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Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 309-315
Etiogenic study on oral lichenoid reactions among Tamil Nadu population: A prospective cohort study


1 Dental Surgeon, Raj Dental Clinic, Madurai, Tamilnadu, India
2 Statistician, Raj Dental Clinic, Madurai, Tamilnadu, India
3 PG student in Oral Medicine and Radiology at SRM Dental College, Chennai, Tamilnadu, India

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Date of Submission28-Jan-2012
Date of Decision02-Aug-2012
Date of Acceptance18-Aug-2012
Date of Web Publication12-Sep-2013
 

   Abstract 

Background: Most of the clinical, epidemiological, and etiogenic studies on oral lichenoid reactions (OLRs) have been undertaken in the United States, UK, Scandinavia, and other European countries. So far, very few cohort studies on a small population have been documented from South Asian region to implicate the role of various causative agents in the precipitation of OLR.
Objectives: To implicate the role of various allopathic, alternate medicinal drugs, dental materials, etc., in the precipitation OLRs; to evaluate the pattern of remission; and to estimate the time period for the remission of lesions following the discontinuance of the suspected agents in the population of Tamil Nadu.
Materials and Methods: A total of 102 patients were included, of whom 51 (mean age 43.3 years, SD 14.59) formed the study group, who possessed a positive drug history to the intake of either potential allopathic or alternate drugs or had recent dental metallic fillings/restorations, and 51 were (mean age 47.86 years, SD14.67) in the control group possessing oral lichen planus (OLP). The patients were followed up at a monthly interval period for a period of 18 months.
Results: Complete remission of signs and symptoms was noticed in 41 patients, partial remission in 6, no change in 2, newer lesions in 1, and flaredup lesions were observed in 1 participant in the study group. The mean onset time for lichenoid eruptions was found to be 2.5 months (SD 58.82) and the mean remission time after discontinuing the drug was 9.1 months (SD 4.7).
Conclusion: OLR could be implicated to documented lichenoid agents like calcium channel blockers, ACE inhibitors, atarvastatin, metformin, glibenclamide, dapsone, carbimazole, silver amalgam fillings, etc.in southSouth Indian population. Furthermore, the drugs like oflaxacin, arsenical album, and yellow orpimentumwere also found to have strong implication in the precipitation of OLR. Discontinuance of the suspected agents resulted in healing in the majority of cases.

Keywords: Lichenoid agents, lichenoid eruptions, oral lichen planus, oral lichenoid reactions

How to cite this article:
Nagaraj E, Eswar P, Kaur RP. Etiogenic study on oral lichenoid reactions among Tamil Nadu population: A prospective cohort study. Indian J Dent Res 2013;24:309-15

How to cite this URL:
Nagaraj E, Eswar P, Kaur RP. Etiogenic study on oral lichenoid reactions among Tamil Nadu population: A prospective cohort study. Indian J Dent Res [serial online] 2013 [cited 2019 Nov 15];24:309-15. Available from: http://www.ijdr.in/text.asp?2013/24/3/309/117992
Oral lichenoid drug reaction (OLR) is a delayed hypersensitivity response implicated to a variety of drugs such as antihypertensives, [1] oral hypoglycemics, [2],[3] allopurinol [2] antimalarials, [4] nonsteroidal anti-inflammatory drugs (NSAIDs), [5] heavy metals, [6] dapsone, [7] , dental restorative materials, [8],[9],[10],[11],[12] etc. The lesions clinically and histologically resemble oral lichen planus (OLP) which is a relatively common mucocutaneous disorder of middle-aged and elderly persons, characterized by white keratotic lesions often associated with painful erosions and ulcerations.

Extensive epidemiological and clinical studies of OLRs have been undertaken in the United States, UK, Japan, and Scandinavia, [13],[14] while studies on possible disease associations have been reported on Japanese, British, and other European patients. [1],[15],[16] Most of these studies have been undertaken in the western world andhave not been done on South Indian population. So far, very few cohort studies have been documented from South Asian region to implicate therole of newer drugsin the precipitation of OLR None of the studies associated the role of heavy metals in traditional siddha/ayurveda medicines and homeopathic drugs possessing traces of heavy metals in eliciting the delayed hypersensitive response. No large cohort has been reported so far on OLP amongst South Indian population. It appears from the increasing number of publications that contact OLRs are becoming an increasing problem due to the advent of newer drugs in the western countries and the same needs to be justified in South Indian population.

The aim of this study is to implicate the role of traditional medicines, allopathic drugs, dental materials, etc., amongst the patients in southernTamil Nadu in the precipitation of OLR and to estimate the pattern of remission of the large cohort of OLR patients in South TamilNadu.


   Materials and Methods Top


Subjects

The study group comprised 51 participants referred to the Stomatology Centre, Raj Dental Clinic in South Tamil Nadu during 2008-2011. Inclusion criteria required a clinical diagnosis ofOLR/OLP, along with a positive drug history (including a baseline drug history for a series of documented lichenoid agents) upto 6 months prior to the onset of lesions. The clinical diagnostic criteria included white striated/reticular, erythematous, erosive, pigmented, and ulcerative patterns associated with or without the complaints of soreness and pain. An equal number of participants identified as OLP formed the control group for comparison such that for each patient of OLR, a matched patient of the same age with OLP within 5 years was included. A marked symptomatic and clinical improvement (as recorded through clinical staging and patient's subjective scoring) following the withdrawal of the causative medications implicates those drugs as the most likely cause of lichenoid reactions.

Lesions (test and control groups)

The clinical features of OLRs were variable and included white or red patches, reticular, erosive, ulcerative, or pigmented forms. [17] Symptoms accompanying the lesions were recorded for sore mouth and pain. Most of the lesions were erosive (n = 60) and associated with burning sensation or pain (n = 97) at the time of screening. A score of 3 was given to erosions with or without white striae/pigmentation. A score of 2 was given to white lesions with pigmentation alone. And a score of 1 was given to the pigmented lesion identified as the residual pigmented area. Similarly score A was given for intense soreness, B for soreness only on taking food and during brushing, and C referred to no symptoms. F was given for flaring lesions, R for regressing lesion, and N to onset of newer lesions during the course of the study [Table 1], [Table 2] and [Table 3].
Table 1: Clinical assessment scale of OLP and OLR

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Table 2: Staging of symptoms

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Table 3: Subjective evaluation of prognosis of oral lichenoid lesions

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Clinical results were graded as:

  • Complete remission (complete regression of clinical signs and symptoms with or without residual pigmentation)
  • Partial remission (remission of erythema, partial remission in the clinical signs and symptoms, reduction in the size of the lesion)
  • No change
  • Regressed lesion
  • Flared lesion
  • Newer lesions.
Withdrawal of the suspected metallic homeopathic (arsenical album), siddha (lead compounds), ayurveda (mercury containing medications) agent was done with the consent of patients and the concerned practitioners. Similarly the suspected allopathic drugs were discontinued and replaced with suitable alternate allopathic drug. Also, the metallic restorations were replaced with eugenol fillings. Patients were followed up for a period of 18 months. Follow-up examination included monthly evaluation and a clinical photographic record at the first visit and whenever a clinical change was noticed.

Statistical methods

Statistical analysis involved descriptive statistics and Chi-square, wherever appropriate.


   Results Top


Age and gender

The number of participants with oral lichenoid lesions in the study group was 51 of whom 14 were males and 37 were females. In controls, 26 were males and 25 were females. The mean age was 43.3 years (SD 14.59) in the study group and 47.86 years (SD 14.67) in the control group.

Medical status (test group OLR and control OLP)

There was statistical difference in the medical status betweenthe two groups of patients [Table 4]. At the time of screening, the study group patients were significantly associated with cardiovasculardiseases, joint disorders, respiratory diseases, hyperthyroidism, diabetes (60%), etc., while a good number of patients with OLP in the control group were without systemic illness at the time of screening. Among those in the control group who had associated illness, liver disorders in 10 patients, atopic respiratory illness in 10, and recent past history of chikungunya in 4 and joint disorder in 1were evidenced (<50%). A small number of patients subsequently developed diabetes, hypertension, and cardiovascular problems during the study period (n = 6).
Table 4: Medical status among the study and control group

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Maternal, paternal, and social status

Most of the patients belonged to upper and lower middle-class group. Familial distribution could be attributed in three situations. Father-daughter association (genital lichen planus and OLP) was found in one case in the control group and mother-daughter association in two cases in the study group. Five patients attributed the onset following shifting of their residences. Further studies are needed to confirm or refute the inverse relationship between OLR and trace element concentrations in drinking water.

Healing of OLLs

Among the study group patients, lesions healed or improved markedly, and symptoms resolved, in the majority of patients after the withdrawal of the suspected agents. Complete healing (total remission of symptoms with or without specks of residual pigmentation) was noticed in 41 patients (total remission of signs in 34 and residual pigmentation in 7). Partial remission was observed in six patients (two patients showed complete remission by 24 months; one was implicated to arsenical album and the other to yellow orpimentum), no change was noticed in one, new lesions were encountered in one, and the lesions showed aggravation in signs and symptoms in one. Complete remission could be elicited in a period of 24 months in two patients who showed partial remission during the study period. Among the controls, 9 participants showed complete remission (total remission of symptoms and signs in 5 and remission of symptoms with specks of residual pigmentation in 4), 19 showed partial remission, 6 showed no changes, 1 participant showed newer lesions, etc., The lesions showed aggravation in 17 controls [Table 5]. The mean onset time for lichenoid eruptions was found to be 2.5 months (SD 58.82) and the mean remission time after discontinuing the drug was 9.1 months (SD 4.7). Earliest signs of prognosis were noticed in 3 weeks in a few patients, though some patients took as much as 15 months for improvement. Remission percentage was marginally higher inbuccal mucosa and tongue compared to other sites in the study group as well as in the control group. So also, the healing in lateral (33%) and ventral surfaces (0%) of the tongue, lips (0%), floor (0%), and gingiva (25%) was prolonged in the control group. Among controls, 9 patients showed complete remission (total remission of symptoms and signs in 5 and total remission of symptoms with specks of residual pigmentation in 4), 19 showed partial remission, 5 showed no changes, 1 participant had newer lesions, etc., The lesions showed flaring in 17 controls.
Table 5: Pattern of remission of OLR/OLP

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   Discussion Top


OLP is thought to reflect a cell-mediated reaction, with T lymphocytes as the main effector cells. Diagnosis is by history, clinical examination, and confirmatory biopsy. Current treatment may reduce the pain and severity of lesions, but is not curative. [14] OLR is a delayed hypersensitivity response implicated to a variety of drugs such as antihypertensives, oral hypoglycemics, NSAIDs, heavy metals, chemotherapeutics, antimalarials, dental restorative materials, etc. [11] The lesions clinically and histologically resemble OLP. Therefore, it is important to distinguish between the two groups of lesions as their etiology and hence their treatment is different.

This study was conducted with an aim to find the association of precipitation of OLRs with the exposure to certain allopathic, alternate medicines, dental restorative materials, etc., and to compare the remission pattern of OLR and OLP through Chi-square testing. We also attempted to evaluate the mean time of onset after exposureto the suspected agents and the mean remission time following the discontinuance or removal of implicating factors.

In general, the results of this study on OLR confirm some observations from previous studies conducted in the UK, USA, Europe, and Scandinavia. [13],[18],[19],[20] In agreement with the reports on western patients, most of the OLR and OLP cases were found to develop lesions in middle to late life (highest prevalence was seen in those between 40 and 50 years of age), but a few developed in the early adulthood as well as in late childhood of 13 years. But the rarity of OLP in childhoodwas quoted by Scully et al. [7] in 1994. The majority of the lesions were located in the molar and retromolar areas of the buccal mucosa and the tongue, as quoted in most of the studies. Likewise, in agreement with other similar studies, females outnumbered males in the study group. [6] The prevalence of OLL among women was higher compared with the prevalence among men (2.5:1). But in the control group, prevalence was almost equal, similar to that reported in some epidemiological studiesthat men and women are affected almost equally.

The mean onset time for lichenoid eruptions was found to be 2.5 months (SD 58.82) and the mean remission time after discontinuing the drug was 9.1 months (SD 4.7). Earliest signs of prognosis were noticed in 3 weeks in a few patients, though some patients took as much as 15 months for improvement (refer [Table 6] for onset and remission time for individual implicating factors). Remission percentage was higher inbuccal mucosa and dorsum compared to the other sites in both study as well as control groups. So also, the healing in ventral surface and gingiva was prolonged [Figure 1].
Table 6: The mean onset and remission time in relation to the various implicating factors of OLR

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Figure 1: Comparison between the study and the control groups

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Ingafou et al.[21] studied the long-term behavior of OLP in 690 UKpatientsand found that 13% of these patients had complete resolution of OLP in a period of 12-246 months. Other data suggest that 17-20% of OLP patients will have spontaneous resolution of signs andsymptoms. [18] In this study, complete remission could be observed in 41 (81%) patientsof OLR in the study group and 16 patients of OLP (31%) among the controls [Table 5]. The difference in the remission pattern between OLR and OLP was tested through Chi-square analysis at 4 d.f. and at 95% level of confidence. The Chi-square value obtained was 14.03, which was much greater than the tabulated Chi-square value of 9.49. So, we conclude that there is a significant difference in the remission pattern between the OLR and OLP patients.

The pattern of symptomatic remission and the pattern of clinical prognosis proved significantly different for the study and control groups, as tested by Chi-square analysis. Complete symptomatic remission was evidenced in 47 patients and partial remission in 4 patients in the study group, as against the control group where complete remission of symptoms was noticed in 19, partial remission in 6, and no improvement in 26 patients. A complete symptomatic remission was attained in most of the cases within 6.5 months in the study group, particularly those cases implicated to hypoglycemics, statins, Angiotensin converting enzyme (ACE) inhibitors, and silver amalgam fillings. Likewise, complete remission in clinical signs in the study group was noticed in 29, remission of white striae and erythema in 19, and remission of erythema alone in 3 patients. Among the controls, complete remission was evidenced in 9, remission of white striae and erythema in 16, and remission of erythema alone in 9 patients (5 patients showed complete absence of signs while 4 patients showed specks of residual pigmentation). The lesions evidenced flaring in 17 patients. The remission pattern was evidenced from the second month onward and was complete within 6 months in most of the OLR patients. But appreciable change was noticed from 12 to 18 months among the remission cases [Figure 2] and [Figure 3].
Figure 2: Pattern of symptomatic remission among the study group patients

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Figure 3: Pattern of clinical prognosis among the study group patients

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Many studies have reported the association of allergic reactions and dental restorative materials. [9],[10],[12],[14],[22],[23],[24],[25],[26] The most commonly reported problems of local exposure to restorative materials are local inflammatory reactions due to their toxic, irritant, or allergic effects. Biodegradation of dental materials and the release of elements from them is attributed for the precipitation of OLR. With amalgam alloys, mercury may be released as a result of dissolution, evaporation, corrosion, or other form of degradation. The released mercury is reported as being taken up by oral soft tissues, and in some patients, this appears to result in local toxic or allergic effects that present as oral lichenoid lesions. [14] Lygreet al. observed adverse reactions in the oral mucosa among 253 patients and strongly implicated the role of various dental materials including dental amalgam fillings in the precipitation of OLRs. [14] In this study, replacement of restorations in 8 patients resulted in complete remission in 6, partial remission in 1, and no change in 1. The mean remission period was 6.6 months with SD 3.02.

Kaomongkolgit [3] in his case report reported spontaneous remission of OLR in a period of 2 weeks after the discontinuance of hypoglycemics and antihypertensives, thus implicating the role of hypoglycemic and antihypertensive agents in the precipitation of OLR. In this study, we could attribute the role of oral hypoglycemicsin the precipitation of OLR in seven patients. Among them, six patients developed OLR to glibenclamide and three patients developed OLR to metformin. Both glibenclamide and metformin could be implicated in two patients. All the patients showed complete remission after discontinuing the drug. The mean remission period was 5.86 months and SD 2.61 months. The mean onset time was estimated as 3 months. Habbab et al. [1] studied the incidence of OLR in 531 patients who were put on medications for cardiovascular problems and concluded that 14.1% among them developed oral lesions. Lakshmi et al. [27] in their case report of OLR implicated the role of calcium channel blocker amlodepine ina 58-year-old female patient. In our study, amlodepine could be implicated for OLR in 5 patients. Complete remission could be evidenced in a mean period of 9.25 months (SD 1.26) in all the patients. Similarly, a number of case reports implicating ACE inhibitor captopril for OLR have been documented. Barbet et al. reported a case of genital LR to captopril. Firth and Reade [28] reported two cases of OLR to captopril and enalopril. Phillips et al. and Reinhardt et al. [29] each reported a single case of OLR to captopril. In this study, we could observe OLR in two patients on ACE inhibitors. Both showed remission in a period of 4.5 months (SD 0.71) after the discontinuance of ACE inhibitors.

A single case report by Hamanakaet al. [30] has been documented implicating the role of quinolone sparfloxacin in the precipitation of OLR. In this study, 11 cases developed OLR following the intake of oflaxacin (mean onset 3.2 months). Among the 11 patients, 10 showed complete remission in a mean period of 6 months (SD 3.74). One showed partial remission during the study period after the discontinuance of the drug. Subsequently, the patient showed complete remission in a period of 24 months. Among the 11 patients, 1developed OLR at a later stage when the drug was rechallenged.

Drugs like azoles [31] and dapsone, [32],[33],[34] which are used in the management of OLP, are implicated in the precipitation of OLR. In this study, carbimazole could be implicated in three patients (the mean onset time was 8 weeks and the mean remission time was found to be 7 months) followingits discontinuance and dapsone in one patient. Drugs like quetipine, chloramphenicol, ergotamine, ursodeoxycholic acid (n = 1), and beta-blockerswere implicated to OLR in 6 patients. However, we could not establish the lichenoid potential of these drugs as they were found to be a component of polypharmacy or confounded with silver fillings.

Heavy metals have been implicated in the precipitation of lichenoid eruptions. [11] Heavy metals like lead, arsenic, mercury, etc., [14] are included in negligible concentrations in the traditional preparations of ayurveda and siddha and in homeopathy medicines. [12] In this study, we observed OLR in 19 patients to alternate medications. Among them, 18 had developed reactions to arsenic containing compounds. Orpiment is an orange to yellow mineral of arsenical sulfide used in siddha preparations for respiratory disorders. Arsenical album is a frequently used homeopathicsubstance [12] that homeopaths prepare by diluting arsenic trioxide generally until there are no molecules left in the solution. [13] It is used by homeopaths to treat a range of symptoms that include digestive disorders. Although it is considered generally safe, rare reports of arsenic poisoning from poorly prepared homeopathic treatments sold in India have been reported. [12]

We could notice OLR in buccal mucosa and gingiva in most of these patients. Ten patients developed OLR following the intake of yellow orpimentum, a siddha preparation containing arsenic. Similarly, eight patients developed OLR to the intake of arsenical album. None of these patients showed toxicity as evidenced by AASP testing of arsenic. All the patients of siddha medication showed remission in a mean period of 10.33 months (SD 3.74). All but one patient of arsenical album showed complete remission in a mean period of 11.33 months (SD 5.96). One patient subsequently showed total remission by the 24 th month following withdrawal of the drug. One patient exposed to mercury containing ayurveda drug as well as silver filling showed remission in a period of 9 months following the withdrawal.

Ingafou et al. reported that 1.9% of the 690 patients developed oral carcinoma. Other epidemiological studies [35] report 0-6.25% of malignant transformation rates. In this study, we could not find malignant transformation in any of the 102 patients as well as the control groups in a period of 24 months.

Summarizing the weaknesses against the strengths in this study, the confounding effects of more than one implicating factor could be evidenced in 15 participants, out of which polypharmacy was identified in 11 patients [Table 7]. Silver amalgam fillings were associated with any one of the systemic drugs like quetiapine, ergotamine, chloramphenicol, and ursodeoxycholic acid in 4 participants. The potential weakness of this study due to the confounding effects can be partially overcome by analyzing the monopharmacy and polypharmacy groups separately.
Table 7: Polypharmacy group

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Thus, in polypharmacy group, complete remission was noticed in two patients of group 1 in a period of 4-5 months. All the participants in group 2 showed complete remission in a period of 3-6 months after discontinuance. In group 3, the patients showed complete remission in a period of 4 months. Clayton et al.[5] in their retrospective study on 106 patients with OLR, conducted in the Department of Dermatology, Royal Berkshire Hospital, Reading, UK, found that patients with mucosal LP were more likely to be on NSAIDs and beta-blockers, though noinverse relationship was found between patients with oral LP and beta-blockers.


   Conclusion Top


OLRs could be implicated to documented lichenoid agents like calcium channel blockers, ACE inhibitors, atarvastatin, metformin, glibenclamide, dapsone, carbimazole, chemotherapeutics, silver amalgam fillings, etc., on South Indian population. Furthermore, the drugs like oflaxacin, arsenical album, yellow orpimentum, etc., were also found to have strong implication in the precipitation of OLRs as evidenced in large cohorts from Tamil Nadu. Discontinuance of the suspected drugs/dental materials and replacing them with suitable alternate agents will bring about healing in a majority of cases. Malignant transformation of OLR appears rare among South Indian population as not a single case could be identified from a large cohort.


   Acknowledgement Top


Dr. Sivapathasundaram, Prof & Head Department of Oral Pathology, Meenakshi Ammal Dental College. Dr. Parthiban, Prof. Department of Dermatology.

 
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Correspondence Address:
Eswar Nagaraj
Dental Surgeon, Raj Dental Clinic, Madurai, Tamilnadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.117992

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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

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[Pubmed] | [DOI]
2 CD1a+ dendritic cells in oral lichen planus and amalgam lichenoid reaction
Giovanna Ribeiro Souto,Laiz Fernandes Mendes Nunes,Barbara Brandão Tanure,Ricardo Santiago Gomez,Ricardo Alves Mesquita
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2016; 121(6): 651
[Pubmed] | [DOI]



 

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    Abstract
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