Oral Lichen Planus (OLP)

Lichen planus is an idiopathic t-cell mediated inflammatory condition. Although its etiology is unknown OLP is sometimes associated with other medical conditions such as hypothyroidism, diabetes mellitus, graft vs host disease, HIV infection, Hepatitis C infection, and psychological stress.4,54,77,98 Although the issue is controversial there continue to be reports suggesting a slightly increased incidence of oral cancer among individuals with longstanding OLP or lichenoid mucositis.1,53,54,55,89

Figure 11. DG in a patient with OLP.
ce481-fig11-desquamative-gingivitis

OLP can affect individuals of all ages, although it usually involves individuals ranging in age from 40-70 years with a female to male ratio of at least 2:1.16,69,99 Data from the TAMUBCD Stomatology Center indicates a female to male ratio of 3:1 among more than 1000 OLP patients with an average age of 56.0 years.74 In 1968, Andreason described OLP as occurring in 6 different forms: papular, reticular, plaque-like, atrophic, ulcerative and bullous.6 However, more recently it is common to simplify the terminology designating a keratotic (reticulated) form consisting of papular, reticular or plaque-like lesions, an erythematous (atrophic) form and an erosive form (ulcerative or bullous lesions).23 Any of these forms of OLP can affect the gingiva. The buccal mucosa is the most frequent clinical site (62%); 55% of patients in the Stomatology Center have gingival lesions, while nearly 20% have lesions confined entirely to the gingiva. DG primarily represents the erythematous and erosive forms of OLP, and it has been reported approximately 30% of OLP patients will have DG.77

Histopathologic features of OLP include a band-like infiltration of lymphocytes in the sub-basal connective tissue and liquefaction degeneration of the basal cells of the epithelium.49,75 The basal cell liquefaction may cause the epithelium to detach from the connective tissue, especially if traumatic forces are present as in the gingiva.

Some authorities feel it is not necessary to perform DIF on patients with OLP, although most agree that histopathologic evaluation is desirable. Their rationale is if DIF is found to be necessary it can be accomplished with another biopsy. This is certainly a valid concept, especially since DIF is often relatively expensive, but, in our opinion, DIF is important in DG to assist in ruling out other diseases. Although the DIF findings are non-specific, they are supportive of diagnosis of OLP if there is a linear deposition of fibrin or fibrinogen along the basement membrane zone and possibly immunoglobulin cytoid bodies in the underlying connective tissue.39,54,75

Figure 12. Severe oral lichen planus.
ce481-fig12a-severe-olp-desquamtive-ging
ce481-fig12b-severe-olp-desquamtive-ging
ce481-fig12c-severe-olp-desquamtive-ging
DG with histologic confirmation and DIF support showing a linear pattern of fibrinogen at the basement membrane zone.
Figure 13. Corticosteroid omnivac carrier tray.
ce481-fig13a-omnivac-carrier-tray
ce481-fig13b-omnivac-carrier-tray
Figure 14. Effective carrier tray treatment.
ce481-fig14a-effective-carrier-tray-treatment
ce481-fig14b-effective-carrier-tray-treatment
ce481-fig14b-effective-carrier-tray-treatment
DG with histologic confirmation and DIF support showing a linear pattern of fibrinogen at the basement membrane zone.
Figure 15. The “key” for oral lichen planus - early diagnosis and treatment.
ce481-fig15a-oral-lichen-planus
ce481-fig15b-oral-lichen-planus

OLP-related DG may be particularly resistant to treatment compared to other mucosal sites. Some authorities recommend the use of a dexamethasone oral rinse but DG may be resistant to that approach. Therefore, treatment is often accomplished in a stair-step format beginning with a high potency topical corticosteroid such as fluocinonide or a very high potency steroid such as clobetasol.91 The gel form of these products seems to be more retentive on oral mucosa than the cream or ointment form. Other topical treatments may include topical tacrolimus) or topical pimecrolimus).19 Management may require the fabrication of a soft, flexible, 1-mm thick vacu-form plastic removable appliance to serve as a carrier for the topical medication. The appliance should be constructed so it covers involved gingiva but with spacing to allow pain free insertion and removal.51 If trays are used, the topical medication should first be manually applied to the gingiva, then the carrier tray is gently placed to cover the gingiva and increase the time of contact of the immune suppressant with the gingival lesions. One suggested protocol is to use the trays twice daily for 20 minutes during each application.

Although effective oral hygiene has been reported as important to DG resolution, it is often difficult to achieve during the acute phase of gingival lichen planus.9,78 However, it is most important to improve plaque control even in the early stages of the disease.30,40,75

  • Instruct patients to gently perform oral hygiene measures using a super-soft toothbrush and a bland toothpaste.
  • Use a non-alcohol containing antimicrobial mouthrinse twice daily.
  • Patients may be able to gently floss without tissue damage. If not, they should forgo the use of floss pending improvement in their gingival health.
  • Maintain a 2-3 month recall interval to provide professional assistance in plaque control.
    • Gentle debridement of plaque and calculus is indicated but vigorous scaling and root planning should be avoided.
    • Hand instruments may be best for debridement since sonic or ultrasonic devices may tend to dislodge friable epithelial and cause sloughing.

It is important to remember DG with clinical and histologic features of lichen planus or a lichenoid mucositis may be caused by a lichenoid drug reaction or a contact lichenoid reaction to dental materials or dental hygiene products.42 Patients who are resistant to conventional lichen planus therapy should possibly be investigated for such etiologic possibilities.30,95 A variety of treatment options have been described although use of long-term (> 2-3 weeks) systemic immunosuppressive medicaments may be best performed by the patient’s physician.4,9,14,19