Comparison of the effect of photodynamic therapy and topical corticosteroid on oral lichen planus lesions.

OBJECTIVE: In this study, the effect of photodynamic therapy with topical corticosteroid in oral lichen planus patients was compared. MATERIAL AND METHODS: In this randomized, double-blind clinical trial, eight patients with bilateral oral OLP lesions were recruited. Toluidine blue was applied on the lesions of both sides; a 660-nm diode laser InGaAlP was irradiated for 10 min (power: 25 mW, fluence: 19.23 J/cm2 , probe cross section: 0.78 cm2 ) for three sessions. In the control side of the oral mucosa, only sham laser was used. Follow-up sessions were held on weeks 3 and 7. In week 3, oral paste triamcinolone acetonide 0.1% was prescribed. Response rates were assessed clinically by VAS, Thongprasom sign scoring, clinical severity index, efficacy indices, and the amount of reduction in the size of the lesions. The Mann-Whitney test was used to evaluate the treatment outcomes. RESULTS: In spite of the control side, all scores improved significantly between sessions 0 and 4 for the intervention side. The differences between the changes in almost all scores between sessions 0 and 4 in both the intervention and control sides were significantly considerable (p value < .05). CONCLUSION: Photodynamic therapy can be used as an alternative therapy alongside standard methods or as a new modality for refractory OLP.

Successful treatment of isolated oral lichen planus on lower lip with traditional Chinese medicine and topical wet dressing: A case report.

RATIONALE: Biopsy is very important for the diagnosis of oral lichen planus (OLP) on the lips. Traditional Chinese medicine (TCM) can be used to coordinate the whole body, soften and eliminate swellings and masses, and regulate the functions of qi and blood. Therefore, TCM could be an effective and safe treatment for OLP. Wet dressing is particularly important for the treatment of lip diseases. We report on a rare case of OLP on the lower lip. PATIENT CONCERNS: A 38-year-old female patient presenting with a history of recurrent erosion, bleeding, and pain on her lower lip for 10 years. DIAGNOSES: Erosive OLP of the lower lip. INTERVENTIONS: The patient was treated for 4 months using TCM comprising "Qingwen Jiedu Kouyankang granules," total Paeonia glucosides, and a combination of hormones and anti-inflammatory agents applied locally using a wet dressing. OUTCOMES: Lip erosion was improved remarkably after 1 month, and there was no recurrence or aggravation of the condition. The duration of the follow-up period was 5 months. LESSONS: The therapeutics used here were effective and safe for the treatment of OLP and could improve the quality of life in patients with lip erosion. The therapeutics provide new insight into the treatment of OLP on the lip.

Lichen planus and lichenoid dermatoses: Conventional and emerging therapeutic strategies.

Having reviewed the diverse clinical subtypes of lichenoid disease and the postulated molecular basis thereof in the first article in this 2-part continuing medical education series, we discuss herein the existing and emerging treatment strategies in the most common clinical forms of lichenoid inflammation and provide an overview of their pharmacodynamics and evidence base. The scope of this review is not to exhaustively discuss treatment modalities for all lichenoid variants discussed in the previous article of this series. Instead, the focus will be on frequently encountered subtypes of lichen planus and on linking mechanisms of disease with mechanisms of drug action. Future directions and potential avenues for translational research will also be discussed.

Efficacy of photodynamic therapy or low level laser therapy against steroid therapy in the treatment of erosive-atrophic oral lichen planus.

BACKGROUND: The efficacy of photodynamic therapy (PDT) or low level laser therapy (LLLT) in the treatment of oral lichen planus (OLP) is debatable. The aim of this study was to compare the effects of PDT, LLLT or topical corticosteroid application in the treatment of erosive-atrophic OLP. MATERIALS AND METHODS: Forty-five adult patients with erosive-atrophic biopsy-proven OLP on the tongue or buccal mucosa (size ≤3 cm) were randomly divided into three groups. Group-1: patients receiving PDT topical application of 50 µl toluidine blue (1 mg/ml) with micropipette and after 10 min treated by laser irradiation using GaAlAs laser (630 nm, 10 mW/cm2, continuous wave, spot size: 1 cm2); Group-2: patients receiving LLLT using diode laser (630 nm, 10 mW, continuous wave, spot size: 1 cm2); and Group-3: patients receiving topical corticosteroid applications consisting of dexamethasone (0.5 mg in 5 ml water) mouthwash for 5 min. Demographic data, type, and severity of the lesions and pain were recorded before and after treatment and then at the 1 year follow-up. RESULTS: There was a significant difference in sign score changes before and after the treatment in the PDT group (p = 0.03), LLLT group (p = 0.04) and in the control group (p = 0.02). There was a statistically significant difference between group-1 (p = 0.001) and group-2 (p = 0.001) against group-3 before and after treatment. Mean amount of improvement in pain was significantly greater in the control group in comparison with the PDT and LLLT groups (p < 0.001). The efficacy index of the PDT group improved significantly more than the LLLT (p = 0.001) and corticosteroid groups (p = 0.001). CONCLUSION: Within the limits of the present RCT, it is indicated that PDT and LLLT are effective in the treatment of erosive-atrophic forms of OLP in adult patients. However, further comparative clinical trials are needed to obtain strong conclusions in this regard.

Efficacy of low-level laser therapy compared to steroid therapy in the treatment of oral lichen planus: A systematic review.

BACKGROUND: Low-level laser therapy (LLLT) has been proposed as a potential treatment strategy for the treatment of oral lichen planus (OLP). The aim of this systematic review was to assess the efficacy of LLLT, in comparison with corticosteroid therapy, in the treatment of OLP. MATERIALS AND METHODS: This systematic review aimed to address the following focused question: "Does LLLT yield better clinical outcomes than corticosteroid therapy in the treatment of OLP?" Indexed databases were searched up to and including April 2017. Clinical trials in humans diagnosed clinically and/or histologically with OLP allocated to test (LLLT) versus control (steroid therapy) groups were included. RESULTS: Five clinical studies were included. The risk of bias was considered high in four studies and moderate in one study. Laser wavelengths, power, spot size, and duration of laser exposure ranged between 630 and 970 nm, 10-3000 mW, 0.2-1.0 cm2 , and 6-480 seconds, respectively. The follow-up period ranged from 4 to 48 weeks. All included studies reporting clinical scores showed that LLLT was effective in the treatment of OLP in adult patients at follow-up. Three studies showed significantly higher improvements with topical use of corticosteroids compared to LLLT, while one study showed significant improvement with LLLT. One study showed comparable outcomes between LLLT and corticosteroid application. CONCLUSION: It remains debatable whether LLLT is more effective as compared to corticosteroids in the treatment of OLP, given that the scientific evidence is weak. These findings are preliminary and further randomized clinical trials are recommended.

Tratamiento del liquen plano oral. Revisión sistemática y protocolo de actuación / Treatment of oral lichen planus. Systematic review and therapeutic guide

En la presente revisión sistemática se analizaron 55 artículos estructurados sobre la eficacia terapéutica frente al dolor y a los signos clínicos del liquen plano oral (LPO). La búsqueda bibliográfica se elaboró siguiendo los criterios del sistema PRISMA, seleccionando los ensayos realizados mediante alguno de los siguientes diseños metodológicos: entre fármaco (principio activo) vs. mismo fármaco en diferente excipiente o concentración, fármaco vs. diferente principio activo, fármaco vs. fitoterapia y fármaco vs. tratamiento con fototerapia. Basándonos en los resultados se propone un algoritmo que sirva de guía para establecer el tratamiento del LPO en sus formas clínicas atrófica y erosiva. Se destaca el empleo del propionato de clobetasol al 0,025-0,05% de aplicación tópica como primera alternativa terapéutica. En segundo lugar, el tacrolimús al 0,1% y pimecrolimús al 1% también formulado para su pauta tópica. Y, finalmente, se aborda el empleo de corticosteroide sistémico y la aplicación de láser de diodo (AU)

In this systematic review, 55 structured articles on the therapeutic efficacy against pain and clinical signs of oral lichen planus (OLP) were analysed. The literature search was developed according to the criteria of the PRISMA system, selecting the tests performed using one of the following methodological designs: drug (active ingredient) vs. drug in different excipient or concentration, drug vs. different active principle, drug vs. phytotherapy and drug vs. treatment with phototherapy. Based on the results, an algorithm is proposed to guide the treatment of OLP in its atrophic and erosive clinical forms. The use of clobetasol propionate at 0.025-0.05% of topical application as the first therapeutic alternative is highlighted. Secondly, 0.1% tacrolimus and 1% pimecrolimus also formulated for its topical regimen. And finally, we address the use of systemic corticosteroids and the application of diode lasers (AU)

Treatment of oral lichen planus. Systematic review and therapeutic guide. / Tratamiento del liquen plano oral. Revisión sistemática y protocolo de actuación.

In this systematic review, 55 structured articles on the therapeutic efficacy against pain and clinical signs of oral lichen planus (OLP) were analysed. The literature search was developed according to the criteria of the PRISMA system, selecting the tests performed using one of the following methodological designs: drug (active ingredient) vs. drug in different excipient or concentration, drug vs. different active principle, drug vs. phytotherapy and drug vs. treatment with phototherapy. Based on the results, an algorithm is proposed to guide the treatment of OLP in its atrophic and erosive clinical forms. The use of clobetasol propionate at 0.025-0.05% of topical application as the first therapeutic alternative is highlighted. Secondly, 0.1% tacrolimus and 1% pimecrolimus also formulated for its topical regimen. And finally, we address the use of systemic corticosteroids and the application of diode lasers.

Clinical Management Protocol for Dental Implants Inserted in Patients with Active Lichen Planus.

PURPOSE: To propose a treatment protocol for management of implant candidates suffering from active lichen planus. MATERIALS AND METHODS: Twenty-three patients who were diagnosed with active lichen planus were referred to a dental practice seeking dental implants. Patients received dental implants using open flap technique and sequential osteotomy. After a healing time of 6 weeks, implants were put into occlusal contact using interim prostheses. Of the 55 inserted implants, 42 failed after a short clinical service time (7 to 11 weeks). Failed implants were surgically removed, and osteotomy sites were carefully cleaned using manual curettes and scrubbing of osteotomy walls. CD4/CD8 cell count and gingival biopsies were collected from the surgical sites. Patients were put on an ascending dose (5 mg/10 days) of oral corticosteroids until a daily dose of 20 mg/day was achieved and maintained for 2 weeks. All patients received ten sessions of low-energy soft tissue laser irradiation at the implant insertion sites to assess soft tissue healing through improving blood circulation, reduction of inflammation, and sterilization of the osteotomy region. After approximately 8 weeks, a new set of 42 implants was placed, and definitive restorations were cemented using early loading technique. Marginal bone levels around inserted implants were periodically evaluated every 3 months using digital periapical radiographs (α = 0.05). RESULTS: Primary blood tests revealed a high CD8 cell count, while soft tissue biopsies revealed infiltration of inflammatory cells at the epithelium soft tissue interface of the examined tissue. Repetition of immunological investigations after administration of the oral corticosteroids and soft tissue laser irradiation revealed reduction of CD8 cell counts and disappearance of inflammatory cell infiltration of the examined soft tissue biopsy. Patients reported marked improvement of the oral mucosa after treatment. All implants (n = 42) were functional after 3 years of clinical observation. There was an initial reduction in marginal bone level after 3 months from insertion time, after which it remained constant during the following observation periods. CONCLUSION: Active lichen planus should be managed with oral corticosteroids and soft tissue laser irradiation before insertion of dental implants.

[Clinical effect of Nd:YAG laser combined with total glucosides of paeony for the treatment of erosive oral lichen planus].

PURPOSE: To investigate the clinical effect of Nd:YAG laser combined with total glucosides of paeony (TGP) taken orally for the treatment of erosive oral lichen planus (OLP). METHODS: Sixty patients who were diagnosed as erosive OLP with clinical symptoms were divided into experimental group (n=28) and control group (n=32) using a random number table. All patients received TGP while the patients in the experimental group were given Nd:YAG laser irradiation. The clinical effects were evaluated 3 months after treatment. The data were analyzed using SPSS 17.0 software package. RESULTS: Three months later, the average VAS score and sign score had improved significantly to (1.36±1.39) and (2.32±1.56) in the experimental group. The same tendency was observed in the control group and at the time point no significant difference was observed between the experimental group and the control group. The effectiveness of the experimental group was significantly higher than the control group (82.1% vs 53.1%). CONCLUSIONS: Nd: YAG laser combined with TGP can improve the efficacy of erosive OLP. The regime is safe and effective, which is worth of wide clinical application.

Possible alternative therapies for oral lichen planus cases refractory to steroid therapies.

Oral lichen planus (OLP) is a chronic inflammatory disorder with a multifactorial etiopathogenesis. Immune dysregulation plays a critical role in the development and progression of this disease. Patients' lives may be affected by pain caused by atrophic-erosive lesions. Given the obscure etiology, treatment is usually symptomatic. Topical steroids remain the mainstay of management. However, their therapeutic benefits are not always evident. There are substantial data on the possible therapeutic strategies that are effective in OLP cases refractory to steroids. This review provides an overview of the current approaches for the management of steroid-refractory OLP. The miscellaneous treatment regimens include tacrolimus, pimecrolimus, thalidomide, low-level laser therapy, photodynamic therapy, and surgical excision. Some results obtained from these studies were promising. However, further studies, especially randomized controlled trials with strict inclusion and exclusion criteria and larger sample sizes, are required for the evaluation of the long-term safety and efficacy of these therapies.

Epigenetic Modifications and Accumulation of DNA Double-Strand Breaks in Oral Lichen Planus Lesions Presenting Poor Response to Therapy.

Epigenetics refers to changes in cell characteristics that occur independently of modifications to the deoxyribonucleic acid (DNA) sequence. Alterations mediated by epigenetic mechanisms are important factors in cancer progression. Although an exciting prospect, the identification of early epigenetic markers associated with clinical outcome in premalignant and malignant disorders remains elusive. We examined alterations in chromatin acetylation in oral lichen planus (OLP) with distinct clinical behavior and compared the alterations to the levels of DNA double-strand breaks (DSBs). We analyzed 42 OLP patients, who had different responses to therapy, for acetyl-histone H3 at lys9 (H3K9ac), which is associated with enhanced transcription and nuclear decondensation, and the presence of DSBs, as determined by accumulation of phosphorylated γH2AX foci. Patients with high levels of H3K9ac acetylation failed to respond to therapy or experienced disease recurrence shortly after therapy. Similar to H3K9ac, patients who responded poorly to therapy had increased accumulation of DNA DSB, indicating genomic instability. These findings suggest that histone modifications occur in OLP, and H3K9ac and γH2AX histones may serve as epigenetic markers for OLP recurrence.

HBO: a possible supplementary therapy for oral potentially malignant disorders.

Oral potentially malignant disorders (OPMDs) are chronic inflammatory diseases in which cells suffer hypoxia referring to deprivation of adequate oxygen supply. Hyperbaric oxygen treatment (HBO), which can increase oxygen tension and delivery to oxygen-deficient tissue, is a supplementary therapy to improve or cure disorders involving hypoxia. Although the applications of HBO in wound healings, acute ischemic stroke, radiation-induced soft tissue injury and cancers are extensively reported, there are only few studies on their effect in OPMDs. Not only does HBO furnish oxygen-it also possesses potent anti-inflammatory properties. At the cellular level, HBO can decrease lymphocyte proliferation and promote apoptosis of fibroblasts. At the molecular level, it can decrease expression of HIF, ICAM-1, TNF-α, TGF-ß, and IFN-γ, as well as increase vascular VEGF expression and angiogenesis. Thus, we hypothesize that HBO may contribute to treat OPMDs, including oral lichen planus, oral leukoplakia, and oral submucous fibrosis both at the cellular level and the molecular level, and that it would be a safe and inexpensive therapeutic strategy.

Phototherapy approaches in treatment of oral lichen planus.

Oral lichen planus (OLP) is a chronic immunologic mucocutaneous inflammatory disease of the oral mucosa. Since the etiopathology of OLP is idiopathic, treatment is usually symptomatic, therefore showing low predictability. Currently, topical corticosteroids are widely accepted as the standard therapy. However, for patients unresponsive to standard therapy for OLP, new treatment modalities have been sought. Phototherapy has recently been accepted as an alternative or adjunctive treatment modality for many conditions in medicine and dentistry. The aim of this study is to present the advantages and disadvantages of the different kinds of phototherapy used in treatment of OLP (UV phototherapy, lasers, and photodynamic therapy). The main outcome measures compared were improvement of signs and symptoms and OLP recurrence. Although some phototherapy techniques in the selected articles have demonstrated limited effects, there is no solid basis in evidence for the effectiveness of any of these treatments for OLP. Therefore, further research, especially randomized controlled clinical trials with long-term follow-up, is needed to give any solid recommendation on the use of phototherapy in the field of OLP treatment.

Topical therapies for oral lichen planus management and their efficacy: a narrative review.

Oral Lichen Planus (OLP) is a chronic inflammatory condition implicating T cell-mediated cytotoxicity, and involving oral mucosal surfaces. Several therapeutic regimens have been evaluated to treat OLP and pain related, but often without high level of evidence. Topical formulations are the favourite for the majority of cases; bioadhesive formulations have been considered very useful and practical for local drug delivery in oral mucosa, due to the increased residence time on the oral mucosa of the dosage forms and better therapeutic efficacy. In this narrative review, authors try to illustrate the current topical managements for OLP from the accessible literature on this topic. Steroids are very helpful in discomfort and making better quality of life: they are considered the first-line treatment even if they could cause secondary candidosis, and sometimes bad taste, nausea, dry mouth, sore throat or swollen mouth. Other substances or devices by topical administration are adopted especially when the first line approach is refractory. This is the case when retinol with its synthetic and natural analogues (retinoids), hyaluronic acid, or Aloe Vera are chosen. Recent topical applications for OLP therapy include phototherapy and low/high energy pulsing light; the treatment with extracorporeal photochemotherapy is also reasonable and promising. Finally, calcineurin inhibitors (i.e. cyclosporine, tacrolimus and pimecrolimus), antioxidant and biologics (i.e alefacept, efalizumab, basiliximab, TNF-α inhibitors - infliximab, rituximab) may be alternative approaches when OLP does not respond to the standard protocols. In this scenario, there are several studies on molecules different from glucocorticosteroids, but not sufficient or statistically adequate to justify their evidence-based use in OLP; large randomized placebo controlled trials are required to evaluate the safety and effectiveness of these non conventional therapies. In conclusion, since OLP is a chronic disease and requires long-term management, the dental/medical practitioner, who treats OLP patients, needs to know the natural history of OLP, how to monitor, and how to treat, taking in account all of the available modalities conventional and not, with pros and cons.

Treatment of erosive oral lichen planus with local ultraviolet B phototherapy.

BACKGROUND: Oral lichen planus (OLP) is a chronic inflammatory disease that can significantly affect the patient's quality of life. OBJECTIVE: We sought to demonstrate the therapeutic efficacy of local ultraviolet (UV) B phototherapy in OLP. METHODS: Patients with biopsy-confirmed erosive OLP recalcitrant to previous medical therapy were treated with the TheraLight UV 120-2 system (TheraLight Inc, Carlsbad, CA). Lesions were accessed directly using a flexible fiber guide. Local phototherapy was delivered 3 times a week, with gradual increase in UVB dose every other session. Affected oral mucosa was defined as the area showing erosions or symptomatic reticular lesions. Complete response was defined as reduction of at least 80% in the affected mucosal area, and partial response was defined as a reduction of 50% to 80% in the affected mucosal area. The primary end point was efficacy after 8 weeks of treatment. RESULTS: Fourteen patients were included in the study. Nine achieved complete response and 5 partial response after 8 weeks. Ten patients were continued on maintenance therapy and were able to maintain their response for another 29 weeks. None of the patients showed any serious side effects from local UVB therapy. LIMITATIONS: The study was performed in a small series of patients at a single medical center. Further studies with larger patient samples are required to validate our findings. CONCLUSION: Local UVB phototherapy may be a promising treatment modality for erosive OLP.

Interventions for treating oral lichen planus.

BACKGROUND: Oral lichen planus (OLP) is a common chronic autoimmune disease associated with cell-mediated immunological dysfunction. Symptomatic OLP is painful and complete healing is rare. OBJECTIVES: To assess the effectiveness and safety of any form of therapy for symptomatic OLP. SEARCH STRATEGY: The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 26 January 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 26 January 2011) and EMBASE via OVID (1980 to 26 January 2011). There were no restrictions regarding language or date of publication. SELECTION CRITERIA: All randomised controlled clinical trials (RCTs) of therapy for symptomatic OLP which compared treatment with a placebo or between treatments or no intervention were considered in this review. DATA COLLECTION AND ANALYSIS: The titles and abstracts of all reports identified were scanned independently by two review authors. All studies meeting the inclusion criteria were assessed for risk of bias and data were extracted. For dichotomous outcomes, the estimates of effects of an intervention were expressed as risk ratios (RR) together with 95% confidence intervals. For continuous outcomes, mean differences (MD) and 95% confidence intervals were used to summarise the data for each group. The statistical unit was the patient. Meta-analyses were done only with studies of similar comparisons reporting the same outcome measures. MAIN RESULTS: 28 trials were included in this review. Pain is the primary outcome of this review because it is the indication for treatment of OLP, and therefore this review indicates as effective, only those treatments which significantly reduce pain. Although topical steroids are considered first line treatment for symptomatic OLP, we identified no RCTs that compared steroids with placebo. There is no evidence from the three trials of pimecrolimus that this treatment is better than placebo in reducing pain from OLP. There is weak evidence from two trials, at unclear and high risk of bias respectively, that aloe vera may be associated with a reduction in pain compared to placebo, but it was not possible to pool the pain data from these trials. There is weak and unreliable evidence from two small trials, at high risk of bias, that cyclosporin may reduce pain and clinical signs of OLP, but meta-analysis of these trials was not possible.There were five trials that compared steroids with calcineurin inhibitors, each evaluating a different pair of interventions. There is no evidence from these trials that there is a difference between treatment with steroids compared to calcineurin inhibitors with regard to reducing pain associated with OLP. From six trials there is no evidence that any specific steroid therapy is more or less effective at reducing pain compared to another type or dose of steroid. AUTHORS' CONCLUSIONS: Although topical steroids are considered to be first line treatment, we identified no RCTs that compared steroids with placebo in patients with symptomatic OLP. From the trials in this review there is no evidence that one steroid is any more effective than another. There is weak evidence that aloe vera may reduce the pain of OLP and improve the clinical signs of disease compared to placebo. There is weak and unreliable evidence that cyclosporin may reduce pain and clinical signs of OLP. There is no evidence that other calcineurin inhibitors reduce pain compared to either steroids or placebo. From the 28 trials included in this systematic review, the wide range of interventions compared means there is insufficient evidence to support the effectiveness of any specific treatment as being superior.