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Management of a patient with severe erosive lichen planus in need of an immediate complete denture: A clinical report
Management of a patient with severe erosive lichen planus in need of an immediate complete denture: A clinical report Alejandro Rabanal, DDS,a Michael Bral, DDS,b and Gary Goldstein, DDSc New York University College of Dentistry, New York, NY This clinical report describes the treatment of a patient in need of an immediate complete denture who presented with severe erosive lichen planus. In conjunction with an immediate complete denture, tacrolimus (0.1%) ointment, an immunosuppressive agent, was applied topically over the lesions. There was a significant reduction in the size of the lesions at the second week of treatment, allowing the patient to tolerate the prosthesis without pain, thereby improving her quality of life. (J Prosthet Dent 2007;98:256-259)
Lichen planus is a chronic inflammatory mucocutaneous disease that is considered to be an immunologically mediated process. It was first described by Erasmus Wilson in 1869 and affects almost 1% of the world population. Most patients are middleaged, with women more commonly affected than men.1 T-cell–secreted tumor necrosis factor alpha (TNF-α) and matrix metalloproteinase (MMP9) may be implicated in the pathogenesis of this condition.2 This condition can affect the skin, oral mucosa, or both. The histological presentation is characterized by a subepithelial lympho-histiocytic infiltrate, an increase in the number of intraepithelial lymphocytes, degeneration of basal keratinocytes, and changes in the epithelial basement membrane that result in microscopic gaps between the epithelium and the connective tissue.3 Clinically, the central area of the lesion is ulcerated, and a fibrinous plaque or pseudomembrane covers the ulcer. The periphery of the lesion is usually surrounded by reticular or radiating keratotic striae that become painful when the pseudomembrane
is disturbed.3 As part of the dental treatment, irritating factors must be removed. Scaling and root planing should be performed on a regular basis, ill-fitting restorations should be replaced, and teeth with sharp angles must be reshaped.2 Erosive lichen planus can be treated systemically and locally. Systemic therapy with corticosteroids is indicated for lesions that do not respond to a local treatment. Local therapy includes dexamethasone mouth rinses and triamcinolone or fluorinated steroids applied over the lesions on a daily basis. Combinations of systemic and local therapy are also used successfully. Other agents such as cyclosporine, azathioprine, and levamisole are also used in the treatment of erosive lichen planus.2 The use of the immunosuppressive agent tacrolimus (Protopic; Fujisawa Healthcare, Inc, Deerfield, Ill) is reported in the literature as an effective agent for the control of symptoms of erosive lichen planus.4,5,6,7 Lener et al4 treated a patient with erosive lichen planus lesions of the lip and oral mucosa with 0.1% tacrolimus ointment
and reported complete healing of the lip lesions after daily application for 1 month. The ulcerations of oral mucosa that were treated with the same concentration were in remission 3 months after the start of the treatment. The authors reported that the lesions were in complete remission for a year without maintenance therapy.4 Olivier et al5 evaluated the efficacy of a topical preparation of a 0.5-mg tacrolimus capsule diluted in 500 mL of distilled water. Patients were instructed to rinse with 15 mL for 2 minutes, 4 times a day. The frequency of the rinses was adjusted according to the severity of the symptoms. The author concluded that palliative effects were rapid and significant but not curative. Byrd et al,6 using a questionnaire mailed to 37 patients treated with topical tacrolimus, found that the majority of the patients reported an improvement in the lichen planus lesions and that maintenance therapy was necessary. Thomson et al,7 in a retrospective study, reported on 23 patients with oral lichen planus treated with 0.1% topical tacrolimus. Six weeks after the treatment began,
Former Resident, Advanced Education Program in Prosthodontics. Professor, Department of Periodontics. c Professor, Department of Prosthodontics. a
b
The Journal of Prosthetic Dentistry
Rabanal et al
257
October 2007 21 out of the 23 patients showed improvement of at least 50% of symptoms such as pain, burning sensation, irritation, and altered taste. The longest asymptomatic period was 29 months, and the shortest was 4 months. Fifteen patients were placed on maintenance therapies because of relapses after stopping treatment. Adverse reactions are uncommon but included parasthesia and dysguesia. The Food and Drug Administration, found at http://www.fda.gov/ cder/drug/InfoSheets/HCP/ProtopicHCP.pdf, issued the following alert in March 2005: “The FDA has issued a public health advisory to inform healthcare professionals and patients about a potential cancer risk from use of Protopic (tacrolimus). This concern is based on information from animal studies, case reports in a small number of patients, and knowledge of how drugs in this class work. It may take human studies of 10 years or longer to determine if use of Protopic is linked to cancer. In the meantime, this risk is uncertain, and FDA advises Protopic should be used only as labeled, for patients after other prescription treatments have failed to work or cannot be tolerated.” The purpose of this clinical report is to present the treatment of a patient with severe erosive lichen planus in need of an immediate complete denture treated in conjunction with tacrolimus (0.1%) ointment, an immunosuppressive agent.
CLINICAL REPORT A 75-year-old white woman presented with a complaint of “sores in the mouth” (Figs. 1 and 2). Intraoral examination revealed multiple lesions on the buccal and labial mucosa, the lateral borders of the tongue, the gingiva, and the hard palate. Diffuse erythematous areas were interspersed with desquamative and ulcerative foci. Several areas were asymptomatic, while in other areas burning sensation and/or pain was experienced. No cutaneous or genital lesions were present or reported. All maxillary poste-
Rabanal et al
1 Maxillary view of erosive lichen planus lesion on hard palate.
2 Erosive lichen planus lesions on lateral border of tongue. rior teeth were missing. The maxillary anterior teeth had mobility patterns ranging from 1 to 2+ and probing depths of 4 to 6 mm (Figs. 3 and 4). The remaining mandibular teeth had nonsignificant probing depths and mobility patterns and tested vital. The marginal lichen planus lesions made conventional daily hygiene practices difficult to manage, and supragingival calculus accumulations required bimonthly visits for scaling. Past medical history consisted of uterine cancer, cholecystectomy, and high blood pressure. The patient’s medications included nifedipine (Procardia; Pfizer Inc, Clearwater, Fla) 60 mg, pravastatin sodium (Pravachol; Bristol-Myers Squiff, New York, NY) 20
mg, metoprolol tartrate (Lopressor; Novartis Pharmaceuticals Corp, East Hanover, NJ) 50 mg, atorvastatin calcium (Lipitor; Pfizer Inc) 20 mg, celecoxib (Celebrex; Pfizer Inc) 100 mg, and aspirin 81 mg. A clinical diagnosis of erosive lichen planus was confirmed by histological, immunohistochemical, and immunofluorescence evaluations. Palliative and supportive treatment was provided with periodic use of dexamethasone by her physician. Because of concern with prolonged use of corticosteroids, Protopic (tacrolimus 0.1% ointment) was prescribed to be used twice daily by her physician in 2002. The patient had refused a maxil-
258
Volume 98 Issue 4 lary removable partial denture because of the fear that it would worsen her palatal lesions. Her maxillary teeth deteriorated over time, and she finally accepted the treatment plan, including an immediate maxillary complete denture. At this time, no other viable treatment plan existed. The patient was given the option, once the denture had started to lose retention due to resorbtion in the surgical site, to replace the immediate complete denture with a new complete denture or an implant-retained prosthesis, the type to be determined after a maxillary computed tomography scan. The primary concern regarding treatment was that the patient would not be able to tolerate a complete denture in contact with the palatal lesions. The maxillary anterior teeth were decoronated, and the immediate complete denture was inserted (Figs. 5-7).8 The
patient was instructed to place the tacrolimus 0.1% ointment over the erosive lichen planus lesions, twice daily, before the insertion of the denture. At the 24-hour postinsertion visit, minimal adjustment of the denture base was necessary. The surgery was planned 6 days after the insertion of the immediate maxillary complete denture. The decoronated maxillary teeth were removed atraumatically, and the sockets were sutured with resorbable sutures. Healing was uneventful. After 2 weeks (Fig. 8), the patient was free of pain and able to function with the complete denture. The lesions present were more diffuse but not as ulcerated. The lesions remained unchanged over the next few months. The patient was informed of the FDA announcement and referred to the website for additional information. After being informed, she elect-
ed to continue using the medication periodically, as it allowed her to wear her denture free of pain. While the lesions were not eliminated, they were more superficial, only mildly ulcerated, and the patient reported no pain associated with the palate. This was probably due to the fact that the tacrolimus remained in the area and was not immediately washed away with saliva, since the tongue (which requires cortisone injections by her dermatologist) and cheek lesions remained unchanged. The patient reported the ability to adequately function, although pain from the tongue lesions remained. She reported that the esthetic improvement and ability to eat made the treatment worthwhile. The patient has been under continuous care (more than 1 year) since the placement of the prosthesis.
3 Maxillary right anterior view demonstrating periodontal condition of anterior teeth.
4 Maxillary left anterior view showing periodontal condition of anterior teeth.
5 Maxillary view after remaining teeth were decoronated.
6 Maxillary immediate complete denture.
The Journal of Prosthetic Dentistry
Rabanal et al
259
October 2007
7 Immediate maxillary complete denture after insertion.
SUMMARY This report presents the management of a patient with severe erosive lichen planus in need of an immediate complete denture. The patient was able to tolerate the complete denture well, and her quality of life was improved.
REFERENCES 1. Neville BW, Damm DD, Allen CM, Buiquot JE. Oral and maxillofacial pathology. St. Louis: Elsevier; 2002. p. 680-5. 2. Sugerman PB, Savage NW, Zhou X, Walsh
8 Less ulcerative, more diffuse lesions after denture insertion.
LJ, Bigby M. Oral lichen planus. Clin Dermatol 2000;18:533–9. 3. Sugerman PB, Savage NW, Walsh LJ, Zhao ZZ, Zhou XJ, Khan A, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002;13:350–65. 4. Lener EV, Brieva J, Schachter M, West LE, West DP, el-Azhary RA. Successful treatment of erosive lichen planus with topical tacrolimus. Arch Dermatol 2001;137:419– 22. 5. Olivier V, Lacour JP, Mousnier A, Garraffo R, Monteil RA, Ortonne JP. Treatment of chronic erosive oral lichen planus with low concentrations of topical tacrolimus: an open prospective study. Arch Dermatol 2002;138:1335–8. 6. Byrd JA, Davis MD, Bruce AJ, Drage LA, Rogers RS. Response of oral lichen planus to topical tacrolimus in 37 patients. Arch
Dermatol 2004;140:1508–12. 7. Thomson MA, Hamburger J, Stewart DG, Lewis HM. Treatment of erosive oral lichen planus with topical tacrolimus. J Dermatolog Treat 2004;15:308–14. 8. Woloch MM. Nontraumatic immediate complete denture placement: a clinical report. J Prosthet Dent 1998;80:391–3. Corresponding author: Dr Gary Goldstein NYU College of Dentistry Department of Prosthodontics 345 E 24th St New York, NY 10010 Fax: 212-753-7614 E-mail: [email protected] Copyright © 2007 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature A 3-year prospective clinical and radiologic analysis of early loaded maxillary dental implants supporting single-tooth crowns Turkyilmaz I. Int J Prosthodont 2006;19:389–90. In this study, 19 patients were treated with 36 Branemark System MK III TiUnite implants in the maxilla. Definitive implant-supported single crowns were delivered to patients 6 weeks after implant placement. Clinical and radiographic parameters were recorded at baseline, and at 1, 2, and 3 years. Both implant and prosthesis success rates were 94% after 3 years. The average marginal bone loss was 0.97 mm after 3 years. The results of this study indicate that 6-week early loading of TiUnite surface implants in the maxilla was reliable and predictable for this patient population and may offer an alternative to the standard loading protocol. Reprinted with permission of Quintessence Publishing.
Rabanal et al
Lichen planus is a chronic inflammatory mucocutaneous disease that is considered to be an immunologically mediated process. It was first described by Erasmus Wilson in 1869 and affects almost 1% of the world population. Most patients are middleaged, with women more commonly affected than men.1 T-cell–secreted tumor necrosis factor alpha (TNF-α) and matrix metalloproteinase (MMP9) may be implicated in the pathogenesis of this condition.2 This condition can affect the skin, oral mucosa, or both. The histological presentation is characterized by a subepithelial lympho-histiocytic infiltrate, an increase in the number of intraepithelial lymphocytes, degeneration of basal keratinocytes, and changes in the epithelial basement membrane that result in microscopic gaps between the epithelium and the connective tissue.3 Clinically, the central area of the lesion is ulcerated, and a fibrinous plaque or pseudomembrane covers the ulcer. The periphery of the lesion is usually surrounded by reticular or radiating keratotic striae that become painful when the pseudomembrane
is disturbed.3 As part of the dental treatment, irritating factors must be removed. Scaling and root planing should be performed on a regular basis, ill-fitting restorations should be replaced, and teeth with sharp angles must be reshaped.2 Erosive lichen planus can be treated systemically and locally. Systemic therapy with corticosteroids is indicated for lesions that do not respond to a local treatment. Local therapy includes dexamethasone mouth rinses and triamcinolone or fluorinated steroids applied over the lesions on a daily basis. Combinations of systemic and local therapy are also used successfully. Other agents such as cyclosporine, azathioprine, and levamisole are also used in the treatment of erosive lichen planus.2 The use of the immunosuppressive agent tacrolimus (Protopic; Fujisawa Healthcare, Inc, Deerfield, Ill) is reported in the literature as an effective agent for the control of symptoms of erosive lichen planus.4,5,6,7 Lener et al4 treated a patient with erosive lichen planus lesions of the lip and oral mucosa with 0.1% tacrolimus ointment
and reported complete healing of the lip lesions after daily application for 1 month. The ulcerations of oral mucosa that were treated with the same concentration were in remission 3 months after the start of the treatment. The authors reported that the lesions were in complete remission for a year without maintenance therapy.4 Olivier et al5 evaluated the efficacy of a topical preparation of a 0.5-mg tacrolimus capsule diluted in 500 mL of distilled water. Patients were instructed to rinse with 15 mL for 2 minutes, 4 times a day. The frequency of the rinses was adjusted according to the severity of the symptoms. The author concluded that palliative effects were rapid and significant but not curative. Byrd et al,6 using a questionnaire mailed to 37 patients treated with topical tacrolimus, found that the majority of the patients reported an improvement in the lichen planus lesions and that maintenance therapy was necessary. Thomson et al,7 in a retrospective study, reported on 23 patients with oral lichen planus treated with 0.1% topical tacrolimus. Six weeks after the treatment began,
Former Resident, Advanced Education Program in Prosthodontics. Professor, Department of Periodontics. c Professor, Department of Prosthodontics. a
b
The Journal of Prosthetic Dentistry
Rabanal et al
257
October 2007 21 out of the 23 patients showed improvement of at least 50% of symptoms such as pain, burning sensation, irritation, and altered taste. The longest asymptomatic period was 29 months, and the shortest was 4 months. Fifteen patients were placed on maintenance therapies because of relapses after stopping treatment. Adverse reactions are uncommon but included parasthesia and dysguesia. The Food and Drug Administration, found at http://www.fda.gov/ cder/drug/InfoSheets/HCP/ProtopicHCP.pdf, issued the following alert in March 2005: “The FDA has issued a public health advisory to inform healthcare professionals and patients about a potential cancer risk from use of Protopic (tacrolimus). This concern is based on information from animal studies, case reports in a small number of patients, and knowledge of how drugs in this class work. It may take human studies of 10 years or longer to determine if use of Protopic is linked to cancer. In the meantime, this risk is uncertain, and FDA advises Protopic should be used only as labeled, for patients after other prescription treatments have failed to work or cannot be tolerated.” The purpose of this clinical report is to present the treatment of a patient with severe erosive lichen planus in need of an immediate complete denture treated in conjunction with tacrolimus (0.1%) ointment, an immunosuppressive agent.
CLINICAL REPORT A 75-year-old white woman presented with a complaint of “sores in the mouth” (Figs. 1 and 2). Intraoral examination revealed multiple lesions on the buccal and labial mucosa, the lateral borders of the tongue, the gingiva, and the hard palate. Diffuse erythematous areas were interspersed with desquamative and ulcerative foci. Several areas were asymptomatic, while in other areas burning sensation and/or pain was experienced. No cutaneous or genital lesions were present or reported. All maxillary poste-
Rabanal et al
1 Maxillary view of erosive lichen planus lesion on hard palate.
2 Erosive lichen planus lesions on lateral border of tongue. rior teeth were missing. The maxillary anterior teeth had mobility patterns ranging from 1 to 2+ and probing depths of 4 to 6 mm (Figs. 3 and 4). The remaining mandibular teeth had nonsignificant probing depths and mobility patterns and tested vital. The marginal lichen planus lesions made conventional daily hygiene practices difficult to manage, and supragingival calculus accumulations required bimonthly visits for scaling. Past medical history consisted of uterine cancer, cholecystectomy, and high blood pressure. The patient’s medications included nifedipine (Procardia; Pfizer Inc, Clearwater, Fla) 60 mg, pravastatin sodium (Pravachol; Bristol-Myers Squiff, New York, NY) 20
mg, metoprolol tartrate (Lopressor; Novartis Pharmaceuticals Corp, East Hanover, NJ) 50 mg, atorvastatin calcium (Lipitor; Pfizer Inc) 20 mg, celecoxib (Celebrex; Pfizer Inc) 100 mg, and aspirin 81 mg. A clinical diagnosis of erosive lichen planus was confirmed by histological, immunohistochemical, and immunofluorescence evaluations. Palliative and supportive treatment was provided with periodic use of dexamethasone by her physician. Because of concern with prolonged use of corticosteroids, Protopic (tacrolimus 0.1% ointment) was prescribed to be used twice daily by her physician in 2002. The patient had refused a maxil-
258
Volume 98 Issue 4 lary removable partial denture because of the fear that it would worsen her palatal lesions. Her maxillary teeth deteriorated over time, and she finally accepted the treatment plan, including an immediate maxillary complete denture. At this time, no other viable treatment plan existed. The patient was given the option, once the denture had started to lose retention due to resorbtion in the surgical site, to replace the immediate complete denture with a new complete denture or an implant-retained prosthesis, the type to be determined after a maxillary computed tomography scan. The primary concern regarding treatment was that the patient would not be able to tolerate a complete denture in contact with the palatal lesions. The maxillary anterior teeth were decoronated, and the immediate complete denture was inserted (Figs. 5-7).8 The
patient was instructed to place the tacrolimus 0.1% ointment over the erosive lichen planus lesions, twice daily, before the insertion of the denture. At the 24-hour postinsertion visit, minimal adjustment of the denture base was necessary. The surgery was planned 6 days after the insertion of the immediate maxillary complete denture. The decoronated maxillary teeth were removed atraumatically, and the sockets were sutured with resorbable sutures. Healing was uneventful. After 2 weeks (Fig. 8), the patient was free of pain and able to function with the complete denture. The lesions present were more diffuse but not as ulcerated. The lesions remained unchanged over the next few months. The patient was informed of the FDA announcement and referred to the website for additional information. After being informed, she elect-
ed to continue using the medication periodically, as it allowed her to wear her denture free of pain. While the lesions were not eliminated, they were more superficial, only mildly ulcerated, and the patient reported no pain associated with the palate. This was probably due to the fact that the tacrolimus remained in the area and was not immediately washed away with saliva, since the tongue (which requires cortisone injections by her dermatologist) and cheek lesions remained unchanged. The patient reported the ability to adequately function, although pain from the tongue lesions remained. She reported that the esthetic improvement and ability to eat made the treatment worthwhile. The patient has been under continuous care (more than 1 year) since the placement of the prosthesis.
3 Maxillary right anterior view demonstrating periodontal condition of anterior teeth.
4 Maxillary left anterior view showing periodontal condition of anterior teeth.
5 Maxillary view after remaining teeth were decoronated.
6 Maxillary immediate complete denture.
The Journal of Prosthetic Dentistry
Rabanal et al
259
October 2007
7 Immediate maxillary complete denture after insertion.
SUMMARY This report presents the management of a patient with severe erosive lichen planus in need of an immediate complete denture. The patient was able to tolerate the complete denture well, and her quality of life was improved.
REFERENCES 1. Neville BW, Damm DD, Allen CM, Buiquot JE. Oral and maxillofacial pathology. St. Louis: Elsevier; 2002. p. 680-5. 2. Sugerman PB, Savage NW, Zhou X, Walsh
8 Less ulcerative, more diffuse lesions after denture insertion.
LJ, Bigby M. Oral lichen planus. Clin Dermatol 2000;18:533–9. 3. Sugerman PB, Savage NW, Walsh LJ, Zhao ZZ, Zhou XJ, Khan A, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002;13:350–65. 4. Lener EV, Brieva J, Schachter M, West LE, West DP, el-Azhary RA. Successful treatment of erosive lichen planus with topical tacrolimus. Arch Dermatol 2001;137:419– 22. 5. Olivier V, Lacour JP, Mousnier A, Garraffo R, Monteil RA, Ortonne JP. Treatment of chronic erosive oral lichen planus with low concentrations of topical tacrolimus: an open prospective study. Arch Dermatol 2002;138:1335–8. 6. Byrd JA, Davis MD, Bruce AJ, Drage LA, Rogers RS. Response of oral lichen planus to topical tacrolimus in 37 patients. Arch
Dermatol 2004;140:1508–12. 7. Thomson MA, Hamburger J, Stewart DG, Lewis HM. Treatment of erosive oral lichen planus with topical tacrolimus. J Dermatolog Treat 2004;15:308–14. 8. Woloch MM. Nontraumatic immediate complete denture placement: a clinical report. J Prosthet Dent 1998;80:391–3. Corresponding author: Dr Gary Goldstein NYU College of Dentistry Department of Prosthodontics 345 E 24th St New York, NY 10010 Fax: 212-753-7614 E-mail: [email protected] Copyright © 2007 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature A 3-year prospective clinical and radiologic analysis of early loaded maxillary dental implants supporting single-tooth crowns Turkyilmaz I. Int J Prosthodont 2006;19:389–90. In this study, 19 patients were treated with 36 Branemark System MK III TiUnite implants in the maxilla. Definitive implant-supported single crowns were delivered to patients 6 weeks after implant placement. Clinical and radiographic parameters were recorded at baseline, and at 1, 2, and 3 years. Both implant and prosthesis success rates were 94% after 3 years. The average marginal bone loss was 0.97 mm after 3 years. The results of this study indicate that 6-week early loading of TiUnite surface implants in the maxilla was reliable and predictable for this patient population and may offer an alternative to the standard loading protocol. Reprinted with permission of Quintessence Publishing.
Rabanal et al