oral lichen planus an update on pathogenesis and treatment

7/23/2019 Oral Lichen Planus an Update on Pathogenesis and Treatment

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J Oral Maxillofac Pathol. 2011 May-Aug; 15(2): 127–12.

!oi: 10."10#0$7-02$%.&""7"

PM': PM'2$*$2

Oral lichen planus: An update onpathogenesis and treatment

+ ,aaya/ P Jayathi/ a!i 3 4ao/ a! 3 4agaatha

Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Uthandi,

Chennai, India

Address for correspondence: Dr. N a!anya, "enior ect#rer, Department of Oral and Maxillofacial Pathology, Ragas Dental College, $%&'$, (ast Coast Road, Uthandi, Chennai )

*'' &&+, India. ()mail la!anya-ds%at%yahoo.com

'oyright : 6 Joural of Oral a! Maxillofacial Pathology

hi8 i8 a o-acc88 articl !i8tri9ut! u!r th tr8 of th 'rati 'oo8 Attri9utio- +ocorcial-har Ali .0 ort!/ <hich rit8 ur8trict! u8/ !i8tri9utio/ a!

rro!uctio i ay !iu/ roi!! th origial <or i8 rorly cit!.

ABSTRACT

Oral lich lau8 (O,P) i8 a chroic iflaatory !i8a8 that affct8 th ucu8 9ra of

th oral caity. t i8 a -cll !iat! autoiu !i8a8 i <hich th cytotoxic '&= cll8

triggr aoto8i8 of th 9a8al cll8 of th oral ithliu. ral atig-8cific a!o8cific iflaatory chai88 ha 9 ut for<ar! to xlai th accuulatio a!

hoig of '&= cll8 8u9ithlially a! th 8u98>ut ratiocyt aoto8i8. A <i!

8ctru of tratt o!aliti8 i8 aaila9l/ fro toical cortico8troi!8 to la8r a9latio of thl8io. thi8 ri</ < !i8cu88 th ariou8 coct8 i th athog8i8 a! currt tratt

o!aliti8 of O,P.

Keywords: Aoto8i8/ autoiu/ 9a8al ratiocyt8/ cortico8troi!8/ oral lich lau8

INTRO!CTION

,ich lau8 i8 a chroic iflaatory !i8a8 that affct8 th 8i a! th ucu8 9ra.Oral lich lau8 (O,P)/ th uco8al coutrart of cutaou8 lich lau8/ r8t8

fr>utly i th fourth !ca! of lif a! affct8 <o or tha i a ratio of 1.":1.?1@h !i8a8 affct8 1–2 of th oulatio.?2/@ t i8 8 cliically a8 rticular/ aular/ la>u-li/ ro8i/ atrohic or 9ullou8 ty8. traorally/ th 9uccal uco8a/ togu a! th gigia ar

cooly iol! although othr 8it8 ay 9 rarly affct!.?"@ Oral uco8al l8io8 r8t

alo or <ith cocoitat 8i l8io8. h 8i l8io8 r8t a8 iolacou8 flat-to! aul8 i al8/ <ri8t/ a! gitalia/ 9ut charactri8tically th facial 8i i8 8ar!.

http://dx.doi.org/10.4103%2F0973-029X.84474

http://www.ncbi.nlm.nih.gov/pubmed/?term=Lavanya%20N%5Bauth%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jayanthi%20P%5Bauth%5D


http://www.ncbi.nlm.nih.gov/pubmed/?term=Rao%20UK%5Bauth%5D


http://www.ncbi.nlm.nih.gov/pubmed/?term=Ranganathan%20K%5Bauth%5D


http://www.ncbi.nlm.nih.gov/pmc/about/copyright.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329692/?report=printable#ref1




http://www.ncbi.nlm.nih.gov/pubmed/?term=Lavanya%20N%5Bauth%5D




http://www.ncbi.nlm.nih.gov/pmc/about/copyright.html





http://dx.doi.org/10.4103%2F0973-029X.84474



h tiology a! athog8i8 of O,P ha8 9 th focu8 of uch r8arch/ a! 8ral atig-

8cific a! o8cific iflaatory chai88 ha 9 ut for<ar! to xlai th

athog8i8. Although o8tly alliati/ a 8ctru of tratt o!aliti8 i8 i ractic/ frotoical alicatio of 8troi!8 to la8r thray. thi8 ri</ < !i8cu88 th rct coct8 i

th athog8i8 a! currt tratt o!aliti8 of O,P.

"AT#O$%N%SIS

O,P i8 a -cll !iat! autoiu !i8a8 i <hich th auto-cytotoxic '&= cll8 triggraoto8i8 of th 9a8al cll8 of th oral ithliu.?5@ A arly t i th !i8a8 chai8

iol8 ratiocyt atig xr88io or ua8ig of a atig that ay 9 a 8lf-ti!

or a hat 8hoc roti.?1/*@ Bollo<ig thi8/ cll8 (o8tly '&=/ a! 8o '"= cll8)igrat ito th ithliu ithr !u to ra!o coutr of atig !urig routi 8urillac

or a choi-!iat! igratio to<ar! 9a8al ratiocyt8.?1@ h8 igrat! '&= cll8

ar actiat! !irctly 9y atig 9i!ig to aCor hi8tocoati9ility colx (MD')-1 oratiocyt or through actiat! '"= lyhocyt8. a!!itio/ th u9r of ,agrha cll8

i O,P l8io8 ar icra8! alog <ith urgulatio of MD'- xr88io; 8u98>ut atig r8tatio to '"= cll8 a! trlui (,)-12 actiat8 '" = hlr cll8 <hich actiat

'&= cll8 through rctor itractio/ itrfro E (+B – E) a! ,-2. h actiat! '&= cll8 i tur ill th 9a8al ratiocyt8 through tuor cro8i8 factor (+B)-F/ Ba8–Ba8,

!iat! or graGy H actiat! aoto8i8.?1/*@

A C&TOKIN%'(%IAT% )&("#OC&T% #O(IN$

(%C#ANIS(

Attractio of th lyhocyt8 to th ithliu–cocti ti88u itrfac ha8 al8o 9

roo8! to 9 !u to cytoi-!iat! urgulatio of a!h8io olcul8 o !othlial cll8a! cocoitat xr88io of rctor olcul8 9y circulatig lyhocyt8. O,P/ thr i8

icra8! xr88io of th a8cular a!h8io olcul8 ('*2I/ '5"/ '10*) 9y th

!othlial cll8 of th 8u9ithlial a8cular lxu8.?7@ h ifiltratig lyhocyt8 xr88

rcirocal rctor8 ('11a) to th8 a8cular a!h8io olcul8. hi8 8uort8 th a9o-xlai! hyoth8i8 that th cytoi-!iat! lyhocyt hoig chai8 lay8 a

iortat rol i th athog8i8 of lich lau8. o of th cytoi8 that ar r8o8i9l

for th urgulatio of th a!h8io olcul8 ar: +B-F/ B+-E a! ,-1. h8 ar !ri!fro th r8i!t acrohag8/ ,agrha8 cll8/ lyhocyt8 a! th orlyig ratiocyt8

th8l8/ thu8 8ttig u a iciou8 cycl.?7@

h oral itgrity of th 9a8t 9ra i8 aitai! 9y a liig 9a8al ratiocyt !uto it8 8crtio of collag " a! laii 5 ito th ithlial 9a8t 9ra Go. tur/ratiocyt8 r>uir a 9a8t 9ra !ri! cll 8urial 8igal to rt th o8t of

it8 aoto8i8. Aototic ratiocyt8 ar o logr a9l to rfor thi8 fuctio/ <hich r8ult8

i !i8rutio of th 9a8t 9ra. Agai/ a o-itact 9a8t 9ra caot 8! acll 8urial 8igal. hi8 8t8 i a iciou8 cycl <hich rlat8 to th chroic atur of th !i8a8.

?1/&@
























h atrix tallorotia88 (MMP) ar ricially iol! i ti88u atrix roti

!gra!atio. MMP- $/ <hich cla8 collag "/ alog <ith it8 actiator8 i8 urgulat! i O,P

l8ioal cll8/ r8ultig i icra8! 9a8t 9ra !i8rutio.?$@

4A+I (4gulat! o Actiatio/ +oral -cll Ixr88! a! crt!) i8 a 9r of th

'' choi faily <hich lay8 a critical rol i th rcruitt of lyhocyt8 a! a8tcll8 i O,P. ''41/ ''4/ ''4"/ ''45/ ''4$ a! ''410/ <hich ar cll 8urfac rctor8

for 4A+I/ ha 9 i!tifi! i lich lau8.?1/10@ h rcruit! a8t cll u!rgo8!graulatio u!r th ifluc of 4A+I/ <hich rla88 chya8 a! +B-F. h8

8u98tac8 urgulat 4A+I 8crtio 9y O,P l8ioal cll8. hi8 agai 8t8 i a iciou8

cycl <hich rlat8 to th chroic atur of th !i8a8.?10@

*0 a8t cll8 ha 9 fou! to 9 !graulat! i O,P coar! to 20 i oral uco8a.

Ma8t cll !graulatio rla88 a rag of ro-iflaatory !iator8 8uch a8 +B-F/ chya8

a! tryta8. +B-F urgulat8 th xr88io of !othlial cll a!h8io olcul8 ('*2I/

'5" a! '10*) i O,P/ <hich i8 r>uir! for lyhocyt a!h8io to th luial 8urfac8 of

9loo! 88l8 a! 8u98>ut xtraa8atio a! 8tiulat8 4A+I 8crtio fro cll8.'hya8/ a a8t cll rota8/ i8 a o< actiator of MMP-$/ la!ig to 9a8t 9ra

!i8rutio i O,P.?1/$@

a xr88io of tra8forig gro<th factor (KB)-L1 ha8 9 fou! i O,P. KB-L1!ficicy ay r!i8o8 to autoiu lyhocytic iflaatio. h 9alac 9t<

KB-L1 a! B+-E !tri8 th ll of iuological actiity i O,P l8io8. ,ocal

orro!uctio of B+-E 9y '"= cll8 i O,P l8io8 !o<rgulat8 th iuo8ur88iffct of KB-L1 a! urgulat8 ratiocyt MD' cla88 xr88io a! '&= cytotoxic -

cll actiity.?1/&@

#%"ATITIS C *IR!S IN+%CTION AN ORA) )IC#%N")AN!S

Ii!iological i!c8 fro or tha $0 cotroll! 8tu!i8 <orl!<i! 8trogly 8ugg8t that

Datiti8 ' iru8 (D') ay 9 a tiologic factor i O,P. h a88ociatio 88 to 9

ralt i outhr Iuro/ Jaa a! A. Do<r/ coutri8 <ith high8t ralc ofD' rort gati or o8igificat a88ociatio8 8ugg8tig that th ,P–D' a88ociatio

caot 9 xlai! o th 9a8i8 of high ralc i oulatio alo. O,P/ D'

rlicatio ha8 9 rort! i th ithlial cll8 fro uco8a of ,P l8io8 9y rr8tra8critio#olyra8 chai ractio or in)sit# hy9ri!iGatio; al8o/ D'-8cific '" a!

'& lyhocyt8 <r rort! i th 8u9ithlial 9a!. h8 ro9a9ly 8ugg8t that D'-

8cific lyhocyt8 ay lay a rol i th athog8i8 of O,P. h charactri8tic 9a! lilyhocytic ifiltrat ight thu8 9 !irct! to<ar! D' ifct! cll8. hthr D' ifct!

atit8 ha icra8! ri8 of !loig O,P or atit8 <ith O,P ha hac! ri8 of

!loig D' ifctio i8 yt to 9 a8<r!. h utati athogtic li 9t< O,Pa! D' 8till rai8 cotror8ial a! !8 a lot of ro8cti a! itrtioal 8tu!i8 for

a 9ttr u!r8ta!ig.?11@























I++%R%NTIA) IA$NOSIS

h !iago8i8 of rticular lich lau8 ca oft 9 a! 9a8! o th cliical fi!ig8 alo.

trlacig <hit 8tria aarig 9ilatrally o th o8trior 9uccal uco8a i8 oft athogooic. ifficulti8 ari8 oft <h thr i8 8urio8! ca!i!al ifctio <hich

a8>ura!8 th cla88ic rticular attr a! i licitig th ro8i a! rythatou8 for8 ofO,P. h !iffrtial !iago8i8 ca iclu! ch ch<ig#frictioal rato8i8/ lichoi!ractio8/ luolaia/ luu8 rythato8u8/ higu8/ ucu8 9ra higoi!/

rythatou8 ca!i!ia8i8 a! chroic ulcrati 8toatiti8. ,ichoi! !rug ractio8 ar u8ually

uilatral i !i8tri9utio/ accoai! 9y a hi8tory of < !rug ita. h o8t rlia9l tho!to !iago8 lichoi! !rug ractio8 i8 to ot if th ractio r8ol8 aftr th off!ig !rug i8

<ith!ra</ a! rtur8 if th atit i8 challg! agai. tal r8torati atrial i!uc!

lichoi! ractio8 ca 9 i!tifi! <h O,P li l8io8 ar cofi! to ara8 of th oral

uco8a i clo8 cotact or roxiity to r8torati atrial8/ u8ually aalga. A o8iti atcht8t/ a 8trog cliical corrlatio of roxiity of a r8toratio a! 9io8y 8ugg8ti of !iffu8

lyhocytic ifiltrat rathr tha a 8u9ithlial 9a! faor a !iago8i8 of oral lichoi!

ractio8. 'liically/ l8io8 of luu8 rythato8u8 (,I) o8t oft r89l ro8i lich lau8 9ut t! to 9 l88 8ytrically !i8tri9ut!. h ratotic 8tria of ,I ar uch or

!licat a! 8u9tl tha ichaN8 8tria a! 8ho< a charactri8tic ra!iatio fro th ctral

focu8. Hio8y of ,I 8ho<8 a charactri8tic ria8cular ifiltrat.

Iro8i or atrohic ty8 that u8ually affct th gigia 8houl! 9 !iffrtiat! fro higoi!/ a8 9oth ay ha a !8>uaati cliical aarac. Hoth higu8 a!

higoi! occur a8 8olitary rythatou8 l8io8 a! ar ot a88ociat! <ith ay <hit 8tria.

hi8 ca ai! i cliical !iffrtial !iago8i8 a8 ro8i a! atrohic for8 of O,P u8ually 8ho<cocoitat rticular for. Plig of th ithliu fro th ithliu–cocti ti88u

Cuctio o 8light latral r88ur i oaffct! ara (+iol8yN8 8ig) !iffrtiat8 it fro

ro8i a! rythatou8 for8 of lich lau8. A 9io8y fro th ril8ioal ti88u ca!iago8 higu8 or higoi!/ <hich 8ho< itraithlial or 8u9ithlial 8lit

hi8tologically. 8o ca88/ rytha ultifor (IM) ca r89l 9ullou8 lich lau8/ 9ut

IM i8 or acut a! grally iol8 th la9ial uco8a. 'hroic ulcrati 8toatiti8 (')

i8 a iu-!iat! !i8or!r affctig th oral uco8a <hich cliically a!hi8toathologically r89l8 lich lau8. iago8i8 of ' i8 9a8! o !irct

iuofluor8cc 8tu!i8 <hr autoati9o!i8 ar !irct! agai8t * i th 9a8al a!

ara9a8al layr8 of th ithliu. h8 l8io8 ha to 9 !iffrtiat! fro lich lau8 9cau8 ' !o8 ot r8o! to cortico8troi! thray a! ha8 to 9 trat! u8ig atialarial

!rug8.?12@

R%C%NT CONC%"TS IN TR%AT(%NT

'ortico8troi!8 ha 9 th ai8tay of aagt of O,P; yt/ othr o!aliti8 licalciuri ihi9itor8/ rtioi!8/ !a8o/ hy!roxychloro>ui/ ycoholat oftil a!

oxaari ha cotri9ut! 8igificatly to<ar! tratt of th !i8a8.Aaly8i8 of currt

!ata o athog8i8 of th !i8a8 8ugg8t8 that 9locig ,-12/ B+-E/ +B-F/ 4A+I/ or





MMP-$ actiity or urgulatig KB-L1 actiity i O,P ay 9 of thrautic alu i th

futur.?1/1@

Corticosteroids

h8 ar th o8t cooly u8! grou of !rug8 for th tratt of O,P.?1"@ h ratioal 9hi! thir u8ag i8 thir a9ility to o!ulat iflaatio a! iu r8o8. hy act 9y

r!ucig th lyhocytic xu!at a! 8ta9iliGig th ly8o8oal 9ra.?15@ oicali!otcy cortico8troi!8 8uch a8 triaciolo actoi!/ high-ott fluoriat!

cortico8troi!8 8uch a8 fluocioi! actoi!/ !i8o!iu 9tatha8o ho8hat/ a! or

rctly/ 8urott halogat! cortico8troi!8 8uch a8 clo9ta8ol ar u8! 9a8! o th8rity of th l8io. h grat8t !i8a!atag i u8ig toical cortico8troi!8 i8 thir lac of

a!hrc to th uco8a for a 8ufficit lgth of ti. Although trial8 <r !o u8ig toical

8troi!8 alog <ith a!h8i 9a8/ o 8tu!y 8ho<8 thir 8uriority <h coar! to 8troi!8<ithout th 9a8 (car9oxythyl cllulo8).?1*@ Do<r/ th 8a 8tu!y al8o rco!8 th

u8ag of a!h8i a8t u8! for !tur8/ <hich cotai8 oly iacti igr!it8 a8 a hicl

to carry th toical alicatio. hi8 ha8 8ho< xcllt 9ioa!h8i rorti8/ !u to it8 higholcular <ight (a9o 100/000) a! th flxi9ility of th olyric chai. all a!

acc88i9l ro8i l8io8 locat! o th gigia a! alat ca 9 trat! 9y th u8 of a

a!hrt a8t i a a!-to-a8ur tray (cu8to tray)/ <hich allo<8 for accurat cotrol or

th cotact ti a! 8ur8 that th tir l8ioal 8urfac i8 xo8! to th !rug8.? 17@ Patit8<ith <i!8ra! for8 of O,P ar r8cri9! high-ott a! 8urott cortico8troi!8

outh<a8h8 a! itral8ioal iCctio8. ,og-tr u8 of toical 8troi! ca la! to th

!lot of 8co!ary ca!i!ia8i8 <hich c88itat8 atifugal thray.?15@ h ottialtachyhylaxi8 a! a!ral i8ufficicy i8 high <h u8ig 8urott 8troi!8 li clo9ta8o l/

8cially <h u8! for a logr rio! of ti. y8tic cortico8troi!8 ar r8r! for

rcalcitrat ro8i or rythatou8 ,P <hr toical aroach8 ha fail!. y8tic

r!i8olo i8 th !rug of choic/ 9ut 8houl! 9 u8! at th lo<8t o88i9l !o8ag for th8hort8t !uratio ("0–&0 g for 5–7 !ay8).?1"@

OT#%R I((!NOS!""R%SSANTS AN

I((!NO(O!)ATOR& A$%NTS

Calcineurin inhi,itors

'alciuri i8 a roti ho8hata8 <hich i8 iol! i th actiatio of tra8critio of ,-2/<hich 8tiulat8 th gro<th a! !iffrtiatio of -cll r8o8.?1&@ iuo8ur88i

thray/ calciuri i8 ihi9it! 9y cyclo8ori/ tacroliu8 a! icroliu8. h8 !rug8 arcall! calciuri ihi9itor8.

Cyclosporine

'yclo8ori/ a calciuri ihi9itor/ i8 a iuo8ur88at u8! <i!ly i o8t-allogic

orga tra8lat to r!uc th actiity of atitN8 iu 8y8t. hi8 8lctily 8ur888 -

cll actiity/ th ai ra8o for tra8lat rCctio/ a! hc hac8 th uta of th





















forig orga. 'yclo8ori 9i!8 to th cyto8olic roti cyclohili of iuocott

lyhocyt8/ 8cially -lyhocyt8. hi8 colx of cylo8ori a! cyclohili ihi9it8

calciuri/ <hich u!r oral circu8tac8 i!uc8 th tra8critio of ,-2. hy al8oihi9it lyhoi ro!uctio a! , rla8/ la!ig to a r!uc! fuctio of ffctor -cll8.

'yclo8ori i8 u8! a8 a outh ri8 or toically <ith a!h8i 9a88 i O,P. Do<r/ th

8olutio i8 rohi9itily x8i a! 8houl! 9 r8r! for highly rcalcitrat ca88 of O,P.y8tic a98ortio i8 ry lo<.?1"@ t i8 o< to cau8 !o8-rlat! gu hyrla8ia <hich

r!uc8 <h th !rug i8 <ith!ra<.

Tacrolimus

acroliu8/ al8o a calciuri ihi9itor/ i8 a 8troi!-fr toical iuo8ur88i agtaro! for th tratt of atoic !ratiti8. t i8 10–100 ti8 a8 ott a8 cyclo8ori a!

ha8 gratr rcutaou8 a98ortio tha cyclo8ori. t ha8 9 8ucc88fully u8! i

rcalcitrat O,P ca88. hi8 8u98tac i8 ro!uc! 9y "treptomyces ts##-aensis a! 9log8 to

th acroli! faily. h iuo8ur88i actio of tacroliu8 i8 8iilar to that of

cyclo8ori/ although it ha8 a gratr caacity to trat th uco8a. t ihi9it8 th fir8t ha8of -cll actiatio/ ihi9itig th ho8hata8 actiity of calciuri. Hurig 88atio i8 th

coo8t 8i! ffct o98r!; rla88 of O,P aftr c88atio ha al8o 9 o98r!. h Boo! a! rug A!ii8tratio ha8 rctly i88u! a ottial cacr ri8 fro th rolog!

u8 of tacroliu8 a! ha8 rco!! it8 u8 for 8hort rio!8 of ti a! ot cotiuou8ly.

?1"/1&@

"imecrolimus

Picroliu8 ihi9it8 -cll actiatio 9y ihi9itig th 8yth8i8 a! rla8 of cytoi8 fro

cll8. Picroliu8 al8o rt8 th rla8 of iflaatory cytoi8 a! !iator8 fro

a8t cll8. 1 toical cra of icroliu8 ha8 9 8ucc88fully u8! a8 tratt for O,P.Picroliu8 ha8 8igificat ati-iflaatory actiity a! iuoo!ulatory caa9iliti8<ith lo< 8y8tic iuo8ur88i ottial.?1$/20@

Retinoids

oical rtioi!8 8uch a8 trtioi/ i8otrtioi a! frtii!/ <ith thir iuoo!ulatig rorti8/ ha 9 rort! to 9 ffcti i O,P. 4r8al of <hit 8tria ca 9 achi!

<ith toical rtioi!8/ although ffct8 ay oly 9 torary. y8tic rtioi!8 ha 9

u8! i ca88 of 8r lich lau8 <ith aria9l !gr of 8ucc88. h o8iti ffct8 ofrtioi!8 8houl! 9 <igh! agai8t thir rathr 8igificat 8i! ffct8 li chiliti8/ latio of

8ru lir Gy8 a! triglycri! ll8 a! tratogicity.?&/21@

apsone

A8 a ati9actrial agt/ !a8o ihi9it8 9actrial 8yth8i8 of !ihy!rofolic aci! a! hc i8

u8! i th tratt of lro8y. h u8! for th tratt of 8i !i8a88/ it ro9a9ly act8 a8

a ati-iflaatory agt 9y ihi9itig th rla8 of chotactic factor8 for a8t cll8.?22@h o8t coo uto<ar! ffct of !a8o i8 holy8i8 of aryig !gr/ <hich i8 !o8





















rlat! a! !lo8 i alo8t ry i!ii!ual a!ii8tr! 200–00 g of oral !a8o !aily.

Kluco8-*-ho8hat !hy!roga8 (K*P) !ficicy ca icra8 th ri8 of holytic

aia or thoglo9iia i atit8 rciig !a8o. crig for K*P !ficicy i8r>uir! 9for r8cri9ig !a8o. Dyr88itiity ractio to !a8o call! a8o

ractio i8 fr>ut i atit8 rciig ultil !rug thray. h 8yto8 of ra8h/ fr a!

Cau!ic grally occur <ithi th fir8t * <8 of thray a! ca 9 aliorat! 9ycortico8troi! thray.?2@

(ycophenolates

Origially u8! to trat 8oria8i8/ ycoholic aci! (o< rforulat! a8 ycoholatoftil) ha8 9 ritro!uc! i !ratological !ici. Hig a ry <ll-tolrat!

iuo8ur88i !rug u8! i orga tra8lat/ it ha8 9 8ucc88fully u8! to trat 8r

ca88 of O,P. Mycoholat8 ar >uit x8i a! ffcti <ith log-tr u8ag.?2"@

)ow'dose- low molecular weight heparin .eno/aparin0

,o<-!o8 hari !oi! of aticoagulat rorti8 ihi9it8 lyhocyt haraa8 actiity

<hich i8 crucial i -cll igratio to targt ti88u8. hi8 roi88 to 9 a 8il/ ffcti a!8af tratt for O,P <h iCct! 8u9cutaou8ly a8 it ha8 o 8i! ffct8.?25@

%fali1uma,

t i8 a rco9iat huaiG! oocloal ati9o!y <hich i8 u8! a8 a iuo8ur88at ith tratt of 8oria8i8. IfaliGua9/ a oocloal ati9o!y to '11a/ 9i!8 to thi8 a!h8io

olcul a! cau88 irot i O,P 9y !cra8! actiatio a! trafficig of

lyhocyt8. In !itro 8tu!i8 of oouclar cll8 i O,P ha !o8trat! a !cra8 of *0

i igratio 9y rihral 9loo! oouclar cll8 aftr rtratt <ith ati-'11aati9o!i8. t i8 a!ii8tr! oc a < a8 a 8u9cutaou8 iCctio. t i8 currtly a aro!

!rug for th tratt of la>u 8oria8i8.?2*@ Bigur 1 gi8 a 8chatic rr8tatio of th ro9a9l 8it8 of actio of !rug8 9a8! o thir rorty i O,P.

NON'"#AR(ACO)O$ICA) (OA)ITI%S

"!*A therapy

hi8 o-haracologic aroach u88 hotochothray <ith &-thoxy8oral a! log

<a ultraiolt light (PA). P8oral8 ar coou!8 fou! i ay lat8/ <hich a th8i torarily 88iti to ra!iatio. Mthoxy8oral i8 gi orally/ follo<! 9y

a!ii8tratio of 2 hour8 of ra!iatio itraorally i th affct! 8it8. t ha8 98ucc88fully u8! i th tratt of 8r ca88 of O,P.?27@ <o aCor !i8a!atag8 of

PA thray iclu! th a!r8 ffct8 of au8a a! !iGGi88 8co!ary to 8oral a! 2"-

hour hoto88itiity <h thi8 !ici i8 ta orally. Al8o/ !o8itry ca 9 !ifficult <ithith colicat! gotry of th outh/ 9cau8 PA i8 u8ually a!ii8tr! o 8i or

larg/ o 8urfac8.?2&@





http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329692/figure/F1/













"hotodynamic therapy

Photo!yaic thray (P) i8 a tchi>u that u88 a hoto88itiGig coou! lithyl 9lu/ actiat! at a 8cific <algth of la8r light/ to !8troy th targt! cll ia

8trog oxi!iGr8/ <hich cau8 cllular !aag/ 9ra ly8i8/ a! roti iactiatio. P

ha8 9 u8! <ith rlati 8ucc88 i th fil! of ocology/ ota9ly i ha! a! c tuor8.P i8 fou! to ha iuoo!ulatory ffct8 a! ay i!uc aoto8i8 i th

hyrrolifratig iflaatory cll8 <hich ar r8t i 8oria8i8 a! lich lau8. hi8 ay

rr8 th hyrrolifratio a! iflaatio of lich lau8.?2$@

)aser therapy

atit8 <ho ar 8uffrig fro aiful ro8i O,P a! ar ur8o8i to toical

8urott cortico8troi!8/ 8urgical aagt u8ig cryo8urgry a! !iffrt ty8 of la8rha al8o 9 tri!. A $&0- io! la8r/?0@ 'O2 la8r aoratio/?1@ 9io8tiulatio <ith a

ul8! !io! la8r u8ig $0"- ul8! ifrar! ray8?2@ a! lo<-!o8 xcir 0&- la8r

<ith -H ray8 ha 9 tri!.?2&@ All ty8 of la8r !8troy th 8urficial ithliucotaiig th targt ratiocyt8 9y roti !aturatio. A !r tratig 9a li th

!io! la8r !8troy8 th u!rlyig cocti ti88u <ith th iflaatory coot alog th

ithliu. h f< 8tu!i8 !ocut! 8ho< a lot of roi8/ 9ut thir ffcti88 i8 yt to

9 ro.

+o thray for O,P i8 coltly curati; th goal of tratt for 8ytoatic atit8 i8

alliatio. h follo<ig ?Bigur 2@ 8il 8y8tatic rotocol <ill ai! i ffcti tratt.

4lif ca 9 achi! i a aCority of ca88 through toical alicatio of cortico8troi!8/ <ith

or <ithout th co9iatio of othr iuoo!ulator8. ry rarly !o8 th co!itio

c88itat 8y8tic thray. ,a8r thray a! othr rct o!aliti8 ar tri! a8 th fialr!y.

CONC)!SION

O,P i8 a ry coo oral !rato8i8 a! o of th o8t fr>ut uco8al atho8i8coutr! 9y !tal ractitior8. t i8 irati that th l8io i8 i!tifi! rci8ly a!

ror tratt 9 a!ii8tr! at th arli8t. A ror u!r8ta!ig of th athog8i8 of

th !i8a8 9co8 iortat for roi!ig th right tratt.

Clinical Feature

Diagnosis and Management of Oral Lichen Planus

Complex and incurable, OLP demands careful, continuous attention

Nelson L. Rhodus, D.M.D., M.P.H.,*















Sandra Mers, D.D.S., M.S.,** and

Shanti !aimal, ".D.S., M.D.S.***

#ntroduction

#t $as %rasmus &ilson $ho coined the term 'lichen (lanus' in )+. He considered

this to -e the same disease as 'leichen ru-er', (reiousl descri-ed -

He-ra.&ic/ham noted the (unctuations and striae ato( the lesions that currentl

-ear his name.0 1oda, lichen (lanus, including the cutaneous form and oral lichen

(lanus 2OLP3, is recogni4ed as a chronic mucocutaneous

in5ammator condition of the strati6ed s7uamous e(ithelia.

Oral lichen (lanus 2OLP3 is a (oorl de6ned and misunderstood chronic

in5ammator condition inoling the oral mucosal tissues. 1he condition is mostoften seen in middle8aged (atients, and a9ects more $omen than men.:8;

Children are onl rarel a9ected. < 1he etiolog of lichen (lanus is most li/el of

multifactorial origin.+

OLP is -elieed to -e a 18cell mediated autoimmune disorder, although the initial

eent in OLP lesion formation and the factors that determine OLP susce(ti-ilit are

un/no$n.; Others -eliee that OLP has a genetic (redis(osition and is initiated -

a ariet of factors, including emotional stress and h(ersensitiit to drugs,

dental materials, or food.<8 Some of the (otential contri-utors to OLP and its

(eriodic e=acer-ations are listed in 1a-le #.



Clinical Presentation 1he clinical (resentation of OLP is aria-le, and it ma (resent as an one of the

follo$ing clinical forms> atro(hic, -ullous, erosie, (a(ular, (la7ue8li/e, or reticular,

$ith the reticular form the most common.:8;

Lesions of OLP are t(icall -ilateral. ?n location in the oral cait ma -e

inoled, $ith the most common site -eing the (osterior -uccal mucosa.@ Other

common locations cited for OLP include> tongue, gingia, retromolarA tu-erosit

area, esti-ule, (alate, 5oor of the mouth, and li(. ?lthough OLP lesions generall

hae a distinct clinical mor(holog, the ma also (resent a confusing arra of

(atterns and forms. ?t least si= clinical a((earances hae -een descri-ed, and it isnot uncommon to hae more than one form in an indiidual (atient. #t is also not

uncommon for the lesions to change not onl in character and seerit -ut also in

intraoral anatomic locations.

Forms of Lichen Planus



Recticular form 1his is the most common t(e. #t consists of slightl raised slender

$hitish lines in an interloc/ing lace8li/e (attern 2'Honiton lace' or '&ic/hamBs

striae'3 or in an annular arrangement. 1his lace8li/e net$or/ is often inters(ersed

$ith (a(ules or rings 2Figure )3.

Pa(ular form Minute $hite (a(ules ma -e seen. 1hese graduall enlarge and

coalesce to form either a reticular, annular, or (la7ue (attern.

Pla7ue8li/e form 1he (la7ue form ma -e dicult to distinguish from leu/o(la/ia,

-ut in OLP there is usuall no change in the 5e=i-ilit of the a9ected mucosa.

?nother distinguishing feature ma -e the (resence of a reticular (eri(her.

?tro(hic form ?tro(hic OLP (resents as a di9use red or erthro(la/ic lesion.

%rosie form %rosie OLP often (resents an amalgamation of erthematous and

ulceratie areas surrounded - /eratotic striae. ingial inolement $ith this form(roduces des7uamatie

gingiitis 2Figure 03.



"ullous form 1his form of OLP is 7uite rare. 1he intraoral -ullae ru(ture soon after

the a((ear, resulting in the classic a((earance of erosie OLP.

Signi6cant (ain and discomfort accom(an the atro(hic, erosie, and -ullous

forms. 1(icall there is a ccle of $a=ing and $aning $ith res(ect to the

sm(toms. 1he ccles ma ar, -ut usuall occur a-out eer three to four

$ee/s. Cutaneous lesions occasionall accom(an OLP in a-out :E of cases.)E

1he characteristic cutaneous lesion is a 5at8to((ed, erthematous or

iolaceous (ruritic (a(ule t(icall inoling the 5e=or surfaces of the legs and

arms, es(eciall the $rists. 1he (a(ules occur either as isolated lesions or in

aggregate (atterns and ma sho$ a 6ne trans(arent su(er6cial scale. &ic/hamBs

striae ma -e (resent on man (a(ules. H(er(igmentation ma -e a se7uela,

and is often 7uite mar/ed -ut tem(orar. 1he nail -eds ma also -e a9ected,

resulting in ridging, thinning, and su-ungual h(er/eratosis. Scal( inolement, if

untreated, can lead to scarring and (ermanent hair loss.)E

Diagnosis

Lesions of OLP often (resent a diagnostic dilemma. #n addition to the (atterns and

forms enumerated a-oe, a num-er of lesions can simulate OLP and are

designated as 'lichenoid'. Oral lichenoid lesions can follo$ the administration of a

sstemic drug 2non8steroidal anti8in5ammator drugs, -eta -loc/ers etc.3,

(lacement of a dental restoration, or (roision for a denture.)E8)) Flaorings,



es(eciall cinnamates in tooth(aste, ma also trigger lichenoid contact sensitiit

reactions)08): 21a-le #3.

%motional stress has -een considered to -e a strong contri-uting factor - man

inestigators, es(eciall for the e=acer-ation (hases of OLP.08)) Most of these

lesions are unilateral and usuall regress after remoal of the causatie 2or(reci(itating3 factor. #n general, -ilateral lesion distri-ution is a /e clinical

diagnostic feature of OLP, $hile unilateral distri-ution is a detractor rendering true

OLP less li/el.:, ):8);

Man of the clinical descri(tions (roided - clinicians contain generic terminolog

such as $hiteA$hitish, red and $hite, h(er/eratosis, and leu/o(la/ia. 1hese terms

ma descri-e lesions other than OLP, ranging from chronic chee/ che$ing to

to-acco8(ouch /eratosis and errucous carcinoma. Some clinicians, on the other

hand, su((ort their (roisional clinical diagnosis -

(roiding de6nitie descri(tions, such as striae of &ic/ham, and s(ecifing a

location for the oral lesions. 1he clinical a((earance and location, in com-ination

$ith medical and dental 6ndings,are alua-le clues for clinicians formulating and

Gustifing (roisional and di9erential clinical diagnoses. 1he are also alua-le

considerations for (athologists in rendering de6nitie 6nal diagnoses.

?((ro=imatel :E8<E of (atients $ith OLP also hae concomitant s/in lesions.

1he (resence of these characteristic cutaneous lesions can also aid in the

diagnosis of OLP.

1he diagnosis of OLP a((ears to hae -een e=tended - the use of modifing

terminolog to include lesions that hae less than de6nitie features. 1he use of

modi6ers such as (ossi-le, (ro-a-le, suggestie of, and consistent $ith OLP inde6nitie 6nal diagnoses $hen the 6ndings are less than classic ma -e

misleading to clinicians formulating treatment o(tions and follo$8u( care.

1herefore the use of such confusing terminolog should -e restricted.8

#n a recent stud , it $as re(orted that the ratio of females to males diagnosed

$ith OLP $as a((ro=imatel t$o to one oer a ten8ear (eriod, and the mean age

for females increased - <.0 ears $hile the mean age for males decreased -

)0.0 ears. 1he (ercentage of all oral lesions -io(sied oer the time (eriod $hich

$ere diagnosed as OLP increased from ).+ to ;.). Ho$eer, the (ercentage of

de6nitiel diagnosed OLP lesions decreased from )EE to ;0 oer the sametime (eriod. 1hese results indicate the dicult $ith $hich OLP is diagnosed -

histo(atholog alone. #t is er im(ortant to include com(lete clinical information

in the diagnosis of OLP.

http://www.mndental.org/archive/march/features/article_2/




Histo(atholog

1he histo(athological features of OLP hae -een $ell esta-lished.);8)< 1he

re7uisite features are li7uefaction degeneration of the -asal cells and a -and8li/ein6ltrate of lm(hoctes $ithin the lamina (ro(ria that intimatel intermingles $ith

the -asal cell region of the surface e(ithelium. ?dditional features are the 'sa$8

toothed' rete (egs, h(er/eratosis or (ara/eratosis, se(aration of surface

e(ithelium from the underling connectie tissue, and the formation of 'Ciatte

-odies'); 2Figure :3. 1hese features are often (resent -ut are not a (rere7uisite for

diagnosis.

1he a((earance of the classic histologic features ma/es the diagnosis of OLP fairl

straightfor$ard. #t is onl $hen the 6ndings are aria-le and nons(eci6c that the

diagnostic (rocess is fraught $ith errors. 1he use of 7ualifing and dis7ualifingfactors to rule in or rule out identi6a-le causes can su-stantiall narro$ the clinical

and histo(athologic diagnosis of lesions considered 'true' OLP.

Historicall, -oth the histologic and clinical diagnoses of OLP hae -een enigmas.

Histologic diagnostic criteria to se(arate OLP from lichenoid lesions and lichenoid

ds(lasia hae -een elucidated - seeral inestigators ):8); 2Figure :3.



Relationshi( &ith S7uamous Cell Carcinoma

Case studies)+8) hae sho$n that some (atients $ith a diagnosis of OLP also

deelo( s7uamous cell carcinoma 2SCC3 $ithin or adGacent to lichenoid lesions

2Figure ;3. Some inestigators)80) hae attem(ted to demonstrate that OLP has

(remalignant (otential and can (rogress to SCC. Ho$eer, the 7uestion of $hether

the (remalignant e(ithelial ds(lasia or the OLP came 6rst remains controersial. ?

signi6cant (ro-lem in esta-lishing a relationshi( -et$een OLP and the

deelo(ment of SCC is the dicult in di9erentiating histologicall -et$een the

aria-le 6ndings in OLP and those of ds(lastic lesions $ith lichenoid features.):8

); #n an e9ort to inestigate these as t$o distinct and se(arate histo(athologicentities, researchers are e=amining (<: a (rotein (roduct of a tumor8su((ressor

gene inoled in DN? re(air and cell ccle as $ell as other arrest molecular

-iomar/ers 2Figure :3.0080;

1reatment



No /no$n cure e=ists for oral lichen (lanus. 1he treatment modalities in OLP are

still em(irical. 1he rationale for treatment is to (roide oral comfort for the (atient

if the lesions are sm(tomatic, to im(roe function 2eating, s(ea/ing, slee(ing,

$earing dental (rostheses etc.3, as $ell as to (reent or (rolong the fre7uenc and

seerit of e=acer-ations. Sstemic and local relief $ith anti8in5ammator and

immunosu((ressant agents is often indicated. #n some cases concomitant to(icalanesthetics, analgesics, and antifungal agents are also indicated. #denti6cation of

an (reci(itating factors including diet, dental materials, dental hgiene (roducts,

or medication 2lichenoid drug reaction3 21a-le #3 should -e underta/en to ensure

against a h(ersensitiit reaction or e=acer-ation. 1reatment or (reention of a

secondar fungal infection $ith a sstemic antifungal agent also should -e

considered in most cases.

#n general, the 7uiescent, asm(tomatic reticular and (la7ue forms do not $arrant

(harmacological interention, $hile the erthematous and erosie forms are

associated $ith a high degree of mor-idit. Regardless of clinical t(e or

(resentation, lesions of OLP undergo (eriods of e=acer-ation and 7uiescence.

1reatment is therefore aimed at reducing the seerit and length of these e(isodic

out-rea/s.

Maintenance of oral hgiene $ith a non8a-rasie dentifrice and aoidance of

alcohol8containing mouth$ashes is im(ortant since these hae -een o-sered to

reduce seerit of the sm(toms.

Potential for Malignanc and Periodic "io(sies?n chronic andAor refractor lesion should -e considered for a -io(s, 6rst to

esta-lish a diagnosis and su-se7uentl to rule out malignanc. Periodic -io(sies

are indicated for (ersistent lesions as there is a (otential for malignant

transformation. 1he re(orted incidence of malignant transformation is

a((ro=imatel 08<. 1he mean length of time for OLP to transform to s7uamous

cell carcinoma is @.0 ears.;,)<,),0< 1hese 6gures indicate the need for long8

term, a((ro(riate follo$8u( and monitoring.

1o(ical SteroidsStated again, there is no cure for OLP. 1hera( should -e indiiduall tailored to

the s(eci6c (atient and is aimed at reduction of in5ammation. 1hera(ies $ith

steroids and immunomodulating drugs are (resented to inform the clinician that

such modalities are aaila-le. 1here are seeral of these agents, and there is no

single recommended thera(. "ecause of the (otential for side e9ects, close

colla-oration $ith the (atientBs (hsician is recommended $hen these medications

are (rescri-ed. 1hese modalities ma -e -eond the sco(e of clinical e=(erience of



general dentists, and referral to a s(ecialist in oral medicine, a dentist $ith training

and e=(erience in this area, or to an a((ro(riate (hsician ma -e necessar.0+

Prolonged use of to(ical steroids 2for a (eriod of greater than t$o $ee/s

continuous use3 ma result in mucosal atro(h and secondar candidiasis, and

ma increase the (otential of sstemic a-sor(tion. 1he concomitant (rescri-ing ofantifungal thera( along $ith the to(ical steroids ma -e necessar. 1hera( $ith

to(ical steroids, once the lichen (lanus is under control, should -e ta(ered to

alternate8da 2or less3 thera( de(ending on control of the disease and the

tendenc to recur. ? usual course of steroid thera( should not e=ceed )E8); das,

$ith an interim (eriod a((ro=imatel the same -efore re8instituting the steroid

thera(.

Steroid thera( ma include an of the follo$ing.

Potent> De=amethasone 2Decadron3 oral rinse, E.< mgA< ml

Fluocinonide 2Lide=3 gel, E.E<

#ntermediate> "etamethasone alerate 2alisone3 ointment E.)

1riamcinolone acetonide 2!enalog3 ointment E.)

Lo$> Hdrocortisone gel or ointment, ).E

Iltra8(otent> Clo-etasol (ro(ionate 21emoate3 ointment, E.E<

Halo-etasol (ro(ionate 2Iltraate3 ointment, E.E<

%=am(les of (rescri(tions for OLP $ould -e>

J Fluocinonide 2Lide=3 gel E.E<

J Dis(> :E gm tu-e

J Sig> Coat the lesion $ith a thin 6lm after each meal and at -edtime.Or 8

J De=amethasone 2Decadron3 eli=ir E.< maA< ml

J Dis(> )EE ml

J Sig> Rinse $ith one teas(oonful for t$o minutes 7id and s(it out. Discontinue

$hen lesions -ecome asm(tomatic.

Maintenance

#n (eriods of remission and 7uiescence, OLP ma -e /e(t under control and the

sm(tomatic e=acer-ation (hase reduced in fre7uenc - seeral interentions.First, elimination or aoidance of (reci(itating or (er(etuating factors such as SLS8

containing dentifrices, s(ic or acidic foods,tissue trauma, and =erostomia8inducing

agents 21a-le #3. ? 'magic mouth$ash' containing -enadrl, /ao(ectate 2or

carafate3, and mil/ of magnesia as a -ase to $hich nstatin andAor lidocaine ma

-e added 2de(ending u(on the clinical indications3 is 7uite e9ectie as a thera(

for mildl sm(tomatic cases or as maintenance thera(.



Oral candidiasis ma result from to(ical steroid thera(. 1he oral cait should -e

monitored for emergence of fungal infection on (atients $ho are (laced on steroid

thera(. Most often oral candidiasis (resents clinicall as macular erthema,

angular cheilosis, or (seudomem-ranous $hite (la7ues $hich can -e scra(ed o9

the mucosa. Ho$eer, signi6cant candidiasis ma -e (resent $ith fe$ clinical

signs. Pro(hlactic antifungal thera( should -e initiated in (atients $ith a historof fungal infection andAor immunosu((ressed (atients andAor those $ith (rior

steroid administration.0+,0@

Phased and Com-ination 1hera(ies

Due to the (hasic nature of OLP alternating -et$een sm(tomatic e=acer-ations

and remissions, often a (hased se7uence of thera( is $arranted and

e9ectie.0+,0@ #n these cases, a more (otent regimen of to(ical corticosteroid for a

$ee/ or t$o follo$ed - a second (hase regimen of lesser (otent to(ical

corticosteroids $ill (roide e9ectie thera(. ?dditionall, often during (eriods of

acute e=acer-ation, com-inations of more than one to(ical corticosteroid ma -e

e9ectie

K for e=am(le, 6rst the de=amethasone oral rinse follo$ed - a((lication of

5uocinonide or triamcinolone ointment. 1here are man com-inations $hich ma

-e utili4ed, de(ending u(on the indiidual clinical scenario.

O-iousl, (ro(er diagnosis and recognition of the nature of the OLP in the

indiidual (atient along $ith detailed (atient information and self8thera(

instruction are essential.

Sstemic steroids and immunosu((ressants (rescri-ed for more seere cases

$ould include>

J De=amethasone 2Decadron3 eli=ir E.< mgA< ml

J Dis(> :0E ml

J Sig> ). For : das, rinse $ith ) ta-les(oonful 2)< ml3 7id and s$allo$. 1hen 0. For

: das, rinse $ith teas(oonful 2< ml3 7id and s$allo$. 1hen :. For : das, rinse

$ith ) teas(oonful 2< ml3 7id and s$allo$ eer other time. 1hen ;. Rinse $ith )

teas(oonful 2< ml3 7id and e=(ectorate.

Or K

J Prednisone ta-lets )E mgJ Dis(> 0+ ta-lets

J Sig> 1a/e ; ta-lets in the morning for < das, then decrease - ) ta-let on each

successie da.

Or 8

J Prednisone ta-lets < mg

J Dis(> ;E ta-lets

J Sig> 1a/e < ta-lets in the morning for < das, then < ta-lets in the morning eer



other da until

gone.

#f oral discomfort recurs, the (atient should return to the clinician for reealuation.

Man studies suggest that oral lichen (lanus has an intrinsic (ro(ert (redis(osingto malignant transformation. Ho$eer, the etiolog is com(le=, $ith interaction

among factors including infectious agents, genetic aria-les, enironmental

in5uences, and lifestle elements. Pros(ectie studies hae demonstrated that

lichen (lanus (atients hae a slightl increased ris/ to deelo( oral s7uamous cell

carcinoma. ?ll (atients e=hi-iting lichen (lanus intraorall, (articularl those $ho

hae had the ulceratie form, should receie (eriodic follo$8u(.

1hera( $ith medications such as sstemic steroids, immunosu((ressants, and

immunomodulators is (resented to inform the clinician that such modalities hae

-een re(orted e9ectie for (atients su9ering from ulceratie lichen (lanus.

Medications such as a4athio(rine, mco(henolate mofetil, tacrolimus hdro8

=chloro7uinesulfate, acitretin, and cclos(orine8? are used to treat (atients $ith

seere (ersistent ulceratie lichen (lanus -ut should not -e routinel used

-ecause of the (otential for side e9ects. Close colla-oration $ith the (atientBs

(hsician is recommended $hen these medications are (rescri-ed.

Summar

Oral lichen (lanus is a com(le= and (oorl understood clinical condition $hich

cannot -e cured. ? de6nitie diagnosis and careful, conscientious follo$8u( are

im(eratie. Sm(toms and com(lications are common and challenging -ut ma -emanaged $ith a ariet of thera(ies including orall administered and sstemic

medications as $ell as lifestle alterations and reduction of (reci(itating factors.

References

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0. &ic/ham, L.F.> Sur un signe (athognomoni7ue delichen du &ilson 2lichen (lan3

stries et (unctuations grisatres.?nn Dermatol S(h +> )@80E, )<.

:. incent, S.D., Fotos, P.., "a/er, !.?. et al> Oral lichen (lanus> the clinical,

historical, and thera(eutic features of )EE cases. Oral Surg Oral Med Oral Pathol

@E> )+<8)@), )E.;. Lo4ada8Nur, F., and Miranda, C.> Oral lichen (lanus> e(idemiolog, clinical

characteristics, and associated diseases. Sem Cutan Med Surg )+> 0@:80@@, )@.

<. ungell, P.> Oral lichen (lanus> a reie$. #nt Oral Ma=illofac Surg 0E2:3> )08):<,

)).

+. Scull, C., "eli, M., Ferreiro, M.C., Ficarra, ., riths, M. et al> I(date on oral

lichen (lanus> etio(athogenesis and management. Crit Re Oral "iol Med 2)3> +8

)00, ).



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