Oral lichen planus and stress: An appraisal

A New Scoring System of Oral Lichen Planus

Lichen planus (LP) is a chronic, immune-mediated mucocutaneous disorder increasingly becoming common in the general population with female predominance. Clinically, there are different forms of lichen planus with the presence of the main characteristic feature of Wickham striae. Literature, to date, is abundant with various scoring systems of oral lichen planus, and among them, the most commonly followed scoring system was the one proposed by the Thongprasom system because of its simplicity and ease of application.

Aim

The aim of the present study is to critically review all the disease scoring systems on oral lichen planus (OLP) that have been reported in the literature during the past decades. A systematic literature search was performed using PUBMED, MEDLINE, EMBASE, and COCHRANE Library with language restriction to English. The search was carried out incorporating the published literature from 1980 to 2020 using the MeSH (medical subject heading) terms. A literature search was done using keywords: Staging, Grading, Oral lichen planus, Diagnostic, and Therapeutic. Out of 25 publications, related to search strategy, 22 full articles, which were related to the disease scoring system for oral lichen planus, were acquired for further inspection. Out of the 22 articles, 15 articles met the inclusion criteria. The data was collected and a brief summary of the studies regarding the different disease scoring systems for oral lichen planus was explained. Taking into consideration, the parameters were not included in the previous disease scoring system. A new proposal encompassing a scoring system for oral lichen planus considering the missing parameters along with an amalgamation of histopathological criteria of dysplasia is presented. It also proposes to grade and stage the lesions and recommend appropriate therapy for each of such lesions.

Psychological Functioning of Women Diagnosed with Lichen Planus and Other Diseases of the Oral Cavity-Explorative Study

The role of psychosocial factors in the development of changes in lichen planus and other diseases of the oral cavity has been implicated, but is still understudied. Therefore, the aim of our study was to describe the specific profile of psychological functioning of patients with these diseases, including the role of temperamental traits, action-oriented personality components, and self-esteem. In total, 94 adult women participated in the study: (1) with lichen planus (LP; n = 46; Mage = 54.80, SD = 12.53), (2) with other oral conditions (n = 25; Mage = 34.76, SD = 16.03), (3) without chronic disease (n = 24; Mage = 40.96, SD = 13.33). The following questionnaires were used: ZKA-PQ/SF, Polish Adaptive and Maladaptive Perfectionism Questionnaire, ACS-90, PROCOS, and MSEI. Results indicated no significant differences in temperament dimensions between studied groups. However, women diagnosed with LP presented lower levels of maladaptive perfectionism and social support than healthy women. Furthermore, women with LP also obtained lower scores for social resourcefulness and higher scores for moral self-approval than healthy women. Summarizing, patients with LP often use compensatory mechanisms that negatively affect their social functioning; thus diagnostic/therapeutic programs directed towards those group should be holistic, including psychologists and psychiatrists who support patients' psychological well-being.

French guidelines for the management of oral lichen planus (excluding pharmacological therapy)

INTRODUCTION

Oral lichen is a chronic inflammatory disease for which diagnostic management and follow-up are heterogeneous given the absence of specific guidelines in France. Our objective was to develop French multidisciplinary guidelines for the management of oral lichen.

MATERIALS AND METHODS

Working groups from the Groupe d'Etude de la Muqueuse Buccale (GEMUB) formulated a list of research questions and the corresponding recommendations according to the "formal consensus" method for developing practice guidelines. These recommendations were submitted to a group of experts and the degree of agreement for each recommendation was assessed by a scoring group.

RESULTS

Twenty-two research questions, divided into 3 themes (nosological classification and initial assessment, induced oral lichenoid lesions, and follow-up) resulted in 22 recommendations. Initial biopsy for histology is recommended in the absence of reticulated lesions. Biopsy for direct immunofluorescence is recommended for ulcerated, erosive, bullous types and for diffuse erythematous gingivitis. Management should include a periodontal and dental check-up, and investigation for extra-oral lesions. Hepatitis C testing is recommended only if risk factors are present. Definitions, triggering factors and the management of "induced oral lichenoid lesions" were clarified. Oral lichen must be monitored by a practitioner familiar with the disease at least once a year, using objective tools.

CONCLUSION

This formalised consensus of multidisciplinary experts provides clinical practice guidelines on the management and monitoring of oral lichen.

A comparison of proliferative capacity of reticular and erosive variants of oral lichen planus by argyrophilic nucleolar organizer regions method

Background

Oral lichen planus (OLP), an immune mediated disorder, has been recognized since 1869 and is presented as any one of the six variants. Reticular and erosive are the most frequently encountered. Its proliferative capacity can give some information regarding its progression. We adopted the argyrophilic nucleolar organizer regions (AgNORs) method because of its simplicity to use and dependable results. We evaluated AgNORs in basal, suprabasal, and squamous cell layers. We also compared these three layers within two variants, reticular, and erosive.

Materials and Methods

Thirty clinically diagnosed patients of OLP were included in the study. Reticular and erosive variants were included in our study. This was followed by hematoxylin and eosin staining and later by the AgNOR method. The mean number of AgNORs per nucleus was calculated.

Results

Thirteen males and 17 females were the gender distribution. Twenty-three (76.67%) had reticular pattern and seven (23.33%) had erosive pattern. The basal cell layer had the highest mean AgNOR compared to suprabasal and squamous layers. Even among, erosive and reticular variants, the former had higher mean AgNOR counts.

Discussion

Our results suggest that the inflammatory infiltrate close to the epithelial cells can alter the proliferation index for the pattern of protein synthesis of these cells. Moreover, the high proliferative index in OLP can be related to a specific immunologic response.

Conclusion

We conclude that AgNOR can be used as a proliferative marker in earlier lesions to detect the severity.

Case Report: Treatment of Oral Lichen Planus With a Focus on Psychological Methods

Oral lichen planus (OLP) is one of the most common chronic diseases; however, its etiology remains unknown. More and more studies have revealed that emotional instability is one of the risk factors for the onset and expansion of OLP, especially in patients suffering from depression, anxiety disorder, and acute stress. In this case report, we had a 32-year-old female OLP patient who had no obvious response to conventional OLP drugs. Then we switched to a combination of psychotropic drugs and psychotherapies. By regulating mood through drugs and psychological counseling, the patient's oral disease was alleviated. Our case shows that clinicians should consider the mental problems of OLP patients. It also emphasizes the importance of medications and psychological counseling in the treatment of somatic diseases.

Relationship of psychological factors with salivary flow rate and cortisol levels in individuals with oral lichen planus: A case-control study

OBJECTIVE

The objective of this study was to analyze the relationship between psychological factors and salivary flow rate and cortisol levels in individuals with oral lichen planus.

STUDY DESIGN

A case-control study of 21 individuals with clinical and histopathological diagnosis of oral lichen planus and 21 individuals without the disease (controls), matched by sex and age, was performed. The Beck Anxiety and Depression Inventories and Perceived Stress Scale were administered, and the salivary flow rate and salivary cortisol secretion pattern were determined. Data were statistically analyzed using Mann-Whitney U, McNemar's χ², and Student's t tests and the Spearman correlation coefficient. The significance level adopted was 5%.

RESULTS

Individuals with oral lichen planus had higher anxiety (P = .001), depression (P = .005), and perceived stress (P = .026) scores, but no association was found between the disease and salivary flow rate (P = .29) or with the pattern of salivary cortisol secretion (at awakening: P = .98; 30 min post-awakening: P = .95; at bedtime: P = .97).

CONCLUSION

An association was observed between oral lichen planus and anxiety, depression, and stress scores through psychological tests but not in relation to salivary flow rate and the pattern of salivary cortisol secretion.

Anxiety and oral lichen planus

OBJECTIVES

To investigate the association between oral lichen planu(OLP) and anxiety.

SUBJECTS AND METHODS

This study included 174 OLP patients and 174 healthy controls. We assessed anxiety by Self-rating Anxiety Scale (SAS) and recorded OLP lesion type and severity. t test and analysis of variance were applied for continuous variants and chi-square test was performed for categorical variants. Multiple linear regression and logistic regression analysis were used for multi-variable analysis.

RESULTS

he SAS score of OLP patients was higher than that of healthy individuals. There was no significant difference in SAS score between the OLP subgroups, obtained according to age, type, and severity, respectively. Multiple linear regression analysis showed gender was the only factor that affected the SAS score of OLP patients. Compared with weakly anxiety-related groups, the SAS score and female ratio of highly anxiety-related group were obviously higher. Logistic regression analysis demonstrated that males were less exposed to highly anxiety-related types than females.

CONCLUSIONS

OLP patients tend to be more anxious compared with healthy individuals, and female patients are more anxious than male patients. There might be two types of OLP patients: weakly anxiety-related or highly anxiety-related. These results highlight the significance of psychological counseling in OLP disease management.

Serological and psychological assessment of patients with oral lichen planus using serum cortisol levels and hads questionnaire-a case control study

BACKGROUND

Oral lichen planus (OLP) is a T cell-mediated chronic autoimmune disorder directed against antigens secreted by the basal cell layer, with an incidence of 0.02-0.22% in Indian population and showing female predilection. Stress is considered one of the etiological factors in the causation, progression, and recurrence of this disease.

OBJECTIVES

To evaluate the levels of serum cortisol, anxiety, and depression in patients with symptomatic OLP and to correlate the levels of serum cortisol with anxiety and depression.

METHODS

Sixty subjects were categorized into two groups. Group A: 30 adults with no history of OLP and no psychological history of anxiety and depression. Group B: 30 patients with clinically and histopathologically diagnosed symptomatic OLP. The subjects in both groups were evaluated for anxiety and depression levels using the Hospital Anxiety and Depression Scale (HADS) questionnaire and serum cortisol levels (8-9 am sample) using the chemiluminiscence method.

RESULTS

Higher depression and anxiety levels were significantly associated with group B with significant P values (P < 0.0001 and <0.0002 respectively) when compared with group A; higher mean serum cortisol levels were seen in group B compared with group A, with P < 0.0001. In group A, a positive correlation was found between depression, anxiety, and serum cortisol levels with non-significant P-value. In group B, a positive correlation was found between depression, anxiety, and serum cortisol levels with a significant P value (P < 0.0001).

CONCLUSION

Increased levels of depression and anxiety with increased serum cortisol levels were observed in subjects with OLP.

Lichen Planus − the role of the general dental practitioner

Oral lichen planus is frequently encountered in primary and secondary dental care. The soft tissues of the mouth should always be examined carefully at check-ups and any abnormality be palpated to detect change in consistency (induration) along with any changes in colour or general appearance. Such changes should prompt a referral for specialist review.

CPD/Clinical Relevance: The general dental practitioner (GDP) can play a simple yet effective role in the management of lichen planus by removing obvious traumatic stimuli, improving oral hygiene and advising on simple topical treatment.

Cutaneous, genital and oral lichen planus: A descriptive study of 274 patients

Background

Lichen planus (LP) is a chronic autoimmune disease that affects the oral mucosa as well as the skin, genital mucosa and other sites. Objective: to evaluate the correlation between oral, genital and cutaneous lichen planus, in a sample of LP patients.

Material and Methods

This descriptive study reviewed 274 clinical histories of patients, who all presented histological confirmation of lichen planus verified by a pathologist, attending research centers in Barcelona.

Results

A total of 40 LP patients (14.59%) presented genital lesions. Of 131 patients with cutaneous LP (47.8%), the most commonly affected zones were the body’s flexor surfaces, representing 60.1% of cases. 24% of patients (n=55) related the start of the lesions with previous stress events. Of the 131 subjects with cutaneous lesions, 19% (n=25) also presented oral lichen planus (OLP). Of the total sample, 53.6% (n=147) of patients presented oral lesions. The systemic diseases most commonly associated with this patient sample were psychological problems such as stress, anxiety and depression (48%), hypertension (27%), gastric problems (12%), and diabetes (9.7%). A family history of lichen planus was found in only 2 cases (0,72%) out of the total of 274.

Conclusions

Any patient with OLP should undergo a thorough history and examination to investigate potential extraoral manifestations. The fact that 37 patients with OLP in this patient series were identified with simultaneous involvement at more than one site highlights the need for thorough evaluation and multidisciplinary approaches to this disease.

Key words:Oral lichen planus, extra-oral manifestations, cutaneous lichen planus, genital lichen planus.

State of the Art on the Use of Portable Digital Devices to Assess Stress in Humans

The aim of this study is to review the current tools for the assessment of stress response in humans, ranging from the use of psychological questionnaires to the latest tools involving portable digital devices. Practical implications in educational context are further discussed.

How general dentists could manage a patient with oral lichen planus

BACKGROUND

The literature hardly contains information on how patients suffering from oral lichen planus could be managed by dentists.

MATERIAL AND METHODS

Based on the limited available literature and particularly on the long-term clinical and histopathological experience of one of the authors, suggestions on how dentists could manage patients with oral lichen planus have been put forward.

RESULTS

In most cases, the dentist should be able to establish a correct diagnosis. Occasionally, the dentist may call upon a specialist, usually an oral medicine specialist or an oral and maxillofacial surgeon for confirmation of the diagnosis, possibly a biopsy procedure, and management of the patient in case of severe symptoms. Proper patient information is of utmost importance in the management.

CONCLUSIONS

General dentists can be expected to manage the majority of patients with oral lichen planus. Some patients may need to be referred for diagnostic purposes to a specialist; this is also the case for the rare patient with severe symptoms, possibly requiring systemic treatment.

Scoring systems for Oral Lichen Planus used by differently experienced raters

Background

Scoring systems have been widely used to evaluate the severity and activity of oral lichen planus (OLP). The aim of the present study was to compare two existing (one modified) scoring systems in the evaluation of OLP severity and correlation with pain. Three differently experienced raters were involved.

Material and Methods

Consecutive patients with OLP were assessed for pain using the Visual Analogue Scale and examined at 10 intraoral sites before starting (T0) and three weeks after (T1) steroid therapy (Clobetasol). Three differently experienced raters evaluated photographs using two scoring systems designated White-Erosive-Atrophic (WEA) modified from an older WEA system (WEA-MOD) and Reticular-erythematous-Ulcerative (REU) systems. WEA-MOD Kendall’s W and interclass correlation coefficient were calculated and correlation between REU/WEA-MOD and pain was calculated using Spearman coefficient.

Results

Most patients showed lesions on buccal mucosa (85-93,5%) and maxillary/mandibular gingivae (31,8-31,2%), predominantly reticular. At T0, Kendall-W coefficients of 0.89 and 0.74 were obtained for the REU and WEA respectively. At T1, Kendall-W coefficients of 0.83 and 0.58 were obtained for the REU and WEA respectively. Interclass correlation coefficient ranged from 0.87 to 0.90 for REU and from 0.58 to 0.87 for WEA. REU and WEA scores significantly decreased after therapy (p<0.000) as well as VAS (p<0.05). REU score showed correlation with VAS.

Conclusions

All the raters achieved comparable measures using REU whereas WEA and WEA-MOD seem less reproducible. REU seems to correlate to disease activity and pain.

Key words:Oral lichen planus, scoring system, VAS, REU, WEA, rater.

Incidence of Oral Lichen Planus in Perimenopausal Women: A Cross-sectional Study in Western Uttar Pradesh Population

Background:

Hormonal fluctuations during menopause lead to endocrine changes in women, especially in their sex steroid hormone production. Studies have documented the role of estrogen and progesterone (Pg) on autoimmune disorders such as multiple sclerosis, systemic lupus erythematosus, and rheumatoid arthritis. Lichen planus (LP), an autoimmune disorder, seen frequently in perimenopausal women, may also get affected by sex steroid hormones, but no direct relationship has been established yet.

Aim:

The aim of this study is to find the incidence of oral LP (OLP) in perimenopausal women and evaluate the factors associated with it.

Materials and Methods:

This cross-sectional study was conducted over a period of 1 year. All the perimenopausal women (44.69 ± 3.79 years) who came to the dental outpatient department were evaluated for the presence of LP and various factors associated with it. Depression Anxiety Stress Scale-21 questionnaire was used for psychometric evaluation of perimenopausal women.

Results:

According to our study, incidence of LP in postmenopausal women was 10.91%, which is higher than incidence of LP in general population, i.e., 0.5% to 2.0%. Incidence of LP increased with the severity of depression in perimenopausal women (P = 0.000).

Conclusion:

The incidence of OLP is higher in perimenopausal women than in general population and increases significantly with increase in the severity of depression. LP in perimenopausal women can be mediated by declined level of estrogen and Pg directly or indirectly through causing depression that can trigger LP.

Clinical characteristics and analysis of familial oral lichen planus in eight Chinese families

Oral lichen planus (OLP) is one of the most common oral mucosa diseases; however, familial OLP is uncommon. The present study reported and analyzed patients with familial OLP (n=18) in eight different Chinese families between January 1, 2012 and December 31, 2013. Parameters analyzed include gender, age at diagnosis, lesion distribution and lesion type. The follow-up period for each patient was a minimum of 1 year. In this survey, 18/88 individuals in the eight families were affected. Females were more frequently affected, and the female to male ratio for familial OLP (2.2:1) was higher compared with that previously reported for nonfamilial OLP (1.4:1). The age at diagnosis, lesion distribution and lesion type showed consistency with reports concerning nonfamilial OLP, with the exception of family VI, in which 4/5 children had OLP/LP lesions and were of an early age at diagnosis. There were two families in which three generations had been affected by OLP. In addition, it appeared that patients of the same generation in the same family were of a similar age at diagnosis. No malignant or premalignant lesion was identified in the 18 individuals diagnosed with OLP from the eight families. The present study supports the hypothesis that genetic predisposition may serve a role in the etiology of OLP.