Expression of CD1 and HLA-DR by Langerhans cells (LC) in oral lichenoid drug eruptions (IDE) and idiopathic oral lichen planus (LP)

Numbers of Langerhans ceils (LC) expressing the common thymocyte antigen (T6/CD1) are similar in oral lichen planus (LP) and in normal oral epithelium: however, expression of class II major histocompatibility antigens (HLA-DR/Ia) by Langerhans cells is greater in lichen planus than in normal epithelium, a phenomenon believed to be associated with activation and antigen presentation. This study quantified the numbers of T6+ve and HLA-DR + ve Langerhans cells in oral lichen planus and lichenoid drug eruptions (LDE) to investigate whether differences may reflect differing routes of antigen presentation. Six patients with oral lichenoid drug eruptions and six control idiopathic oral lichen planus patients had lesional biopsies. An immunoperoxidase technique was used to demonstrate binding of T6 and HLA-DR antibodies to identify dendritic intra-epithelia! cells as Langerhans cells and activated Langerhans cells, respectively. In lichenoid drug eruptions, the number of HLA-DR+ve LC was significantly lower than the number of T6+ve LC ( P < 0.05), whereas in idiopathic lichen planus the numbers of T6+ve and HLA-DR+ve LC did not differ significantly ( P = 0.20). The results provide evidence for differences in the routes of antigen presentation in lichenoid drug eruptions and idiopathic lichen planus.     

Lichen planus--specific antigen in oral lichen planus and oral lichenoid drug eruptions

OBJECTIVE: To investigate the usefulness of lichen planus-specific antigen as a marker to distinguish idiopathic oral lichen planus from oral lichenoid drug eruptions.Study Design: Biopsy samples were taken from 6 patients with oral lichenoid drug eruptions and 6 patients with idiopathic oral lichen planus. Each biopsy sample was examined for the presence of lichen planus-specific antigen by using a modification of a previously described immunofluorescence method that uses autologous serum and also allogenic sera from the remaining 11 cases. RESULTS: All autologous and allogenic immunofluorescence tests showed negative findings for lichen planus-specific antigen. CONCLUSIONS: Lichen planus-specific antigen is not a useful marker to distinguish oral lichenoid drug eruptions from idiopathic lichen planus. This finding is in contrast with our findings in an earlier study of basal cell cytoplasmic autoantibodies.     

Oral lichen planus: A disease or a spectrum of tissue reactions? Types,causes, diagnostic algorhythms,prognosis, management strategies

Oral lichen planus and lichenoid lesions comprise a group of disorders of the oral mucosa that likely represent a common reaction pattern to 1 or more unknown antigens. The coexistence of hyperkeratotic striation/reticulation, varying degrees of mucosal inflammation from mild erythema to severe widespread ulceration, and a band‐like infiltrate of mononuclear inflammatory cells including activated T lymphocytes, macrophages, and dendritic cells, are considered suggestive of oral lichen planus and lichenoid lesions. Several classification systems of oral lichen planus and lichenoid lesions have been attempted, although none seem to be comprehensive. In this paper, we present a classification of oral lichen planus and lichenoid lesions that includes oral lichen planus, oral lichenoid contact lesions, oral lichenoid drug reactions, oral lichenoid lesions of graft vs. host disease, discoid lupus erythematosus, and systemic lupus erythematosus, lichen planus‐like variant of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome, chronic ulcerative stomatitis, lichen planus pemphigoides, solitary fixed drug eruptions, and lichen sclerosus. We present the clinical and diagnostic aspects of oral lichen planus and lichenoid lesions, and discuss related treatment options.     

Oral lichenoid lesion: A review of the literature

The oral lichenoid lesion (OLL) is response that occurs on the oral mucosa. The OLL include allergic response to the dental materials, drugs, and on graft-vs-host disease (GVHD). OLL to dental material happen when restorative materials, most commonly amalgam, are in direct contact with the mucosa in sensitized individuals. Medications that produce OLL are oral hypoglycemic agents, angiotensin-converting enzyme inhibitors, and nonsteroidal anti-inflammatory agents. GVHD is a complication in bone marrow transplantation and OLL is a common lesion observed in this disease especially in chronic GVHD. The clinical and histological aspects of OLL are similar to oral lichen planus and turn it difficult to make a differential diagnosis. The purpose of this paper is review about OLL related to the dental materials, drug use and GVHD.     

Histochemical analysis of pathological alterations in oral lichen planus and oral lichenoid lesions

Lichen planus is a dermatologic disease of unknown etiology characterized by keratotic plaques on the skin. Many patients also harbor white lesions of the oral mucosa. The literature contains numerous reports of lichen planus-like lesions evolving in conjunction with the administration of a variety of pharmacologic agents. It is difficult, if not impossible, to distinguish such lesions from one another. The present study evaluated the epithelial and basement membrane thickness, mast cells (intact cells and degranulated cells subepithelially) and the presence or absence of blood vessels in oral lichen planus and oral lichenoid lesions. The evaluation was done using the periodic acid-schiff (PAS) and toluidine blue staining techniques on 20 cases each of oral lichen planus and oral lichenoid lesions and 5 control specimens of normal buccal mucosa. The results showed an increased number of degranulated mast cells in areas of basement membrane degeneration, increased vascularity and increased PAS-positive basement membrane thickness in oral lichen planus as compared with oral lichenoid lesions. Reduced epithelial thickness was found in oral lichen planus. The present study emphasizes the importance of these parameters in differentiating oral lichen planus from oral lichenoid lesions using special staining techniques.     

Oral lichenoid drug eruptions: their recognition and management

Lichen planus is a relatively common, often clinically distinctive, mucocutaneous condition with an uncertain aetiology. One variant of lichen planus is the so-called 'lichenoid drug eruption'. In contrast to idiopathic lichen planus, lichenoid drug eruptions, where practicable, may be managed by substitution of the offending drug. The dental clinician is in a prime position to identify these lesions and liaise with medical colleagues regarding their management. This article reviews oral lichenoid drug eruptions, emphasizing those aspects of relevance to the general dental practitioner.     

Linear IgA disease histopathologically and clinically masquerading as lichen planus.

In each of 2 cases reported, the patient presented with features of erosive lichen planus or lichenoid drug eruptions and an incisional biopsy taken from the patient was diagnosed histologically as lichen planus. Subsequent recurrences or exacerbations were associated with vesiculobullous lesions. Simultaneous or subsequent direct immunofluorescence studies--from the same tissue sample in one case and from a similar site in the other case--demonstrated classic features of linear IgA disease. Both patients were originally treated for lichen planus with systemic and/or topical corticosteroids with limited success. One patient was treated with sulfapyridine with minimal improvement. Both patients were subsequently treated with dapsone and demonstrated significant clinical improvement. We propose that linear IgA disease may be more common than reported in the oral cavity, inasmuch as many cases of recalcitrant lichen planus, erosive lichen planus, and lichenoid drug eruptions, especially those with a vesiculobullous component, may in reality represent linear IgA disease. We recommend that direct immunofluorescence be done in any case in which bullous lichen planus is suspected.     

Amalgam-related oral lichenoid reaction

Abstract – In 52 patients with oral lichen planus topographically related to amalgam restorations, the fillings were replaced by other materials in 18, 16 of whom experienced complete remission of the lessions within 1–12 months. These results are discussed in relation to the results of epicutaneous patch tests for possible allergy to a number of mercury compounds. The term "oral lichenoid reaction", is suggested to describe these lesions.     

HLA-DR3 antigens in erosive oral lichen planus, cutaneous lichen planus, and lichenoid reactions

HLA antigens were examined in patients with erosive oral lichen planus (OLPe), cutaneous lichen planus (CLP), or lichenoid reactions (LR) adjacent to amalgam fillings. The control group had amalgam restorations in contact with the oral mucosa but without any reactions. A strong association was found between HLA-DR3 and OLPe, with an RR value of 21.0 (p less than 0.05). The corresponding values for CLP and LR were 2.3 and 1.5, respectively (NS). The haplotype A1-B8-DR3 was more frequently found in OLPe (p less than 0.05) and CLP (p less than 0.05) than in LR and controls (NS). The data indicate that OLPe, CLP, and LR, which present with virtually the same histopathologic features, are different in their association with HLA-DR3. Moreover, the increased frequency of HLA-DR3 in OLPe suggests an autoimmune component in the pathogenesis of this disorder.     

Clinical and histologic analysis of mucous membrane lesions associated with dental restoration

Fifteen cases of mucous membrane lesions associated with dental restorations were reported. Eleven cases appeared as lichen planus-like lesions clinically, three leukoplakia like lesions and one erythema with ulceration. Biopsies were taken in six cases, five of them were lichen planus, histologically like and epithelial dysplasia was present in one case. All lesions disappeared or improved after the amalgam restorations were changed. Diagnosis and differential diagnosis were discussed.     

Lichenoid reaction associated to amalgam restoration

Hypersensitivity to mercury associated with amalgam restorations may occur and present in one of two different ways. Most commonly it presents as an oral lichenoid reaction affecting oral mucosa in direct contact with an amalgam restoration and represents a delayed, type IV, cell mediated immune response to mercury or one of the other constituents of the dental amalgam. We report a case of oral lichenoid reaction associated to amalgam restoration. A 38 year-old woman presented a caries lesion of tooth #37. A Blacks class I preparation was performed and filled with amalgam. After 19 months, intra-oral examination revealed atrophic lesion, lightly erythematous, affecting the left buccal mucous. The lesion contacted directly with the amalgam restoration in the lower first molar. The right buccal mucosa was normal. His medical history was unremarkable, he was taking no medication and had no known allergies. However, the patient had felt certain rare sensation in that zone when eating sharp meals. Biopsy showed histological changes compatible with oral lichen planus. The patient decided not to change again the restoration, because she did not have important annoyances and she did not wish to be treated again. Other restorations were performed with composite resins, and no reaction was evidenced in the mucosa.     

Histological evidence for lichen planus in clinically normal perilesional tissue

The objective of this study was to examine the histological features of apparently normal oral mucous membrane adjacent to lesions of oral lichen planus. Twenty-six patients attending an oral medicine unit with clinical lesions typical of oral lichen planus had biopsies of lesional and perilesional sites. Biopsies were examined for histopathological features of oral lichen planus. Twenty-two (85%) of lesional biopsies and 12 (46%) of the perilesional biopsies were reported as either typical or showing some features of lichen planus. Twelve of these 22 cases (55%) had both lesional and perilesional biopsies reported as either typical or showing some features of lichen planus. These 12 cases represented 46% of all cases. In four cases (15%) neither the lesional nor the adjacent perilesional biopsy was reported as lichen planus. The inflammatory process in oral lichen planus may extend beyond the confines of the clinical lesion into adjacent mucous membrane of normal appearance.     

Amalgam-contact hypersensitivity lesions and oral lichen planus

OBJECTIVE: The purpose of this study was to investigate the relationship between amalgam restorations and oral lichen planus. STUDY DESIGN: Eighty-one patients with oral lichenoid lesions were characterized clinically and skin patch tested for amalgam or mercury hypersensitivity. Thirty-three of these patients had amalgam fillings in contact with oral lesions replaced and were followed to determine the outcome. RESULTS: Clinically, 2 patient groups were identified: (1) 30 patients with probable amalgam-contact hypersensitivity lesions (ACHLs) and (2) 51 patients with oral lichen planus (OLP) but no clear relationship with amalgam. Seventy percent of ACHL cases were patch test positive for amalgam or mercury compared with only 3.9% of OLP cases (P < .0001). Amalgam replacement resulted in lesion improvement in 93% of ACHL cases. No such improvement was observed in the OLP cases treated (P < .001). CONCLUSION: OLP is a heterogeneous condition within which an ACHL subgroup can be identified. ACHLs, but not other OLP lesions, respond favorably to amalgam replacement. A strong clinical association between lesions and amalgam restorations plus a positive patch test result was a good predictor of lesion improvement on amalgam replacement.     

Lichen planus and the vulvovaginal-gingival syndrome

Lichen planus is a dermatologic disease that affects both skin and mucosa. Here we report five cases of lichen planus that presented as the oral component of the vulvovaginal-gingival syndrome. Four of the cases were associated with biopsy-proven oral lichen planus, and all five patients had oral lesions that clinically resembled lichen planus. Three patients were taking medications that are associated with lichenoid drug reactions; four patients were postmenopausal; and all five patients had desquamative vulvovaginitis. Clinicians may see these patients when they show persistent signs and symptoms of oral lichen planus. We report five case histories and review the 127 cases found in the literature to make the practicing clinician aware of this unusual clinical entity. The hepatitis C virus association and drug-induced lichenoid mucositis are topics that are addressed. In addition, clarification of the issues surrounding the premalignant potential of oral lichen planus is provided with evidence, rationale, and data from the literature to support the position that true oral lichen planus has no inherent predisposition to become malignant.     

The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus.

OBJECTIVE: Lichen planus, in its classical presentation, involves the oral cavity and skin. This study evaluated patients with oral lichen planus for extraoral manifestations of the disease. STUDY DESIGN: A total of 584 patients with oral lichen planus were evaluated for cutaneous, genital, scalp, nail, esophageal, and ocular lichen planus. RESULTS: Extraoral manifestations included cutaneous lichen planus in 93 patients, genital lichen planus in 19% of 399 examined women and 4.6% of 174 examined men, nail involvement in 11 patients, lichen planopilaris in 6 patients, esophageal lichen planus in 6 patients, and conjunctival lichen planus in 1 patient. Thirty-three patients developed lichen planus in 3 or more sites. CONCLUSIONS: Because a relatively high percentage of patients with oral lichen planus develop extraoral manifestations, a thorough evaluation should routinely be performed. A complete history and physical examination by a multidisciplinary group of health care providers uncovers common and uncommon extraoral features of the disease.     

Lichen planus, lichenoid drug reactions, and lichenoid mucositis

Lichen planus is a common mucocutaneous disease affecting a significant portion of the general population. This article reviews the most current concepts on the epidemiology, etiology, pathogenesis, clinical presentations, and treatment of oral lichen planus, lichenoid drug reactions, and lichenoid mucositis.     

Comparison of eosinophil densities in oral mucosal lichen planus and lichenoid drug reactions

The eosinophil density in various tissue compartments in oral mucosal lichen planus and oral mucosal lichenoid drug reactions was studied using a variety of staining methods and histomorphometry. No significant differences were found, indicating that the presence of eosinophils cannot be used as a reliable histologic criterion for establishing a diagnosis of oral mucosal lichenoid drug reactions.     

Amalgam-related oral lichenoid reaction

In 52 patients with oral lichen planus topographically related to amalgam restorations, the fillings were replaced by other materials in 18, 16 of whom experienced complete remission of the lesions within 1-12 months. These results are discussed in relation to the results of epicutaneous patch tests for possible allergy to a number of mercury compounds. The term "oral lichenoid reaction", is suggested to describe these lesions.     

Successful treatment of oral lichen planus-like chronic graft-versus-host disease with topical tacrolimus: a case report

BACKGROUND: Bone marrow transplantation (BMT) is a common treatment used for deficiencies of host marrow or in the control of blood malignancies. Post-allogeneic BMT complications include graft-versus-host disease (GVHD). GVHD occurs when immunologically active T lymphocytes are transplanted into an immunosuppressed recipient who is genetically disparate from the donor. In this case report we describe the occurrence of oral lichen planus-like lesions as the first manifestation of chronic GVHD (c-GVHD) and the subsequent management of this disease with topical tacrolimus. METHODS: Diagnostic aids included routine histology and direct immunofluorescence studies to rule out immunobullous diseases and to confirm the c-GVHD. Treatment consisted of topical application of 0.1% tacrolimus ointment three times a day. RESULTS: Routine histology confirmed the clinical diagnosis of oral lichen planus-like c-GVHD. Treatment with tacrolimus ointment completely resolved the oral lesions after 2 months of therapy. CONCLUSIONS: Topical tacrolimus at low concentrations (0.1%) shows promise in the management of oral lichen planus-like c-GVHD. Controlled studies are necessary to assess the efficacy, the duration of therapy required for effective results, and the safety of this treatment over the long-term.