Clinical Controversies in Oral and Maxillofacial Surgery: Part OneOral lichen planus: A benign lesion*
Section snippets
A critical study
If OLP is as common a disease as has been suggested, it is difficult to reconcile the disparity between the relatively few cases of cancer that have purportedly arisen in it with the formidable indictment with which it has been charged. This was recognized by Krutchkoff et al,12 who, in 1978, critically reviewed 223 previously published cases of malignant transformation in OLP. Several impressive findings emerged from this study. First, a strict analysis of the data ultimately led these
Errors of histologic interpretation
Although the cited documentary inadequacies and concerns regarding carcinogenic influences are compelling in themselves, what is probably an even greater detractor from arguments favoring malignant transformation has since been identified, and resides within the arena of histologic interpretation. Both in past and current reports where there are published photomicrographs of purported pretransformation OLP, the illustrations frequently show features that are, at minimum, diagnostically
Classic clinical features of OLP
OLP is generally considered to be one of the most frequently encountered chronic inflammatory oral mucosal diseases.9, 10, 19, 21 Descriptions of its classic clinical features evoke a familiar constellation of lacy, white, keratotic papules and striae on an erythematous background, distributed bilaterally on buccal mucosae and gingivae. Similar-appearing lesions that involve the tongue, the lips, and other oral locations often accompany involvement of the latter sites. Erosive, atrophic, and
Classic histomorphologic features of OLP
At the microscopic level, protean features of OLP reflect its immunologically mediated foundation. The focal point of an as yet only partially defined pathogenetic process is the epithelial basal cell, whose surface has somehow undergone antigenic alteration. Consequently, that cell is perceived and targeted as “foreign” through a series of events that begin with antigen processing and presentation by Langerhans cells and macrophages, and culminates in basal cell liquefaction attended by dense,
Nonspecific lichenoid features
In addition to the aforementioned features, it is not unusual to encounter surface parakeratosis, individually dyskeratotic or necrotic cells (so-called Civatte or hyalin bodies), and fibrinous deposits at the epithelial-stromal interface. However, none of the latter findings is considered peculiar to or emblematic of OLP.5, 9, 14, 25 Any one or several of these findings also can be seen in biopsy specimens of other defined diseases such as chronic discoid lupus erythematosus,26 in lichenoid
Atypical lichenoid stomatitis (ALS) and lichenoid dysplasia (LD)
One other cardinal histologic criterion that is astonishingly underemphasized, but nonetheless is diagnostically pivotal for OLP, is a profile of normal epithelial cytomorphology, maturation, and architecture. Although some consider this criterion to be overly rigid and exclusionary,4, 10, 30 others contend that it cannot be stressed strongly enough, and that any histomorphologic evidence of obvious or even subtle departure from normal epithelial maturation and growth altogether precludes a
OLP: A distinct clinicopathologic entity
Clearly, if one relies on clinical criteria alone to discern true OLP from the multitude of conditions that share some of its gross features, it may be difficult, if not impossible, to do so with accuracy and confidence. Particularly in view of reports in which it is claimed that atrophic or erosive lesions seem especially vulnerable to transformation, this is a real concern.4, 11, 22, 25, 29, 30 That may be why there is growing acceptance of the maxim that precise and reliable diagnosis of OLP
Diagnostic histology pitfalls
It would follow, then, that definitive diagnosis of OLP and other clinically lichenoid lesions largely rests on histologic evaluation of a representative biopsy, coupled with respectful attention to the clinical picture.22 Although it would be ideal if this approach consistently assured reliable and precise diagnoses, microscopic interpretation is fraught with its own challenges, and pathologists are not always stringent about what they call OLP. Just as there is acknowledged resemblance among
The lichenoid infiltrate
Alone, the lichenoid pattern of inflammatory infiltration is not an especially unique or decisive feature in the diagnostic sense. It merely reflects a robust local immunologic response to some species of antigenic modification involving the adjacent epithelium. Complex and various in scope, these modifications can range widely in character, from reactive and benign, to precancerous, and to frankly malignant. Recall that in OLP specifically, the epithelial cytology, stratification, and
Pathologists' error
Pathologists' failure to recognize epithelial atypia and dysplasia in some microscopically lichenoid oral lesions, coupled with the rampant tendency to permissively diagnose any lichenoid lesion as OLP, is a long-standing problem.5, 6, 7, 8, 14, 15 Such diagnostic missteps continue to complicate the proper assessment and clinical management of oral lichenoid lesions to this day. Most certainly, these kinds of errors have contributed to what many now believe is the mistaken notion that OLP is a
Clinicians' error
It is sobering to contemplate the ramifications of pathologists' errors. Yet, mistakes derive from more than one source and, pathologists' fallibility notwithstanding, pitfalls of diagnosis and disease management riddle what is really a 2-way road. Clinicians also bear culpability for errors of interpretation and judgment that are uniquely theirs. Specifically with regard to OLP, the evidence that clinicians make mistakes is especially consonant; just like their pathologist counterparts, there
Clinical judgment
After the biopsy has been performed and the diagnosis rendered, the clinician's responsibility as a diagnostician is far from over. Because most pathologists' judgments are based on the limited material they view through the microscope, it is ultimately the clinician, with the advantage of having actually seen the lesion and taken the history, who must judge whether the given histologic diagnosis makes sense. Especially in the context of OLP and other lichenoid lesions, clinicians' exercise of
Diagnostic terminology
Yet another critically important dimension of the relationship between clinicians and pathologists concerns the use and meaning of diagnostic terminology. When they report diagnoses, pathologists use descriptive terms and nomenclature that reflect the most contemporary understanding of any particular disease. Hence, clinicians are obliged to also keep abreast of any new conceptual developments and corresponding changes in terminology that might arise as a consequence relative to conditions they
Molecular genetics: The future is now
Zhang and colleagues35 beautifully demonstrated in a recent study that there are actual substantive and identifiable molecular differences between OLP and oral epithelial dysplasia. In an attempt to address the question of whether OLP is premalignant, these investigators performed a comparative microsatellite analysis of several diverse oral epithelial lesions, which included OLP, benign reactive hyperplasia, various degrees of dysplasia, and squamous carcinomas. They focused on determining
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Survivin and autoimmunity; the ins and outs
2018, Immunology LettersIntegrative analysis of mRNA and miRNA expression profiles in oral lichen planus: preliminary results
2017, Oral Surgery, Oral Medicine, Oral Pathology and Oral RadiologyCitation Excerpt :Therefore, further exploration of additional mechanisms relevant to immune activities in OLP is warranted. The etiology of OLP and its potential to represent a premalignant phenotype remain poorly understood.8,33 However, miRNAs were shown to be of value as biomarkers to predict the risk of oral premalignant lesions.34
Diagnostic Infrared Thermography of the Tongue and Taste Perception in Patients with Oral Lichen Planus: Case-Control Study
2024, Journal of Clinical MedicineOral Lichen Planus and Lichenoid Lesions: Etiopathogenesis, Diagnosis and Treatment
2023, Oral Lichen Planus and Lichenoid Lesions: Etiopathogenesis, Diagnosis and TreatmentIs OLP potentially malignant? A clue from ZNF582 methylation
2023, Oral Diseases
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Address correspondence and reprint requests to Dr Eisenberg: Oral and Maxillofacial Pathology, MC-0925, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030-0925; e-mail: eeisenberg@@nso2.uchc.edu