eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Oral Lichen Planus: Follow-up

Author: Philip Sugerman, MDSc, PhD, FRACDS, FDSRCS, FFOPRCPA, Clinical Science Manager, Abbott Immunology, Abbott Laboratories
Coauthor(s): Stephen R Porter, MD, PhD, FDS, RCS, FDS, RCSE, Professor of Oral Medicine, University College London; Academic Head, Director of Research Strategy, Oral Medicine/Special Needs Unit, Division of Maxillofacial Diagnostic, Medical and Surgical Sciences, Eastman Dental Institute for Oral Health Sciences
Contributor Information and Disclosures

Updated: Jul 31, 2009

Follow-up

Further Outpatient Care

  • Re-examine patients with oral lichen planus (OLP) every month during active treatment, and monitor lesions for reduction in mucosal erythema and ulceration and alleviation of symptoms.
    • Continue active treatment and try alternative therapies until erythema, ulceration, and symptoms are controlled.
    • Follow up with patients with oral lichen planus at least every 6 months.
  • Advise patients with oral lichen planus to pay attention to when symptoms are exacerbated or when lesions change. Such changes generally indicate a phase of increased erythematous or erosive disease.
  • In view of the potential association of oral lichen planus with oral SCC, an appropriate specialist should follow up with the patients every 6-12 months. In addition, advise patients to regularly examine their mouths and seek the help of a specialist if persistent red or ulcerative oral mucosal lesions develop.
  • Candidal cultures or smears may be obtained periodically.
    • Infections can be controlled with topical antimycotic preparations.
    • These tests may be of limited clinical value because oral C albicans is present in at least 70% of all healthy persons.

Deterrence/Prevention

  • Patients with oral lichen planus may have a slightly increased risk of oral cancer, although the precise risk is unknown.
  • The risk of oral cancer in patients with oral lichen planus may be reduced by means of the following:
    • Elimination of smoking and alcohol consumption
    • Effective treatment of atrophic, erosive, and plaque oral lichen planus lesions
    • Consumption of a nutritious diet including fresh fruit and vegetables
    • Elimination of C albicans superinfection
    • Clinical examination with any exacerbation of symptoms or change in lesion presentation
    • Regular clinical examination and repeat biopsy as required. Oral brush biopsy can be used to limit the number of scalpel biopsies (see Oral Brush Biopsy with Computer-Assisted Analysis). The frequency of brush biopsy for oral lichen planus patient follow-up has not been established. However, if the clinical features of the lesions change, scalpel biopsy should be repeated.

Complications

  • Oral lichen planus and its treatment may predispose people to oral C albicans superinfection.
  • Patients with oral lichen planus may have a slightly increased risk of oral cancer, which they may be able to reduce (see Deterrence/Prevention).
  • Oral SCC in patients with oral lichen planus is a feared complication and a controversial issue.
    • In retrospective studies, fewer than 5% of patients with oral lichen planus who were not using tobacco products developed oral SCC.
    • Atrophic, erosive, and plaque lesions may be at greater risk of malignant change, although SCC may arise in the unaffected oral mucosa as well.
    • The most important risk factors of oral SCC remain the concomitant use of alcohol and tobacco products. Any additive effect of oral lichen planus is difficult to detect in patients who use both.
  • Proposed reasons for the increased risk of oral SCC in patients with oral lichen planus include the following:
    • Compared with healthy mucosa, the oral mucosa affected by oral lichen planus may be more sensitive to C albicans and to the exogenous mutagens found in tobacco, alcohol, and betel quid.
    • In patients with oral lichen planus, the chronic inflammatory response and the simultaneous healing response of epithelial wounds may increase the likelihood of cancer-forming gene mutations.
  • Guidelines fromthe National Collaborating Centre for Primary Care, Referral guidelines for suspected cancer in adults and children,32 may be of interest.

Prognosis

  • Oral lichen planus is a chronic inflammatory disease.
    • The lesions of cutaneous lichen planus typically resolve within 1-2 years, whereas the lesions of oral lichen planus are long lasting and persist for 20 years or longer.
    • Resolution of the white striations, plaques, or papules is rare.
    • Symptomatic oral lichen planus (ie, atrophic or erosive disease) characteristically waxes and wanes, although the associated white patches do not resolve.
  • Current immunosuppressive therapies usually control oral mucosal erythema, ulceration, and symptoms in patients with oral lichen planus with minimal adverse effects. However, a range of therapies may need to be tried.
  • Advise patients that oral lichen planus lesions may persist for many years with periods of exacerbation and quiescence.
  • Follow up patients with oral lichen planus at least every 6 months for clinical examination and repeat biopsy as required, although patients should be advised to seek medical care whenever the symptoms are exacerbated or the presentation of the lesions change.
  • In the context of appropriate medical care, the prognosis for most patients with oral lichen planus is excellent.

Patient Education

  • Patient education is important. Many patients with oral lichen planus are concerned about the possibilities of its malignancy and contagiousness. Many patients are frustrated by the lack of available patient education concerning oral lichen planus.33
  • Inform patients with oral lichen planus of the following:
    • The chronicity of oral lichen planus and the expected periods of exacerbation and quiescence
    • The aims of treatment, specifically the elimination of mucosal erythema, ulceration, pain, and sensitivity
    • The lack of large randomized controlled therapeutic clinical trials
    • The possibility that several treatments may need to be tried
    • The potentially increased risk of oral cancer
    • The possibility of reducing the risk of oral cancer (see Complications)
  • Information about oral lichen planus is currently available online. For instance, an oral lichen planus chat room is available at the homepage of the International Lichen Planus Support Group Web.
  • For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer of the Mouth and Throat.

Miscellaneous

Medicolegal Pitfalls

  • Be alert for the use of any systemic drug in patients with oral lichenoid lesions, because it may be a cause.
  • Patients with oral lichen planus may have a slightly increased risk of oral cancer, although the precise risk of oral cancer in patients with oral lichen planus is unknown. Any risk of oral cancer in patients with oral lichen planus may be reduced (see Patient Education).
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.



More on Oral Lichen Planus

Overview: Oral Lichen Planus
Differential Diagnoses & Workup: Oral Lichen Planus
Treatment & Medication: Oral Lichen Planus
Follow-up: Oral Lichen Planus
Multimedia: Oral Lichen Planus
References
[ CLOSE WINDOW ]

References

  1. Sugerman PB, Satterwhite K, Bigby M. Autocytotoxic T-cell clones in lichen planus. Br J Dermatol. Mar 2000;142(3):449-56. [Medline].

  2. Sugerman PB, Savage NW, Walsh LJ, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med. 2002;13(4):350-65. [Medline].

  3. Younes F, Quartey EL, Kiguwa S, Partridge M. Expression of TNF and the 55-kDa TNF receptor in epidermis, oral mucosa, lichen planus and squamous cell carcinoma. Oral Dis. Mar 1996;2(1):25-31. [Medline].

  4. Sklavounou A, Chrysomali E, Scorilas A, Karameris A. TNF-alpha expression and apoptosis-regulating proteins in oral lichen planus: a comparative immunohistochemical evaluation. J Oral Pathol Med. Sep 2000;29(8):370-5. [Medline].

  5. Khan A, Farah CS, Savage NW, Walsh LJ, Harbrow DJ, Sugerman PB. Th1 cytokines in oral lichen planus. J Oral Pathol Med. Feb 2003;32(2):77-83. [Medline].

  6. Thongprasom K, Dhanuthai K, Sarideechaigul W, Chaiyarit P, Chaimusig M. Expression of TNF-alpha in oral lichen planus treated with fluocinolone acetonide 0.1%. J Oral Pathol Med. Mar 2006;35(3):161-6. [Medline].

  7. Simon M Jr, Gruschwitz MS. In situ expression and serum levels of tumour necrosis factor alpha receptors in patients with lichen planus. Acta Derm Venereol. May 1997;77(3):191-3. [Medline].

  8. Simark-Mattsson C, Bergenholtz G, Jontell M, et al. Distribution of interleukin-2, -4, -10, tumour necrosis factor-alpha and transforming growth factor-beta mRNAs in oral lichen planus. Arch Oral Biol. Jun 1999;44(6):499-507. [Medline].

  9. Karagouni EE, Dotsika EN, Sklavounou A. Alteration in peripheral blood mononuclear cell function and serum cytokines in oral lichen planus. J Oral Pathol Med. Jan 1994;23(1):28-35. [Medline].

  10. Sugermann PB, Savage NW, Seymour GJ, Walsh LJ. Is there a role for tumor necrosis factor-alpha (TNF-alpha) in oral lichen planus?. J Oral Pathol Med. May 1996;25(5):219-24. [Medline].

  11. Sklavounou A, et al. Elevated serum levels of the apoptosis related molecules TNF-alpha, Fas/Apo-1 and Bcl-2 in oral lichen planus. J Oral Pathol Med. 2004;33:386-390.

  12. Rhodus NL, Cheng B, Myers S, Bowles W, Ho V, Ondrey F. A comparison of the pro-inflammatory, NF-kappaB-dependent cytokines: TNF-alpha, IL-1-alpha, IL-6, and IL-8 in different oral fluids from oral lichen planus patients. Clin Immunol. Mar 2005;114(3):278-83. [Medline].

  13. Carrozzo M, Uboldi de Capei M, Dametto E, et al. Tumor necrosis factor-alpha and interferon-gamma polymorphisms contribute to susceptibility to oral lichen planus. J Invest Dermatol. Jan 2004;122(1):87-94. [Medline].

  14. Dereure O, Basset-Seguin N, Guilhou JJ. Erosive lichen planus: dramatic response to thalidomide. Arch Dermatol. Nov 1996;132(11):1392-3. [Medline].

  15. Camisa C, Popovsky JL. Effective treatment of oral erosive lichen planus with thalidomide. Arch Dermatol. Dec 2000;136(12):1442-3. [Medline].

  16. Sampaio EP, Sarno EN, Galilly R, Cohn ZA, Kaplan G. Thalidomide selectively inhibits tumor necrosis factor alpha production by stimulated human monocytes. J Exp Med. Mar 1 1991;173(3):699-703. [Medline].

  17. Moreira AL, Sampaio EP, Zmuidzinas A, Frindt P, Smith KA, Kaplan G. Thalidomide exerts its inhibitory action on tumor necrosis factor alpha by enhancing mRNA degradation. J Exp Med. Jun 1 1993;177(6):1675-80. [Medline].

  18. Porter SR, Kirby A, Olsen I, Barrett W. Immunologic aspects of dermal and oral lichen planus: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Mar 1997;83(3):358-66. [Medline].

  19. Scully C, Beyli M, Ferreiro MC, et al. Update on oral lichen planus: etiopathogenesis and management. Crit Rev Oral Biol Med. 1998;9(1):86-122. [Medline].

  20. Sugerman PB, Savage NW, Zhou X, Walsh LJ, Bigby M. Oral lichen planus. Clin Dermatol. Sep-Oct 2000;18(5):533-9. [Medline].

  21. Axéll T, Rundquist L. Oral lichen planus--a demographic study. Community Dent Oral Epidemiol. Feb 1987;15(1):52-6. [Medline].

  22. Eisen D. The clinical features, malignant potential, and systemic associations of oral lichen planus: a study of 723 patients. J Am Acad Dermatol. Feb 2002;46(2):207-14. [Medline].

  23. Eisenberg E. Oral lichen planus: a benign lesion. J Oral Maxillofac Surg. Nov 2000;58(11):1278-85. [Medline].

  24. Silverman S Jr. Oral lichen planus: a potentially premalignant lesion. J Oral Maxillofac Surg. Nov 2000;58(11):1286-8. [Medline].

  25. Eisen D. The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Oct 1999;88(4):431-6. [Medline].

  26. Koch P, Bahmer FA. Oral lesions and symptoms related to metals used in dental restorations: a clinical, allergological, and histologic study. J Am Acad Dermatol. Sep 1999;41(3 Pt 1):422-30. [Medline].

  27. Lodi G, Porter SR, Scully C. Hepatitis C virus infection: Review and implications for the dentist. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Jul 1998;86(1):8-22. [Medline].

  28. Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K. Current controversies in oral lichen planus: report of an international consensus meeting. Part 1. Viral infections and etiopathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Jul 2005;100(1):40-51. [Medline].

  29. Chan ES, Thornhill M, Zakrzewska J. Interventions for treating oral lichen planus. Cochrane Database Syst Rev. 2000;CD001168. [Medline].

  30. Eisen D. The therapy of oral lichen planus. Crit Rev Oral Biol Med. 1993;4(2):141-58. [Medline].

  31. McCartan B, McCreary C. What is the rationale for treating oral lichen planus?. Oral Dis. Jul 1999;5(3):181-2. [Medline].

  32. [Guideline] Referral guidelines for suspected cancer in adults and children. National Collaborating Centre for Primary Care, Royal College of General Practitioners. National Guideline Clearinghouse. Jun 2005.

  33. Burkhart NW, Burkes EJ, Burker EJ. Meeting the educational needs of patients with oral lichen planus. Gen Dent. Mar-Apr 1997;45(2):126-32; quiz 143-4. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

oral lichen planus, OLP, oral lichenoid lesions, oral mucosal lichenoid lesions, lichen planopilaris, lichenoid drug reactions, idiopathic OLP, Koebner phenomenon, contact hypersensitivity reaction

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Philip Sugerman, MDSc, PhD, FRACDS, FDSRCS, FFOPRCPA, Clinical Science Manager, Abbott Immunology, Abbott Laboratories
Philip Sugerman, MDSc, PhD, FRACDS, FDSRCS, FFOPRCPA is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology and International Association for Dental Research
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen R Porter, MD, PhD, FDS, RCS, FDS, RCSE, Professor of Oral Medicine, University College London; Academic Head, Director of Research Strategy, Oral Medicine/Special Needs Unit, Division of Maxillofacial Diagnostic, Medical and Surgical Sciences, Eastman Dental Institute for Oral Health Sciences
Stephen R Porter, MD, PhD, FDS, RCS, FDS, RCSE is a member of the following medical societies: British Association of Oral and Maxillofacial Surgeons, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Gregory J Raugi, MD, PhD, Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle
Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.