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


 
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ORIGINAL ARTICLE  
Year : 2022  |  Volume : 26  |  Issue : 4  |  Page : 509-517
 

Prevalence of oral lichen planus in patients with hypothyroidism versus non-hypothyroidism – A case control study of 1000 cases


1 Department of Oral Medicine and Radiology Faculty of Dental Sciences, IMS BHU Varanasi, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, People's College of Dental Sciences and Research Centre, Bhopal Madhya Pradesh, India
3 Department of Oral Medicine and Radiology BBD Dental College, BBD University, Lucknow, Uttar Pradesh, India
4 Department of Oral and Maxillofacial Pathology, UCMS Teaching Hospital Bhairahawa, Nepal
5 Bhagwati Dental Care Clinic, Lucknow, Uttar Pradesh, India

Date of Submission29-Dec-2020
Date of Decision03-Aug-2022
Date of Acceptance18-Aug-2022
Date of Web Publication22-Dec-2022

Correspondence Address:
Nisha Maddheshiya
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, IMS BHU, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomfp.jomfp_517_20

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   Abstract 


Background: The oral cavity is a unique environment where systemic maladies may be amplified by the oral mucosa. Oral diseases are usually local, but may also be the sign of systemic disease. Oral lesions are mostly one of the first indications of a systemic problem. Lichen planus (LP) is an inflammatory disease that involves the skin and mucous membrane. It is one of the most common oral diseases that manifest itself in the oral cavity. The exact cause of oral lichen planus (OLP) is unknown, but the immunologic system plays a leading role in the pathogenesis. It is well documented that OLP represents a cell-mediated immune response.
Materials and Methods: The study population was drawn from the patients attending the outpatient Department of General Medicine and Department of Oral Medicine and Radiology with a total of 1000 subjects, out of which 500 subjects were clinically diagnosed with hypothyroidism and 500 subjects were without the history of hypothyroidism. The data collected was compiled and analysed to obtain the result. A Chi-square test was used to compare the categorical variables and the analysis was carried out on SPSS 16.0 version.
Results: The study revealed an increased prevalence of OLP in hypothyroidism. Cases clearly had a predilection of 2.37 times more tendency to develop OLP as compared to the control.
Conclusion: To conclude, it seems that OLP was more prevalent in hypothyroid individuals, especially in females in the third and fourth decades of life.


Keywords: Cutaneous lichen planus, hypothyroidism, levothyroxine, oral lichen planus, stress


How to cite this article:
Maddheshiya N, Shivakumar G C, Misra N, Rastogi V, Kumar S. Prevalence of oral lichen planus in patients with hypothyroidism versus non-hypothyroidism – A case control study of 1000 cases. J Oral Maxillofac Pathol 2022;26:509-17

How to cite this URL:
Maddheshiya N, Shivakumar G C, Misra N, Rastogi V, Kumar S. Prevalence of oral lichen planus in patients with hypothyroidism versus non-hypothyroidism – A case control study of 1000 cases. J Oral Maxillofac Pathol [serial online] 2022 [cited 2023 Feb 3];26:509-17. Available from: https://www.jomfp.in/text.asp?2022/26/4/509/364825





   Introduction Top


The mouth is a mirror of health or disease, a watchman or early warning system. The oral cavity is considered as a window to the body because many systemic diseases present with oral manifestations.[1]

Oral lichen planus (OLP) is a chronic inflammatory disease, affecting nearly 1–2% of the adult population with the prevalence being generally higher in middle-aged women.[2] Oral lesions in OLP are chronic, potentially premalignant, hardly ever undergo spontaneous remission and are a frequent source of morbidity, but in the majority of instances, cutaneous lesions of lichen planus (LP) are self-limiting and cause itching. To date, the precise aetiology remains unknown[2] and it possibly represents a cell-mediated immunological response to an induced antigenic change in the skin or mucosa in predisposed patients.[3] Most therapies are symptomatic[2] and numerous drugs have been used with shifting results. The management of OLP is commonly empirical, with no adequate control groups or corrected study designs[3] even if the best treatment remains high-potency topical corticosteroids.[4],[5],[6],[7]

LP is the most common mucocutaneous disease affecting the oral mucosa.[8] OLP is a T-cell-mediated chronic inflammatory mucocutaneous disease of unknown aetiology, and OLP lesions contain few B cells or plasma cells with minimal deposits of immunoglobulin or complement. Activated CD8+ T lymphocytes are found mostly within the epithelium and adjacent to the damaged basal cell keratinocytes.[9],[10],[11],[12] CD8+ T cells may also trigger keratinocyte apoptosis in OLP.[13]

Etiopathogenesis of many diseases is discovered and managed at an early stage, still, some diseases are considered as idiopathic, hence diagnosis and treatment plan of such diseases always becomes controversial. Stress is one such predisposing factor in many diseases and also plays a major role as an aetiological factor in a few oral lesions such as OLP, aphthous ulcers, burning mouth syndrome and myofascial pain dysfunction syndrome. OLP being one of the most common oral lesions associated with stress.[14]

LP is significantly associated with dyslipidaemia and the association of LP has also been found to be more prominent in hypothyroidism, diabetes, hypertension, socioeconomic status and obesity, including age, sex and smoking.[15]

Hypothyroidism is believed to be a common health issue in India, as it is worldwide.[16] Hypothyroidism is a clinical endocrine disorder commonly encountered by the primary care physician. The most common aetiology of hypothyroidism in the United States is autoimmune thyroid disease. It results either from the deficiency of thyroid hormone or as a result of primary gland failure. It may also result from thyroid hormone impaired activity at the tissue level or insufficient thyroid gland stimulation by the hypothalamus or pituitary gland.[17]

According to the National Health and Nutrition Examination Survey, about one in 300 persons in the United States has hypothyroidism, with an approximate prevalence of 2% in adult women and 0.2% in adult men.

Deficiency of the hormone has a wide range of effects because thyroid hormone is required by all metabolically active cells.[18] Untreated hypothyroidism can lead to hypertension, dyslipidaemia, infertility, cognitive impairment and neuromuscular dysfunction.

Hence, this study was done to assess the prevalence of OLP in patients with a history of hypothyroidism versus non-hypothyroidism.


   Materials and Methods Top


This study was conducted between 20/5/2016 and 30/10/2017 in the Department of Oral Medicine and Radiology of Babu Banarasi Das College of Dental Sciences, Lucknow, and Department of General Medicine RML Hospital, Lucknow. The subject's rights have been protected by an appropriate Institutional Review Board of BBD College of Dental Sciences, Lucknow, Uttar Pradesh, India (IEC CODE/IRB NO: 19), and written informed consent was granted from all subjects. Ethical approval was obtained by the irc committee on 12/5/2016.

Study design: The present study is a descriptive, case-control study to assess the association of OLP in hypothyroidism patients versus non-hypothyroidism individuals. The study population was drawn from the patients attending the outpatient Department of General Medicine and Department of Oral Medicine and Radiology. A total of 1000 subjects were equally divided into cases (500 each) and controls (500 each) out of which 500 subjects were clinically diagnosed with hypothyroidism and 500 subjects were without a history of hypothyroidism. 2.8% of the cases were diagnosed with OLP while 1.2% of controls were assessed with OLP.

The diagnosis of OLP was made based on the criteria by Shirasuna.[19]

  1. OLPs are a mixture of white and red lesions that usually exhibit multiple foci.
  2. It has a bilaterally symmetric pattern showing a lace-like network of fine white lines known as Wickham's striae.
  3. It affects buccal mucosa most frequently and, in some cases, also involves tongue, gingiva and lower lip.
  4. The white lesion has a reticular, papule, plaque-like appearance and red lesion can appear atrophic, erosive or bullous.


To confirm the diagnosis of patients with OLP, the medical records of the patients were requested from the physician who made the initial diagnosis of hypothyroidism.

Further, the clinical diagnosis of OLP was confirmed by the histopathological diagnosis according to the diagnostic criteria set forth by the American Academy of Oral and Maxillofacial Pathology.[20]

The diagnostic criteria are as follows:

  1. Multifocal symmetric distribution of white and red lesions exhibiting one or more of the following forms – reticular/popular, atrophic (erythematous), erosive (ulcerative), plaque/bullous.
  2. Band-like or patchy, predominantly lymphocytic infiltrate in the lamina propria confined to the epithelium – lamina propria interface and basal cell liquefactive degeneration [Figure 1].
Figure 1: Lymphocytic infiltrates in the lamina propria and basal cell liquefactive degeneration

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Sample size: By using Rao soft sample size calculator, with an error of margin 5% and in the area of survey, 1 Lakh hypothyroidism cases response distribution is 50%. The sample size recommended was 383, which was rounded off to 400 in each group. But due to the availability of the sample during the study, the sample size was increased to 500 in each group.

Sampling technique: Participants who were fulfilling the inclusion criteria were included in the study.

ARMAMENTARIUM USED [Figure 2].
Figure 2: Armamentarium used

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Examination of subjects was done using the following armamentarium:

  1. Pair of sterile disposable gloves and mouth mask.
  2. Stainless steel kidney tray, mouth mirror, straight probe, tweezers and explorer.
  3. Sterile gauze piece and a cotton swab.


Examination of Patients

The study was employed to target the association between OLP and hypothyroidism.

  • The study subjects were made to sit comfortably on a dental chair. Patients were examined under artificial illumination using sterile gloves.


All the enrolled subjects were then subjected to a detailed interview.

The data was collected in two parts:

  1. History taking: Demographic information (age, gender, location, occupation, etc.) and history taking were elicited. The history of hypothyroidism, especially with reference to treatment taken was recorded.
  2. Clinical examination: OLP was diagnosed as per the criteria of Shirasuna[19] and relevant data were entered in performa.


    • Each patient was informed about the protocol after obtaining written consent.


INCLUSION AND EXCLUSION CRITERIA.

Inclusion criteria for the control group

  1. Subjects of either gender aged between 20 and 45 years.
  2. Subjects reporting to outpatients in the Department of Oral Medicine and Radiology (BBDCODS).


Exclusion criteria for the control group

  1. Pregnant, menstruating and subjects on oral contraceptives and with other systemic diseases.
  2. Subjects having any systemic diseases.
  3. Subjects failing to give their consent.


Inclusion criteria for case group

  1. Subjects of either gender aged between 20 and 45 years.
  2. Subjects with a history of hypothyroidism.
  3. Subjects attending the Department of General Medicine R.M.L Hospital Lucknow.


Exclusion criteria for case group

  1. Pregnant, menstruating and subjects on oral contraceptives and with other systemic diseases.
  2. Subjects having any systemic diseases excluding hypothyroidism.
  3. Subjects having unilateral LP lesions.
  4. Subjects failing to give their consent.



   Results Top


The present study was conducted in the Department of Oral Medicine and Radiology and Department of General Medicine RML Hospital Lucknow with the objective to study the prevalence of OLP in patients with a history of hypothyroidism. A total of 500 cases and 500 controls were included in the study.

The results are presented in frequencies, percentages and mean ± standard deviation (SD). The Chi-square test was used to compare the categorical variables. The P value <0.05 was considered significant. All the analysis was carried out on SPSS 16.0 version (Chicago, Inc., USA).


   Discussion Top


OLP [Figure 3] is a chronic inflammatory condition implicating T-cell-mediated cytotoxicity, and involving oral mucosal surfaces. There are six recognized types of OLP having oral manifestations, i.e., reticular [Figure 4], papular, plaque, erosive [Figure 5], atrophic [Figure 6] and bullous.[21] The reticular form being the commonest type presents as papule and plaques with interlacing white keratotic lines (Wickham's striae) with an erythematous border and the striae occur bilaterally on the buccal mucosa, mucobuccal fold and gingiva.[22] Apart from the oral manifestation, LP is also seen on the skin and is referred to as cutaneous lesions of OLP [Figure 7]. Several therapeutic regimens have been evaluated to treat OLP and pain related, but often without a high level of evidence. Topical formulations are the favourite for the majority of cases; bio-adhesive formulations have been considered very useful and practical for local drug delivery in oral mucosa, due to the increased residence time on the oral mucosa of the dosage forms and better therapeutic efficacy. Steroids are very helpful to relieve discomfort and making a better quality of life. They are considered the first line of treatment even if they could cause secondary candidiasis, and sometimes bad taste, nausea, dry mouth, sore throat or swollen mouth. Other substances or devices by topical administration are adopted especially when the first line approach is refractory. Since OLP is a chronic disease and requires long-term management, the dental/medical practitioner, who treats OLP patients, needs to know the natural history of OLP as how to monitor, and how to treat it, taking into account all of the available modalities conventional and not, with pros and cons.[23]
Figure 3: Oral lichen planus on the dorsum of the tongue

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Figure 4: Oral lichen planus – Reticular type on the right buccal mucosa

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Figure 5: Oral lichen planus – Erosive type on the left buccal mucosa

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Figure 6: Oral Lichen Planus – Atrophic type on right alveolar mucosa

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Figure 7: Cutaneous Lichen Planus on left ankle

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Hypothyroidism is a common disorder, most prevalent in women and most often caused by autoimmune thyroiditis. Overt hypothyroidism can present with classic symptoms of fatigue, weight gain, cold intolerance and constipation.[24]

According to the American Thyroid Association,[24] there can be many reasons why the cells in the thyroid gland cannot make enough thyroid hormone. Some of the major causes are autoimmune disease, surgical removal of part or all of the thyroid gland and radiation treatment.

The present study clearly denoted a female predilection with a good 3.1% (12) of subjects females who were diagnosed with OLP as against 1.8% (2) of male subjects who were diagnosed with the same lesion [Table 1] and [Graph 1]. The same findings were reported by several authors (Silverman et al., 1985; Thorn et al. 1988; Eisen 2002; Xue et al. 2005).[25],[26],[27],[28]
Table 1: Comparison of diagnosis according to gender among cases

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This fact could be probably supported by varied statistics on hypothyroidism between the genders. The present study assessed the prevalence of hypothyroidism in males to be 24.7% and 70.9% in females [Table 2] and [Graph 2]. A similar finding was reported by Fatemeh lavaee and Marjan Majd 2016[29] who reported 2.19% and 6.46% prevalence in men and women, respectively. Aminorroaya et al. 2009[30] also found a prevalence of 4.8% and 12.8% in men and women accordingly for hypothyroidism.
Table 2: Prevalence of hypothyroid according to gender among cases

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The present study reported an OR of 2.37 (CI of 0.90 to 6.22), which means that cases clearly had a predilection of 2.37 times more tendency to develop OLP as compared to the control [Table 3] and [Graph 3]. This is almost similar to the study conducted by Siponen et al.2010[31] who reported an OR of 2.39 (CI of 1.05 to 5.61) for those with OLP. However, a study conducted by Munde et al. 2013[21] reported a reverse tendency with men outnumbering women for OLP (Male: Female ratio 1.61: 1).
Table 3: Comparison of diagnosis between cases and controls

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Our study reported a significant number of OLP patients in the third and fourth decade [Table 4] and [Graph 4]. OLP was found in 50% of the third decade and 3.3% of the fourth decade. A similar finding was reported by Mundeet al. 2013[21] with OLP prevalent in the third decade of life with a mean age of 36.9 years, which was similar to the study reported by Maria Jose Garcia-Pola et al. 2016[32] and Carbone et al. 2009[33] also predicted OLP cases most in the fifth decade and sixth decade.
Table 4: Comparison of diagnosis according to age among cases

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Amongst the control population, a simultaneous cutaneous lesion was noted in one female subject who had mucosal OLP [Table 5] and [Graph 5]. This is in concordance with studies conducted by Maria Siponen et al.[31] Eisen 1999[34] reported a 15% prevalence of cutaneous LP amongst OLP patients. However, the designation of cutaneous LP needs to be seen with caution as the patients' skin lesions were not diagnosed by the dermatologist. As a specialist in oral medicine, we should carefully examine the skin, hands, feet and legs of the patients with OLP, enquire regarding the sign and symptoms and when relevant should refer them to an appropriate specialist. 80% of the study subjects presented with a burning sensation [Table 6] and [Graph 6], which was in concordance with the study conducted by several authors (Shankargouda Patil et al. 2014[35] & Silverman et al. 1985).[24] Soreness [Table 6] and [Graph 6] was recorded in 10% of our OLP cases, which was contradictory to Carbone et al. 2009[4] wherein they found a total of 40% cases with oral soreness as a common finding.
Table 5: Distribution of OLP amongst cases and control

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Table 6: Distribution of OLP patients according to their symptoms

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Among the location-wise distribution of OLP, 75% of the patients exhibited buccal mucosal involvement followed by gingiva (20%) and tongue (5%) [Table 7] and [Graph 7]. The same results were seen in Munde et al. 2013[21] study. Studies did report multilocalized lesions, i.e., the presence of OLP in combinations of buccal, lingual or gingival sites. However, the present study found OLP to be confined to a single location. All the cases and controls diagnosed exhibited a bilateral distribution of OLP in our study. This was supported by World Health Organization (WHO) which proposes bilateral symmetrical distribution of OLP in the buccal mucosa.[21]
Table 7: Distribution of OLP according to their location

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The reticular type of OLP was the most commonly manifested form in our study accounting for 85% of OLP (86% of cases and 83% of controls). The erosive form was seen in 10% of the total subjects with OLP followed by 5% in the atrophic form [Table 8] and [Graph 8]. These findings are consistent with the study conducted by Mundaeet al. 2013[21] where the reticular type was found in 83.5% of the patients, erosive form in 15.6% and 0.78% of the patients noted with atrophic. However, the reports of Eisen D 2002[26] differed with erosive form of OLP to be predominant type in his study patients. These results could be interpreted correlating to the natural history of the disease. According to Carbone M et al 2009[4] and Thron JJ et al 1998[27], the lesion in any form (erosive, erythematous) adopts a reticular pattern over a period of time and hence reticular lesions are reported with greater prevalence.
Table 8: Distribution of OLP lesion according to the type of presentation

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45% of OLP cases were present between 1 and 3 years of duration, including the category of 3–5 years of duration. We found a majority of our OLP cases on the chronic site (1–3 years and 3–5 years) [Table 9] and [Graph 9]. This finding correlates to the chronic nature of oral disease owing to the asymptomatic nature of their lesion; there could have been patients who had it for a much longer period of time whenever diagnosed or reported.
Table 9: Distribution of OLP according to duration/chronicity

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   Conclusion Top


The current study design cannot establish an aetiological association between hypothyroidism and OLP but the study showed more prevalence of OLP in cases of hypothyroidism. The exact information of hypothyroidism could be detected by measuring serum levels of thyroid hormones and autoantibodies besides the medical history of OLP. Further study is recommended employing these measures to reduce any possible confounding factor. In total, most of the characteristics of the present study are consistent with the previous studies with a few differences. LP is a chronic disease where treatment is directed to control and alleviate the symptoms. Long-term monitoring is essential to evaluate for any symptomatic flare-ups and possible malignant transformation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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