Medical Care
Medical treatment of oral lichen planus (OLP) is essential for the management of painful, erythematous, erosive, or bullous lesions. The principal aims of current oral lichen planus therapy are the resolution of painful symptoms, the resolution of oral mucosal lesions, the reduction of the risk of oral cancer, and the maintenance of good oral hygiene. In patients with recurrent painful disease, another goal is the prolongation of their symptom-free intervals. [52, 53, 54]
The main concerns with the current therapies are the local and systemic adverse effects and lesion recurrence after treatment is withdrawn. No treatment of oral lichen planus is curative.
Eliminate local exacerbating factors. Treat any sharp teeth or broken restorations or prostheses that are likely to cause physical trauma to areas of erythema or erosion by using conventional dental means. Scale the teeth to remove calculus deposits and reduce sharp edges. If the patient has an isolated plaquelike or erosive oral lichen planus lesion on the buccal or labial mucosa adjacent to a dental restoration, and if an allergy is detected by means of skin patch testing, the lesion may heal if the offending material is removed or replaced. (However, most lichenoid lesions adjacent to dental restorations are asymptomatic.) Stress control such as relaxation training may help in treatment.
If systemic drug therapy (eg, treatment with NSAIDs, antimalarials, or beta-blockers) is suspected as the cause of oral lichenoid lesions, changing to another drug may be worthwhile. This change must be undertaken only by the patient's attending physician. However, the switch rarely resolves the erosion and almost never resolves the white patches of oral lichen planus.
Inform all patients with oral lichen planus about their slightly increased risk of oral squamous cell carcinoma (SCC), the most common of all oral malignancies. [55] As with all patients, advise those with oral lichen planus that this risk may be reduced by eliminating tobacco and alcohol consumption and by consuming a diet rich in fresh fruits and vegetables, among other measures. Erosive and atrophic lesions can be converted into reticular lesions by using topical steroids. Therefore, the elimination of mucosal erythema and ulceration, with residual asymptomatic reticular or papular lesions, may be considered an endpoint of current oral lichen planus therapy. With respect to plaque lesions, the effect of treatment on the risk of oral cancer is unclear.
A 2020 article outlines a potentially useful treatment algorithm along with a novel staging system that may helpful to facilitate management decisions. [56]
Consultations
An oral medicine specialist/oral pathologist typically makes the primary diagnosis of oral lichen planus (OLP). Opinions may be sought from the following specialists if patients have relevant signs or symptoms:
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Dermatologist - For the diagnosis, treatment, and review of skin, nail, genital, and scalp lesions
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Otolaryngologist - For the diagnosis, treatment, and review of laryngeal and esophageal lesions
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Ophthalmologist - For the diagnosis, treatment, and review of conjunctival lesions
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Gynecologist - For the diagnosis, treatment, and review of vulval and vaginal lesions
Because exacerbations of oral lichen planus have been linked to periods of stress and anxiety, a psychological assessment may be beneficial in some patients with oral lichen planus. [57] However, objective data to support this link are limited.
Diet
When the lesions are symptomatic, patients may avoid certain foods that may aggravate the symptoms. They are often on a soft diet, which may be a predominantly carbohydrate diet. Advise patients with oral lichen planus (OLP) that a diet rich in fresh fruit and vegetables may help reduce the risk of oral SCC. Patients with oral lichen planus have a slightly increased risk of oral SCC, although the precise risk of oral cancer in patients with oral lichen planus is unknown.
Activity
Advise patients with oral lichen planus (OLP) to do the following:
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Eliminate smoking and alcohol consumption.
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Eat a nutritious diet, including fresh fruit and vegetables, because this may help reduce the risk of oral cancer.
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Pay attention when symptoms are exacerbated or when lesions change.
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Be aware of the need for regular re-examination and repeat lesion biopsy, especially if clinical changes in the lesion occur.
Although oral lichen planus does not increase the risk of dental caries or gingival disease, painful oral lichen planus lesions (particularly those on the gums) can limit the patient's ability to maintain good oral hygiene. Therefore, advise all patients with oral lichen planus of the appropriate methods of oral hygiene and to see their dentists often.
Prevention
Patients with oral lichen planus (OLP) 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:
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Elimination of smoking and alcohol consumption
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Effective treatment of atrophic, erosive, and plaque oral lichen planus lesions
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Consumption of a nutritious diet including fresh fruit and vegetables
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Elimination of C albicans superinfection
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Clinical examination with any exacerbation of symptoms or change in lesion presentation
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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.
Long-Term Monitoring
Re-examine patients with oral lichen planus (OLP) 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.
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Plaquelike oral lichen planus on the buccal mucosa on the left side.
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Reticular oral lichen planus on the buccal mucosa on the left side.
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Ulcerative oral lichen planus on the dorsum of the tongue.
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Lichen planus nail involvement.
