Oral lichen planus
Oral lichen planus is a long-lasting inflammatory condition that affects the tissue lining inside your mouth, appearing as white patches, red areas, or open sores, and while it cannot be cured, treatments can help manage symptoms and reduce discomfort.
Table of contents
- What is oral lichen planus?
- Types of oral lichen planus
- Symptoms and appearance
- Causes and immune system involvement
- Triggers and risk factors
- How is it diagnosed?
- Treatment options
- Complications and cancer risk
- Outlook and living with the condition
What is oral lichen planus?
Oral lichen planus is a chronic inflammatory condition that primarily affects the tissue lining inside your mouth, called the mucous membranes or mucosa[1]. The condition can affect various parts of your mouth, including the inside of your cheeks, gums, tongue, and the inner tissues of your lips[1][2].
The name “lichen planus” was coined by British dermatologist Erasmus Wilson in 1869[4]. The term “lichen” comes from the Greek word for moss, referring to a plant often seen growing on rocks with a mossy, web-like appearance. “Planus” is Latin for “flat”[4][3].
Oral lichen planus affects approximately 2 percent of the population[3][12]. Women are affected 3 to 4 times more often than men[2]. Although the condition can occur at any age, most people diagnosed are between 30 and 70 years old, with the average age being 56 years[2][3].
The condition is not contagious, meaning you cannot catch it from or pass it to another person[1][2]. It also does not run in families[6].
- Oral mucosa (mouth lining)
- Buccal mucosa (inside of cheeks)
- Gums (gingiva)
- Tongue
- Inner lip tissue
- Palate (roof of mouth)
Types of oral lichen planus
There are two main types of oral lichen planus, each with different characteristics and levels of severity[1][2].
Reticular oral lichen planus is the most common and mildest form. This type appears as white patches in the mouth that can look lacy, with white, thread-like or web-like patterns[1][2]. These white lines are slightly raised and sometimes called Wickham’s striae[3]. The reticular type usually has no related symptoms and is often painless[1][2]. It typically does not need treatment or lead to major complications[1].
Erosive oral lichen planus is the more severe form. This type appears as bright red, swollen tissues or open sores in the mouth[1][2]. It can cause significant discomfort, including a burning feeling or pain[1]. People with erosive lichen planus often experience pain when eating, drinking, or brushing their teeth[2]. Ulcers can develop in one or more places inside the mouth[2].
Other less common forms include plaque-like lichen planus, which appears as a dense thickening of the tissue inside the mouth[3][12].
Symptoms and appearance
Symptoms of oral lichen planus differ based on which type you have. The condition often occurs as occasional flare-ups that may go away on their own or with treatment[2].
With the reticular type, you may notice white, web-like or lacy patterns inside your cheeks or on your tongue[2]. You might also see white spots or patches on your tongue or gums[2]. These white, lacy patches typically do not cause pain, soreness, or other discomfort[1]. Some patients may be unaware they have the condition until their dentist or dental hygienist brings it to their attention[3].
The erosive type can cause more noticeable symptoms. You may experience bright red gums and ulcers on your gums, tongue, or the roof of your mouth[2]. This form often causes mild to severe pain, especially when brushing your teeth or eating certain foods, particularly acidic, crunchy, salty, or spicy foods[2][3]. Other symptoms can include a burning sensation, sensitivity to hot foods and drinks, bleeding and irritation during toothbrushing, and inflammation of the gums[2][1].
Some people may notice early symptoms such as dryness or a metallic, burning taste in the mouth[8].
The inside of the cheeks is the most common location for oral lichen planus to appear[1]. However, it can also affect the gums, tongue, inner tissues of the lips, and the palate[1].
People with oral lichen planus often also have skin lichen planus, which can cause an itchy rash on the genitals or scalp[2]. Approximately 15% of patients with oral lichen planus develop skin lesions, and around 20% develop genital lesions[4].
Causes and immune system involvement
The exact cause of oral lichen planus is not completely understood[3][6]. However, doctors know that it is related to the immune system[1][2].
Normally, your immune system releases immune cells that attack harmful substances like germs, keeping you healthy. With oral lichen planus, something causes the immune system to behave abnormally. The condition occurs when the immune system attacks cells of the oral mucous membranes for reasons that are not known[1][2].
Research suggests that oral lichen planus is a T-cell-mediated autoimmune disease. Specifically, T cells (a type of white blood cell) appear to trigger the death of cells in the mouth lining[5][4]. The immune system may be reacting to something on the surface of the skin or mucosa, similar to an allergic-type reaction[3].
Several factors may be involved in the development of oral lichen planus. Genetics and immunity may play a role[3][12]. Some research has found a connection between oral lichen planus and hepatitis C virus infection. Studies show that patients with lichen planus are more likely to have hepatitis C, though there is no known explanation for this association[13][5].
Oral lichen planus appears more often in people who take certain medications, including antifungals, antiparasitic drugs, antiseizure medications, beta-blockers, diuretics, and nonsteroidal anti-inflammatory drugs[2][6]. It also sometimes occurs with diseases like hepatitis B, hepatitis C, human papillomavirus, and primary biliary cirrhosis, though more research is needed to understand these connections[2].
Triggers and risk factors
Many people with oral lichen planus learn to recognize triggers that cause symptom flare-ups[2]. Common triggers include allergic reactions to foods, toothpaste, floss, or materials used in dental procedures[2]. Dental issues such as a misaligned bite or having jagged teeth can also trigger symptoms[2].
Other triggers include certain medications, mouth injuries, mouth infections, and stress or anxiety[2]. Emotional stress, spicy foods, or citrus fruits can often cause symptoms to worsen[6].
A condition called lichenoid reactions can resemble lichen planus both in appearance and under the microscope, but these are caused by an allergic response[3][12]. The list of substances that can cause lichenoid reactions is extensive and includes medications, oral hygiene products, and occasionally metallic filling materials placed by dentists[3][12].
The main risk factors for developing oral lichen planus include being female, as women are affected 3 to 4 times more often than men[2]. While the condition can develop at any age, most people diagnosed are between 30 and 70 years old[2]. Women over age 50 are most commonly affected[3][12].
How is it diagnosed?
A healthcare professional may diagnose oral lichen planus based on several steps[9][17].
First, your doctor will talk with you about your medical and dental history and the medicines you are taking[9][17]. They will go over symptoms happening in your mouth and any other places on your body[9][17]. Then they will look at your mouth and other areas as needed[9][17].
Usually, oral lichen planus can be diagnosed after a careful examination by a specialist[6]. Classic cases may be diagnosed based on appearance alone. However, because the appearance and symptoms can be similar to other conditions, additional tests are often needed[6].
A biopsy is usually needed to be sure about the diagnosis[6][9][17]. A biopsy is a simple procedure done under local anesthetic, where a small tissue sample is taken from one or more spots in your mouth[6][9][17]. This sample is studied under a microscope to see if oral lichen planus is present[9][17]. The area usually heals within 7 to 10 days[6].
Other tests may include taking a sample of cells from your mouth using a cotton swab to look for a secondary fungal, bacterial, or viral infection[9][17]. Blood tests may be done to find conditions such as hepatitis C or other diseases that may be related to oral lichen planus[9][17].
Treatment options
There is no cure for oral lichen planus, but treatments can help manage symptoms and provide relief[2][9][17]. Treatment focuses on healing and easing pain or other symptoms that bother you[9][17].
If you have no pain or other discomfort and only have white, lacy signs of reticular oral lichen planus in your mouth, you may not need any treatment[9][17][6]. Usually, oral lichen planus only needs to be treated when there are painful symptoms[6].
For more severe symptoms, high-potency topical corticosteroids (steroid creams or ointments) are the main treatment for all forms of oral lichen planus[5][16][9][17]. These are applied directly to the affected areas in the mouth. In rare cases, corticosteroids may be given as injections for a specific lesion or as tablets for widespread disease[5][6].
If oral lichen planus does not respond to topical corticosteroids, other treatments may be used. Topical tacrolimus, a medication that affects the immune system, appears to be effective, especially for erosive oral lichen planus[5][16]. This is considered a second-line treatment[13].
For severe cases that do not respond to other treatments, doctors may consider additional medications such as cyclosporine, hydroxychloroquine, azathioprine, mycophenolate mofetil, or dapsone[5][16]. Systemic corticosteroids (taken by mouth) may be used for severe, widespread lichen planus[13].
Treatments such as numbing agents can give short-term relief in areas that are very painful[9][17]. Some topical treatments may increase the risk of oral yeast infections, which can be treated with antifungal medications[16].
In addition to medications, your doctor may recommend eliminating local factors that make the condition worse. Any sharp teeth, broken restorations, or prostheses that might cause physical trauma should be treated[16]. Teeth should be scaled to remove deposits and reduce sharp edges[16].
Your doctor may also advise avoiding things that trigger symptoms, such as spicy foods and substances you may be allergic to[9][17][6]. Some patients have found it helpful to use milder toothpastes instead of tartar control products[22].
Managing stress through techniques like relaxation training may help with treatment[16]. A few studies have reported improvement in patients who have regular professional teeth cleaning and are careful with their home care[22].
Complications and cancer risk
Oral lichen planus can lead to several complications. If eating becomes very painful, it can cause weight loss if you skip meals[2]. Damage to the tissue inside your mouth can increase your risk of yeast and bacterial infections[2].
One of the most important concerns is the potential connection between oral lichen planus and mouth cancer. Healthcare professionals should check erosive oral lichen planus regularly because it can lead to mouth cancer[1]. People who have oral lichen planus need regular checkups, especially those with the erosive type, as it may raise the risk of getting mouth cancer in the affected areas[1].
Research shows that about 1% to 4% of people with oral lichen planus develop oral cancer[2][6]. The chance is greater if you have erosive oral lichen planus, the more severe form[2]. Around 1 to 3 percent of patients who have had lichen planus for a long time may develop mouth cancer[6]. The exact connection between oral lichen planus and cancer is not certain, and only a very few patients ever develop cancer[6].
If you have had a biopsy and a pathologist has confirmed that the lesion is lichen planus, you can be sure that you do not have cancer in that site at that time[22]. However, it is important to try to control the disease, and additional biopsies may be necessary occasionally to check for any potential tissue changes[22].
Outlook and living with the condition
Oral lichen planus is a lifelong condition[9][17]. The duration and severity of the disease is not predictable[22]. Some patients have lichen planus for many years, while others find the disease disappears after a few months and may or may not return[22].
Mild forms may go away on their own but can flare up later[9][17]. Oral lichen planus may resolve spontaneously within one to two years, although recurrences are common[13]. However, lichen planus affecting mucous membranes may be more persistent and resistant to treatment[13].
Usually, oral lichen planus never goes away completely. Patients typically continue to have white patches on the lining of the mouth[6]. Treatment can lessen pain, although it is not usually possible to predict when the condition will become painful[6].
While reticular oral lichen planus is relatively easy to control, erosive oral lichen planus is extremely painful and can be difficult to treat, limiting quality of life[11].
To manage your condition, it is important to maintain good oral hygiene. Brush your teeth twice each day and floss once a day[12]. Have your teeth cleaned regularly[12]. Avoid foods that irritate your mouth[12]. Stop smoking, stop using smokeless tobacco, and avoid alcohol[12].
To reduce the risk of serious disease of the mouth lining, it is important not to smoke, not to drink large amounts of alcohol, and to eat plenty of fresh fruits and vegetables[6]. You should have your teeth and gums checked regularly by a dentist so that any changes in the lining of your mouth can be easily spotted[6].
Many patients find it helpful to keep a diary or log of factors they feel may trigger outbreaks, such as certain spicy or citrus foods, flavoring agents like peppermint or cinnamon, or stressful events[22].
