Form expert panels to develop diagnosis and management protocols.

Abstract

The diagnosis and management of patients with oral lichen planus is one of the most common responsibilities of clinicians in the field of oral medicine. Not long ago, the standard of care for patients with lichen planus was relatively straightforward. A clinical evaluation was usually followed by a biopsy to confirm the diagnosis, and treatment consisted chiefly of topical therapy accompanied by reassurance. However, as more information is discovered about this scientifically intriguing and sometimes distressingly painful disorder, appropriate patient evaluation and management has increased in complexity, requiring more time and knowledge on the part of clinicians. This issue contains an article by Thornhill et al that describes a study of 81 patients with oral lichen planus who also had amalgam restorations. In individuals with a close association between the involved mucosa and amalgam, 70% had positive patch tests to mercury or other components of amalgam. In the group of patients who had amalgams in contact with lichen planus lesions as well as positive patch tests to mercury, over 90% had complete or substantial improvement of the lesions after the amalgam was removed. Although this finding would be more robust if the study had been controlled for the natural history of the disease, it is consistent with the findings of several other reports published since the early 1980s describing the association of some cases of lichenoid oral mucositis and contact allergy to amalgam. Thus, while the findings of Thornhill et al are not new, they do highlight the growing body of evidence that suggests that proper management of patients with oral lichen planus or lichenoid lesions should not be confined to topical therapy and reassurance but should include a thorough search for an underlying cause—such as contact allergens, drug reactions, or underlying diseases, particularly hepatitis C or tumors such as thymoma or Castleman's tumor. At present, few recommendations exist for establishing a sensible evaluation protocol for patients with oral lichen planus. Clinicians need guidance in determining when certain procedures are indicated, including cutaneous patch testing for contact allergens to detect oral lichenoid reactions to substances such as dental materials and flavoring agents; removing and changing dental materials, without encouraging unnecessary dental procedures; testing for hepatitis C; discontinuing or switching medications that could be causing a lichenoid reaction; and evaluation for an underlying neoplasm such as thymoma. Treatment protocols should be developed and published that describe, summarize, and evaluate the current state of knowledge regarding the use of high-potency topical steroids on the oral mucosa; indications for other topical therapy with retinoids, tacrolimus, and cyclosporine; and indications for systemic therapy with steroids, retinoids, and immunosuppressive drugs. It would be useful at this time to organize a panel composed of expert, experienced clinicians and researchers from the fields of oral medicine, oral pathology, dermatology, and immunology who would review and analyze the best currently available studies of lichen planus and lichenoid reactions and propose a pilot protocol for the diagnosis and management of this common oral disease. The report should also highlight the areas in which further research is required before a more permanent protocol can be recommended. In addition, this panel should critically and unemotionally analyze the current evidence for lichen planus as a risk factor in oral cancer. The answer to this question is too important to our patients to remain chiefly a topic for armchair speculation and Internet chats. The World Workshops in Oral Medicine were an excellent step in analyzing the current state of the art of management of major oral diseases. Leaders in the field of oral medicine should demand comprehensive diagnosis and evidence-based treatment protocols that also stress future research directions. Lichen planus, a classic disease in oral medicine, would be an excellent place to start.