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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 59-61

Atrophic lichen planus of gingiva and its management


Department of Oral Medicine and Radiology, CSMSS Dental College and Hospital, Aurangabad, Maharashtra, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Rashmi Ganesh Phadnis
F-21, Cidco N-4, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_20_18

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  Abstract 


Lichen planus (LP) is an autoimmune mucocutatenous disorder. Orally, the most commonly involved sites are buccal mucosa, tongue, and gingiva. About 10% of the patients with oral LP have lesions confined to the gingiva. The purpose of this article is to report a case of atrophic LP of gingiva in 30-year-old female patient with a chief complaint of burning sensation in the oral cavity from the past 1 year. Histopathological examination was carried out to confirm the diagnosis. The patient was treated with topical corticosteroids using occlusal tray following which the lesions and symptoms of burning sensation in the mouth are resolved. Thus, this case report highlights the correct diagnosis and the treatment plan and timely management of such cases.

Keywords: Atrophic lichen planus, gingiva, oral lichen planus


How to cite this article:
Phadnis RG, Kale L, Pawar A, Jadhav M. Atrophic lichen planus of gingiva and its management. Indian J Oral Health Res 2018;4:59-61

How to cite this URL:
Phadnis RG, Kale L, Pawar A, Jadhav M. Atrophic lichen planus of gingiva and its management. Indian J Oral Health Res [serial online] 2018 [cited 2019 Aug 24];4:59-61. Available from: http://www.ijohr.org/text.asp?2018/4/2/59/257149




  Introduction Top


Oral lichen planus (OLP) is a chronic, inflammatory mucocutaneous disease of unknown etiology, with a prevalence rate of 0.2%–4% in the population.[1] It is more frequently seen in women, with a male-to-female ratio of 2:3.[2],[3] OLP occurs usually between the ages of 30 and 70 years. Children and adolescents are rarely affected.

Intraorally, the buccal mucosa is the nearly all commonly affected site (64.3%); however, the gingiva may be involved with a similar frequency (59.8%), in approximately 10% of the patients, the oral lesions are confined to the gingiva[4] varying in its clinical appearance, and OLP can appear keratotic (reticular or plaque-like), annular erythematous, atrophic, hypertrophic, and ulcerative and is often accompanied by the skin lesion. About 40% of the patients had mucosal and skin lesions, 35% had skin lesions, while 25% had mucosal lesions only.[5],[6],[7] This mucocutaneous disease can manifest as desquamative gingivitis, asymptomatic Wickham striae or plaques, or severe, painful erosions or ulcerations anywhere in the oral cavity.

The cause of lichen planus (LP) remains unclear. Current evidence suggests that OLP is a T-cell-mediated process. Lesional LP tissue shows massive local activated T-cell populations, with an increased local expression of cytokines and altered adhesion molecule expression.[8],[9] Mental stress, malnutrition, infection (viral), mechanical trauma, and tobacco use are the precipitating factors of OLP.

OLP with manifestation confined to the gingiva may be clinically characterized by the presence of erythema (atrophic LP) and the presence of ulcerations (erosive and/or ulcerated LP) or vesiculobullous lesions (bullous LP).[10] The oral manifestation of the LP generally has typical clinical aspects and distribution, but the atrophic and erosive forms may be challenging even for the most experienced dental practitioner.[11] Frequently, the atrophic and erosive forms of LP cause pain and burning in the affected area. Difficulties in the establishment of the diagnosis of gingival LP may arise if gingivitis and periodontitis are superimposed on the lesions. Here, we present a case of gingival atrophic LP with special emphasis on its clinical and microscopic features along with management.


  Case Report Top


A 30-year-old female patient reported to the Department of Oral Medicine and Radiology CSMSS Dental College, Aurangabad, Maharashtra, India, with a chief complaint of burning sensation in the mouth for 1 year with severity increasing while taking spicy food substances. Oral examination showed the presence of multiple bilateral erythematous and desquamative areas on both upper and lower buccal gingival mucosa, involving marginal and attached gingiva with distinct white striations at the periphery. On the right buccal mucosa, hyperkeratotic white striations seen in the reticular pattern extending 2.5 cm from the corner of the mouth till retromolar pad, which were nontender, nonscrapable on palpation [Figure 1]. On anamnesis, the patient did not report relevant medical history or any history of allergy to amalgam or other dental materials. She had no history of any skin lesions. An incisional biopsy was performed from the posterior left maxillary gingival lesion.
Figure 1: Intraoral picture showing intense erythematous gingival lesion

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An incisional biopsy was performed obtaining a gingival tissue from most prominent area which was the buccal side of left maxillary molars. The histopathological report revealed a flattened epithellium with a band of acute and chronic inflammatory cell infitrate in the subepithelial portion of connective tissue. Based on clinical and histopathological findings, the final diagnosis was atrophic lichen planus of gingiva and reticular lichen planus with right buccal mucosa was arrived. The patient was treated with a corticosteroid applied topically to the gingiva twice daily using soft occlusal splints (clobetasol propionate 0.05% along with orabase as adhesive) [Figure 2]. The complete remission of lesions was observed after 2 months and 1-year follow-up did not detect exacerbation of the lesions [Figure 3].
Figure 2: Topical application of steroid along with adhesive using occlusal splints

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Figure 3: Regression of gingival lesions (follow up after 2 months)

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  Discussion Top


LP is a chronic T-cell-mediated autoimmune disease, which affects the oral mucosa, skin, genital mucosa, scalp, and nails.[12] Among the various forms of OLP (reticular, patch, Plaque type, atrophic, erosive, and bullous), atrophic LP, although not as common as the reticular form, it is of more significance for the patient as such lesions are usually symptomatic. In the present case, the patient showed atrophic and erythematous areas on the gingiva. The periphery of the atrophic regions was bordered by fine, white striations. Correlating with clinical picture, definitive diagnosis of atrophic LP was given after histopathologic examination.

The presence of gingival erosive LP in women may be associated with the vulvo-vaginal syndrome. The vulvovaginal-gingival syndrome is a variant of mucosal LP characterized by erosions and desquamation of the vulva, vagina, and gingiva.[13] All patients presenting oral lesions of LP should be questioned about and examined specifically for signs of genital involvement. The clinical appearance known as desquamative gingivitis is not pathognomonic of oral erosive LP and may represent the gingival manifestation of many other diseases such as cicatricial pemphigoid and pemphigus vulgaris. In such conditions, another biopsy sample for direct immunofluorescent study should be obtained to confirm the diagnosis. In the present case, the patient did not have any other signs, except for the gingival lesions, and due to the characteristic clinical appearance of white striations at the periphery of lesions, which is highly suggestive of OLP, the second biopsy was not performed in our case. The possibility of lichenoid drug reaction which shows similar clinical and histologic findings to OLP was ruled out as there was no specific association of administration of a drug, contact with a metal, foodstuff, or systemic disease.

The mainstay of treatment for OLP remains topical corticosteroids owing to their action of suppressing cell-mediated immunity. Hence, it is commonly used to reduce pain and inflammation. Even in our case, the patient had a good response to topical steroids which were given in a soft splint that covers gingiva which helped in the sustained effect of steroids. Significant reduction in erythema and burning sensation was reported at follow-up visit after 1 month. The complete remission of lesions was observed after 2 months, and a 1-year follow-up did not detect exacerbation of the lesion. Although such application of topical steroids requires the close monitoring due to side effects such as candidiasis and effects of systemic absorption.

In the condition recalcitrant to topical therapy, intralesional injections of the steroid can be effective. Occasionally, systemic steroids are indicated for the brief treatment of severe exacerbations or for short periods of treating recalcitrant lesions that fail to respond to topical therapy. Alternative treatment includes fluocinonide, chloroquine, cyclosporine, retinoids, azathioprine, tacrolimus, surgery, photodynamic therapy, and carbon dioxide laser.[14]

The range of malignant transformation of OLP per year, as described in the literature, is between 0.04% and 1.74%.[15] It is generally accepted that the malignant transformation or development of malignancy in the presence of OLP is more likely to occur in atrophic, erosive, or ulcerative lesions. Clinically, it is important that patients with OLP undergo regular follow-up evaluations, and repeat biopsy should be performed when indicated. This strategy seems most important with patients who have erosive and atrophic LP.


  Conclusion Top


This article highlights the classic picture of atrophic LP, its diagnosis, and its timely management. The prognosis was good postmedication. Considering the malignant potential of OLP, it must be emphasized that a strict follow-up of atrophic LP is necessary.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Radwan-Oczko M, Mendak M. Differential diagnosis of oral leukoplakia and lichen planus – On the basis of literature and own observations. J Stoma 2011;64:355-70.  Back to cited text no. 1
    
2.
van der Waal I. Oral lichen planus and oral lichenoid lesions; a critical appraisal with emphasis on the diagnostic aspects. Med Oral Patol Oral Cir Bucal 2009;14:E310-4.  Back to cited text no. 2
    
3.
Ismail SB, Kumar SK, Zain RB. Oral lichen planus and lichenoid reactions: Etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 2007;49:89-106.  Back to cited text no. 3
    
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Scully C, el-Kom M. Lichen planus: Review and update on pathogenesis. J Oral Pathol 1985;14:431-58.  Back to cited text no. 4
    
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Stoopler ET, Sollecito TP, DeRossi SS. Oral lichen planus. Update for the general practitioner. N Y State Dent J 2003;69:26-8.  Back to cited text no. 5
    
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Mollaoglu N. Oral lichen planus: A review. Br J Oral Maxillofac Surg 2000;38:370-7.  Back to cited text no. 6
    
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Eisen D. The clinical manifestations and treatment of oral lichen planus. Dermatol Clin 2003;21:79-89.  Back to cited text no. 7
    
8.
Kawamura E, Nakamura S, Sasaki M, Ohyama Y, Kadena T, Kumamaru W, et al. Accumulation of oligoclonal T cells in the infiltrating lymphocytes in oral lichen planus. J Oral Pathol Med 2003;32:282-9.  Back to cited text no. 8
    
9.
Iijima W, Ohtani H, Nakayama T, Sugawara Y, Sato E, Nagura H, et al. Infiltrating CD8+ T cells in oral lichen planus predominantly express CCR5 and CXCR3 and carry respective chemokine ligands RANTES/CCL5 and IP-10/CXCL10 in their cytolytic granules: A potential self-recruiting mechanism. Am J Pathol 2003;163:261-8.  Back to cited text no. 9
    
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Salgado DS, Jeremias F, Capela MV, Onofre MA, Massucato EM, Orrico SR, et al. Plaque control improves the painful symptoms of oral lichen planus gingival lesions. A short-term study. J Oral Pathol Med 2013;42:728-32.  Back to cited text no. 10
    
11.
Scully C, Beyli M, Ferreiro MC, Ficarra G, Gill Y, Griffiths M, et al. Update on oral lichen planus: Etiopathogenesis and management. Crit Rev Oral Biol Med 1998;9:86-122.  Back to cited text no. 11
    
12.
Sugerman PB, Savage NW. Oral lichen planus: Causes, diagnosis and management. Aust Dent J 2002;47:290-7.  Back to cited text no. 12
    
13.
Eisen D. The vulvovaginal-gingival syndrome of lichen planus. The clinical characteristics of 22 patients. Arch Dermatol 1994;130:1379-82.  Back to cited text no. 13
    
14.
Thongprasom K, Carrozzo M, Furness S, Lodi G. Interventions for treating oral lichen planus. Cochrane Database of Systematic Reviews 2011.  Back to cited text no. 14
    
15.
Epstein JB, Wan LS, Gorsky M, Zhang L. Oral lichen planus: Progress in understanding its malignant potential and the implications for clinical management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:32-7.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
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