art 791

633
CONTINUED MEDICAL EDUCATION
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*
Oral lichen planus
Líquen plano oral

Marcello Menta Simonsen Nico1 Juliana Dumet Fernandes2

Silvia Vanessa Lourenço3

Abstract: Oral lichen planus (OLP) is a relatively common mucosal disease that can present isolated
or associated with cutaneous lichen planus. Contrarily to its cutaneous counterpart, though, OLP tends
to be chronic, relapsing, and difficult to treat. Severe morbidity is related to erosive forms, and more
aggressive presentations have been described, such as the "gingivo-vulvar syndrome". This article
reviews the current knowledge about the pathogenesis, clinical picture, differential and laboratorial
diagnosis, prognosis, and treatment of OLP.
Keywords: Lichen planus; Lichen planus, oral; Oral medicine

Resumo: O líquen plano da mucosa oral (LPO) é afecção relativamente comum, que pode aparecer
isolado ou associado ao líquen plano cutâneo, havendo, no entanto, significantes diferenças clínico-
evolutivas: o LPO tende a ser crônico, recidivante e de difícil tratamento, levando a importante mor-
bidade, principalmente em sua forma erosiva. Novas formas clínicas agressivas têm sido salientadas na
literatura, como a forma gingivo-vulvar. Este artigo revisa a etiopatogenia, as formas clínicas, a diag-
nose diferencial e laboratorial, a prognose e o tratamento do LPO, além de mencionar, brevemente, a
experiência dos autores com esta enfermidade, vivida no Ambulatório de Estomatologia da Divisão de
Dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo.
Palavras-chave: Líquen plano; Líquen plano bucal; Medicina bucal

INTRODUCTION
Lichen planus is a T-cell mediated chronic patients with diagnosis of oral lichen planus (OLP). 8
inflammatory mucocutaneous disease of unknown It is estimated that the prevalence of OLP varies from
cause. 1 It is characterized by a papular skin eruption 0.5 to 4% of the general population, 9-13 being more
that occurs in most cases between 30 and 60 years of common in females.2,7,14-16 A hundred and three pati-
age; however, occurrence in children has been increa- ents with OLP were treated at the Outpatient Clinic of
singly observed. 2-4 It may affect the mucous membra- Stomatology, Division of Dermatology, Clinics
nes, particularly the oral and genital mucosa, and very Hospital, University of Sao Paulo School of Medicine,
rarely, the mucosa of the anus, nose, larynx, conjunc- between 2003 and 2010; 33 of these patients were
tiva and urethra. Oral mucosal lesions occur in 50 to men and 70, women (unpublished data). The objecti-
70% of the patients with lichen planus and may be ve of this study is to review the etiopathogenesis, cli-
exclusive in 20 to 30% of them. 5-7 Nonetheless, skin nical manifestations, diagnosis and treatment of OLP.
lesions of lichen planus were observed in 15% of the

Received on 20.09.2010.
Approved by the Editorial Board and accepted for publication on 25.10.2010.
*
Work conducted at the Outpatient Clinic of Stomatology, Service of Dermatology, Clinics Hospital, University of Sao Paulo School of Medicine - Sao Paulo
(SP), Brazil.
Conflict of interest: None / Conflito de interesse: Nenhum
Financial funding: None / Suporte financeiro: Nenhum
1
PhD – Professor, Department of Dermatology, University of Sao Paulo School of Medicine. Outpatient Clinic of Stomatology, Service of Dermatology, Clinics
Hospital, University of Sao Paulo School of Medicine (FMUSP - Sao Paulo (SP), Brazil.
2
PhD – University of Sao Paulo. Assistant professor of Dermatology, State University of Feira de Santana (UEFS)- Feira de Santana (BA), Brazil.
3
Faculty Member (livre-docente) – Associate Professor, Department of Stomatology, University of Sao Paulo School of Dentistry - Sao Paulo (SP), Brazil.

©2011 by Anais Brasileiros de Dermatologia

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634 Nico M, Fernandes JD, Lourenço SV

ETIOPATHOGENESIS
Although it is believed that OLP is a T-cell that research of liver abnormalities or HCV infection
mediated autoimmune disease, its cause remains unk- in patients with OLP should be conducted only in
nown. 17 Current evidence suggests that the disease is individuals with suspicious clinical and epidemiolo-
related to an alteration of cell-mediated immunity, gical history.
triggered by endogenous or exogenous factors, which Genetic polymorphisms of several cytokines
results in an altered response to autoantigens. 18.19 also appear to be associated with the clinical presen-
Most activated T cells in the inflammatory infiltrate of tation of the disease. Interferon-� polymorphisms
OLP are CD8 +.20.21 Activated T cells of the inflamma- have been associated to lichen planus with exclusive
tory infiltrate, associated with increased production of oral involvement, and TNF-α polymorphisms have
Th1 cytokines (IL-1, IL-8, IL-10, IL-12, TNF-α) increase been associated with forms that affect the oral muco-
the expression of intercellular adhesion molecules sa and skin. It is, however, hasty to say that OLP is a
(ICAM-1) on Langerhans cells and macrophages, lea- genetically determined disease. These findings must
ding to presentation of major histocompatibility com- be confirmed by studies conducted in different geo-
plex antigens by keratinocytes. This altered immune graphical areas. 19
response results in apoptosis of keratinocytes in the A severe form of the disease, the so-called “vul-
basal layer and may determine disease activity.22-27 vovaginal-gingival syndrome” of lichen planus appears
Other mechanisms that may also be involved in the to be associated with an HLA class II allele (HLA-
etiopathogenesis of the disease are mast cell degranu- DBQ1). 36
lation and activation of matrix metalloproteinases.13 Another interesting aspect to be discussed is
Moreover, some researchers believe that the chronici- the presence of lesions identical to those of lichen pla-
ty of OLP can be partly explained by a deficiency in the nus in graft versus host disease (GVHD). Clinical and
mechanisms of immunosuppression mediated by histopathological findings of lichenoid oral lesions in
transforming growth factor beta; 28 however, the cau- chronic GVHD are indistinguishable from idiopathic
ses that lead to the onset of the process have not yet OLP lesions. In GVHD, donor T lymphocytes attack
been fully clarified. tissue antigens of the minor histocompatibility com-
The relationship between OLP and hepatitis C plex of the host cell. Thus, GVHD appears as an inte-
virus is not stable, since the prevalence of this virus in resting model in the study of the pathophysiology of
patients varies based on studies, ranging from 0% to OLP. 32
over 60%, according to the country where these studi- Several authors have also shown that oral liche-
es are conducted. 1, 29-32 The rates of HCV infection in noid reactions may result from contact with dental
patients with LP appear to be high in Japan, Italy and restoration materials, especially those containing
Brazil 33 and low in the U.S., France, Nordic countries, amalgam, metallic mercury or ammoniated mercury.
UK and Germany. 31 However, results in Brazil are This can be shown in those cases in which the repla-
controversial, as a recent study shows. 34 Data by these cement of these materials leads to the improvement of
authors show a frequent observation in our clinical OLP lesions, a fact mainly observed when there are no
practice: it is rare to diagnose HCV positivity in pati- skin lesions and all oral lesions are in contact with the
ents with OLP, but it is common to see OLP in indivi- restorations. 1,32,37-40
duals known to be carriers of the virus. The importance attributed to psychological
The difference in the prevalence of HCV infec- factors varies according to the authors; there is
tion in different geographic locations may not have controversy over whether psychiatric disorders
been clearly explained, but it is believed to be due (anxiety, depression) are involved in the genesis of
to differences in the socioeconomic status and to the disease or are a consequence of chronic painful
the selection bias of the subjects studied (mean age lesions. In a study of 16 patients with OLP without
and gender) in their respective countries . 1,31,35 Given mental complaints and without subjective need for
this geographical heterogeneity, the hypothesis that psychiatric help, psychiatric examination showed
some genetic change may facilitate the development that 5 of them had a moderate disorder and one
of OLP in a subgroup of patients with hepatitis C has had signs of “neurosis.” Association with depres-
been raised 31.32 A recent meta-analysis of the literatu- sion 41 is reported by some authors and refuted by
re led us to conclude that “ HCV infection is associa- others. 41.42
ted with a statistically significant risk for the deve-
lopment of OLP, suggesting that the presence of eit- CLINICAL MANIFESTATIONS
her HCV or certain types of lichen planus can be OLP may present in the following forms: reticu-
used as predictive markers of one another in certain lar, atrophic, papular, erosive, bullous and erythema-
geographical regions.”33 Therefore, it is suggested tous. These different clinical presentations represent

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Oral lichen planus 635

variations of intensity and duration of the disease the boundary between the lip vermillion and skin of
(Figures 1-6). These different forms may present the lip, unlike some other cheilitis.
simultaneously, and the predominant clinical morp- The presentation form of “desquamative gingi-
hology can change over time in the same patient.43.44 vitis” is peculiar, and can occur isolated or associated
OLP lesions are often bilateral and symmetrical, which with lesions in other areas. Painful erosions, which
differentiates them from contact lichenoid reactions interfere with tooth brushing, are observed in the gin-
of the oral mucosa. Unilateral lesions of OLP are rare gival mucosa. 45 ,47-49
and atypical. 41 The most affected sites are the buccal Residual mucosal pigmentation is common in
and gingival mucosa, back of the tongue, lip mucosa dark-skinned individuals, often associated with the
and lip vermilion. 2,4,43-45 The gingival mucosa is fre- presence of active lesions (lichen planus pigmento-
quently affected, and the disease presents in the form sum).
of “chronic desquamative gingivitis.” OLP lesions may Lesions resulting of the reaction caused by con-
appear at sites of trauma (koebnerization). tact of the mucous membranes with dental restora-
The primary lesion of OLP is a small opalescent tions containing metal are indistinguishable from
papule, whitish and keratotic (not removable with a those of idiopathic lichen planus, except for the fact
spatula). Lesions may be isolated or assume different that they are asymmetrically distributed in the muco-
patterns; for instance, arboriform, striated or annular. sa, because they are near dental restorations. 1.33, 37-39 Of
These features are commonly found bilaterally in the the 103 patients, 4 presented these characteristics
buccal mucosa. 2,6,46-50 Lesions at the back of the tongue (unpublished data).
tend to be more keratotic, isolated or plaque-like, due There appears to be no correlation between the
to the peculiar characteristics of this epithelium.2,6,46,47 extent and severity of oral and skin lesions of lichen
Lesions of long evolution tend to become atrophic planus. 8 Concomitant extraoral involvement such as
due to epithelial tissue correction. Depapillation of scalp, nails, conjunctiva, esophagus, larynx, urethra,
the tongue caused by atrophy may result in gustatory vagina, vulva and perianal region can result in severe
changes, with consequent burning upon contact with morbidity. The association between severe forms of
certain foods. oral and vulvar lichen planus has been recently hig-
In the erosive form, bright red well-demarcated hlighted (“vulvovaginal-gingival syndrome”). 36,50,51
erosions are observed, characteristically surrounded Several publications, especially articles in den-
by typical papulae. When the disease progresses tal journals, address a supposedly “premalignant”
rapidly, bullae may be rarely observed. Pain is usually potential of OLP lesions. Indeed, several studies have
intense and can affect the patient’s quality of life. 48.49 been conducted on the subject, with essentially
Lesions identical to those described above may inconclusive results with regard to possible “risks of
also appear in the lip vermillion and tend to diffusely malignancy” 1.52 -55. In our opinion, the development of
affect this area; however, they almost always respect squamous-cell carcinoma in lesions of lichen planus

A B

FIGURE 1: A. To the left: typical ker-

atotic papules; B. To the right: con-
fluence of reticular lesions

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636 Nico M, Fernandes JD, Lourenço SV

A B

FIGURE 2: A. To the left: conflu-

ence of annular lesions; B. To the
right: symmetrical papules form-
ing a keratotic plaque, atrophy
and erosion symmetrically distrib-
uted

only occurs in very old atrophic-cicatricial lesions, but cases progresses by short-term outbreaks that almost
this is rare. Dermatologists are very familiar with thi always respond well to treatment or even regress after
situation when it affects the skin, but this phenome- a few months, OLP is characterized by its chronicity,
non may involve the mucous membranes (Marjolin’s persistence and resistance to therapy.
ulcer). Other conditions that may present atrophic-
cicatricial lesions in the oral mucosa may also be rare- DIAGNOSIS
ly associated with carcinomas, such as lupus erythe- The diagnosis is achieved through clinical and
matosus and syphilitic glossitis. 56 Among our 103 pati- histopathological examination. Histopathological
ents, three presented with lesions of squamous-cell manifestations include acanthotic (keratotic lesions),
carcinoma associated with OLP, all of whom with hig- atrophic (old lesions), prominent or absent (erosive
hly cicatricial disease of long evolution (unpublished lesions) epithelium. There is liquefaction of the basal
data). layer associated with superficial lymphocytic inflam-
Unlike cutaneous lichen planus, which in most matory infiltrate at the junction of the epithelium with

A B

FIGURE 3: A. To the left: erosions

surrounded by whitish lesions; B.
To the right: lesion in the vicinity
of a dental restoration

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Oral lichen planus 637

A B

FIGURE 4: A. To the left: pigmenta-

tion and whitish lesions; B. To the
right: atrophic-cicatricial aspect in
a case of long evolution

lamina propria. Numerous eosinophilic spheric bodi- was not always uniform in the analyzed studies. Van
es are seen in the conjunctival epithelium, known as der Meij and Van der Waal found that in 42% of cases,
cytoid bodies, apoptotic bodies or Civatte bodies, in in which there was full agreement on the clinical diag-
adittion to varying degrees of pigment leakage (Figure nosis of the disease, there was no consensus on histo-
7). 1,2,50 Interface inflammation reaching excretory por- pathological diagnosis 60. On the other hand, in 50% of
tions of minor salivary glands has been recently cha- the cases in which there was a consensus, there was
racterized by our group (“salivary lichen planus”, an no clinical agreement. In our opinion, diagnosis is
analogy with lichen planopilaris). 57 safe if proper clinical and pathological criteria are fol-
Biopsies should be preferably done in keratotic lowed, dismissing the possibility of other diseases
areas to avoid erosions, because they are devoid of epit- such as traumatic keratosis, lupus erythematosus,
helium, making microscopic examination difficult. 58.59 erythema polymorphe and incipient tumors. 59.50
Histopathological analysis of specimens of OLP Direct immunofluorescence from perilesional

A B

FIGURE 5: A. Vulvovaginal-gingival
syndrome:" erosions, synechiae and
reduction of the oral and vulvar
orifices in one patient

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638 Nico M, Fernandes JD, Lourenço SV

A A B

FIGURE 7: A. To the left: Histopathological aspect of papular lesion

in the mucosa - hyperkeratosis, irregular acanthosis, hydropic
degeneration of basal layer and inflammatory infiltrate forming a
band in the superficial portions of lamina propria. (Hematoxylin-
eosin); B. To the right: detail showing epithelial ridge with degen-
eration of the basal layer and many dyskeratotic keratinocytes
("Civatte bodies"). The inflammatory infiltrate is predominantly lym-
phocytic. (Hematoxylin-eosin)

incipient squamous-cell carcinoma. Erosive lichen pla-

nus should be adequately differentiated from aphthae,
C
mucous membrane pemphigoid, pemphigus vulgaris,
drug reactions, erythema polymorphe and acute
lesions of lupus erythematosus. The differential diag-
nosis of the pigmented form is done with multiple
causes of mucosal pigmentation.
It is sometimes difficult to clinically diagnose
“desquamative gingivitis” when lesions in other sites
are absent. Mucous membrane pemphigoid, pemphi-
gus vulgaris and OLP may present as desquamative
gingivitis of very similar clinical aspect; therefore, it is
essential to conduct histopathological examination
FIGURE 6: A. Striated lesions and erosions restricted to the lip ver- and direct immunofluorescence for proper diagnosis.
million; B. desquamative gingivitis-erosive aspect with keratotic
areas, C. Squamous-cell carcinoma over atrophic-cicatricial area TREATMENT
The treatment of OLP aims to relieve the symp-
biopsy may be useful to differentiate OLP from other toms and minimize the functional impact of the disea-
mucosal diseases with an inflammatory component of se. No treatment is effective for all cases of OLP
the interface, especially lupus erythematosus, erythe- because its cause is unknown. 5 Professional experien-
ma polymorphe and drug eruptions. The most com- ce is, therefore, important. One should take into acco-
mon finding in OLP is the presence of IgM deposits unt the extent of lesions and severity of symptoms.
and, less frequently, of IgA and C3 in subepithelial Hence, treatment is individualized for each patient.
cytoid bodies. 5 Exclusive reticular papular lesions are asymptomatic
and do not require treatment. Sequelae are observed
DIFFERENTIAL DIAGNOSIS in exclusively atrophic lesions and these lesions do
It depends on the morphology of the lesions. not respond to any treatment. Erosive lesions are
Reticular papular lesions should be differentiated those that require drug therapy because of severe
from discoid lupus erythematosus, candidiasis, morsi- pain.
catio buccarum (mucosal exfoliation due to the habit Oral hygiene practices are important, especially
of nibbling) and other traumatic injuries, mucous periodontal care given by a professional dentist, when
patches of secondary syphilis, pilous leukoplakia and gingival lesions are present, since tartar and dental

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Oral lichen planus 639

plaques can stimulate local inflammation and exacer- carcinomas in OLP, because in addition to acting on
bate disease activity. 1.61-63 Replacement of metal resto- the immune system, they would also act directly on
rations is indicated when reactions to these substan- cells. For instance, according to Becker et al,54 70 tacro-
ces are suspected. Improvement occurs more com- limus appears to interfere with a few important intra-
monly in those cases in which all the lesions are loca- cellular signaling pathways, especially those related to
ted in areas close to the restorations. 37-39 p53 protein, whose mutation is present in several
The drugs most often prescribed are potent types of cancers. Therefore, the potential systemic
topical corticosteroids - mouthwash, ointment or ora- absorption and malignancy of such agents reinforce
base paste, used two to three times a day. It is impor- the need for further long-term evaluation of these
tant to note that creams are never recommended for drugs.
use in the oral mucosa, and orabase paste is only used Some authors have reported efficacy of topical
for intraoral lesions (wet); lesions located in the lip retinoids in the treatment of OLP, especially when
vermillion should be treated with ointments. Oral and used in combination with topical corticosteroids for
intralesional corticosteroids are almost never used by reticular or hyperkeratotic lesions. 71-73. Imiquimod has
us in cases of exclusive intraoral manifestation, as the been recently used in a small series of cases.74 We have
therapeutic target (inflammatory infiltrate) is easily not used these drugs.
topically treated, if we consider that only bare lesions Several anti-inflammatory drugs commonly
(erosive) will be treated. used in dermatology, such as levamisole, sulfone, gri-
The potency of topical corticosteroids and their seofulvin and chloroquine were used by several aut-
frequency of use should be reduced as clinical manife- hors, with anecdotal results and without scientific
stations and symptoms improve. The intraoral use of basis. 3.75-78
topical steroids is safe and well tolerated. The most Immunosuppressive therapies such as PUVA,
common adverse effect is oral candidiasis, which can methotrexate, azathioprine and mycophenolate mofe-
be prevented with the prophylactic use of topical til can be attempted in very severe and resistant cases.
79-82
nystatin and by advising the patient not to sleep with
dental prostheses. CO 2 laser treatment has been attempted by
Erosive gingival lesions are particularly resi- some health professionals, but in our opinion, the
stant. As previously mentioned, in addition to drug method lacks scientific basis for this indication (laser
treatment, there should be specialized periodontal is not used in the treatment of cutaneous lichen pla-
monitoring, which has been shown to be very useful. nus).83.84
The use of molded dentures to improve contact of the Patients should be periodically followed-up due
drug with the mucosa is sometimes prescribed. We to the need to gradually reduce the medication and,
have not found any need for their use; in addition, especially, monitor atrophic-cicatricial lesions.
exaggerated contact of a potent corticosteroid with Individuals with concomitant psychopathology,
the gingival mucosa can lead to retraction. 63 especially those with symptoms of depression or
The topical calcineurin inhibitors - tacrolimus anxiety, may deserve specialized care. 1.85 ❑
and pimecrolimus - were introduced in the treatment
of OLP at the beginning of the last decade. They are
topical immunosuppressive drugs that have been
used as steroid sparers in OLP and have shown intere-
sting therapeutic results.64-69 Tacrolimus ointment is
used at a concentration of 0.1% and pimecrolimus
ointment is used at a concentration of 1%. The oint-
ment must be applied twice daily, but use may be
increased to four times daily until remission or symp-
tomatic relief. 1.32 Adverse reactions include burning
and stinging at the application site. Systemic levels of
pimecrolimus and tacrolimus were detected after
application to the oral mucosa. 68.69 In theory, it is sug-
gested that these drugs may increase the frequency of

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640 Nico M, Fernandes JD, Lourenço SV

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2007;46(Suppl 3):25-6. Rua Itapeva, 500 - 3º andar
73. Scardina GA, Messina P, Carini F, Maresi E. A randomized trial assessing the
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How to cite this article / Como citar este artigo: Nico M, Fernandes JD, Lourenço SV. Oral lichen planus. An Bras
Dermatol. 2011;86(4):633-43.

An Bras Dermatol. 2011;86(4):633-43.

642 Nico M, Fernandes JD, Lourenço SV

QUESTIONS
▲
1. It is correct to state the following about oral 6 - It is correct to state the following about oral
lichen planus: lichen planus:
a- It is more common in women a- The different clinical forms (reticular, atrophic,
b- It is more typical in adolescence papular, erosive, etc.) mainly reflect differences in
c- It is accompanied by skin lesions in 5 to 15% of cases genetic susceptibility
d- It is believed that approximately 10% of the b- Bilateral and symmetrical lesions are usually
population will present with at least one caused by drugs
manifestation in their lifetime c- The predominant clinical morphology can
change over time in the same patient
2 - It is correct to state the following about oral d- Keratotic lesions tend to be intensely
lichen planus: symptomatic
a- Cells in the inflammatory infiltrate are
predominantly lymphocytes b 7 - It is correct to state the following about oral
b- Idiopathic oral lichen planus-specific antigen lichen planus:
has been recently individualized a- Whitish papules are easily removed with a spatula
c- Apoptosis of keratinocytes in the basal layer is b- Atrophy of the mucosa of the tongue develops quickly
an important occurrence in the disease c- Typical papulae are almost never observed in
d- Unlike the skin, the infiltrate is predominantly erosive forms of the disease
constituded by T lymphocytes d- Atrophy of the mucosa of the tongue may lead
to gustatory changes
3 - It is correct to state the following about the rela-
tionship of oral lichen planus with hepatitis C virus: 8 - It is incorrect to state the following about oral
a- It varies according to the region of study. lichen planus:
b- The rates are high in patients in Germany, a- Lesions in the lip vermillion tend not to advance
United Kingdom and the United States to the skin of the lip
c- The medical literature indicates whether to b- Due to the characteristics of the epithelium,
investigate the presence of hepatitis C virus in all lesions in the lip vermillion do not become erosive
patients with OLP c- Lichen planus pigmentosus is associated with
d- Studies uniformly show that the ratio is high in Brazil whitish lesions
d- Bullous lesions are rare
4 - It is incorrect to state the following about oral
lichen planus: 9 - It is incorrect to state the following about oral
a- the "vulvovaginal-gingival syndrome" appears to be lichen planus:
associated with an HLA class II allele (HLA-DBQ1) a- There appears to be no correlation between the
b- Clinical and histopathological findings of extent and severity of oral and skin lesions of
lichenoid oral lesions in chronic graft versus host lichen planus.
disease are indistinguishable from findings of b- The "vulvovaginal-gingival syndrome" results in
idiopathic OLP lesions severe morbidity
c- Genetic polymorphisms of several cytokines also c- Concomitant extraoral involvement such as scalp,
appear to be associated with the clinical nails, conjunctiva, esophagus, larynx, urethra,
presentation of the disease vagina, vulva and perianal area may rarely occur
d- In GVHD, donor T lymphocytes attack tissue d- Erosive lesions rarely affect the gingiva
antigens of the minor histocompatibility complex
of the host cell. 10 - It is incorrect to state the following about oral
lichen planus:
5 - It is correct to state the following about oral a- Study results are essentially inconclusive as to
lichen planus: the potential "risk of malignancy" of the lesions
a- The replacement of dental materials produces a b- Squamous cell carcinoma only develops in old
50% improvement of OLP lesions lesions
b- Oral lichenoid reactions may result from contact c- Other atrophic and cicatricial conditions of the
with dental restoration materials, especially those mucosa may predispose to tumors
containing gold d- Sarcomas may rarely occur in erosive lesions of
c- Restorations containing amalgam, metallic or long evolution
ammoniated mercury are not suspected of causing
lichenoid reactions
d- Lesions that improve with the replacement of
restorations are only those that are in contact with them
An Bras Dermatol. 2011;86(4):633-43.
Oral lichen planus 643

11 - It is correct to state the following about oral 17 - It is correct to state the following about the
lichen planus: treatment of oral lichen planus:
a- Its psychogenic cause is well documented a- The use of molded dentures is safe because it
b- Psychiatric disorders are always present does not lead to retraction
regardless of the clinical form of the disease. b- Oral corticosteroid is the treatment of choice
c- There is controversy over whether psychiatric c- Creams will chemically bind to saliva facilitating
disorders are involved in the genesis of the disease adherence to the mucosa
or are the consequence of chronic painful lesions. d- Prophylaxis of oral candidiasis should be done if
d- Cases in individuals with mucocutaneous forms of topical corticosteroids are used
the disease have a lower correlation with psychiatric
disorders than those with only mucosal lesions. 18 - It is incorrect to state the following about the
treatment of oral lichen planus:
12 - It is correct to state the following about oral a- Although there is no study to confirm this,
lichen planus: retinoids are excellent to treat erosive lesions
a- It is characterized by chronicity, persistence and b- Calcineurin inhibitors have been increasingly used
resistance to therapy. c- Drugs such as levamisole, sulfone, griseofulvin
b- Skin lesions take longer to disappear and chlororquine need to be further studied
c- It often disappears without treatment d- There is no scientific basis for the use of lasers
d- If there are concomitant skin lesions, they tend
to be more severe 19 - It is correct to state the following about the
prognosis of oral lichen planus:
13 - It is correct to state the following about the a- It is a high-risk disease, with considerable risk of
histopathology of oral lichen planus: malignancy
a- The epithelium is acanthotic and parakeratotic b- Atrophy of the papillae of the tongue, although
b- Degenerate basal layer dismisses the diagnosis clinically visible, does not affect the patient
c- The infiltrate never reaches the salivary gland duct c- After the disease is controlled, it is better to
d- "Civatte bodies" are eosinophilic abruptly suspend treatment to avoid the side
effects of medication
14 - It is correct to state the following about d- Idiopathic cases are more difficult to control
desquamative gingivitis: than those associated with dental restorations
a- Immunofluorescence is not useful in the
differential diagnosis 20 - It is correct to state the following about biop-
b- Its features allow for easy clinical diagnosis of its causes sies in oral lichen planus:
c- Cases of lichen planus must be distinguished a- They must always be performed in areas of erosion
from those of lupus erythematosus b- They should be avoided in gingival lesions
d- Cases of oral lichen planus only occur in the gingiva c- They must be sent for direct
immunofluorescence in all cases
15 - It is correct to state the following about the d- They are diagnostic in most cases
treatment of oral lichen planus:
a- Corticosteroids are the only effective medication Answers
b- Lesions in the lip vermillion are treated with creams Immunopathology of allergic contact dermatitis. An
c- Orabase paste is inappropriate for use in the lip Bras Dermatol. 2011;86(3):419-33.
vermillion
d- Atrophic lesions improve with oral treatment 1d 7c 13b 19d
2c 8b 14b 20d
16 - It is correct to state the following about the 3a 9b 15a
treatment of oral lichen planus: 4c 10d 16a
a- Periodontal treatment should only be
5a 11b 17a
prescribed after complete healing of the lesions
b- Erosive lesions improve with treatment with 6c 12c 18d
steroid ointments
c- Corticosteroid injections are used to treat Papers
reticular or papular forms of the disease Information for all members: The EMC-
d- Orabase paste should not be used to treat D questionnaire is now available at the home-
erosive lesions page of the Brazilian Annals of Dermatology:
www.anaisdedermatologia.org.br. The deadline
for completing the questionnaire is 60 days
from the date of online publication.

An Bras Dermatol. 2011;86(4):633-43.