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Oral lichen planus - Oral Mucosal Lesion
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Oral lichen planus - Oral Mucosal Lesion

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Contributors: Susan Burgin MD, Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc
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Synopsis

Oral lichen planus is a T-cell-mediated inflammatory mucosal disease that likely represents a hypersensitivity disorder to a contactant or circulating antigens; sometimes the antigen is not identified. It affects middle-aged and older adults with a predilection for females (2:1). Lichenoid hypersensitivity reactions in the mouth are often indistinguishable from oral lichen planus, and the two terms are sometimes used interchangeably.

Patients may have few to no symptoms if they have the classic or reticular form of lichen planus. Erosive / erythematous and ulcerative lichen planus lesions are associated with increased sensitivity to acidic, spicy, and crunchy foods as well as pain. Some patients present with erosive / erythematous and ulcerative lesions on the gingiva, representing the clinical entity desquamative gingivitis. Patients with desquamative gingivitis are more likely to have the vulvovaginal-gingival or peno-gingival syndrome (see anogenital summaries for lichen planus). Brushing often causes pain and bleeding, so oral hygiene is generally poor. Up to 25% of patients report lichen planus on the skin. It may also be on the scalp.

Medications such as anti-hypertensive agents, some NSAIDs, sulfasalazine, and carbamazepine are associated with the development of skin and oral lichen planus. Statins have been implicated in skin lichen planus. Patients with hepatitis C, lupus erythematosus, and chronic graft-versus-host disease often develop oral lesions that are clinically indistinguishable from oral lichen planus. Lesions may also appear locally as a result of hypersensitivity to a contactant (such as amalgam and composite restorations, and cinnamic aldehyde compounds).

Lesions are usually present for months and years and will relapse and remit.

Related topics: Lichenoid drug eruption, Lichen planopilaris

Codes

ICD10CM:
L43.9 – Lichen planus, unspecified

SNOMEDCT:
235049008 – Oral lichen planus

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Candidiasis – These lesions are not reticulated and often, although not invariably, can be scraped off leaving a raw, red surface.
  • Oral hairy leukoplakia – This is not usually reticulated and has typical vertical grooves aligned perpendicularly to the long axis of the tongue; if in doubt, a biopsy is indicated.
  • Some cases of leukoedema may present as painless, delicate reticulations on the buccal mucosa. Disappearance of these lesions with stretching is characteristic for leukoedema.
  • Hepatitis C is associated with lesions of oral lichen planus, mainly in populations with a genetic predisposition (HLADR6) including some Mediterranean populations.
  • Lupus erythematosus is associated with erythematous macular areas of the oral mucosa (especially hard palate) that may have faint reticulations. Biopsy of affected mucosa exhibits the positive lupus band test on immunofluorescence, and patients with systemic disease will have a positive titer for anti-nuclear antibody.
  • Chronic graft-versus-host disease occurs more than 100 days after allogenic hematopoietic stem cell transplantation and may be indistinguishable from lesions of typical lichen planus except for the history of transplantation.
  • Mucous membrane pemphigoid and other autoimmune vesiculobullous disorders (including pemphigus vulgaris, linear IgA disease, and epidermolysis bullosa acquisita) may present as a desquamative gingivitis. All patients with this clinical entity without obvious symmetric white reticulations should be biopsied for immunofluorescence studies to rule out such autoimmune diseases.
  • Chronic ulcerative stomatitis may appear similar clinically but histologically will show antibodies directed against the nuclei of stratified squamous epithelium on direct immunofluorescence studies. Such lesions also tend to be somewhat more refractory to treatment.
  • Erythema multiforme is not associated with reticulations and is of acute onset, with a history of reactivation of or recrudescent herpes simplex virus (HSV) infection. There is usually but not invariably skin involvement with typical target lesions on the hands.
  • Erythro-leukoplakia is not usually reticulated and appears as a red and white lesion that is usually painless. Biopsy is always indicated.

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Updated: 05/15/2019
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Oral lichen planus - Oral Mucosal Lesion
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Oral lichen planus : Oral erosions, Oral white plaque, Reticular configuration
Clinical image of Oral lichen planus
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