dr. Sciubba as our expert today. He is a world-renowned expert in a variety of oral pathologic conditions and he has special knowledge about oral lichen planus so we know that this is going to be a wonderful presentation and the kind of format we will follow today . So Dr. Sciubba will have some comments to make and then we’ll spend the remainder of the time with questions and answers. As art said we probably won’t have time to address all of those but we will get back to you those questions sooner or later, and with that I’ll turn things over and let Nancy say hello to you. Hi everyone. First of all I want to wish everyone happy holidays. We have a lot of festivities coming up. Dr. Sciubba was a guest early on. gg we’ve been doing this since 1997 as Dr. Rees just said and he was a guest early on so this is new for him. Before he was one of the typist with the scrolling and 209 everything we did early on.
00:04:42,200 –>00:04:42,210 think that’s going to be a great presentation. I look forward to your emails. I get emails from you periodically and if you have any questions at anytime whether it’s related to the presentation today or any other questions that come up about your oral lichen planus or your family member please just contact us will be glad to answer it and get back to you. If we don’t know the answer we will find someone who does. So with that I’m going to turn this over to Dr. Sciubba and we look forward to his presentation. Dr. Sciubba- Lichen planus has been recognized for many years going back to the late eighteen hundreds by an English physician, Erasmus Wilson calling the term lichen planus later the details of the disease began to be worked out and particular features were noted such as striaform, lesions now known as Wickham’s stria. which many people use to identify the clinical manifestations. While this particular discussion focuses on oral lichen planus, we must not lose sight of the fact that lichen planus affects many different places in addition to the oral cavity These include the patient’s skin, scalp Nails, the esophagus less commonly so and the ano-genital region in a fairly regular fashion while a small percentage of the population is affected by lichen planus 1% of 315 million people is a lot. of complaints Most of our patients are women and most of the time lichen planus presents on the skin and oral cavity in many of our patients. Among those with oral lichen planus of concurrent skin lesions as well the duration of my complaints can bury from the few years to a few decades and as we will see in the next few minutes it will show various forms of clinical presentation up to a third of my patients and patients in general with oral LP complaints have concurrent or concomitant skin lesions at the same Time. Many of the patients with oral lichen planus
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will not have a cutaneous disease but most do, and importantly we must keep in mind that lichen planus can affect many different locations. When it involves the gum tissues lichen planus can be desquamative, meaning that it shows the tissues to be very friable and fragile and they will oftentimes peel Off. and the word used for this qualitative is used . Hence the term desquamative
00:07:21,420 –>00:07:21,430 Gingivitis. Oral lican planus is one of the reasons why you can get desquamative gingivitis in addition to a few other diseases that are similar to but not the same as lichen planus. More importantly lichen planus takes many clinically different presentations The lesion on the upper left is the more classic reticular or striaform form of lichen planus.
When you see the dentition you can see the gum tissue here being very red and inflamed. This is the atrophic form of lichen planus. The lower-left figure it shows atrophy which is also surrounded by white areas. This is a reason why lesions are frequently very
00:08:06,990 –>00:08:07,000 Bothersome. The lower-right lesion is normally called hypertrophic or enlarged stage of lichen planus. These are the forms as well that are discussed predominantly in dermatological literature and less so in the oral literature I call your attention to the fifth line down To something called lichen planus-pemphigoidies means there’s an entity that some people use, called lichen planus pemphigoides where there’s a degree of overlap between our condition lichen planus and another similar condition known as pemphigoid. The differences can be subtle and they could only be separated by a laboratory analysis. Classically and typically lichen planus occurs on both sides of the oral cavity usually on the inside of the cheeks. To begin with you can see these white striae or lines that intersect, overlap and branch and more importantly and I put an asterisk next to the term several patterns and that you can see erosive
00:09:13,240 –>00:09:13,250 lichen planus, atrophic lichen planus, reticular lichen planus, all the same time in our patients. So you have to be aware of the variable degrees of presentation. Most patients at a point in the evolution of this disease will show the reticular lesions that I showed you Earlier; a smaller percentage show hyperkeratotic relations and yet a small it’s still small percentage will show ulcerative disease. the atrophic and erosive 434
00:09:40,540 –>00:09:40,550 forms like those tend to be the more symptomatic and brings up an important Point. I think you recognize and appreciate is that lichen planus can last for a very long period of time especially in the mouth. Skin lesions Often times will fade away or burn out as it’s called within 4 to 5 years but oral lichen planus–>00:10:03,710 tends to be more persistent, sometimes over decades rather than simply a few years. In location and site frequency the cheeks in particular, the gum tissues, the top and side of the tongue and less commonly so on the hard Palate. The most common form is the
00:10:24,220 –>00:10:24,230 reticular form followed by atrophic lichen planus and then somewhat less commonly, erosive and ulcerative aspects of this disease. Its important to understand that lichen planus is not a static disease. It is a very dynamic process that will change its appearance and symptomatology over time. Patients who are being treated with maybe very good control for months, if not years, suddenly will have a flare without apparent good reason that has to be dealt with so the initial stage, six months to a year patients often times will complain about some symptoms or sensitivity to the dentist perhaps but minimally so. The dentist in turn may see lesions that are red or white that will call attention to the patient’s disease leading ultimately to its diagnosis. The intermediate stage shows obvious Particular varifications as we’ve seen a few minutes ago we’ll see areas that tend to be quite asymptomatic and other areas which are more red and inflamed and quite bothersome at times that the doctor is not aware of. Consequently, I see our patients many times. will show you erosive disease where the surface of tissue of the mucous membranes appears to be very thin and the surface my even break apart and be rotated or even Ulcerated. These are very problematic and demand treatment subsequent to the later phases of the intermediate stage of the Disease. You can sometimes see brown surface alterations which is not post inflammatory pigmentation which oftentimes is the signal of a decrease in the intensity of the disease. The late stage status can last for many years and as a result we can often find that thinning of the mucous membranes on the top of the tongue, of the borders, and the tissue will show you loss of papillae to become more smooth rather than more like a rough surface of a cats tongue, so to speak. The gum tissues can be smooth and glassy rather than stiff and rough, suggesting that keratinization is declining. Late-stage patients might complain that the back of the cheeks and where the cheek and the gums meet you will often find loss of periodontal attachment and the onset of periodontal problems in the same area. So there are three stages that typify this disease; the initial stage of short Duration. the intermediate stage which can last for several years and then the late stage which goes on for years after that. Even so, chronically we can see scarring, ultimately with resolution of the inflammation or we may see thinning of the mucous membrane,
00:13:23,660 –>00:13:23,670 smoothing out of the tongue, scarring on the inside of the cheeks especially. Toward the back or oropharynx. So we see loss of the mucobuccal fold where the cheek and gum tissues meet and as I said earlier you see hyperpigmentation. One colleague of ours
00:13:47,449 –>00:13:47,459 Dr.Drore Eisen, identified the vulvo-vaginal-gingival
00:13:51,499 –>00:13:51,509 lichen planus syndrome in which, many times, we find we can comment on concurrent genital disease along with oral disease where the gum tissues are involved as well as the mucosa over the vulva and the inner aspect of the vagina. This can lead to significant symptomatology where the gynecologist is brought into the management team. Note there is a subset of lichen planus patients with particular genetic qualities which make this a more likely occurrence. But this in fact is the minority of women with this disease. So with vaginal and oral syndrome disease it can involve not only the gingiva but the inner aspect cheeks; less commonly on its on, and even less commonly the hard palate and floor of the mouth. One of the things we face clinically many times is determining whether or not a drug therapy petition may be helping lichen planus establish itself. In that case there is a lichenoid drug eruption and many drugs that are in common use every day including antibiotics and 200 antihypertensives for those people with blood pressure problems, antidepressants for those with depression problems. antidiabetics. and certain forms of diuretics, such as the thiazide drug class, can produce lichenoid lesions which tend to fit under the open umbrella of oral lichen planus, but there’s a really long list of drugs that one should be aware of as potentially being involved. with lichenification. So here is a series of lichen lesions. This is the classic reticular branching surrounding some areas which are a little bit thin. I read this as a more classic heavily keratinized or reticulated form of lichen planus again involving the inner aspect of the cheek extending into the mucosal vestibule right next to the jaw. This is a combination of atrophic lichen
00:16:20,570 –>00:16:20,580 planus a board widely based reticular pattern on the gingiva. This is usually found on both sides in a symmetrical distribution left or right. As for lichen planus there’s a point where there’s a line where the trauma of routine day-to-day function can often times
00:16:42,620 –>00:16:42,630 exacerbate or encourage lichen planus to form along that trauma or occlusal line site. Right here you see a concurrent reticular and punctate lichen planus in association with an ovoid area of atrophic-like involvement. This is more papular lichen planus and it is more common on skin but less commonly in the oral cavity but papular lichen planus does occur in the mouth. And here you see that with a distinct absence of the more classic reticular or striaform
00:17:18,199 –>00:17:18,209 lichen planus. This is a more advanced stage of disease where we
00:17:22,400 –>00:17:22,410 have hypertrophic or thickened mucous membranes. This is mostly keratinized Tissue. This is a pattern of reticular and erosive disease or atrophic disease and this is classic erosive lichen planus. This is very bothersome; toothpaste bothers, spicy foods, salad Dressings, and so forth, will oftentimes be off limits to our folks with this particular form of lichen planus. Here again is another kind of a y-shaped area. This is an ulcer that’s covered with a substance called fibrin which covers the ulcer in an attempt to form a healing plaque and this is a lady who just lost that. Can you still hear me I hope? This is a lady that I have been following for some years with severe lichen planus envolving the dorsum of the tongue. We still Are we still on? I think we may have lost that but I’ll continue. This is a lady that has severe lesions On the dorsum of the tongue. This is after she’s been treated. okay hear me know this is the dorsum of tongue lichen planus.Can you still hear me? Let me make a call to make sure that we’re still in business here. Good, so this is a later form of lichen involving the tongue and here you see the loss of tissue and really depicts the nodular heavily keratinized disease very different than what you see on the cheeks and the skin. This is a close-up of another case of late-stage lichen and it’s involving the tongue surface more classically and you lose the papillae. Here are some residual papillae here and there but here a large thick heavy plaques of lichen planus as well again another case of erosive or ulcerative-like complaints involving the cheek the lateral side of the tongue. Here is a relatively mild case of lichen planus involving the attached gingiva where it looks like a patient would have gingivitis but in fact that’s not the case. What often happens to folks with gingival lichen planus. They find it difficult to brush their teeth, then they develop heavy accumulations of plaque which make the lichen planus even worse. So you have two things going on, you’ve got Lichen planus on one hand and you’ve got a plaque induced gingival inflammation on the other. Here’s another such case. You see some hyperkeratinized areas in association with eroded areas of general lichen planus. Again another example of gum disease where you have
00:20:20,490 –>00:20:20,500 gingival recession, loss of attached Gingiva, local attachment loss, and then again very heavily inflamed tender symptomatic gingival inflamed tissues and finally, lichen planus.
00:20:34,530 –>00:20:34,540 It’s a bit unusual but we do see it and you see concomitant deep ulceration
00:20:39,870 –>00:20:39,880 associated with thickened areas as well as annular ring like configurations all consistent with lichen planus. You’re gonna see a severe case where you have parallel development so the associations and cofactors involved with lichen planus elaboration if not causation including drugs of various drug Classes. Persistent yeast infections can produce a lichenoid reaction, certain contact substances, certain types of dental fillings. Old silver fillings can sometimes do this, even some forms of plastic or composite restorations can induce localized lichenoid reactions. Physical trauma. Lichen planus as with psoriasis can respond to trauma so if the patient has lichen planus and there’s an area of frequent dental trauma on the cheeks or the side of the tongue you will see lichen planus
00:21:37,020 –>00:21:37,030 involving those specific areas and likewise with smoking a lot smoking can irritate and likewise exacerbate or make lichen planus worse. Dental plaque is another causative factor which I believe is very important I stress scrupulous hygiene in my patients and they spend a lot of time with the dental hygienist trying to keep their teeth as clean as possible. The issue of stress is always a consideration in our patients oh I I feel comfortable in saying that stress itself doesn’t cause lichen planus but in many patients with existing lichen planus stressful situations often times can make it worse. so there is the stress relationship and it probably is manifesting through the immune system which drives lichen planus To begin with we talked about restorative materials before as causing this. This is what the pathologist will see down the Microscope. In a classic case of lichen planus if you look at this blue area right here that’s the Lymphocytes, the t-cells in particular which are driving this and actually producing the disease lesion there. This is the reticular variant of lichen Planus. We can see this a pink surface Material, that’s the keratin which is the white stuff we see clinically. If you look more closely at the top layer here we’re moving my arrow and the basal layer here the lymphocytes infiltrate actually through and into the epithelium they disrupt the basal layer which is 1. the layer which keeps layers of tissues Intact, It forms new cells on a day-to-day Basis. it’s the disruption of the spacer layer which oftentimes is responsible for the ulcers and erosive lesions of lichen Planus. Also, we oftentimes would need to do immunofluorescence studies to separate lichen planus from similar diseases especially in particular mucous membrane pemphigoid or cicatricial pemphigoid. In lichen planus we see a bright yellowish green line right up the basement membrane or junctional zone between the overlying epithelium and the underlying connective tissue fibers
00:24:02,790 –>00:24:02,800 depositions rather characteristic of lichen planus and all other immunoreactive or negative with lichen
00:24:09,450 –>00:24:09,460 planus which is why this can be an important diagnostic test to separate like complaints from other similar appearing lesions clinically and microscopically. The yellowish green bodies here are cytoid bodies which are degenerative keratinocytes or epithelial cells which are coated with immunoglobulin usually something called IgG or IGM which is often found in lichen planus, but it’s not specific to it. OK, let’s talk about the lots of different therapeutic approaches to lichen
00:24:43,260 –>00:24:43,270 Planus.
00:24:44,649 –>00:24:44,659 The cornerstone of management when lichen planus is symptomatic and must be managed are steroids, topical steroids cortisone type derivatives. Dr. Rees, Dr. Burkhardt and I oftentimes talk about topical management of lichen planus. It is still the mainstay of most of our patients with lichen planus. Occasionally with more stubborn lesions we actually inject steroids beneath and around the areas of persistent lichen planus and in severe cases in order to gain early and quick control, we will give steroids by mouth depending upon the severity, the dosage can be a scaled up or down. Some individuals use synthetic retinoids if patients are steroid intolerant for various reasons and Retinoids can be used topically as well as Systemically. Plaquenil is an anti-malarial drug that has some utility in lichen planus as can
00:25:44,680 –>00:25:44,690 Dapsone, another systemic drug which can be helpful. More recently we’ve been using drugs called cyclophosphimides, topical tacrolimus which is something known as a calcineurin inhibitor which can be effective and sometimes can be used as a steroid sparing agent. I do not believe that lichen planus is a surgical disease that is to say we don’t usually cut out Lichen planus and expect it not to come Back. So in my experience there is
00:26:17,169 –>00:26:17,179 little use of surgery other than in establishing the diagnosis by way of a biopsy. There is some recent literature using certain forms of laser therapy in particular soft lasers or KTP lasers there may be something to this. There’s an evolving philosophy of management and maybe down the road, lasers will be used more consistently than they are routinely today, and importantly as I said earlier in cases where there’s significant gum or gingival involvement of lichen planus, I insist upon scrupulous Oral hygiene, frequent visits to the dental hygienist and oftentimes the use of a drug called chlorhexidine which will also keep down plaque and reduce bacterial burdens So why is oral hygiene important and to simplify this slide nevermind really what it says in detail but just appreciate the fact that the bacterial component in dental plaque by way of activating the innate immune system can likewise exacerbate or worsen Oral lichen planus. If we eliminate as best we can the oral bacterial component we can likewise get a leg up on the management of our lichen planus patients. In treating this condition corticosteroids remain the mainstay, retinoids less likely as is plaquenil (hydroxychloroquine). There is another non-steroidal alternative which can be useful in some patients. Other Treatments. As I said, using topical tacrolimus Or the drug protopic in various strengths can be used rather effectively is azathioprine which is a chemotherapeutic drug that I have used in the past but I don’t use it any longer. i think that acidity of this is significant so I kind of left this along the wayside. jjI no longer Use erbium laser ablation as mentioned earlier, although it does have some increasingly useful role in the management of lichen planus. Oh I will often use drugs in the tetracycline class in particular with significant gingival disease or gum disease. Doxycycline or minocycline in my hands has a role and this has to do with a certain molecular collagenase activity at the basement membrane zone. The literature talks about the use of a drug called phenytoin which in my in my mind has no utility whatsoever and likewise a drug called interferon has been used in the past but i find very little utility because we have far less expensive and more effective drugs than the latter two. Topical steroids by all means, protopic which is a calcineurin Inhibitor, antifungals may have a role here in reducing yeast burdens in the mouth and likewise can commonly improve the response to our more typically used drugs, and likewise chlorhexidine i think has a role to play because it is a very effective and inexpensive topical antibiotic which is a prescription drug.What we need to do ultimately is reduce the activity of the t cells which are
00:29:54,460 –>00:29:54,470 are really driving this disease. One of those drug classes that are used to reduce t cell activity is is tacrolimus which was developed initially for use in the transplant patient but topical application of this is effective for many immune driven skin and mucous membrane diseases including eczema and now lichen planus as well. We use calcineurins. I definitely use .1% Tacrolimus. It’s effective and in some studies t is shown to be as effective as steroids. It’s quite possible that oftentimes will use both since pimecrolimus can act As a steroid sparing effect. a There’s a fairly recent study in the dermatological literature which uses very very low concentrations of tacrolimus
00:30:43,900 –>00:30:43,910 in an aqueous or water Solution. This was a study by Olivier and her colleagues published in the Archives of Dermatology some years ago. I will use it on occasion but I think this drug while it is the same as pimecrolimus, it’s very very diluted and almost homeopathic doses and tacrolimus cream, something called pimecrolimus or Elidel has a role to play as well as in a similar fashion to Protopic. and finally the last subject to cover before we open this up to questions is a question I get all the time from my Patients. Can this be related to cancer and the answer is yes, but we’re talking about a relatively small number of cases so yes the 800-pound gorilla remains. Is lichen planus the preeminent condition? In a small percentage of cases I think you have to say yes and what seems to be driving that is the long-term presence of chronic inflammation which can act as a transformational factor leading to pre-cancer if not cancer. It is so important in the entire equation to have continued follow up by your management team for Lichen planus to make sure that it remains as lichen planus only and nothing else. So while it is somewhat controversial in in my mind over the last nearly 40 years of practice I believe that lichen planus must be followed for that reason alone if not for many other reasons. We have various forms of
00:32:24,190 –>00:32:24,200 lichen planus, but the erosive form is of
00:32:26,260 –>00:32:26,270 most concern. The erosive and atrophic forms are those types which tend to transform rather than the reticular type which in my mind and I’ve never seen that happen does not occur. The duration of lichen planus can be decades but it’s usually in the longer-term cases where you see this transformation occur. As I said earlier and repeating myself the reason for this transformation is probably persistent chronic inflammation relating itself back to what we call DNA mismatch repair where cellular repair and healing doesn’t occur normally and it leads to dysplasia and precancerous conditions so this is an evolving area of study. We are certainly able to recognize this disease, we have diagnostic parameters which are well-defined at this point. We have clinical algorithms which can be very effective in management and we certainly appreciate the relationship of cancer development in a very small percentage of cases. I received a three-part
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question 1460
00:33:33,360 –>00:33:33,370 from an individual whose mother has biopsy confirmed lichen planus. It’s been successfully treated and she is now under control but she’s going to be returning to her native country where she won’t really have very knowledgeable encounters with dental health professionals, and so part one of the question is she’s been told to start treatment if she starts to develop recurrent lesions and so the question is how can you identify early signs of lichen planus? Well yeah
00:34:14,490 –>00:34:14,500 that’s a good question. The patient has certainly experienced that at this point as to what the abnormalities are asymptomatic lichen planus is oftentimes disregarded by our patients or forgotten. I think a keen eye and routine examinations by the patient with a good light and a good mirror should keep them pretty much on top of any subtle changes that may be occurring. I would tie that With any symptoms may be evolving at the same time I totally agree with that. The next question about the same Individual, when the patient was being treated she have some candidiasis in the biopsy site so the question is how does she know she’s getting a recurrence of her candidiasis which has been successfully treated up until now? That’s a good question. Many times people who carry candida or yeast organisms in the mouth as just part of their being. Many people are carriers, in fact the majority of patients do carry candida I guess. The question in that equation is does the presence of canada in lichen
00:35:30,180 –>00:35:30,190 planus tend to make lichen planus
00:35:33,210 –>00:35:33,220 more persistent? If my biopsy shows lichen planus along with candida concurrently I will treat the candidiasis with the topical or even systemic antifungal drugs. Again I totally agree with what you just said I think that since we use so many topical steroids that we can predispose patients to secondary candidiasis resulting from the treatment and we have to be aware of that, and on guard against it. You are three hundred percent absolutely right. The third question has to do with with the concern about possible malignant transformation and how much of a risk is that? I think we’ve already answered that. There is apparently a very small risk, if it is a risk, but one of the early signs of malignancy that his mother should be looking for. That is a very good question and it’s not an easily answered question in that early stages of cancer or dysplasia sometimes look similar to
00:36:47,340 –>00:36:47,350 lichen planus where the area is deeply red or even a little bit velvety or there may be some textual surface changes that you can appreciate. Great persistent ulcers or when you run your finger over your tongue over the area It is thick or indurated. Those are some of the signs that I would pay attention to as perhaps bolded information if not cancer
00:37:11,400 –>00:37:11,410 development. Thank you yes. May I just add one thing to that? I think that there are some good videos and CE courses that are online that give the patient an idea of what to look for in the mouth with any abnormality whether it’s lichen planus or any anything else and retracting the tongue sitting in front of a makeup mirror using good lighting as Dr. Xu but just said and really looking at getting used to what is normal and what is not normal. I think if you go online you can find some of those. If you have trouble finding them email me and I will Send you a link. Okay we have a question here the question is “I haven’t found any toothpaste that doesn’t cause my mouth to Burn. Recently I dropped using toothpaste entirely but I worry about whether there is a downside to my overall dental health. I thought about using baking soda but read that it’s too abrasive for everyday brushing. Your thoughts are Appreciated. I can share that. I’m sure Terry Nancy likewise have opinions Oh yes toothpaste can be a problem. Many of the commercially available toothpastes with the flavoring systems and the detergent systems within them can be bothersome. Some people like to use Biotene toothpaste and products which is a rather bland toothpaste Glaxo had to change that formulation and some people are now bothered by the use of Biotene but they are looking into that. I just had a conference call with those folks a week or two ago and they will be examining it again I oftentimes will have my patients use the children’s toothpaste which has much milder flavoring agents in it, and less Detergent. As another alternative I would continue to try to find things that would be helpful to you. Yes baking soda can be abrasive. You don’t want to be using it every day There’s a role for it but I would look for children’s toothpaste to start with and buy two or three different kinds to see which one can be most effective and even between meals you may want to use a toothbrush that you soaked in fluoride rinse that is available over the counter Act mouth rinse which doesn’t contain alcohol Soak your toothbrush in that as a help you get your fluoride and you can remove your plaque at the same time. have I would agree with everything you said and to my way of thinking the catchphrase here is that she stopped using a toothbrush and I think that
00:40:05,780 –>00:40:05,790 evidence shows that is detrimental not only to your overall dental health but to lichen planus as well if the gum tissue is involved with the lesions so I think it’s really important to find a toothpaste that doesn’t burn and that’s our cardinal Rule, if it burns don’t use it. Sometimes you do have to experiment a little bit with the children’s paste
00:40:29,180 –>00:40:29,190 example there’s one and i’ll go ahead and say it, Crest that has cinnamic aldehyde in it which is an irritant sometimes for some patients even in the children’s formula. But some of the other major carriers don’t have that. I’ll add something to that. As Dr. Sciubba just said, sometimes patients will stay away from the gum tissue because it will get so inflamed and irritated. So finding a very soft bristle brush that you can use at those times is really very important and I know that
00:41:04,790 –>00:41:04,800 Biotene did make a really soft one. Dr. Rees and I were just talking about this yesterday so we’re hoping to locate that brush again and there are some that we can recommend that are very soft but the whole idea is to keep the area very clean and plaque free. A question said that there was a recent study showing that there was quite a bit of improvement using purslane. Would you care to comment on it? Purslane
00:41:41,180 –>00:41:41,190 is a common household plant you can even grow indoors and in warmer weather it grows outside very nicely. in fact we had some in our
00:41:51,120 –>00:41:51,130 garden here. The purslane study Was, I think, generated from Tehran One patient of mine actually bought some purslane and used the leaves as a kind of
00:42:06,240 –>00:42:06,250 mouthwash. There may be some beneficial effect of it but but i think we have better things available. Ok,one question asks if you’ve heard of using antibiotics and niacinamide to successfully treat oral lichen planus? the role of niacinamide and antibiotics in particular have been used for the management of mucous membrane pemphigoid that was originally shown in the opthalmology literature some years ago So there may be some benefit from that, particularly tetracyclines and niacinamide. But oftentimes niacinamide has significant side effects in terms of flushing, and elevated liver enzymes.
00:42:56,580 –>00:42:56,590 You’ve got to be a little careful with that particular drug in high concentrations on a consistent basis. Um you mentioned that you have some success for gingival lichen planus
00:43:09,990 –>00:43:10,000 using minocycline so do tell us how you use that how do you how do you administer it? Yes I like minocycline or doxycycline low-dose. I start with 50 milligrams twice a day and once I get it controlled back down to periostat 20 milligrams twice a day and the reason I find that effective in many patients but not all, is that we may derail the destruction of the basement membranes caused by the enzymes that are elaborated as part of the inflammatory Process. so we protect the collagenases by shutting down some of the matrix metalloproteinases which are inhibited by the tetracyclines.
00:43:58,940 –>00:43:58,950 A questioner asks can olp be transmitted to another person? We get this question a lot and it’s usually the person in the middle of the night that’s emailing and concerned about it. but I know you cannot infect another person and you didn’t get it from
00:44:19,310 –>00:44:19,320 Anyone. You can’t give it to anyone and contagion is always a question that we’ve had from the very beginning and it’s something to be concerned about but we can usually alleviate your fears in that regard. But maybe Dr. Sciubba might want to comment on candida being transferred to another person. It usually seems to relate to an altered immune system and probably not easily transmitted, but we have heard of cases. I don’t know the specifics about transmission of candida. I mean it’s gotta come from somewhere you’re not born with it right, but candida presence in
00:44:56,930 –>00:44:56,940 mouth begins fairly early in life so yes it comes from someone somewhere so theoretically you can transfer candida. I’m not suggesting you don’t kiss your mate or your loved ones and so forth because it is such a part of our being as organisms. I’m going to carry candida and staf and other organisms as part of us as human beings. Thank you. My olp has now become erosive under my tongue on both sides very painful but my plastic mouth guard which is for sleep apnea has caused or exacerbated this condition. It’s possible that the device may be playing a role, in particular if the tongue has been traumatized by the cpap rather by the 1994
00:45:42,829 –>00:45:42,839 sleep apnea device. Yes we know that
00:45:50,089 –>00:45:50,099 lichen planus can be exacerbated by local physical trauma. I doubt very much that the plastic itself is involved as the topical allergen but I would place the role on maybe the traumatic aspect. I would have the dentist make sure that the edges or margins of the appliance are smooth and highly polished and well contoured to eliminate that particular possibility. A patient wants to know if you’re taking new patients so maybe most of the attendees want you. Yeah yeah if you want I will be available tomorrow. Well, we have placed patients with Dr. Sciubba in Baltimore and in that vicinity. So okay all right well maybe you have some discussion that you’d like to carry on with Doctor Sciubba? I think we’re getting down on the questions and if anyone has any more questions you can go ahead and submit them now. It is getting close to the end of the session So Jim you talked about the response to treatment and the possibility of early recurrence. What I tell patients is that since we don’t know what’s causing lichen planus we are treating symptoms, we’re not treating the etiology of the condition and that they will likely have recurrences but that as long as it’s painless in the reticular
00:47:26,700 –>00:47:26,710 form or they may be small areas of the plaque-like form that that’s ok, but when they have discomfort is when they should seriously consider using the effective medication that they have for a few days to get it under control. I agree with that. I would amplify on that. Yeah I agree with the philosophy Terry. for sure what I do with my lichen planus patients, those folks that are being treated by one means or another I will follow them clearly unequivocally. Those folks that are asymptomatic and have reticular disease only, I oftentimes return them back to their referring doctor, usually their dentist to be Evaluated. If they choose to come back to see me that’s fine as well, but I do believe that they should be followed by someone who understands a bit about the disease and separate this from what normal mucosa looks like. Right The only thing I’ll add to that is especially in women, Dr. Scuibba had mentioned the vaginal aspect and sometimes these patients get lost in transition they may be seeing a gynecologist but the gynecologist doesn’t know about the oral lichen planus
00:48:45,829 –>00:48:45,839 and maybe the dentist doesn’t ask about you know any vaginal lesions so that connection is often lost, and that I think needs to be strengthened but you know the women need to make sure that both parties know what’s going on. And also Dr. Sciubba’s presentation
00:49:04,519 –>00:49:04,529 mentioned the esophageal connection too. We do get quite a few emails from patients who think that they may have esophageal lichen planus and we suggest that they go to their ENT physician and get that evaluated and check because it can occur in any lining of the mucosa. Right Nancy so that the two subspecialties that we’re talking about here,
00:49:27,920 –>00:49:27,930 the ENT doctor and the GYN person I think it’s important for those folks who develop swallowing issues in the case of oral or skin lichen planus to be sure that it’s not esophageal LP which is a very difficult type of LP to treat and that also has to be differentiated from Barrett’s esophagitis and other things that can have similar Symptoms. In particular difficulty swallowing, dysplasia etc. As far as the GYN aspect of the disease is concerned within my intake exam if the patient that comes with a diagnosis of lichen planus or we prove the diagnosis, we have no hesitancy in asking
00:50:07,999 –>00:50:08,009 questions about GYN complaints, rectal itching or other Symptomatology, and if the answer is yes bringing the gynocological practitioner into the fold. This indicates to patients that this is not a mystery, that means of controlling vaginal LP are available just as we can control oral LP and we often find ourselves discussing this with the patient’s treating gynecologist. That’s a really good point and sometimes women suffer needlessly for years and again as long as that goes on the scarring gets worse and it just complicates I think scarring in late-stage of vaginal lichen planus
00:50:47,490 –>00:50:47,500 definitely increases this problem and all kinds of issues or interpersonal issues. That the marriage and relationship also can be affected. oh I think that the many women will come to us and say well yes I have or I get yeast infections all the time vaginally.
00:51:05,339 –>00:51:05,349 In fact it’s not vaginal yeast its lichen planus.
00:51:08,550 –>00:51:08,560 Because itching is common to both conditions that’s what kind of collaboration has to be about. Right? That’s a really good point. Ok I want to remind everybody, thank you Dr. Sciubba. By the way it’s been fantastic, our first skype session. Dr. Sciubba was one of the first people to join us on our old chat room, typing it all and and so it’s been great to have you this morning with us and and everyone else who was here. I want you all to realize that after the session is over the recording will be here on the live stream site for about I don’t know three or four weeks afterwards but we will be retaining the recording and moving it to our website so please keep an eye out for that. Also the questions that have not been answered yet we will do our best to deal with by email and you can check back here. Underneath the video screen is the comment section and participate in the chats as these go on. So I want to thank Dr. Rees, Dr. Burkhardt and again Dr. James Sciubba for joining us on this segment of webcasts from the International Oral Lichen Planus Support Group at Texas A&M University Baylor College of Dentistry. We will see you all next time bye now. Thanks everybody, thank you very much.

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