Erosive oral lichen planus in an elderly patient: Effect on the quality of life: Case report

Yuli Fatzia Ossa; Anandina Irmagita Soegyanto; Harum Sasanti

doi:10.4103/SDJ.SDJ_3_22

CASE REPORTS

Year : 2022 | Volume : 6 | Issue : 2 | Page : 101-106

Erosive oral lichen planus in an elderly patient: Effect on the quality of life: Case report

Yuli Fatzia Ossa¹, Anandina Irmagita Soegyanto², Harum Sasanti²
¹ Oral Medicine Residency Program, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia; Department of Oral Medicine, Faculty of Dentistry, Universitas Syiah Kuala, Banda Aceh, Indonesia
² Department of Oral Medicine, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia

Date of Submission	24-Jan-2022
Date of Decision	03-Apr-2022
Date of Acceptance	15-Apr-2022
Date of Web Publication	12-Jul-2022

Correspondence Address:
Yuli Fatzia Ossa
Department of Oral Medicine, Faculty of Dentistry, Universitas Syiah Kuala, Banda Aceh
Indonesia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_3_22

Abstract

Background: Erosive oral lichen planus (EOLP) causes pain, burning sensation, swelling, and bleeding and can affect the quality of life because of pain and discomfort. Here, we report a case of EOLP in an elderly patient, which decreased the quality of life, and a comprehensive management of the case. Case Report: A 75-year-old woman was referred to the Oral Medicine Department of Dental Hospital, Faculty of Dentistry, Universitas Indonesia, with oral discomfort. She complained of pain during meals for 1 year, which results in weight loss. The patient admitted to the hospital because of psychological stress and hypertension. The clinical examination of the right buccal mucosa showed reticular plaque, and erosive and erythema lesions on the left buccal mucosa and soft palate. The patient was diagnosed with EOLP and treated with a topical corticosteroid and multivitamin, and also was treated for the management of stress. Conclusion: EOLP treatment in the elderly patients has its own challenges, because of chronic disease, affects the quality of life, and requires long-term therapy. Treatment must be comprehensive and must pay attention to the systemic and psychological condition of the patient.

Keywords: Elderly, erosive oral lichen planus, quality of life

How to cite this article:
Ossa YF, Soegyanto AI, Sasanti H. Erosive oral lichen planus in an elderly patient: Effect on the quality of life: Case report. Sci Dent J 2022;6:101-6

How to cite this URL:
Ossa YF, Soegyanto AI, Sasanti H. Erosive oral lichen planus in an elderly patient: Effect on the quality of life: Case report. Sci Dent J [serial online] 2022 [cited 2023 Apr 2];6:101-6. Available from: https://www.scidentj.com/text.asp?2022/6/2/101/350759

Background

World Health Organization (WHO) describes oral lichen planus (OLP) as a chronic inflammatory disease that affects oral mucosa and can occur without lesion on the skin.^[1],[2] This disease affects 0.5%–2% of the population around the world.^[2],[3] OLP most often occurs in individuals with an age range of 30–80 years, and predilection for women is the most common.^[3] The exact cause of OLP is unknown. The disease is characterized by the inflammation of the epithelial cell layer and the damage to basal cell layer of the epithelium. The damage to the epithelium is caused by an abnormal response of T cells that activate CD4+ Th cell and stimulate the release of cytokine resulting in a damage to the basal cell.^[2],[3],[4]

OLP has six forms of clinical features: reticular, atrophic, erosive, papular, plaque, and bullous. The distribution of lesion is usually bilateral, most often on buccal, gingival, and tongue mucosa.^[5] Not all types of OLP cause complaints; only the erosive and atrophic types cause pain, burning sensation, swelling, and bleeding in some cases. Pain occurs especially when patients consume spicy food. Erosive oral lichen planus (EOLP) is the second most common type.^[3],[4] Although the main cause of OLP is unknown, there are several factors that can trigger this condition. Some of these factors include: stress, hypersensitivity reactions, and certain drugs.^[6] These factors can not only trigger the emergence of OLP conditions but also exacerbate the existing conditions.

The treatment of EOLP in the elderly patients has its own challenges, because it causes pain and can affect the patient’s quality of life. The quality of life is the individual’s perception about the position in life in the values system, the context of culture in which they live and also relates to their personal expectation and concern.^[7] Age, systemic conditions, and also patient’s psychological state should be taken into consideration in the management of EOLP. The purpose of this case report is to describe the conditions and management of OLP case in an elderly patient, which is caused by stress and exacerbated by systemic condition.

Case Report

On August 6, 2018, a 75-year-old female patient was referred to the Oral Medicine Department of Dental Hospital Faculty of Dentistry, Universitas Indonesia, with working diagnosis of leukoplakia. The patient complained of sore mouth on the left cheek and palate that appeared a year ago without any history of trauma. She was initiatively treated with policresulen and triamcinolone acetonide in Orabase, but it did not heal. The patient had a history of recurrent aphthous stomatitis that never reappeared again after menopause. She admitted to having knee joint complaints for the past 3 months. One and a half years ago, her daughter died of breast cancer, and since then, she had no appetite to eat and rarely eating fruit and vegetables. A year after her daughter passed away, the first oral complaints began on both oral buccal mucosa. The patient also had a history of hypertension and high cholesterol for 3-4 years, and routinely consumes angiotensin-converting enzyme inhibitor, amlodipine, and simvastatin. A history of betel chewing, alcoholic beverages, smoking, and allergy was denied.

Extraoral examination showed a mild desquamation on the upper and lower lips, whereas intraoral examination revealed a poor oral hygiene with sub- and supracalculus, debris, stain, and gingival inflammation. There were white striae on the right buccal mucosa in the first and second mandibular molars area and on the left buccal mucosa in the second maxillary premolar extending to the second molar area [Figure 1]. She used removable partial denture with posterior clasp contact with the lesion on the left buccal area. She has carried out hematologic laboratory test from doctor who treated before which resulted anti-nuclear antibody (ANA) profile: anti mitochondrial antibody (AMA) M2 (M2)++, proliferating cell nuclear antigen (PCNA)+, 1.6% eosinophil, 1.2% basophils, erythrocyte sedimentation rate (ESR) 49 mm/s.

Figure 1: A, White striae plaque in the right buccal mucosa; B, erosive lesion with erythema in the left buccal mucosa at the second molar region of mandibular; C, erosive lesions and erythema in the right soft palate

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Based on the history and clinical findings, the patient was diagnosed with EOLP. She was educated to improve oral hygiene and diet intake and also suggested to have stress management. The lesions were treated with dexamethasone mouth rinse 2 mg in the morning and 1 mg in the afternoon, followed by the application of topical corticosteroid to the lesions three times a day. We also referred her to an allergist/rheumatologist with a consideration of ANA+ laboratory result and a history of arthritis.

On August 13, 2018, she came for the second visit. She admitted to using the dexamethasone mouth rinse as instructed. Intraoral examination showed worsened erosive lesion on the left buccal mucosa with more widespread erythema compared with the first visit. The lesion on the right buccal mucosa persisted, whereas the lesion on the soft palate mucosa was improved [Figure 2]. The patient stated that she used her denture during meals and its clasp contacted the left buccal lesion. The patient were re-educated about oral findings and management, to improve oral hygiene by tooth brushing twice a day and to not use her denture temporarily. For the lesion treatment, she was instructed to continue to use dexamethasone and topical corticosteroid. She was referred to the Department of Periodontology for scaling.

Figure 2: A, White striaes plaque in the right buccal mucosa; B, erosive lesions with erythema that extends to retromolar pad at the left buccal mucosa; C, lesion in the soft palate on healing

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On August 21, 2018, the patient came for the third visit, she complained of a new lesion in that palate that erupted after she ate spicy food. Dexamethasone mouth rinse is used regularly according to instructions, in the morning and evening. The intraoral lesions from the previous visit persisted with an extended erosive lesion from the right soft palate to hard palate [Figure 3]. On the third visit, the treatment was modified with dexamethasone mouth rinse with an increased dose to 4 mg in the morning and 2 mg in the afternoon and the application of sodium hyaluronate and aloe vera mixture gel three times a day, as well as one tablet daily of multivitamin 2 weeks. She was re-educated not to think about things that made her sad and to increase activities that make her happy such as meeting up with her friends.

Figure 3: A, Erosive lesion with erythematous in the left buccal mucosa; B, erosive and erythematous lesion in the soft palate that extended to the right hard palate; C, white plaque lesion and striae in the left hard palate

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The fourth visit was on October 29, 2018, 2 months after the patient’s last visit. Her oral medication was discontinued because she did not come on the scheduled follow-up visit. She stated that the pain in the oral cavity has diminished and the sore on the right cheek and palate was healing, but the wound on the left cheek persisted, the buccal mucosa feels thick, and sometimes still caused pain when eating spicy food. She said that she was much calmer and happier since returning from her hometown. Her weight increased by 1 kg since her appetite was improved. At the moment she was under the care of an allergist and rheumatologist and consumed dexamethasone tablets three times a day for 1 week, and then tapered down to one tablet per day until the laboratory result test come out.

The latest laboratory result from allergist/rheumatologist, the ANA anti-dsDNA-NcX profile < 10 International Unit (IU)/mL (within normal limits); Ig E, total 3571 IU/mL; vitamin D 25-OH, total 21.2 ng/mL. From the allergist and rheumatologist department, the patient was diagnosed with hyper Ig E, but no skin test was performed to find out the allergens; they only recommended avoiding gluten/wheat-containing foods, and the patient was given mycophenolic acid 180 mg in the morning and 180 mg in the afternoon, and vitamin D 1000 IU. Hypertension drugs such as ACE inhibitor and amlodipine were still routinely consumed but the patient has not returned control to cardiologist. The differential diagnosis of this case was systemic lupus erythematosus and oral lichenoid reaction.

Intraoral examination showed that the lesion in the palate healed, the striaes on the right buccal mucosa has faded, and erosive lesion on healing in the left buccal mucosa [Figure 4]. Then, she was measured for the anxiety level, depression, and stress using Hamilton Anxiety Rating Scale (HARS) questionnaire and the Depression Anxiety Stress Scale (DASS)—all within normal limits. The patient was informed that the lesion was in the healing process, to maintain a good mood, and to lessen stress that could trigger lesions’ occurrence. The remaining lesion was treated with sodium hyaluronate gel, which was applied to lesions three times a day, and also was instructed to take the one multivitamin tablet a day.

Figure 4: A, Striae on the right buccal mucosa; B, lesion on healing in the left buccal mucosa. The lesion in palate was healed

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Discussion

In this case report, we presented a case of lesion with EOLP. This diagnosis was established based on the characteristic of white striaes of OLP. The pathognomonic of clinical features are usually sufficient for the diagnosis.^[2] That is why we did not do the histopathology examination. The exact cause of OLP is unknown. OLP causes the inflammation in the epithelial cell layer and the damage to the basal cell layer of the epithelium. This damage is caused by an abnormal response from T cells that activated CD4+ Th cells and stimulated the release of cytokines resulting in damage to basal cell.^[2],[3],[4] T cell mediated chronic inflammation proceeded by presenting antigen major histocompatibility complex (MHC I) which activates CD8+ T cell in basal target keratinocyte cell in OLP. Cytotoxic reactions attack the basal cell layer, CD8+ T cell secrete tumor necrosis factor (TNFα), granzyme B, Fas ligand causing apoptosis of keratinocyte cell. CD8+ T cell also produces chemokine, which can recruit inflammatory cells, so that the inflammatory process will continue.^[1]

Several factors can trigger OLP. Some of these include aging, stress, hypersensitivity reactions, and certain drugs. These factors also can exacerbate existing condition.^[6],[8],[9] We reported a case of EOLP that occurred in a 75-year-old woman who has been considered elderly based on the WHO criteria, that is someone who has reached the age of 60 years and above.^[10] Elderly patients can have any health problems such as physical or psychological. These can trigger depression, stress, decreased immunity, infection, malnutrition, constipation, and also sleep disorders.^[10] Elderly are prone to depression and stress. The main cause of depression in the elderly patients is usually the loss of someone who they loved, which could be a child, a husband, or other family members.^[11] In this case report, the patient said that she felt depressed after her daughter passed away. The lesion appeared when she was in a state of depression. Stressful condition can trigger EOLP. Sandhu et al. (2014) in his study described that there was an association between OLP and stress [Figure 5].^[12]

Figure 5: Mechanism stress-induced OLP^{[10],[11],[12]}

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In our case report, the patient who was elderly suffers from the erosive type of OLP. Unlike other types of OLP, EOLP is chronic diseases and can cause pain and discomfort that can affect the quality of life. Since it is a chronic disease with recurrent symptoms, many of the affected patients not only have significant oral limitations, but also have social and psychological impairments.^[13] The pain arises especially when eating spicy and sour foods. In addition, EOLP lesion also causes spontaneous symptoms such as burning sensation and lesion that can bleed. Besides that, EOLP causes difficulties when eating, and so can lose their weight. All of these can lead to the decreased quality of life of the patient.^[3],[13] According to the WHO, the quality of life is an individual’s perception of their position in life. The quality of life is important in patient care and extensively applied as a part of daily practice. Any disturbance related to oral cavity can disturb normal oral function, and a persistent discomfort subsequently result in the decreased quality of life.^{[14],[15],[16]}

The treatment of EOLP in this case report is comprehensive. Comprehensive actions taken include improving oral health by scaling, which is done by the periodontics department, and then the patient was also referred to allergist/rheumatologist and also for the management of stress. In addition to pharmacological therapy with drugs, the patient is also psychologically approached. Pharmacological therapy observed in this case report was carried out using topical corticosteroid. Corticosteroids are used as anti-inflammatory and immunosuppressive agent. Corticosteroids work by changing the regulation of protein synthesis, which inhibits phospholipase A2 and the metabolism of arachidonic acid, prostaglandin, and thromboxane that occur during inflammatory process. Immunosuppressive effects of corticosteroid by suppressing the proliferation of T cell inhibit the release of inter-leukin (IL-1) from monocyte.^[17],[18] Corticosteroid used is dexamethasone 2 mg in the morning and 1 mg in the afternoon. On the second and third follow-up, the lesion did not experience significant changes, because the patient is still in a state of stress, which greatly affects her health condition.

Because of the suspected allergic reaction, the patient was also referred to an allergist at the fourth visit. The allergist prescribed her with systemic corticosteroid drug as dexamethasone tablet and mycophenolate mofetil, an immunosuppressive drug that can inhibit the proliferation of lymphocytes.^[17] Lesion in the buccal mucosa was faded as in [Figure 4]. And at the fourth visit, remaining lesion was treated with sodium hyaluronate and aloe vera gel and multivitamin that contain alpha-lipoic acid combination, ascorbate calcium, zinc picolinate, selenium, and beta-carotene. Multivitamin was used as an antioxidant to protect body from free radicals, besides it also plays a role in repairing damaged cells.^[18]

Between her follow-up visits, the patient went back to her hometown. She admitted to felt uncomfortable during the treatment and that she truly missed her hometown. It turned out that hometown-returning trip brought improvement on her complaints. She returned to follow-up with happier look and weight gain. The trip to hometown is part of the patient’s stress management. We evaluate the stress, anxiety, and also depression level by using the DASS questionnaire and continued using the HARS questionnaire at the fourth follow-up visit after she returned from the hometown, and the results were all within normal limits. Although DASS and HARS result in a normal limit, we still assume that going back to her hometown is one of stress management to make her more comfortable after returning home. Many studies believed that the stress, especially mental stress, is one of the possible risk factors for the development of OLP, and in the postmenopausal women, stress could lead to anxiety, and depression is the common reason triggering OLP.^{[19],[20],[21]}

The increased life expectancy of elderly has caused the growing number of elder populations. In order to make the best of their life, the elderly should have a good quality of life. When they experience oral disease, pain, and/or discomfort associated with negative experiences, these conditions can impact the quality of life of the elderly. EOLP in the elderly patients caused chronic oral discomfort. This condition makes the elderly patient difficult to eat and increased depression and anxiety that have an impact on the quality of life of the patient.^[20],[21] In our case, we did not use any tools like questionnaire of oral health-related quality of life to measure the level of the quality of life. We only ask the patient about the discomfort caused by the lesion.

In this case report, EOLP management was carried out comprehensively, with giving attention to the patient’s quality of life. For causative management, the lesions were treated with steroid, stress management, and referral to allergist/rheumatologist, and the supportive therapy has been done by providing multivitamin. Because of the chronic condition of EOLP that can affect the patient’s quality of life, the treatment requires long-term and comprehensive therapy, with consideration in avoiding predisposing factors that can aggravate the disease, and patient’s systemic condition in order to maximize the treatment result.

Conclusion

EOLP treatment in the elderly patients has its own challenges, because it is chronic disease, affects the quality of life in the elderly patients, and requires a long-term therapy. The treatment must be comprehensive, and attention should be given to systemic and psychological conditions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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