Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Oral lichen planus
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Oral lichen planus (OLP) is a common chronic inflammatory disorder affecting all areas of the oral mucosa that rarely undergoes complete remission, even with treatment.
Management Strategy
All treatment should be aimed at eliminating erythematous and ulcerative lesions, alleviating symptoms, and potentially reducing the risk of malignant transformation. Given the premalignant nature of OLP, it is important to monitor all patients carefully and long term.
Although the etiology of OLP is unknown, the possibility of a hypersensitivity reaction (oral lichenoid reaction) should be considered when lesions are confined to mucosa in close proximity to a dental restoration. In such cases, identifying allergies to dental materials by patch testing and then removing the fillings with positive reactions or empirically removing the fillings often results in resolution. Rarely, drugs induce lichenoid reactions. A thorough medication history with emphasis on non-steroidal antiinflammatory drugs (NSAIDs) is warranted, as drug-induced reactions are reversible when the implicated drug is withdrawn.
Exacerbating factors, including sharp dental restorations and poorly fitting dental appliances, should be eliminated. Stress, anxiety, and depression are increased in OLP patients and should be addressed. An optimal oral hygiene program that minimizes dental plaque and calculus can significantly improve gingival OLP.
All agents employed for the treatment of OLP are for off-label indications and lack adequate efficacy studies; thus, optimal dose, duration of treatment, safety, and their true efficacy remain unknown.
The most useful agents for the treatment of OLP are potent topical corticosteroids. Asymptomatic reticular lesions do not require therapy. For intractable erosive lesions, intralesional corticosteroids repeated every 2–4 weeks are highly effective.
Unresponsive OLP may benefit from topical immunomodulators (i.e., tacrolimus, pimecrolimus, and ciclosporin), which may be used as alternatives to, or in conjunction with, topical corticosteroids. Relapses after cessation of therapy are to be expected. Their long-term safety for this chronic disease is unknown.
A number of herbal preparations have been reported anecdotally or in small clinical trials to benefit OLP, including curcuminoids (6000 mg/day), lycopene (8 mg/day), zinc acetate (50 mg/day), and topical preparations of hyaluronic acid (0.2%), propolis (5%), aloe vera (70% concentration), and chamomile gel (2%).
Photodynamic therapy has also been shown to be beneficial in alleviating OLP symptoms.
For patients with severe oral disease or with extraoral manifestations, the addition of systemic immunosuppressives is indicated. The author has found that methotrexate (12.5–20 mg/week), azathioprine (100–150 mg/day), mycophenolate mofetil (1–2 g/day), acitretin (25–50 mg/day), and hydroxychloroquine (400 mg/day) are the most useful systemic agents. Ciclosporin, thalidomide, and tumor necrosis factor-alpha (TNF-α) inhibitors may be used for refractory cases, but data are limited.
Systemic corticosteroids (30–80 mg of prednisone) should be reserved for acute flares and not as maintenance therapy. Secondary candidiasis frequently complicates all therapies and requires treatment with topical or systemic agents. All treatments for OLP are palliative and not curative, and patients should expect a chronic course with intermittent acute exacerbations.
Specific Investigations
Direct immunofluorescence in oral lichen planus
Buajeeb W, Okuma N, Thanakun S, et al. JCDR 2015; 9: ZC34–7.
Biopsies of gingival OLP are often non-diagnostic. Immunofluorescence shows characteristic shaggy fibrinogen deposition at the basement membrane zone .
Malignant transformation risk of oral lichen planus: a systematic review and comprehensive meta-analysis
Gonzalez-Moles MA, Ruiz-Avila I, Gonzalez-Ruiz L, et al. Oral Oncol 2019; 96: 121–30.
Although the malignant potential of OLP remains controversial, the overall rate of transformation approximates 1%, requiring continued regular observation of patients .
Hepatitis C virus infections in oral lichen planus: a systematic review and meta-analysis
Alaizari NA, Al-Maweri SA, Al-Shamiri HM, et al. Aust Dent J 2016; 61: 282–7.
Routine hepatitis screening in northern European and American OLP patients without risk factors may not be warranted, but OLP is significantly associated with hepatitis C infections in southern Europe and Japan .
Association between oral lichenoid reactions and amalgam restorations
Pezelj-Ribarić S, Prpić J, Miletić I, et al. J Eur Acad Dermatol Venereol 2008; 22: 1163–7.
When patch test reactions to mercury compounds were positive, partial or complete replacement of amalgam fillings led to a significant improvement in nearly all patients.
Oral lichen planus and thyroid gland diseases: possible associations
Kats L, Goldman Y, Kahn A, et al. BMC Oral Health 2019; 19: 169.
Although several reports have shown a possible association between lichen planus (LP) and thyroid disease, these, and other, authors did not.
Randomized, placebo-controlled, double-blind trial of clobetasol propionate 0.05% in the treatment of oral lichen planus
Arduino PG, Campolongo MG, Sciannameo V, et al. Oral Dis 2018; 24: 772–7.
A randomized triple-blind clinical trial to compare the effectiveness of topical triamcinolone acetonate (0.1%), clobetasol propionate (0.05%), and tacrolimus orabase (0.03%) in the management of oral lichen planus
Sivaraman S, Santham K, Nelson A, et al. J Pharm Bioallied Sci 2016; 8: S86–9.
High-potency preparations are more effective than mid-potency preparations. Once the disease becomes controlled, topical steroids may be used several times weekly to prevent flare-ups . Prednisone should be reserved only for acute exacerbations.
Efficacy of intralesional betamethasone for erosive oral lichen planus and evaluation of recurrence: a randomized, controlled trial
Liu C, Xie B, Yang Y, et al. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116: 584–90.
Patients with erosive disease received either 1.4 mg intra- lesional betamethasone or 8 mg of intralesional triamcinolone acetonide once a week for 2 weeks. Both were effective but the more potent betamethasone more so and with a reduced recurrence rate.
Intralesional triamcinolone and betamethasone are highly efficacious for erosive lesions .
Comparison of topical tacrolimus and clobetasol in the management of symptomatic oral lichen planus: a double-blinded, randomized clinical trial in Sri Lanka
Hettiarachchi P, Hettiarachchi RM, Jayasinghe RD, et al. J Investig Clin Dent 2017; 8.
In a 3-week double-blind study with 68 OLP patients, tacrolimus was more effective than clobetasol.
Topical pimecrolimus versus betamethasone for oral lichen planus: a randomized clinical trial
Ezzatt OM, Helmy IM. Clin Oral Investig 2019; 23: 947–56.
In a 4-week double-blind study involving 30 patients, pimecrolimus resulted in a more rapid improvement and a lower recurrence rate than betamethasone.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here