Preliminary investigation of the association of oral lichen planus and hepatitis C

Bidirectional Association between Lichen Planus and Hepatitis C-An Update Systematic Review and Meta-Analysis

Lichen planus (LP) is a chronic, inflammatory mucocutaneous disorder associated with systemic diseases such as hepatitis C (HCV). The objective of this study is to evaluate the association between LP and HCV bidirectionally through a systematic review and meta-analysis. A comprehensive search of studies published was performed in the databases of PubMed, Embase, and Web of Science. Out of 18,491 articles, 192 studies were included. The global prevalence of HCV positive (HCV+) in LP patients registered from 143 studies was 9.42% [95% confidence interval (CI), 7.27-11.58%], and from these, 84 studies showed HCV+ 4-fold more frequent in LP than a control group (OR, 4.48; 95% CI, 3.48-5.77). The global prevalence of LP in patients HCV+ recorded from 49 studies was 7.05% (95% CI, 4.85-9.26%), and from these, 15 registered a 3-fold more LP in HCV (OR, 3.65; 95% CI, 2.14-6.24). HCV+ in LP patients showed great geographic variability (OR, 2.7 to 8.57), and the predominantly cutaneous location was higher (OR, 5.95) than the oral location (OR, 3.49). LP in HCV+ patients was more frequent in the Eastern Mediterranean (OR, 5.51; 95% CI, 1.40-15.57). There is a higher prevalence of HCV+ in LP and vice versa than in the control group, especially in certain geographical areas that should be taken into consideration when doing screening in countries with an upper prevalence of HCV among the general population.

Comparative Evaluation of Pimecrolimus Cream 1% and Triamcinolone Aceonide Paste in Treatment of Atrophic-Erosive Oral Lichen Planus

Objectives

This study was done to assess the effects of pimecrolimus cream 1% and triamcinolone aceonide paste in the treatment of atrophic-erosive oral lichen planus.

Materials and Methods

A total of 100 patients diagnosed both clinically and histopathologically as lichen planus were considered in the present study. Subjects were classified into two groups. Group I: Patients in this group were treated with 1% pimecrolimus cream and Group II: Patients falling under this group were treated with triamcinolone acetonide in 0.1% concentration.

Results

None of the patients reported worsening clinical signs and symptoms. No significant difference in efficacy and reduction in burning sensation of either pimecrolimus or trimcinolone acetonide was present.

Conclusion

Present study found no significant difference in the efficacy of both the agents studied.

Global prevalence of hepatitis C in general population: A systematic review and meta-analysis

BACKGROUND

According to published reports from the World Health Organization, it is estimated that more than 3% of the world's population is infected with HCV. Given the impact of various factors on the prevalence of HCV in the world's population and the lack of general statistics around the world, this study aims to review the studies conducted in this field and statistical analysis of the results of general statistical studies on the prevalence of HCV in the world population.

METHODS

In this study, systematic review and meta-analysis of information of the studies related to the prevalence of HCV in the world using keywords including: Prevalence, HCV, Hepatitis C, Healthy Population, Healthy subjects, and General Population in SID, MagIran, IranMedex, IranDoc, ScienceDirect, Embase, Scopus, PubMed, Web of Science (WoS) databases and Google Scholar search engine were extracted without time limit until April 2020. In order to perform the analysis of qualified studies, the model of random effects was used, and the inconsistency of studies with I² index was investigated. Data analysis was performed with Comprehensive Meta-Analysis (Version 2).

RESULTS

In a study of 98 studies with a total sample size of 236,964 people in the world, the overall prevalence of HCV was 1.8% (95% CI: 1.4%-2.3%). Also, according to the subgroup analysis in different continents; the highest prevalence of HCV in the African continent was 7.1% (95% CI: 4.4-11.5%).

CONCLUSION

The results of this study show that the prevalence of hepatitis C in the world's population, especially in Africa, is almost high. Therefore, the officials of the World Health Organization should design measures to prevent the spread of this infection.

Cutaneous manifestations of HAV, HBV, HCV

Hepatotropic viral infections are a relevant global health problem and present multiple extrahepatic manifestations in addition to hepatic disease. Along with generic cutaneous symptoms correlated to the cholestatic liver disease that may arise during the infection, some cutaneous manifestations of hepatotropic viral infections are characteristic, enabling to suspect the underlying infection. This review will present the principal cutaneous manifestations of hepatotropic virus infection. Cutaneous manifestations are rare in HAV infections: these include urticaria, panniculitis, scarlatiniform eruption, evanescent skin rash, maculopapular prolonged rash, serum sickness-like illness rash, cutaneous vasculitis, cryoglobulinemia. The commonest cutaneous manifestation associated to HBV infection is serum sickness-like syndrome. Polyarteritis nodosa (PAN) is among the most common and serious cutaneous manifestations of HBV infection. In children, HBV infection may acutely manifest as papular acrodermatitis of childhood (Gianotti-Crosti Syndrome), with non-pruritic, non-coalescing, round papules. Patients with chronic HBV infection may also develop mixed cryoglobulinemia, that is, inter alia, the most documented extrahepatic manifestation of HCV infection. Cutaneous lichen planus has been associated to HBV and HCV infection. As for oral lichen planus, the association with HBV and HCV is more debated. Interestingly, patients with oral lichen planus with HCV have a higher risk of developing oral squamous cell carcinoma. Dermatologists should be aware of the possible cutaneous manifestations associated to viral hepatitis.

Oral lichen planus and its relationship with systemic diseases. A review of evidence

BACKGROUND

Oral lichen planus (OLP) is one of the most common dermatological diseases which are present in the oral cavity. It is a chronic autoimmune, mucocutaneous disease that affects the oral mucosa as well as the skin, genital mucosa and other sites.

OBJECTIVE

Review the relevant information to OLP and its relationship with systemic diseases.

MATERIAL AND METHODS

Searches were carried out in the Medline/PubMed, Lilacs, Bireme, BVS, and SciELO databases by using key-words. After an initial search that provided us with 243 papers, this number was reduced to 78 from the last seven years. One of the first criteria adopted was a selective reading of the abstracts of articles for the elimination of publications that presented less information regarding the subject proposed for this work. All the selected articles were read in their entirety by all of the authors, who came to a consensus about their level of evidence. The Scottish Intercollegiate Guidelines Network (SIGN) criteria were used as the criteria of methodological validation.

RESULTS

Only 9 articles showed an evidence level of 1+, 2+, 3 or 4, as well as a recommendation level of A, B, C or D. Three of them were non-systematic reviews, one was a cohort study and only one was a controlled clinical trial. Three of the studies were case series, with respective sample sizes of 45, 171 and 633 patients.

CONCLUSIONS

Several factors have been associated with OLP. Patients with OLP are carriers of a disease with systemic implications and may need the care of a multidisciplinary team. The correct diagnosis of any pathology is critical to making effective treatment and minimizes iatrogenic harm. For OLP is no different, taking into account its association with numerous systemic diseases that require special attention from health professionals. Periodic follow-up of all patients with OLP is recommended. Key words:Oral lichen planus, etiopathogenesis, systemic diseases.

Association between hepatitis C infection in Thai patients with oral lichen planus: A case-control study

AIM

The aim of the present study was to investigate the prevalence of hepatitis C virus (HCV) infection and evaluate liver enzyme levels in patients from upper northern Thailand with oral lichen planus (OLP).

METHODS

A case-control study of 101 patients with OLP and 101 patients without OLP was conducted. Peripheral blood was taken from each patient and screened for anti-HCV antibody using immunochromatography. Positive samples were further confirmed using chemiluminescent microparticle immunoassay (CMIA) and reverse transcription-polymerase chain reaction. In addition, liver enzyme levels, alanine transaminase, aspartate transaminase, and alkaline phosphatase were evaluated using spectrophotometry.

RESULTS

Immunochromatography and CMIA revealed that nine patients with OLP (8.9%) were positive for anti-HCV antibodies, whereas only one patient without OLP was HCV positive (odds ratio = 9.78). All patients who were HCV positive had significantly higher liver enzyme levels than patients who were HCV negative.

CONCLUSIONS

The results of the present study indicated that OLP in certain patients was significantly associated with HCV. This could warrant screening for HCV-infected patients with OLP in Thailand.

Hepatitis C virus infections in oral lichen planus: a systematic review and meta-analysis

BACKGROUND

A role for hepatitis C virus in oral lichen planus has been postulated. This systematic review and meta-analysis of the existing epidemiological studies was conducted to determine if there is a correlation between oral lichen planus and hepatitis C virus infection.

METHODS

We examined the association between hepatitis C virus and oral lichen planus by conducting a systematic review and meta-analysis of case-control studies that examined the prevalence of anti-HCV antibodies in the serum of cases and controls. We searched PubMed, Embase and The Cochrane Library databases from 2005 to January 2015. Associations were measured using random-effect odds ratios (ORs) combined with 95% confidence intervals.

RESULTS

Nineteen eligible studies, encompassing 1807 cases of OLP and 2519 controls, were retrieved and included in this review. The summary estimate OR for all studies was 6.07 (95% CI: 2.73-13.48), showing a statistically significant difference in the proportion of HCV seropositivity among oral lichen planus patients, compared with controls and substantial heterogeneity between studies (I(2) = 65%) as a result of a variety of geographical distributions.

CONCLUSIONS

The association of hepatitis C virus infection with oral lichen planus emphasizes the importance of hepatitis C virus screening in oral lichen planus patients.

Microenvironmental regulation of the progression of oral potentially malignant disorders towards malignancy

Oral potentially malignant disorders (OPMD) develop in a complex tissue microenvironment where they grow sustainably, acquiring oral squamous cell carcinoma (OSCC) characteristics. The malignant tumor depends on interactions with the surrounding microenvironment to achieve loco-regional invasion and distant metastases. Unlike abnormal cells, the multiple cell types in the tissue microenvironment are relatively stable at the genomic level and, thus, become therapeutic targets with lower risk of resistance, decreasing the risk of OPMD acquiring cancer characteristics and carcinoma recurrence. However, deciding how to disrupt the OPMD and OSCC microenvironments is itself a daunting challenge, since their microenvironments present opposite capacities, resulting in diverse consequences. Furthermore, recent studies revealed that tumor-associated immune cells also participate in the process of differentiation from OPMD to OSCC, suggesting that reeducating stromal cells may be a new strategy to prevent OPMD from acquiring OSCC characteristics and to treat OSCC. In this review, we discuss the characteristics of the microenvironment of OPMD and OSCC as well as new therapeutic strategies.

Oral lichen planus: a literature review and update

Lichen planus (LP) is a common chronic inflammatory condition that can affect skin and mucous membranes, including the oral mucosa. Because of the anatomic, physiologic and functional peculiarities of the oral cavity, the oral variant of LP (OLP) requires specific evaluations in terms of diagnosis and management. In this comprehensive review, we discuss the current developments in the understanding of the etiopathogenesis, clinical-pathologic presentation, and treatment of OLP, and provide follow-up recommendations informed by recent data on the malignant potential of the disease as well as health economics evaluations.

Thyroid Disease and Oral Lichen Planus as Comorbidity: A Prospective Case-Control Study

BACKGROUND

Thyroid disease has been mentioned to have a possible relation to the development of oral lichen planus (OLP).

OBJECTIVE

Because goiter is considered endemic in many countries, we proposed to determine whether thyroid disease constitutes a comorbidity of OLP.

METHODS

Two hundred and fifteen patients diagnosed as having OLP were evaluated concerning their serum thyroid-stimulating hormone and thyroxine (T4) levels. The results were contrasted with those obtained in control series of the same number of subjects matched for age and sex.

RESULTS

Diagnosis of thyroid disease was present in 15.3% of OLP patients (33/215) and in 5.2% (12/215) of the control group. In relation to OLP patients, the odds ratio of presence of thyroid disorders was 3.06 and that of using levothyroxine medication 3.21.

CONCLUSIONS

In the present study, OLP patients were associated with thyroid disease, specifically with hypothyroidism. Because most thyroid patients need T4 treatment, our findings confirmed that OLP and thyroid disease could be comorbidities.

Meteorological influences on the incidence of lichen planus in a north Indian population

Lichen planus is a chronic, autoimmune, mucocutaneous disease that shows differences in clinical presentation at different times of the year. The present retrospective study was conducted to clarify the meteorological factors that influence the incidence of lichen planus, as well as the general features and clinical presentation of this condition during three consecutive years, 2008, 2009, and 2010, in Moradabad district (Western Uttar Pradesh, India). The study group comprised 1,355 patients extracted from the records of the outpatient department of Kothiwal Dental College Research Centre and Hospital, who were clinically diagnosed as having lichen planus during this three-year period. The highest number of patients (735) were recorded in summer, and the lowest (56) in winter. Females were affected more often, and psychosocial influences were also evident. There were significant differences in the incidence of lichen planus in different seasons, and the summer peak was attributable to the intensity of sun exposure (actinic lichen planus and summertime lichen planus).

Diabetes and Hepatitis Frequency in 140 Lichen Planus Cases in Çukurova Region

The aim of the present study was to determine the Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and diabetes mellitus (DM) frequencies in lichen planus (LP) cases in our region. We performed a retrospective review of records from all cases that were diagnosed with LP at the our department between 1997 and 2002. The results were compared with the control group (any type of dermatosis other than LP). The 260 LP cases included 108 (41.5%) males and 152 (58.5%) females aged between 5 and 78 years. The clinical distribution of the lesions were 127 (48.8%) with skin lesions and 133 (51.2%) with oral mucosal lesions. The duration of disease ranged from 1 to 240 months. In 140 of 260 LP cases, hepatitis serology and pre-prandial blood glucose were examined. We found HBV positivity in 24 (17.1%) cases, Anti-HCV positivity in 7 (5%) cases, and DM in 22 (15.7%) cases. The control group included 116 (41.4%) males and 164 (58.6%) females. Their ages ranged between 10 and 82 years. In this group, we found HBV positivity in 20 (7.1%), Anti-HCV positivity in 4 (1.4%), and DM in 20 (7.1%) cases. We believe that the co-association of LP with HCV is significant and this co-association ratio indicates variance depending on clinical attributes of the lesions and racial characteristics of the patients. Although we found co-associations between HBV and LP or DM and LP, we believe that further studies are necessary to determine if they are significant.

Oral Lichen Planus as an Extra-hepatic Manifestation of Viral Hepatitis-Evaluation in Indian Subpopulation

BACKGROUND

Oral Lichen Planus (OLP) is considered to be associated with numerous systemic conditions one of which includes Chronic Liver Disease (CLD). Hepatitis virus B and C (HBV and HCV) have known to be important causative agents of CLD and can be prevalent in asymptomatic carriers that can make them difficult to identify. Off late, the association of viral hepatitis with OLP has been a subject of controversy due to conflicting reports. Indian studies on this regard are sparse to evaluate the same. Association between the hepatitis virus and OLP, if present and established, can be of great help to format a protocol for identifying carrier states of viral hepatitis due to HBV and HCV.

METHODOLOGY

Forty five cases of clinically and histologically confirmed OLP were subjected to a serological screening of hepatitis B and C viruses by detection of hepatitis B surface antigen and anti-hepatitis C virus antibodies.

RESULTS

None of OLP cases were seropositive for the hepatitis viruses.

CONCLUSION

We could not demonstrate any association between OLP and viral hepatitis. This could be attributed to lower prevalence of hepatitis viruses compared to the countries hyper endemic for these viruses or genotypic variation of the viruses or other etiological factors contributing for the present group of patients.

Candidiasis and other oral mucosal lesions during and after interferon therapy for HCV-related chronic liver diseases

Background

Oral lichen planus (OLP) is seen frequently in patients with hepatitis C virus (HCV) infection. The aim of this study was to evaluate the occurrence of oral candidiasis, other mucosal lesions, and xerostomia during interferon (IFN) therapy for HCV infection.

Methods

Of 124 patients with HCV-infected liver diseases treated with IFN therapy in our hospital, 14 (mean age 56.00 ± 12.94 years) who attended to receive administration of IFN once a week were identified and examined for Candida infection and other oral lesions and for the measurement of salivary flow. Serological assays also were carried out.

Results

Cultures of Candida from the tongue surfaces were positive in 7 (50.0%) of the 14 patients with HCV infection at least once during IFN therapy. C. albicans was the most common species isolated. The incidence of Candida during treatment with IFN did not increase above that before treatment. Additional oral mucosal lesions were observed in 50.0% (7/14) of patients: OLP in three (21.4%), angular cheilitis in three (21.4%) and recurrent aphthous stomatitis in one (7.1%). OLP occurred in one patient before treatment with IFN, in one during treatment and in one at the end of treatment. 85.7% of the oral lesions were treated with topical steroids. We compared the characteristics of the 7 patients in whom Candida was detected at least once during IFN therapy (group 1) and the 7 patients in whom Candida was not detected during IFN therapy (group 2). The prevalence of oral mucosal lesions (P=0.0075) and incidence of external use of steroids (P=0.0308) in group 1 were significantly higher than in group 2. The average body weight of group 1 decreased significantly compared to group 2 (P=0.0088). Salivary flow decreased in all subjects throughout the course of IFN treatment and returned at 6^th months after the end of treatment. In group 1, the level of albumin at the beginning of the 6^th month of IFN administration was lower than in group 2 (P=0.0550). According to multivariate analysis, one factor, the presence of oral mucosal lesions, was associated with the detection of Candida. The adjusted odds ratio for the factor was 36.00 (95% confidence interval 2.68-1485.94).

Conclusion

We should pay more attention to oral candidiasis as well as other oral mucosal lesions, in patients with weight loss during IFN treatment.

Hepatitis C virus infection and autoimmune diseases

Hepatitis C virus (HCV) infection is associated with a number of extrahepatic disorders. The most studied conditions associated with HCV are type II mixed cryoglobulinemia and B cell lymphoma. However, many reports suggest that HCV might also be associated with a number of autoimmune disorders, both organ-specific and not organ-specific. Although concomitant treatment of HCV infection is a confounding factor when ascertaining the actual role of HCV in inducing autoimmune disease, a considerable amount of experimental data indicates that HCV is able to subvert the immune system and consequently induce autoimmunity. In the present review, we report a series of observations which associate chronic HCV infection with the onset of autoimmune disorders.

Hepatitis C virus-host interactions: Etiopathogenesis and therapeutic strategies

Hepatitis C virus (HCV) is a significant health problem facing the world. This virus infects more than 170 million people worldwide and is considered the major cause of both acute and chronic hepatitis. Persons become infected mainly through parenteral exposure to infected material by blood transfusions or injections with nonsterile needles. Although the sexual behavior is considered as a high risk factor for HCV infection, the transmission of HCV infection through sexual means, is less frequently. Currently, the available treatment for patients with chronic HCV infection is interferon based therapies alone or in combination with ribavirin and protease inhibitors. Although a sustained virological response of patients to the applied therapy, a great portion of patients did not show any response. HCV infection is mostly associated with progressive liver diseases including fibrosis, cirrhosis and hepatocellular carcinoma. Although the focus of many patients and clinicians is sometimes limited to that problem, the natural history of HCV infection (HCV) is also associated with the development of several extrahepatic manifestations including dermatologic, rheumatologic, neurologic, and nephrologic complications, diabetes, arterial hypertension, autoantibodies and cryglobulins. Despite the notion that HCV-mediated extrahepatic manifestations are credible, the mechanism of their modulation is not fully described in detail. Therefore, the understanding of the molecular mechanisms of HCV-induced alteration of intracellular signal transduction pathways, during the course of HCV infection, may offer novel therapeutic targets for HCV-associated both hepatic and extrahepatic manifestations. This review will elaborate the etiopathogenesis of HCV-host interactions and summarize the current knowledge of HCV-associated diseases and their possible therapeutic strategies.

A retrospective case-control study of hepatitis C virus infection and oral lichen planus in Japan: association study with mutations in the core and NS5A region of hepatitis C virus

Background

The aims of this study were to assess the prevalence of hepatitis C virus (HCV) infection in Japanese patients with oral lichen planus and identify the impact of amino acid (aa) substitutions in the HCV core region and IFN-sensitivity-determining region (ISDR) of nonstructural protein 5A (NS5A) associated with lichen planus.

Methods

In this retrospective study, 59 patients (group 1-A) with oral lichen planus among 226 consecutive patients who visited our hospital and 85 individuals (group 1-B, controls) with normal oral mucosa were investigated for the presence of liver disease and HCV infection. Risk factors for the presence of oral lichen planus were assessed by logistic regression analysis. We compared aa substitutions in the HCV core region (70 and/or 91) and ISDR of NS5A of 12 patients with oral lichen planus (group 2-A) and 7 patients who did not have oral lichen planus (group 2-B) among patients (high viral loads, genotype 1b) who received interferon (IFN) therapy in group1-A.

Results

The prevalence of anti-HCV and HCV RNA was 67.80% (40/59) and 59.32% (35/59), respectively, in group 1-A and 31.76% (27/85) and 16.47% (14/85), respectively, in group 1-B. The prevalence of anti-HCV (P < 0.0001) and HCV RNA (P < 0.0001) in group 1-A was significantly higher than those in group 1-B. According to multivariate analysis, three factors - positivity for HCV RNA, low albumin level (< 4.0 g/dL), and history of smoking - were associated with the development of oral lichen planus. The adjusted odds ratios for these three factors were 6.58, 3.53 and 2.58, respectively, and each was statistically significant. No significant differences in viral factors, such as aa substitutions in the core region and ISDR of NS5A, were detected between the two groups (groups 2-A and -B).

Conclusion

We observed a high prevalence of HCV infection in patients with oral lichen planus. Longstanding HCV infection, hypoalbuminemia, and smoking were significant risk factors for the presence of oral lichen planus in patients. It is advisable for Japanese patients with lichen planus to be tested for HCV infection during medical examination.

The magnitude of the association between hepatitis C virus infection and oral lichen planus: meta-analysis and case control study

Although hepatitis C virus (HCV) infection is associated with oral lichen planus (OLP), a case-control study and a meta-analysis were designed to investigate the magnitude of such an association. A total of 413 presumptive OLP patients (18-75 years) who referred to a dental clinic in Rasht (Iran) were consecutively selected. OLP was diagnosed clinically (typical forms) and histologically (atypical forms) by a calibrated examiner. A total of 487 adults (20-77 years) attending the same dental clinic were the controls. The two groups were homogeneous in terms of age, gender and occupation. Subjects were tested for anti-HCV antibodies. The odds ratio (OR) for OLP attributable to HCV infection was non-significant [OR 1.2, 95% confidence interval (95CI) 0.3-4.8], suggesting that the association between HCV and OLP was weak in the Iranian context. Meta-analysis of observational studies characteristics of primary studies were that cases were diagnosed clinically (only typical forms) and histologically and exposure was assessed through anti-HCV antibodies. Exposed/unexposed cases/controls were extracted and zero values were appropriately transformed. As much as 44 studies, including the present, were located. Publication bias could not be totally excluded. The pooled OR, estimated using the random-effect model, was 2.8 (95CI 2.4-3.2). Sensitivity analysis confirmed the robustness of results. Subgroup analysis showed non-significant differences between American/European and Asian/African studies. The fraction of global OLP cases associated with HCV (population attributable fraction) was 2.1% (95CI 1.9-2.2%). Although HCV and OLP were significantly associated, the majority of OLP patients were not affected by HCV.

Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies

Lichen planus (LP) is an inflammatory disease of the stratified squamous epithelia of unknown etiology. LP affects most frequently the oral mucosa, but it may also involve other mucosa and the skin. Oral LP (OLP) most frequently affects woman aged between 30 and 60 years. Histopathologic examination typically shows orthokeratotic hyperkeratosis, basal cell degeneration, and a dense well-defined infiltrate of lymphocytes in the superficial dermis. OLP lesions may result from the induction of keratinocytes apoptosis by cytotoxic CD8+ T cells stimulated by a yet unidentified self-antigen on a genetically predisposed patient. The association of OLP with hepatitis C virus (HCV) has been more consistently demonstrated in the Mediterranean area. Although HCV RNA and HCV-specific CD4+ and CD8+ T cells have been retrieved in the mucosal lesions of patients with chronic HCV infection and OLP, the eventual pathophysiology of HCV in OLP lesions remains unclear. Available treatments of OLP are not curative, and many have potentially prominent side effects. The objectives of OLP management should be to prevent and screen for malignant transformation and alleviate symptoms on the long-term. Avoidance of potential precipitating drugs, tobacco, alcohol, and local trauma, as well as strict oral hygiene, is essential. The first-line pharmacologic treatment relies on topical steroids. Systemic steroids should be limited to the short-term cure of severe refractory OLP. Life-long clinical follow-up, at least annually, is fundamental.

Oral lichen planus: clinical features, etiology, treatment and management; a review of literature

Lichen planus is a chronic inflammatory mucocutaneous disease. Mucosal lesions are classified into six clinical forms and there is malignant potential for two forms of OLP; therefore, follow-up should be considered. There are many un-established etiological factors for OLP and some different treatment modalities are based on etiology. The aims of current OLP therapy are to eliminate mucosal erythema and ulceration, alleviate symptoms and reduce the risk of oral cancer. We have used review papers, case reports, cohort studies, and case-and-control studies published from 1985 to 2010 to prepare this review of literature.

Extrahepatic manifestations of hepatitis C virus infection

Hepatitis C virus may cause hepatic and extrahepatic diseases. Extrahepatic manifestations range from disorders for which a significant association with viral infection is supported by epidemiologic and pathogenetic data, to anecdotal observations without clear proof of causality. This article describes the diagnosis and treatment of these diseases.

Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation

Lichen planus, a chronic autoimmune, mucocutaneous disease affects the oral mucosa (oral lichen planus or OLP) besides the skin, genital mucosa, scalp and nails. An immune mediated pathogenesis is recognized in lichen planus although the exact etiology is unknown. The disease most commonly affects middle-aged females. Oral lichenoid reactions (OLR) which are considered variants of OLP, may be regarded as a disease by itself or as an exacerbation of an existing OLP, by the presence of medication (lichenoid drug reactions) or dental materials (contact hypersensitivity). OLP usually presents as white striations (Wickham's striae), white papules, white plaque, erythema, erosions or blisters. Diagnosis of OLP is established either by clinical examination only or by clinical examination with histopathologic confirmation. Direct immunofluorescence examination is only used as an adjunct to the above method of diagnosis and to rule out specific autoimmune diseases such as pemphigus and pemphigoid. Histopathologic features of OLP and OLR are similar with suggestions of certain discriminatory features by some authors. Topical corticosteroids are the treatment of choice for OLP although several other medications have been studied including retinoids, tacrolimus, cyclosporine and photodynamic therapy. Certain OLP undergo malignant transformation and the exact incidence and mechanisms are still controversial. In this paper, etiopathogenesis, diagnosis, management and malignant transformation of OLP and OLR have been reviewed.

Oral diseases associated with hepatitis C virus infection. Part 2: lichen planus and other diseases

Some of the most frequent extrahepatic manifestations of hepatitis C virus (HCV) infection involve the oral region predominantly or exclusively. Part 2 of this review discusses the current evidences regarding the association of lichen planus (LP) and other diseases frequently involving the oral cavity with HCV. Epidemiological data suggest that LP may be significantly associated with HCV infections especially in southern Europe and Japan but not in northern Europe. These geographical differences are possibly influenced by immunogenetic factors, the duration of the HCV infection and the design of the published studies. Because of the fact that most of the studies published are retrospective, it is impossible to establish whether the HCV exposure occurred earlier to or after the onset of disease and more prospective studies are clearly warranted. As the virus may replicate in the skin and oral mucosa and HCV-specific T lymphocytes can be found in the oral mucosa of patients with chronic hepatitis C and LP, HCV may be implicated in the pathogenesis of LP. However, little attention has been paid to the variable effect of therapy with interferon-alpha (IFN-alpha), with or without ribavirin for LP. Conversely, it is unlikely that other oral diseases such as oral carcinoma, pemphigus and Behcet disease are triggered by HCV.

Extrahepatic manifestations of Hepatitis C Virus infection: a general overview and guidelines for a clinical approach

Hepatitis C Virus is associated with a wide series of extrahepatic manifestations. Based on available data the link between the virus and some of these extrahepatic diseases is only suggested and needs further confirmation. Hepatitis C Virus-related lymphoproliferative disorders, whose prototype is mixed cryoglobulinaemia, represent the most closely related extrahepatic manifestations of Hepatitis C Virus. Other Hepatitis C Virus-associated disorders include nephropathies, thyreopathies, sicca syndrome, idiopathic pulmonary fibrosis, porphyria cutanea tarda, lichen planus, diabetes, chronic polyarthritis, cardiopathy and atherosclerosis. A pathogenetic link between Hepatitis C Virus and some extrahepatic manifestations was confirmed by their responsiveness to antiviral therapy, which is now deemed the first therapeutic option to consider. By contrast, there are diseases where treatment with interferon was ineffective or dangerous. The aim of the present paper is to outline the most recent evidence concerning extrahepatic disorders that are possibly associated with Hepatitis C Virus infection. Special emphasis will be given to discussion of the most appropriate clinical approaches to be adopted in order to diagnose, treat (possibly prevent) and follow-up extrahepathic diseases in patients with Hepatitis C Virus infection.

Squamous cell carcinoma of the tongue after bone marrow transplantation in a patient with Fanconi anemia

Fanconi anemia (FA) is an autosomal recessive disorder that might cause a variety of congenital and developmental abnormalities. The most important features of FA are progressive bone marrow failure and development of malignancies, particularly acute myeloid leukemia and solid tumors. This paper reports the case of a 12-year-old patient with FA assisted at the Stomatology and Bucomaxillofacial Cancer Prevention Service of São Lucas Hospital, Brazil, who had been submitted to bone marrow transplantation (BMT) at the age of 5 and exhibited oral lesions characteristic of chronic graft versus host disease (GVHD). The patient was treated and followed-up for the oral lesions. Eleven years after the BMT, he developed squamous cell carcinoma of the tongue with an aggressive behavior, which was considered an untreatable condition. The patient died few months later from asphyxia at the age of 16. The reasons for development of these malignant conditions are unknown. However, chromosomal instability typically observed in FA cases, BMT factors and GVHD have been considered. Systematic follow-up of these patients allows early and less invasive therapeutic approaches.

Prevalence of oral lichen planus in Brazilian patients with HCV infection

OBJECTIVE

The objective of this investigation was to assess the prevalence of oral lichen planus (OLP) in Brazilian patients infected with hepatitis C virus (HCV) from the state of Rio de Janeiro.

STUDY DESIGN

The study group consisted of 134 patients with HCV infection. The control group consisted of 95 individuals. All patients were physically examined for evidence of OLP. The diagnosis of OLP was established on the basis of usual clinical features and histological findings.

RESULTS

The prevalence of OLP was 1.5% in patients with HCV infection and 1.1% in the control group. There was no statistically significant difference between the 2 groups (P = .63).

CONCLUSION

Our findings indicate that there is no association between OLP and HCV infection in Brazilian patients from the state of Rio de Janeiro.

Current controversies in oral lichen planus: Report of an international consensus meeting. Part 1. Viral infections and etiopathogenesis

Despite recent advances in understanding the immunopathogenesis of oral lichen planus (LP), the initial triggers of lesion formation and the essential pathogenic pathways are unknown. It is therefore not surprising that the clinical management of oral LP poses considerable difficulties to the dermatologist and the oral physician. A consensus meeting was held in France in March 2003 to discuss the most controversial aspects of oral LP. Part 1 of the meeting report focuses on (1) the relationship between oral LP and viral infection with special emphasis on hepatitis C virus (HCV), and (2) oral LP pathogenesis, in particular the immune mechanisms resulting in lymphocyte infiltration and keratinocyte apoptosis. Part 2 focuses on patient management and therapeutic approaches and includes discussion on malignant transformation of oral LP.

Mucosal vulval lichen planus: outcome, clinical and laboratory features

BACKGROUND

Mucosal lichen planus of the vulva is a rare but increasingly recognized condition. It has potentially severe complications such as fusion of the labia and vagina; the risk of developing squamous cell carcinoma (SCC) may be increased. An association between hepatitis B and C infection and skin or oral lichen planus appears to exist in certain geographical areas.

OBJECTIVE

To investigate the course of mucosal vulval lichen planus, its response to treatment and associated laboratory features.

SUBJECTS AND METHODS

Forty-four women with mucosal vulval lichen planus were studied between 1997 and 2000 and laboratory data were collected.

RESULTS

Thirty of 44 patients had additional oral lesions, only nine had cutaneous findings compatible with lichen planus. We did not find an association with antibodies to hepatitis B or C virus in this British study population. All women were treated with potent to very potent topical corticosteroids; however, in the majority of patients symptoms persisted. In seven (16%) patients vulval lichen planus was in remission after a disease duration between 2 and 18 years (mean 10.6 years). One patient developed a vulval SCC.

CONCLUSIONS

Screening for hepatitis B and C in women with mucosal vulval lichen planus in the UK seems unnecessary. We recommend long-term follow-up, and that all non-healing ulcerative and papular lesions should be biopsied.

Hepatitis C virus-associated oral lichen planus: is the geographical heterogeneity related to HLA-DR6?

BACKGROUND

The association between hepatitis C virus (HCV) and oral lichen planus (OLP) is more common in the Mediterranean area and Japan, possibly because of immunogenetic factors.

METHODS

Intermediate-resolution HLA-DRB typing by hybridization with oligonucleotide probes was performed in 31 Italian OLP patients with HCV infection, in 45 Italian OLP and in 48 British OLP patients without HCV infection. As healthy controls we included data from 145 unrelated Italian and 101 unrelated British bone marrow donors.

RESULTS

Italian HCV+ve OLP patients possessed the HLA-DR6 allele more frequently than Italian and British OLP patients without HCV infection (51.6% vs. 17.7% vs. 16.7%; P corrected = 0.028 and 0.017, respectively). There was no difference in the frequency of the HLA-DR6 allele between Italian and British control subjects.

CONCLUSIONS

The present data suggest that HLA-DR6 may be responsible for the peculiar geographic heterogeneity of the association between HCV and OLP.

Lichen planus and hepatitis C virus: a multicentre study of patients with oral lesions and a systematic review

BACKGROUND

An association between hepatitis C virus (HCV) infection and lichen planus (LP) has been investigated, but results have been inconsistent.

OBJECTIVES

To investigate the relationship between LP and HCV seropositivity. Methods In a cross-sectional study we tested the sera of 303 consecutive newly diagnosed patients with histologically proven LP referred to three Italian centres for the presence of anti-HCV IgG. A comparable control group was also tested. Next, in a systematic review, studies were identified by searching different databases in April 2004. Inclusion criteria were: (i) analytical study design; (ii) clinical and histological diagnosis of LP; and (iii) serological test for anti-HCV antibodies as main outcome. The risk of bias was assessed on the basis of characteristics of the study group, appropriateness of the control group and study design. Pooled data were analysed by calculating odds ratios (ORs), using a random effects model.

RESULTS

In the cross-sectional study, nearly one in five (19.1%) of the LP group was HCV positive, while a much lower prevalence of infection was found in the control group (3.2%) [OR 7.08; 95% confidence interval (CI) 3.43-14.58]. The systematic review yielded 25 relevant studies, six of which had a low risk of bias. There was a statistically significant difference in the proportion of HCV-seropositive subjects among patients with LP, compared with controls (OR 4.80; 95% CI 3.25-7.09). Following subgroup analyses, the variability of HCV prevalence in patients with LP seemed to depend on geographical area, but not on age.

CONCLUSIONS

Anti-HCV circulating antibodies are more common in patients with LP than in controls, although such an association may not be significant in some geographical areas.

Detection of hepatitis C virus RNA in saliva is not related to oral health status or viral load

Hepatitis C is a worldwide public health problem and its transmission is clearly associated with the parenteral route, however, the virus has also been isolated from other body fluids. Hepatitis C virus (HCV) RNA has been detected in saliva, yet the relationship between HCV and oral pathology is not clearly understood. Therefore, an investigation on HCV-RNA in saliva and its correlation with oral pathology was undertaken. Saliva and blood samples were collected from 50 anti-HCV positive patients and from 25 patients with non-HCV chronic liver disease. HCV-RNA was detected in all of the saliva samples from the HCV positive group. None of the saliva or serum samples from the non-HCV group were positive for HCV-RNA. The patients were examined for dental and oral health (dentate, partially dentate, edentulous, evidence of gum disease, or mucosal lesions); however, no correlation was found between HCV-RNA in saliva, oral health, and viral load. These results suggest that HCV-RNA presence in saliva is independent of the viral load and the oral pathology of HCV positive individuals.

Lichen planus and hepatitis C virus infection: an epidemiologic study

The reported prevalence of hepatitis C virus (HCV) infection in patients with lichen planus (LP) shows variations from different regions. The aim of this study was to investigate the prevalence of HCV infection in patients with LP, in Diyarbakir region of Turkey. A total of 128 patients with LP and 128 healthy controls were detected for HCV infection, using a third generation enzyme-linked immunosorbent assay. Eight of 128 patients (6.25%) with LP were found to have anti-HCV antibodies, whereas only one patient (0.78%) in control group was found to have anti-HCV antibodies. A statistically significant difference was found between LP and control group (p < 0.001). In conclusion, the coexistence of HCV infection and lichen planus is more than coincidental, and it is appropriate to screen all patients with lichen planus for HCV infection.

Hepatitis C virus and lichen planus

Hepatitis C virus (HCV) is an important factor in the development of chronic liver disease and hepatocellular carcinoma. In recent years it has become known that HCV induces various extrahepatic manifestations including mixed cryoglobulinemia, membranoproliferative glomerulonephritis, Sjögren's syndrome, autoimmune thyroiditis, malignant lymphoma, porphyria cutanea tarda and lichen planus. Although the mechanisms of extrahepatic manifestations remain unclear, it is known that interferon (IFN) therapy and coadministration of IFN with ribavirin are effective in promoting the disappearance or alleviation of such extrahepatic lesions, which have tended to be overlooked. The present review focuses on lichen planus, one of the major extrahepatic manifestations.

HCV infection and oral lichen planus: a weak association when HCV is endemic

Oral lichen planus (OLP), an immune-mediated disorder, has been reported as an extra-hepatic manifestation of Hepatitis C virus (HCV) infection, especially in HCV hyperendemic areas such as southern Europe and Japan. The aim of this study was to investigate from an epidemiological standpoint whether HCV infection is an important factor affecting the relative risk of OLP in a Mediterranean population or whether this relates to the degree of HCV endemicity. Two cohorts of OLP patients resident in two different regions of southern Italy (Campania and Sicily; n = 859) were evaluated for HCV infection status and categorized into five age classes to respective region-matched controls. No significant difference was found between OLP patients and the general population in this area, when data were corrected by the age-stratified prevalence of HCV. Therefore, the age-specific prevalence of HCV infection in OLP patients shows a close trend of direct association with increasing age, without significant differences with the general population of each geographical area. An aetiological link between OLP and HCV cannot be inferred solely by epidemiological data.

Lack of evidence of hepatic disease in patients with oral lichen planus in Serbia

OBJECTIVE

The reported frequency of chronic liver disease, and particularly, Hepatitis C virus (HCV) infection in patients with oral lichen planus (OLP) shows geographical variation. The aim of this study was to determine the prevalence of chronic hepatic disease, Hepatitis B virus and HCV infection in patients with OLP and control subjects resident in Serbia.

PATIENTS AND METHODS

In this prospective study 48 patients with OLP (33 women and 15 men, with a mean age of 49.7 years) and 60 control subjects (38 women and 22 men, with a mean age of 46.7 years) were examined for the presence of serological evidence of chronic hepatic disease, Hepatitis B surface antigen (HBsAg) and anti-HCV seropositivity.

RESULTS

All patients with OLP had normal liver function. HBsAg was not found in any of the patients with OLP or control group. None of the patients with OLP or control subjects were HCV seropositive.

CONCLUSION

Patients with OLP resident in Serbia do not have evidence of chronic liver disease or infection with HBV or HCV. The exact aetiological role between hepatic disease and OLP remains unclear.

Oral lichen planus, hepatitis C virus, and HIV: No association in a cohort study from an area of high hepatitis C virus endemicity

OBJECTIVES

We sought to assess the age-specific prevalence of oral lichen planus (OLP) in Mediterranean patients with chronic hepatitis C virus (HCV) and to evaluate the features of OLP in relation to sex, smoking, HCV genotype, HIV-1 coinfection, and antiviral treatments.

METHODS

In all, 178 anti-HCV-positive adults (60 women and 118 men; age range 20-66 years) recruited from two cohorts (104 HIV-negative patients and 74 patients with HIV coinfection) underwent oral examination.

RESULTS

Overall prevalence of OLP was 2.8% (5 of 178) (male/female ratio 0.2; odds ratio=0.119; 95% confidence interval=0.013-1.106), only among HIV-negative participants, always in the reticular pattern, and in the adult age. HCV genotype, tobacco smoking, and treatment (interferon alfa/ribavirin) were not significantly associated to OLP.

CONCLUSIONS

Among HCV-infected patients, we found a low prevalence of OLP. The absence of OLP in HIV-coinfected patients suggests immunosuppression secondary to defective CD4 functions.

Hepatitis C virus and lichen planus: A review

INTRODUCTION

The relationship between hepatitis C virus (HCV) infection and oral lichen planus (OLP) remains a matter of controversy. It is important to determine whether there is an association between OLP and HCV infection so that guidelines regarding the routine HCV testing of patients with OLP can be developed for clinicians.

OBJECTIVES

The objective of this article was to review and summarize the published literature on the association between OLP and HCV and to describe future directions.

METHODS

A search of the computerized database MEDLINE (1966-June 2003) was conducted. The bibliographies of articles identified by means of MEDLINE were also searched. Any studies reporting the prevalence of HCV in a group of patients with LP either with or without a control group were included in this review. Also included were studies comparing the clinical and histologic features of LP among patients with and without HCV infection, studies on the presence of HCV within LP lesions, and studies of HCV genotypes among patients with LP.

RESULTS

Thirty-two studies conducted in various parts of the world were identified. Study types included prevalence studies on HCV exposure among patients with OLP (0%-62%), prevalence of OLP among patients with HCV infection (1.6%-20%), and case-control studies of this association. In addition, the results from 3 studies on the replication of HCV in the oral mucosa, 3 studies on the genotype of HCV in OLP patients, and 4 studies comparing the clinical and histologic features of OLP in HCV-infected and uninfected individuals have been summarized.

CONCLUSION

At present, studies on the association of OLP and HCV provide enough information to raise a number of interesting questions about this association. Important biases-including selection bias; investigator bias due to lack of blinding and the possible resultant nondifferential misclassification of disease; and possible confounding by age in the studies published-make it difficult to draw firm conclusions. However, the need for future studies that take into consideration all these factors in the study methodology is highlighted by this review.

Relationship of Oral Lichen Planus to Hepatitis C Virus in Southern Taiwan

Oral lichen planus (OLP) is a relatively common skin and oral disease that manifests as a mucous reaction to a variety of etiologic factors, including autoimmune disease, drug reaction, diabetes mellitus (DM), hypertension, hepatitis C virus (HCV), urolithiasis, psychogenic factors, and bacterial infection. The purpose of this study was to investigate the relationship between HCV infection and OLP as there is a high prevalence of HCV infection in Taiwan. A total of 1,075 subjects aged at least 15 years participated in the study. The total prevalence of OLP was 3% (32/1,075). OLP was significantly associated with DM (odds ratio, OR, 3.09) and HCV (OR, 2.05). Atrophic-erosive OLP (13/32) and reticular OLP (21/32) were significantly associated with HCV and DM, respectively. Logistic regression analysis showed that elevation of alanine aminotransferase (ALT) significantly increased the risk of atrophic-erosive OLP. We concluded that OLP is significantly associated with HCV and DM in southern Taiwan, particularly in HCV patients with elevated serum ALT levels and atrophic-erosive OLP.

Hepatitis C virus infection in Thai patients with oral lichen planus

OBJECTIVE

Many studies focusing on the association between hepatitis C virus (HCV) infection and oral lichen planus (OLP) have been conducted. Diversities of geographical locations could be a major factor influencing the prevalence of HCV. This study was aimed to define whether there was a relationship between the OLP and HCV infection in Thailand.

MATERIALS AND METHODS

Serum samples of 60 patients (with OLP) and 60 controls (without OLP), whose age and gender were matched, were respectively screened for anti-HCV by ELISA (third generation), and reverse transcription polymerase chain reaction (RT-PCR) for HCV-RNA.

RESULTS

We found five patients (8.33%) with OLP infected with HCV: three patients were positive for both anti-HCV and HCV-RNA; one patient was only positive for anti-HCV; and one patient was only positive for HCV-RNA; whereas all the controls were negative for both anti-HCV and HCV-RNA (P=0.029). Three of five cases of OLP with HCV infection had histories of blood transfusions over 10 years ago.

CONCLUSION

The present study reports a small, but statistically significant high prevalence of HCV infection among patients with OLP, although the underlying mechanism still remains unknown.

Correlation between clinical and histopathologic diagnoses of potentially malignant oral lesions

BACKGROUND: The serious nature of potentially malignant oral lesions (PMOL) demands that the final diagnosis be made on both clinical and histopathologic grounds. The aim of the present study was to determine the correlation between clinical and histopathologic diagnoses of PMOL using a discrepancy index (DI). METHODS: Fifty-one patients with PMOL were examined clinically, and a biopsy was taken from each one. The results of histopathologic diagnosis were compared with the clinical diagnosis. We established that the histopathologic diagnosis was incompatible when the clinical diagnosis was not confirmed. On the basis of the incompatible diagnosis, we calculated a discrepancy index between the clinical and histopathologic diagnosis. RESULTS: Clinically, the homogeneous leukoplakia was the most frequent lesion followed by erosive lichen planus and reticular lichen planus. No cases of erythroplakia were observed. Lesions were most frequently seen at the buccal mucosa, followed by the gingiva (alveolar mucosa) and tongue. The histopathologic diagnosis showed that the majority of the lesions were benign keratoses followed by lichen planus. Three cases of epithelial dysplasia were mild. The DI between clinical and histopathologic diagnosis was 17.6 %. The higher DI was found in erosive lichen planus. CONCLUSION: The obtained findings show that in 90% of leukoplakias, clinical diagnosis was confirmed by histopathologic examination. The discrepancy between clinical and histopathologic diagnoses in 17.6 % of cases suggests that all PMOLs should be submitted to histological analysis.

Position Paper: Oral Features of Mucocutaneous Disorders

Part of periodontology involves the diagnosis and treatment of a variety of non-plaque-related diseases of the periodontium. The International Workshop for a Classification of Periodontal Diseases and Conditions noted that the periodontist may be called upon to manage non-plaque-related mucocutaneous disorders either alone, or as part of a treatment team consisting of physicians, dentists or other allied health care professionals. This informational paper will review the etiology, clinical manifestations, diagnosis, and treatment of the most common chronic mucocutaneous diseases, including those that may present as desquamative gingivitis or intraoral vesiculobullous lesions. This paper is intended for the use of periodontists and other members of the dental profession.

Oral diseases possibly associated with hepatitis C virus

Morbidity associated with hepatitis C virus (HCV) infection can involve a variety of extrahepatic conditions, including lichen planus (LP) and sialadenitis, predominantly or exclusively involving the oral region, conditions which have been largely neglected in reviews. The literature suggests that HCV-infected patients may frequently have Sjögren-like sialadenitis with mild clinical symptoms, whereas oral LP may be significantly associated with HCV infections in Southern Europe and Japan but not in Northern Europe. These geographical differences could be related to immunogenetic factors such as the HLA-DR6 allele, significantly expressed in Italian patients with OLP and HCV. Analysis of experimental data suggests that HCV could be involved in the pathogenesis of both these diseases. Moreover, parotid lymphoma may arise in patients with sialadenitis, mainly with type II cryoglobulinemia. Little attention has been paid to oral health needs in HCV-infected patients and the variable effect of interferon-alpha therapy on oral tissues. Further research is needed, because of the potentially great influence of oral diseases possibly linked to HCV on the quality of life of millions of patients.

The clinical manifestations and treatment of oral lichen planus

The progress in research on OLP and other autoimmune diseases has been significant. Coupled with a growing recognition of the clinical features and treatment options by dentists and physicians and fueled by the advances in immunosuppressive therapies, research will undoubtedly provide new insights into this complex disorder. It is likely that what is learned will enhance the understanding not only of OLP but also of many other mucocutaneous diseases.