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ORIGINAL ARTICLE
Ahead of print publication  

Characterization of oral lichen planus in a subset of patients: A single-center experience


 Department of Oral Diagnostic Sciences, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission28-Feb-2020
Date of Decision31-May-2020
Date of Acceptance12-Jun-2020
Date of Web Publication01-Sep-2020

Correspondence Address:
Soulafa A Almazrooa,
Department of Oral Diagnostic Sciences, Faculty of Dentistry, King Abdulaziz University, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_11_20

  Abstract 


Introduction: Lichen planus (LP) is a common chronic, mucocutaneous inflammatory disorder with unclear pathophysiology. The aim was to describe the epidemiology and clinicopathological characteristics of oral lichen planus (OLP) patients at King Abdulaziz University Dental Hospital (KAUDH) in Jeddah.
Materials and Methods: This was a retrospective, chart-review study which included OLP patients previously seen at KAUDH from June 2012 to June 2018. Demographic data, clinical features, management, and outcome were collected and analyzed. Diagnosis of LP was done using clinical criteria with or without histopathologic diagnosis, and the scoring system by Escudier et al. was used.
Results: Fifty patients with a mean age of 48 years (range: 21–71) and 2.5:1 female-to-male ratio were included in this study. The most concomitant systemic diseases were diabetes mellitus (30%) and hypertension (26%). Reticular OLP was the most common form (98%), followed by erythematous (66%), ulcerative (26%), and plaque-like type (8%). More than half of the patients were asymptomatic (64%), whereas twenty-two symptomatic patients were managed with either topical steroids, a combination of topical and systemic steroids, and/or intralesional steroid injections with 68% improvement.
Conclusion: Based on the current data, clinical features at KAUDH matched what has been previously reported in the literature. In addition, the response to different treatment modalities varied between patients which could be linked to factors such as disease extension and severity.

Keywords: Lichen planus, lichen planus characteristics, lichen planus treatment, oral lichen planus, oral ulcers



How to cite this URL:
Alhelo AF, Almazrooa SA, Mansour GA, Alhamed SA, Alfarabi S, Akeel SK, Binmadi NO, Alhindi NA, Alsulaimani L, Alamri MA, Mawardi HH. Characterization of oral lichen planus in a subset of patients: A single-center experience. Saudi J Oral Sci [Epub ahead of print] [cited 2020 Sep 23]. Available from: http://www.saudijos.org/preprintarticle.asp?id=294189




  Introduction Top


Lichen planus (LP) is a common chronic mucocutaneous inflammatory disorder affecting various body sites, including the skin, scalp, nails, and mucus membranes.[1] Oral lichen planus (OLP) is restricted to the oral cavity and can affect any oral mucosal site.[1] The reported worldwide prevalence of OLP ranges between 0.5 and 4% compared to 0.3%–1.8% in Saudi Arabia.[2],[3],[4],[5] LP tends to be more common in adults with a strong female predilection.[6],[7] The pathophysiology of this disease has yet to be determined. However, OLP is considered an immune-mediated condition. Epithelial destruction occurs when activated T-cells recognize the human cell surface antigens (human leukocyte antigen) as foreign.[8] Factors such as stress, viral infections, and hypersensitivity to medications or restorative materials have been implicated as potential triggers for LP.[8] The disease has also been linked to other medical conditions, which is still controversial, such as hepatitis C, thyroid disease, hypertension (HTN), and diabetes mellitus (DM).[9],[10],[11],[12],[13],[14] Furthermore, patients with hematologic malignancies who have undergone stem cell transplantation can manifest with OLP-like features as part of chronic graft-versus-host disease.[15],[16]

OLP is characterized by periods of remission and exacerbation in which the patient's symptoms are the main determinants for treatment.[17] Six clinical subtypes of OLP have been reported in the literature. In general, they are reticular, erosive, atrophic, papular, bullous, and plaque-like. The first two are the most common.[18] Typically, OLP has a bilateral and symmetrical clinical presentation; however, it may present unilaterally in some cases.[6],[19] Histopathologically, OLP often exhibits various degrees of hyperorthokeratosis or parakeratosis and thickening of the stratum granulosum and spinosum with the formation of civatte bodies. In addition, the connective tissue shows a subepithelial dense band-like lymphocytic infiltrate.[20] The management of OLP is typically focused on relieving the patient's pain and symptoms. Combinations of topical and/or systemic immunosuppressive therapies, starting with corticosteroids, are considered the main treatment options to get disease remission.[12],[17]

Considering the potential relationship between OLP prevalence and clinical presentation with geographical and genetic factors, this study aimed to describe OLP in patients who were treated at King Abdulaziz University Dental Hospital (KAUDH) in Jeddah, Saudi Arabia. We expect that the results might increase the awareness of OLP in the region and consequently contribute to enhance the management of this disease.


  Materials and Methods Top


Ethical approval for human subjects' research was obtained through KAUDH before the start of the study (ID 087-16). A retrospective chart review study was conducted to include all OLP patients who were seen in the oral medicine clinic at KAUDH and managed by all oral medicine specialists from June 2012 to June 2018. The study inclusion criterion was patients diagnosed with OLP based on either clinical or a combination of clinical and histopathological evaluations, as documented in their medical records. Data on age, gender, systemic diseases, and medications were collected. The OLP subjective and objective criteria, such as the patients' symptoms, clinical features, histological reports, and treatments, were also included. Patients with missing information were excluded from the study.

The OLP diagnosis was based on clinical criteria with or without the histopathologic diagnosis. The clinical criterion includes a bilateral, symmetrical presentation with lace-like reticulation along with the other forms. The histopathologic criteria include band-like lymphocytic infiltrate, liquefactive necrosis of the basal cells, and the absence of epithelial dysplasia. An OLP scoring system previously described by Escudier et al. to evaluate disease activity at each visit was used as reported.[21] This scoring system included the subjective and objective parameters and lesion activity for each involved site, as well as the patient pain score, which was recorded with the Visual Analog Scale (VAS). Each site was given a score 0, 1, or 2 (0, no detectable lesion; 1, evidence of LP; and 2, 0.50% of the buccal mucosa, dorsum of tongue, floor of mouth, hard palate, soft palate, or oropharynx affected) and severity 0–3 (0, keratosis only; 1, keratosis with mild erythema [3 mm from gingival margins]; 2, marked erythema [e.g., full-thickness of gingivae, extensive with atrophy, or edema on nonkeratinized mucosa]; and 3, ulceration). Then, the activity was calculated by multiplying the site with the severity. The study data, which were mainly descriptive, were analyzed with IBM SPSS Statistics for Windows, version 20.0 (IBM®, Armonk, NY, USA).


  Results Top


A total of 79 patients were identified, but only 50 patient charts met the inclusion criteria and were included in this study.

Demographic description

The majority of the study population was female (72.0%; 36⁄50), with a mean age of 48 (range: 21–71). Thirty-six patients (72.0%) were receiving active treatment for systemic comorbidities (DM, HTN, hypothyroidism, and hyperlipidemia) and 6% (3/50) reported a history of hepatitis B. The remainders were otherwise healthy. Eight patients (16.0%) had significant allergy histories to medications and/or food items. Forty patients (80.0%) had never smoked, eight were current cigarette smokers (16.0%), and two (4.0%) reported a history of cigarette smoking. Demographic data are listed in [Table 1].
Table 1: Demographic data and systemic comorbidities of study participants

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Clinical features

A majority of the patients (80.0%; 40⁄50) were diagnosed with OLP on the basis of clinical presentation only. Patients with atypical clinical features, such as unilateral presentation or the absence of lace-like reticulation (20.0%; 10⁄50), underwent biopsies for histopathological confirmation [Figure 1]. Single-site oral involvement was reported in 28.0% (14⁄50) of the patients; 34.0% (17⁄50) had two affected sites, and the remaining 38.0% (19⁄50) had more than two involved sites [Figure 2] and [Figure 3]. The buccal mucosa (90.0%), tongue (50.0%), and gingiva (44.0%) were the most affected sites. Around 38% of the patients (19/50) presented with more than one form of OLP [Figure 3]. The reticular form was noted in 98.0% of the patients (49/50), followed by 66% of the erythematous type (33/50), ulcerative 26% (13/50), and 8% of the plaque-like form (4/50). OLP was evident in only 78.0% (39⁄50) of the patients. The remaining 22% (11⁄50) had associated skin, scalp, and/or genital involvement.
Figure 1: (a) Hyperkeratosis and band-like lymphocytic infiltrate (×100 magnification view). (b) The destruction of the basal cells and rare colloid body (×200 magnification view)

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Figure 2: An asymptomatic patient (in this study) presenting with oral lichen planus at office visit (Panel A): extensive reticular changes with minor erythema of the labial mucosa, hard palate, and dorsal surface of the tongue were observed. Following treatment with prednisolone syrup as a mouthwash for 2 months, the patient showed clinical improvement (Panel B)

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Figure 3: Oral lichen planus patient at office visit (Panel A) presenting with reticular changes of the buccal mucosa bilaterally combined with erythema on the left side. In addition, there were white keratotic changes with postinflammatory hyperpigmentation on the right lower lip. Following treatment with dexamethasone mouthwash for 4 weeks, the patient exhibited clinical improvement, mainly reticulation (Panel B)

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Eighteen patients (36.0%) reported oral symptoms, including pain, sensitivity, and/or a burning sensation. Overall, the reported average oral pain VAS score was higher for females (2.19) than for males (1.29), with an overall mean of 1.94 (range: 0–10), and the mean OLP disease activity score at the office visits was 12.08. Unpublished, preliminary data from KAUDH showed that 38% (19/50) of the OLP patients who completed a psychological assessment questionnaire in which 79% (15/19) had stressors in their lives that coincided with the development or severity of the disease. Complete clinical features are listed in [Table 1] and [Table 2].
Table 2: Summary of clinical features of oral lichen planus cases

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Treatment outcomes and follow-up

Twenty-eight patients (56.0%) were managed by reassurance and education because of the absence of symptoms (54.0%) or patient refusal of treatment (2.0%). Twenty-two patients (44.0%) received one or more forms of treatment as follows: 34% (17⁄50) were prescribed only topical corticosteroids (i.e., clobetasol cream 0.05%, or prednisolone syrup as a mouth was 15 mg/5 ml) and 10% (5⁄50) were treated with a combination of systemic (prednisolone 0.5–2 mg/kg) and topical corticosteroids. Two of this latter group (2⁄5) also received intralesional injections. Only 23 patients (46%) had one or more follow-up visits. Fifteen patients (68.2%) reported symptom improvement, which was evidenced by improvements in the VAS scores. Eight patients (34.8%) reported no symptom changes. Data are listed in [Table 3].
Table 3: Treatment modalities combined with oral lichen planus scoring, Visual Analogue Scale scores, and overall patient response

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In terms of the malignancy potential of OLP, neither dysplastic transformation nor oral cancer was reported in any of the patients during the study.


  Discussion Top


OLP is a common immune-mediated condition with a wide range of clinical presentations in which the oral mucosa is affected.[1] Although it has been linked to several risk factors, including medications and genetics, its prevalence and clinical presentation are related to additional factors, such as race and geography. A published prevalence of 0.35%–1.7% was identified in Saudi Arabia.[2] Thus, the treatment modalities, protocols, and outcomes may depend on the patient populations and medical or dental centers.[22] The availability of regional epidemiological studies could, therefore, help fill this gap in knowledge and provide a better understanding of OLP in Saudi Arabia. Accordingly, the aim of this study was to describe the epidemiological and clinicopathological characteristics of OLP patients at one of the largest specialized dental centers in Jeddah.

Jeddah, the second largest city in Saudi Arabia, has an estimated population of more than three million. Because of its unique location, it is the most racially and culturally diverse city in the country. In addition to Arabs, people of Asian, African, European, and other backgrounds constitute the population.[23] Many medical and dental centers have been established to provide the needed health-care services to these communities. This includes KAUDH, the main referral center for all dental specialties, including oral medicine. Therefore, the epidemiological data at the KAUDH could provide a sampling pool to compensate for the limited number of studies on the prevalence and clinical presentation of OLP in Jeddah.[24] In general, the demographic and clinical data including female predominance and presentation in older populations (aged 40–50 years) were similar to the data reported in the literature.[2] However, the results of the current study might not match the findings of male predominance observed in the city of Jizan.[4] One explanation could be cultural barriers as male patients in Jizan were more likely to seek dental consultations than females in the past. This observation might not be the same in Jeddah which is a more cosmopolitan city compared to more conservative Jizan. Furthermore, a significantly lower percentage of active smokers were reported in this study than in previous studies which could be attributed a higher awareness of the adverse effects of smoking in the current population.[4]

In terms of concurrent systemic diseases, several studies have reported an increased prevalence of OLP in association with DM (11.5%), HTN (19.2%), hyperlipidemia (11.5%), and thyroid disease (1.5%).[25] This relationship has been attributed to the associated therapies rather than disease activity.[11],[26],[27] Saudi Arabia has the highest prevalence of DM and HTN in the eastern Mediterranean region. Thus, the finding that 74% of the patients were in active therapy for systemic diseases was consistent with the literature.[28],[29] None of the study cases showed an association with hepatitis C although there was a 47% association reported in the literature.[30]

In the current study, the reticular form of OLP was the most prevalent clinical presentation. This was followed by the erythematous and ulcerative forms. The buccal mucosa was the most commonly affected site, followed by either the gingiva or the tongue. These findings are in accordance with those.[31],[32] In the absence of a consensus on the OLP diagnostic criteria, the classic clinical features were considered satisfactory for diagnosis of most of the patients (40 ⁄ 50).[33],[34] Questionable cases with less than the classic OLP criteria (10 ⁄ 50) were histopathologically examined to exclude any dysplastic changes.

As has been reported in the literature, corticosteroids are considered the first line of treatment for symptomatic OLP in systemic and/or topical formulations. The corticosteroid selection process depends on several factors, including disease severity, the number of involved sites, the symptoms, and the patient's medical history.[35] In this study, additional factors played a role in the treatment options provided to patients. The lack of some commonly used medications in Jeddah, such as dexamethasone, had a major effect on the decision-making process; consequently, most patients received a prednisolone mouthwash. Compared to prednisolone, dexamethasone which has been evaluated in clinical settings has an extended half-life, better bioavailability, and a 5–6-fold increase in anti-inflammatory effects.[36],[37] However, its use in daily clinical practice in Saudi Arabia has been a challenge because of its availability. Dexamethasone elixir is commercially available in North America and Europe; however, this is not the case in Saudi Arabia as it has to be compounded. An ongoing study is being conducted to evaluate the efficacy of these alternative medications for patients with vesiculobullous diseases.

On the basis of the patient symptoms and pain scores, the treatment options for the symptomatic patients in this study included clobetasol cream 0.05% and systemic corticosteroids (prednisolone 0.5–2 mg/kg). In patients with localized moderate-to-severe symptomatic lesions, intralesional triamcinolone injections produced a considerable response. Overall, 30% of the patients reported symptom improvement, and 16% experienced no change which is similar to response rates reported in the literature (30%–100%).[38] Furthermore, 54% did not attend follow-up appointments. This could be attributed to the lack of patient awareness, the absence of symptoms, the resolution of symptoms, transportation difficulties, and the overall cost. Future studies that increase the understanding of patient compliance with follow-up visits would be helpful.

Several scoring systems were developed to characterize OLP and/or to assess treatment response. The disease activity scoring system developed by Escudier et al. was used in this study.[21] The implementation of this scoring system facilitates patient management and follow-up. In the current study, the mean OLP activity score at the office visit was 12.08, which was higher than the mean of 7.4 ± 4.87 reported in previous studies.[39] One possibility is that the patients in this geographic region tend to visit a clinic at a more advanced and severe stage of the disease.

The recent WHO categorization of OLP as a potentially malignant lesion is controversial due to lack of supporting literature.[40] Therefore, long-term follow-up has been recommended for the early detection of malignant transformation.[35],[41] None of the patients in the current study were diagnosed with oral dysplasia or malignancy at their most recent follow-ups. All the patients were placed on a long-term annual follow-up program for the early detection of possible dysplastic changes.

A major limitation of this study was its retrospective nature which included cases managed by different practitioners and might have affected the diagnosis, availability of follow-up, and OLP scoring records for analysis. Second, most of the patients' group with no histopathological examination refused to undergo a confirmatory biopsy procedure and elected to continue treatment based on clinical diagnosis only. Even with the WHO OLP diagnosis criteria advice for a histopathological confirmation, many clinicians continue to rely on OLP clinical features for diagnosis specifically for classical cases.[42],[43] Third, the small sample size makes generalizations of the results to the Saudi population challenging. Fourth, since the patients' record system in the dental clinic is not linked to medical charts at our center, reported OLP medical comorbidities were determined based on patients' narration. As a result, the actual prevalence of these comorbidities among this cohort of patients may have been underestimated. Finally, the short treatment duration and follow-up did not allow for the complete assessment of treatment outcomes and long-term prognoses.


  Conclusion Top


OLP is a common disease with various clinical presentations and treatment responses. The current study describes the epidemiological and clinical characteristics of a group of OLP patients in Jeddah. A majority of the findings are consistent with previous regional studies. Considering its reported malignant potential, long-term follow-up of OLP patients is recommended for early detection of malignant transformation. Larger epidemiological studies on OLP in all regions of Saudi Arabia with longer follow-ups through collaborative, multi-center approach are needed.

Financial support and sponsorship

This study was funded by the Deanship of Scientific Research, King Abdulaziz University, Jeddah, Saudi Arabia (Grant No. G721-165-38).

Conflicts of interest

There are no conflicts of interest.



 
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