oral lichen planus presentation

Lichen planus (LP) is derived from the Greek leichen meaning tree moss and the Latin planusmeaning flat

Lichens are primitive plants composed of symbiotic algae and fungi

Planus in Latin for flat.

Term suggests flat fungal condition

Current evidence indicates –Immunologicalymediated mucocutaneous disorder.

Text book of oral medicine and radiology –ongole first edition

Erasmus Wilson first described LP in 1869, as a chronic disease affecting the skin, scalp, nails, and mucosa, with possible rare malignant degeneration.And is thought to affect 0.5 to 1% of the worlds population. Francois Henri Hallopeau reported the first oral lichen planus (OLP)–relatedcarcinoma in 1910.Thibierge first described the oral lesions symmetrically in 1893


WICKHAM 1895 described the characteristic appearance of whitish striae and punctuations that develop atop the flat surfaced papules


cont.....

Definition Oral lichen planus (OLP) is defined as a common

chronic immunological mucocutaneous disorder that varies in appearnce from keratotic to erythematous and ulcerative

Lichen planus is relatively common disorder of the stratified squamous epithelia

Wilson 1896

Duske and frick,1982: skully and El-kom1985

Eisen D 2005 defined oral lichen planus as a relatively common chronic inflammatory disorder affecting the statified squamousepithelia

Lichen planus (LP) is a common disorder in which auto-cytotoxic T lymphocytes trigger apoptosis of epithelial cells leading to chronicinflammation. Oral LP (OLP) can be a source of severe morbidity and has a small potential to be malignant.

Crispian Scully 2007


Inspite of extensive research ,exact etiology is still unknown

The most accepted and current data suggests that OLP is a T cell mediated inflammatory disease (Regezi et al., 1978) (Gilhar et al., 1989), (Porter et al., 1997) (Sugerman et al., 2002) in which there is a production of cytokines which leads to apoptosis

Auto cytotoxic CD8 and Tcells trigger apoptosis of oral epithelial cells.(eversole 1997 porter et al 1997

Abnormal recognition and expression of basal keratinocytesof epithelium as foreign antigens by langerhans cells


Other possible theories include the genetic background ,where the weak association between HLA antigen and lichen planus was found by POWELL et al 1986 and roston 1994

Vincent et al 1990 ,soto araya et al 2004 reported the strong association of psychological factors like higher level of anxiety, greater depression and psychic disorders in patients with erosive lichen planus.


PREDISPOSING FACTORS

GENETIC BACKGROUND

AUTO IMMUNITY –ASSOCIATED WITH OTHER AUTO IMMUNE DISEASE

IMMUNODEFICIENCY

DRUGS

DENTAL MATERIALS

STRESS

HABITS

pathogenesis of oral lichen planus j oral pathol med 2010 19;729_734

1•ANTIGEN SPECIFIC CELL MEDIATED MECHANISM

2•NON SPECIFIC MECHANISM

3•AUTOIMMUNE RESPONSE

4•HUMORAL IMMUNITY

PATHOGENESIS OF OLP

The various mechanisms hypothesized to be involved in the immunopathogenesis are:

1•THE EPITHELIAL BASEMENT MEMBRANE

2•MATRIX METALLOPROTENINASES

3

•CHEMOKINES

4•MAST CELLS

NON SPECIFIC MECHANISMS

pathogenesis of oral lichen planus j oral pathol med 2010 19;729_734

Sugerman PB, Savage NW. Oral lichen planus: causes,diagnosis and management. Aust Dent J. 2002 ;47:290-7

EPIDEMIOLOGY

•Very common- 1% of population •In Indians 1.5%(average) •3.7% mixed oral habits •0.3% non users of tobacco •Risk more among who smoke and chew tobacco

RACE

Oral lichen planus affects all racial groups.SEXThe female-to-male ratio for oral lichen planus is 1.4:1

Text book of oral medicine-burkete‟s 11th edition

Oral lichen planus is invariably a disease that affects regions of the oral cavity bilaterally.

Oral lesions usually involve the posterior buccal mucosa, or less commonly the tongue and although any site can be involved palatal and sublingual lesions are not common

AGE- middle aged or elderly people

MEAN AGE OF ONSET- 5 th decade of life

rarely in young adults and children

Lichen planus commonly affects 1-2% of the general population ,prevalance rate being 0.5to 2.2%

40% lesions occur on both oral and cutaneoussurfaces, 35% occur on cutaneous surfaces alone,and25% occur on oral mucosa alone


Cutaneous lesions of lichen planus (LP) are self-limiting and cause itching.

Appears as purple, pruritic ,polygonal, flat topped –flexor surfaces

Fine lace like network of white lines

(whikam s striae)


Louis frederic wickhamdescribed the presence of fine white or grey lines or dots seen on the top of the pruritic rash on the skin in lichen planus .

These striae are popularly referred to as

“WICKHAMS STRIAE or HONITON LACE”


CLINICAL MANIFESTATIONS

SKIN LESIONS

•Purple, pruritic and polygonal papules •May be discrete or gradually coalesce into plaques each covered by fine glistering scale •Bilaterally symmetrical •Increase in size if subjected to any irritation •Usually self limiting unlike the oral lesions lasting only one year or less


•Initially red > purple or violaceous hue > a dirty brownish color •Periods of regression and recurrence •“ Koebner’s phenomenon”- skin lesions extend along the areas of injury or irritation (ISOMORPHIC RESPONSE)•Most often on wrist, forearms, knees, thighs and trunk •Face remains uninvolved

TYPES OF CUTANEOUS LICHEN PLANUS

HYPERTROPHIC PLAQUES

VESICULAR LICHEN PLANUS

LICHEN PLANUS PEMPHIGOIDES

http://162.129.70.33/images/eruptive_lichen_planus_1_050331.jpg

LICHEN PLANUS OF NAILS

LICHEN PLANOPILARIS

ACTINIC KERATOSIS (ON ARM)

ULCERATIVE LICHEN PLANUS

OVERLAP SYNDROME

TYPES OF ORAL LICHEN PLANUS:

The lichen planus can manifest in various clinical forms ANDREASENS 1968 have described the clinical types.They may be appearing as:

RETICULAR

PAPULES

PLAQUE LIKE

ATROPHIC

EROSIVE

BULLOUS


Most common and most readily recognized form

Mostly on posterior buccal mucosa.

May not be seen on tongue ,less commonly in gingiva &lips

They are usually bilaterally seen.

Characteristic pattern of interlacing white lines (whikam s striae)

The striae often displays a peripheral erythematous zone ,which reflects the subepithelial inflammation

• Lines are wavy and parallel

• Reticular olp can sometimes be observed at the vermillion border

92%


The papular type of olp is usually present in the initial phase of the disease.

It is clinically characterized by small white dots,which in most occasions intermingle with the reticular form.

Sometimes the papular elements merge with striae as part of the natural course.

SIZE 0.5MM

11%


Plaque type olp shows a homogenous well demarcated white plaque often, but not always surrounded by striae.

Plaque type lesions may clinically be very similar to homogenous leukoplakia

Common in tobacco users

Single / multi focal

36%


It is characterized by a homogenous red area.

smooth, poorly defined erythematus areas with or without peripheral striae

Usually associated with Desquamative gingivitis

ATROPHIC TYPE


44%

Pain and burning sensation

Keratotic changes combined with mucosal erythema

Erythematous OLP requires a histopathologicexamination in order to arrive at a correct

When this type of lp is present in the buccalmucosa or in the palate striae are frequently seen in the periphery

ATROPHIC TYPE


More significant for the patient because the lesions are usually symptomatic.

Atrophic areas with central ulceration of varying degree

Periphery of the atrophic regions is usually bordered by fine ,white radiating striae

Atrophy and ulceration are –gingival mucosa

• Pain, burning sensation, bleeding, desquamative gingivitis

• Pseudo membrane covered ulcerations with keratosis and erythema


9%

BULLOUS TYPE Vesciculobullous presentation combined with reticular or erosive pattern

Rare form characterized by large vesicles or bullae (4mm to 2cm)

Lesions usually develop within an erythematus base, rupture immediately leaving painful ulcers

Usually have peripheral radiating striae and seen on posterior part of buccal mucosa

1%


Severe form with extensive degeneration and separation of epithelium from connective tissue

Faint white zone resembling radiating striae seen at the junction with normal epithelium

Commonly on buccal mucosa and vestibule

More dysplasia and malignant

transformation


They are the most disabling form of oral lichen planus

Clinically ,the fibrin coated ulcers are surrounded by an erythematous zone frequently displaying radiating white striae.

This appearance may reflect a gradient of the intensity of sub epithelial inflammation that is most prominent at the centre of the lesion.


Buccal mucosa 80%

Tongue 65%

Lips 20%

Gingiva,floor

of mouth& palate 10%


Histopathology FIRST DESCRIBED BY DUBRENILL 1906

later revised by Shklar in 1972◦Hyper orthokeratinisation or hyper parakeratinisation

◦Thickening of granular layer

◦Acanthosis of spinous layer

◦Intercellular oedema in spinous layer

◦“ Saw-tooth” rete pegs

◦Liquefaction necrosis of basal layer- Max Joseph spaces

◦Civatte ( hyaline or cytoid) bodies

◦Juxta epithelial band of inflammatory cells

◦An eosinophilic band may be seen just beneath the basement membrane and represent fibrin covering lamina propria


HISTOLOGICAL PICTURES

Oral Lichen PlanusPallavi Parashar, BDS, DDS

Oral Lichen PlanusPallavi Parashar, BDS, DDS

World Health Organization diagnostic criteria(1978) of oral lichen planus (OLP)

CLINICAL CRITERIA

Presence of white papule, reticular, annular, plaque-type lesions,gray-white lines radiating from the papules

Presence of a lace-like network of slightly raised gray-whitelines (reticular pattern)

Presence of atrophic lesions with or without erosion, may also Bullae

Correlation between clinical and histopathologic diagnoses oforal lichen planus based on modified WHO diagnosticcriteria -Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:796-800)

HISTOPATHOLOGIC CRITERIA

Presence of thickened ortho or parakeratinized layer in sites with normally keratinized, and if site normally non keratinized this layer may be very thin

Presence of Civatte bodies in basal layer, epithelium and superficial part of the connective tissue

Presence of a well-defined band like zone of cellular infiltration that is confined to the superficial part of the connective tissue,consisting mainly of lymphocytes

Signs of „liquefaction degeneration‟ in the basal cell layer

Correlation between clinical and histopathologic diagnoses oforal lichen planus based on modified WHO diagnosticcriteria -Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:796-800)

Modified World Health Organization diagnosticcriteria of OLP and OLL

CLINICAL CRITERIA

Presence of bilateral, more or less symmetrical lesions

Presence of a lacelike network of slightly raised gray-white lines(reticular pattern)

Erosive, atrophic, bullous and plaque-type lesions are accepted only as a subtype in the presence of reticular lesion else where in the oral mucosa

In all other lesions that resemble OLP but do not complete the aforemented criteria, the term “clinically compatible with”should be used

HISOPATHOLOGIC CRITERIA

Presence of a well-defined bandlike zone of cellular infiltrationthat is confined to the superficial part of the connective tissue,consisting mainly of lymphocytes

Signs of liquefaction degeneration in the basal cell layer

Absence of epithelial dysplasia

When the histopathologic features are less obvious, the term“histopathologically compatible with” should be used

FINAL DIAGNOSIS FOR OLP OR OLL

To achieve a final diagnosis, clinical as well as histopathologiccriteria should be included

OLP A diagnosis of OLP requires fulfillment of both clinical and histopathologic criteria

The term OLL will be used under the followingconditions:

1- Clinically typical of OLP but histopathologically only compatible with OLP

2- Histopathologically typical of OLP but clinically only compatible with OLP

3- Clinically compatible with OLP and histopathologically compatible with OLP

CD8+ T cells are activated in OLP andCD8+ T cells co-localize with apoptotic keratinocytes

in OLP lesions. CD8+ cytotoxic T cells are known to trigger apoptosis of virally infected cells.

Herpes simplexvirus (HSV: human herpesviruses types 1 and 2) causes an acute gingivostomatitis, herpes labialis (cold sores)and recurrent intra-oral herpes.

Oral lichen planus: Causes, diagnosis and managementAustralian Dental Journal 2002;47:(4):290-297

Varicella-zoster virus

(VZV) human herpes virus 3causes chicken pox with oral ulceration in children and shingles with pain and oral ulceration in adults.

Epstein-Barr virus (EBV)

Human herpes virus 4 causes glandular fever (infectious mononucleosis) with associated sore throat and petechiae on the soft palate


Cytomegalovirus (CMV:

Human herpes virus is associated with aphthous-type oral

ulceration

Human papillomavirus (HPV) 6 and 11

It cause oral warts (squamous papilloma) and condyloma

accuminatum whereas HPV 16 and 18 are associated with

some oral squamous cell carcinomas

The coxsackie RNA viruses may also infect the oral

mucosa. Coxsackie A4 causes herpangina, coxsackieA10

causes acute lympho reticular pharyngitis and coxsackie A16

causes hand, foot and mouth disease

Lichen planus is often associated with immune mediated diseases like

Alopecia areata

Dermatomyositis

Lichen sclerosis et atrophicus

Morphea

Myasthenia gravis

Ulcerative colitis

Primary biliary sclerosis


GRINSPAN SYNDROME is the association of OLP with diabetes and hypertension.

GRAHAM LITTLE SYNDROME and VULVO-VAGINO- GINGIVAL SYNDROME are other syndromes associated with ORAL LICHEN PLANUS, in which there is mucosal involvement of gingival and genital

region, usually of erosive type.


OLP is considered a pre-malignant condition

The reported transformation rates vary from 0 .5 to 2%. Over a period of 5 years

1.Increased risk of oral squamous cell carcinoma 2.Frequency of transformation is low, between 0.3% an3% 3.Erosive and atrophic forms commonly undergo transformation

Holmpstrup et al 1998

COMPLICATIONS

Oral lichen planus and its treatment may predispose people to oral C albicans super infection

Patients with oral lichen planus may have a slightly increased risk of oral cancer,

Oral SCC in patients with oral lichen planusis a feared complication an controversial issue.

Oral Lichen PlanusJ:ournal of Dental Sciences & Research 2:1: Pages 62-87

Clinical aspect Histopathological features

3 essential features1. Hyperortho or para keratosis2. Saw tooth rete pegs3. Basal cell liquefaction degeneration

Additional features1. T lymphocyte infilterate2. Civatte or colloid bodies3. Artificial tearing b/t epithelium and

connective tissue.

Oral Lichen Planus is a diagnosis

that demands careful correlation of

the clinical setting with the results

of routine biopsy examination.

Lichenoid reaction

Oral leukoplakia

Frictional keratosis

Discoid Lupus Erythematosus

Chronic Ulcerative Stomatitis

Erythema multiformae

Pemphigus Vulgaris

Benign Mucous Membrane PemphigoidDD for Oral Maxillofacial Lesions-Wood&Goaz

1. LEUKOPLAKIA

known irritant factor

Clinical appearance

Histopathology

2. LICHENOID LESION Clinical appearance contact

with restoration Unilateral Histopathology Lesion resolve after

withdrawal of agent.

3.LUPUS ERYHTEMATOSUS

Well demarcatedcutaneous lesions with round or oval erythematous plaques with scales and follicular plugging

Histopathology Direct

immunofluorescence Butterfly like rashes

over the cheeks and nose known as malarrash.

4.PEMPHIGUS VULGARIS

Nikolsky sign positive in pemphigus vulgaris

Patient gives the recurrence history of bullae and vesicle formation

5.BENIGN MUCOUS MEMBRANE PEMPHIGOID

Eye involvementMucosal blistering, ulceration, subsequent scaringDesquamative gingivitis is the most common manifestation and may be the only manifestation of the disease appearing bright red

It is typically clinically characterized by a white lesion without any red elements

The lesion is observed in areas of the oral mucosa subjected to increased friction, or trauma caused by ,for example food intake.

Lesion is non symptomatic

7.ERYTHEMA MULTIFORMAE

Bullae and vesicle formationAppear as a target or iris lesion More severe form of erythema multiformae is STEVEN JOHNSON SYNDROMECourse of lesion is acute

8.CHRONIC ULCERATIVE STOMATITIS

Painful, exacerbating and remitting oral erosions, and ulcerations

Biopsy of the lesion should be done to confirm the diagnosis

Erosive lichen planus may be examined histopathologically to assess for dysplastic features

Hypertrophic form of lichen planus resembles homogenous leukoplakia

In order to differentiate this condition from leukoplakia the lesion can be biopsied.


DIAGNOSTIC TESTS

Direct immunofluorescence is useful in distinguishing OLP from other lesions, especially vesiculobullous lesions such as PV BMMP and linear immunoglobulin A (IgA) bullousdermatitis

Direct immunofluoresence demonstates a shaggy band of fibrinogen in the basement membrane zone is 90 to 100 % cases Specimens for immunofluoresence should be stored in MICHEL”S BOUINS SOLUTION or normal saline and then sent to histopathology

Indirect immunofluorescence studies are not useful in the clinical diagnosis of OLP. Serum test is negative


Periodic acid-Schiff (PAS)staining of biopsy specimens and candidal cultures or smears may be performed.

Other TestsSkin patch testing may be helpful in identifying a contact allergy in some patients with oral lichen planus.


Oral lichen planus is a chronic inflammatory disease.

The lesions of cutaneous lichen planus typically resolve within1-2 years, whereas the lesions of oral lichen planus are long lasting and persist for 20 years

Resolution of the white striations, plaques, or papules is rare.

Current immunosuppressiv etherapies usually control oral mucosal erythema, ulceration,andsymptoms in patients with oral lichen planus with minimal adverse effects.


Advise patients that oral lichen planus lesions may persist for many years with periods of exacerbation and quiescence

In the context of appropriate medical care, the prognosis for most patients with oral lichen planus is excellent.


PATIENT EDUCATION IN ORAL LICHEN PLANUS

The importance of patient education in OLP hasbeen reported.

The chronicity of oral lichen planus and the expectedperiods of exacerbation and quiescence

The aims of treatment,specifically the elimination of mucosal erythema, ulceration,pain, and sensitivity

The possibility that several treatments may need to betried

The potentially increased risk of oral cancer

The possibility of reducing the risk of oral cancer .Oral Lichen PlanusJ:ournal of Dental Sciences & Research 2:1: Pages 62-87

Lichen planus like eruptions were first reported in military personnel in World War II who had been prescribed anti-malarial drugs.

Since that time, a wide variety of drugs have been associated with precipitating lichen planus – like eruptions and this phenomenon has been termed lichenoid drug reaction.

Lichenoid lesions may be unilateral, asymmetric and occur in uncommon sites and tend to be erosive.

Histological examination may show a more diffuse lymphocytic infiltrate and more colloid bodies than in classic LP

ORAL LICHENOID REACTION (OLR):

Lichenoid reaction is a term used for lesions that resemble OLP clinically and histologically, but have an identifiable aetiology.

Precipitants include chronic graft verses host disease (cGVHD), some dental materials and a range of drugs

They may be a manifestation of disease like lupus erythematosus.

Oral mucosal disease;British Journal of Oral and Maxillofacial Surgery 46 (2008) 15–21

Lichenoid reaction to the amalgam restoration on the buccalaspect of the molar tooth. This is an isolated response without thesymmetrical distribution seen in typical OLP.


treatment

General consideration

Achieve specific goal

Eliminate atrophic and ulcerated lesions

Allevate symptoms

Avoid mechanical trauma and irritation

Absolutely there is no treatmentfor OLP

If no symptoms – no active treatment is needed except reassurance ,reviewed regularly.

Corticosteroids

Retinoid

Grisofulvin

Cyclosporin

More useful in management of OLP

Topical corticosteriods

Systemic steroids are contraindicated or the patient refuses intralesional injections

Safer , long-term use needs follow up

Causes adrenal suppression

Secondary candidiasis

These have great value when there is acute exacerbation of symptoms

Used in combinations with topical steroids

Adverse effects-GI upset, polyurea , insomnia

Retinoids First used for the treatment of

asymptomatic reticulated lichenplanus

Tretinoin is the available Vit A 0.1% (applied locally).

RETINOIDS

TOPICAL – 0.1% vit A

Rapid elimination but with relapse

0.1% isotretenoin gel

Tretenoin ointment – burning sensation and irritation

Systemic --- Etretinate 25 -75 mg/day relapse after discontinuatuon

CYCLOSPORIN Immunosuppressant

reduces lymphokines Reduces the proliferation

and function of T-lymphocytes

Renal dysfunction

GRISEOFULVIN In treatment of erosive Lp

when steroid is contraindicated or

When lesion is resistant to steroids.

Its appropriate to use topical with intralesional preparations

Causes atrophy of tissues and secondary candidiasis

DRUG THERAPYOptimal dose, duration and true

efficacy remain variable.

Corticosteroids Topical 0.1% triamcinolone acetonide Potent preparation --- 0.1%

fluocinolone acetonide--- 0.05%

fluocinonideOrobase Elixir form --- dexamethasome

---- triamcinolone---- clobetasol

SYSTEMIC STEROIDS

Reserved for recalcitrant LP

Daily dose of prednisone 40-80mg for initial 5-7 days – gradually withdrawal over 2-4 weeks

Alternate day administration.

TACROLIMUS

Immunosuppressive –inhibit T cell activation

Tacrolimus ointment 0.1% -- penetrate oral mucosa

Local irritation

Relapse common

Potential carcinogen

CYCLOSPORIN

Suppress T cell cytokine production

Solution of 100mg/ml --- bad taste,

burningsensation , high cost

Alternative for initial control

MISCELLANEOUS

1. ANTIFUNGAL

Topical clotrimazole

2. ANTIBIOTIC

2% auromycin mouth wash

Tetracycline mouth wash

Surgery

Surgical excision, cryotherapy, CO2 laser, andND:YAG laser have all been used in the treatment of OLP. In general, surgery is reserved to removehigh-risk dysplastic areas.

management of oral lichen planus Arch Iranian Med 2005; 8 (4): 252 –256

Laser

The 308 nm excimer laser has been used as apossible and additional method in the treatment

of OLP.

Treatments are painless and well tolerated.

Clinical improvement has been achieved in mostpatients. Excimer 308 nm lasers could be aneffective choice in treating symptomatic OLP


PHOTOCHEMOTHERAPY

In this method, clinician uses ultraviolet A(UVA) with wavelengths ranging from the 320 –400 nm, after the injection of psoralen.

The use of PUVA therapy in OLP waits further evaluation in large controlled trails. In two studies ,UVA was applied to lesions, 2 hours after theinjection of psoralen.

After 2 months, most of thelesions had been notably improved and the remission times ranged from 2 to 17 months

One potential draw back of PUVA therapy isthe risk of the squamous cell carcinoma (SCC) development in a condition with premalignant potential,


CONCLUSION

OLP is a chronic condition that is immune mediated and is characterized by episodic exacerbations and remissions.

It is known to be a T cell–mediated condition withpredominantly cytotoxic CD8 T cells.

A definite diagnosis of OLP is based ona combination of clinical and histologic findings.The cause of OLP remains elusive,and therefore the treatment goals are directed at alleviating related signs and symptoms

Topical steroids are the first line of treatment of symptomatic OLP

Regular and long-term follow-up of patients with OLP is recommended to evaluate for changes in the lesion and to screen for malignancies.

Text Book of Oral Medicine-Burkete‟s 11th Edition

Text Book of Oral Pathology-Shafer-4th Edition

Text book of oral & maxillofacial pathology –Neville 3rd Edition

TEXT BOOK OF ORAL MEDICINE AND RADIOLOGY-ONGOLE

CAWSONS ORAL PATHOLOGY AND ORAL MEDICINE

TEXT BOOK OF ORAL PATHOLOGY .REGEZZI

SUGERMAN PB, SAVAGE NW. ORAL LICHEN PLANUS: CAUSES,DIAGNOSIS AND MANAGEMENT. AUST DENT J. 2002 ;47:290-7

ORAL LICHEN PLANUS –REVIEW MOLLAOGLU .N BOMFS 2000

ORAL LICHEN PLANUS –REVIEW PETER JUNGELL 1990 JOPM

PATHOGENESIS OF ORAL LICHEN PLANUS J ORAL PATHOL MED 2010 VOL 39 729-734

CORRELATION BETWEEN CLINICAL AND HISTOPATHOLOGIC DIAGNOSES OFORAL LICHEN PLANUS BASED ON MODIFIED WHO DIAGNOSTIC CRITERIA -ORAL SURG ORAL MED ORAL PATHOL ORAL RADIOL ENDOD 2009;107:796-800)

ORAL LICHEN PLANUS: CAUSES, DIAGNOSIS AND MANAGEMENTAUSTRALIAN DENTAL JOURNAL 2002;47:(4):290-297

ORAL MUCOSAL DISEASE;BRITISH JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY 46 (2008) 15–21

ORAL LICHEN PLANUS: CLINICAL FEATURES, ETIOLOGY, TREATMENT AND MANAGEMENT; A REVIEW OF LITERATURE JODDD, VOL. 4, NO. 1 WINTER 2010

LICHEN PLANUS IS A DISEASE THAT IS NOT “CURED” IN THE USUAL SENSE OF THE WORD BUT MERELY “CONTROLLED”

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oral lichen planus presentation

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