Universal Diagnostic Criteria for Oral Lichen Planus

Universal Diagnostic Criteria for Oral Lichen Planus ABSTRACT: For years, dissentions and debates on the malignant transformation of oral lichen planus (OLP) have been sparked not only by a lack of an accurate diagnostic criteria but also due to the failure on our part in not following single universal one. In this short communication, we try to reiterate its importance, with a goal of making the clinicians and pathologists aware of its serious implications. Keywords: Oral lichen planus, oral lichenoid lesion, dysplasia BACKGROUND: The lack of a universal diagnostic criteria for the diagnosis of oral lichen planus (OLP) can be made accountable for the current scepticism and controversies over its malignant transformation. Van der meij et al have stressed for a need of a diagnostic criteria to be universally adopted for its firm diagnosis.1,2 A clinical and a histopathological definition of OLP was formulated by the WHO in 19783 (Table 1). Later, in 2003, van der Meij and van der Waal4, proposed a modification in the WHO criteria (Table 2), stating OLP diagnosis should be clinico-pathological. Results of Rad M et al’s4 study in 2009 showed higher clinicopathologic correlation in the diagnosis of OLP based on the modified criteria of OLP (van der Meij 2003) compared with the 1978 criteria. Studies in the past, and present have substantiated the malignant potential of OLP.6-9 So, now that we have evidence for its malignant transformation and a suitable criteria in hand, what could be the problem? 1978 WHO CRITERIA VS MODIFIED 2003 CRITERIA: There have been studies related to the malignant nature of OLP since 1924 by Williger et al. to a recent meta-analysis by Fitzpatrick SG et al8 in 2014. It has to be noted, that, over the years, the diagnostic criteria of OLP has undergone a number of significant changes. A criteria was agreed by WHO in 19783 and again modified in 2003 by van der Meij and van der Waal4. There are pathologists who still favour the 1978 criteria and others who follow the 2003 modified criteria. This difference in opinion among pathologists has a very significant bearing on the data collected in literature. What would have been an OLP to one pathologist following a particular criteria could seem to be an oral lichenoid lesion(OLL) to another following a different criteria. Let us consider the following hypothetical examples: Hypothetical scenario 1: Let us consider an OLP lesion clinically manifesting with white radiating striae unilaterally in the buccal mucosa. If the oral medicine and pathology specialists agree to follow the 2003 modified criteria(clinico-pathologic), then, this lesion being clinically compatible(unilateral), will have to be diagnosed as OLL, though it could be histologically typical of OLP. However, the diagnosis would be OLP according to the 1978 criteria. One should make note of the lines quoted by van der Meij and van der Waal4(2003), in their paper which says: â€Å" We do realise that application of these criteria will exclude a number of patients who actually may have the disease but do not meet the strict criteria.† This line has considerable relevance if we consider the above example. Also, if this in turn progresses to carcinoma, a false record of malignant transformation of OLL is generated,when in reality the lesion could possibly have been a true OLP. This example quoted, cannot be rejected on the grounds of being hypothetical, as there is every possibility of OLP manifesting unilaterally though it often manifests bilaterally. ABSENCE OF DYSPLASIA :AN EXCLUSION CRITERIA FOR OLP – IS THIS JUSTIFIED? The heated debate of OLP and dysplasia started with Krutchkoff and Eisenberg’s10 paper in 1985, â€Å"Lichenoid dysplasia: A distinct histopathologic entity†. While they could have been right about epithelial dysplasia with lichenoid features being misdiagnosed as OLP, the possibility of OLP showing dysplasia cannot be ruled out. The present 2003 modified criteria of OLP have dysplasia as an exclusion criteria. Van der Meij and van der Waal3 in their paper, in 2003, state that â€Å"To avoid confusion over the terminology- ‘Lichenoid Dysplasia’ we propose to regard the presence of epithelial dysplasia as an exclusion criterion for the histopathological diagnosis of OLP†. This is not convincing enough to make ‘absence of dysplasia’ as a criterion because, there is accumulating evidence of OLP’s malignant potential and it is rather logical to assume that it could manifest dyplastic features. In fact, exclusion of all lesions that re semble OLPs but exhibit epithelial dysplasia may lead to an underestimation of the rate of malignant transformation.11 This fact was restated by Mignona et al12 in 2007, where they reported severe epithelial dyaplasia and carcinoma in situ in their series of OLP. Rejecting a diagnosis of OLP solely due to the presence of dysplasia, therefore requires consideration. LICHENOID DYSPLASIA: Krutchkoff and Eisenberg’s conclusion of epithelial dysplasias manifesting with lichenoid features were substantiated in the recent papers published by Patil et al13 and Fitzpatrick et al14. Moreover, Patil et al13 observed features of dysplasia in OLP and OLL in their case series, further reiterating the malignant potential of these entities. These papers enlighten us about the co-existence of lichenoid features in OLP,OLL and epithelial dysplasia, further stamping the necessity for an accurate and universal diagnostic criteria for the distinction of these lesions. Also, the lesion, lichenoid dysplasia deserves some consideration and requires further appraisal by a panel of experts. Hypothetical scenario 2: Assuming there is a case of OLP manifesting bilaterally (clinically typical) and the histopathology, though being very typical, reveals dysplasia, what then, should it be diagnosed as? According to 2003 modified criteria, it should be branded as an OLL, since it is histologically compatible (shows dysplasia). But is this diagnosis justified? Pathologists would also consider other different diagnoses like: OLP with dysplasia, lichenoid dysplasia or simply, epithelial dysplasia. Hypothetical scenario 3: If a patient with a history of OLP, consults another pathologist, unaware of the fact that it has become dysplastic, he/she would again be diagnosed with OLL if the 2003 diagnostic criteria are followed. SIGNIFICANCE OF DIAGNOSING ORAL LICHENOID LESIONS: van der Meij et al4 proposed the designation OLL for cases that are clinically typical and histologically compatible, clinically compatible and histologically typical, or clinically and histologically compatible with OLP. As already stated and explained in the first hypothetical scenario, not all patients with OLP manifest with the classical bilateral white striae. In such situations, clinicians and pathologists must exercise prudence in blindly branding the lesion as OLL by strict adherence to the 2003 modified criteria. Whether the lesion to be diagnosed represents an OLP like disease can be suspected by other clinical manifestations like: manifestation in cancer-prone areas (floor of the mouth, lateral border and ventral surface of the tongue, retromolar trigone and soft palate–uvula complex), lesions accompanied or preceded by skin manifestations suggestive of other diseases like lupus erythematosus, lesions that have a plaque-type keratosis or a verruco-papillary nature and lesions that may have a possible etiology like restorations(silver amalgam) or drugs.10 Differentiating between OLP and OLL is very significant as both the lesions are potentially malignant. It becomes all the more pertinent as two prospective studies by van der Meij et al15,16 one in 2003 and one in 2007 showed that only OLLs in their many cases turned malignant. DIAGNOSIS OF CANDIDIASIS IN OLP PATIENTS: Culture studies have demonstrated Candida infection in 37% to 50% of OLP cases.17 There appears to be no differences in the frequency of Candida infection between ulcerated OLP and non-ulcerated OLP.18 Candida albicans produces nitrosamine which is harmful carcinogen. Thus, OLP and candidiasis together provide a fertile background for malignant transformation of oral epithelium. Moreover, candida albicans isolated from potentially malignant oral disorders are able to produce mutagenic amounts of carcinogenic acetaldehyde when exposed to substrates such as wine and ethanol.19 Thus, one cannot disregard oral candidiasis from OLP. Both the lesions together can act synergistically and/or additively in progression to oral squamous cell carcinoma. Hence, we believe that this association needs serious considerartion in the revision of diagnostic criteria of OLP. WHAT IF BOTH THE CRITERIA ARE FOLLOWED IN DIFFERENT PARTS OF THE GLOBE? This could possibly be the situation today as there is no universal consensus on any specific criteria to be followed. This would be a serious issue, as there would be a gross under or overestimation in the diagnosis of OLP or OLL, inadvertently leading to false data regarding its malignant potential. Studies done on the current topic by different institutions using different diagnostic criteria would generate contrasting data in literature precipitating confusion and controversies. UNIVERSAL DIAGNOSTIC CRITERIA – THE NEED OF THE HOUR! So, how then, do we undo the debates surrounding the current issue? The answer lies in not only formulating more accurate diagnostic criteria but also in universally following them. Of course, further molecular or immunological studies on OLP would throw further light. We, in this commentary have tried to explain the possible demerits and confusions that could possibly arise if the current criteria are used and not universally followed. The 1978 WHO criteria may need more accuracy while the 2003 modified criteria could be rigid and strict. Devising an accurate criteria taking into consideration, the above mentioned points, would go a long way in eliminating the confusion and disputes surrounding OLP.

Alike or Different Essay

We can try and change ourselves, by changing our appearance, putting on makeup, wearing different clothes, jewellery, etc. But it’s not just a case of appearance, but it also involves the person underneath that mask everyone tries to hide behind. Nobody has ever tried to look at the person underneath before judging them. It’s just ego that stands in the way. What will the result be when people are stripped of all their accessories, when that mask is removed? What we get is a rollercoaster of emotions. Things that people can never guess are hidden underneath. And that’s yet another similarity, which makes mistaken judgment also put into account. Feelings are also something to look at. For example, people do get happy, angry and sad in different situations, but everyone still gets those emotions at times, regardless of reason. And everyone goes through the same life cycle, how they’re born, turn to children, then the teenage, middle aging comes after, then being old, and finally death. Everyone will face death someday. And everyone is made by God, and made of the same materials, as some believe. Everyone eats and breathes, everyone has the five senses, nobody can live without a vital organ, and no one can have supernatural powers. And these are all similarities. * A lot more people don’t believe in that saying, they believe that people differ in a lot of things, and the things that they have in common with others can be looked at from a different angle, making them into another difference. For example, everyone is a human being, but everyone is a different kind of human being, depending on personality, looks, and abilities. And the fact that everyone has a dream that is to be fulfilled can also be a difference, like everyone has a different dream and a different goal for the future. As for the life, everyone does have a life, but it depends on how they live it, and how everyone uses it that makes a difference. Besides, some people are born to have the personality to be good leaders, and others have the power and will to work hard in what they’re good at, while others don’t treasure their abilities, and instead they use it for their own good, to get the better out of things, while they cause hurt to everyone else around them. That’s an example of being and not being able to be a useful person, to not use life wisely, and another way why people are different. Some believe that people differ in how they look (both on the outside and the inside), how they react to things around them, their personality, beliefs, ethics and religions. What can also count as a difference is how everyone is raised, what they’re taught to believe, where and when they were born and who they lived with. People often adopt habits from those they live with, which can sometimes be good, and sometimes be bad. That can make a lot of differences compared to someone who was born rich, lived rich, and died rich. Another way of looking at things is people’s appearance. Some people really care about how they look, and always try to look their best at times. Some wouldn’t give that subject a second thought. Some do care, but not so much. And that’s related to both personality and physical appearance. Language spoken is also a difference. And the fact that some of us can do something that others can’t, which comes down to ability. Furthermore sometimes people have disabilities that others don’t have. Sometimes there are illnesses and diseases that run in families, and some inherit that disease and some don’t, which is another difference. If we try and list these differences they will not have an end, and just thinking would take long too. So it’s not a case of what is the same and what can be different, it’s just how people think about things in their own point of view. So regardless of what there is that can be used as an argument, and however we think the ones who think the opposite are wrong, and no matter which angle we use look at things, it all goes back to opinion, and opinions are very important. And my opinion stays the same, but what about yours? And what’s more important is to reason why we look at things from that point of view, and if we really are being fair, or if we are just judging others by what we think of them, and how we think of them. And most importantly, are we really being fair, or do we just think we are?

Factors of Suspense in the Most Dangerous Game Essay

Suspense is what makes a story popular because it is interesting to read. Suspense is used in most stories to make the plot interesting. There are several factors that generate suspense in the story The Most Dangerous Game produced by Richard Connell. The use of pauses by punctuations, recurring vivid imagery, and the dialogue itself helped create mystery and suspense. These are just a few of the many ways that Richard Connell used to make the reader lust for emotionally satisfying events. The use of pauses by punctuations is a writing style used by Richard Connell to help generate suspense. In the story, wanted information is sometimes delayed by action. For example, in the conversation by Rainsford and General Zaroff, the information is often delayed by the author. â€Å"The General took from his pocket a gold cigarette case†Ã¢â‚¬ ¦ (Richard Connell, 7) This action happened when the general stated that hunting tigers ceased to interest him. The author delayed the wanted information when Rainsford was obviously curious to know what animal the General hunts. Furthermore, Richard Connell also frequently used a dash ( — ) during a conversation. The dash showed that the talking character may be interrupted by an action or to the least that the author wanted to accentuate the words after the dash. The conversing characters may have been opening a door or even using hand gestures during the conversation to help emphasize their point. Whatever it may be, the author used this technique to slightly delay the information which causes the reader to try and visualize the character during the conversation which also produces mystery and suspense. An example is the conversation of Rainsford to his friends in the beginning of the story. As one of his friends suggested â€Å"The Place has a reputation—a bad one.†(Whitney, 1) Though writing style alone does not generate enough tension to make the reader crave for the wanted information. Richard Connell also used vivid imagery in order to make the story more interesting. While reading the story, the reader may notice that the author used similarly colored objects for the imagery. Throughout the story, a red colored imagery is used constantly. The first use of the red image was when Rainsford was wandering around the ship trap island. â€Å"†¦; one patch of weeds was stained crimson,† (Richard Connell, 4) This quote alone provided enough mystery and suspense to make the reader wonder. Reddish images were also used all throughout the story. From the blood-warm waters, to the part where they drank borsch; a red Russian soup, they drank port; a type of red liquor and the General gave Rainsford a red lipped-smile, the constant use of the red imagery portents and highlights a murderous and bloodlust filled atmosphere which in turn, generates anxiety of the reader for Rainsford. The reader may have even begun to suspect that something supernatural is to happen such as the General to be Count Dracula. Furthermore, the author also used dark images throughout the story. While Rainsford was still boarding the yacht, Rainsford described the fog with the words â€Å"Ugh! It’s like moist black velvet.†(Rainsford, 1) Especially that Rainsford’s companions described that they could feel evil surrounding Ship Trap Island as if it was tangible. Also, when Rainsford found Zaroff’s villa or castle, the author gave this scene a very dark imagery. The bleak darkness, the shadows, the gargoyle, and even Ivan’s astrakhan clothing echoed an evil and mystery filled atmosphere to the story. A reader with no clue about the story’s plot may think that the story’s protagonist accidentally stumbled upon Transylvania. Although imagery delivers a lot of suspense, it is still not enough to satisfy the author’s desire to fill the story with thrill. The dialogue itself is one of the main contributors for suspense in the story. Even when the protagonist was still onboard the yacht, the author tried to build up as much suspense as possible. â€Å"The place has a reputation—a bad one.†(Whitney, 1); said by one of Rainsford’s friends. This alone persuades the reader to ask themselves to what is so special about Ship Trap Island. Also, during Rainsford’s conversation with Zaroff, Zaroff explained to Rainsford that he has recreated hunting. â€Å"Here in my preserve on this island †¦ I hunt more dangerous game.†(Zaroff, 7) Again, just as Rainsford, the author made the readers desire and lust for the answer to the mystery. This quote helped the cause of building suspense. Moreover, during the hunt, whenever Rainsford managed to make the General retreat, Zaroff stated that â€Å"†¦ I shall be back.†(Zaroff, 17) To make things worse, after his second retreat, â€Å"†¦ Ill see what you can do against my whole pack†¦Ã¢â‚¬ (Zaroff, 17) What’s gonna happen to Rainsford? How is he going to escape Zaroff? These are just the types of questions that the reader might have asked themselves. To hunt or to be hunted, and only the strongest will survive, this is the logic behind the madness of this monstrous persona. Ironic as it is that Rainsford is also a hunter, now he is the mouse and Zaroff is the cat. Also, as the story is about over, Rainsford managed to ambush Zaroff in his room. â€Å"I’m still a beast at bay† (Rainsford, 20), Rainsford stated to Zaroff, as soon as the reader discovers this; their lust for the emotionally satisfying ending kicks in. Who would win the final fight? Even in the end, Richard Connell still gave us something to think about when Zaroff, who used to be the hunter, switches roles with Rainsford to be the hunted. Suspense is the whole reason to why people claim that they stay past their bedtime reading books. A reader does not stop reading until their desire for the answer to their questions about the plot is answered. People who have read The Most Dangerous Game may say that this story created by Richard Connell is one of the most suspense filled story ever produced. Richard Connell used many techniques to create suspense, the usage of pauses in his writing style, recurring vivid imagery, and dialogue. What and when was the last time that you read a story just as mystery and suspense filled as The Most Dangerous Game by Richard Connell?

Critical Thinking and Society Exercise - 1121 Words

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This would be trying to subject someone to your point of view that you might consider the truth. In the critical thinking process everyone does not have to conform to your views or beliefs and we cannot subject others to your point of view. Y our point of view might not be truth to others based on their opinions and experiences. My own personal experience with hindrances would be everyday when we have our Youth League Board meetings. My opinions differ from others based on my experiences and I definitely think things through before responding. I am the Fund Raising Coordinator and I have brought an improvement to our league based on my prior experiences and knowledge. 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