Gingival Involvement of OralLichen PlanusFabio Camacho-Alonso,* Pıa Lopez-Jornet,* and Ambrosio Bermejo-Fenoll*

Background: Oral lichen planus (OLP) is one of the mostcommon oral mucosa disorders. OLP gingival involvement isvery frequently observed and is characterized by a wide rangeof clinical appearance, symptomatology, and locations. Thepurpose of this study was to analyze the prevalence and clin-ical aspects of gingival lesions in a series of 213 patients af-fected by OLP.

Methods: We analyzed the prevalence and clinical aspects(location, morphology, and symptomatology) of the gingivallesions in a total of 213 clinically and histopathologicallyassessed patients affected by OLP.

Results: Gingival lesions were diagnosed in 38.4% of cases.White lesions were the most frequently observed in the gingiva(42.7%), followed by mixed lesions (31.7%), and red lesions(25.6%). For the three clinical forms, the most frequent gingi-val location was the simultaneous involvement of the attachedand marginal gingiva. None of the white lesions presentedsymptomatology, whereas most red lesions or mixed formspresented symptoms that varied from discomfort to severeoral pain or a burning sensation.

Conclusions: Considering the high frequency of gingivalinvolvement in OLP, the diversity of clinical manifestations,and its potential relationship with general and oral health inpatients, periodontists should be familiar with the most com-mon clinical aspects of OLP in the gingiva. J Periodontol 2007;78:640-644.

KEY WORDS

Gingiva; oral lichen planus.

Lichen planus is a chronic inflam-matory disease of the skin and mu-cous membranes that frequently

involves the oral mucosa. The exactetiopathogenesis has not been discov-ered, but the immunologic system is be-lieved to play a leading role. Oral lichenplanus (OLP) characteristics have beenwell described in several series, com-prising large numbers of patients all overthe world. The disease is relatively com-mon, affecting 1% to 2% of the popula-tion,1 with a female predilection and amean age at onset in the fourth to fifthdecade. The buccal mucosa is the mostcommon site. Patients with OLP fre-quently have concomitant lesions in oneor more extraoral sites.

Whereas in most instances cutaneouslesions of lichen planus are self-limitingand cause itching, oral lesions in OLPare chronic, rarely undergo spontaneousremission, are potentially premalignant,and are often a source of morbidity. Fur-thermore, oral lesions, unlike cutaneouslesions, are difficult to palliate.

OLP lesions usually have recognizableand distinctive clinical features and acharacteristic distribution. OLP may mani-fest in one of three clinical forms: 1) white(reticular, papular, and plaque-like); 2)mainly red (atrophic and erosive); or 3)mixed (white and red oral lesions).

OLP is a disease characterized by hav-ing multiple, bilateral, symmetric loca-tion. The posterior buccal mucosa is themost frequently involved site, followedby the tongue, gingiva, labial mucosa,and vermilion of the lower lip.2,3 Lesions

* Department of Oral Medicine, Faculty of Medicine and Odontology, University of Murcia,Murcia, Spain.

doi: 10.1902/jop.2007.060303

Volume 78 • Number 4

640

on the palate, floor of the mouth, and upper lip are un-commonly noted.

In 10% of patients with OLP, the disease is confinedto the gingiva.4 Gingival lichen planus presents assmall, raised white, lacy papules or plaques, andmay resemble keratotic diseases, such as leukoplakia.Erythematous lesions affecting the gingiva result indesquamative gingivitis, the most common typeofgin-gival lichen planus. Erosive lesions resembling thoseobserved in other vesiculoerosive diseases, includingpemphigoid, pemphigus, linear immunoglobulin A(IgA) disease, and foreign body gingivitis,5 also pro-duce desquamative gingivitis, not easily identified aslichen planus unless there are coexistent reticular le-sions on the gingiva or elsewhere in the oral cavity. Li-chen planus isolated to a single oral site other than thegingiva is uncommon. The purpose of this study was toanalyze the prevalence and clinical aspects of gingivallesions in a series of 213 patients affected by OLP.

MATERIALS AND METHODS

The study involved 213 patients (43 men and 170women; age range: 14 to 90 years) with OLP who wereobserved at the Oral Medicine Unit of the University ofMurcia between 1992 and 2006. Written informedconsent was obtained from all subjects. The investiga-tion was approved by the Bioethical Committee of thesame University. The patients were diagnosed clini-cally and confirmed as having OLP by biopsy, accord-ing to the World Health Organization criteria.6 Thehistopathologic features used as diagnostic criteriawere hyperortho-hyperparakeratosis, a subepitheliallymphocytic band-like infiltrate, and the focal signsof basal layer degeneration. We excluded patientstaking drugs that might cause a lichenoid reactionand those with lesions of the skin or other locationsother than the oral mucosa. Medical and serologicscreening of patients was performed at the time of di-agnosis by evaluating routine hematologic parame-ters and testing for liver disease (hepatitis B or C).

According to the clinical appearance, the gingival le-sions were categorized as mainly white (reticular, papu-lar, and plaque-like); mainly red (atrophic and erosive);or mixed (white and red oral lesions). We also analyzedthe locations of lesions and the symptoms (these weremeasured as none, discomfort, mild oral pain, moderateoral pain, severe oral pain, and burning sensation).

We analyzed the data with a statistical program.† Adescriptive study was made of each variable. The as-sociations between the different qualitative variableswere studied using the Pearson x2 test. Statistical sig-nificance was accepted for P £0.05.

RESULTS

Eighty-two (38.4%) of 213 patients showed gingivalinvolvement. Sixty-seven (81.7%) were women and

15 (18.3%) were men, with a mean age of 57.35 years(range: 14 to 90). The clinical forms of OLP gingivallesions are detailed in Table 1, observing that all threeforms occurred more frequently in women, althoughwith no statistical significance.

The white forms appeared in 35 (42.7%) patients(Table 1); 25 (30.5%) were reticular, having a verycharacteristic appearance with variable patterns ofkeratotic ‘‘striae,’’ slightly elevatedwhitish lines cross-ing each other and producing an arboriform distribu-tion. In the 10 remaining cases (12.2%), the whitelesions presented in plaque-like formation (Fig. 1).Of the 35 white lesions, only 10 (all those presentingin plaques) were exclusively located in attached gin-giva, the simultaneous involvement of attached gin-giva and marginal gingiva being the most frequent

Table 1.

Clinical Forms of Gingival Oral LichenPlanus (gender predilection)

Clinical

Forms

Total

(N [%])

Men

(N [%])

Women

(N [%])

x2

Test

P

Value

White lesions 35 (42.7) 6 (17.1) 29 (82.9) 0.05 0.816

Reticular 25 (30.5) 5 (20) 20 (80)

Plaques 10 (12.2) 1 (10) 9 (90)

Red lesions 21 (25.6) 5 (23.8) 16 (76.2) 0.57 0.448

Atrophic 2 (2.4) 1 (50) 1 (50)

Erosive 19 (23.2) 4 (21.1) 15 (78.9)

Mixed 26 (31.7) 4 (15.4) 22 (84.6) 0.21 0.643

Total 82 (100) 15 (100) 67 (100)

Figure 1.White lesions in plaque formation involving the whole of the attachedgingiva and the marginal gingiva only partially.

† SPSS version 12.0 for Windows, SPSS, Chicago, IL.

J Periodontol • April 2007 Camacho-Alonso, Lopez-Jornet, Bermejo-Fenoll

641

(71.4% of cases), with statistically significant dif-ferences (P <0.001) (Table 2). With respect to symp-toms, 100% of the white lesions were asymptomatic(Table 3).

The red lesions (Fig. 2) represented 25.6% (21cases)of thesample,allofwhich(100%ofcases)simul-taneously involved attached and marginal gingival.Six of these red lesions had no symptoms, whereasmost (15 cases) presented some type of discomfort,the presence of symptoms in this type of lesion beingsignificantlyhigher (P = 0.002),producing awidespec-trum of symptoms (Table 3).

Finally, the mixed forms (Fig. 3) represented 31.7%(26 cases) of the sample and, as occurred with the redforms, simultaneously affected the attached and mar-ginal gingival in all cases (Table 2). Regarding symp-

tomatology, only six cases were symptom free, thepresence of some symptomology being significantlyhigher (P <0.001). Of the 20 cases with symptoms,two presented severe pain and eight presented a burn-ing sensation.

DISCUSSION

OLP occurs preferentially in women, and the largestnumber of cases occurs between the ages of 40 and59.3,7-9 In our series, we also found a predilectionfor women, and the average age was similar to thatpresented in these previous reports.

After the oral mucosa and tongue, the gingiva isone of the most frequently affected areas in patientswith OLP.9,10 The prevalence of gingival involvementin our series was 38.4%, similar to that presented in2005 by Mignogna et al.11 (48%).

Regarding the clinical forms of OLP presented in thegingiva, in our series the most frequent were the white

Table 2.

Clinical Forms in Relation to TheirGingival Location

Clinical

Forms

Total

(N)

Exclusive to

Attached

Gingiva

(N [%])

Attached and

Marginal

Gingiva

(N [%])

x2

Test

P

Value

White lesions 35 10 (28.6) 25 (71.4) 15.29 <0.001

Reticular 25 0 (0) 25 (100)

Plaques 10 10 (100) 0 (0)

Red lesions 21 0 (0) 21 (100) 3.92 <0.048

Atrophic 2 0 (0) 2 (100)

Erosive 19 0 (0) 19 (100)

Mixed 26 0 (0) 26 (100) 5.28 <0.021

Table 3.

Clinical Forms and Symptoms

Clinical

Forms

Total

(N)

Absence of

Symptomatology (N)

Presence of Symptomatology

x2 Test P ValueD MiP MP SP BS

White lesions 35 35 0 0 0 0 0 45.47 <0.001

Reticular 25 25 0 0 0 0 0

Plaques 10 10 0 0 0 0 0

Red lesions 21 6 8 2 1 0 4 9.53 <0.002

Atrophic 2 1 1 0 0 0 0

Erosive 19 5 7 2 1 0 4

Mixed 26 6 5 4 1 2 8 18.24 <0.001

D = discomfort; MiP = mild oral pain; MP = moderate oral pain; SP = severe oral pain; BS = burning sensation.

Figure 2.Erosive form of OLP.

Oral Lichen Planus and Gingiva Volume 78 • Number 4

642

form (42.7%), followed by mixed lesions (31.7%) andthe red form (25.6%). In this respect, such authors asLopez-Jornet et al.12 and Jing-Ling et al.9 have alsopresented series of patients with OLP (not exclusivelyin the gingiva), in which the white form was the mostfrequent. However, authors such as Mignona et al.,11

in their series of gingival OLP, found that the mixedforms were the most frequent.

Furthermore, in our study we observe that the pre-dominant gingival location in all the clinical forms wasthesimultaneous involvementofattachedandmarginalgingiva, highlighting that the only clinical forms com-pletely and exclusively to involve the attached gingivawere the plaque-like white forms, coinciding with thegingival locations presented by Mignogna et al.11

Finally, regarding the presence or absence ofsymptomatology, many authors9-11,13,14 coincide inindicating that the white forms of OLP present noor scant symptomatology; in our study, none of thesepatients presented symptomatology. The lack ofsymptoms may lead to a confusion of the diagnosticpattern and to unawareness of the disease by the pa-tient. This in turn often means that appropriate medicalreferral is not made, thus causing misdiagnosis or non-diagnosis. Because gingival involvement in OLP hasa high incidence, its recognition during routinely per-formed periodontal procedures could help to reduceundiagnosed or misdiagnosed cases and to establishappropriate management. Thus, periodontists shouldbe involved in OLP diagnosis and become familiar withits clinical aspects, as detailed previously. The diag-nostic process in OLP should begin with the clinicalidentification of oral lesions, and should proceed withbiopsy to obtain histopathologic confirmation.

In contrast, and in agreement with an earlier re-port,11 both the red and mixed forms described asymptomatology that ranged from discomfort to se-vere pain and burning sensation. Probably because

of this increase in symptomatology with the red andmixed forms, such authors as Ramon-Fluixa et al.15

found that these patients had poor oral hygiene andan increased plaque index. However, dental plaquecan act as an irritating factor, worsening the lesionsand contributing to the relationship observed betweenmore aggressive lesions and increased indices.16

CONCLUSION

Considering the high rate of gingival involvement inOLP, the diversity of clinical manifestations, and theirpotential relationship with general and oral health inthese patients, periodontists should be familiar withthe most frequent clinical aspects of OLP in the gin-giva.

REFERENCES1. Scully C, Beyli M, Ferreiro MC, et al. Update on oral

lichen planus: Etiopathogenesis and management.Crit Rev Oral Biol Med 1998;9:86-122.

2. Bagan-Sebastian JV, Milian-Masanet MA, Penarrocha-Diago M, Jimenez Y. A clinical study of 205 patientswith oral lichen planus. J Oral Maxillofac Surg 1992;50:116-118.

3. Eisen D, Carrozzo M, Bagan-Sebastian JV, ThongprasomK. Oral lichen planus: Clinical features and management.Oral Dis 2005;11:338-349.

4. Scully C, el Kom M. Lichen planus: Review and updateon pathogenesis. J Oral Pathol 1985;14:431-458.

5. Gordon SC, Daley TD. Foreign body gingivitis: Clin-ical and microscopic features of 61 cases. Oral SurgOral Med Oral Pathol Oral Radiol Endod 1997;83:562-570.

6. Kramer IR, Lucas RB, Pindborg JJ, Sobin LH. Defini-tion of leukoplakia and related lesions: An aid tostudies on oral precancer. Oral Surg Oral Med OralPathol 1978;46:518-539.

7. Gorsky M, Raviv M, Moskona D, Laufer M, Bodner L.Clinical characteristics and treatment of patients withoral lichen planus in Israel. Oral Surg Oral Med OralPathol Oral Radiol Endod 1996;82:644-649.

8. Silverman S Jr., Bahl S. Oral lichen planus update:Clinical characteristics, treatment responses, and malig-nant transformation. Am J Dent 1997;10:259-263.

9. Jing-Ling Xue, Ming-Wen F, Shou-Zhi W, Xin-Ming C,Yuan L, Li W. A clinical study of 674 patients with orallichen planus in China. J Oral Pathol Med 2005;34:467-472.

10. Eisen D. The clinical features, malignant potential,and systemic associations of oral lichen planus: Astudy of 723 patients. J Am Acad Dermatol 2002;46:207-214.

11. Mignogna MD, Lo Russo L, Fedele S. Gingival involve-ment of oral lichen planus in a series of 700 patients.J Clin Periodontol 2005;32:1029-1033.

12. Lopez-Jornet P, Camacho-Alonso F, Gomez-Garcıa F,Bermejo Fenoll A. The clinicopathological charac-teristics of oral lichen planus and its relationshipwith dental materials. Contact Dermatitis 2004;51:210-218.

13. Seoane J, Romero MA, Varela-Centelles P, Diz-Dios P,Garcia-Pla MJ. Oral lichen planus: A clinical and

Figure 3.Mixed form of OLP.

J Periodontol • April 2007 Camacho-Alonso, Lopez-Jornet, Bermejo-Fenoll

643

morphometric study of oral lesions in relation toclinical presentation. Braz Dent J 2004;15:9-12.

14. Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ.Course of various clinical forms of oral lichen planus.A prospective follow-up study of 611 patients. J OralPathol 1988;17:213-218.

15. Ramon-Fluixa C, Bagan-Sebastian JV, Milian-MasanetMA, Scully C. Periodontal status in patients with orallichen planus: A study of 90 cases. Oral Dis 1999;5:303-306.

16. Holmstrup P, Schiotz AW, Westergaard J. Effect of den-tal plaque control on gingival lichen planus. Oral SurgOral Med Oral Pathol 1990;69:585-590.

Correspondence: Dr. Fabio Camacho-Alonso, UniversitaryDentistry Clinic, Hospital Morales Meseguer, Avda. Marquesde los Velez s/n, Murcia 30008, Spain. Fax: 34-968-239565; e-mail: fcamacho@um.es.

Accepted for publication October 13, 2006.

Oral Lichen Planus and Gingiva Volume 78 • Number 4

644