|Year : 2020 | Volume
| Issue : 2 | Page : 75-77
Therapeutic management of lichenoid dysplasia
Department of Dentistry, Burdwan Medical College and Hospital, Purba Burdwan, West Bengal, India
|Date of Submission||27-Apr-2020|
|Date of Acceptance||20-Jun-2020|
|Date of Web Publication||31-Oct-2020|
Dr. Shiladitya Sil
Department of Dentistry, Burdwan Medical College and Hospital, Khosbagan, Purba Burdwan - 713 104, West Bengal
Source of Support: None, Conflict of Interest: None
Lichenoid dysplasia (LD) refers to a condition that clinically resembles oral lichen planus (OLP) and/or oral lichenoid lesions (OLL), but histologically harbors epithelial dysplasia. LD has a greater tendency to acquire malignant transformation and although it resembles OLP/OLL, many authors have classified LD as a separate and distinct entity. Herein, we report a case of a 45-year-old female patient with severe burning sensation for the last 6 months. Clinically, she had lichenoid features and histologically mild epithelial dysplasia. She had extensive lesions that made surgical management complicated. Therapeutic management was instituted for her with periodic follow-up. There was adequate reduction in lesion size, burning sensation as well as in the inflammatory component of the lesion. A proper clinical and histopathological classification system is the need of the hour for OLP, OLL, and LD that will help clinicians to identify and treat the condition.
Keywords: Lichen planus, lichenoid dysplasia, lichenoid lesions, oral epithelial dysplasia, oral epithelial dysplasia with lichenoid features, oral lichen planus with dysplasia
|How to cite this article:|
Sil S. Therapeutic management of lichenoid dysplasia. Indian J Oral Health Res 2020;6:75-7
| Introduction|| |
Oral lichen planus (OLP) is a T-cell mediated chronic mucocutaneous disease having oral as well as dermatological manifestations. Erasmus Wilson was the first person to describe OLP in 1869.
Oral lichenoid lesions (OLL) have clinical presentation similar to OLP but in response to an allergen such as dental restoration, graft versus host reactions, drugs, chemicals, and tobacco.
OLP and OLL have been classified by the World Health Organisation as potentially malignant disorders. The annual malignant transformation rate of OLP is 0.5%–2%, whereas it is 2.1% for OLL.
Krutchkoff and Eisenberg first coined the terms lichenoid dysplasia (LD) and epithelial dysplasia with lichenoid features (EDL).
Herein we report an exceptional case of LD, initially diagnosed as erosive lichen planus, that underwent complete therapeutic treatment with follow-up.
| Case Report|| |
A 45-year-old female patient reported to our outpatient department with a chief complaint of burning sensation that has been gradually increasing for the last 6 months. No relevant medical history was elicited. A positive history of chewing tobacco with slaked lime and areca-nut 2–3 times per day for the last 10 years was elicited. On intraoral examination, lesions were appreciated on both right and left buccal mucosa, palate and the tongue.
Right buccal mucosa revealed a well-defined white patch measuring 1 mm × 1.5 mm in diameter with radiating white striae extending along the occlusal plane, approximately 2 cm posterior to the retrocommisural area. A diffuse white patch could also be appreciated in the buccal vestibule. Posterior to the white patch, a diffuse erosive area with few foci of ulceration and sloughing could be appreciated that extends along the occlusal plane, 0.5 cm anterior to the retro-molar trigone. Similar lesions could be appreciated in the left buccal mucosa [Figure 1].
|Figure 1: The initial presentation of the patient in the right buccal mucosa (left side) and left buccal mucosa (right side)|
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Differential diagnosis of erosive lichen planus, lichenoid reaction, and speckled leukoplakia was given. The patient was advised immediate habit cessation. As the lesion was more extensive in the right buccal mucosa, incisional biopsy was performed from that site, after obtaining the patient's consent. The patient was put on benzydamine mouthwash 0.15% for palliation.
Histopathological examination revealed hyper-orthokeratinized atrophic epithelium with dysplasia around basal and para-basal cell layer with mild degree of abnormal epithelial stratification. Moderate chronic inflammation of underlying connective tissue was appreciated [Figure 2].
|Figure 2: The hemotoxylin and eosin-stained histopathological sections at ×40 (left side) and ×60 (right side). Photomicrograph reveals hyper-orthokeratinized atrophic stratified squamous epithelium with dysplasia around basal and parabasal cell layer with a mild degree of abnormal epithelial stratification. Moderate chronic inflammation of the underlying connective tissue was appreciated|
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The patient was put on topical tacrolimus ointment 0.1% for a month. Simultaneously, 2 ml of placental extracts with lignocaine hydrochloride 0.1% in 1:1 ratio was administered by intralesional injection, once a week for a total duration of 8 weeks. No corticosteroids were used.
There was a gradual reduction of burning sensation along with reduction in size and extent of the lesion [Figure 3] and [Figure 4] As she was unwilling for excision even after the reduction of the lesion size, she has been under regular follow-up and is apparently healthy.
|Figure 3: The posttherapeutic presentation of the right buccal mucosa (left side) and left buccal mucosa (right side) at 4-week interval|
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|Figure 4: The posttherapeutic presentation of the right buccal mucosa (left side) and left buccal mucosa (right side) at 10-week follow-up|
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| Discussion|| |
The patient was female in the fourth decade of life, parameters that favor OLP. She had a positive history of smokeless tobacco since last 10 years that makes the chances of finding epithelial dysplasia markedly high.
The patient was not aware of any intraoral lesions and hence it cannot be commented as to from when the lesion had started, whether tobacco consumption had aggravated the condition or the lesion underwent any change following the onset of symptoms.
She had extensive lesion with involvement of multiple sites that indicates lichenoid pattern rather than leukoplakic pattern. The patient had burning sensation, bilateral lesions with white radiating striae, typically indicating OLP.
It is difficult to comment what might have triggered the condition. Tobacco may be considered along with other precipitating factors such as chronic stress. Following habit cessation, there was no reduction in the lesion size, excluding OLL.
Tacrolimus is an immune-modulator that decreases the production of Interleukin-2. Benzydamine is widely used as an anti-inflammatory, analgesic, and anti-pyretic agent. Park et al. had demonstrated the anti-oxidative and anti-inflammatory action of placental extracts on carcinogens.
With subsequent therapy, gradual reduction in lesion size and burning sensation was reported. The regression from ulcerated/erosive lesion to reticular one by therapy implies improvement. Similar improvements were documented in our case.
One major drawback of this case report is that, due to the patient's noncompliance, posttherapeutic biopsy was not performed, which would have helped to assess the molecular changes following regression of lesion size and symptoms.,
This case reported at a stage when we elicited dysplastic changes in first biopsy, for which a clinical diagnosis of LD was given. If the first biopsy would have been dysplasia free and on subsequent biopsies, we would have encountered dysplasia this would have qualified for OLP with dysplasia.
OLP/OLL possesses inherent predilection to undergo malignant transformation because the chronic inflammation leads to atypical changes similar to dysplasia.
The similarity in the clinical appearance of OLP and LD can be attributed to the lichenoid infiltration elicited by antigens expressed by the basal keratinocytes and the dysplastic cells respectively. The immunologically mediated mucosal lesions with a subset of lichenoid features and dysplasia from the onset can be categorized as LD/EDL. This is a drawback as their management strategies differ greatly. Histopathological examination is mandatory before treatment.,
Kumar et al. stated that when lichen planus-like histological features are present in dysplastic epithelium, it can be regarded as LD. The mere presence of atypical cells in OLP should not be considered.
| Conclusion|| |
This is one of the few case reports where the nonsurgical therapeutic management of LD is highlighted with satisfactory results. Although surgical excision is preferred treatment, not all patients may be medically fit. Preoperative therapeutic treatment not only reduces the burning sensation significantly but also the lesion size favoring surgical removal.
When instituting the management of LD, the extent of dysplasia or atypical cells should be of prime importance rather than the degree of lichenoid infiltrates.
There is a need to formulate a classification of red/white/ulcerated mucosal lesions with lichenoid and dysplastic features to aid clinical and histopathological diagnosis and management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]