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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: Jeffrey M. Cohen MD, Susan Burgin MD, Carl Allen DDS, MSD, Sook-Bin Woo MS, DMD, MMSc
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Synopsis

Oral lichen planus (LP) is a T-cell-mediated inflammatory mucosal disease that can be seen with cutaneous LP or in isolation. It usually affects middle-aged and older adults with a predilection for females (2:1). Lichenoid hypersensitivity reactions in the mouth are often indistinguishable from oral LP, and the two terms are sometimes used interchangeably. In contrast to cutaneous LP, oral LP commonly has a chronic course.

Patients may have few to no symptoms if they have the classic or reticular form of oral LP. Erosive / erythematous and ulcerative oral LP 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 known as desquamative gingivitis. Patients with desquamative gingivitis are more likely to have the vulvovaginal-gingival or peno-gingival syndrome with genital involvement in addition to oral involvement. Brushing often causes pain and bleeding, so oral hygiene is generally poor. Up to approximately 40% of patients have cutaneous LP in addition to oral LP.

Medications such as antihypertensive agents, some NSAIDs, sulfasalazine, and carbamazepine are associated with the development of cutaneous and oral LP. Statins have been implicated in cutaneous LP. Oral LP is also associated with hepatitis C. Lesions may also appear locally as a result of hypersensitivity to a contactant (such as amalgam and composite restorations, gold, and cinnamic aldehyde compounds).

Lesions are usually present for months and years and will relapse and remit. There is felt to be potential for malignant transformation to well-differentiated squamous cell carcinoma. There is disagreement in the literature regarding the risk, with up to 5% of individuals with oral LP reported with malignant transformation.

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 typically has 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.
  • Lupus erythematosus is associated with erythematous macular areas of the oral mucosa (especially the 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 antinuclear 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 LP 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 infection. There is usually but not invariably skin involvement with typical target lesions on the hands.
  • Mycoplasma-induced rash and mucositis (MIRM) is a relatively uncommon mucocutaneous condition resulting from Mycoplasma pneumoniae infection that is characterized by prominent mucositis. MIRM is usually seen in children and adolescents.
  • Mucous membrane patch of syphilis
  • Erythroleukoplakia 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 Reviewed: 08/13/2019
Last Updated: 09/03/2019
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Oral lichen planus - Oral Mucosal Lesion
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Oral lichen planus : Buccal mucosa, Oral erosions, Oral white plaque, Painful oral ulcers, Reticular configuration, Tongue, Wickham striae
Clinical image of Oral lichen planus
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