Presentation: A 58-year-old woman is a new patient seeking treatment, and has some concerns about her oral condition.
by Nancy Burkhart, RDH, EdD
Presentation: A 58-year-old woman is a new patient seeking treatment, and has some concerns about her oral condition. The patient has moderate plaque, light calculus, and some ulceration in the posterior areas of the mouth with inflammation of the anterior gingiva. She states that brushing is very difficult for her and that she no longer uses an electric toothbrush. She has trouble using her manual brush because of the discomfort. She also says that she is embarrassed to smile because of the red color of the tissue (Figure 1).
Notes and findings: The woman suffers from pain and burning of the tissues most of the time. Her condition has progressively become worse during the past few years. She was examined two years prior to her current appointment, but she has received no diagnosis of her condition. Although she has not seen a dentist in several years, she is currently under the care of her primary physician. Additionally, she maintains close contact with her gynecologist because she is post-menopausal and suffers from frequent vaginal yeast infections. She also reports that she may need to see a dermatologist because of the patches she continues to develop on her arms (Figure 2). The patient takes the following medicines:
- Levothyroxine (Synthroid)
- Fluticasone (Flonase)
- Multivitamin supplements
Clinical impressions: The patient may have gingivitis, but it appears she has multiple complaints that may be all linked together, such as the skin lesions, vaginal yeast infections, and the ulcerative oral condition.
Diagnosis: Lichen planus was confirmed through biopsy and immunofluorescence.
Etiology: Lichen planus is a cell-mediated immune response affecting approximately 2 percent of the population. Although the disorder may occur in all age groups, women over age 50 are the most affected. The etiology is not completely understood, but genetics and immunity may be involved.
Method of transmission: There is no contagion factor. This is a concern for most patients, and they should be told that it is not contagious. The patient will need reassurance that a partner or family member will not be infected by lichen planus.
Pathogenesis: Lichen planus is a chronic mucocutaneous disorder. T-lymphocytes are recruited to the skin or oral mucosa where they produce damage to the surface epithelium. While the reaction suggests that the body is reacting to an antigen within the surface epithelium, to date the specific antigen has not been identified. While some authorities consider lichen planus to be an autoimmune disorder, until the antigen(s) is identified, some believe it is premature to consider lichen planus an autoimmune disease.
Perioral and intraoral characteristics: Lichen planus may occur in six different patterns: reticular, plaque, erosive, bullous, atrophic, and papular. Generally, most clinicians classify the lesions as erosive or reticular patterns. Lichen planus may affect any lining mucosa including the eyes, lips, and esophageal regions.
Extraoral characteristics: Lichen planus may affect any skin surface and external skin lesions are exhibited in up to 45 percent of reported cases. Women who have frequent vaginal yeast infections may have vaginal lichen planus and should be referred to a gynecologist to be evaluated, if they do have oral lichen planus. Often, the connection of oral and vaginal lesions is missed by both the dentist and the gynecologist and should be fully evaluated. Men may also have penile lichen planus. External skin lesions can be severe and require referral to a dermatologist in a team approach. Some patients suffer from full body lesions exhibiting purple, pruritic, and polygonal patches.
Distinguishing characteristics: The reticular pattern of lichen planus is characterized by a lacy web-like white pattern called Wickham’s Striae. The name lichen is derived from the lichen plant that has a mossy, web-like appearance and is often seen growing on rocks.
Significant microscopic features: Some distinct microscopic characteristics are observed in oral lichen planus. The rete ridges are irregular and have what is described as a “saw tooth” appearance. The basal cell layer is damaged demonstrating liquefaction and degeneration. Additionally, below the basement membrane, a band-like inflammatory infiltrate is observed (Figure 3).
Differential diagnosis: In many cases, lichen planus is not distinguishable from other mucosal diseases such as those listed below. A biopsy and other procedures such as immunofluorescence are needed to confirm the clinical diagnosis.
Other considerations would be pemphigus vulgaris, pemphigoid, lupus, or allergy-type responses.
Treatment and progress: After a confirmation of oral lichen planus, the asymptomatic forms are usually only monitored. The more erosive forms should be controlled since it is believed that any type of inflammation in the body is detrimental. Lichen planus should be carefully monitored and occasional biopsies may be needed when lesions are persistent or a change is noted in the tissue.
Low-dose topical corticosteroids are the treatment of choice or, for the most persistent cases, higher dose topicals. Sometimes systemic steroids may be needed for some lesions. With the use of any steroid product, candida may develop and this infection may be treated with antifungal products. Since lichen planus may be chronic for some patients, treatment may consist of bouts of remission and re-treatment.
The patient should be asked to keep a diary of possible “trigger” factors that may contribute to recurrence. Sometimes foods or dental products have been suggested as factors in oral irritations due to the sensitivity of certain agents and/or the combination of such products. A bland toothpaste is suggested with as little consumption of flavoring agents as possible. Often, hidden cinnamons and flavoring agents are found in foods, mints, gums, and even dental products. Careful monitoring of the diet is usually helpful.
As with most mucosal lesions, a picture is worth a thousand words and intraoral photography is a great asset in evaluating the tissue during each appointment. Maintenance appointments should occur every three to four months with as little disruption to the tissue as possible using nonabrasive products for prophylaxis.
Nancy Burkhart, RDH, EdD, is an adjunct associate professor in the Department of Periodontics at Baylor College of Dentistry, Texas A & M Health Science Center in Dallas. Nancy is also a co-host of the International Oral Lichen Planus Support Group through Baylor (www.bcd.tamhsc.edu/lichen). She can be contacted at email@example.com.