The patient was an 18-year-old Chinese female with
the chief complaint of painful tongue with tightness
in the cheeks with some surface roughness. She
reported not being able to eat well. The oral
symptoms had started about three months ago.
She is healthy with no known drug allergies and no
reported use of tobacco or alcohol. She does not
take any medications regularly.
On examination, her oral hygiene was fair with
minimal plaque and she was caries-free.
PRESENTATION ON EXAMINATION
She presented with white reticular striations on the
bilateral lateral surfaces of the tongue (Figures
1 and 2) with erosive mucosal changes, covered
with yellowish fibrinous exudate and erythematous
Figure 1 Right lateral
border of tongue.
Central area of
by yellow fibrinous
membrane with surrounding white
Figure 2 Left lateral
focal area of erosive
Both sides of the buccal mucosa presented with
patches of white reticular striations with no ulcerations
or mass effect (Figure 3). These lesions are
Figure 3 Left (A) and right (B) buccal mucosae with white
The clinical differential diagnosis included oral lichen
planus (OLP), oral involvement of an underlying
systemic autoimmune condition such as systemic
lupus erythematosus or discoid lupus. An incisional
biopsy was performed to confirm the definitive
Microscopic findings were consistent with lichenoid
mucositis, recommending clinicopathologic correlation
for the diagnosis of OLP.
Blood serology tests to check for autoimmune
conditions including rheumatoid factor (RF), anti-nuclear
antibody (ANA) and double-stranded DNA
(dsDNA) were done with no significant findings.
The patient was diagnosed with OLP based on the
clinical and histopathologic findings.
What is oral lichen planus
Oral lichen planus (OLP) is a chronic mucocutaneous
inflammatory condition that tends to affect the oral
mucosa, although the skin and other mucosal surfaces
such as the oesophageal and vaginal mucosae can
OLP has several clinical presentations including the
reticular, plaque-like, erosive/atrophic, ulcerative
and bullous forms. An individual patient can have a
combination of these types.
Reticular OLP. The most common and
characteristic of OLP. This form of OLP is usually
asymptomatic, commonly found on bilateral
buccal mucosa as lacy, white lines referred to as Wickham’s striae. One of the common complaints
from patients with reticular OLP is roughness of
the cheeks with some tightness.
Plaque-like OLP. A less common form of OLP, it
commonly occurs on the dorsum of the tongue
and can be accompanied by depapillation of the
surrounding dorsal surfaces of the tongue. Some
patients complain of dysgeusia or reduced taste
Erosive/atrophic OLP. The mucosa commonly presents with redness due to thinning of the
surface epithelium and can affect any mucosal
surface, including the tongue, gingiva and buccal
mucosa. In most instances, individuals with erosive
lichen planus are uncomfortable when eating and
drinking, particularly with foods and drinks that are
at extremes of temperature, acidic, coarse or spicy.
Ulcerative OLP. In severe cases, ulceration can
develop. Individuals affected by ulcerations may
experience pain even when not eating or drinking,
with complaints of reduced quality of life.
Bullous OLP. It is the rarest form of OLP. It is
characterised by the formation of vesicles or
bullae, which usually develop in the presence
of the other forms of OLP. These bullae tend to
rupture easily forming shallow ulcerations in
the background of striations and erythematous
Managing and treating oral lichen planus
The main treatment goal is elimination of oral
symptoms to improve quality of life.
The reticular form of OLP often does not require
any treatment. Adequate information on OLP should
be made available to the patient. Most importantly,
patients must be informed of the importance of
periodic observation even if the oral lesions remain
Erosive/ulcerative lesions in most cases tend to be more symptomatic, especially when eating spicy
foods or drinking hot drinks, while in other cases, the
lesions may be asymptomatic. Management of these
erosive/ulcerative lesions involves the use of topical
immunosuppressive agents such as corticosteroids, tacrolimus or intralesional corticosteroid injections
for recalcitrant lesions. In severe cases, a short
course of systemic corticosteroids can be prescribed.
At times, patients may develop oral candidiasis
(pseudomembranous or erythematous types), a
type of fungal infection, even before the initiation of
topical corticosteroid therapy.
In cases with oral candidiasis (pseudomembranous
or erythematous types), topical antifungals and/or
systemic antifungals can be prescribed.
Chlorhexidine mouthwash can also be given as it
has some fungicidal properties.
In the author’s experience, nystatin suspension has
been ineffective in eradicating oral candidiasis due
to several reasons such as the need for multiple
dosing daily, containing high sugar content and
bad tastes which in turn lead to poor patient
compliance. A preferred topical antifungal agent
is miconazole 2% gel or ketoconazole 2% gel in
addition to chlorhexidine rinse.
In some cases, a course of systemic fluconazole can
REFERRING FOR SPECIALIST CARE
In patients with persistent erosions/ulcerations
who are unresponsive to topical therapy, referral
to an oral medicine trained dentist may be
With an ageing population, there is also an
increasing number of patients with other medical
comorbidities that can affect the management
of these oral lesions, such as those with poorly-controlled
diabetes and hepatitis B infection.