Laboratory Studies

The history, typical oral lesions, and skin involvement are usually sufficient to diagnose oral lichen planus (OLP), although laboratory studies and biopsy may be required (see Procedures).

Direct immunofluorescence testing can help in distinguishing erosive or the rare bullous oral lichen planus from pemphigus vulgaris, benign mucous membrane pemphigoid, dermatitis herpetiformis, and linear immunoglobulin A (IgA) disease. The most characteristic feature of oral lichen planus is shaggy linear fibrin distribution.

Some studies show an increased incidence of C albicans infection in patients with oral lichen planus. Periodic acid-Schiff (PAS) staining of biopsy specimens and candidal cultures or smears may be performed. However, these tests may be of limited clinical value because oral C albicans is present in more than 70% of the population as a common organism in oral flora. The presence of C albicans and the oral load of this organism do not aid either the diagnosis or the treatment of oral lichen planus.

Other Tests

Skin patch testing may be helpful in identifying a contact allergy in some patients with oral lichen planus (OLP).^[39]The current recommendation is to use a standard series; a dental prosthesis series; and a metal salt series that includes gold, mercury, and palladium salts as well as other salts of metals used in dental restorations. Late readings, or those obtained at 10 and 17 days after the application of the skin patch, may be required.

Although the assessment of hepatic function in the treatment of otherwise healthy southern European and Japanese patients with oral lichen planus may be warranted, similar screening in British and American patients appears to be of limited benefit. Formal studies are still ongoing. Consider hepatic biochemical testing only when patients have proven oral lichen planus and suspected liver disease.^[49]

Procedures

Biopsy may be required to exclude malignancy or to differentiate between oral lichen planus (OLP) and other white or chronic ulcerative oral lesions, including reactive keratoses, chronic hyperplastic candidosis, epithelial dysplasia, discoid lupus erythematosus, gastrointestinal disease (including oral Crohn disease), and anemic states.

Histologic Findings

Histopathologic examination of lesional tissue is the most relevant investigation in cases of oral lichen planus (OLP). It should be appreciated that biopsy technique and handling is extremely important to allow for an accurate pathological diagnosis.^[50]

Consistent findings include a bandlike subepithelial mononuclear infiltrate consisting of T cells and histiocytes, increased numbers of intraepithelial T cells, and degenerating basal keratinocytes that form colloid (Civatte, hyaline, cytoid) bodies, which appear as homogenous eosinophilic globules. Variable findings include parakeratosis, acanthosis, and sawtooth rete pegs.

Degeneration of the basal keratinocytes and disruption of the anchoring elements of the epithelial basement membrane and basal keratinocytes (eg, hemidesmosomes, filaments, fibrils) weakens the epithelial-connective tissue interface. As a result, histologic clefts (ie, Max-Joseph spaces) may form, and blisters on the oral mucosa (bullous lichen planus) may be seen at clinical examination. B cells and plasma cells are uncommon findings.

Immunoglobulin or complement deposits are not a consistent feature of oral lichen planus, although fibrin is deposited in a shaggy linear pattern in the basement membrane zone. Colloid bodies contain fibrin, immunoglobulin M (IgM), C3, C4, and keratin. Laminin and fibronectin staining may be absent in areas of heavy fibrin deposition and colloid body formation. This finding suggests basement membrane damage in these areas.

In oral lichen planus, electron microscopy is used principally as a research tool. The ultrastructure of the colloid bodies suggests that they are apoptotic keratinocytes, and studies using the end-labeling method revealed DNA fragmentation in these cells. Electron microscopy shows breaks, branches, and duplications of the epithelial basement membrane in oral lichen planus.^[51]

Treatment & Management

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Media Gallery

Plaquelike oral lichen planus on the buccal mucosa on the left side.
Reticular oral lichen planus on the buccal mucosa on the left side.
Ulcerative oral lichen planus on the dorsum of the tongue.
Lichen planus nail involvement.

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Author

Jaisri R Thoppay, DDS, MBA, MS President, Center for Integrative Oral Health, Inc

Jaisri R Thoppay, DDS, MBA, MS is a member of the following medical societies: American Academy of Oral Medicine, American Academy of Orofacial Pain, American Association for Dental Research, American Dental Association, American Dental Education Association, International Association for Dental Research, Richmond Dental Society, Virginia Dental Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Dermatology of Southwest Ohio

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

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

Disclosure: Nothing to disclose.

Additional Contributors

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; 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.

Stephen R Porter, MD, PhD, FDSRCS(Eng), FDSRSE 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, UK

Stephen R Porter, MD, PhD, FDSRCS(Eng), FDSRSE 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, Royal Society of Medicine

Disclosure: Nothing to disclose.

Philip B Sugerman, MDS, PhD Senior Clinical Science Manager, Abbott Immunology, Abbott Laboratories

Philip B Sugerman, MDS, PhD is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, International Association for Dental Research

Disclosure: Nothing to disclose.

Oral Lichen Planus Workup

Laboratory Studies

Other Tests

Procedures

Histologic Findings

References

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