]
search for




 

Management of Gingival Oral Lichen Planus with Free Gingival Graft: 10-Year Follow-Up Case Report
J Oral Med Pain 2022;47:161-166
Published online September 30, 2022;  https://doi.org/10.14476/jomp.2022.47.3.161
© 2022 Korean Academy of Orofacial Pain and Oral Medicine

HeeYung Chang1 │ YoungJoo Shim2,3

1Dental Spa Clinic, Daejeon, Korea
2Department of Oral Medicine, School of Dentistry, Wonkwang University Daejeon Dental Hospital, Daejeon, Korea
3Wonkwang Research Institute, School of Dentistry, Wonkwang University, Iksan, Korea
Correspondence to: YoungJoo Shim
Department of Oral Medicine, School of Dentistry, Wonkwang University Daejeon Dental Hospital, 77 Dunsan-ro, Seo-gu, Daejeon 35233, Korea
Tel: +82-42-366-1128
Fax: +82-42-366-1115
E-mail: gc21@wku.ac.kr
https://orcid.org/0000-0001-7514-5974

This study was supported by Wonkwang University in 2021.
Received August 25, 2022; Revised September 6, 2022; Accepted September 6, 2022.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Oral lichen planus (OLP) is a chronic oral mucosal disease affecting the buccal cheek, tongue, palate, lip, and gingival mucosa. Lesions in the gingiva make it difficult to control dental plaque due to pain. As a result, the disease is often accompanied by gingivitis or periodontitis. If OLP and dental plaque are not properly managed, the patient’s periodontal condition will worsen. Thus, clinicians treating OLP should emphasize periodic visits and dental plaque control. Here, we report the management of a patient who struggled with OLP for 20 years and discuss the importance of periodic regular observations and active periodontal management.
Keywords : Dental plaque; Free gingival graft; Gingival recession; Oral lichen planus
INTRODUCTION

Oral lichen planus (OLP) is a chronic immunologically mediated mucocutaneous disease with an unknown etiology [1]. Gingiva is one of the most frequently affected regions in OLP. The prevalence of gingival involvement of OLP ranges from 38.4% to 48% [2,3]. Atrophic OLP exclusively affecting the attached gingiva is presented as desquamative gingivitis (DG). DG is characterized by atrophy and erosion of the attached gingiva. Patients with painful gingival OLP have difficulties controlling dental plaque [4]. Gingival OLP is usually misdiagnosed as plaque-induced periodontal disease and is combined with plaque-induced gingivitis or periodontal diseases. If the dental plaques and gingival OLP are not well controlled, the periodontal condition of the patient becomes worse. Thus, the clinicians treating OLP should emphasize regular visits and provide additional periodontal care.

Here, we report a case in which gingival OLP was managed with a free gingival graft (FGG). The improvement in the quality of the periodontal tissue allowed for a better prognosis of gingival OLP. The protocol of this study was approved by the Institutional Review Board of the Daejeon Dental Hospital of Wonkwang University (IRB no. W2208/002-001) and exemption of written informed consent was obtained.

CASE REPORT

A 44-year-old woman visited the Department of Oral Medicine at Wonkwang University Daejeon Dental Hospital with a chief complaint of pain and redness in the upper and lower gingiva. She was diagnosed with OLP about 10 years ago and had been experiencing pain since then. She had been treated with topical corticosteroids for some years; however, the regimen was not effective. Her symptoms had been waxing and waning over the years. The patient reported no habits of smoking or drinking alcohol. There was no specific medical history that could explain this. She had a history of side effects of gastrointestinal disturbance, insomnia, moon face, and face flushing on systemic prednisolone.

During the intraoral clinical examination, erosive and atrophic areas on the bilateral buccal mucosa were observed. The periphery of the atrophic regions was bordered by fine, white, and radiating striae. Atrophic areas were also detected in the upper and lower gingiva. There was no Nikolsky sign in the gingiva. The gingiva was swollen with dental plaque accumulation and bled easily (Fig. 1). The simplified Debris Index (DI-S) was 2.1 [5], the simplified Calculus Index (CI-S) was 0 [5], and the Oral Disease Severity Score (ODSS) was 48 [6]. The attached gingiva in the buccal side of the posterior teeth was almost lost and the patient had no cutaneous lesions. She underwent incisional biopsy during her first visit and routine hematologic investigations, including anti–hepatitis C virus and antinuclear antibodies.


The result of incisional biopsy was OLP, and the results of routine hematologic investigations were within normal limits. Patient was educated and made aware about her condition. Symptomatic treatment was given first preference. As the lesions failed to respond to topical corticosteroid, tapering oral prednisolone Solondo (Yuhan, Seoul, Korea; from 15 mg to 2.5 mg) course was administered for 4 weeks. Minocycline solution (minocycline 200 mg in 100 mL water) was also administered topically. Symptoms and signs improved after 4 weeks. The DI-S was 1.5, and the ODSS was 35. There were no side effects of systemic prednisolone.

The patient was referred to a periodontist to manage her periodontal condition. She showed a thin gingival biotype, and the buccal attached gingiva was almost lost, but the probing depth itself was not high (about 3-4 mm). During each visit to the periodontist, soft and gentle dressing with 0.12% chlorhexidine solution was performed. Fig. 2 shows the patient’s clinical features after primary periodontal treatment.


The periodontal condition with loss of attached gingiva made it difficult to control dental plaque. The higher the gingival recession, the higher the DI-S and the severity of OLP. To improve the quality of the tissue and prevent further gingival recession, FGGs were performed on the lower anterior incisors, upper left premolars, lower right premolars, first molar, and lower left premolars. Standard surgical procedures were as follows: (1) local anesthetics were administered to the gingival and palatal mucosa; (2) the gingival recipient site was prepared, where an incision was made on the mucogingival junction, the flap was partially dissected, and the epithelium and connective tissues were positioned apically; (3) the healthy gingival graft was harvested from the ipsilateral hard palate; (4) the graft was trimmed and adapted to the recipient site; (5) the graft was sutured in position at the recipient site; and (6) the donor site was covered with CollaTape (Zimmer Dental, Mississauga, ON, Canada) for healing. The sutures were removed after 2 weeks. The patient showed normal tissue healing. Along with FGG, the exposed root surfaces were restored with composite resin to make the surface smooth. Fig. 3 shows the FGG in the lower anterior teeth.


During regular follow-up observations, it was observed that the marginal gingiva were arranged in harmony, and the attached gingiva were formed at width of about 2 to 5 mm. Teeth with poor prognosis were extracted and an implant on the right upper first molar was inserted without any special problem. Improvement in the tissue environment made it easier to control dental plaque (Fig. 4). The OLP was well controlled without any medication. Fig. 5 shows the state upon the final visit. The DI-S was 0.3, and the ODSS was 13.

DISCUSSION

When the gingiva show erythema, desquamation, erosion, and blister, the clinician should differentiate plaque-induced gingival disease from non–plaque-induced gingival disease, such as lichen planus, mucous membranous pemphigoid, pemphigus vulgaris, lupus erythematosus, and so forth [7,8]. Because of pain in the gingiva, most patients have difficulty controlling dental plaque. Although OLP is not a direct cause of periodontal diseases, patients with gingival OLP show more gingival inflammation than patients who do not have the disease [9,10]. The patient in this study suffered for a long time without medical aid and hence, suffered from alveolar bone loss and severe gingival recession on the buccal side. The deteriorated periodontal condition made the severity of OLP worse. The patient was in a vicious cycle. Previous studies reported that plaques might prevent gingival OLP lesions from healing, which changes the characteristics of the lesions into more aggressive forms, such as erosive lesions [11], whereas plaque control improves the painful symptoms of gingival OLP [12-14]. To break the vicious cycle, controlling severe OLP symptoms and signs was prioritized. Hence, the ODSS and DI-S decreased after the administration of systemic corticosteroids. Subsequently, the management of the periodontal condition was carried out. Even in the primary periodontal treatment, it was difficult to control dental plaque in the patient due to the loss of the attached gingiva and irregularity of the marginal gingiva. Therefore, it was necessary to correct the patient’s periodontal environment for easy self-control of dental plaque which was done by the implementation of FGG. FGG is a periodontal plastic surgery used to improve periodontal tissue quality, root coverage, and keratinized tissue augmentation [15]. After FGG, the patient’s ability to perform oral hygiene was improved. The symptoms and signs of OLP also improved.

The implementation of FGG in the gingival OLP is not commonly performed, and only a few cases have been reported [16-18]. All of these cases were refractory to corticosteroid treatment, including occlusive steroid therapy with stent and topical steroid treatment without gingival recession. The connective tissue and epithelium were removed completely, and a new normal tissue was transplanted. From the theoretical background, when the recipient site is prepared, the periosteum should be free of submucosal tissue. New basal epithelial cells without any antigenic properties grows in the graft. As a result, the graft remains free of lesions and appears clinically healthy [16]. The results of reported cases were somewhat satisfactory. Among 22 grafts in 14 patients, three (13.6%) grafts were changed to generally OLP-like gingiva and six (27.3%) grafts were change to mild OLP-like gingiva, and 13 (59.1%) grafts were unchanged. Although, the main purpose of FGG in this study was to augment the keratinized tissue and prevent more gingival recession, we expected the grafted gingiva to remain clinically normal. Since the affected OLP lesions remained in the recipient site, the grafted gingiva was gradually changed to clinical OLP-like gingiva.

Although many disease scoring systems for OLP have been reported, there is no standard system for uniform use [19]. The measure used in this study is the ODSS [6]. This scoring system was developed as a standardized outcome measure of OLP treatment. The oral cavity is divided into 17 sites, and criterion-based numerical scores for each site are given. The scale consists of site score (extent of the lesion), activity score (severity of the lesion at each site), and pain score. The possible maximum score for site score is 24, activity score is 72, and pain score is 10. The maximum combined score is 106. The ODSS is easy to use, reproducible, and sensitive for detecting clinical responses to therapy. When we evaluate the disease severity of OLP or the responses to therapy, it is better to use outcome measures such as the ODSS, which can be applied easily in clinical practice, along with quality-of-life measures.

The simplified Oral Hygiene Index (OHI-S) evaluates oral hygiene [5]. The OHI-S is simple and easy to score. The OHI-S consists of two parts, including the Debris Index (DI) and Calculus Index (CI), which measure the amount of plaque and calculus present on the surface of six representative teeth in each region of the mouth (Table 1). Debris scores are summed and divided by the number of examined teeth. The average score is the DI-S. The same process is used to calculate the CI-S. In this case, the patient’s DI-S was 2.1 during the first visit, which decreased to 1.5 after one week of systemic corticosteroid therapy. In the maintenance phase after FGG, the DI-S was 0.3 to 1. Additionally, OHI-S, a measure of oral hygiene, should be recorded at all regular visits to evaluate the patient’s ability to manage oral hygiene. Emphasis on controlling dental plaque can improve the prognosis of OLP.


The patient has exhibited side effects of systemic corticosteroids administered in the past, including gastrointestinal disturbance, insomnia, moon face, and face flushing. Thus, we prescribed corticosteroids with tapering. When severe erosions occurred, the symptoms and signs were controlled by systemic corticosteroids. The patient showed no particular side effects due to controlled administration. Tapered prednisolone (from 10 mg to 5 mg) was also administered two weeks before surgery to prevent erosion at the recipient site, and tapered prednisolone was administered for one week after surgery. As a result, the patient showed a normal wound-healing course.

The patient’s efforts and compliance are important in disease management. The patient was not properly managed in the first 10 years after diagnosis, resulting in severe gingival recession and painful symptoms. As a result of regular visits and efforts over the next 10 years, her OLP is now well controlled without special medication. Because OLP is an intractable disease, constant observation and management should be emphasized through patient education.

In this article, we reported the management of gingival involvement of OLP for 10 years. The patient’s great efforts and compliance resulted in a good prognosis. Poor control of dental plaque can affect the prognosis of OLP. Therefore, it is very important to alleviate the symptoms of OLP using proper medications and to modify the periodontal environment to make dental plaque management easy.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

Figures
Fig. 1. Clinical features of the case at the first visit. The atrophic lesions were found in all gingiva. The gingiva were swollen with easy bleeding and dental plaque accumulation generally. The buccal gingiva in the posterior teeth was almost lost. (A) Right upper and lower posterior gingiva. (B) Anterior gingiva. (C) Left upper and lower posterior gingiva.
Fig. 2. Clinical features after primary periodontal treatment (2 years after the first visit). Gingival recession and irregularity of the marginal gingiva were observed. (A) Right upper and lower posterior gingiva. (B) Anterior gingiva. (C) Left upper and lower posterior gingiva.
Fig. 3. Free gingival graft (FGG) in the lower anterior teeth. Augmentation of the gingiva was observed, but the graft gingiva was changed to clinically lichen planus–like gingiva after 1 month. (A) Recipient site before FGG. (B) Harvested graft from the hard palate was sutured in the recipient site. (C) Recipient site after 1 month.
Fig. 4. Clinical features 3 years after free gingival graft (5 years after the first visit). Gingival recession was improved, and augmentation of gingival tissues was observed. (A) Lower anterior gingiva. (B) Left upper gingiva. (C) Right lower gingiva. (D) Left lower gingiva.
Fig. 5. Clinical features at the last visit (10 year after the first visit). The atrophic OLP gingival lesions and dental plaque were well controlled, and the marginal gingiva were arranged in harmony.
Tables

Criteria of the simplified oral hygiene index score

Calculus score criteria Score Debris score criteria
No calculus present O No debris or stains present
Supragingival calculus covering not more than one-third of the exposed tooth surface being examined 1 Soft debris covering not more than one-third of the tooth surface or presence of extrinsic stains without other debris regardless of the area covered
Supragingival calculus covering more than one-third but not more than two-thirds of the exposed tooth surface, or the presence of individual flecks of subgingival calculus around the cervical portion of the tooth 2 Soft debris covering more than one-third but not more than two-thirds of the exposed tooth surface
Supragingival calculus covering more than two-thirds of the exposed tooth surface or a continuous heavy band of subgingival calculus around the cervical portion of the tooth 3 Soft debris covering more than two-thirds of the exposed tooth surface

Six representative teeth: four posterior and two anterior teeth. Facial surface of the right upper first molar, right upper incisor, left upper first molar, left lower incisor; lingual surface of the right lower first molar, left lower first molar.

References
  1. Sugerman PB, Savage NW, Walsh LJ, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002;13:350-365.
    Pubmed CrossRef
  2. Camacho-Alonso F, López-Jornet P, Bermejo-Fenoll A. Gingival involvement of oral lichen planus. J Periodontol 2007;78:640-644.
    Pubmed CrossRef
  3. Mignogna MD, Lo Russo L, Fedele S. Gingival involvement of oral lichen planus in a series of 700 patients. J Clin Periodontol 2005;32:1029-1033.
    Pubmed CrossRef
  4. Azizi A, Rezaee M. Comparison of periodontal status in gingival oral lichen planus patients and healthy subjects. Dermatol Res Pract 2012;2012:561232.
    Pubmed KoreaMed CrossRef
  5. Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.
    Pubmed CrossRef
  6. Escudier M, Ahmed N, Shirlaw P, et al. A scoring system for mucosal disease severity with special reference to oral lichen planus. Br J Dermatol 2007;157:765-770.
    Pubmed CrossRef
  7. Lo Russo L, Fedele S, Guiglia R, et al. Diagnostic pathways and clinical significance of desquamative gingivitis. J Periodontol 2008;79:4-24.
    Pubmed CrossRef
  8. Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-implant diseases and conditions- introduction and key changes from the 1999 classification. J Periodontol 2018;89 Suppl 1:S1-S8.
    Pubmed CrossRef
  9. Ramón-Fluixá C, Bagán-Sebastián J, Milián-Masanet M, Scully C. Periodontal status in patients with oral lichen planus: a study of 90 cases. Oral Dis 1999;5:303-306.
    Pubmed CrossRef
  10. Tricamo MB, Rees TD, Hallmon WW, Wright JM, Cueva MA, Plemons JM. Periodontal status in patients with gingival mucous membrane pemphigoid. J Periodontol 2006;77:398-405.
    Pubmed CrossRef
  11. Liu H, Chen H, Liao Y, et al. Comparative analyses of the subgingival microbiome in chronic periodontitis patients with and without gingival erosive oral lichen planus based on 16S rRNA gene sequencing. Biomed Res Int 2021;2021:9995225.
    Pubmed KoreaMed CrossRef
  12. Salgado DS, Jeremias F, Capela MV, Onofre MA, Massucato EM, Orrico SR. Plaque control improves the painful symptoms of oral lichen planus gingival lesions. A short-term study. J Oral Pathol Med 2013;42:728-732.
    Pubmed CrossRef
  13. Guiglia R, Di Liberto C, Pizzo G, et al. A combined treatment regimen for desquamative gingivitis in patients with oral lichen planus. J Oral Pathol Med 2007;36:110-116.
    Pubmed CrossRef
  14. López-Jornet P, Camacho-Alonso F. Application of a motivation-behavioral skills protocol in gingival lichen planus: a short-term study. J Periodontol 2010;81:1449-1454.
    Pubmed CrossRef
  15. Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontol 2000 2015;68:333-368.
    Pubmed CrossRef
  16. Tamizi M, Moayedi M. Treatment of gingival lichen planus with a free gingival graft: a case report. Quintessence Int 1992;23:249-251.
  17. Vatankhah M, Taghi Chitsazi M, Mehdipour M, Taghavi Zenouz A, Estakhri R. Treatment of desquamative gingivitis with free gingival graft: a case report. J Dent Res Dent Clin Dent Prospects 2010;4:33-36.
  18. Axéll T, Henriksen BM. Treatment of gingival lichen with free palatal grafts. J Oral Pathol Med 2007;36:105-109.
    Pubmed CrossRef
  19. Wang J, van der Waal I. Disease scoring systems for oral lichen planus; a critical appraisal. Med Oral Patol Oral Cir Bucal 2015;20:e199-e204.
    Pubmed KoreaMed CrossRef


Title_page_TemplateEngKor
Body_page_TemplateEngKor
September 2022, 47 (3)