Oral lichen planus: A retrospective study of 110 Brazilian patients

Oral Lesions of Immune-Mediated and Autoimmune Diseases: A 12-year Experience at a Single Brazilian Referral Center

BACKGROUND

Oral lesions of immune-mediated and autoimmune diseases have been well-documented, but studies from Brazil are limited. The varied spectrum of oral lesions within this demographic group poses challenges to clinicians, particularly when they occur in isolation. This study aimed to evaluate the occurrence, clinical characteristics, and management of patients with oral lesions of immune-mediated and autoimmune diseases at a single center in Brazil.

METHODS

A retrospective cross-sectional study was conducted from 2010 to 2022. Clinicodemographic data, histopathological features, and treatment modalities were analyzed descriptively and analytically.

RESULTS

Of the 3,790 oral and maxillofacial lesions diagnosed, 160 (4.2%) were confirmed as immune-mediated or autoimmune diseases. The population surveyed predominantly consisted of women (73.7%), with a mean age of 60.2 years. Oral lichen planus (51.3%), mucous membrane pemphigoid (MMP) (23.7%), and pemphigus vulgaris (PV) (19.4%) were the most prevalent lesions. The buccal mucosa (59.4%) was predominantly affected, with pain reported in 46.2% of cases, notably in individuals with PV and MMP. The average time to disease stabilization post-local and/or systemic corticosteroid therapy was 15.8 months for systemic lupus erythematosus, 8.7 months for MMP, and 6.5 months for PV.

CONCLUSION

Although oral lesions related to immune-mediated and autoimmune diseases are uncommon, their diverse clinicopathological aspects require multidisciplinary management.

Oral Lichen Planus: An Updated Review of Etiopathogenesis, Clinical Presentation, and Management

Lichen planus (LP) is a chronic idiopathic immune-mediated inflammatory condition. LP is a heterogeneous disease with varied clinical presentations having different natural history, prognosis, sequelae, and outcomes. It can affect skin, hair, nails, and mucosae. Mucosal LP (including oral LP) tends to be persistent and resistant to treatment, compared to cutaneous LP. Oral LP (OLP) is broadly divided into two main categories: hyperkeratotic (usually asymptomatic) and erosive (commonly symptomatic). It can present with symptoms including odynophagia, dysphagia, dysgeusia, and sensitivity to hot spicy foods. Apart from the superficial epidermal changes, which vary with the type of clinical presentation, histopathologically oral LP shows a unifying similar and consistent feature of a lichenoid interface dermatitis. Recently, researchers have highlighted the critical role played by IL-17 in the pathogenesis of OLP. World Health Organization has categorized oral LP as one of the oral potentially malignant disorders (OPMD), albeit with a low risk of malignant transformation. Also, in the last couple of years there have been various reports on the usage of newer drugs like anti-IL17, anti-IL12/23, anti-IL 23, PDE4 inhibitors, and JAK inhibitors in the management of refractory OLP. The principal aim of treatment still remains to resolve the symptoms, prolong the symptoms free period, and reduce the risk of potential malignant transformation. We have described many new revelations made in recent times regarding the etiopathogenesis, associated conditions as well as management of OLP. Thus, the objective of this review is to present a comprehensive up-to-date knowledge including the recent advances made regarding OLP.

Clinicohistological Characteristics of Patients with Oral Lichenoid Mucositis: A Retrospective Study for Dental Hospital Records

Oral lichenoid mucositis (OLM) of the oral mucosa is a histological diagnosis mainly characterised by a band of inflammatory infiltrate in lamina propria and basal cell degeneration. These features describe oral lichen planus or oral lichenoid reaction. However, it could be seen in oral dysplasia. The study aimed to assess the demographics and clinicohistological characteristics of patients with OLM and their relevance to dysplastic changes in the oral mucosa. This was a cross-sectional and retrospective study of archived and electronic records of individuals with histological confirmation of OLM at King Saud University Medical City, Saudi Arabia. The descriptive and correlation assessments were used to describe the demographics and clinicohistological characteristics and their associations, respectively [p < 0.05]. The analysis included 140 records of patients with histological confirmation of OLM with a mean age of 47 (±13), and 57% (n = 81) were females. Notably, 40% of patients had at least one medical condition, mainly diabetes mellitus, 74% were asymptomatic, and 52% had lesions in the buccal mucosa. Dysplasia was seen in 18 (12%) of the 140 reviewed records. Regarding the associations between study variables, dysplastic changes were associated with the male gender [p = 0.024] and were of no significance with increased age [p = 0.594]. Moreover, having oral symptoms was associated with older age [p < 0.001], medical history of diabetes [p = 0.0132] and hypertension [p < 0.001]. The present study findings could help indicate the individuals with histologically confirmed OLM who suffer the most from the clinical disease and have an increased risk of dysplastic changes. Therefore, symptomatic management and long-term follow-up can be planned accordingly.

Artificial Intelligence-Based Diagnosis of Oral Lichen Planus Using Deep Convolutional Neural Networks

OBJECTIVE

 The aim of this study was to employ artificial intelligence (AI) via convolutional neural network (CNN) for the separation of oral lichen planus (OLP) and non-OLP in biopsy-proven clinical cases of OLP and non-OLP.

MATERIALS AND METHODS

 Data comprised of clinical photographs of 609 OLP and 480 non-OLP which diagnosis has been confirmed histopathologically. Fifty-five photographs from the OLP and non-OLP groups were randomly selected for use as the test dataset, while the remaining were used as training and validation datasets. Data augmentation was performed on the training dataset to increase the number and variation of photographs. Performance metrics for the CNN model performance included accuracy, positive predictive value, negative predictive value, sensitivity, specificity, and F1-score. Gradient-weighted class activation mapping was also used to visualize the important regions associated with discriminative clinical features on which the model relies.

RESULTS

 All the selected CNN models were able to diagnose OLP and non-OLP lesions using photographs. The performance of the Xception model was significantly higher than that of the other models in terms of overall accuracy and F1-score.

CONCLUSIONS

 Our demonstration shows that CNN models can achieve an accuracy of 82 to 88%. Xception model performed the best in terms of both accuracy and F1-score.

Reticular Oral Lichen Planus: A Clinical Experience of ENT Surgeons

Reticular Oral lichen planus (OLP) is a chronic autoimmune disease that presents as fine, white, linear and lace like lesions of the oral cavity referred to as Wickham striae. The clinical characteristics of 30 patients with reticular oral lichen planus is presented so that cases are not missed/misdiagnosed by ENT surgeons. The clinical records noted for each patient were gender, age and clinical presentation of reticular OLP (site affected, presence of symptoms and extraoral manifestations of the disease, smoking habit, and consumption of alcoholic beverages). Twenty patients were females (66.7%) and 10 (33.3%) were males giving a female to male ratio of 2:1. Majority of patients (50%) among both males and females were in the age group of 31-40 years followed by 41-50 years (20%). Oral discomfort/burning sensation was the chief symptom in 24 (80%) patients followed by asymptomatic oral white patches in 5 (16.6%).The buccal (cheek) mucosa was the site most affected (76.8%) followed by the buccal mucosa plus retromolar trigone mucosa (10%) and tongue (6.6%), Extraoral lesions were observed in 2 (6.6%) of patients at presentation with oral lesions and were on the nails in 1 patient and wrist in 1 patient. Tobacco smoking, alcohol use, diabetes and hypertension were reported in 3 (10%), 0%, 2 (6.7%) and 4 (13.3%) patients respectively. ENT surgeons routinely see patients with oral discomfort/oral ulcerations and as such they should be well versed with classical clinical characteristics of reticular oral lichen planus.

Rate of Malignant Transformation Differs Based on Diagnostic Criteria for Oral Lichenoid Conditions: A Systematic Review and Meta-Analysis of 24,277 Patients

OBJECTIVES

This systematic review and meta-analysis aims to evaluate the evidence on the malignant potential of oral lichenoid conditions (OLCs) including oral lichen planus (OLP), oral lichenoid lesions (OLL), and lichenoid mucositis dysplasia (LMD). In addition, it aims to compare the rate of malignant transformation (MT) in OLP patients diagnosed according to different diagnostic criteria, and to investigate the possible risk factors for OLP MT into OSCC.

MATERIALS AND METHODS

A standardized search strategy was applied across four databases (PubMed, Embase, Web of Science, and Scopus). Screening, identification and reporting followed the PRISMA framework. Data on MT were calculated as a pooled proportion (PP), subgroup analyses and possible risk factors for MT were pooled as odds ratios (ORs).

RESULTS

Among 54 studies with 24,277 patients, the PP for OLCs MT was 1.07% (95% CI [0.82, 1.32]). The estimated MT rate for OLP, OLL and LMD was 0.94%, 1.95% and 6.31%, respectively. The PP OLP MT rate using the 2003 modified WHO criteria group was lower than that using the non-2003 criteria (0.86%; 95% CI [0.51, 1.22] versus 1.01%; 95% CI [0.67, 1.35]). A higher odds ratio of MT was observed for red OLP lesions (OR = 3.52; 95% CI [2.20, 5.64]), smokers (OR = 1.79; 95% CI [1.02, 3.03]), alcohol consumers (OR = 3.27, 95% CI [1.11, 9.64]) and those infected with HCV (OR = 2.55, 95% CI [1.58, 4.13]), compared to those without these risk factors.

CONCLUSIONS

OLP and OLL carry a low risk of developing OSCC. MT rates differed based on diagnostic criteria. A higher odds ratio of MT was observed among red OLP lesions, smokers, alcohol consumers, and HCV-positive patients. These findings have implications for practice and policies.

Demographics, Clinicopathological Profile of Oral Lichen Planus of South Kerala Population: A Cross-Sectional Study

Background: Oral lichen planus (OLP) is a chronic mucocutaneous inflammatory lesion of unknown cause. The buccal mucosa is the most frequently affected anatomic site and the lesion is bilateral. The objective of this retrospective study was to investigate the epidemiological and clinical characteristics of 250 OLP patients in South Kerala. This was done by figuring out these patients’ epidemiological and clinical characteristics.

Materials and methods: In the present study, patients who reported between September 2018 and December 2021 were selected employing the diagnostic criteria consistent with the WHO classification of OLP. Data of all the patient’s characteristic features were collected and evaluated using the Statistical Package for the Social Sciences (SPSS) software for statistical analysis.

Results: Out of 250 patients, 52% were females and 48% were males. Reticular (n = 145, 58%) and erosive forms (n = 105, 42%) were the two clinical presentations of the lesions that were most consistently observed. The age group of 25-34 years reported the highest number of cases (n = 71, 28.4%). According to the chi-square test, there were statistically highly significant differences between the hyperpigmentation, age, and type of OLP. While 43.2% (n = 108) of cases reported a burning sensation, pain, or soreness, 56.8% (n = 142) of cases were asymptomatic. There were statistically significant differences between the type of OLP and the reported symptoms (p = 0.001). Mild to moderate dysplastic changes were documented in 5.6% during the follow-up period. A successful treatment outcome with topical steroid administration was recorded in the study sample.

Conclusion: It was apparent that patients typically have bilateral lesions involving the buccal and labial mucosa, manifesting with varying degrees of oral discomfort. Although patients frequently have more than one variant of OLP, the lesions are typically reticular or erosive in nature. A meticulous follow-up is crucial to determine its malignant change.

Clinical features of oral lichen planus and oral lichenoid lesions: an oral pathologist's perspective

The clinicopathological features that precisely characterize oral lichen planus (OLP) and oral lichenoid lesions (OLL) still represent a challenge. The aim of the present study was to analyze, from an oral pathologist perspective, the clinical features from OLP and OLL. Specimens fullfilling the histological criteria for OLP and OLL, and also compatible with OLP (OLP-C), were selected and clinical information was retrieved from the laboratory forms. The final sample was composed by 221 cases, including 119 OLP (53.8%), 65 OLP-C (29.4%) and 37 OLL (16.7%). Females were more affected in the three groups, but the number of males was higher in OLL. Mean age was lower in OLP (52.3 years) in comparison with OLL (57.9 years) (p=0.020). Buccal mucosa and tongue involvement was more frequent in OLP; gingival involvement was uncommon in OLL. The reticular pattern was more frequently found in OLP, while the association of reticular and atrophic/erosive/ulcerated patterns was more common in OLP-C and OLL (p=0.025). In conclusion, gender and mean age of the patients, and anatomical location and clinical manifestation of OLL are different from OLP, and could help to better characterize this group of conditions. Specimens diagnosed as OLP-C showed clinical parameters close to OLP.

Oral Potentially Malignant Disorders: Etiology, Pathogenesis, and Transformation Into Oral Cancer

Among oral diseases, oral cancer is a critical health issue due to its life-threatening potential. Globocan, in its 2020 report, estimated ∼0.37 million new cases of oral cancer, with the majority of them coming from the Asian continent. The WHO has anticipated a rise in the incidences of oral cancer in the coming decades. Various factors, such as genetic, epigenetic, microbial, habitual, and lifestyle factors, are closely associated with oral cancer occurrence and progression. Oral lesions, inherited genetic mutations (dyskeratosis congenital syndrome), and viral infections (HPV) are early signs of oral cancer. Lesions with dysplastic features have been categorized under oral potentially malignant disorders (OPMDs), such as oral leukoplakia, erythroplakia, oral submucous fibrosis (OSMF), and proliferative verrucous leukoplakia, are assumed to have a high risk of malignancy. The incidence and prevalence of OPMDs are recorded as being high in South-Asian countries. Early detection, prevention, and treatment of OPMDs are needed to prevent its malignant transformation into oral cancer. Many advanced diagnostic techniques are used to predict their progression and to assess the risk of malignant transformation. This communication provides insight into the importance of early detection and prevention of OPMDs.

Global Prevalence and Incidence Estimates of Oral Lichen Planus: A Systematic Review and Meta-analysis

Importance

Integrated information on the global prevalence and incidence of oral lichen planus (OLP) is lacking.

Objective

To examine the global prevalence and incidence of OLP in a systematic review and meta-analysis.

Data Sources

A systematic review of population-based studies and clinic-based studies reporting the prevalence and incidence of OLP was performed using 3 electronic medical databases (Cochrane Database of Systematic Reviews, Embase, and MEDLINE) from their inception to March 2019. The search terms included "(lichen planus or LP) and (prevalence or incidence or epidemiology)." No language restriction was applied.

Study Selection

Observational descriptive studies investigating the prevalence and incidence of OLP were included.

Data Extraction and Synthesis

Data were extracted by continent, sex, and other characteristics. The risk of bias was assessed by the Joanna Briggs Institute Critical Appraisal Instrument for Studies Reporting Prevalence Data using random-effects models to synthesize available evidence.

Main Outcomes and Measures

The primary outcome was the prevalence (with 95% CIs) of OLP among the overall population and among subgroups. Between-study heterogeneity was assessed using the I2 statistic.

Results

Among 46 studies, the overall pooled estimated prevalence of OLP was 0.89% (95% CI, 0.38%-2.05%) among the general population (n = 462 993) and 0.98% (95% CI, 0.67%-1.43%) among clinical patients (n = 191 963). Among the 15 population-based studies, the prevalence of OLP was 0.57% (95% CI, 0.15%-2.18%) in Asia, 1.68% (95% CI, 1.09%-2.58%) in Europe, and 1.39% (95% CI, 0.58%-3.28%) in South America. Among the 31 clinic-based studies, the prevalence was 1.43% (95% CI, 1.12%-1.83%) in Africa, 0.87% (95% CI, 0.61%-1.25%) in Asia, 1.03% (95% CI, 0.51%-2.09%) in Europe, 0.11% (95% CI, 0.07%-0.16%) in North America, and 3.18% (95% CI, 0.97%-9.95%) in South America. The pooled prevalence of OLP by sex was 1.55% (95% CI, 0.83%-2.89%) for women and 1.11% (95% CI, 0.57%-2.14%) for men in the population-based studies and 1.69% (95% CI, 1.05%-2.70%) for women and 1.09% (95% CI, 0.67%-1.77%) for men in the clinic-based studies. In 5 clinic-based studies providing the age distribution of patients with OLP, the prevalence by age was 0.62% (95% CI, 0.33%-1.13%) among patients younger than 40 years and 1.90% (95% CI, 1.16%-3.10%) among patients 40 years and older.

Conclusions and Relevance

This study identified the global prevalence and incidence of OLP in terms of its spatial, temporal, and population distribution. The overall estimated pooled prevalence of OLP was 0.89% among the general population and 0.98% among clinical patients. A higher prevalence of OLP was found in non-Asian countries, among women, and among people 40 years and older. The findings should be considered with caution because of the high heterogeneity of the included studies.

Clinicopathologic data of individuals with oral lichen planus: A Brazilian case series

Background

The aim of the present series was to analyze the sociodemographic characteristics, clinicopathologic features, and oral health-related quality of life of 41 individuals with oral lichen planus (OLP).

Material and Methods

In a retrospective analysis (1998-2018), individuals with a clinical diagnosis of OLP from a referral service of Oral Medicine of Brazil were invited for follow-up. The individuals were assessed using the Oral Health Impact Profile-14 (OHIP-14) form. Histopathological data were reviewed according to the latest criteria proposed by the American Academy of Oral and Maxillofacial Pathology (AAOMP/2016).

Results

This series mainly consisted of females (70.7%) in their forties (31.7%). The buccal mucosa (68.2%) was the most commonly affected site. Reticular (56.1%) and erosive (34.3%) appearances were the most frequent. According to OHIP-14, individuals with OLP at multiple sites in the oral cavity showed worse values in the handicap domain and those who did not respond to corticosteroids showed a higher score on the psychological discomfort domain.

Conclusions

The findings of the present study, using the AAOMP/2016 criteria, agree with case series and retrospective studies reported in the literature. Besides, OLP in its more severe clinical forms had an influence on patient quality of life.

Key words:Diagnosis, epidemiology, oral lichen planus, oral mucosa, quality of life.

Potentially malignant disorders of the oral cavity and oral dysplasia: A systematic review and meta-analysis of malignant transformation rate by subtype

IMPORTANCE

Potentially malignant disorders of the oral cavity (OPMD) are a heterogeneous group of lesions associated with a variable risk of malignant transformation (MT) to invasive cancer. Leukoplakia (LE), lichen planus (LP), oral lichenoid lesions (OLL), oral erythroplakia (OE), oral submucous fibrosis (OSF), and proliferative verrucous leukoplakia (PVL) are among the most common of these lesions. Oral dysplasia is a mucosal area characterized by cellular and architectural derangement, which may be associated with OPMDs or not.

OBJECTIVE

To define the MT rate of OPMDs and the risk of development into cancer of mild vs moderate/severe oral dysplasia. This in order to implement adequate follow-up strategies and treatment decisions.

STUDY DESIGN

We performed a systematic review and meta-analysis on studies reporting the MT rates of OPMDs and oral dysplasia. Ninety-two studies were included for the analysis. Cumulative rates were reported for OPMDs overall and as a subgroup, a comparison was made of mild vs moderate/severe dysplasia. Meta-regression on OPMD and year of publication was also performed.

MAIN OUTCOME AND MEASURES

Overall MT rates of OPMDs and odds ratio of MT of mild vs moderate/severe dysplasia.

RESULTS

Overall MT rate across all OPMD groups was 7.9% (99% confidence interval [CI] 4.9%-11.5%). MT rates of the specific OPMD subgroups were as follows: LP 1.4% (99% CI 0.9%-1.9%), LE 9.5 (5.9%-14.00%), OLL 3.8% (99% CI 1.6%-7.00%), OSF 5.2% (99% CI 2.9%-8.00%), OE 33.1% (99% CI 13.6%-56.1%), and PVL 49.5% (99% CI 26.7%-72.4%). Regarding the dysplasia grades comparison, the meta-analysis showed that moderate/severe dysplasia is meaningfully associated to a much greater risk of MT compared to mild dysplasia with an odds ratio of 2.4 (95% CI 1.5-3.8) [Correction added on 27 December 2019, after first online publication: CI updated from 99% to 95%.]. Heterogeneity was not significant. Annual MT rates were approximated based on the average follow-up as reported in the various subgroups. Lichen planus had an annual MT of 0.28%, OLL of 0.57%, leukoplakia of 1.56%, PVL of 9.3%, and OSF of 0.98%. Mild dysplasia had an annual MT of 1.7%, while severe dysplasia of 3.57%. Meta-regression showed a significant negative correlation of PVL MT rate and year of the study (P value <.001).

CONCLUSIONS AND RELEVANCE

OPMDs and oral dysplasia are relatively common conditions that general practitioners, head and neck, and oral medicine specialists, face in their everyday practice. Our analysis confirms the significant risk of MT of these lesions, although variable among the subgroups. Moderate/severe dysplasia bears a much higher risk of cancer evolution than mild dysplasia. It is important to raise public health awareness on the MT rates of these conditions, at the same time efficacious communication with the patient is of utmost importance. This, coupled with strict follow-up measures and optimal treatment strategies, would help in reducing the transformation of these oral conditions into invasive cancer.

Clinical profile of 102 patients with oral lichen planus in Thailand

Background

Oral lichen planus (OLP) is a chronic inflammatory disease of the skin and mucous membrane presented with various clinical appearances. The aim of the present study was to elucidate the clinical profile of patients with OLP.

Material and Methods

The dental records of 102 patients who visited Oral Medicine Clinic, Dental Hospital, Naresuan University during 2002-2018 were retrospectively reviewed.

Results

There were 75 (73.5%) women and 27 (26.5%) men, giving a female to male ratio of 2.8:1. The age of OLP patients ranged 20-81 years old with the mean age of 56.4 ± 13.2 years old. Seventy-eight patients (76.5%) had the history of systemic diseases and hypertension was the predominantly one. Most patients were non-smokers (98%), non-drinkers (86.3%) and non-betel nut chewers (98%). The atrophic form (93.1%) was the most common OLP. The lesions were mainly symptomatic (92.2%) and involved multiple locations (67.6%) where the buccal mucosa (79.4%) primarily affected. Only 2% were extraoral lesions detected on the skin. Patients had no family history of OLP or malignant transformation. Ninety-one patients (89.2%) were treated with topical steroid and only 4 patients were prescribed a combination of tropical and systemic steroid.

Conclusions

The results of the study indicated that most of characteristics are in accordance with previous studies. Since, OLP is a chronic inflammatory oral mucosal disease with high recurrence rate, early detection, accurately diagnosis, and long-term follow-up are necessary to evaluate the exacerbation and malignant transformation.

Key words:Clinical profile, demographic, oral lichen planus, retrospective study.

Malignant transformation risk of oral lichen planus: A systematic review and comprehensive meta-analysis

OBJECTIVES

To evaluate current evidence on the malignant transformation of oral lichen planus (OLP), oral lichenoid lesions (OLLs), and oral lichenoid reactions (LRs) and to determine the variables with greatest influence on cancer development.

MATERIAL AND METHODS

We searched PubMed, Embase, Web of Science, and Scopus for studies published before November 2018. We evaluated the quality of studies (QUIPS tool). We carried out meta-analyses to fulfill our objectives. We examined the between-study heterogeneity and small-study effects, and conducted sensitivity studies and subgroup analyses.

RESULTS

Inclusion criteria were met by 82 studies (26,742 patients. The combined malignant transformation rate was 1.14% for OLP (95% CI = 0.84-1.49), 1.88% for OLLs (95% CI = 0.15-4.95) and 1.71% for LRs (95% CI = 0.00-5.46). Subgroup analysis revealed a higher malignant transformation rate in studies when the presence of epithelial dysplasia was not an exclusion criterion (p = 0.001), when both clinical and histopathological criteria were used for diagnosis (p < 0.001), when the follow-up was at least 12 months (p = 0.048), and when there was lower risk of potential bias (p = 0.002). Malignant transformation risk factors were: tongue localization (RR = 1.82, 95% CI = 1.21-2.74, p = 0.004), presence of atrophic-erosive lesions (RR = 4.09, 95% CI = 2.40-6.98, p < 0.001), tobacco use (RR = 1.98, 95% CI = 1.28-3.05, p = 0.002), alcohol consumption (RR = 2.28, 95% CI = 1.14-4.56, p = 0.02), and hepatitis C virus infection (RR = 4.46, 95% CI = 0.98-20.22, p = 0.053).

CONCLUSIONS

The malignant transformation rates of OLP, OLLs and LRs are underestimated due essentially to restrictive diagnostic criteria, inadequate follow-up periods, and/or low quality of studies.

Reverse Koebnerization in a linear oral lichenoid lesion: A case report

The spectacle of Koebner’s phenomenon (KP) is interesting in that trauma precipitates a subset of pathologically distinct conditions, indicating the subtle interplay between sensitization and dermato-mucosal integrity. KP is interesting because, if factors initiating it are controlled, then it may be possible to prevent these debilitating conditions through induction of reverse Koebnerization. Herein, we present a report of a patient with an erosive lesion, localized to the occlusal plane on buccal and lingual mucosa, that interestingly subsided following 1 week after a dental scaling procedure. This report analytically describes the role of dental calculus and cuspal trauma as important triggers surrounding the genesis of oral lichenoid lesion and oral lichen planus. An engaging discussion on these closely related enigmatic entities forms the central theme of this report.

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

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

Correlation between tissue expression of microRNA-137 and CD8 in oral lichen planus

OBJECTIVES

Oral lichen planus (OLP) is a chronic, inflammatory condition, classified by the World Health Organization as a premalignant lesion. We performed this study to evaluate the correlation between microRNA-137 (miR-137) and CD8 oral tissue expression in OLP patients.

MATERIALS AND METHODS

Twenty OLP patients [classified into three groups: (a) papular, reticular, or plaque; (b) atrophic; and (c) erosive] and 20 healthy controls were subjected to biopsy of the oral mucosa. To evaluate CD8 tissue expression, we performed immunohistochemical examination, followed by immunostaining and computerized quantification. The expression of miR-137 was evaluated using real-time quantitative PCR. We used SPSS software (version 15 for windows) to perform the statistical analysis.

RESULTS

Our analysis showed an increased tissue expression of CD8 (p < 0.01) and reduced expression of miR-137 (p < 0.001) in OLP patients, compared to the control group. Moreover, there was a statistically significant difference (p = 0.001) between OLP subgroups in terms of CD8 tissue expression [highest in erosive OLP and lowest in papular/reticular/plaque OLP]. However, these subgroups showed no significant difference (p = 0.168) in terms of miR-137 expression. A negative correlation (p < 0.05) between tissue expression of miR-137 and CD8 was noted with a varying correlation coefficient in different OLP subgroups (-0.250 in erosive OLP, -0.491 in atrophic OLP and -0.616 in papular/reticular/plaque OLP).

CONCLUSIONS

Our findings indicate reduced expression of miR-137 and a reverse correlation between tissue expression of miR-137 and CD8 in the oral mucosa of OLP patients.

CLINICAL RELEVANCE

Future studies should investigate the therapeutic potential of miR-137 overexpression in OLP patients.

Clinicopathological Profile and Malignant Transformation in Oral Lichen Planus: A Retrospective Study

OBJECTIVES

The aim of this study was to analyze the histopathologically diagnosed cases of oral lichen planus (OLP) in terms of age, gender, clinical variant, site, hyperpigmentation, systemic illness, grade of dysplasia, and associated malignant transformation. This study also intended to do a review of reported cases of OLP with malignant transformation.

MATERIALS AND METHODS

One hundred and forty-three cases of histopathologically diagnosed OLP between 2010 and 2016 were retrospectively reviewed. Demographic and clinicopathological data including malignant transformation were obtained. The data obtained were analyzed using the Statistical Package for the Social Sciences (SPSS) software for Windows version 20.0 (IBM SPSS, SPSS Inc., Chicago, IL, USA). A review of published literature on OLP with malignant transformation was also done from 1988 to 2017 and tabulated.

RESULTS

OLP in this study showed a male predilection with most of the patients in the third decade. The buccal mucosa (bilateral presentation) was the most common site (79.72%), and reticular type was the most common clinical type (79.02%) followed by erosive type (20.98%). The majority (92.31%) of cases were diagnosed with OLP without dysplasia. The rest (7.69%) of dysplastic cases were predominantly seen in the buccal mucosa of 58 years and above, female patients manifesting mainly as erosive type. Two patients (1.4%) previously diagnosed clinically and histopathologically as OLP developed oral squamous cell carcinoma.

CONCLUSION

The present investigation revealed the predominance of OLP among middle-aged male population and the prevalence of bilateral involvement of buccal mucosa. Two of our cases showed malignant transformation over an average period of 3.5 years. The outcome of this study emphasizes the role of clinical follow-up of patients with OLP.

Malignant transformation of oral lichen planus and oral lichenoid lesions: A meta-analysis of 20095 patient data

OBJECTIVES

For over a century, a heated debate existed over the possibility of malignant transformation of oral lichen planus (OLP). We performed this meta-analysis to evaluate the malignant potential of OLP and oral lichenoid lesions (OLL) and investigate the possible risk factors for OLP malignant transformation into oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

We searched Medline, Scopus, and Web of Knowledge for relevant observational studies. Data on OLP malignant transformation were calculated as a pooled proportion (PP), using the Der-Simonian Liard method. We performed subgroup analyses by OLP diagnostic criteria, site, and clinical type, using Open Meta[Analyst] software. Data on possible risk factors for malignant transformation were pooled as odds ratios (ORs), using Comprehensive Meta-Analysis software.

RESULTS

Pooling data for OLP malignant transformation from 57 studies (19,676 patients) resulted in an overall PP of 1.1% [95% CI: 0.9%, 1.4%], while pooling data from 14 recent studies that used the World Health Organization-2003 diagnostic criteria resulted in an overall-PP of 0.9% [95% CI: 0.5%, 1.3%]. The risk of malignant transformation was higher (PP=2.5%, 95% CI [1%, 4%]) in OLL patients (419 patients). A significant increase of malignant transformation risk was noted among smokers (OR=2, 95% CI [1.25, 3.22]), alcoholics (OR=3.52, 95% CI [1.54, 8.03]), and HCV-infected patients (OR=5, 95% CI [1.56, 16.07]), compared to patients without these risk factors.

CONCLUSION

A small subset of OLP patients (1.1%) develop OSCC; therefore, regular follow-up for these patients is recommended. A higher incidence of malignant transformation was found among smokers, alcoholics, and HCV-infected patients; however, these associations should be further investigated.

Clinical profile of 108 cases of oral lichen planus

Oral lichen planus (OLP) is a T cell-mediated chronic inflammatory disease with a varied clinical presentation. The present clinical study was carried out to clarify the demographic and clinical profile of 108 patients with OLP. The patients were identified based on the diagnostic criteria proposed by van der Meij et al. (2003) modified from the WHO (1978) clinical and histopathologic definition of OLP. Information such as age, gender, clinical presentation and type of OLP, site of involvement, symptoms, extraoral involvement, history of systemic disease, familial occurrence and risk factors like chewing and smoking tobacco, chewing betel quid, alcohol consumption were obtained. Mean age of OLP patients was 45.4 years, and among the identified patients, 70.4% were females. The most frequent clinical type was the reticular form (80.6%). The OLP lesions were symptomatic in 77.8% of the patients. The buccal mucosa was the most affected site (87.9%) and multiple oral lesions were observed in 41.7% of the patients. Among the OLP patients, 36.1% and 4.7% reported chewing tobacco and smoking tobacco, respectively. Histopathologically, epithelial dysplasia was seen in two cases. The chronic nature of OLP warrants patient education, psychological support and long-term follow up. (J Oral Sci 58, 43-47, 2016).

Clinical and Histopathologic Characterization of Canine Chronic Ulcerative Stomatitis

Canine chronic ulcerative stomatitis, also known as chronic ulcerative paradental stomatitis, is a painful condition of the oral cavity. The purpose of this study was to determine if there are commonalities in clinical and radiographic features among patients, whether the histopathologic evaluation might inform the pathogenesis, and whether the condition appears similar to human oral mucosal diseases. To do this, we prospectively collected clinical, radiographic, and histopathologic data from 20 dogs diagnosed with the disease. Clinical data were based on a clinical disease activity index, oral and periodontal examination parameters, and full-mouth dental radiographs. The histopathological and immunohistochemical data were based on oral mucosal samples obtained from erosive or ulcerated areas. Our findings revealed that canine chronic stomatitis is clinically characterized by painful oral mucosal ulcers of varying size, pattern, appearance, and distribution, most often associated with teeth with early periodontitis. Histologic examination revealed a subepithelial lichenoid band (interface mucositis) where B cells, T cells, and Forkhead-box protein 3 (FoxP3)- and interleukin-17-expressing cells were present. These cells might play a role in the underlying immune response and an immune-mediated pathogenesis is suspected. The clinical and histopathologic features of this chronic inflammatory mucosal disease in dogs resemble those of oral lichen planus in humans.

Management of symptomatic erosive-ulcerative lesions of oral lichen planus in an adult Egyptian population using Selenium-ACE combined with topical corticosteroids plus antifungal agent

Aim:

Oral lichen planus (OLP) is a chronic mucocutaneous disease with an immunological etiology. This study was conducted to evaluate the effect of selenium combined with Vitamins A, C & E (Selenium-ACE) in the treatment of erosive-ulcerative OLP as an adjunctive to topical corticosteroids plus antifungal agent.

Subjects and Methods:

Thirty patients with a confirmed clinical and histopathologic diagnosis of OLP participated in this clinical trial. Patients were randomly allocated into one of three groups and treated as follows: (I) Topical corticosteroids, (II) topical corticosteroids plus antifungal, and (III) SE-ACE combined with topical corticosteroids plus antifungal. The patients were followed for 6 weeks. The pain and severity of the lesions were recorded at the initial and follow-up visits. All recorded data were analyzed using paired t-test and ANOVA test. A P ≤ 0.05 was considered significant.

Results:

The experimental groups showed a marked reduction in pain sensation and size of lesions, particularly in the final follow-up period, but there was no significant difference between the first two Groups I and II. However, healing of lesions and improvement of pain sensation was effective in Group III since a significant difference was found favoring Group III over both Groups I and II.

Conclusion:

No significant difference was found in treating erosive-ulcerative lesions of OLP by topical corticosteroids alone or combined with antifungal. However, when using SE-ACE in combination with topical corticosteroids plus antifungal, this approach may be effective in managing ulcerative lesions of OLP; but more research with a larger sample size and a longer evaluation period may be recommended.

Clinical Assessment of the Efficiency of Low Level Laser Therapy in the Treatment of Oral Lichen Planus

BACKGROUND:

Oral lichen planus (OLP) is a chronic inflammatory disease of the oral mucosa of uncertain etiology.

AIM:

To evaluate the effect of using low level laser therapy (LLLT (970 nm Siro laser Advance) for the treatment of symptomatic (OLP).

SUBJECTS AND METHODS:

The present study was conducted on ten patients suffering from persistent oral lichen planus (OLP). Patients were treated with diode laser (970nm) for the symptomatic relief of pain and burning sensation. The patients were assessed before, during and after the completion of the laser treatment which was done twice weekly for two successive months with maximum of ten sessions. The assessment was performed using visual analogue scale (VAS) and clinical investigation for each patient.

RESULTS:

Detailed significant reduction in lesion size and showed complete remission of burning sensation and pain. No reported complications or therapy side effects were observed in any of the treated patients.

CONCLUSION:

Diode laser therapy seems to be an effective adjunctive treatment modality for relieving pain and clinical symptoms of OLP.

Oral lichen planus: study of 21 cases

BACKGROUND:

Lichen planus is considered to be the most common dermatological disease involving the oral mucosa.

OBJECTIVE:

To investigate the profile, clinical features, and the presence of dysplasia and candidiasis in patients with oral lichen planus.

METHODS:

A total of 21 patients were selected from 258 patients at risk for oral cancer development.

RESULTS:

Most of the patients were white (76,2%), female (66,6%), with mean age of 58.8 years. Eight were smokers and seven were alcohol consumers. The buccal mucosa was the most affected site, followed by the tongue and the gingiva. The reticular pattern was the most common appearance. Histopathology depicted dysplasia in nine cases and cytopathology was positive for Candida in eight cases in the first appointment.

CONCLUSION:

Our data are similar to the literature. Cytopathology was important for the diagnosis of candidiasis. Although the presence of dysplasia was verified, further studies are necessary to clarify the importance of this finding.

A retrospective study of 171 patients with oral lichen planus in the East Bohemia - Czech Republic - single center experience

Objectives: Oral lichen planus is chronic inflammatory disease with a high prevalence in the population. This study describes the epidemiological and clinical characteristics of group of patients with oral lichen planus in the Czech Republic. Material and Methods: Data was taken from the medical records of 171 patients referred to the Oral Medicine Unit at the University Hospital in Hradec Králové with histologically confirmed clinical diagnosis of oral lichen planus in the period 2003 – 2013. The data were retrospectively reviewed. Results: Of the 171 patients, 116 (67.8%) were women and 55 (32.2%) were men. The mean age was 55.2 ± 12.4 years (range of 85.0 – 20.9). The reticular form was the most frequent 93.6% (160 pts.), desquamative gingivitis was 12.9% (22). The buccal mucosa was the site most affected 89.5% (153 pts.). The lesions were asymptomatic in 52 patients (30.4%). Extraoral lesions were observed in 20.5% (35 pts.) of the patients, skin involvement was in 16.4% (28 pts.). Smokers were 29 patients. Local treatment used 116 (67.8%), only 6 patients used systemic short tome corticoid therapy. No evidence between OLP and malignant transformation was observed. Conclusions: This retrospective study show very similar profile and clinical features of the patients with OLP as in other studies.

Key words:Oral lichen planus, clinical features, extraoral manifestation.

A study on oral mucosal lesions in 3500 patients with dermatological diseases in South India

BACKGROUND

Oral mucosal lesions that are observed in the dermatological diseases are categorized under mucocutaneous conditions. The oral lesions in dermatological diseases may be the early aspects of the disease manifestation or the most significant clinical appearance or the only sign/and or symptom of such dermatological diseases and occasionally lesions occur simultaneously in the skin as well as mucous membrane.

AIM

This present study attempts to find out the prevalence of oral mucosal lesions in patients with dermatological diseases.

SUBJECTS AND METHODS

The study includes 3500 patients who attended out-patient Department of Dermatology. Patients with oral manifestation were subjected for clinical examination in the Department of Oral Pathology. Diagnostic procedures were performed to confirm the clinical oral diagnosis. The results of the study were analyzed by SPSS software version 19.0 (Armonk, NY) and presented as descriptive statistics. Correlation of oral manifestions with their respective dermatological disease was statistically analysed by Pearson's correlation test.(P < 0.05 were considered as statistically significant).

RESULTS

The prevalence rate of oral mucosal lesions in the present study was 1.8% (65/3500). The most frequent lesions observed were psoriasis 32.3% (21/65), lichen planus 18.4% (12/65), Stevens Johnson Syndrome 18.4% (12/65), pemphigus 10.7% (7/65), toxic epidermal necrolysis 4.6% (3/65), systemic lupus erythematosus 3% (2/65), discoid lupus erythematosus 1.5% (1/65), pemphigoid 1.5% (1/65). Gender distribution in the study population was statistically significant (P < 0.001). Employed and unemployed individuals in the study population were statistically significant (P < 0.001). Pearson's correlation analysis of oral manifestations with their respective dermatological disease showed r = 0.466 and signifies a positive correlation and is statistically significant at the 0.01 level (two-tailed).

CONCLUSION

The prevalence rate of oral mucosal lesions in patients with dermatological diseases was relatively low. However, predominant oral mucosal lesions observed in the study were autoimmune in origin with a high morbidity and mortality index. Hence, multidisciplinary approach will definitely help in the prognosis of patients.

Evaluation of efficacy of a bioresorbable membrane in the treatment of oral lichen planus

BACKGROUND

Gingival involvement is commonly seen in lichen planus, a chronic mucocutaneous inflammatory condition of the stratified squamous epithelia. It is often painful and may undergo malignant transformation and thus warrants early diagnosis and prompt treatment. The aim of this study is to evaluate the use of a bioresorbable membrane (Polyglactin 910) in the management of erosive lichen planus of gingiva.

MATERIALS AND METHODS

A split-mouth randomized controlled trial was carried out. Fifteen patients with identical bilateral lesions of lichen planus on gingiva were included in the study. Three parameters were selected for the clinical assessment of gingival lesions: Surface texture, color, and burning sensation. After complete oral prophylaxis, an excisional biopsy procedure was carried out for lesions on both sides, but on the experimental side, the biopsy procedure was combined with placement of the bioresorbable membrane. The statistical significance of intergroup differences in measurements was tested by using an independent sample t-test. A two-tailed P-value less than 0.05 was considered as statistically significant.

RESULTS

Intragroup comparisons revealed a statistically significant difference between mean value of grades at 6, 12, and 24 weeks in both groups for the surface texture, color, and burning sensation of gingiva, respectively. For intergroup comparison of change in surface texture, color, and burning sensation of gingiva between group A and group B, differences were statistically nonsignificant.

CONCLUSION

Surgical management of the lesion accomplished significant improvement of lesion with no significant additional clinical benefits with the application of bioresorbable membrane. Worsening of baseline scores was not observed in any case at the end of the study.

Oral lichen planus - retrospective study of 563 Croatian patients

Objectives: To investigate the epidemiological and clinical characteristics of oral lichen planus (OLP) in a group of Croatian patients seen between 2006 and 2012. Study Design: A group of 563 patients with a diagnosis of OLP was retrospectively reviewed in our clinic. Data regarding age, gender, medical history, drugs, smoking, alcohol, chief complaint, clinical type, localization, histology, treatment and malignant transformation were registered. Results: Of the 563 patients, 414 were females and 149 were males. The average age at the diagnosis was 58 (range 11-94). The most common site was buccal mucosa (82.4%). Most of our patients did not smoke (72.5%) or consume alcohol (69.6%). Patients reported oral soreness (43.3%), mucosal roughness (7%), xerostomia (3%), gingival bleeding (2%) and altered taste (0.5%) as the chief complaint, while almost half of them were asymptomatic (44.2%). The most common types of OLP were reticular (64.8%) and erosive (22.9%). Plaque-like (5.7%) atrophic/erythemtous (4.3%) and bullous (2.3%) type were also observed. Malignant transformation rate of 0.7% was recorded. Conclusions: OLP mostly affects non-smoking middle-aged women. Buccal mucosa is the most commonly affected site. In almost half of the cases patients are asymptomatic. In spite of the small risk for malignant transformation all patients should be regularly monitored.

Key words:Oral lichen planus, malignant transformation, epidemiology, retrospective study.

A retrospective comparative study on clinico-pathologic features of oral lichen planus and oral lichenoid lesions

Introduction:

Oral Lichen Planus (OLP) and Oral Lichenoid Lesions (OLLs) are clinically and histopathologically similar lesions but with different etiologies and treatment plan, thus differentiating these two has been the center of many researches. Studies in different populations have been performed on clinical and histopathologic features of OLP and OLLs. Thus aim of the present study was to evaluate and also compare the clinical and histopathologic features of these two diseases in a 10-year period in Esfahan.

Materials and Methods:

This descriptive–analytic study was based on retrospective survey of 232 records with clinical and histopathologic diagnosis of OLP and OLLs available from archive of oral pathology, Esfahan dental school 2000-2010. Data was statistically analyzed by use of independent t-test, Fisher exact, and Chi-square.

Results:

Involvement of lip was the only clinically significant difference between OLP and OLLs, most seen in OLLs. Band-like inflammatory infiltrate mainly composed of lymphocyte, saw toothed rete ridges, Max Joseph space, and atrophic epithelium was significantly seen in OLP. While hyperkeratosis, deep connective tissue infiltrate composed of eosinophil, neutrophil, and plasma cell were seen in OLLs.

Conclusion:

Involvement of lip was the only clinically significant difference between OLP and OLLs. Histopathologically strict band like infiltration, atrophic epithelium, saw toothed rete ridges, and Max Joseph space are reliable criteria for differentiation of OLP as deep connective tissue infiltration and hyperparakeratosis are for diagnosis of OLLs.

Periodontopathogen profile of healthy and oral lichen planus patients with gingivitis or periodontitis

Oral lichen planus (OLP) is a chronic inflammatory disease that is frequently detected in oral tissues. The aim of our study was to identify the prevalence of the detection of periodontopathogenic microorganisms (Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia and Treponema denticola in OLP patients and to compare with this prevalence of periodontopathogenic microorganisms in healthy non-OLP patients. Our study included 27 (18 chronic periodontitis (OLPP) and 9 gingivitis (OLPG)) patients diagnosed with OLP along with 26 (13 chronic periodontitis (HP) and 13 gingivitis (HG)) healthy non-OLP patients. The multiplex polymerase chain reaction (PCR) with subsequent reverse hybridization method (micro-IDent) was used for identifying periodontopathogenic microorganisms present in subgingival plaque samples. The percentages of detection for A. actinomycetemcomitans, P. gingivalis, P. intermedia, T. forsythia and T. denticola in subgingival plaque samples taken from OLP patients (OLPG and OLPP) were 18.5%, 85.1%, 81.4%, 88.8% and 74%, respectively. Meanwhile, in the non-OLP patients (HG and HP), these values were 7.6%, 50%, 46.1%, 73% and 57.7%, respectively. Thus, comparing the non-OLP groups with the OLP groups, the periodontopathogens' percentages of detection in the OLP groups were higher than those in the non-OLP groups. According to our study results, OLP patients have higher levels of infection with A. actinomycetemcomitans, P. gingivalis, P. intermedia, T. forsythia and T. denticola than non-OLP patients. We argue that the high percentages in patients with OLP may help identify the importance of periodontopathogenic microorganisms in the progress of periodontal diseases of OLP.

A retrospective study of 370 patients with oral lichen planus in Turkey

Objectives: Although several detailed studies concerning the patient profile and clinical features of oral lichen planus have been undertaken all over the world in different populations, a similar study has not yet been conducted in a Turkish population. The purpose of this retrospective study was to describe the demographic and clinical characteristics of a group of patients with oral lichen planus in Turkey. Study Design: Charts of 370 patients, from the archive of Oral Diagnosis and Radiology Department of Marmara University Faculty of Dentistry (Istanbul, Turkey), with histologically confirmed clinical diagnosis of oral lichen planus in the period 1990-2010 were retrospectively reviewed. Results: Of the 370 patients, 260 (70.3%) were women and 110 (29.7%) were men. The mean age was 49.84±13.41 years (range of 16-83). The lesions were asymptomatic in 63 patients (17%). Nearly half of the patients (47.6%) had multiple sites of involvement. Predominantly red forms were the most frequent, affecting 60.5% of patients. Approximately 17% of the patients had symptoms of possible extraoral involvement. No evidence suggesting a connection between oral lichen planus and tobacco or alcohol use was found. Only one out of the 370 cases had histologically proven malignant transformation. Conclusions: The patient profile and clinical features of oral lichen planus in Turkey were generally similar to those described in other populations. The preponderance of the red forms and also the fact that majority of patients referred themselves to our clinic highlighted the lack of awareness among Turkish health care providers about lichen planus.

Key words:Oral lichen planus, clinical features, patient profile.

Clinical variants of lichen planus

Lichen planus is characterized by lichenoid, polygonal papules with fine white lines, called Wickham striae. Lesions most commonly occur on the limbs and on the dorsal aspect of the trunk. At the same time often leukoplakia of mucous membranes as well as nail disorders are seen. There are numerous variants of lichen planus which can be distinguished from the classical form on the basis of morphology and distribution of the lesions. The typical primary lesion of lichen planus may be replaced by other forms, such as patches, hyperkeratoses, ulcerations, or bullous lesions. Moreover, distribution patterns of these lesions may vary and include erythrodermic, inverse or linear arrangements. In contrast to these numerous clinical features, histologic findings remain characteristic in the variants, so that the diagnosis can be made securely. Differential diagnoses of lichen planus include diverse dermatoses such as bullous pemphigoid or paronychia.

Oral lichen planus: REU scoring system correlates with pain

OBJECTIVES

The objectives of this study were to correlate a semiquantitative scoring system for oral lichen planus (OLP) with pain before versus after treatment and to analyze sites of involvement and candidal status of patients in a retrospective study.

STUDY DESIGN

Reticulation/keratosis, erythema, and ulceration (REU) scores and numerical rating scale (NRS) for pain were used. Correlation was tested using Spearman rank correlation, and the change in REU and NRS scores using the paired t test.

RESULTS

One hundred fifteen patients were evaluable with 55 follow-up visits. Pain showed positive correlation with the total weighted score (r = .40), erythema (r = .35), ulceration (r = .31), and reticulation scores (r = .29), all at P < .005. There was improvement in REU and NRS scores before versus after treatment (P < .0001). The internal consistency reliability analysis yielded good reliability with Cronbach coefficient alpha of 0.70. The ventral tongue, floor of mouth, and soft palate were never the only sites affected. Candidal carriage was present in 24% of cases but candidiasis developed in only 10% of carriers.

CONCLUSIONS

The REU system is easy to use, correlates with an NRS for pain, and reliably reflects improvement attributable to treatment. Ventral tongue, floor of mouth, and soft palate were sites of OLP only if other sites were involved and candidiasis did not always develop in patients who were carriers.