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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists

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Year : 2022  |  Volume : 26  |  Issue : 3  |  Page : 309-310

Is oral lichen planus a potential malignant disorder?: A critical appraisal

Department of Oral Pathology and Microbiology, Nair Hospital Dental College, Mumbai, Maharashtra, India

Date of Submission10-Feb-2022
Date of Acceptance26-Jul-2022
Date of Web Publication17-Oct-2022

Correspondence Address:
Rajiv S Desai
Department of Oral Pathology and Microbiology, Nair Hospital Dental College, Mumbai - 400 008, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jomfp.jomfp_72_22

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How to cite this article:
Desai RS, Shirsat PM, Bansal SP, Fukate CA. Is oral lichen planus a potential malignant disorder?: A critical appraisal. J Oral Maxillofac Pathol 2022;26:309-10

How to cite this URL:
Desai RS, Shirsat PM, Bansal SP, Fukate CA. Is oral lichen planus a potential malignant disorder?: A critical appraisal. J Oral Maxillofac Pathol [serial online] 2022 [cited 2022 Dec 3];26:309-10. Available from: https://www.jomfp.in/text.asp?2022/26/3/309/358751

Dear Editor,

“The difficulty lies not in new ideas, but in escaping old ones”

- John Keynes

Oral lichen planus (OLP) is a chronic inflammatory oral mucosal disease of unknown etiology.[1] One of the most controversial aspects of OLP is its potentially malignant nature.[2] Numerous studies on OLP have reported varying malignant transformation rates of OLP from very high to almost negligible giving rise to conflicting findings.[2],[3] Recent studies have reported malignant transformation of OLP ranging between 0.44 and 2.28%.[4],[5],[6] In this letter, we would like to put forth our views regarding the malignant transformation of OLP and its inclusion in oral potential malignant disorders (OPMDs).

GLOBOCAN in 2018 reported the estimated average age-standardized rate of oral cancers worldwide as 4 per 100 000 (range between 0.4 and 20.4 per 100 000). So, based on the estimated worldwide prevalence of OLP, 5–20 OLP patients per 100 000 of the general population will develop oral cancer within 5 years. On comparing the global cancer prevalence rate with OLP, it shows that most oral squamous cell carcinoma (OSCC) cases have apparently developed from OLP, which seems questionable.[7]

In most of the systematic reviews and meta-analyses, after application of strict criteria to the clinical appearance of the affected site and transformed location, histopathological presentation, habits, comorbid conditions, age, and gender, it is evidenced that the malignant transformation rate of OLP is exaggerated due to insufficient diagnostic criteria, inaccurate follow-up and/or average quality of investigation.[8]

The diagnosis of OLP requires the presence of both clinical and histopathological features.[9] Unfortunately, many times diagnosis is solely based on clinical judgement without biopsy. It is quite possible that OSCC may clinically present as OLP and the clinician may institute topical/systemic steroid therapy without histopathological examination. Subsequent biopsy of those unresponsive lesions turns out to be OSCC, resulting in an inadvertent increase in the malignant transformation rate of OLP in studies.

Topical/systemic steroid treatment results in decreased local immunity, providing a potential cause for conversion to cancer that cannot be ignored.[3],[10],[11] Systemic condition like diabetes causes disturbances in cellular and humoral immune functions, reducing the immunity in OLP-affected patient which may lead to malignant transformation.[12] Association of tobacco and/or alcohol may also play a role in mucosal alteration at the microscopic level, increasing the likelihood of malignant transformation.[3]

Though the investigators have supported the potentially malignant nature of OLP, a small but significant number of OSCC occur in non-smokers and non-drinkers with a range of 3–24%. Even with this finding the overall malignant transformation rate of OLP remains lower compared to the occurrence of OSCC in non-smokers and non-drinkers (OLP—2.28% vs OSCC in non-smokers and non-drinkers 3–24%).[6],[13],[14],[15] Based on the above observations, it is high time for us to rethink whether OLP should still be considered as an OPMD?

Once diagnosed with OLP, informing the patient about possible malignant transformation induces cancerophobia, causing stress and disturbing their emotional status further aggravating the signs and symptoms of OLP.[16] Until then, based on the literature reporting the potentially malignant nature of OLP, we suggest the need for psychological counseling for all OLP patients. This will definitely serve to alleviate their anxiety, thus making them more receptive to treatment.

We hope our letter will generate a healthy discussion among the readers to arrive at a common consensus by putting forth their views on this topic.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K. Current controversies in oral lichen planus: Report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:164-78.  Back to cited text no. 1
Warnakulasuriya S, Kujan O, Aguirre-Urizar JM, Bagan JV, González-Moles MÁ, Kerr AR, et al. Oral potentially malignant disorders: A consensus report from an international seminar on nomenclature and classification, convened by the WHO Collaborating Centre for Oral Cancer. Oral Dis 2021;27:1862-80.  Back to cited text no. 2
Gonzalez-Moles MA, Scully C, Gil-Montoya JA. Oral lichen planus: Controversies surrounding malignant transformation. Oral Dis 2008;14:229-43.  Back to cited text no. 3
Idrees M, Kujan O, Shearston K, Farah CS. Oral lichen planus has a very low malignant transformation rate: A systematic review and meta-analysis using strict diagnostic and inclusion criteria. J Oral Pathol Med 2021;50:287-98.  Back to cited text no. 4
González-Moles MÁ, Ramos-García P, Warnakulasuriya S. An appraisal of highest quality studies reporting malignant transformation of oral lichen planus based on a systematic review. Oral Dis 2021;27:1908-18.  Back to cited text no. 5
Ramos-García P, González-Moles MÁ, Warnakulasuriya S. Oral cancer development in lichen planus and related conditions-3.0 evidence level: A systematic review of systematic reviews. Oral Dis 2021;27:1919-35.  Back to cited text no. 6
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.  Back to cited text no. 7
González-Moles MÁ, Ruiz-Ávila I, González-Ruiz L, Ayén Á, Gil-Montoya JA, Ramos-García P. Malignant transformation risk of oral lichen planus: A systematic review and comprehensive meta-analysis. Oral Oncol 2019;96:121-30.  Back to cited text no. 8
González-Moles MÁ, Warnakulasuriya S, González-Ruiz I, González-Ruiz L, Ayén Á, Lenouvel D, et al. Worldwide prevalence of oral lichen planus: A systematic review and meta-analysis. Oral Dis 2021;27:813-28.  Back to cited text no. 9
Giuliani M, Troiano G, Cordaro M, Corsalini M, Gioco G, Lo Muzio L, et al. Rate of malignant transformation of oral lichen planus: A systematic review. Oral Dis 2019;25:693-709.  Back to cited text no. 10
Gonzalez-Moles MA, Bravo M, Gonzalez-Ruiz L, Ramos P, Gil-Montoya JA. Outcomes of oral lichen planus and oral lichenoid lesions treated with topical corticosteroid. Oral Dis 2018;24:573-9.  Back to cited text no. 11
Geerlings SE, Hoepelman AI. Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunol Med Microbiol 1999;26:259-65.  Back to cited text no. 12
Wiseman SM, Swede H, Stoler DL, Anderson GR, Rigual NR, Hicks WL Jr, et al. Squamous cell carcinoma of the head and neck in nonsmokers and nondrinkers: An analysis of clinicopathologic characteristics and treatment outcomes. Ann Surg Oncol 2003;10:551-7.  Back to cited text no. 13
Koo K, Barrowman R, McCullough M, Iseli T, Wiesenfeld D. Non-smoking non-drinking elderly females: A clinically distinct subgroup of oral squamous cell carcinoma patients. Int J Oral Maxillofac Surg 2013;42:929-33.  Back to cited text no. 14
Ranganathan K, Rooban T, Rao UM. Oral squamous cell carcinoma in patients with and without predisposing habits in glossal and extra-glossal site: An institutional experience in South India. Indian J Cancer 2015;52:625-7.  Back to cited text no. 15
[PUBMED]  [Full text]  
Adamo D, Calabria E, Coppola N, Lo Muzio L, Giuliani M, Bizzoca ME, et al. SIPMO (Italian Society of Oral Pathology, Medicine). Psychological profile and unexpected pain in oral lichen planus: A case-control multicenter SIPMO studya. Oral Dis 2021. doi: 10.1111/odi.13787.  Back to cited text no. 16


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