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July 2017 - Articles Archive

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Looks and acts just like conventional OLP

Dr. Terry Rees
Texas A&M College of Dentistry

At this stage of our knowledge of oral lichen planus it is obvious that medications may sometimes cause a so-called lichenoid drug reaction that looks and acts just like conventional oral lichen planus.  In fact, on this website we have a long list of medications reported to have caused such reactions.  However, it is very important to realize that nearly all of these reports were published as single case findings rather than from extensive studies. This suggests that these reactions are pretty rare.  I think that is important for everyone to understand because as you and your health care provider(s) search for a cause of your oral lichen planus outbreak the question of a possible drug reaction often comes up.  I think it is very important not to assume that you have a drug induced lichen planus just because it is on our or someone else’s list.  As I’m sure most of you are aware, medications are being prescribed more and more often as we age and begin to develop chronic, sometimes life threatening diseases and disorders.  This is especially so since so many new medications are being developed and produced by the drug companies.  For example, drugs used for patients with diabetes have risen from just a few only a short time ago to nearly 50 potential drugs to help control the condition and its side effects.

Many times, if a specific medication does appear to possibly be contributing to oral lichen planus lesions we find that our physician colleagues are sometimes very reluctant to change medications.  This is often true because you may have been taking the suspected medication for many years before the lichen planus came along or because the medication has successfully stabilized a chronic condition that has been affecting you.  Another reason for reluctance is that many times the alternative drugs available to treat a particular condition have the same basic structure as the one you are currently taking and there may be a good possibility that changing meds will not benefit your mouth discomfort.

So what do we do? 

Well, not everyone agrees with me, but I believe that most lichenoid drug reactions are not as responsive to treatment as other forms of lichen planus.  As the years have rolled by we have become pretty confident that we can help control conventional oral lichen planus and our long-term goal is often to have you become able to discontinue your mouth treatment and only use the prescribed treatment agent very early when you first begin to develop a new sore spot.  Because of this observation, we suggest that patients don’t ask their physicians to change medications until we see how you respond to the customary treatment.  If you are not responsive or of you quickly have a recurrence when you stop your treatment then it may be time to consider a lichenoid drug reaction and to ask your physician to consider an alternative medication.

Of course, there are exceptions to this approach.  If you have just started a new medication and you begin to develop oral lichen planus a few weeks later, we will be very suspicious of the new drug and might consider asking for an alternative at that point. This would apply whether or not the drug is on our list since, in theory, any drug can cause a lichenoid drug reaction in some individuals. So my suggestion to you is to first ask about the possibility of a drug induced reaction, but, other than for the specific exception I mentioned, be patient and try conventional oral lichen planus treatment first and for long enough to learn how responsive you are to the treatment.  Please remember that treatment is often a step by step process.  We may find that we need to make carrier drug trays for your gum lichen planus if you are not as responsive to treatment as we expect.  We also know we have to deal with potential development of a secondary yeast infection if we prescribe a topical corticosteroid, which we often do.  That may slow our treatment efforts and cause it to take longer to get the control we all want so don’t get impatient.

 Do talk with your health provider who is treating your mouth problems and make sure you have an understanding of what is happening and what to expect.  Together we can make good things happen!

Terry Rees DDS, MSD
Director, Stomatology Center

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For the patient with a mucosal disorder

Dr. Nancy Burkhart
Texas A&M College of Dentistry

  • Patients should have professional cleanings every 2 to 3 months. Periodontal patients may need to be seen every 2 months, depending upon the patient's status and periodontal health.
  • Careful scaling of all teeth should be performed with as little disruption of the tissue as possible. When significant periodontal pocketing is present, multiple appointments with gentle scaling and debridement are preferable to conventional deep scaling and root planing.
  • All soft tissue areas should be evaluated. Findings should be described and recorded, with any suspicious areas being reevaluated. Careful evaluation for Candida is suggested, especially for patients who are using topical corticosteroids.
  • The practitioner should note any areas that are in contact with sharp edges, crowns, or restorative materials.
  • Tissue areas that do not respond to treatment may need further evaluation and possibly future biopsy.
  • Ultrasonic scalers should not be used for extensive subgingival debridement to minimize irritation to the tissue.
  • Polishing paste that is gritty or coarse should not be used because of irritation to the tissue both above and below the gingival margin.
  • Mouth rinses containing alcohol should be avoided to prevent patient discomfort and tissue irritation. Some flavoring agents such as mint or cinnamon may act as an irritant to the tissues and should be changed or discontinued if there is any reaction.
  • Air polishers are too disruptive to the tissues and should not be used.
  • Any polishing of the teeth should be performed using a mild paste such as the toothpaste currently used by the patient and this can be applied with a prophy cup. Simply brushing the teeth with the paste in the dental office will be of some benefit.
  • For home care, recommend toothpaste without additives (such as sodium lauryl sulfate), flavor-free products, and the use of a soft bristle brush. Paste without many additives can be tolerated by most patients. It is also highly effective in patients with xerostomia.
  • A children’s toothpaste is usually tolerated well with patients since these pastes have limited ingredients.
  • Patients should be instructed to discontinue the use of chewing gum, candy, mints, toothpastes, or mouth rinses that contain flavoring agents such as wintergreen, peppermint, spearmint, and cinnamon.
  • Periodic oral digital photographs both for initial and for follow-up appointments are suggested. This allows better evaluation of treatment progress or lack of progress. Encourage patients to take photos on their cell phones or with their own digital camera so that the clinician has a good understanding of how the tissue responds between appointments.
  • Encourage patients to document any tissue irritations and to keep a log of possible “trigger” mechanisms that may have caused lesions or irritations. The causes may be certain foods, beverages, changes in toothbrush or oral care products, oral injury, etc.

Prepared by Dr. Terry Rees and Dr. Nancy W. Burkhart. Adapted from International Oral Lichen Support Group Web site, https://dentistry.tamu.edu/olp/