December 2020

The International Oral Lichen Planus Support Group: December 2020, Newsletter

Tips and Management Pearls for Those Living with Lichen Planus.

Thank you all for the kind comments that we have received during this past year! We have tried to offer educational and emotional support to those who deal with any chronic disease states and specifically oral lichen planus. 2020 has been a most difficult year for all of us and we look forward to 2021 with the possibility of a vaccine. Hopefully, it will be a more normal type of world next year.

Some changes have occurred during this year and because of the virus, limited patient treatment, and more virtual meetings instead of our usual face-to-face meetings. As a result,  we were unable to offer any webcasts this year. However, we asked some of our dental supporters, past guests and colleagues to offer some tips/advice on oral lichen planus that we have included in our newsletter. The newsletter will also be posted on our site.

Dr. Jacqueline M. Plemons has become the director of the stomatology clinic at the dental school. Dr. Celeste Abraham is also a faculty within the clinic and continues to offer her expertise as well. As you know, the stomatology center has one of the largest concentrations of patients who have been diagnosed with lichen planus. We are all part of the Department of Periodontics with our department chair, Dr. Thomas Diekwisch. We do plan to have some webcasts during 2021. 

Dr. Terry Rees will still be affiliated with the IOLPSG and offer his expertise to our group.  We are always available to assist you in finding treatment and also happy to answer any of your questions. Please do not hesitate to contact us at any time.

The International Oral Lichen Planus Support Group is part of “Outreach” and we are a non-profit organization. If you consider any donations in the near future, please think of the IOLPSG. There is a link leading to donations on our front web page. The entire donation assists us in providing the webcasts, newsletters and continuation of our “outreach” application. The IOLPSG is affiliated with NORD, the AAOM, the NIDCR (Patient Advocacy Council) and the AADR.

Please enjoy the newsletter with some specific tips for you.  We wish you the best of 2021 and enjoyment with your family and friends over the holidays. 

Dr. Nancy W. Burkhart
nancy.burkhart@tamu.edu

Resilience: A connection with oral lichen planus?

We have known for some time that optimistic people tend to have certain qualities that may assist in fighting disease states. The person may also be able to recover from an adversity much faster than those who maintain a pessimistic state. Another quality that is helpful is that of resilience. So, what does it mean to be resilient? One definition is the capacity to recover quickly from difficulties or the ability to spring back into shape. This is very important to our health and well-being.

“In physics, resilience is the ability of an elastic material (such as rubber or animal tissue) to absorb energy (such as from a blow) and release that energy as it springs back to its original shape. The recovery that occurs in this phenomenon can be viewed as analogous to a person's ability to bounce back after a jarring setback. Author P. G. Wodehouse took note of this when he wrote: "There is in certain men … a quality of resilience, a sturdy refusal to acknowledge defeat, which aids them as effectively in affairs of the heart as in encounters of a sterner and more practical kind." The word resilience derives from the present participle of the Latin verb resilire, meaning "to jump back" or "to recoil." The base of resilire is salire, a verb meaning "to leap" that also pops up in the etymologies of such sprightly words as sally and somersault. ¹ 

Hart, et al. 2014, reviewed the characteristics of resilience in nurses and those who demonstrated greater resilience. Examples of intrapersonal characteristics include hope, self‐efficacy, and coping. Cognitive reframing, toughening up, grounding connections, work‐life balance and reconciliation are resilience building strategies.²

Along with the above mentioned in resilience building, consider those listed below as tips for increasing your resilience in dealing with a chronic disease.

• Try to find the humor in a situation. As Einstein says in a quote: "Live life to the fullest. You have to color outside the lines once in a while if you want to make your life a masterpiece. Laugh some every day. Keep growing, keep dreaming, keep following your heart. The important thing is not to stop questioning. ~ Albert Einstein
• Expect change. (Especially with a lesion like LP that waxes and wanes. Some days will be better than others).
• Find creative ways to improvise and figure out how to balance your work and life with this condition in mind.
• Practice Gratitude. Try to find at least two events, people, or thoughts that you feel grateful for each day. Write them down
• Seek a support group. You’re not alone-many live with this condition.
• Take regular breaks from your work (helps you focus less on your pain- which in turn will help you with chronic pain).
• Try to surround yourself with people who make you happy, feel good about yourself and make you laugh. This is not always possible but try to connect with these people. These people will become your support system.
• Develop coping skills. We have known about the importance of coping skills for many years and proactive planning assists in fully developing these skills. Coping skills involve an element of “self-efficacy” and knowing that you have the power to control your environment and to make the best of a given situation. Coping skills can be developed.
• Accept your limitations. Do not obsess on what you can’t do and focus on what you’re able to do. Do your best to manage your lichen planus and do not create unnecessary stress if you forget to apply your steroid.
• Keep a journal and look for “patterns” that help you keep or divert oral lesions/skin lesions in their least problematic state. It is known that journaling also assists in good social/psychological health as well. You may be able to identify certain “triggers” that appear to add to outbreaks of lichen planus.
• Patients with oral lichen planus, we have found, are very curious, inquisitive individuals who research their disorder and are usually searching for answers. This is a good thing! Being involved, informed and asking good questions will assist you in developing ongoing resilience.
• Find activities, even exercise, that you enjoy and look forward to daily. Walking has so many health benefits and it clears the mind. The world has been very chaotic lately and we need to be able to detach from the constant state of confusion and disorder. Try Tai Chi and Yoga! Meditation, a healthy diet, as well as getting enough rest. Sleep deprivation can lead to reduced immune function and you may not be able to cope with stress as you would like to.
• Finally, take time for yourself. Sometimes we become so on autopilot that we only focus on what needs to be completed daily and we forget that we need to focus on what we, as a person, need in our life. What makes you happy? Who makes you happy? What do you want to do with the rest of your life? Do you need to change your routine? What is your purpose in life? What makes you fulfilled? It is never too late to ponder these questions and make changes. Most people find that as life evolves, so do our dreams.^3,4
• Once you start on these tips, keep practicing these resilience skills. They will make you stronger internally and help fight the condition and keep the lesions at bay.

Dr. Nancy W. Burkhart, Adjunct Professor
Dr. Celeste Abraham, Clinical Associate Professor
Department of Periodontics
College of Dentistry, Texas A&M University
3302 Gaston Ave.
Dallas Texas, 75246

Tips and Management Pearls for Those Living with Lichen Planus.

Dr. Ross Kerr
Clinical Professor
Department of Oral and Maxillofacial Pathology, Radiology and Medicine
New York University College of Dentistry
ark3@nyu.edu

1. Know your disease pattern. This can take months to work out. Recognize the early signs of a flare, so you can be treated early and effectively. Understand how to optimize the use of medications you have been prescribed by your lichen planus doctor, so that you don’t overuse them. No medication, even topical medications, is 100% safe.
2. If your symptoms don’t respond to medications, call your lichen planus doctor.
3. Make sure you periodically see your lichen planus doctor, even if you feel no symptoms. A very small proportion of patients are at higher risk for developing oral cancer.
4. Always tell your primary care physician which medications you are taking for your lichen planus.
5. Identify and avoid foods and beverages that irritate your mouth. Find a toothpaste that doesn’t sting, this may require some trial and error.
6. Excellent oral hygiene that is gentle to the gums is important. Use an ultra-soft bristled toothbrush and ask your dentist or dental hygienist to demonstrate proper technique.
7. Get regular dental cleanings and don’t be shy to ask for topical or local anesthesia if it’s uncomfortable.
8. Stay hydrated to avoid dry mouth, because a lack of lubrication can lead to a worsening of symptoms. Some people with dry mouth and lichen planus are prone to developing medication-related fungal infections (candida) and may be candidates for antifungal medications to prevent this from happening.

Tips and Pearls for Living with Oral Lichen Planus

James J. Sciubba DMD, PhD

Allow performance of a simple biopsy of the oral lesion to confirm the working clinical diagnosis of Lichen Planus provided by your doctor or specialist.

Learn and appreciate the nature of Lichen Planus from responsible sources such as any office handouts or brochures provided by your doctor, rather than what you may read on the Internet.

Appreciate that Lichen Planus can also affect the skin, scalp, genital area, nails and even the esophagus.

Have your provider evaluate your current medications, including over the counter medications to determine the possibility of them producing a Lichen Planus type of mouth soreness.

Know the small but real risk of oral Lichen Planus evolving into oral cancer, thus the need for routine  and regular follow-up visits with your dental provider or family doctor.

Stop smoking and use of tobacco products, as they can elevate the risk of cancer development.

Maintain proper use of prescribed medications for the Lichen Planus. When improvement is noted, do not discontinue treatment on your own without evaluation and input from your treating doctor. Premature discontinuation of successful treatment usually results in return of symptoms.

On occasion, treatment-related side effects including oral yeast infections (thrush) can develop which must be evaluated by your dental provider, confirmed, and treated.

When Lichen Planus affects the gum tissues, periodic oral hygiene treatments by your dental hygienist are especially important as the presence of bacterial biofilm and dental plaque increases the inflammatory reaction associated with lichen planus.

Avoid consumption of spicy foods as they can trigger lichen planus flare ups.

Find a toothpaste that can be used comfortably. Begin with a children’s formula product or lesser known brands which your dental provider can advise you about that may be more gentle than popular adult brands. Do not stop brushing your teeth if there is gum discomfort.

Other conditions may look similar to oral Lichen Planus and could be serious and must be confirmed by your dentist or an oral disease specialist.

Above all, oral Lichen Planus is manageable with proper use of prescription drugs but is often a chronic problem which must be followed by your oral health care provider or specialist on a routine basis.

Lichen Planus and the Importance of Clinicopathologic Correlation

Paras Bharatkumar Patel, DDS 

• Thinking back to when you were informed of your diagnosis of lichen planus, it is likely that many things went through your head and you had many questions about what was to come. Very few people question the diagnosis itself, due to the fact that a biopsy was performed and read by a pathologist. However, it is not always as straightforward as you think.
• Pathologists are trained to understand the complexities of their practice and the limitations that they can encounter in reviewing histologic biopsy specimens in the absence of appropriate clinical correlation. Lichen planus is one of these complex diseases. The histology of oral lichen planus is characterized by a pattern inflammation that is superficial in nature and is often described as “band like”, with evidence of damage to the basal epithelial cells and limited crossover of the inflammatory cells into the epithelium. The infiltrate should be predominantly lymphocytic, meaning that the inflammation consists of mainly one type of inflammatory cell, a lymphocyte. Now, while these features sound specific, we have come to realize that other pathologic processes can produce a similar pattern of inflammation, which is termed lichenoid, literally meaning “lichen-like”. The following diseases can produce a lichenoid pattern of inflammation and should be considered by a pathologist when making the diagnosis of lichen planus.
• Autoimmune diseases
  • Chronic ulcerative stomatitis
  • Lupus erythematosus
  • Lichen planus pemphigoides

• Allergy
  • Contact mucositis
    • Dental materials
    • Dental metals
    • Topical substances and products
      • Cinnamon containing
        • Gums, Mints and Toothpastes
      • Drug reactions 

• Other Inflammatory
  • Graft versus host disease
  • Oral epithelial dysplasia
  • Proliferative verrucous leukoplakia
    • Premalignant disease process

As you can see the list includes a spectrum of diseases, ranging from those that are autoimmune in nature to an inflammatory response to premalignancy. The American Academy of Oral and Maxillofacial Pathology has long recognized this dilemma and took on the monumental effort of producing a position paper in 2016, which provides guidance to clinicians and pathologists alike that can aid in making the diagnosis of lichen planus¹. The paper proposes a checklist of clinical findings, which can provide the pathologist with the necessary information to make an accurate diagnosis. The importance of correlating your clinical disease with the histologic findings of your biopsy cannot be emphasized enough and are of the utmost importance, as your diagnosis can drastically change the way you will be clinically managed.   

• Cheng YS, Gould A, Kurago Z, Fantasia J, Muller S. Diagnosis of oral lichen planus: a position paper of the American Academy of Oral and maxillofacial pathology. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;122:332–4. https://doi.org/10.1016/j.oooo.2016.05.004.

Paras Bharatkumar Patel, DDS 
Assistant Professor Oral and Maxillofacial Pathology
Texas A&M University College of Dentistry
ppatel10@tamu.edu