Management of oral lichen planus

Oral Lichen Planus (LP), a disease defined as reticular, erosive, atrophic, or bullous in nature, is an immune mediated condition that typically develops in women in their fifth and sixth decade. Reticular LP, absent erythema, is asymptomatic and does not usually need intervention. However reticular LP associated with erythema or erosions needs treatment and periodic re-evaluation as there is potential for conversion to carcinoma. The literature suggests that erosive and ulcerated LP is best managed with topical corticosteroid preparations and in refractory cases, systemic steroids. Several other immunosuppressive medications and non-medication based interventions are also available but at greater cost and with greater potential for adverse reactions and side effects. This educational review article focuses on the best practices management of oral lichen planus. Educational Objectives At the conclusion of this educational activity participants will be able to: 1. Describe interventions used to manage oral lichen planus. 2. Identify the appropriate medications to be prescribed for managing erosive and ulcerative oral lesions. 3. Implement treatment strategies for managing oral ulcers associated with the disease. 4. Identify the interventions mentioned in the literature that are supported by limited evidence. Author Profile Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, University of Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associates. He can be reached at jeffreyaburgess@ hotmail.com. Author Disclosure Jeff Burgess, DDS, MSD has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. Publication date: Feb. 2015 Expiration date: Jan. 2018 This educational activity has been made possible through an unrestricted grant from PerioSciences. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.com Educational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. PennWell designates this activity for 3 continuing educational credits. Dental Board of California: Provider 4527, course registration number CA# 03-4527-15002 “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452. 2 www.ineedce.com Educational Objectives At the conclusion of this educational activity participants will be able to: 1. Describe interventions used to manage oral lichen planus. 2. Identify the appropriate medications to be prescribed for managing erosive and ulcerative oral lesions. 3. Implement treatment strategies for managing oral ulcers associated with the disease. 4. Identify the interventions mentioned in the literature that are supported by limited evidence. Abstract Oral Lichen Planus (LP), a disease defined as reticular, erosive, atrophic, or bullous in nature, is an immune mediated condition that typically develops in women in their fifth and sixth decade. Reticular LP, absent erythema, is asymptomatic and does not usually need intervention. However reticular LP associated with erythema or erosions needs treatment and periodic re-evaluation as there is potential for conversion to carcinoma. The literature suggests that erosive and ulcerated LP is best managed with topical corticosteroid preparations and in refractory cases, systemic steroids. Several other immunosuppressive medications and non-medication based interventions are also available but at greater cost and with greater potential for adverse reactions and side effects. This educational review article focuses on the best practices management of oral lichen planus.Oral Lichen Planus (LP), a disease defined as reticular, erosive, atrophic, or bullous in nature, is an immune mediated condition that typically develops in women in their fifth and sixth decade. Reticular LP, absent erythema, is asymptomatic and does not usually need intervention. However reticular LP associated with erythema or erosions needs treatment and periodic re-evaluation as there is potential for conversion to carcinoma. The literature suggests that erosive and ulcerated LP is best managed with topical corticosteroid preparations and in refractory cases, systemic steroids. Several other immunosuppressive medications and non-medication based interventions are also available but at greater cost and with greater potential for adverse reactions and side effects. This educational review article focuses on the best practices management of oral lichen planus. Introduction Lichen Planus (LP) is an immune mediated condition that can cause inflammation and erosion of the oral mucosa. Oral LP is characterized as reticular, erosive, atrophic, and bullous with the sub-diagnosis primarily based on clinical presentation. The condition typically develops in the fifth and sixth decade with women more likely to express the disease. It is rare in children. Disease prevalence rates for all forms of oral LP range from one percent1 to 6.3 percent.2 The prevalence rate for LP that causes mucosal erosion or erosive/bullous lesions is considerably less that the rate for reticular LP (one estimate: one percent of LP lesions) but a higher frequency of lesions may be reported because the symptoms associated with these latter problems tend to be more severe. The disease is often chronic with episodes of remission and reoccurrence. Reticular LP without adjacent erythema is asymptomatic. Erosive/ulcerative LP (ELP) is associated with significant inflammation and tissue erosion, and sometimes bullous oral lesions. When this is the case the patient is likely to describe a continuous moderate to severe aching pain that at times feels like burning.3 Pain is worsened with eating (particularly spicy or hot foods) or when the lesions contact alcohol. Widespread distribution of lesions throughout the mouth can be quite debilitating.4 The cause (or causes) of oral LP remains unclear but considerable research suggests that the primary disease mechanism is immune mediated.5 It is now thought that in most cases mucosal pathology is triggered by keratinocytes or modified Langerhans cells in either antigen specific (keratinocyte killing by CD8 cytotoxic cells) or antigen non-specific reactivity (mast cell degranulation and matrix metalloproteinase activation).6 It has also been proposed that in some cases of LP refractory to immunologic intervention the underlying cause may be partly neurogenic.7 Other factors or conditions that are reported in relation to the development of mucosal lichen planus include genetics,8 infection (e.g. the Hepititis C virus9 – even though the magnitude of the association may be minimal10), medication effects (termed a lichenoid drug reaction),11 vitamin or mineral deficiencies (e.g. b-12 insufficiency and iron deficient anemia),12 systemic disease (e.g. autoimmune diseases such as Sjӧgren’s disease, rheumatoid disease, pemphigus or graft versus host disease,13 and amalgam hypersensitivity.14 The fact that oral LP results from an immune system abnormality, regardless of the above considerations, informs most treatment considerations related to patient care. If underlying disease or a lichenoid drug reaction is strongly suspected as the cause of oral LP the patient should be referred for additional medical evaluation or in the case of medication, medical consultation. Even though oral lichen planus has been associated with a number of medical problems, the treating clinician should not conclude that the patient with oral lichen pl