ORIgINAL PAPERS

original papers
Adv Clin Exp Med 2011, 20, 4, 495–501
ISSN 1230-025X
© Copyright by Wroclaw Medical University
Małgorzata Radwan-Oczko, Zbigniew Kozłowski
Oral Lichen Planus Lesion Assessment
in Relation to General Health and Oral Symptoms
Ocena kliniczna zmian liszaja płaskiego błony śluzowej jamy ustnej
w powiązaniu z ogólnym stanem zdrowia i objawami w jamie ustnej
Department of Oral Pathology, Chair of Periodontology, Wroclaw Medical University, Poland
Abstract
Background. Lichen planus is a chronic inflammatory mucocutaneous disease with an unclear pathogenesis. Oral
lesions may occur anywhere and in various clinical forms – white, red or red-white, alone or coexistent with skin
lesions.
Objectives. This study was aimed to assess the clinical presentation of oral lichen planus lesions in relation to
general health and oral symptoms.
Material and Methods. The authors investigated a group of patients with oral lichen planus lesions consisting of 30
women and 10 men between the ages of 25–80 years.
Results. White oral lichen planus lesions were found in 33 patients and red lichen lesions in 11 patients. The range
of duration of the pathology was from 1 to 144 months. The most frequently present form was the reticular oral
lichen planus form. Buccal mucosa was the most common site of involvement. Candida infection was confirmed
in 10 patients. Systemic diseases were reported in 16 patients. As is characteristic for lichen planus, concurrent skin
lesions were detected in 5 subjects and nail lesions in 3 patients. In no cases was there malignant transformation.
Conclusions. OLP is a chronic disease with broad clinical presentations and symptoms. It is said that, after a long
time, some lesions may undergo malignant transformation. All irritating factors should be avoided. Patients should
be examined periodically. It is important to pay special attention in erosive, bullous or atrophic forms (Adv Clin
Exp Med 2011, 20, 4, 495–501).
Key words: oral lichen planus, lichen planus skin lesions, general health.
Streszczenie
Wprowadzenie. Liszaj płaski jest chorobą przewlekłą skóry i błon śluzowych o niejasnej patogenezie. Zmiany na
błonie śluzowej w jamie ustnej mogą występować wszędzie i w wielu postaciach klinicznych – jako zmiany białe,
czerwone lub biało czerwone. Mogą pojawiać się tylko w jamie ustnej lub towarzyszyć zmianom skórnym.
Cel pracy. Ocena kliniczna obecności zmian liszaja płaskiego błony śluzowej jamy ustnej w powiązaniu z ogólnym
stanem zdrowia badanych i objawami w jamie ustnej.
Materiał i metody. Zbadano grupę 30 kobiet i 10 mężczyzn w wieku 25–80 lat ze zmianami liszaja płaskiego błony
śluzowej jamy ustnej.
Wyniki. Zmiany białe liszaja płaskiego stwierdzono u 33, a czerwone u 11 badanych. Czas trwania choroby wynosił 1–144 miesięcy. Najczęściej występowała postać siateczkowa liszaja płaskiego. Rejonem najczęstszej obecności
zmian była błona śluzowa policzków. Infekcję Candida potwierdzono u 10 pacjentów. U 16 badanych występowały
choroby ogólnoustrojowe. Typowe dla liszaja płaskiego współistniejące zmiany skórne stwierdzono u 5 pacjentów,
a na płytkach paznokciowych zaobserwowano je u 3 osób. U żadnego z pacjentów nie stwierdzono transformacji
nowotworowej w obrębie zmian.
Wnioski. Ustna postać liszaja płaskiego jest chorobą o przewlekłym przebiegu z różnym obrazem klinicznym
zmian. Towarzyszą jej również różne objawy w jamie ustnej. Uważa się, że po dłuższym czasie występowania
patologii niektóre zmiany mogą przekształcić się w nowotwór. Pacjenci powinni unikać wszystkich potencjalnych
czynników miejscowo drażniących i pozostawać pod stałą okresową kontrolą. Wzmożoną uwagą lekarza dentysty
powinni być objęci chorzy ze zmianami postaci nadżerkowej, pęcherzowej i zanikowej liszaja płaskiego (Adv Clin
Exp Med 2011, 20, 4, 495–501).
Słowa kluczowe: liszaj płaski błony śluzowej jamy ustnej, zmiany skórne liszaja płaskiego, choroby układowe.
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M. Radwan-Oczko, Z. Kozłowski
Lichen planus is a chronic mucocutaneous
inflammatory disease, the etiopathogenesis of
which remains obscure. It may affect the skin, mucous membranes, genitalia and nails. The prevalence of lichen planus varies according to different
studies but is rather rare, from 0.9% to no more
than 2% of the adult general population [1].
Oral lichen planus (OLP) involves the mucous
membrane and this may accompany skin lesions or
may be the only manifestation of the disease. On
the basis of numerous studies, various hypotheses
have been proposed for the pathogenesis of lichen
planus. Immunologic reactions (e.g. cell-mediated
immune response, autoimmune response, humoral
immunity), and infectious agents, genetic predisposition, trauma and also psychological status in
relation to stress have been suggested as etiological
factors. Usually it is more common among women
and middle-aged people, although in some cases it
can also appear in young and elderly patients. It can
affect from 0.1% to 4% of the population [2–5].
Oral lichen planus can occur anywhere in the
oral cavity. Usually it appears as bilateral or multiple more-or-less symmetrical lesions situated
mainly on the posterior buccal mucosa. Besides
this location, the sites affected in order of frequency
are the gums, lips, tongue, floor of the mouth and
palate, though these lesions have been described
as uncommon. Clinically, OLP has many different
presentations. The reticular, papular and plaquelike forms are white keratotic lesions, usually
painless. Red-white, erosive, atrophic and bullous
forms are associated with a burning sensation and,
especially in combination with irritating and spicy
food, may cause severe pain. The most common
of oral lichen planus is the reticular form, which is
present as a lacelike network of slightly raised gray
to white lines, most often on the buccal mucosa or
rarely on the gums or the lips (Fig. 1). The papular form is uncommon. It presents
small white pinpoint papules and can be overlooked during a quick, non-specific oral examination. Plaque-like OLP occurs as homogenous
multifocal white patches and may resemble homogenous leukoplakia. The dorsum of the tongue
is the typical site for this lesion (Fig. 2). In the
atrophic form, redness of the oral mucosa is diffused with typical white striae around the lesion
(Fig. 3). When the attached gums are involved,
it can also manifest with erythematous gingival
desquamation (Fig. 4). In the erosive form of oral
lichen planus, the well-defined erosions or ulcers
Fig. 1. OLP reticular form – buccal mucosa
Fig. 3. OLP atrophic form – buccal mucosa
Ryc. 1. Postać siateczkowa liszaja płaskiego na błonie
śluzowej policzka
Ryc. 3. Postać atroficzna liszaja płaskiego błony
śluzowej policzka
Fig. 2. Plaque-like OLP – dorsum of the tongue
Ryc. 2. Postać płytkowa liszaja płaskiego na powierzchni grzbietowej języka
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Lichen Planus Oral Lesions and General Health
Fig. 4. Desquamative gingivitis
Ryc. 4. Złuszczające zapalenie dziąseł
are covered with a pseudo-membrane or fibrinous
plaque. When they are disturbed or burst, the lesions are extremely painful and difficult to treat.
The bullous form is rarer than the other forms of
OLP. Small bullae or vesicles are present, that tend
to rapture easily and leave an ulcerated and painful surface. OLP lesions may be infected by different Candida species with higher frequency than in
healthy oral mucosa [4, 6–8].
In connection with the different clinical forms,
there is also different microscopic appearance. It is
possible to see parakeratosis, acanthosis, degenerating basal keratinocytes that form colloid bodies
and epithelial basement membrane changes. Oral lichen planus lesions and oral lichenoid
lesions (OLL) may also often be a diagnostic dilemma for both dental clinicians and pathologists.
OLL has an identifiable etiology but may, clinically and histologically, resemble OLP lesions. OLL
may present a more diffuse lymphocytic infiltrate
and may contain eosinophils and plasma cells, and
more colloid bodies than in real OLP. When it occurs in combination with dental materials (including amalgams, composite resins and cobalt) it is
described as a contact lichenoid reaction. Apart
from those oral lichenoid reactions induced by
drugs, have been reported with non-steroidal antiinflammatory agents, angiotensin-converting enzyme inhibitors and beta-blockers [6, 9].
OLP is considered a premalignant condition
although there is considerable controversy regarding its malignant transformation. Some authors
have put forth a theory that ‘‘true’’ OLP is a benign disorder and that many of the reported cases
when OLP developed into oral cancer are in fact
not OLP, but rather dysplastic lesions related with
lichenoid lesions.
On the other hand, it has been said that patients with chronically inflamed oral mucosa may
be at increased risk for malignant transformation
[6, 8, 10–12].
Because of such a variety of OLP clinical presentation, the differential diagnosis of OLP includes: chronic candidiasis, mucous membrane
pemphigoid, pemphigus vulgaris, oral lichenoid
lesions (OLL), lichenoid drug reactions, contact
lichenoid reactions, leukoplakia, graft-versus-host
disease (GVHD) and erythema multiforme [8].
A wide spectrum of topical and systemic therapies has been used in the treatment of OLP. The
standard treatment is carried out in symptomatic
lesions and consists of the topical use of antifungal ointments, corticosteroids, immunosuppressive agents – calcineurin inhibitors and retinoids,
depending on the severity of the disease and the
patient’s medical history [8, 10].
Material and Methods
An observational retrospective and questionnaire study was made on patients of the Department of Periodontology and Oral Pathology,
Wrocław Medical University, Poland. The study
group consisted of 40 subjects, at ages ranging
from 25 to 80 years. Data was collected on parameters such as patient age, gender, the clinical form
of the OLP and its location. The questionnaire included information about the duration of disease,
who found the lesions, and the patients’ oral complaints, general health and drugs applied.
The results obtained were analyzed using
Pearson’s correlation and chi-square test with
Yates correction. The level of significance was set
to 0.05.
Results
The mean age of the 40 investigated OLP
patients was 55.85 ± 14.36 years. There were
30 women and 10 men. In 14 cases, the presence of
the lesions was discovered by the patients, because
of unspecified discomfort and/or sensitivity, burning sensations and pain. In most cases (26) the patients were unaware of the presence of the lesions
which were found by the dentist during a routine
oral examination. As to the clinical presentation,
33 patients showed lesions corresponding to the
white oral lichen form, which included reticular (29
subjects) and plaque (4 subjects) forms. Red lichen
lesions, which included atrophic-erosive forms,
were present in 11 cases and 6 of them were documented as desquamative gingivitis. In 4 patients,
there were 2 different forms of OLP, so there were
44 lesions present (Table 1). The range of duration
of the pathology was from 1 month to 144 months
(mean duration 25.71 ± 39.65 months).
498
M. Radwan-Oczko, Z. Kozłowski
Table 1. Characteristics of investigated features
Tabela 1. Charakterystyka badanych cech
Number (Liczba)
N = 40
Women (Kobiety)
N = 30
Men (Mężczyźni)
N = 10
n
%
n
%
n
%
Discovered by the patient (Wykrył pacjent)
14
35
12
30
2
5
Found by the dentist (Wykrył lekarz)
26
65
18
45
8
20
OLP (Liszaj błony śluzowej jamy ustnej)
40
100
30
75
10
25
Reticular form (Postać siateczkowa)
29
72.5
20
50
9
22.5
Atrophic/erosive form (Postać atroficzno-nadżerkowa)
11
27.5
9
22.5
2
5
Plaque-like form (Postać tarczkowa)
4
10
3
7.5
1
2.5
tion smear for Candida in 10 cases. 3 of the patients were smokers.
Systemic diseases were reported in 16 patients.
These were hypertension in 13 and diabetes in
3 subjects. 5 patients had concurrent skin lesions,
in 1 the genitalia were involved. Another 3 patients
showed pterygium formation of the nails (Fig. 5).
Patients were not able to give information which
lesions, mucous or skin, developed first.
There were positive correlations between OLP
and age, hypertension, duration of hypertension
and Candida infection (Table 4).
In the treatment, antifungal ointments, topical
steroids, immunosuppressive agents and vitamin
A, and Solcoseryl dental adhesive paste and linseed were used.
A histological examination was performed in
only 5 questionable cases and 3 of them were located on the floor of the mouth.
In the group investigated, the OLP lesions
were present in typical sites. Buccal mucosa was
the most common site of involvement – in 34 patients. In order of frequency, gingival mucosa in
17, tongue in 10 and both lips and the floor of the
mouth were affected in 3 patients (Table 2). There
were no observed lesions on the palate mucosa.
No statistical correlation was found between
the gender of the patients and the sites and forms
of lichen planus lesions.
When considering the age (Table 3), most
patients with OLP, 50%, were at the age of 51–60
years. Oral symptoms and complaints related to
dryness were found in two cases. A metallic taste
was noted by 10 patients, and they all had amalgam fillings or metal prosthetic crowns, but without direct contact with the lesions.
Candida infection was confirmed by evalua-
Discussion
Oral lichen planus affects the oral mucous
membrane with a variety of clinical presentations
Table 2. Sites and the incidence of OLP lesions
Tabela 2. Miejsca obecności i częstość zmian liszaja płaskiego
Site (Miejsce)
Number (Liczba)
N = 40
Women (Kobiety)
N = 30
Men (Mężczyźni)
N = 10
n
%
n
n
Buccal mucosa
(Błona śluzowa policzka)
34
85
28
6
Gingival mucosa
(Błona śluzowa dziąsła)
17
42.5
15
2
Lingual mucosa
(Błona śluzowa języka)
10
25
7
3
Floor of the mouth
(Błona śluzowa dna jamy ustnej)
3
7.5
1
2
Lips (Błona śluzowa warg)
3
7.5
2
1
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Lichen Planus Oral Lesions and General Health
Table 3. The incidence of OLP lesions according to age
Tabela 3. Częstość zmian liszaja płaskiego w odniesieniu
do wieku
Age – years
(Wiek – lata)
Number of patients
(Liczba pacjentów)
20–30
3
31–40
2
41–50
5
51–60
20
61–70
5
71–80
5
Fig. 5. Nail lesions related to lichen planus
Ryc. 5. Zmiany na płytkach paznokci w przebiegu
liszaja płaskiego
Table 4. The correlations between OLP lesions and evaluated features
Tabela 4. Korelacje między zmianami liszaja płaskiego błony śluzowej jamy ustnej a badanymi cechami
OLP
(Liszaj błony śluzowej jamy ustnej)
Feature (Cecha)
Reticular form
(Postać siateczkowa)
Atrophic/erosive form
(Postać atroficzna/ erozyjna)
r
p=
r
p=
r
p=
Age (Wiek)
0.4995
0.001
0.4951
0.001
0.5100
0.001
Hypertension
(Nadciśnienie)
0.9983
0.00
0.9990
0.00
0.9991
0.00
Duration of hypertension
(Czas trwania
nadciśnienia)
0.9444
0.000
0.9419
0.000
0.9452
0.000
Candida overgrowth/
Infection
(Wzrost/infekcja
Candida)
0.9983
0.00
0.9990
0.00
0.9993
0,00
r = the correlation coefficient.
p = level of statistical significance.
including white and red-white lesions. In our
study, the incidence of the type of the OLP lesions
and involved sites were consistent with previous
studies. The most common was the reticular form,
present in 72.5% of investigated patients diagnosed
with OLP. Atrophic/erosive forms were present in
11 patients. In 6 cases, the atrophic/ erosive form
involved attached gums, with symptoms of chronic desquamative gingivitis (DG).
Desquamative gingivitis is a descriptive term
for inflamed, peeling gums. It is a clinical nonpathognomonic term rather than a distinct diagnosis and may be present as an oral clinical symptom of various systemic mucocutaneous diseases
including lichen planus. The patients experience
discomfort and intense pain, sensitivity to spicy
food and irritation from toothbrushing or rinsing
solutions (Fig. 3). This clinical state may be complicated and worsened by inflammation related
to the presence of bacterial plaque, because of
a lack of proper hygiene. It should be underlined
that, other than in OLP, desquamative gingivitis
may also be a symptom of pemphigus vulgaris
and pemphigoid and chronic ulcerative stomatitis (CUS) [7].
In investigated group, the authors did not find
a lot of coexistent general symptoms or disorders.
Only three subjects had changes of the nails in
a clinical presentation of pterygium formation and
four patients showed characteristic skin lichen lesions. In the dental literature the skin involvement
ranges from 6% to 44% of the patients with OLP.
Conversely, about 70% of patients with lichen
planus skin lesions present oral lesions [1].
Although present in only 13 cases (32.5%), in
this study we have found a correlation between
OLP lesions and hypertension and the duration of
hypertension treatment.
500
M. Radwan-Oczko, Z. Kozłowski
3 patients suffered from diabetes type II, noninsulin-dependent, and 2 of them complained of
a dry mouth.
It has been shown that in some patients, a dry
mouth appears to be linked to OLP lesions, although a real association cannot be determined.
Research carried out by Colquhoun and Ferguson
revealed Sjögren syndrome and related xerostomia
in 10.4% of patients with OLP [13]. The results obtained in other investigations
showed the presence of Candida species in about
37% of oral LP lesions [10]. The study confirmed this
relationship in 25% of the patients investigated.
Candida overgrowth and infection exacerbates OLP symptoms, therefore antifungal treatment can improve the clinical state and can also
reduce the potential of Candida to produce carcinogens such as N-nitrosobenzylmethylamine.
Topical steroids are used to limit pain and inflammation. The immunosuppressive drug Tacrolimus ointment 0.1% is useful, effective, safe and
well tolerated in atrophic, erosive-bullous OLP
lesions. However it was shown that lesions may
relapse after discontinuation of the treatment.
Retinoids such as vitamin A gel 0.1 or Isotretinoin can eliminate or reduce white, reticular,
plaque-like forms, but lesions also relapsed after
some weeks when treatment was discontinued
[10, 14, 15].
Almost all OLP patients are subjected to topical treatment for long periods with some breaks
of time. Immunosuppressive drugs are thought to
be able to trigger malignant transformation. However, this hypothesis is still not clear. On the other hand erosive and atrophic forms in particular
undergo malignant transformation [8, 10]. In the
investigated group, the average duration of oral
lesions amounted to more than 2 years, and the
longest was 12 years. Despite this long time, there
was no malignant transformation.
The exacerbation or flare-ups of OLP lesions
may be triggered by spicy and/or acidic foods, mechanical irritations and by stress. Therefore, patients should be informed and instructed how to
avoid factors that trigger the disease and how to
keep good oral hygiene, which is necessary.
Regular and thorough examination of the oral
cavity and general symptoms is of high importance. Even patients without any symptoms, who
are not given treatment, require regular visits for
review, sooner if they get any symptoms. It would
seem essential to inform the patients with OLP of
the possible link between the lesions and development of oral cancer.
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Address for correspondence:
Małgorzata Radwan-Oczko
Department of Oral Pathology
Chair of Periodontology
Wroclaw Medical University
Krakowska 26
50-425 Wrocław
Poland
Tel.: +48 71 784 03 84
E-mail: [email protected]
Conflict of interest: None declared
Received: 23.02.2011
Revised: 31.03.2011
Accepted: 1.08.2011