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Lichen planus is a chronic cell-mediated immune disorder that can affect the oral mucosa, skin, genital mucosa, scalp and nails. Oral lesions often occur in the absence of skin lesions. The symptoms show waxing and waning over a long period of time. The disease is more often seen among middle-aged people, especially women Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K (2005). Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100: 164-178.. The prevalence of this disease ranges from 0.5 to 2.6% Murti PR, Daftary DK, Bhonsle RB, Gupta PC, Mehta FS, Pindborg JJ (1986). Malignant potential of oral lichen planus: observations in 722 patients from India. J Oral Pathol 15: 71-77.Ikeda N, Handa Y, Khim SP, Durward C, Axell T, Mizuno T, Fukano H, Kawai T (1995). Prevalence study of oral mucosal lesions in a selected Cambodian population. Community Dent Oral Epidemiol 23: 49-54.Ismail SB, Kumar SK, Zain RB (2007). Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 49: 89-106..

Etiology:

Although the exact etiology is not known, an immune-mediated pathogenesis is recognised. Auto-cytotoxic T lymphocytes trigger apotosis of epithelial cells, leading to chronic inflammation  Scully C, Carrozzo M (2008). Oral mucosal disease: Lichen planus. Br J Oral Maxillofac Surg 46: 15-21.. Stress is one of the most frequent causes of acute exacerbation of these lesions. Other associated factors include poor oral hygiene, trauma and dental procedures Ismail SB, Kumar SK, Zain RB (2007). Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 49: 89-106.. The association between chronic liver disease and OLP is controversial. However, a strong association between hepatitis C and OLP has been reported by several authors Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K (2005). Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100: 164-178.Gandolfo S, Carrozzo M (2002). Lichen planus and hepatitis C virus infection. Minerva Gastroenterol Dietol 48: 89., and geographical heterogeneity exists. This association is found more in Mediterranean areas and Japan, possibly because of immunogenetic factors Carrozzo M, Brancatello F, Dametto E, Arduino P, Pentenero M, Rendine S, Porter SR, Lodi G, Scully C, Gandolfo S (2005). Hepatitis C virus-associated oral lichen planus: is the geographical heterogeneity related to HLA-DR6? J Oral Pathol Med 34: 204-208..

Diagnosis:

Clinically, OLP can present as white striations (Wickham striae), white papules, white plaque, erythema, erosion or blisters. They usually present as symmetrical and bilateral or multiple lesions. Buccal mucosa, dorsum of tongue and gingivae are commonly affected. Based on its clinical appearance it is classified into six types, i.e., reticular or annular, papular, plaque-like, erosive, atrophic and bullous  Pindborg JJ, Reichart PA, Smith CJ, van der Waal I, (1997). World Health Organisation International Histological Classification of Tumours.Histological Typing of Cancer and Precancer of the Oral Mucosa. 2 ed. Berlin: Springer..The two major clinical forms are reticular and erosive types. The reticular form appears as bilateral asymptomatic, white, lacy striae or papules. The erosive forms manifests as areas of tender erythema and painful ulcers surrounded by peripheral white, radiating striae. It may also manifest itself as generalized erythema and ulceration of the gingiva, known as desquamative gingivitis. Lichen planus is often asymptomatic; however, the atrophic and erosive forms can cause a burning sensation and sometimes severe pain.

Oral lichenoid reactions (OLR), which have oral lesions similar to OLP, may be regarded as a disease in its own right caused by certain medications or dental amalgam restorations. Lichenoid lesions are also seen following graft versus host reaction in transplant patients. Lichenoid lesions are also demonstrated where betel quid is usually placed in the oral cavity Daftary DK, Bhonsle RB, Murti RB, Pindborg JJ and Mehta FS (1980). An oral lichen planus-like lesion in Indian betel-tobacco chewers. Scand. J. Dent. Res., vol. 88, no. 3, pp. 244-249..

There is considerable controversy regarding the malignant potential of OLP. Several studies have shown its malignant potential, ranging from 0.4 to 5.6%; however, the highest rate is seen in erosive OLP and lichenoid lesions Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K (2005). Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100: 164-178.Ismail SB, Kumar SK, Zain RB (2007). Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 49: 89-106.Zheng TZ, Boyle P, Hu HF, Duan J, Jian PJ, Ma DQ, Shui LP, Niu SR, Scully C, MacMahon B (1990). Dentition, oral hygiene, and risk of oral cancer: a case-control study in Beijing, People's Republic of China. Cancer Causes Control 1: 235-241.van der Meij EH, Schepman KP, van dW, I (2003). The possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 96: 164-171.Al-Hashimi I, Schifter M, Lockhart PB, Wray D, Brennan M, Migliorati CA, Axell T, Bruce AJ, Carpenter W, Eisenberg E, Epstein JB, Holmstrup P, Jontell M, Lozada-Nur F, Nair R, Silverman B, Thongprasom K, Thornhill M, Warnakulasuriya S, van dW, I (2007). Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 103 Suppl: S25-12.Ingafou M, Leao JC, Porter SR, Scully C (2006). Oral lichen planus: a retrospective study of 690 British patients. Oral Dis 12: 463-468.. The diagnosis of OLP can be made from the clinical features if there are sufficient characteristics, but biopsy is recommended to confirm the diagnosis and to exclude dysplasia and malignancy.

Histopathology:

Microscopic findings include hyperkeratosis, acanthosis with intercelluar oedema of the squamous cells, ‘saw tooth’ appearance of the rete pegs, liquefaction, degeneration of the basal layer of the cells and a dense band of subepithelial lymphocytic infiltration. Small round eosinophilic globules called colloid or civatte bodies may be seen in the epithelium, mostly in the spinous and basal cell layers. Atrophic lesions show thinning or flattening of the epithelium.

Differential diagnosis:

The following differential diagnosis should be considered for OLP:

Management:

  • Maintenance of good oral hygiene
  • Elimination of precipitating factors
  • Treatment of super added fungal infection
  • Topical steroids
  • Topical isotretinoin gel & tretinoin ointment
  • Topical tacrolimus & cyclosporins
  • Systemic isotretinoin
  • Systemic steroids


Generally OLP is asymptomatic. However, the erosive forms can cause symptoms ranging from a burning sensation to severe pain, and require treatment. Maintenance of good oral hygiene and removal of factors which exacerbate these lesions can enhance healing and lessen symptoms. In symptomatic cases, drugs such as anti-inflammatory agents, mainly topical steroids, have been tried. Systemic steroid therapy is reserved for severe exacerbations. Candida albicans is present in about 37% of OLP, and the symptoms may be aggravated by thisLodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K (2005). Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100: 164-178.Hatchuel DA, Peters E, Lemmer J, Hille JJ, McGaw WT (1990). Candidal infection in oral lichen planus. Oral Surg Oral Med Oral Pathol 70: 172-175.. Antifungal treatment of erosive lesions can change the lesion to the reticular form. Miconazole gel is found to be useful in the treatment of OLP with candidiasisLodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K (2005). Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100: 164-178. . Several other agents like topical or systemic retinoids, topical tacrolimus or cyclosporin and photodynamic therapy have also been tried in OLP with variable success Ismail SB, Kumar SK, Zain RB (2007). Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 49: 89-106. Scully C, Carrozzo M (2008). Oral mucosal disease: Lichen planus. Br J Oral Maxillofac Surg 46: 15-21.Buajeeb W, Kraivaphan P, Pobrurksa C (1997). Efficacy of topical retinoic acid compared with topical fluocinolone acetonide in the treatment of oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83: 21-25.Hodgson TA, Sahni N, Kaliakatsou F, Buchanan JA, Porter SR (2003). Long-term efficacy and safety of topical tacrolimus in the management of ulcerative/erosive oral lichen planus. Eur J Dermatol 13: 466-470.Aghahosseini F, rbabi-Kalati F, Fashtami LA, Djavid GE, Fateh M, Beitollahi JM (2006). Methylene blue-mediated photodynamic therapy: a possible alternative treatment for oral lichen planus. Lasers Surg Med 38: 33-38.. Surgical management, including cryotherapy and laser, has been tried. However, surgical excision is not recommended as the first choice of treatment Ismail SB, Kumar SK, Zain RB (2007). Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 49: 89-106.. Lesions may develop in the healing wounds and recur in scars producing even more symptoms. Even though several interventions have been tried, with varying success rates, a permanent cure is not yet possible for OLP Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K (2005). Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100: 164-178. .

In the case of OLR, resolution usually occurs following the removal of causative agent Ismail SB, Kumar SK, Zain RB (2007). Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 49: 89-106.Potts AJ, Hamburger J, Scully C (1987). The medication of patients with oral lichen planus and the association of nonsteroidal anti-inflammatory drugs with erosive lesions. Oral Surg Oral Med Oral Pathol 64: 541-543.. Changing medications causing OLR or replacement of causative dental restoration may lead to regression of lesions Ismail SB, Kumar SK, Zain RB (2007). Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 49: 89-106..

In view of the potential for malignant transformation, patients with OLP, especially those with dysplasia, should be kept on regular follow-up, once every 2–3 months Mignogna MD, Fedele S, Lo RL (2006). Dysplasia/neoplasia surveillance in oral lichen planus patients: a description of clinical criteria adopted at a single centre and their impact on prognosis. Oral Oncol 42: 819-824.. However, asymptomatic patients, mainly reticular type, may be reviewed annually Ismail SB, Kumar SK, Zain RB (2007). Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 49: 89-106..


ImageLegend
Figure 1: Annular form of lichen planus on the right buccal mucosa. Note the pigmentation and the ring-like pattern of Wickham striae (yellow arrows).
Figure 2: Annular form of lichen planus on the right buccal mucosa. Note the ring-like pattern of Wickham striae (red arrows).
Figure 3: Annular form of lichen planus on the right buccal mucosa. Note the ring-like pattern of white striae (yellow arrows).
Figure 4: Lichen planus. Note the white 4x3.5 cm patch on the right side of the dorsum tongue intermingled with areas of pigmentation. Another annular form of lichen planus can be seen on the left side of the dorsum tongue.
Figure 5: Lichen planus. Note the diffuse areas of pigmentation of the dorsum tongue intermingled with Wickham striae. The individual papillae on the tongue can be made out distinctly.
Figure 6: Annular lichen planus. Note the ring-like pattern on the right buccal mucosa, retromolar trigone and hard palate.
Figures 7: A reticular form of lichen planus. Note the bilaterally symmetrical patterns, which are characteristic of lichen planus.
Figure 8: Lichen planus. Note the reticular arrangement of Wickham striae on the left buccal mucosa of this 30–year-old female patient.
Figure 9: Reticular lichen planus involving the posterior ventrolateral aspect of the tongue. Note the prominent lingual varicosities anteriorly.
Figure 10: Reticular lichen planus involving right buccal mucosa and dorsum of the tongue.
Figure 11: Reticular lichen planus. Note the extensive lesions involving right buccal mucosa and retromolar trigone.
Figure 12: Lichen planus in the right buccal mucosa. Note the lacy white Wickham striae and the localized hyperpigmentation.
Figure 13: Lichen planus in the left buccal mucosa. Note the Wickham striae posteriorly (yellow arrow) and the Fordyce granules anteriorly (red arrows), which appear as small yellow nodules.
Figure 14: Lichen planus. Fig. 14A: Note the small papules on the dorsum tongue (yellow arrow) intermingled with areas of pigmentation. Fig. 14B: Cutaneous involvement of lichen planus. Note the well-defined macular lesions on the legs of the same person with oral manifestations of lichen planus.
Figure 15: Lichen planus of the tongue.
Figure 16: Plaque type lichen planus. Note the 4x3 cm raised lesion on the dorsum of the tongue surrounded by hyperpigmentation.
Figure 17: Bullous or vesicular lichen planus. Note the fluid-filled vesicles, which project out from the surface (arrow).
Figure 18: Atrophic lichen planus. Note the extensive nature of the atrophic lichen planus involving the hard palate, retromolar trigone, buccal mucosa, labial mucosa and tongue.
Figure 19: Erosive Lichen Planus. An erosive lesion of 2x1 cm size on the right buccal mucosa surrounded by Wickham striae.
Figure 20: Erosive lichen planus on the ventral surface of the tongue, just above the lingual frenum, surrounded by white striae.
Figure 21: Erosive lichen planus. An erosive area of 1x1 cm on the right buccal mucosa, surrounded by Wickham striae.
Figure 22: Erosive lichen planus. Note the erosive patch on the left buccal mucosa surrounded by Wickham striae.
Figure 23: Erosive lichen planus. Note the areas of erosion interspersed with Wickham striae on the left buccal mucosa.
Figure 24: Lichenoid reaction (arrow) in this pan masala chewer. Note the white striae on the left buccal mucosa.
Figure 25: Lichenoid reaction. Note the lichenoid reaction on the left buccal mucosa due to type IV hypersensitivity reaction to amalgam filling in the buccal aspect of first and second molars on the left lower jaw.
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