Analysing the Sex Predilection of Oral Lichen Planus - A Hospital based Retrospective Study
Jagadish Rajkumaar1, Hannah. R2*, SS Raj3
1 Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India.
2 Senior lecturer, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India.
3 Reader, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India.
*Corresponding Author
Dr. Hannah. R,
Senior lecturer, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai - 600077, Tamil Nadu, India.
E-mail: hannahr.sdc@saveetha.com
Received: July 30, 2021; Accepted: August 10, 2021; Published: August 17, 2021
Citation:Jagadish Rajkumaar, Hannah. R, SS Raj. Analysing the Sex Predilection of Oral Lichen Planus - A Hospital based Retrospective Study. Int J Dentistry Oral Sci. 2021;8(8):3856-3860. doi: dx.doi.org/10.19070/2377-8075-21000789
Copyright: Dr. Hannah. R©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Oral lichen planus is a chronic inflammatory disease affecting the mucous membrane. It has a characteristic papular plaque like appearance. It may be caused due to a dental restoration, having a prolonged oral infection, presence of any autoimmune disorder or sustaining an injury to the mouth. And it also has systemic association with hypertension, diabetes, thyroid dysfunction, GVHD. There a very few studies done on the sex predilection of oral lichen planus. This study will be of epidemiological significance in the south Indian population. The current study was done to analyze the sex predilection of oral lichen planus. This study was done under a university setting with the data collected from June 2019 to April 2020. The sample size was 59 patients. The data was collected from the patient records. Data was verified and tabulated and later appropriate statistics was performed. Females showed a higher prevalence with59% and males 41%. Erosive lichen planus 42% was the most common clinical variant followed by reticular type 37%. On correlating gender with the clinical variants, lichen planus was found to be the most common clinical variant among the females. The chi square analysis between the gender and variant of oral lichen planus was insignificant (P value 0.109.)Within the limitations of the study we conclude that oral lichen planus is more prevalent in females than males. Erosive lichen planus is the most common variant followed by the reticular variant.
2.Introduction
3.Conclusion
4.References
Keywords
Oral Lichen Planus; Potentially Malignant Disease; Reticular; Erosive; Female.
Introduction
Oral lichen planus (OLP) is seen as a common inflammatory mucocutaneous
disease with an undefined etiology [50, 14]. The reported
sex predilection is seen to be 2:1 [10] female to male ratio
and the age of onset is generally seen to be in the fourth and sixth
decades of life [32]. Clinically there are six variants of oral lichen
planus and they are reticular, papular, plaque, erosive, atrophic
and bullous types [35]. Histopathologically it shows degeneration
of the basal layer and a dense inflammatory lymphohistiocytic infiltrate
and there is also an increase in the intraepithelial lymphocytes
[5, 12]. If the above three criteria are met, the lesion is considered
an actual typical form of lichen planus from a histological
view; and in a condition where any on these histological criteria
are not met, they are taken to be lesions that are histologically
compatible with lichen planus [8]. The differential diagnosis of
lichen planus and lichenoid reaction will be observed in relation
to the clinical and histological aspects previously mentioned. so
all of the clinical and histological rules must be in the acceptance
in the case of lichen planus [27]. In contrast, lichenoid reaction
patients present with typical lichen planus clinically but not histologically,
and vice versa, Only patients who satisfy both clinical
and histological criteria are considered as lichen planus [42].
The Typical histopathological observations from the lesional
biopsy shows hyper orthokeratosis or hyperparakeratosis, with
acanthosis, which is indicated by the increased thickness of the
granular layer in combination with intercellular edema [19, 42].
Rete pegs reveal “saw tooth” in appearance. Mononuclear infiltration
of the T-cells and histiocytes form an actual band-like appearance
subepithelial. The intraepithelial T-cells and degenerating
keratinocytes together make the content of the colloid bodies,
the homogeneous globules that are eosinophilic are called the
civette, cytoid or the hyaline bodies [46]. The prominent feature
of Max-Joseph space that appears from the degeneration of basal
keratinocytes and supporting units being disrupted. They are known as histologic clefts. The colloid bodies consist of apoptotic
keratinocytes revealing DNA mutation in these cells. The
basement membrane when observed under an electron microscope
reveals duplications, branches, and disruptions [11]. The
etiopathogenesis of Lichen planus reveals that it is usually a T-cell
mediated disease autoimmune in nature where the CD8+ T-cells
initiate the self-destruction of oral epithelial cells at the basal layer
[26].
Keratinocyte antigen appearance and antigen revealing are involved
in the disease process. It may be a heat shock protein [65].
Then followed by the migration of T-cells migrate towards the
basal keratinocytes during the chemokine mediated action. The
antigen directly binds to the newly migrated CD8+ cells by the
major histocompatibility complex-1 (MHC) on keratinocyte [9].
Langerhans cells are high in lesions of lichen planus and there is
increased MHC-II expression. The CD4+ cells and interleukin-12
activate CD8+ T-cells that are involved in the self-destruction
of keratinocytes through FasL and tumor necrosis factor-alpha
(TNF-alpha) [20].There are also other studies which shows some
correlation and association of oral lichen planus with genital and
cutaneous lichen planus [46, 36].
One of the reasons why this lesion has to be treated with utmost
care is due to the frequent malignant transformation of this lesion
to oral squamous cell carcinoma with a rate of malignant transformation
of 0.4-5.3%. Erosive variant was found to be the most
common variant to undergo malignant transformation (Kämmerer,
no date) and this characteristic feature of the lesion leads the
WHO to add it to the potentially malignant disorders under high
risk category. The reticular type is the most widely recognized
variant and presents as papules and plaques with interweaving
white keratotic lines (Wickham striae) with erythematous borders.
The common location of the striae are respectively on the buccal
mucosa, mucobuccal fold, gingiva, and less normally on the
tongue, palate, and lips. The reticular variant has been more regularly
seen in men contrasted with women and is typically asymptomatic.
Erosive, atrophic or bullous types cause burning sensation
and pain.
The demographic and clinical qualities of OLP have been very
much depicted in several studies from developed nations, Though
the demographic studies from developing nations was scant. Furthermore,
there are no universally accepted specific clinical and
histopathological diagnostic rules to date [35]. Biopsy or medical
procedures were not acted on by all patients in a few past examinations,
while different other conditions, for example, leukoplakia,
erythroplakia, and discoid lupus erythematosus can show a
similar clinical appearance [47]. A significant issue in the criteria
of OLP neoplastic change may be because of differences in the
initial case identification, time of development, and data on introduction
to known oral cancer-causing agents [28].
Furthermore some of the earlier studies of the demographic location
and assessment of the clinical variants lacked the gender
correlation. Previously our team has a rich experience in working
on various research projects across multiple disciplines [38, 37, 49,
33, 16, 7, 42, 53, 40, 3, 68, 1, 29, 62, 66]. Now the growing trend
in this area motivated us to pursue this project. So this study aims
ay analyzing the sex predilection of oral lichen planus and then
associate it to the various clinical variants.
Materials And Methods
The study is done under a university setting. The similar characteristics
of the study is that it is done with the available data and
under similar ethnicity of the population. The disadvantage of
the study can be that the geographic location is similar. The study
was approved by the scientific review board of the institution.
Two reviewers were involved in the study. The data was taken
from patients who had checked in the clinic from June 2019 to
April 2020. Total number of sample sizes includes 59 patients.
Data collection was after reviewing 86,000 patient records between
June 2019 and March 2020. 59 patients were selected and
data was collected. The case sheets were verified with the help
of photographs. To minimize the sampling bias, we included all
the data available and there was no sorting of data done. Internal
validity of the study was non-probability inclusion. The external
validity of the study includes homogenization and replication of
experimentation. The data obtained was tabulated and verified by
one external reviewer. The data was then imported to SPSS and
the variables were verified. Chi-square test was done to correlate
gender with variants of oral lichen planus.
Results
The data collected from the patient management software was
tabulated in SPSS and the descriptive statistics were obtained.
Out of total 59 patients, Females showed a higher prevalence of
59% and males 41% as shown graph 1. The clinical variant which showed predominance was erosive lichen planus 42% followed by
reticular type 37%,pigmented type 3.4%,annular type 1.7%, ulcerative
3.4%, papular1.7%,bulous 1.7%. The erosive variant showed
an increased prevalence of 43% in both males and females as
depicted in graph 2. The chi square analysis between the gender
cand clinical variants was not statistically significant P=0.109
(P>0.05). The correlation revealed that erosive lichen planus was
the most common variant seen among the females (graph 3).
Graph 1- Bar graph representing the frequency of gender distribution of the participants. where x axis denotes the gender and y axis denotes the frequency of the population. Red indicates female population(58.32%) and blue indicates male(40.65%).
Graph 2- Bar graph shows the percentage of different clinical variants of oral lichen planus. X axis denotes the different clinical variants and Y axis denotes the percentage of cases. 42.37% of the cases were Erosive lichen planus, followed by reticular type 37.29%, pigmented type 3.39%, annular type 1.69%, ulcerative 3.39%, papular1.69% and bullous 1.69%.
Graph 3- Bar graph representing the association between gender and clinical variants of oral lichen planus. x axis denotes the gender distribution and y axis denotes the percentage of cases. Blue denotes erosive variant, green denotes reticular variant, orange denotes pigmented variant, yellow indicates annular variant, turquoise indicates ulcerative variant, pink indicates papular variant, purple indicates bullous variant. Majority of the females show Erosive lichen planus(blue) as the predominant variant (28%) followed by the reticular variant(green) which constitutes (24%) than males. However, it is not significant statistically.chi square value: 3.663,P=0.190 (P>0.05).
Discussion
Our study shows a higher prevalence of oral lichen planus in females
than in males. Olivera et al. study among the brazilian patients
also concluded with higher prevalence seen among females
similar to varghese et al. [2, 61]. The reason could be because
the incidence of oral lichen planus is higher in perimenopausal
women than in the general population and increases significantly
with increase in the severity of depression. oral lichen planus in
perimenopausal women can be initiated due to lowered levels
of estrogen and progesterone having a direct or indirect effect
causing depression that can trigger lichen planus. Hormonal fluctuations
during menopause leads to endocrine changes causing
changes in sex steroid hormone production [54, 21, 64, 18, 52].
It is well known that estrogen and progesterone have a direct influence
on the immune system and causes much disorder like f
various sclerosis, systemic lupus erythematosus, and rheumatoid
joint pain. Lichen planus, an immune system issue, seen often in
perimenopausal women, may likewise get influenced by sex steroid
hormones; yet no immediate relationship has been set up yet.
Studies in the south indian population also resolves higher prevalence
in females [67, 22, 24, 58, 15, 55]. These studies are in acceptance
with the result of our present study, this may be due to
the similar sample size range between the studies. Munde AD et
al. [31, 61] study shows higher lichen planus prevalence among
males. This is in contradiction with our study.
The more prevalent clinical variant observed in our study was
the Erosive variant 42%. Miranda et al. [28] study also showed
a higher prevalence of the erosive type of lichen planus Erosive
lichen planus is a destructive autoimmune disease of unknown
cause involving T lymphocytes.
Occasionally, it is drug-induced and will resolve on withdrawal
of the responsible drug. Partial response to antifungal agents and
antibiotics indicates an abnormal response to local microflora
may be involved, especially Candida albicans, Cytokine expression
profiling has found increased levels of the interleukins, IL-17 and
IL-23 (Website, no date; [22, 17, 59, 57]). This is in consensus with
our study. There are also other studies which show an increased prevalence of the reticular variant lichen planus. Females showed
a higher predominance in both erosive and reticular variants. This
is in acceptance with the study done by Giuseppina [4]. Kriti et
al. [4, 47] study shows male production in contradiction with our
study. When the clinical variants were associated with gender,
no statistical significance was found, however erosive oral lichen
planus was found to be more common in females than in males.
Few limitations of the study are that the study is single centered,
with less sample size, similar ethnicity and geographical location.
To improve the significance of the study should be done extensively
with a large amount of sample size. So that the results are
reliable.
Our institution is passionate about high quality evidence based
research and has excelled in various fields [39, 40, 44, 13, 44, 56,
63, 6, 30, 45, 48]. We hope this study adds to this rich legacy.
Conclusion
Within the limitations of the study we can conclude that oral lichen
planus is more prevalent in females than males, indicating a
female sex predilection. Erosive lichen planus was the most common
variant observed among females. Erosive lichen planus has
been classified under the high risk category for malignant transformation
and hence these patients need to be followed up in
order to observe any signs of change. Further extensive research
is needed to come to a more comprehensive understanding of
the pathogenesis underlying the female predilection of this lesion.
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