What is Oral Lichen Planus?
Lichen planus is a long-term inflammation disease that impacts the skin, hair follicles, nails, and the mucosa, which refers to the lining of certain body parts. These include the mouth, genital area, eyes, ears, esophagus (the tube connecting your throat to your stomach), and sometimes, though less commonly, the bladder, nose, voice box, and rectum. Usually, the skin and the inside of the mouth are most affected.
When it occurs in the mouth, it is called oral lichen planus. This is a long-lasting condition that has periods of flare-ups and calms down. People with this condition need ongoing treatment to manage symptoms and regular check-ups. About 15% of people with oral lichen planus also get skin lesions, and 20% develop lesions in the genital area.
When it affects the skin, lichen planus typically appears as purple, itchy bumps with overlying white lines, known as Wickham striae. These lesions often show up on the truck of the body or limbs, like the wrists and ankles.
In women, genital lichen planus can present as redness, erosion (where the skin appears to have been worn away), white crisscross patterns, adhesion, shrinking of the labia, or scarring. Men may have ring-shaped lesions with scaling rashes on the head of the penis. Symptoms may include painful urination and painful sexual intercourse.
Over a quarter of people with oral lichen planus also have it in the esophagus. People with this issue often complain of difficulty swallowing and painful swallowing. An endoscopic examination, which uses a flexible tube with a light to examine the esophagus, may show different signs such as fragile mucosa, white spots, redness, ulcers, and narrowings.
What Causes Oral Lichen Planus?
Oral lichen planus is a long-lasting inflammation in the mouth, caused by an overactive response from certain immune cells (T-cells). It affects the oral mucosa, which is the lining that covers the inside of the mouth.
Research indicates that other factors such as mouth injuries, dental plaque (a sticky film of bacteria that builds up on teeth), and stress can worsen the symptoms of oral lichen planus.
It’s also interesting to note that studies have found a strong link between oral lichen planus and Hepatitis C, a liver disease caused by a virus, in certain regions. This association is particularly strong in places like Japan, the Mediterranean region, and large cities in the United States.
Risk Factors and Frequency for Oral Lichen Planus
Oral lichen planus is a condition that affects around 2% of people worldwide. It’s more common in women and is typically diagnosed between the ages of 50 and 60. However, it can also occur in children and young adults.
Signs and Symptoms of Oral Lichen Planus
Oral lichen planus is a condition that two-thirds of patients can feel symptoms of. These symptoms can come and go, but usually involve discomfort when eating spicy or acid-filled food, mouth pain, a gritty feeling inside the mouth, and a sensation of tightness across the mouth’s lining.
The condition comes in six different forms which can be reticular, papular, plaque, atrophic, erosive, and bullous. These types can appear on their own or alongside other types, and they are categorized based on the kind that is the most prominent.
- The reticular, erosive, and plaque forms are most common. Reticular oral lichen planus looks like a white net pattern (also known as Wickham striae) with hardened, thick patches.
- Erosive or atrophic oral lichen planus usually shows up as red areas and sores, often linked with pain and sensitivity. These sores may also have a white net-like pattern around their edges.
- The papular or plaque types appear as white hard spots or patches that may resemble leukoplakia. Patients with darker skin may also see patches of brown or black pigmentation along with these lesions.
Oral lichen planus generally appears on both the left and right sides of the mouth, most commonly showing up on the inner cheeks, the tongue, and the gums, followed by the inside of the lips and the lower lip.
Interestingly, the tendency of the condition to appear in areas that have experienced physical damage (like rough dental work or cheek biting) might explain why it’s more common on the inner cheeks and tongue—areas that typically endure most injuries. Around 10% of oral lichen planus patients present with lesions confined to the gums, appearing as desquamative gingivitis.
Testing for Oral Lichen Planus
To correctly diagnose Oral Lichen Planus (OLP), doctors need to look at several things. First, they ask about your medical history, and then they’ll examine your mouth. Often, they can identify OLP by its distinctive pattern. But they may still need to do a biopsy, which is when a small sample of tissue is removed and examined under a microscope. This is to confirm the diagnosis, as well as to make sure there’s no sign of more serious conditions like cancer.
When OLP shows up as a condition called desquamative gingivitis, which causes red, swollen, and bleeding gums, more tests might be needed. Doctors can use a procedure known as direct immunofluorescence (DIF) to determine if the symptoms are caused by OLP or by similar-looking autoimmune disorders, which are conditions where your immune system mistakenly attacks your body.
Treatment Options for Oral Lichen Planus
Unfortunately, there isn’t a cure for oral lichen planus, a condition that can cause uncomfortable symptoms like sores in the mouth. The purpose of treatment for this condition is to lessen the inflammation (swelling and redness) and ease the symptoms you’re experiencing.
Topical corticosteroids, medications directly applied to the affected areas in your mouth, are the first line of treatment. These can come as a sticky gel or be used as a mouth rinse, and they work by reducing inflammation. They are safer to use than corticosteroids that are taken by mouth or injected, which can have more side effects. After applying the gel, it’s recommended that you avoid eating and drinking for half an hour to give it enough time to work effectively.
If these gels don’t work or if the lesions are widespread or hard to reach with the gel, a mouthwash with a medicine called dexamethasone can also be used. For severe cases where sores don’t get better with the gel or mouth rinse, corticosteroid injections may be given directly into the sores. One common side effect of corticosteroids is a fungal infection in the mouth. If this occurs, you may need additional medication to treat it.
For more serious cases that don’t get better with the gels or rinses, corticosteroids that are taken orally or systemically (impacting the entire body) may be used. These pills can be especially helpful if oral lichen planus affects multiple sites in the body or other parts outside of the mouth. These systemic corticosteroids are typically reduced in dose and used less frequently as the condition improves.
There are also second-line treatments that can be used if the first ones aren’t effective enough. These include medications which, for example, modify the immune response. Like all medications, these can have side effects and so they must be used with caution. There are newer medications available as well, but they’re often used very carefully due to potential serious side effects including an increased risk of cancer or harm to unborn babies if used during pregnancy.
The key point is, while there’s no known cure for oral lichen planus, there are several options available to manage the symptoms and make you more comfortable. Remember to always communicate with your healthcare provider to find the best treatment plan for you.
What else can Oral Lichen Planus be?
There are several conditions that can look similar to oral lichen planus, both in appearance and under a microscope. These can include reactions to certain drugs, reactions to certain materials like dental restorations or flavoring agents, as well as diseases like pemphigoid, lupus, or chronic ulcerative stomatitis.
Medications that most commonly cause reactions that mimic oral lichen planus include NSAIDs (a type of pain reliever), blood pressure medications, epilepsy medications, malaria medications, and HIV medications. There are also other drugs that can cause these reactions, like diabetes medications, dapsone, gold salts, and certain psychiatric medications. Sometimes, these reactions might not happen right away and may even occur years after starting the medication. To diagnose whether a drug is causing the reaction, a detailed patient history may be helpful. In some cases, it might be possible to change the medication and see if the lesions improve, but this process can take several months.
With regards to reactions caused by contact with certain materials, these are typically seen in the mouth where the material touches the mucous membranes. The triggers could include dental materials like metals, composites, and certain types of cement, or flavoring agents like cinnamon, menthol, or eugenol. Among these, dental fillings made from a mix of metals (also called amalgam restorations) are the most common cause. If the offending material or agent is removed or discontinued, the lesions typically get better in a few months.
What to expect with Oral Lichen Planus
Changes to one’s lifestyle and the use of certain medications can help to relieve symptoms and enhance the quality of life for patients. Regular check-ups are important to detect any signs of cancer early, which can lead to a better prognosis in the long run.
Possible Complications When Diagnosed with Oral Lichen Planus
The possibility of oral lichen planus becoming cancerous is a topic of ongoing debate among medical researchers. The reported rates of oral lichen planus transforming into squamous cell carcinoma, a type of skin cancer, varies greatly from 0 to 12.5%. This broad range is attributed to different selection criteria used in various studies. Most of these cancer cases were found in patients with a severe form of oral lichen planus – the atrophic or erosive type, which means it causes tissue damage.
However, a recent comprehensive study that examined 12,838 patients diagnosed with oral lichen planus found a much lower risk of cancer development – only 0.44%. This significant drop is observed once stricter selection criteria are applied. Some factors were found to further increase the risk of cancer in patients, including smoking, heavy drinking, being tested positive for Hepatitis C, or having a red subtype of oral lichen planus.
Even though different studies report varied rates of cancer development in oral lichen planus patients, they all agree on one thing. Long-term regular check-ups are essential for managing patient symptoms and detecting any signs of cancer at its early stages.
Risk Factors:
- Severe (atrophic or erosive) type of Oral Lichen Planus
- Smoking
- Heavy alcohol consumption
- Testing positive for Hepatitis C
- Having red subtype of Oral Lichen Planus
Preventing Oral Lichen Planus
If you have been diagnosed with OLP (Oral Lichen Planus), it’s important to know that the treatments provided may not completely cure the condition, but they can help ease your symptoms. Changing your lifestyle to avoid things that make your symptoms worse, such as eating acidic or spicy foods, can provide some relief.
Another helpful approach is the removal or smoothing of sharp teeth or dental restorations that might aggravate the condition. It’s also crucial to maintain good oral hygiene and manage your stress levels, as these factors can affect the severity of your symptoms.
You should also be aware of the potential of OLP to turn into cancer, which is why regular check-ups are critical. Regular self-examinations at home can also be beneficial, for example, checking for persistent mouth sores or unusual growths. It’s essential to let your doctor know if you notice any suspicious changes.
