Treatment of Oral Dysplasia

Oral epithelial dysplasia refers to a premalignant lesion of the oral cavity. The diagnosis of dysplasia is rendered via pathologic assessment of diseased tissue. There are many different premalignant conditions identified in the oral cavity. These include leukoplakias, erythroplakias, proliferative verrucous leukoplakia, oral submucosal fibrosis, actinic cheilitis, and lichen planus. This article will discuss these different conditions and how they are diagnosed. It will also review the treatment for these entities.

Non-Coding RNAs as Potential Targets for Diagnosis and Treatment of Oral Lichen Planus: A Narrative Review

Oral lichen planus (OLP) is a chronic inflammatory disease that is characterized by the infiltration of T cells into the oral mucosa, causing the apoptosis of basal keratinocytes. OLP is a multifactorial disease of unknown etiology and is not solely caused by the malfunction of a single key gene but rather by various intracellular and extracellular factors. Non-coding RNAs play a critical role in immunological homeostasis and inflammatory response and are found in all cell types and bodily fluids, and their expression is closely regulated to preserve normal physiologies. The dysregulation of non-coding RNAs may be highly implicated in the onset and progression of diverse inflammatory disorders, including OLP. This narrative review summarizes the role of non-coding RNAs in molecular and cellular changes in the oral epithelium during OLP pathogenesis.

[Research progress in the diagnosis and management of proliferative verrucous leukoplakia]

Proliferative verrucous leukoplakia (PVL) is one of the oral potentially malignant disorders (OPMD) with the highest malignant potential. PVL tends to be easily misdiagnosed owing to the resemblance in clinical manifestations between PVL and other diseases such as oral leukoplakia or oral lichen planus. PVL is considered as a special type of oral leukoplakia by some scholars, which is characterized by its tendency of recurrence and metastasis, along with its high risk of malignant transformation. So far, the accurate clinic diagnosis and management of PVL are still intractable due to the lack of definite histopathological definition, unified diagnostic criteria and effective treatment modalities. This review aims to provide the clinical practitioners with a series of advices on the clinical diagnosis and management of PVL by systematically reviewing the diagnostic logistics, therapeutic strategies, malignant transformation detection based on tremendous relevant data and evidence-based medicine.

Onset of oral lichen planus following dental treatments: A nested case-control study

INTRODUCTION

The exposure to amalgam restorations has been reported to bring about altered immunity followed by inflammation and infection.

AIMS

This study aimed at identifying whether patients who received restorative or endodontic treatments, or tooth extraction, would have altered odds of developing oral lichen planus (OLP).

MATERIAL AND METHODS

In this population-based nested case-control study, 421 cases of OLP and 1,684 controls were included after propensity score matching. Logistic regression was used to estimate the adjusted odds ratio (aOR) of OLP in individuals who had received amalgam and composite resin restorations, root canal therapy, and tooth extraction over a follow-up duration of five years.

RESULTS

There were no significantly different odds of OLP for those who underwent either amalgam (aOR = 0.948, 95% CI = 0.853-1.053, p = 0.3170) or resin restorations (aOR = 1.007, 95% CI = 0.978-1.037, p = 0.6557) in both anterior and posterior teeth in an observational period of five  years after restorations. Root canal therapy was associated with significantly lower odds of OLP, with each additional root canal therapy attenuating the risk of OLP at an aOR of 0.771 (95% CI = 0.680-0.874, p = 0.0001) for both anterior (aOR = 0.786, 95% CI = 0.626-0.986, p = 0.0372) and posterior teeth (aOR = 0.762, 95% CI = 0.650-0.893, p = 0.0008). Likewise, each tooth extraction reduced the risk of OLP, with an aOR of 0.846 (95% CI = 0.772-0.927, p = 0.0003), especially for anterior teeth (aOR = 0.733, 95% CI = 0.595-0.904, p = 0.0037).

CONCLUSIONS

We reported no significant association between dental restorations and consequent OLP, and significantly lower odds of OLP following both root canal therapy and tooth extraction.

Effects of cold physical plasma on oral lichen planus: An in vitro study (Effects of CAP on OLP)

OBJECTIVES

In the search for more effective and safe treatment avenues, we investigated cold physical plasma as a new treatment modality for therapy of oral lichen planus (OLP).

MATERIAL AND METHODS

Healthy and diseased human mucosal tissue samples with a size of 3 mm in diameter obtained from OLP patients were subjected to plasma treatment ex vivo or were left untreated. Tissue sections were quantified for immune-infiltration of CD4+ , CD8+ , CD45RA+ , and CD45R0+ T cells. Moreover, the tissues' inflammatory profile was assessed by analyzing 12 different cytokines in the surrounding media.

RESULTS

A significantly increased infiltrate of CD8+ and CD45-R0+ T cells was detected in OLP tissue samples when compared to healthy tissue. A higher concentration of interleukin (IL) 1β, IL6, IL8, and granulocyte macrophage-colony stimulating factor (GM-CMF) was detected in OLP samples compared to healthy mucosal tissue. For all cytokines and chemokines investigated, 23 out of 24 comparisons showed a decrease in tendency (significant for IL1β, IL2, IL10, and GM-CSF) in response to plasma treatment. In ex vivo-treated tissue, a decrease of T-cell infiltrate in OLP lesions compared with healthy tissue was observed.

CONCLUSION

Our findings suggest cold physical plasma can be a promising therapeutic option for OLP that requires further validation in vivo.

Successful treatment of isolated oral lichen planus on lower lip with traditional Chinese medicine and topical wet dressing: A case report

RATIONALE

Biopsy is very important for the diagnosis of oral lichen planus (OLP) on the lips. Traditional Chinese medicine (TCM) can be used to coordinate the whole body, soften and eliminate swellings and masses, and regulate the functions of qi and blood. Therefore, TCM could be an effective and safe treatment for OLP. Wet dressing is particularly important for the treatment of lip diseases. We report on a rare case of OLP on the lower lip.

PATIENT CONCERNS

A 38-year-old female patient presenting with a history of recurrent erosion, bleeding, and pain on her lower lip for 10 years.

DIAGNOSES

Erosive OLP of the lower lip.

INTERVENTIONS

The patient was treated for 4 months using TCM comprising "Qingwen Jiedu Kouyankang granules," total Paeonia glucosides, and a combination of hormones and anti-inflammatory agents applied locally using a wet dressing.

OUTCOMES

Lip erosion was improved remarkably after 1 month, and there was no recurrence or aggravation of the condition. The duration of the follow-up period was 5 months.

LESSONS

The therapeutics used here were effective and safe for the treatment of OLP and could improve the quality of life in patients with lip erosion. The therapeutics provide new insight into the treatment of OLP on the lip.

Oral Lichen Planus: an Overview of Potential Risk Factors, Biomarkers and Treatments

Oral lichen planus (OLP) is an immune-related disorder with unknown exact etiology but established prevalence in females. There are six clinical forms of OLP, ranging from asymptomatic white keratotic lesions to painful erosions and ulcerations. The aim of the present report is to overview pathologic and therapeutic aspects. Peroxidation products, antioxidants, cortisol, and immunoglobulins are potential biomarkers to predict OLP occurrence. The risk of OLP development in patients with hepatitis B and C infection is 2-fold greater than in healthy individuals, while there is no significant relation with diabetes mellitus. Corticosteroids are common drugs to treat OLP and their combination with other agents can be most effective. Folic acid and variants of vitamin B are also potential treatments since they target hematological abnormalities.

Lichen planus: molecular pathway and clinical implications in oral disorders

Stem cells play a role in many mucosal disorders characterised by abnormal proliferation and differentiation of keratinocytes, such as oral lichen planus (OLP). In OLP there were changes in stem cell markers as component of integrin complexes α6 and β1 integrin increased along with increase of melanoma-associated chondroitin sulphate proteoglycan (MCSP) and decreased of notch1 (N1) and keratin 15 (K15). Stem cell marker expression may be altered by pathological signalling in these lesions. Cadherins are transmembrane receptors that provide cell-cell contact and communication function through calcium-dependent homophilic and heterophilic interactions. In actively diseased areas of OLP lesions, basal keratinocytes downregulate CD40 and were focally E-cadherin-negative, in contrast to non-diseased areas and normal oral mucosa. This loss of E-cadherin expression may contribute to epithelial basal cell destruction and T-cell migration into the epithelial compartment in OLP. In addition, Growth factor pathways as a role in OLP and has been analyzed in this review.

Mucocutaneous Diseases: Oral Lichen Planus, Mucous Membrane Pemphigoid and Pemphigus Vulgaris

Mucocutaneous diseases affect the oral cavity and can present a diagnostic challenge. They can have systemic involvement, necessitating multidisciplinary management. Frequently, patients will see their general dentists initially for evaluation. A better understanding of mucocutaneous diseases can prevent delay in appropriate diagnosis and treatment. Oral lichen planus, mucous membrane pemphigoid and pemphigus vulgaris are three mucocutaneous diseases that affect the oral mucosa. This review describes the clinical features, epidemiology, etiology, pathogenesis and management for each condition.

[Clinical effect of Nd:YAG laser combined with total glucosides of paeony for the treatment of erosive oral lichen planus]

PURPOSE

To investigate the clinical effect of Nd:YAG laser combined with total glucosides of paeony (TGP) taken orally for the treatment of erosive oral lichen planus (OLP).

METHODS

Sixty patients who were diagnosed as erosive OLP with clinical symptoms were divided into experimental group (n=28) and control group (n=32) using a random number table. All patients received TGP while the patients in the experimental group were given Nd:YAG laser irradiation. The clinical effects were evaluated 3 months after treatment. The data were analyzed using SPSS 17.0 software package.

RESULTS

Three months later, the average VAS score and sign score had improved significantly to (1.36±1.39) and (2.32±1.56) in the experimental group. The same tendency was observed in the control group and at the time point no significant difference was observed between the experimental group and the control group. The effectiveness of the experimental group was significantly higher than the control group (82.1% vs 53.1%).

CONCLUSIONS

Nd: YAG laser combined with TGP can improve the efficacy of erosive OLP. The regime is safe and effective, which is worth of wide clinical application.

Simultaneous gingival squamous cell carcinoma in an oral lichen planus patient

OBJECTIVE

To describe a case of bilateral simultaneous squamous cell carcinoma of the gingiva affecting the mandible in a lichen planus patient and discuss the pertinent literature.

METHOD AND MATERIALS

We present a case of a 50-year-old woman with a history of oral lichen planus who was diagnosed with a primary and a second primary squamous cell carcinoma originating from the mandibular gingiva. A literature review did not disclose cases of gingival carcinoma arising simultaneously and bilaterally in the mandible.

RESULTS

Presentation of two simultaneous clinically distinct squamous cell carcinoma of gingiva, invading underlying mandible, is rare. Second primary tumor refers to a concomitant malignancy that is independent from the primary tumor. Second primary tumor is an independent prognostic factor since the surgical procedure is highly influenced by the extent of bony invasion.

CONCLUSION

The general practitioner should be aware of the possibility of multiple independent lesions at different sites of the oral cavity. A thorough oral examination of sites remote from the obvious main lesion should be performed. The presence of simultaneous primary oral cancerous lesions may indicate a greater morbidity and a grave outcome for the patient.

Epigenetic Modifications and Accumulation of DNA Double-Strand Breaks in Oral Lichen Planus Lesions Presenting Poor Response to Therapy

Epigenetics refers to changes in cell characteristics that occur independently of modifications to the deoxyribonucleic acid (DNA) sequence. Alterations mediated by epigenetic mechanisms are important factors in cancer progression. Although an exciting prospect, the identification of early epigenetic markers associated with clinical outcome in premalignant and malignant disorders remains elusive. We examined alterations in chromatin acetylation in oral lichen planus (OLP) with distinct clinical behavior and compared the alterations to the levels of DNA double-strand breaks (DSBs). We analyzed 42 OLP patients, who had different responses to therapy, for acetyl-histone H3 at lys9 (H3K9ac), which is associated with enhanced transcription and nuclear decondensation, and the presence of DSBs, as determined by accumulation of phosphorylated γH2AX foci. Patients with high levels of H3K9ac acetylation failed to respond to therapy or experienced disease recurrence shortly after therapy. Similar to H3K9ac, patients who responded poorly to therapy had increased accumulation of DNA DSB, indicating genomic instability. These findings suggest that histone modifications occur in OLP, and H3K9ac and γH2AX histones may serve as epigenetic markers for OLP recurrence.

Why the general dentist needs to know how to manage oral lichen planus

Oral lichen planus (OLP) is a frequently mismanaged chronic disease that requires care throughout a patient's life, and therefore a condition the general dentist must know how to manage. Patients with OLP often suffer considerable physical discomfort and an inability to perform proper oral hygiene, eventually resulting in poor periodontal health. In addition, these patients are confronted with the psychological stress of knowing that OLP is not curable. This is accompanied by a fear of other negative health developments, particularly oral cancer. The objective of this study was to identify major issues surrounding the management of OLP by the general dentist. A literature review of over 1100 articles was performed. An eclectic compilation of the issues revealed 12 major areas of concern. This article reviews those concerns and presents strategies for coping with the myriad signs, symptoms, and complications associated with this disease, as well as educational approaches and legal considerations. A rationale is provided to place the responsibility for the management of these patients under the person best positioned to coordinate care for this condition--the general dentist. A general dentist can contribute to the overall oral health of an OLP patient with timely diagnosis, effective treatment, thorough patient education, and the orchestration of efforts by a team of health care providers.

[Update and review of oral lichen planus]

Lichen planus is a chronic mucucutaneous disease affecting the oral cavity in up to 2% of the population. It has variable oral manifestations, may be asymptomatic or accompanied by severe pain. It has features which are similar to autoimmune diseases although its pathogenesis is not fully understood. Stress is associated with exacerbations and dental materials and/or medications can cause lichenoid reactions. Some reports link hepatitis C with the condition. The chronic nature of the disease, its occasional severity, the fact it is considered a pre-malignant condition, together with its prevalence, make it essential for the general dentist to be aware and informed about it. The dentist's role is important at all stages includes a thorough clinical examination, identification pathological lesions, and following diagnosis, regular dental treatment and minimization of exacerbations. A specialist should be consulted regarding diagnosis and ongoing dental treatments. The specialist will add local or systemic treatments as needed and provide long-term follow-up in order to diagnose malignant changes as quickly as possible.

Oral lichen planus: a report and review of an autoimmune-mediated condition in gingiva

Oral lichen planus (OLP) is a chronic autoimmune, mucocutaneous disease that affects the oral mucosa as well as the skin, genital mucosa, scalp, and nails. It is one of the most common dermatological diseases presenting in the oral cavity. An immune-mediated pathogenesis is recognized in lichen planus, although the exact etiology is unknown. The disease most commonly affects middle-aged females. It is infrequently found in children, with a prevalence of about 0.03%, and reports of this are scarce in the literature. The erosive and atrophic forms of OLP are less common, yet they are more likely to cause symptoms. OLP is the target of much controversy, especially in relation to its potential for malignancy. Thus, it is important for clinicians to maintain a high index of suspicion for all intraoral lichenoid lesions. Periodic follow-up of all patients with OLP is recommended. In view of the above, the authors highlight a case of gingival erosive lichen planus affecting a 17-year-old adolescent without concomitant cutaneous lesions, with special emphasis on clinical and microscopic characteristics of the condition and management with retinoids and steroid therapy.

[The characteristics of oral lichen planus]

Lichen is a chronic, mucocutan disease with unknown origin. Oral lesions are usually bilateral, the most frequent location of the reticular form is the posterior part of the buccal mucosa. It undergo only rarely spontaneous remission, and it has a potential to turn into malignant tumor. It is hypothesized that due to an antigen-specific mechanism, auto-cytotoxic T-cells infiltrates the affected region. T-lymphocytes induces apoptosis in the keratinocytes of the basal epithelium. Since etiology is unknown, there is no cure for lichen. The symptomatic treatment has been focused on reducing the subjective discomfort and to maintain or improve the quality of life. The main course of therapy are topical retinoids, locally given steroids, but immunosuppressive therapies have been also tried. Data about exact etiology, diagnostical criteria and effective treatment are still limited. Therefore, besides the early detection of the disease, symptomatic treatment, and the close observation of dysplastic lesions is recommended.

Oral mucosal lichen planus in nine-year-old child

Lichen planus (LP) is a fairly distinctive mucocutaneous disease. The etiology of the condition appears to be complex and multifactorial, with unique histopathological features. Immunofluorescence studies have provided some insight into a proposed immunopathogenesis. LP is seen frequently in the middle-aged and elderly population. The female-to-male ratio is approximately 2:1. Children are rarely affected. The incidence of oral LP in children is reportedly high among Asians. We present a 9-year-old Indian child with the documented clinical aspects, histopathology and immunofluorescence studies.

Interventions for treating oral lichen planus

BACKGROUND

Oral lichen planus (OLP) is a common chronic autoimmune disease associated with cell-mediated immunological dysfunction. Symptomatic OLP is painful and complete healing is rare.

OBJECTIVES

To assess the effectiveness and safety of any form of therapy for symptomatic OLP.

SEARCH STRATEGY

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 26 January 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 26 January 2011) and EMBASE via OVID (1980 to 26 January 2011). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

All randomised controlled clinical trials (RCTs) of therapy for symptomatic OLP which compared treatment with a placebo or between treatments or no intervention were considered in this review.

DATA COLLECTION AND ANALYSIS

The titles and abstracts of all reports identified were scanned independently by two review authors. All studies meeting the inclusion criteria were assessed for risk of bias and data were extracted. For dichotomous outcomes, the estimates of effects of an intervention were expressed as risk ratios (RR) together with 95% confidence intervals. For continuous outcomes, mean differences (MD) and 95% confidence intervals were used to summarise the data for each group. The statistical unit was the patient. Meta-analyses were done only with studies of similar comparisons reporting the same outcome measures.

MAIN RESULTS

28 trials were included in this review. Pain is the primary outcome of this review because it is the indication for treatment of OLP, and therefore this review indicates as effective, only those treatments which significantly reduce pain. Although topical steroids are considered first line treatment for symptomatic OLP, we identified no RCTs that compared steroids with placebo. There is no evidence from the three trials of pimecrolimus that this treatment is better than placebo in reducing pain from OLP. There is weak evidence from two trials, at unclear and high risk of bias respectively, that aloe vera may be associated with a reduction in pain compared to placebo, but it was not possible to pool the pain data from these trials. There is weak and unreliable evidence from two small trials, at high risk of bias, that cyclosporin may reduce pain and clinical signs of OLP, but meta-analysis of these trials was not possible.There were five trials that compared steroids with calcineurin inhibitors, each evaluating a different pair of interventions. There is no evidence from these trials that there is a difference between treatment with steroids compared to calcineurin inhibitors with regard to reducing pain associated with OLP. From six trials there is no evidence that any specific steroid therapy is more or less effective at reducing pain compared to another type or dose of steroid.

AUTHORS' CONCLUSIONS

Although topical steroids are considered to be first line treatment, we identified no RCTs that compared steroids with placebo in patients with symptomatic OLP. From the trials in this review there is no evidence that one steroid is any more effective than another. There is weak evidence that aloe vera may reduce the pain of OLP and improve the clinical signs of disease compared to placebo. There is weak and unreliable evidence that cyclosporin may reduce pain and clinical signs of OLP. There is no evidence that other calcineurin inhibitors reduce pain compared to either steroids or placebo. From the 28 trials included in this systematic review, the wide range of interventions compared means there is insufficient evidence to support the effectiveness of any specific treatment as being superior.

Autoimmune oral mucosal diseases: clinical, etiologic, diagnostic, and treatment considerations

This article discusses the classic autoimmune diseases: pemphigus vulgaris, mucosal pemphigoid, and oral lichen planus. These are generally considered of autoimmune origin or, at a minimum, immune system mediated. Cause, diagnosis, and treatment are discussed. As management of these diseases progresses, continued advances in molecular pathogenesis will allow insight into which strategies can be employed in interfering with the complex cascade of events leading to mucosal impairment and clinical morbidity.

Lichen ruber planus as a psychiatric problem

Our mouth is the mirror of our health and it might be said that numerous diseases which affect our organism may be manifested in the mouth. Early symptoms occurring within the oral cavity may emerge with diseases related to our blood system, gastrointestinal system, renal system, cardiovascular system, and mental system. They are manifested as a hyperkeratosis, which may have an erithematous background. What we talk about here is lichen ruber planus. Lichen ruber planus is a common chronic immunological inflammatory disease of mucosa and skin, whose manifestations vary from karatolytic to eritematous and ulcerating lesions. The most frequent psychogenic diseases which may lead to the emerging of lichen planus are depression, anxiety and stress. Depression is a condition of decreased psychophysical activity predominated by sadness, apathy and slowed-down pessimistic thinking. Anxiety is a complex feeling comprising anxiety, fear, tension and insecurity, and is accompanied by the activation of autonomic nervous system. Stress is a reaction to trauma, and it enhances survival.

Do metal restorations in mouth alter clinical and histological appearance of oral lichen planus?

The objective of our study was to determine whether clinical and histopathological differences exist between patients with oral lichen planus (OLP) with dental amalgam and those without. The study involved 213 patients with OLP. They were divided into two groups: those with OLP without dental amalgam, and those with OLP with dental amalgam. The most frequent location for both groups was the buccal mucosa and bilateral presentation. No clinical or histopathological statistically significant differences were found between OLP with or without dental amalgam.

Oral lesions in patients with lichen planus

Forty patients with lichen planus admitted to University Department of Dermatology and Venereology, Sestre milosrdnice University Hospital in Zagreb during the 2004-2006 period were assigned to this retrospective study. In these 40 patients (27 female and 13 male), lichen planus was diagnosed on the basis of clinical presentation, laboratory findings and histopathologic analysis. The results obtained indicated an increased prevalence of lichen planus in middle-aged patients (40% of patients were aged 40-60), with a significant female predominance (67.5% vs. 32.5%). The majority of patients with lichen planus presented with both cutaneous and oral lesions (62.5%), one third of cases had only cutaneous lesions (35%), and only one patient had isolated oral lesions (2.5%). The initial symptoms in patients with lichen planus usually manifested on the skin (82.5%), in oral cavity (5%), or both simultaneously. Oral lesions usually developed on buccal mucosa (88.5%) in the form of Wickham's striae. All patients were administered topical therapy (corticosteroids, keratolytics), while 55% of patients were given both systemic and topical therapy (corticosteroids, retinoids). Phototherapy was used in 27.5% of patients. The management of patients with oral lichen planus lesions requires multidisciplinary approach including dermatologists and oral pathologists, general practitioners, as well as ENT specialists, internal medicine specialists, and others.

Erosive oral lichen planus and its management: a case series

Lichen planus (LP), although a dermatosis, is more common in the oral mucous membrane than in the skin. Lesions of oral LP are classically found on the buccal mucosa and gingiva. Among the various types, the reticular lesions are asymptomatic and require no treatment, but pain and severe discomfort accompany the erosive or ulcerative lesions. Malignant transformation to squamous cell carcinoma developing in areas of erosive oral LP (EOLP) being a possibility, it is important for clinicians to maintain a high index of suspicion for all intraoral lichenoid lesions. Therefore, periodic follow-up of all patients with EOLP is recommended. In view of the above, this paper highlights the management of four cases of EOLP with topical corticosteroid and CO2 laser surgery.

A scoring system for mucosal disease severity with special reference to oral lichen planus

BACKGROUND

To date, there is only weak evidence for the superiority of any interventions over placebo for the palliation of symptomatic oral lichen planus (LP). Further research involving large placebo-controlled, randomized clinical trials is needed. These will require carefully selected and standardized outcome measures.

OBJECTIVES

To formulate a scoring system for intraoral LP.

METHODS

One hundred and fifty-six patients with biopsy-confirmed LP were scored at the first and subsequent visits according to (i) extent of site involvement, (ii) disease activity at each site and (iii) an overall pain score as reported by the patient. Overall differences between clinical variants of LP were analysed using the Kruskal-Wallis test and pairwise differences by the Mann-Whitney U-test. Clinical sensitivity (Wilcoxon signed-rank test) was assessed by scoring patients before and after treatment (n = 23).

RESULTS

Reticular LP (n = 48) was the commonest single type of clinical presentation, followed by ulcerative (n = 30), atrophic (n = 22), desquamative (n = 18) and plaque (n = 1). The median severity and activity scores were 13/6 (reticular), 39/20 (ulcerative), 20/9 (atrophic) and 23/11 (desquamative). Two or more clinical variants were seen in 37 cases. Statistical significance was observed for differences between clinical variants (P < 0.0001) and variation in scores (P < 0.01) when ulcerative LP was compared with all other types. Clinical sensitivity was statistically significant (P < 0.01), while reproducibility was high and allowed the response to therapy to be easily assessed.

CONCLUSIONS

It is suggested that this scoring system is easy to use, reproducible and sensitive enough to detect clinical responses to therapy.

Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations

Several therapeutic agents have been investigated for the treatment of oral lichen planus (OLP). Among these are corticosteroids, retinoids, cyclosporine, and phototherapy, in addition to other treatment modalities. A systematic review of clinical trials showed that particularly topical corticosteroids are often effective in the management of symptomatic OLP lichen planus. Systemic corticosteroids should be only considered for severe widespread OLP and for lichen planus involving other mucocutaneous sites. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions that may confuse the differential diagnosis. These include lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. In regard to the approach to oral lichenoid contact lesions the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus-host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids.

Evidence-based practice of oral pathology and oral medicine

Oral pathology is the specialty area of dentistry that deals with the diagnosis and management of oral diseases and more specifically, diseases other than dental caries, periodontal disease, restorative dentistry, and orthodontic therapy. Oral medicine represents the clinical arm of oral pathology and deals with diagnosis and treatment of soft-tissue lesions, whereas oral histopathology is the specialty area that focuses on the microscopic diagnosis of soft- and hard-tissue lesions of the head and neck area. The diagnosis and treatment of oral pathologic conditions is often based on empirical decision-making and many approaches to treatment have not been well-supported by clinicopathologic studies. The need for evidence-based, scientifically documented approaches to both diagnosis and treatment is eminent. Specific diagnostic criteria are lacking for many oral diseases, and therapeutic strategies have not been assessed by the gold standard of placebo-controlled, double-blind trials. Additionally, there are scientific data in the published literature that continue to be ignored by dental practitioners who manage patients with oral pathologic conditions. In this article, specific disease entities that are commonly managed by oral pathologists and oral medicine practitioners will be discussed with recommendations for future scientific studies that can serve as a framework for evidence-based diagnostic and therapeutic approaches.

A systematic review of placebo-controlled randomized clinical trials of treatments used in oral lichen planus

BACKGROUND

Oral lichen planus (OLP) is one of the commoner conditions seen in oral medicine clinics. Current treatments are palliative rather than curative. Numerous treatments have been tried but many have not been evaluated in randomized controlled trials (RCTs).

OBJECTIVES

To review the effectiveness and safety of any therapy compared with placebo for the treatment of symptomatic OLP.

METHODS

A systematic review of 11 RCTs, totalling 223 patients was done. The main outcome measures used were improvement of signs (erythema, reticulation, ulceration) and symptoms (pain, discomfort) usually after 8 weeks of therapy.

RESULTS

Eleven interventions were grouped into four therapeutic classes (topical ciclosporins, topical or systemic retinoids, topical steroids and phototherapy) for comparison. No therapy was replicated exactly. Trials recording the same outcomes in each therapeutic class were pooled. The largest number of pooled trials was four. Small odds ratios with very wide confidence intervals indicating statistically significant but imprecisely known treatment benefits were seen in all but one trial. Only systemic agents were associated with treatment toxicities; all other side-effects were mild and mainly local.

CONCLUSIONS

The results are tempered by the small study sizes, lack of replication, lack of standardized outcome measures and the very high likelihood of publication bias. Therefore this review provides only circumstantial evidence for the superiority of the assessed interventions over placebo for the palliation of symptomatic OLP. There is a need for larger placebo-controlled RCTs with carefully selected and standardized outcome measures.

Oral lichen planus in childhood

Oral lichen planus is rare in childhood, and only a few reports on this subject have appeared in the literature. Our objective was to report individual cases of oral lichen planus in childhood from our practice and to review the literature on this subject. We recruited patients younger than 18 years with oral lichen planus and documented several clinical aspects, the histopathology, patch tests, and blood examination findings. Three patients from about 10,000 dermatology patients younger than 18 years seen from 1994 to 2003 were included. Of these three, an Asian girl aged 11 years had an asymptomatic, hyperkeratotic variant of oral lichen planus, which disappeared without any treatment after 1 year. An Asian boy aged 16 years had an erosive oral lichen planus with severe pain, which healed after intensive local and systemic treatment in 2 years. A Caucasian girl aged 14 years had a hyperkeratotic variant with a little soreness, which disappeared with local treatment after 3 months. Our findings indicated that oral lichen planus in childhood is rare and therefore at present it is not possible to draw firm conclusions considering its nature and etiology. Oral lichen planus in childhood seems to occur preferentially in those of Asian race. The clinical features resemble those of oral lichen planus in adults. However, generally the prognosis of oral lichen planus in childhood seems to be more favorable than in adults.

Lichen planus, lichenoid drug reactions, and lichenoid mucositis

Lichen planus is a common mucocutaneous disease affecting a significant portion of the general population. This article reviews the most current concepts on the epidemiology, etiology, pathogenesis, clinical presentations, and treatment of oral lichen planus, lichenoid drug reactions, and lichenoid mucositis.

Healing of oral lichenoid lesions after replacing amalgam restorations: a systematic review

OBJECTIVE

We sought to systematically review the literature related to oral lichenoid lesions (OLLs) and amalgam restorations.

STUDY DESIGN

Cohort and case-controlled studies (no randomized controlled trials or controlled clinical trials available) were reviewed with respect to inclusion criteria and data on patients with OLLs, treatment interventions, and the measurement of outcomes.

RESULTS

Fourteen cohort and 5 case-controlled trials met the criteria. The study population consisted of 1158 patients (27% male and 73% female; age range, 23-79 years). From 16% to 91% of patients had positive patch test results for at least 1 mercury compound. Of 1158 patients, 636 had to have their restorations replaced. The follow-up period ranged from 2 months to 9 1/2 years. Complete healing ranged from 37.5% to 100%. The greatest improvements were seen in lesions in close contact with amalgam.

CONCLUSIONS

Protocols must be standardized to obtain valid results. The replacement of amalgam restorations can result in the resolution or improvement of OLLs. Patch testing seems to be of limited value. The topographic relationship between an OLL and an amalgam restoration is a useful--but not conclusive--marker.

Oral Lichen Planus and Allergy to Dental Amalgam Restorations

OBJECTIVES

To determine contact allergies in patients with oral lichen planus and to monitor the effect of partial or complete replacement of amalgam fillings following a positive patch test reaction to ammoniated mercury, metallic mercury, or amalgam.

DESIGN

In group A (20 patients), the oral lesions were confined to areas in close contact with amalgam fillings. In group B (20 patients), the lesions extended 1 cm beyond the area of contact with amalgam fillings. In group C (20 patients), the oral lesions had no topographic relationship with amalgam fillings. Partial or complete replacement of amalgam fillings was recommended if there was a positive patch test reaction to ammoniated mercury, metallic mercury, or amalgam. Control group D (20 patients) had signs of allergic contact dermatitis.

RESULTS

Amalgam fillings were replaced in 13 patients of group A, with significant improvement. Dental amalgam was replaced in 8 patients of group B, with significant improvement. In group C, amalgam replacement in 2 patients resulted in improvement in 1 patient. These results were evaluated after 3 months. No positive patch test reactions to mercury compounds were found in patients with concomitant cutaneous lichen planus and in group D.

CONCLUSIONS

Contact allergy to mercury compounds is important in the pathogenesis of oral lichen planus, especially if there is close contact with amalgam fillings and if no concomitant cutaneous lichen planus is present. In cases of positive patch test reactions to mercury compounds, partial or complete replacement of amalgam fillings will lead to a significant improvement in nearly all patients.

[Lichen planus esophagitis without skin, genital or oral mucosa involvement]

Lichen ruber planus is a common skin and mucosal disease, with very rare involvement of the esophagus. We report on a 68-year-old patient suffering from dysphagia, with a reduced general condition and weight loss of 12 kg in the past 6 months due to lichen planus of the esophagus. Treatment by bougienage was very successful. This case report describes a lichen ruber planus of the esophagus without involvement of skin, genital or oral mucosa.