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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 95-98

An unusual presentation of oral lichen planus with desquamative gingivitis


1 Department of Periodontics, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India
2 Department of Oral and Maxillofacial Pathology, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India

Date of Submission05-Dec-2019
Date of Acceptance19-Mar-2020
Date of Web Publication08-Jul-2020

Correspondence Address:
Dr. Nisha Ashifa
Department of Periodontics, Rajah Muthiah Dental College and Hospital, Annamalai University, Annamalai Nagar, Chidambaram - 608 002, Tamil Nadu
India
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DOI: 10.4103/srmjrds.srmjrds_86_19

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  Abstract 

Lichen planus (LP) is a chronic, autoimmune, mucocutaneous disease affecting the skin and mucosa. Oral LP (OLP) usually presents as a bilateral symmetrical lesion that affects approximately 1%–2% of the population. OLP exhibits a wide variety of clinical presentations. This case report deals with a 52-year-old female patient with OLP lesion isolated to the left buccal mucosa and desquamative gingivitis in relation to marginal gingiva of maxillary left premolars with white lacy striae extending from the left- to right-side central incisor region and a brownish-black-pigmented papule to the left angle of lip. Incisional biopsy was performed which revealed typical features of OLP. The patient was advised topical corticosteroids and antioxidants. She was subjected to oral prophylaxis to eliminate local irritating factors and was encouraged to follow meticulous oral hygiene measures to maintain periodontal health following which there was a resolution of the lesion and the symptoms.

Keywords: Desquamative gingivitis, mucocutaneous diseases, oral hygiene, oral lichen planus


How to cite this article:
Ashifa N, Rajasekar S, Kumar S, Parvathi V. An unusual presentation of oral lichen planus with desquamative gingivitis. SRM J Res Dent Sci 2020;11:95-8

How to cite this URL:
Ashifa N, Rajasekar S, Kumar S, Parvathi V. An unusual presentation of oral lichen planus with desquamative gingivitis. SRM J Res Dent Sci [serial online] 2020 [cited 2020 Aug 10];11:95-8. Available from: http://www.srmjrds.in/text.asp?2020/11/2/95/289174


  Introduction Top


Oral lichen planus (OLP), a mucosal variant of chronic inflammatory mucocutaneous disorder, was first reported as white papular eruptions in the oral cavity.[1] The prevalence of OLP is estimated to be 1%–2%, more commonly seen in females in the fourth–fifth decade of life.[2]

OLP classically presents as bilateral lesions, which can occur in six clinical types, namely reticular, papular, plaque-like, atrophic, erosive, and bullous.[3],[4] Histopathology usually reveals hyperkeratotic and acanthotic epithelium, with degeneration of basal keratinocytes and a band-like lymphocytic infiltration in the subepithelium.[5] To ensure accurate diagnosis, it is necessary to correlate clinicopathological and histopathological features.

Almost 10% of the patients with OLP show gingival involvement.[2],[6] Gingival lesions involving the marginal and attached gingiva often present as fiery red, shiny, smooth, and/or atrophic. Such lesions are termed “desquamative gingivitis.”[3],[4]


  Case Report Top


A 52-year-old female patient reported to the Department of Periodontics with a chief complaint of burning sensation in the upper left gum region for the past 2 months which was of insidious onset, moderate intensity, and aggravated on eating spicy food. The patient is a teacher by profession. She had no significant medical history, drug history, and family history. This was the patient's first dental visit. On extraoral examination, a brownish-black-pigmented papule was noted on the left angle of the lip [Figure 1]. On intraoral examination, erythematous marginal gingiva in relation to 24 and 25 [Figure 2], white striae in marginal gingiva in relation to 11, 21, 22, 23, 34, 35, 36, and 37 [Figure 3], and white radiating lines seen in relation to left posterior buccal mucosa in relation to 28 and 38 were noted. An irregular reticular patch measuring 1.5 cm × 1.2 cm was also noted on the left buccal mucosa in relation to 24, 25, 26, and 27 [Figure 4]. Full-mouth periodontal assessment was done. The Simplified Oral hygiene Index was used to assess the oral hygiene status of the patient, which was found to be fair. The generalized periodontal probing depth was PD ≤3 mm.
Figure 1: Brownish-black-pigmented papule at the left angle of the lip

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Figure 2: Erythematous marginal gingiva in relation to 24, 25

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Figure 3: White striae present along the marginal gingiva of 11, 21, 22, and 23

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Figure 4: Irregular reticular patch present in the left buccal mucosa

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On palpation, the lesion on the buccal mucosa was asymptomatic, smooth, and nonscrapable, and the gingival lesions were tender. The patient was subjected to routine hematological investigations and random blood sugar evaluation. The blood parameters were within physiological limits. The history and clinical features were suggestive of OLP, which was considered to be the provisional diagnosis and the differential diagnosis being lichenoid drug reaction.

After obtaining the patient's consent, an incisional biopsy of the left buccal mucosa was done and sent for histopathological evaluation. Histopathological examination of a biopsy specimen showed parakeratinized stratified squamous epithelium with elongated rete ridges and moderately fibrous connective tissue. There was a moderate infiltration of lymphocytes in subepithelial lamina propria, infiltrating the basal portion of the surface epithelium. Basal cell degeneration and separation of the epithelium were also noted [Figure 5] and [Figure 6], thus confirming the diagnosis of OLP.
Figure 5: Histopathological section of biopsy reveals typical features of oral lichen planus. The epithelium shows hyperparakeratosis and acanthosis. There is pronounced chronic inflammatory cells in the subepithelial connective tissue

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Figure 6: The epithelium exhibits hyperparakeratosis and acanthosis with hydropic degeneration of prickle cells

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The patient was advised to use topical triamcinolone 1% ointment three times daily for 2 weeks applied directly to the lesion. She was also prescribed antioxidant capsule Oxitard™ once daily for 2 months. The patient was subjected to oral prophylaxis to eliminate the local irritating factors and also motivated to maintain a high level of oral hygiene and attend regular follow-up appointments to ensure the maintenance of oral health.

The patient was reviewed after 2 weeks. The lesions showed a resolution of erythema in relation to marginal gingiva of 24 and 25 regions. Other areas of the lesion showed a significant improvement. The patient is still under follow-up.


  Discussion Top


Although the trigger factor of OLP is unknown, recent data suggests that its occurrence is attributed to abnormal T-cell-mediated immune response. The increased production of TH1 cytokines is said to be responsible for the development of lichen planus (LP). Genetic polymorphism of cytokines determines the site of occurrence of these lesions. The lesions that develop in the oral cavity alone are associated with interferon-gamma (IFN-γ), and those that involve oral cavity and skin are associated with tumor necrosis factor-alpha The T-cells migrate toward the oral epithelium, bind to keratinocytes and IFN-γ, and upregulate p53, MMP1, and MMP3 that lead to apoptosis of basal keratinocytes. The chronic course of OLP could be a result of the activation of nuclear factor-kappa B.[6]

OLP has the potential for malignant transformation, and the annual malignant transformation rate is reported to be <1%.[7],[8] Mignogna et al. reported that regular follow-up at least three times a year combined with strict clinical examination of the lesions can lead to prompt diagnosis at the early stages of malignant transformation.[9]

Bilateral occurrence of OLP is common and usually appears as a mixture of the clinical subtypes.[4] It is highly unusual for OLP lesions to occur in a single oral site other than gingiva. However, patients occasionally present with isolated lesions on the lip or tongue.[6]

Gingiva is a common site of involvement after buccal mucosa and tongue.[4] Mignogna et al. reported that 48% of the patients (336 out of 700 patients) presented with gingival lesions and isolated gingival involvement was found to be in 7.4% of the cases.[5] Camacho-Alonso et al. also reported a similar prevalence rate of gingival involvement of 38.4%, and the predominant gingival location in all the clinical forms was the simultaneous involvement of attached and marginal gingiva.[2]

Desquamative gingivitis is the most common type of gingival lesions observed in OLP.[6] It is characterized by intense erythema, ulceration, and desquamation of the marginal and attached gingiva. Symptoms may vary from mild discomfort to severe pain and burning sensation, with the severity of symptoms increasing from keratotic to the erosive forms. Due to the discomfort caused by the symptoms, patients may not be able to effectively practice oral hygiene measures. This leads to increased accumulation of local factors, increased gingival inflammation, and periodontal breakdown. For periodontal health maintenance in OLP, it is essential to achieve adequate plaque control. Hence, daily home care and professional oral hygiene measures are required for the symptomatic treatment of OLP lesions.[5],[10],[11] Garcia-Pola et al. reported that methodical maintenance of oral hygiene is effective in reducing clinical signs of the disease regardless of its pathogenesis. The authors also recommend the usage of toothbrushes with soft or extra-soft bristles, dental floss, and chlorhexidine mouthrinse twice a daily, initially with 0.2% concentration, continuing with the 0.12% concentration for 1–4 weeks.[12] Gingival OLP can also occur as small, raised, white, lacy papules or plaque-like lesions.[6]

The diagnosis of OLP and oral lichenoid reaction (OLR) requires a correlation of clinical and histopathological examination. The need for a recognized causative agent is essential for the diagnosis of OLR to establish a cause-to-effect relationship, which resolves on the removal of the offending agent.[3],[13] Furthermore, the correlation of clinical and histopathological features in the present case has led to the confirmation of the diagnosis of OLP.

In the above-mentioned case, the patient reported with symptomatic gingival lesion in relation to 24 and 25; therefore, the patient was prescribed a topical corticosteroid, three times daily for 2 weeks following oral prophylaxis. The patient also presented with a nonscrapable grayish-white-colored patch without any pain or discomfort in the left posterior buccal mucosa and at the left angle of the lip. White lacy striations on the marginal gingiva of 11, 21, 22, 23, 34, 35, 36, and 37 were noted. The patient did not report with any cutaneous lesion. She was not under any medication nor underwent any dental treatment at the time of reporting to the clinics, so the cause-to-effect relationship could not be established. Histopathologically, the lesion showed typical features of OLP. Biopsy of erosive gingival lesions is generally avoided due to the desquamation of the epithelium and the presence of nonspecific inflammatory changes.[14]

This patient presented with lesions on the left buccal mucosa and left angle of the lip. A similar unilateral mucosal presentation of OLP was reported by Bajpai et al.[15] Hartl et al. described a rare case of cutaneous and mucosal linear LP with unilateral restriction, with lesions restricted to the left side of the neck, tongue, and buccal mucosa.[16] Rekha et al. reported multiple brownish-black-pigmented papules in the lips, but in this case, the lesion is isolated to the left angle of the lip.[17] This patient also reported with white lacy striation in the marginal gingiva of 11, 21, 22, 23, 34, 35, 36, and 37, which is similar to white striations in the labial gingiva of 13 and 14, reported by Alsarraf et al.[1]


  Conclusion Top


OLP is an inflammatory mucocutaneous disorder with a significant gingival involvement. Since OLP can occur with wide variations in clinical appearance, they are often misdiagnosed or undiagnosed. Early diagnosis and treatment of OLP is of utmost importance as it can be detrimental to overall and periodontal health. The role of general dentists, periodontists, pathologists, and hygienists is imperative for the proper maintenance of oral, periodontal, and general health of the patient. Vigilant follow-up of the patient is essential due to the risk of malignant transformation of OLP. Patients should be made aware of the triggering factors and the potential risks associated with OLP for them to comply with the treatment measures. This article not only presents an unusual presentation of OLP with desquamative gingivitis but also focuses on the conventional periodontal management for the same.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alsarraf A, Mehta K, Khzam N. The gingival oral lichen planus: A periodontal-oral medicine approach. Case Rep Dent 2019;2019:4659134.  Back to cited text no. 1
    
2.
Camacho-Alonso F, López-Jornet P, Bermejo-Fenoll A. Gingival involvement of oral lichen planus. J Periodontol 2007;78:640-4.  Back to cited text no. 2
    
3.
Ismail SB, Kumar SK, Zain RB. Oral lichen planus and lichenoid reactions: Etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 2007;49:89-106.  Back to cited text no. 3
    
4.
Sugerman PB, Savage NW. Oral lichen planus: Causes, diagnosis and management. Aust Dent J 2002;47:290-7.  Back to cited text no. 4
    
5.
Mignogna MD, Lo Russo L, Fedele S. Gingival involvement of oral lichen planus in a series of 700 patients. J Clin Periodontol 2005;32:1029-33.  Back to cited text no. 5
    
6.
Scully C, Carrozzo M. Oral mucosal disease: Lichen planus. Br J Oral Maxillofac Surg 2008;46:15-21.  Back to cited text no. 6
    
7.
van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; terminology, classification and present concepts of management. Oral Oncol 2009;45:317-23.  Back to cited text no. 7
    
8.
Gandolfo S, Richiardi L, Carrozzo M, Broccoletti R, Carbone M, Pagano M, et al. Risk of oral squamous cell carcinoma in 402 patients with oral lichen planus: A follow-up study in an Italian population. Oral Oncol 2004;40:77-83.  Back to cited text no. 8
    
9.
Mignogna MD, Lo Muzio L, Lo Russo L, Fedele S, Ruoppo E, Bucci E. Clinical guidelines in early detection of oral squamous cell carcinoma arising in oral lichen planus: A 5-year experience. Oral Oncol 2001;37:262-7.  Back to cited text no. 9
    
10.
Guiglia R, Di Liberto C, Pizzo G, Picone L, Lo Muzio L, Gallo PD, et al. A combined treatment regimen for desquamative gingivitis in patients with oral lichen planus. J Oral Pathol Med 2007;36:110-6.  Back to cited text no. 10
    
11.
Stone SJ, McCracken GI, Heasman PA, Staines KS, Pennington M. Cost-effectiveness of personalized plaque control for managing the gingival manifestations of oral lichen planus: A randomized controlled study. J Clin Periodontol 2013;40:859-67.  Back to cited text no. 11
    
12.
Garcia-Pola MJ, Rodriguez-López S, Fernánz-Vigil A, Bagán L, Garcia-Martín JM. Oral hygiene instructions and professional control as part of the treatment of desquamative gingivitis. Systematic review. Med Oral Patol Oral Cir Bucal 2019;24:e136-44.  Back to cited text no. 12
    
13.
Do Prado RF, Marocchio LS, Felipini RC. Oral lichen planus versus oral lichenoid reaction: Difficulties in the diagnosis. Indian J Dental Res 2009;20:361.  Back to cited text no. 13
    
14.
Kumaraswamy KL, Vidhya M, Rao PK, Mukunda A. Oral biopsy: Oral pathologist's perspective. J Cancer Res Ther 2012;8:192.  Back to cited text no. 14
    
15.
Bajpai M, Agarwal D, Bhalla A, VatchalaRani RM, Kumar M. Unilateral lichen planus: A rare case report. J Nat Sci Biol Med 2014;5:453.  Back to cited text no. 15
    
16.
Hartl C, Steen KH, Wegner H, Seifert HW, Bieber T. Unilateral linear lichen planus with mucous membrane involvement. Acta Derm Venereol 1999;79:145-6.  Back to cited text no. 16
    
17.
Rekha SM, Annigeri AB, Galgali SR, Jagadish P. Multivariant lichen planus of lips and gingiva: Report of a case and a review. Int J Oral Health Sci 20181;8:109.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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