Oral Lichen Planus (OLP) presents with a variety of symptoms that can range from barely noticeable to quite bothersome. Despite its prevalence, OLP remains a mystery to many.
Lichen planus affects many areas such as the skin, mucosal surface of the mouth, genitals, eyes, ears, esophagus, and occasionally bladder, nose, larynx, and anus. The oral variant of lichen planus, OLP is an auto-immune T-cell-mediated inflammatory condition of the oral mucosa. It exhibits a higher prevalence in females and is often diagnosed between the fifth and sixth decades of life, yet it can also manifest in children and young adults.
The exact etiology of OLP remains unknown. It has numerous local and systemic risk factors. They are as follows:
Genetic predisposition
Systemic diseases (GIT disturbances, diabetes mellitus, thyroid and liver dysfunction, etc.)
Autoimmune diseases (Multiple sclerosis, ulcerative colitis, etc.)
Microorganisms (HCV, HPV, etc.)
Drugs (antimalarials, antibiotics, antihypertensives, etc.)
Oral health (candidiasis, plaque, etc.)
Dental materials (amalgam, nickel, etc.)
Mucosal trauma (severe attrition, friction from rough dental restorations/ sharp teeth, lip/cheek biting)
Stress
Lifestyle (tobacco chewing)
Nutritional deficiency (Vitamin B12, A, C, D, iron, etc.)
There are six clinical subtypes of OLP. They include:
Reticular - classical white lacy pattern
Papular - small white raised areas
Plaque-like - whitish homogeneous irregularities
Erosive - ulcerative red, inflamed area that may contain a white lacy pattern.
Bullous - blisters that usually rupture, causing ulcerations
Atrophic - two different variants within the lesion, white striae (reticular) in the center and redness (erythematous) surrounding it.
These types appear individually or in combination. The most common types are reticular and erosive-ulcerative. OLP usually manifests bilaterally and predominantly affects the buccal mucosa, tongue, and gingiva, followed by the labial mucosa, and upper lip. OLP doesn't spread from person to person.
Approximately two-thirds of individuals with oral lichen planus experience symptoms, showing alternating phases of exacerbation and remission. Symptom severity fluctuates, with patients commonly reporting sensitivity to spicy or acidic foods, painful and rough oral mucosa, and mucosal tightness.
Oral lichen planus usually shows up on the insides of your cheeks and tongue, especially in areas that get easily irritated. People with this condition often feel discomfort when eating spicy foods, and some might experience itchiness in their mouth and gums.
Dr. Shilpa Shree K.R, MDS, Oral Medicine Specialist and Maxillofacial Radiologist, Research Assistant, University of Pennsylvania, USA
The diagnosis of OLP involves taking a complete medical history of the patient, thorough clinical examination, and investigations including cytology, hematology, and biopsy followed by histopathology and immunofluorescence. To investigate the involvement of lichen planus beyond the oral cavity, clinical assessment by specialists including dermatologists, ophthalmic surgeons, general physicians, and gastroenterologists is necessary.
The first line of treatment is counseling the patient and making them understand the nature of the disease. Emphasis on alleviating fear and stress, thereby reducing the symptoms is crucial. A customized diet rich in macro and micronutrients is advised and nutritional supplements should be given if needed. Pre- and probiotics, along with regular deworming, are recommended to help maintain gut health. Maintaining proper oral hygiene including an antiseptic mouthwash, avoiding mucosa-irritating practices like using abrasive toothpaste and hard bristle toothbrushes, and adjusting the fractured teeth, restorations or appliances causing impingement on the mucosa.
Asymptomatic lesions of OLP (reticular and plaque-like) need regular follow-up but no active treatment. In symptomatic cases, Glucocorticosteroids, the 'gold standard' treatment for OLP, can be administered topically or systemically. In severe instances, a combination of both treatments may be necessary, and localized steroid injections can be considered as a last resort. However, caution is required due to steroid's potential side effects and contraindications to many systemic diseases.
Mycophenolate mofetil (MMF), sirolimus, calcineurin inhibitors, and retinoids are alternative medications for managing steroid risks in OLP, yet they carry potential side effects and contraindications. Several innovative pharmacologic interventions have been explored and shown effectiveness in a limited number of patients as alternatives to traditional immunosuppressive drugs. The plant-based derivatives include piperine, aloe vera gel, curcuminoids, lycopene, and antioxidants like anthocyanins, and flavonoids. Zinc and selenium have also been used to treat OLP.
The non-pharmacologic interventions include hyaluronic acid, platelet-rich plasma, ultraviolet phototherapy, photodynamic therapy, and low-level laser therapy. Surgical excision or cryosurgery is recommended in non-healing lesions.
In the field of oral medicine, there is not a lot of strong evidence about what works best to treat conditions like oral lichen planus. This is because the clinical trials that have been done have had some limitations, like not measuring things in the same way. To help fix this, oral medicine experts all around the world have been working on a project called the Development of Core Outcome Measure Set in Oral Lichen Planus, as a part of World Workshop on Oral Medicine Outcomes Initiative for the Direction of Research (WONDER Project). The goal is to figure out what and how exactly to measure when studying oral lichen planus so that research results can be compared more accurately. That will enable better decision-making in the management of oral lichen planus.
Dr. Shilpa Shree K.R, MDS, Oral Medicine Specialist and Maxillofacial Radiologist, Research Assistant, University of Pennsylvania, USA
The importance of regular follow-up appointments and continuous clinical monitoring is established by educating about the risk of OLP turning into a malignancy. Patients should be encouraged to self-monitor for persistent oral ulcers or growths.
Dealing with OLP can make it hard to sleep, cause irritation, and even lead to difficulty in social interactions and depression. Not to understate the OLP's malignant transformation potential. It is important for both patients and their caregivers to understand that it is a long-term issue and the need to offer support mentally, socially, and physically.
Dr. Shilpa Shree K.R, MDS, Oral Medicine Specialist and Maxillofacial Radiologist, Research Assistant, University of Pennsylvania, USA
Life with oral lichen planus (OLP) is a journey marked by challenges with discomfort, dietary adjustments, and regular dental care. Managing symptoms and the psychological toll of chronic oral lesions become a daily reality. Despite the hurdles, customized treatments, support networks, and a proactive approach to oral health can offer glimpses of relief for patients with this autoimmune condition.
References
Andrea Elenbaas, Reyes Enciso, Kamal Al-Eryani, Oral Lichen Planus: A review of clinical features, etiologies, and treatments, Dentistry Review, Volume 2, Issue 1, 2022, 100007, ISSN 2772-5596, https://doi.org/10.1016/j.dentre.2021.100007.
Manchanda Y, Rathi SK, Joshi A, Das S. Oral Lichen Planus: An Updated Review of Etiopathogenesis, Clinical Presentation, and Management. Indian Dermatol Online J. 2023 Dec 22;15(1):8-23. doi: 10.4103/idoj.idoj_652_22. PMID: 38283029; PMCID: PMC10810384.
1. Raj G, Raj M. Oral Lichen Planus. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Apr 7]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK578201/.
Gururaj N, Hasinidevi P, Janani V, Divynadaniel T. Diagnosis and management of oral lichen planus - Review. J Oral Maxillofac Pathol. 2021 Sep-Dec;25(3):383-393. doi: 10.4103/jomfp.jomfp_386_21. Epub 2022 Jan 11. PMID: 35281147; PMCID: PMC8859620
(By Dr. Nirainila Joseph)
