In this episode of PodMD, Oral Medicine Specialist Dr Elizabeth Arena will be discussing the topic of oral lichen planus and oral lichenoid lesions. We discuss what these conditions are, how they develop, when to refer, and more.
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Elizabeth Arena.
Dr Elizabeth Arena is an AHPRA-registered Oral Medicine Specialist based in St Leonards. Dr Arena attained a Bachelor of Dentistry with Honours, followed by a Doctorate in Clinical Dentistry specialising in Oral Medicine
You can read more about Dr Arena on her profile page on our PodMD website.
*Please listen to our disclosure at the end of this podcast
Today, we’ll be discussing the topic of oral lichen planus and oral lichenoid lesions. Liz, thanks for talking with us on PodMD today.
Elizabeth: Thank you for having me today.
To start us off, for GPs who may not encounter this often, what exactly is oral lichen planus?
Elizabeth: Yeah, this is a really good place to start, particularly because oral lichen planus, or OLP, as we say, is one of the most frequently encountered oral conditions that we see in oral medicine. So in a nutshell, OLP is a chronic disease of established immune-mediated pathogenesis. And more specifically, it’s a delayed type 4 hypersensitivity reaction, which is dominated by cytotoxic CD8T lymphocyte-induced apoptosis of the basal keratinocytes.
Now, so far I’ve been referring to OLP as in strictly the oral presentation of the disease, but really this is a systemic condition which can also in some patients involve the skin, scalp, as well as genital mucosa and even other extraoral sites.
Why do people develop OLP?
Elizabeth: That’s a really good question too, because the etiology is actually unknown and remains quite elusive. Having said that, there are a number of potential contributing factors that have been proposed, none of which have actually been formally established. So these include things like local and systemic inducers of cell-mediated hypersensitivity or an autoimmune response to epithelial antigens, although having said that, definitive evidence of autoimmunity in OLP actually hasn’t been demonstrated.
There’s also been suggestion that microorganisms such as Hepatitis C might be associated, particularly in certain geographical regions, and this then might infer that there could be genetic influences at play. Controversially, also stress has been considered as an inciting factor for OLP.
So what sort of people do you see with OLP?
Elizabeth: Really all sorts. The condition has a prevalence of between 0.5% to 2.2% of the population. But we have to consider here that there’s likely to be a percentage of the population walking around with undiagnosed asymptomatic OLP. So the statistics might be unreliable in terms of disease prevalence. And if we look at disease epidemiology, OLP is slightly more common in women than in men at a 3 to 2 ratio. And this is a disease of the adult population, so it’s really quite rare for children to be affected.
You mentioned that some people may have undiagnosed, asymptomatic OLP. How does OLP present then? And how do people end up being referred to you in the clinic?
Elizabeth: Yeah, that’s correct. And what it all boils down to is that there’s actually various clinical presentations when it comes to OLP. So there’s actually 6 recognised oral presentations of lichen planus and these include reticular, papula, plaque-like, erosive, ulcerative and bullous forms. It should also be mentioned that commonly atrophy of the gingiva is seen in OLP and we term this disquaminative gingivitis. So this is an immune gingivitis and should be distinguished from a bacterial or plaque-induced gingivitis that we would normally see in cases of poor oral hygiene, for example.
So naturally, with such variability in clinical presentation, there will also be variability in symptom profile among patients. This means that usually patients with a quiet, reticular form of the condition will usually remain asymptomatic. Then on the other hand, those patients who have erosive or ulcerative forms of OLP are usually in a fair amount of pain, and typically this presents as burning pain triggered by spicy, chilly or acidic stimulus. And characteristically, patients with symptomatic OLP will also experience burning with use of their toothpaste during toothbrushing.
So when it comes to how patients get to see me in clinic, it’s usually either that they’re complaining of burning oral symptoms, or incidentally for those patients who are asymptomatic, they’ve usually either been to their dentist or GP, or have even self-detected a white patch in the mouth that they’re concerned about. And if that’s the case, usually the first person they’ll tell is their GP.
So with such variability in clinical presentation, how do you come about diagnosing oral lichen planus and is this something GPs could do?
Elizabeth: The diagnosis of oral lichen plainus is actually a really interesting aspect of the condition. There’s been a lot of controversy over the years regarding the diagnostic criteria for OLP and to date there’s actually no universally accepted diagnostic criteria for this condition. In terms of published diagnostic criteria, the WHO in 2003 implemented modifications to its prior 1978 set of clinico-pathological criteria. And these 2003 updates have resulted in substantial increase in consensus in clinico-pathological correlation, although again they’re not universally accepted. And they’ve since been publications by other groups which talk about proposed criteria for OLP diagnosis, but still there is no universal consensus that currently exists.
So when it comes to actually formulating a diagnosis and applying diagnostic criteria, I like to think of the diagnosis of OLP as a combination of clinical and histopathological criteria. So clinically, there should be the presence of bilateral and more or less symmetrical lesions. And to be confident of the diagnosis, I like to see a reticular pattern clinically. And to be a bit more clear, a reticular pattern will look like a lace-like network of white lines. I could also see erosive patches, ulcerations, plaque-type lesions. And when I say that, I’m referring again to those six recognised subtypes of OLP and the huge variation in presentation of this condition. But to be confident on a clinical level, somewhere among those other changes, I like to satisfy the clinical criteria of there needing to be some reticular patterning.
Next, when it comes to histopathological criteria, obviously this requires oral mucosal biopsy and this needs to be of a diagnostic area. In addition, the tissue should include epithelium and connective tissue for diagnosis, so it needs to be a scalpel biopsy, which is a minor oral surgical procedure. And without going into the pathological criteria in too much depth, it’s really crucial to note that in the connective tissue, a superficial band-like inflammation should be noted, and this should comprise only of lymphophytes and macrophages. So when we start to see plasma cells, eosinophils, et cetera, we actually can’t diagnose oral lac and plainness as such histopathologically. Those cases would most likely be signed out as lichenoid stermatitis, but then when clinico-pathologic correlation is made, the overall diagnosis is still compatible with oral lichen plainness and management and other considerations then would be the same.
And lastly, when it comes to pathology, there should be no findings of oral epithelial dysplasia. So if we find this, there is actually no diagnosis of OLP and the dysplasia should be managed as such. So in short, The diagnosis is best made in the context of a clinician who has both adequate expertise and knowledge in the condition, but who also has the appropriate setup for oral examination and biopsy, along with correct interpretation of those results.
How important is biopsy in the diagnosis of OLP then, and at what point should a GP consider referral for one?
Elizabeth: Biopsy is crucial. As I mentioned, it’s important in confirming a diagnosis and in excluding epithelial dysplasia or indeed malignancy for that matter. Establishing a diagnosis via histopathology is crucial in cases where medical management is required as well, particularly if we’re needing to escalate management to more potent agents or even needing to consider systemic agents. In these cases, we really want pathology to support a diagnosis.
So yeah, to touch on that last aspect of your question there as well, I’d say if the GP is able to identify any sort of white patch, whether they suspect it might be oral lichen planus or something else, referral to a specialist with expertise in clinical oral pathology would be appropriate right from the get-go. That patient would require D. detailed oral mucosal examination in the appropriate context, both for a thorough examination, which by the way is always both visual and tactile, so we want to go into the mouth with our fingers and feel around, and potentially also planning for biopsy.
And shifting focus now to oral lichenoid lesions- these can be trickier. How do they differ from classical OLP, and why does it matter clinically?
Elizabeth: Yes, absolutely. And oral lichenoid lesions do need to be distinguished from a traditional OLP for various reasons. Oral lichenoid lesions can arise in the context of medication reactions, such as to hydroxychloroquine, or as contact reactions, which might arise from direct contact of the oral mucosa to dental materials, such as amalgam restorations. SLE as well can present intra-orally as lichenoid-appearing lesions. And another really important context in which oral lichenoid lesions can arise is the context of oral graft-versus-host disease in patients who have undergone allogeneic hematopoietic stem cell transplantation.
Now, the distinction between these particular entities, and again, between those entities and OLP, depends on the patient’s clinical history as well as on clinical examination. As an example, if the clinical history suggests that the patient has undergone allogeneic BMT in the context of, say, hematological malignancy or otherwise, and that patient then presents with lichenoid patterning, oral graft versus host disease should be considered.
Other considerations may involve the patient’s dental or medication history. So have they had dental restorations? Have they started new medications? These considerations might shift the clinical impression from a conventional OLP to an oral lichenoid lesion. Now, having said all of that, it’s important to note that identifying the exact trigger is sometimes impossible to do with all certainty. And once that lichenoid reaction or inflammation has been triggered, it does tend to persist despite cessation of the stimulus.
Now, clinically, the implications of being diagnosed with an oral lichenoid lesion is that we understand these to carry a higher risk of malignant transformation than oral lichen plainness itself. So close clinical surveillance over time is absolutely crucial. From a medical management perspective, we treat any symptoms in the same way that we would a conventional OLP though.
So how do you manage OLP and lichenoid lesions and which parts of management comfortably sit within the GP’s scope?
Elizabeth: I suppose it would be important firstly to emphasise that not all patients actually require active medical management. So once diagnosis has been established, if the patient is asymptomatic, so if they have a reticular type OLP, let’s say, but they’re able to brush their teeth and they’re able to tolerate a full diet, that patient actually won’t require any other intervention at that stage, except for ongoing regular clinical review at appropriate intervals.
But if, on the other hand, the patient is troubled by oral symptoms and ulcerations such that they’re unable to engage in oral hygiene or they have reduced oral intake, well, then that would be an indication for medical intervention. So the treatment of OLP in these symptomatic patients normally would take the form of steroids that will be either topical or systemic. And the appropriate use of steroids requires consideration of the severity of the disease. Is there only one symptomatic erosive area or are there multiple, large, painful ulcerations? Is it reasonable to expect a patient to apply a topical ointment to the area considering the number of lesions and anatomical locations? Or would they need a mouthwash to more effectively and efficiently treat the oral cavity?
When it comes to topical steroid regimens, we can also utilise steroids of varying potency and frequency depending on the patient’s presentation. We also need to consider if the lacan planus is so diffuse and ulcerative that the patient might require systemic steroids or even immunology input for consideration of a steroid-sparing agent. I guess in short, the treatment is bespoke for each patient, so it requires consideration of various factors. Sometimes multidisciplinary input and duration of treatment, again, depends on the individual factors of each patient.
It would be reasonable, in my opinion, for a GP to commence treatment if they felt comfortable to do so, remembering that prior to commencing treatment, a diagnosis needs to be established and that an adequate setup for thorough oral examination needs to be carried out. I’d encourage GPs, even if they have commenced treatment, to refer to an adequately trained specialist to work together in ongoing care.
What would you usually discuss with your patients who have been diagnosed with OLP? What would you suggest a GP speak about with their OLP patients?
Elizabeth: The biggest take-home points that I like to counsel patients on are the fact that OLP is a chronic condition. We can’t cure this condition, so treatment is not a cure. Secondly, I like patients to fully understand that it’s the natural history of OLP to wax and wane in severity. So it’s common for patients to experience disease flare-ups, and this may or may not happen. It’s impossible to predict if and when. But naturally, it would be normal for symptomatic patients to experience periods of time where they don’t feel they need active medical management, but then suddenly their condition worsens and they’ll need to pick up the steroids again in whatever form.
And then I suppose the most important thing when it comes to patient knowledge and understanding is the controversial yet established risk of malignant transformation of this condition. Now, in the literature, the risk of malignant transformation of OLP runs at about 1%, so it’s low. And as I’ve touched on briefly earlier, it’s a bit higher for oral lichenoid lesions. But this is still something I believe patients need to be aware of, also for their own understanding that ongoing clinical surveillance is really crucial. And further biopsy may be required over time of any area that has evolved to look clinically concerning.
So this might be an area that isn’t responding to treatment the way the rest of the oral cavity is responding. Or maybe it’s looking more leukoplakic rather than lichenoid in clinical presentation. or it might feel indurated and firm. These are all concerning features, and if these were new findings in a patient that I’ve known over time, then I’d certainly be inclined to biopsy the concerning area for histopathological examination, and I’d specifically be looking for the presence of oral epithelial dysplasia or malignancy.
What information is most helpful for you to receive in a referral?
Elizabeth: It’s always really helpful to receive information about what the GP has seen clinically. So for example, white patch or suspected like mode lesion, making note of whether there’s any ulceration or pain. If there has been ulceration, how long has it been present for? If management has been trialled, it would be great to hear about what’s been tried and whether it’s been effective.
Additionally, making note of the anatomical location of the lesion in question is always helpful. And in addition, we’ve spoken about the importance of biopsy for OLP or oral lichenoid lesions. So an up-to-date health summary, inclusive of medications, is always appreciated, as well as the most recent set of bloods. So full blood count and biochemistry is always really helpful information when we’re working up that patient for biopsy.
To sum up for us, could you please identify the three key take home messages from today’s podcast?
Elizabeth: Sure. Really briefly, I would say, firstly, OLP and oral lichenoid lesions require adequate assessment and diagnosis. This involves both clinical and histopathological criteria. So oral mucosal biopsy is in most cases recommended.
Secondly, I’d say the goal of medical treatment is to address symptoms, not to cure these chronic conditions.
And lastly, given the low yet established risk of malignant transformation, it’s recommended that these patients are referred for specialist care. Even in asymptomatic cases, management involves thorough ongoing clinical surveillance over time.
Liz, thanks very much for your insights today on PodMD, and we look forward to welcoming you for more sessions.
Elizabeth: Thank you very much. I look forward to it too.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
