Oral lichen planus: A Mysterious Mouth Condition

Oral lichen planus
Lichen planus is among the conditions labeled as idiopathic, meaning they arise without a clearly identifiable cause. While it can manifest anywhere in the body, from hands and feet to the scalp and nails, the mouth is the most commonly affected site. In this article, we will look at the essential facts about this mysterious condition.

What is Oral Lichen Planus?

Oral Lichen Planus is a chronic inflammatory condition affecting certain body parts, particularly the lining tissues like skin and mucous membranes. Mucous membranes or mucosa are the soft tissues lining the inside of cavities and organs throughout the body, such as the mouth, digestive tract, and genital area.

This condition remains a mystery to this day, as the exact cause is unknown. But what we do know is that it involves your immune system acting unusually, attacking its own cells. The outcomes? Lesions popping up in various forms - white patches, lines, red spots, open sores, and inflammation.

About 77% of people dealing with lichen planus experience these lesions in the mouth. And while it can appear anywhere, the inside of your cheeks is the most frequent target. One of the telltale signs of the condition is the symmetry of lesions, affecting both sides of the mouth.

Now, Lichen Planus is not something you can catch or pass on to others. It is a disorder that occurs inside the body, rather than a viral or bacterial infection.

Although the World Health Organization (WHO) classifies it as a potentially malignant oral disease, the actual risk is too low, ranging from 0 to 2% according to studies. Still, to be on the safe side, it's always a good idea to check your symptoms with your doctor, whatever changes you notice in your mouth.

clinical image of oral lichen planus on the tongue

Lichen planus lesion on the surface of the tongue

Quick Lichen Planus Facts

  • Lichen Planus affects 0.5% to 2.0% of the population.

  • Females have double the risk compared to males.

  • It generally appears in middle-aged and elderly people, between the ages of 30 and 60.

  • Children are the least affected.

  • The probability of it turning into oral cancer is exceptionally low.

The Different Forms of Oral Lichen Planus

Oral Lichen Planus presents in various forms, but sometimes multiple subtypes can coexist simultaneously. The three most common manifestations are the Reticular, Erosive, and Plaque Types.

The three most common types of oral lichen planus: reticular, erosive and plaque.

1. Reticular Type:

The reticular type is the most prevalent form. It is characterized by tiny white lines that interlace, forming a distinctive lace-like pattern known as Wickham striae.

These white lines typically appear inside the cheeks and result from the overproduction of a protein called keratin. They often arise symmetrically, affecting both the right and left sides of the mouth.

While often asymptomatic, the lacy white lines may occasionally cause discomfort.

2. Erosive Type:

Erosive Lichen Planus takes the form of red, painful patches resulting from the immune system's destruction of mouth lining tissue. The erosive lesions can look similar to canker sores, except that they are larger with irregular margins.

They can also manifest as thickened areas with redness and ulceration, which may be covered by a whitish or yellowish layer, signifying tissue death.

The discomfort associated with this subtype can be intense, described as a burning sensation, particularly when eating hot or spicy foods.

3. Plaque Type:

The plaque lesions present as raised or flattened white areas on the mucosa with irregular margins. They are predominantly observed on the tongue and inside the cheeks.

These white patches can look like Leukoplakia, another potentially malignant oral condition.

Symptoms of Oral Lichen Planus

Oral Lichen Planus often shows no symptoms initially, as its onset is usually gradual and insidious. However, as it progresses, you might start noticing a few signs.

As the lines or patches thicken, the lining of your mouth might feel rough. Discomfort tends to set in, especially with the erosive and ulcerative forms.

These symptoms can fluctuate, intensifying during flare-ups and subsiding during remission phases. During the flare-up period, you might experience:

  • Burning Sensation and Pain.

  • Sensitivity to Hot, Acidic, or Spicy Foods.

  • Touching the lesions may result in bleeding.

  • Painful, Thick Patches.

  • Everyday activities like talking, eating, or swallowing might become challenging during symptomatic periods.

What Factors Can Worsen Oral Lichen Planus Lesions?

As Oral Lichen Planus is an abnormal immune response, any factor that can influence this reaction or exacerbate the inflammatory response can aggravate or trigger the outbreaks. Here are the most suspected risk factors:

  • Psychological factors like stress and anxiety.

  • Hepatitis C and B virus.

  • Hypertension and diabetes.

  • Allergic reactions to dental materials like amalgam, composite, and nickel-cobalt.

  • Immune reactions after transplant.

  • Some medications, including antihypertensives, hypoglycemics, and non-steroidal anti-inflammatory drugs.

Risk Factors for Malignant Transformation

Malignant transformation of oral lichen planus is a controversial topic, with varying reports on risk factors and associated mechanisms.

While some studies suggest a risk of up to 5%, others propose that malignant transformation may occur independently of lichen planus.

But what is certain is that lichen planus involves chronic inflammation, a condition linked to various forms of cancer. Various risk factors may be involved in oral malignancies:

Erosive and Ulcerative Forms

Most oral lichen planus cases turning malignant are often in the form of ulcers or erosions. The reason might be because these lesions make the oral mucosa more susceptible and exposed to carcinogens.

90% of oral cancers are known as squamous cell carcinomas. The most common symptom is an ulcer that doesn't heal, even after several weeks. It may look like a canker sore, but cancerous ulcers are usually irregular, protruding, anarchic, and hard to the touch.

So, if you notice that an ulcer persists for more than two weeks, don't hesitate to have it checked by your dentist.

Involvement of the Tongue

The tongue, particularly its sides, is a common site for oral cancer. Any persistent lesions in this area of your mouth deserve to be examined.

Smoking and Alcohol

Smoking and excessive alcohol consumption are harmful to both your overall and oral health. Although the evidence of their role in the malignant transformation of oral lichen planus is inconclusive, these habits are known irritants that can worsen existing mouth lesions. Plus, smoking and drinking together increases the risk of mouth cancer by up to 30 times.

Mouth Infections

Certain mouth infections, such as the human papillomavirus and chronic Candida albican infection (candidiasis or oral thrush), have been identified as risk factors for oral cancer.
Treating existing oral infections should also be part of lichen planus treatment.

Oral Lichen Planus Treatment

Lichen planus is a chronic and incurable condition; however, there are diverse measures to provide relief and prevent outbreaks.

Treatment might not be required in the mild and asymptomatic reticular type of oral lichen planus. However, regular monitoring and follow-up are necessary to assess any changes in the lesions.

Yet, for widespread, ulcerative, and painful lesions, treatment focuses on managing risk factors, alleviating symptoms, and minimizing the risk of potential malignant transformation.

1. Managing Risk Factors

The initial treatment step involves identifying potential factors behind the lesions and addressing them:

  • Identify and Treat Underlying General Illness: Conditions like liver disease, diabetes, hypertension, or viral infections should be identified and treated.

  • Managing Psychological Factors: Reducing stress and anxiety can help reduce lichen planus outbreaks.

  • Addressing Local Irritants: This may entail quitting smoking and excessive alcohol consumption, treating cavities, or fixing an old, ill-fitting filling or crown that's hurting your mouth's tissues.

  • Discontinuing Certain Medications: If a specific drug is suspected, replacing it with an alternative may resolve the disease.

2. Symptomatic Treatment

For managing symptoms associated with oral lichen planus, the following approaches are considered:

Topical Corticotherapy: The first-line treatment involves topical corticosteroids in the form of mouthwash, ointment, or gel, applied directly to the lesions.

Systemic Corticosteroids: If topical treatment fails or if the disease has spread, systemic corticosteroids in tablet form may be necessary.

Topical Numbing Agents: In cases of painful ulcers, your doctor may prescribe topical numbing agents like lidocaine.

3. Prevention

Lichen planus can be challenging to control as the underlying cause is unknown. However, certain factors seem to aggravate the condition, and that's where we can take action.

Start by effectively managing periods of heightened stress, and most importantly, don't let the condition take over your mental health.

Improve your diet and oral hygiene with regular brushing, and avoid bad habits and certain foods that can make your symptoms worse.

You should also keep a close eye on your mouth, noting any new lesions and monitoring their progress, whether they regress, worsen, are painful, or are asymptomatic.

In case any lesion persists or causes discomfort for more than two weeks, see your doctor or dentist as soon as possible. Professional guidance at the right time is key for your oral and overall health.