Psychological profiles in patients with symptomatic reticular forms of oral lichen planus: A prospective cohort study

Development and validation of the Oral Lichen Planus-Disease Activity Scale: a novel tool for comprehensive clinical assessment

OBJECTIVE

To develop and validate the Oral Lichen Planus-Disease Activity Scale (OLP-DAS) for assessing overall disease activity of OLP.

METHODS

The OLP-DAS was created by refining the Thongprasom criteria, incorporating inputs from the literature and expert review, and integrating pain assessment. Content validity was evaluated in a virtual meeting with 8 Oral Medicine specialists. Reliability and validity of the final version were examined. Seventeen OLP subjects were assessed for disease activity by 10 investigators using the OLP-DAS, Oral Disease Severity Score (ODSS), OLP-Investigator Global Assessment (OLP-IGA), and Reticular-Erythema-Ulcerative (REU) scale. Convergent validity was assessed by rating 160 OLP subjects using the OLP-DAS, ODSS, and OLP-IGA. Inter-rater and intra-rater reliability, along with convergent validity, were analyzed using intraclass correlation coefficients (ICCs) and Spearman's rank correlation coefficients (rs).

RESULTS

The final OLP-DAS achieved excellent content validity indices. Inter-rater and intra-rater ICCs for total OLP-DAS scores were 0.93 and 0.96, respectively. Total OLP-DAS scores exhibited strong positive correlations with the ODSS and OLP-IGA (rs = 0.94 and rs = 0.76; P < 0.001, respectively). The OLP Severity Index (OLP-SI), a component of the OLP-DAS, showed very strong positive correlations with OLP disease activity parameters of the ODSS (rs = 0.90; P < 0.001).

CONCLUSIONS

The OLP-DAS is a valid and reliable clinician-reported outcome measure (CROM) for evaluating OLP disease activity.

CLINICAL RELEVANCE

The OLP-DAS, as a standardized CROM for OLP, is valuable for both routine clinical assessments and research applications.

Thai version of shortened Oral Impact on Daily Performances index for evaluating oral lichen planus patients

BACKGROUND

Patients' perceptions and Oral Health-related Quality of life (OHRQoL) are important parts of dental treatment in all fields, including oral lichen planus (OLP) patients. A shortened version of the Oral Impact on Daily Performances (OIDP) might be more practical and feasible in clinical setting due to the busy nature of oral medicine clinics and staff availability to conduct the interview for data collection. The aim of the study was to develop a Thai version of shortened OIDP for assessing the OHRQoL in OLP patients.

METHODS

Two types of shortened OIDP versions were tested in 69 OLP patients, one comprising the most commonly interfered with daily performances (OIDP-3 and OIDP-2) and another comprising either the highest frequency (OIDP frequency) or severity score (OIDP severity). The Numeric Rating Scale (NRS) and Thongprasom sign score were used to assess oral pain and clinical severity. Spearman rank-order correlation coefficients (r_s) were used to demonstrate the associations between the shortened and original OIDP, pain, and clinical severity.

RESULTS

OIDP-3 (Eating, Cleaning, and Emotional stability) and OIDP-2 (Eating and Emotional stability) were developed. The associations of the original OIDP with OIDP-3 and OIDP-2 (r_s = 0.965 and 0.911) were significantly higher than those of the original OIDP with OIDP frequency and OIDP severity (r_s = 0.768 and 0.880). The original OIDP, OIDP-3, and OIDP-2 were more significantly associated with pain compared with OIDP frequency and OIDP severity. The association between the clinical severity and oral impacts assessed by the original OIDP, OIDP-3, and OIDP-2 were similar and had higher correlation coefficients compared with those of OIDP frequency and OIDP severity.

CONCLUSION

OIDP-3 and OIDP-2 performed more similarly to the original OIDP than OIDP frequency and OIDP severity in assessing the OHRQoL of OLP patients.

TRIAL REGISTRATION

The trial was registered at the Thai Clinical Trials Registry (TCTR identifier: TCTR 20190828002).

Anxiety and depression in keratotic oral lichen planus: a multicentric study from the SIPMO

OBJECTIVES

Oral lichen planus with exclusive keratotic reticular, papular, and/or plaque-like lesions (K-OLP) is a clinical pattern of OLP that may be associated with a complex symptomatology and psychological alteration. The aim of the study was to evaluate the prevalence of anxiety (A) and depression (D) in patients with K-OLP, analyzing the potential predictors which can affect mental health status.

METHODS

Three hundred K-OLP patients versus 300 healthy controls (HC) were recruited in 15 Italian universities. The Numeric Rating Scale (NRS), Total Pain Rating Index (T-PRI), and Hamilton Rating Scales for Depression and for Anxiety (HAM-D and HAM-A) were administered.

RESULTS

The K-OLP patients showed statistically higher scores in the NRS, T-PRI, HAM-D, and HAM-A compared with the HC (p-value < 0.001**). A and D were found in 158 (52.7%) and 148 (49.3%) K-OLP patients. Strong linear correlations were identified between HAM-A, HAM-D, NRS, T-PRI, and employment status and between HAM-D, HAM-A, NRS, T-PRI, employment status, and female gender. Multivariate logistic regression revealed that HAM-D and HAM-A showed the greatest increase in the R2 value for A and D in the K-OLP patients, respectively (DR2 = 55.5% p-value < 0.001**; DR2 = 56.5% p-value < 0.001**).

CONCLUSIONS

The prevalence of A and D is higher in the K-OLP patients compared with the HC, also found in K-OLP subjects without pain, suggesting that the processing of pain may be in a certain way independent of the processing of mood.

CLINICAL RELEVANCE

Mood disorders and pain assessment should be carefully performed in relation to K-OLP to obtain a complete analysis of the patients.

Where do you live? North versus Central-South differences in relation to Italian patients with oral lichen planus: a cross-sectional study from the SIPMO (Italian Society of Oral Pathology and Medicine)

BACKGROUND

Oral lichen planus (OLP) is an immune-mediated inflammatory chronic disease of the oral mucosa, with different patterns of clinical manifestations which range from keratotic manifestations (K-OLP) to predominantly non-keratotic lesions (nK-OLP). The aim of the study was to analyze the differences in the clinical, psychological profile and symptoms between Italian patients of the North and Central-South with K-OLP and nK-OLP.

METHODS

270 K-OLP and 270 nK-OLP patients were recruited in 15 Italian universities. The Numeric Rating Scale (NRS), Total Pain Rating Index (T-PRI), Hamilton Rating Scales for Depression and for Anxiety (HAM-D and HAM-A), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS) were administered.

RESULTS

The Central-South K-OLP (CS-K-OLP) patients reported a higher frequency of pain/burning compared with the K-OLP patients of the North (N-K-OLP) with higher scores in the NRS and T-PRI (p value < 0.001**). The CS-K-OLP and the CS-nK-OLP patients showed higher scores in the HAM-D, HAM-A, PSQI and ESS compared with the Northern patients (p value < 0.001**). Multivariate logistic regression revealed that the NRS and T-PRI showed the greatest increase in the R2 value for the CS-K-OLP (DR2 = 9.6%; p value < 0.001**; DR2 = 9.7% p value < 0.001**; respectively) and that the oral symptoms (globus, itching and intraoral foreign body sensation) and PSQI showed the greatest increase in the R2 value for the CS-nK-OLP (DR2 = 5.6%; p value < 0.001**; DR2 = 4.5% p value < 0.001** respectively).

CONCLUSIONS

Pain and mood disorders are predominant in patients with OLP in the Central-South of Italy. Clinicians should consider that the geographical living area may explain the differences in oral symptoms and psychological profile in OLP.

Risk of anxiety and depression in patients with lichen planus: A nationwide population-based study

BACKGROUND

This study aims to determine the risk of developing anxiety and/or depression among patients with lichen planus.

METHODS

Based on the Longitudinal Health Insurance Database of Taiwan National Health Insurance Research Database, a total of 4012 patients with lichen planus and 16,048 matched controls (1:4) were enrolled between January 1, 2000, and December 31, 2015. After controlling for the risk variables, multivariate Cox proportional hazard regression and the log-rank test with Kaplan-Meier method were performed to assess the influence of anxiety/depression among individuals with lichen planus under a maximum follow-up period of 16 years.

RESULTS

The subsequent anxiety or depression incidence of the lichen planus group and the comparisons was 19.67% (1962.70 per 10⁵ person-years) and 10.11% (982.23 per 10⁵person-years), respectively. Additionally, after adjustment of the risk variables, the hazard ratios for anxiety, depression, anxiety without depression, depression without anxiety, anxiety or depression, and both anxiety and depression combined were 1.779 (95%CI: 1.289-2.477, p < 0.001), 2.010 (95%CI: 1.454-2.790, p < 0.001), 2.015 (95%CI: 1.463-2.799, p < 0.001), 2.356 (95%CI: 1.705-3.286, p < 0.001), 2.011 (95%CI: 1.457-2.793, p < 0.001), and 1.515 (95%CI: 1.100-2.134, p < 0.001), respectively.

LIMITATIONS

Individuals with lichen planus were unable to be classified into oral subtype and cutaneous subtype based on the ICD-9-CM. Moreover, the results of our study could not demonstrate the mechanism between lichen planus and anxiety and/or depression.

CONCLUSION

Patients with lichen planus was positively associated with developing anxiety or depression. Physicians should to be aware of the signs of anxiety and/or depression while facing the patients with lichen planus during the clinical practices.

Assessment of sleep disturbance in oral lichen planus and validation of PSQI: A case-control multicenter study from the SIPMO (Italian Society of Oral Pathology and Medicine)

BACKGROUND

The wellbeing of oral lichen planus patients (OLPs) may be strongly influenced by a poor quality of sleep (QoS) and psychological impairment. The aims were to analyze the prevalence of sleep disturbance, anxiety, and depression in OLPs and to validate the Pittsburgh Sleep Quality Index (PSQI) in OLPs.

METHODS

Three hundred keratotic OLPs (K-OLPs), 300 with predominant non-keratotic OLP (nK-OLPs), and 300 controls were recruited in 15 Italian universities. The PSQI, Epworth Sleepiness Scale (ESS), Hamilton Rating Scales for Depression and Anxiety (HAM-D and HAM-A), Numeric Rating Scale (NRS), and Total Pain Rating Index (T-PRI) were administered.

RESULTS

Oral lichen planus patients had statistically higher scores than the controls in the majority of the PSQI sub-items (p-values < 0.001**). Moreover, OLPs had higher scores in the HAM-D, HAM-A, NRS, and T-PRI (p-values < 0.001**). No differences in the PSQI sub-items' scores were found between the K-OLPs and nK-OLPs, although nK-OLPs suffered from higher levels of anxiety, depression, and pain (p-values: HAM-A, 0.007**, HAM-D, 0.009**, NRS, <0.001**, T-PRI, <0.001**). The female gender, anxiety, depression (p-value: 0.007**, 0.001**, 0.020*) and the intensity of pain, anxiety, and depression (p-value: 0.006**, <0.001**, 0.014*) were independent predictors of poor sleep (PSQI > 5) in K-OLPs and nK-OLPs, respectively. The PSQI's validation demonstrated good internal consistency and reliability of both the total and subscale of the PSQI.

CONCLUSIONS

The OLPs reported an overall impaired QoS, which seemed to be an independent parameter according to the regression analysis. Hence, clinicians should assess QoS in OLPs and treat sleep disturbances in order to improve OLPs management.

The Influence of Hepatitis C Virus Infection on ORAL Health-Related Quality of Life in Patients with Oral Lichen Planus

Background: oral lichen planus (OLP) is a mucocutaneous disease that affects about 4% of the global population. Hepatitis C virus (HCV) was linked to lichen planus. The current study aimed to assess the impact of OLP associated or not with HCV infection on the oral health-related quality of life (OHRQoL). Methods: The study included patients diagnosed with OLP who filled in the Romanian version of OHIP-14 questionnaire at their first appointment and 6 months later, after the OLP treatment. A control group of OLP-free subjects similar as age and sex was also included in the study. Results: 68 patients with OLP and 46 controls were included in the study. The OHIP scores are significantly higher on OLP group than controls (p-value < 0.0001) and significantly reduced at 6-month follow-up (p-values: < 0.0001 pre- vs. post-treatment in OLP group). Patients with and without HCV associated with OLP demonstrated a similar oral quality of life (p-values > 0.05). Conclusions: the OHRQoL for patients suffering from OLP is compromised but is improved after treatment. The HCV associated with OLP did not influence the overall OHRQoL, but the patients who associate HCV reported more frequently aching in the mouth and discomfort eating food at six-month follow-up.

Impact of Oral Lichen Planus on Oral Health-Related Quality of Life: A Systematic Review and Meta-Analysis

Oral health-related quality of life (OR-QoL) measurement in patients with oral lichen planus (OLP) can provide valuable information for the optimal management of their clinical conditions. The main objective of the present study was to assess the OR-QoL of patients with OLP as measured by the short-form Oral Health Impact profile-14 (OHIP-14) questionnaire. PubMed/MEDLINE, ISI/Web of Science, clinical trial registry, Embase, Scopus, and grey literature (via Google Scholar and Scilit) were searched. Reviewers independently screened titles/abstracts, assessed full-text articles, extracted data, and appraised their quality. Random effect analysis along with subgroup analysis for age, gender, and clinical type was performed. Seventeen studies were included. Mean overall OH-QoL was 15.20, [95% CI 12.176, 18.231]; a higher OHIP-14 score was seen in OLP patients, resulting in poor OH-QoL. The impact of OLP on OH-QoL life was moderate as compared to healthy subjects. However, medical treatment of the disease improved the OH-QoL and thus reduced the impact of OLP on it. OH-QoL among patients with OLP is generally poor. Clinicians and physicians should consider the OH-QoL of these patients as part of patients’ evaluation and modulate the administered treatment based on the OH-QoL response.

Psychological profile and unexpected pain in oral lichen planus: A case-control multicenter SIPMO studya

OBJECTIVES

To analyze psychological profiles, pain, and oral symptoms in patients with oral lichen planus (OLP).

MATERIALS AND METHODS

300 patients with keratotic OLP (K-OLP; reticular, papular, plaque-like subtypes), 300 patients with predominant non-keratotic OLP (nK-OLP; erythematosus atrophic, erosive, ulcerative, bullous subtypes), and 300 controls were recruited in 15 universities. The number of oral sites involved and oral symptoms were recorded. The Numeric Rating Scale (NRS), Total Pain Rating Index (T-PRI), Hamilton Rating Scales for Depression and for Anxiety (HAM-D and HAM-A), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS) were administered.

RESULTS

The OLP patients, especially the nK-OLP, showed higher scores in the NRS, T-PRI, HAM-D, HAM-A and PSQI compared with the controls (p-value < .001** ). A positive correlation between the NRS, T-PRI, HAM-A, HAM-D, and PSQI was found with the number of oral symptoms and number of oral sites involved. Pain was reported in 67.3% of nK-OLP and 49.7% of K-OLP cases with poor correspondence between the site of lesions and the site of the symptoms.

CONCLUSIONS

Mood disorders are frequently associated with OLP with an unexpected symptomatology correlated with the number of oral symptoms and with the extension of disease suggesting a peripheral neuropathy.

Association between Clinical Signs of Oral Lichen Planus and Oral Health-Related Quality of Life: A Preliminary Study

Subjective patient’s symptoms and Oral Health-Related Quality of Life (OHRQoL) are recommended to be involved in oral lichen planus (OLP) studies. This study aims to assess the OHRQoL of OLP patients, and their associations with pain and OLP in Thai patients. Sixty-nine patients were interviewed using the Numeric Rating Scale (NRS) for pain perception and Oral Impacts on Daily Performance (OIDP) index. OLP signs examined included localization, types, number of affected sides and clinical severity using the Thongprasom sign scoring system. There were significant associations (r_s = 0.490, p < 0.001) between clinical severity and the intensity of oral impacts as well as pain (r_s = 0.298, p = 0.013). The intensity of oral impacts and pain increased according to the increasing OLP clinical severity, except for the white striae lesions (Thongprasom sign score 1). The erosive/ulcerative OLP lesions (Thongprasom sign scores 4 and 5) were the most painful symptom and had the highest degree of oral impacts (p < 0.001). No significant associations were found between the number of affected lesion sides and OHRQoL (p = 0.316) and pain (p = 0.284). OHRQoL was associated with OLP type and clinical severity but not with the number of affected sides.

Does the Clinical Form of Oral Lichen Planus (OLP) Influence the Oral Health-Related Quality of Life (OHRQoL)?

(1) Background: The aim of the study was to investigate the oral health-related quality of life (OHRQoL) of patients with oral lichen planus (OLP) and to evaluate differences between the various clinical forms of OLP. Specifically, the differences in OHRQoL, physical pain levels and eating restriction were assessed; (2) Methods: One hundred and twelve patients with clinical and histological features of OLP from the Department of Cranio-Maxillofacial Surgery of the Münster University Hospital participated in this prospective study. OHRQoL was analysed by using the German short version of the Oral Health Impact Profile (OHIP-14). Physical pain levels and restriction in eating were rated on visual analogue scales (VAS). The statistical analysis was performed using the Mann-Whitney U-Test and the chi-squared test with a significance level at p = 0.05; (3) Results: Group 1 consisted of patients with reticular OLP (n = 50) and group 2 of patients with atrophic, erosive-ulcerative or bullous OLP (n = 62). The average OHIP-14 score was 13.54 points and differed significantly between the two groups. There were significant differences in the domains "physical pain", "psychological discomfort", "physical disability" and "social disability". The VAS "physical pain" score and "restriction in eating" score varied significantly between the clinical forms. Positive correlations were found between the OHIP-14 total scores and the VAS scores; (4) Conclusion: The OHRQoL is significantly limited in patients with OLP; especially, patients with erosive-ulcerative OLP are affected.

Evaluation of PD-L1, PD-L2, PD-1 and cytotoxic immune response in oral lichen planus

OBJECTIVE

To investigate the expression of programmed death-ligands 1 and 2 (PD-L1, PD-L2), programmed death-1 (PD-1), CD8 and granzyme B (GrB), as well as its correlation with the severity of oral lichen planus (OLP).

MATERIALS AND METHODS

In a collaborative study, 33 cases of OLP were evaluated according to the latest criteria proposed by the American Academy of Oral and Maxillofacial Pathology (AAOMP/2016) and were submitted to immunohistochemistry. Positivity was measured semiquantitatively (PD-L1, PD-L2) and quantitatively (PD-1, CD8, GrB). The severity of OLP was assessed according to clinical subtype, symptomatology and response to corticosteroid therapy.

RESULTS

Most OLPs were considered to be negative for PD-L1 (66.6%), but high expression of PD-L2 (96.9%) by keratinocytes and immunoinflammatory cells was observed. PD-1⁺ cell density/mm² was reduced compared to CD8⁺ cells. A low cytotoxic immune response (CD8:GrB ratio) was also demonstrated. Interestingly, there were fewer GrB⁺ cells in the intraepithelial region in reticular OLP compared to erosive/bullous OLP.

CONCLUSIONS

PD-L1/PD-1 pathways appear to be compromised in OLP due to low PD-L1 expression in most samples. In contrast, PD-L2 overexpression associated with a possible regulation of the cytotoxic immune response suggests an immune tolerance that may contribute to the chronic profile of OLP.

A Holistic Intervention for Oral Lichen Planus

Oral lichen planus (OLP) is a chronic immune-mediated, inflammatory, and psychosomatic condition that frequently affects the oral mucosa in a typical bilateral pattern, often noticed in middle-aged females.1 It involves the buccal, lingual, and/or gingival mucosa and is also an oral potentially malignant disorder (OPMD). OLP is associated with etiological factors ranging from viruses like hepatitis C, systemic factors like thyroid disorders,2 local factors like dental plaque, calculus and cuspal trauma, to deep rooted, often underestimated, psychological triggers. OLP is routinely encountered in oral medicine clinics and is sometimes accompanied by the simultaneous involvement of skin, nails, genitals, and/or mucous membranes. Although OLP is multifactorial in origin, a large share of these presentations can be attributed chiefly to psychological factors like stress, anxiety, and depression. OLP is even more striking as its genesis, progression, and exacerbation closely mirror the dynamics of emotional disturbance.

Oral health-related quality of life in different clinical forms of oral lichen planus

OBJECTIVES

The aim of the study was to determine the prevalence of clinical forms in a group of oral lichen planus (OLP) patients and to investigate whether the oral health-related quality of life (OHRQoL) of patients with common clinical OLP forms differs significantly from that of other clinical forms of OLP and healthy patients, respectively.

METHODS

OHRQoL was assessed using the Romanian version of the short form of the Oral Health Impact Profile (OHIP-14). OLP patients rated the pain they were currently experiencing on a visual analog scale (VAS). Statistics was performed using parametric and non-parametric tests and multiple linear regression.

RESULTS

Eighty OLP patients and 80 healthy controls were enrolled. The most prevalent OLP clinical form was keratotic form (n = 39, 48.75%, group 1), followed by atrophic (31.25%), erosive-ulcerative (17.5%), and bullous (2.5%) forms, which were included in group 2 (n = 41). The OHRQoL did not differ significantly between group 1 and the other two groups. A negative social impact was reported on psychological discomfort domain for both OLP groups, as compared with healthy controls. VAS scores were significantly associated with OHIP total scores in group 1 (rho = 0.41, n = 39, p = 0.009, Spearman's correlation coefficient). Within the same group, significantly higher OHIP total scores were recorded in patients lacking academic education (p = 0.0086, Mann-Whitney U test).

CONCLUSIONS

Overall, the most common clinical OLP form did not impact significantly the OHRQoL of OLP patients.

CLINICAL RELEVANCE

Psychological therapy and meeting the educational needs might improve the OHRQoL of patients with common clinical forms of OLP.

Severity of oral lichen planus and oral lichenoid lesions is associated with anxiety

OBJECTIVES

Oral lichen planus (OLP) and oral lichenoid lesions (OLL) are chronic inflammatory diseases whose symptoms can impair patient's quality of life (QoL). Psychological factors seem to play an important role in these diseases. This study aimed to determine the impact of oral health and anxiety levels on the QoL of patients with OLP and OLL.

PATIENTS AND METHODS

This was a cross-sectional study composed of OLP and OLL patients and a control group matched by age and sex with no autoimmune/inflammatory or malignant oral lesions. Anxiety levels and oral health impact on QoL were assessed using the Hamilton Anxiety Scale (HAM-A) and the Oral Health Impact Profile-14 (OHIP-14), respectively. The instruments were filled through personal interview before starting the treatment for oral lesions.

RESULTS

A total of 87 patients diagnosed with OLP (n = 45) and OLL (n = 42), and 87 controls were included in the study. Statistical differences were observed for the psychic and somatic anxiety dimensions between severities of diseases. Patients with OLP or OLL had higher scores for the OHIP-14 dimensions physiological discomfort and social limitation compared with controls. In addition, higher scores for physical pain, physical disability, social disability, and handicap were detected among patients with greater severity.

CONCLUSION

Greater severity of OLP and OLL seems to be associated with increased levels of anxiety, higher scores of oral health impact profile, and decreased QoL.

CLINICAL RELEVANCE

Patients with severe OLP/OLL may benefit from additional therapeutic treatments, such as psychological and/or psychiatric management, concomitant to treatment specific to oral lesions.