ORAL LICHEN PLANUS. HOW SHOULD I MANAGE?

INTRODUCTION

At times patients come to the dentist with a complaint of a severe burning sensation in their mouth. On examination, some of them will be diagnosed with lichen planus. But most of them do not understand the nature of disease progression in lichen planus. Hence, I am going to give a brief overview along with natural and home remedies for Oral lichen planus. The terms in this article are going to be simple so that a layperson can also understand. 

In many places in this article, I use the term “OLP” instead of ORAL LICHEN PLANUS. Hence please do bear with us when you read OLP.

PRESENTATION

Oral lichen planus is a chronic inflammatory condition affecting various parts of the oral cavity. One exciting feature of lichen planus is, it has periods of waxing and vanning. Let me explain in detail.

A patient with OLP complains of a severe burning sensation for a few days or weeks, later the disease becomes dormant for another few weeks. Again the same cycle repeats. In simple words, we can say that the disease occurs cyclically with periods of severe illness, followed by periods of no infection.

It is the principal characteristic feature of lichen planus. Hence people with OLP often complain only about, episodic burning sensation of the oral cavity.

There are many types of OLP. Their presentation varies in the oral cavity according to the kind of OLP. In most cases, OLP represents white lacy-like lines on a red background. These can be easily identified in inner cheek regions. It also involves other parts of the oral cavity like the gums, palate, and tongue.

Note: Lichen planus can be represented in various forms in the oral cavity. It is sometimes difficult to identify and many times are confusing to differentiate from other diseases. Hence it’s always better to consult an oral physician or an Oral medicine expert for diagnosing the disease.

OLP ON TONGUE

Oral lichen planus affecting the tongue is seen in many patients. It is usually associated with de-papillation of the tongue, that is, loss of taste buds in the affected area. Sometimes white patches or white lines appear on the tongue related to a severe burning sensation.

ON GUMS

When OLP affects gums, patients suffer from severe swelling of the gums. They also sense severe pain. Red inflamed gums which are tender to touch and bleed easily can be seen in most patients with OLP on gums. Diffuse white areas with red inflamed gums are classic features of OLP.

SYMPTOMS

The primary symptom of OLP is a burning sensation. This feature is observed in almost 90-95% of patients. They find difficulty in eating spicy food. In severe conditions, this burning sensation can increase to such a level, where the patient senses burning sensation even during the drinking water.

In most cases, we can see white lines in the lesion area, on a red or inflamed background. This is called the Reticular lichen planus.

In some patients, we do not see any white lines. But some reddened or inflamed areas can be seen. Such patients with severe burning sensation are usually diagnosed with Erosive Lichen Planus.

In a few cases, OLP patients find bubbling of the affected area, which ruptures and bleeds profusely. This condition is a variant of OLP called bullous OLP.

CAUSES

We cannot attribute OLP to one specific reason. 

In most cases, they are connected with the T-cell immunity of our body. Some consider it as one form of autoimmune disease, where the immune cells of our body fail to recognize our innate cells and destroy our body cells, leading to severe tissue injury.

There are many research articles, which attribute OLP with stress. 

Yes! Stress is one crucial factor that is known to cause and aggravate OLP. Depression, anxiety, and stress can affect the way OLP progresses.

They have a profound impact even on the treatment. Stress management is a primary concern in patients with OLP. The effect of the medication is less effective if the respective patient fails to manage his stress.

OLP – BIOPSY

Many a time the clinical presentation of OLP may not be as classic as we read in books. Sometimes it’s hard to confirm OLP based on clinical presentation only. In such a case, your dentist will advise a biopsy for histopathological confirmation.

The decision whether to go for a biopsy or not will and should be decided by your examining dentist. Histopathological evidence of OLP gives a good idea of the nature of the lesion. It will help the dentist in formulating a proper treatment protocol.

TREATMENT

Almost 90% to 95% of patients with OLP complaint of severe burning sensation. Hence the primary mode of treatment is directed towards decreasing burning sensation. In this regard, patients are advised desensitizing or anesthetic mouthwashes (ORAL LICHEN PLANUS MOUTHWASH) to reduce the burning sensation. This helps the patient in taking a good diet. As a result, the body gets a good nutrition supply.

Along with it, the treatment should be directed towards decreasing inflammatory factors, which aggravate burning sensation. In this regard, the dentist advises various modes of anti-inflammatory drugs like steroids. The method of application depends on the severity of the disease and is decided by the dentist.

The final treatment protocol is directed towards decreasing stress. Patients are counseled to identify their problems. It’s always better to consult a psychologist or stress therapist in case of severe stress.

Patients are also advised nutritional supplements along with the above medication.

ORAL LICHEN PLANUS AND CANCER

The probability of OLP transforming into oral cancer can never be neglected. In a recent article published in the journal of oral disease, a systematic review was done on the malignant transformation rate of OLP. They found a 1.37% chance of OLP turning into malignancy. 

Though the number appears to be small, the impact of OLP on oral cancer is profound.

It is an excellent practice to undergo a biopsy in OLP, which gives a clear idea of the stage of dysplasia, the present cells are. Dysplasia is a measure of malignancy. The more the dysplasia, the more is the chance of lesion turning into cancer.

DIET

I always advise patients with OLP to have a more vegetarian diet full of anti-oxidants. Food with anti-oxidants, help in prompt healing of the lesion. Having green tea in the morning is a good practice, as it contains a high concentration of flavonoids.

Tomatoes contain a high level of anti-oxidants. Lycopene, the natural extract of tomatoes is given as an anti-oxidant supplement in many diseases.

Food rich in omega-3 fatty acids aid in combating inflammation of the oral cavity, aids in the fast healing of the disease.

ORAL LICHEN PLANUS – NATURAL TREATMENT

The primary mode of treating OLP naturally is to control stress. A stressful life not only aggravates the condition of disease but also makes the treatment in vain.

I advise patients to do yoga and meditation regularly. Meditation is a powerful weapon in stress management. There are many proved cases where stress can be managed with meditation.

I have seen an improved effect of meditation on OLP in many patients. Meditation and medication act synergistically. The impact of drugs can be increased through meditation. 

Moreover, I advise patients to be away from foods, which they are allergic. Any allergic material may also aggravate the lesion. It can be even drugs. Hence patients should be cautious and should also observe their allergic status regularly.

A condition called LICHENOID REACTION mimics lesions similar to OLP but is purely from an allergic background.

Q & A

Will OLP go away?

The answer is no. Unfortunately, OLP is a disease that cannot be treated completely. We can only reduce the severity of the lesion.

Can oral lichen planus go away on its own?

Many patients experience this phenomenon. But in reality, the OLP has 2 phases. The waxing phase is represented by an increase in the severity of the lesion. The vanning represents the complete remission of the disease. People obviously think that their disease has gone completely. But again when the disease enters the waxing phase, the oral lesions reappear.

So oral lichen planus usually comes and goes on itself. We provide treatment only to reduce the severity of the lesion.

Can oral lichen planus lead to cancer [squamous cell carcinoma]?

Yes, OLP has malignant transformation potential. In other words, untreated severe forms of OLP can turn into cancer. But don’t worry; these transformation potentials are very minimal. Giuliani et al in their systematic review have advocated that the overall malignant transformation rate in OLP is 1.40%. https://www.ncbi.nlm.nih.gov/pubmed/29738106

Hence Oral lichen planus is considered a pre-cancerous condition.

Can oral lichen planus affect the throat?

Oral lichen planus can occur in any region oral cavity, starting from the gingiva to the floor of the mouth. The effect of OLP on the throat can cause severe pharyngitis-like symptoms in some patients.

Can oral lichen planus be scraped off?

No, the lesion cannot be scraped off. Usually, the lesion has many presentations in the oral cavity. The papular form of OLP mimics Leukoplakia and oral thrush. Lesions in oral thrush can be scraped off, but not in lichen planus.

ALSO READ:

10 things you should know about leukoplakia

Does oral lichen planus hurt?

Yes, most lichen planus lesions produce a severe burning sensation in the mouth. Patients find difficulty in eating spicy food. This is a common symptom in OLP.

Can oral lichen planus spread to other parts of the body?

Usually, a severe and untreated form of OLP can be seen in combination with a dermal counterpart. Dermal lichen planus usually arise from nail beds on the foot and fingers. Hence a dermal check-up in patients with OLP is advisable.

Can oral lichen planus cause swollen lymph nodes?

The presentation is very rare. Usually, they do not produce any lymph node involvement. But in rare cases where there is a malignant transformation [cases where lichen planus turned into malignancy] we can see lymph node involvement.

But remember there are many other reasons for lymph node enlargement. Hence have a thorough check-up for correct diagnosis. Don’t be in a panic, this presentation is very rare.

Does oral lichen planus cause receding gums?

Usually, lichen planus involvement on gums presents with severe inflamed and swollen gums with bleeding tendencies. In longstanding cases, we can see receding gums.

Can oral lichen planus kill you?

OLP is not a life-threatening disease. It has to be managed with regular medication.

Can oral lichen planus cause bad breath?

Yes! Inflamed and swollen gums act as potential areas for food lodgement, which can cause bad breath or oral malodor.

Can oral lichen planus cause burning mouth syndrome

Oral lichen planus causes the burning sensation in the mouth, but it doesn’t produce burning mouth syndrome(BMS). BMS and OLP are different from each other.

Can OLP cause dry mouth?

Oral lichen planus can be associated with dry mouth. Even the medication used to treat OLP can cause dry mouth.

What triggers OLP?

The triggers for oral lichen planus are many. Out of them, the most common trigger is STRESS. Chen HX et al reports 77% of patients in his study supported “EMOTIONAL STRESS” as a major trigger factor to flare up OLP. https://www.ncbi.nlm.nih.gov/pubmed/28732699

What is erosive oral lichen planus?

The erosive form of OLP is one of the severe forms of OLP. They represent few red areas in the oral cavity that are tender and bleed on touch. Patients with erosive forms will have a severe burning sensation.

What medications/drugs cause oral lichen planus?

Usually, medications don’t cause lichen planus. Lesions that mimic lichen planus, but are caused due to medication are called “Lichenoid drug eruptions”. https://www.ncbi.nlm.nih.gov/pubmed/9467343

Most common drugs like anti-hypertensives and anti-hyperglycemic drugs are found to produce lichenoid reactions in the oral cavity. For more information consult your dentist.

Who treats oral lichen planus?

There are Oral Medicine or Oral Biology experts in the field of dentistry who treat the disease. They are mainly concerned with oral mucosal lesions and diseases.

How does oral lichen planus start?

Usually, OLP starts as a small lesion in the oral cavity. In the initial days, it will be presented with a mild burning sensation. But many patients neglect such presentations until they become severe.

Is oral lichen planus an autoimmune disease?

OLP is a chronic inflammatory disease. Its etiology is not well understood. But many researchers support the autoimmune nature of OLP. https://www.ncbi.nlm.nih.gov/pubmed/22017396

Is oral lichen planus contagious?

No! OLP is a non-contagious inflammatory disease with an autoimmune component in it.

Is oral lichen planus hereditary?

No!

Is it a fungal infection?

No!

Is it a symptom of lupus?

No! Lupus is a different entity when compared to oral lichen planus.

OLP on gums

Oral lichen planus on gums produce severe gingival swellings with bleeding tendencies. Patients have a common sign of bleeding while brushing.

OLP on tongue treatment

OLP on the tongue produces a severe burning sensation and altered taste sensation. Patients usually complain if missing the taste of food.

OLP foods to avoid

OLP can be triggered by allergic foods.  Remember allergic foods don’t cause Oral lichen planus, but they may aggravate the symptoms. https://www.ncbi.nlm.nih.gov/pubmed/28732699

OLP and alcohol

Alcohol can aggravate the symptoms of oral lichen planus by causing severe mucosal dryness. Patients usually complain of increased burning sensation.

Oral lichen planus and hepatitis c

The association between Lichen planus and hepatitis C is not confirmed in the literature. There are many studies that support the association between them. https://www.ncbi.nlm.nih.gov/pubmed/26475515

At the same time, we have an equal number of studies that contradict the above statement. https://www.ncbi.nlm.nih.gov/pubmed/26411858

Hence a lot of research work is going on to know the association between Hepatitis C and Oral lichen planus.

Oral lichen planus and diabetes

Patient with oral lichen planus, hypertension, and diabetes common under GREENSPAN SYNDROME.

Which toothpaste should we use in OLP?

Any base toothpaste like Colgate white which doesn’t contain any added flavors to them can be used. Some people have an allergy to clove oil. Such patients can avoid pastes with cloves.

Gel pastes are not advisable to patients with oral lichen planus, as they may increase the burning sensation.

also read:

The toothpaste you should avoid in lichen planus

CONCLUSION

In my practice, I have seen a good number of patients who were diagnosed with OLP. Every time, when I talk to them, I always make it clear that this disease has no end. 

But it has only periods of exacerbation (when the disease becomes severe) and remissions (when the condition becomes dormant).

Even today where medical science has seen vast technical and pharmaceutical advancement, there is no complete remission for OLP. Stress management and proper diet with regular use of medication aids in suppressing the disease remissions.

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