Comment on “Corticosteroid injection in treatment of persistent oral lichen planus: Three cases”

Abstract

To the Editor We have read the paper recently published in this journal by Kurt et al. with great interest. First, we would like to congratulate the authors for making public to the scientific community their experience with the three cases described. However, we believe that some points must be discussed with more attention. The term oral lichen planus (OLP) describes the oral manifestation of a specific autoimmune disease, which may be triggered by several factors, and is classified by the World Health Organization as an oral potentially malignant disorder (Cheng, Gould, Kurago, Fantasia, & Muller, 2016). Along the years, clinicopathologic and molecular evidence supported the better understanding of a wide group of diseases occurring in oral mucosa that is known as oral lichenoid lesions (OLL) (Cheng et al., 2016). These lesions might clinically and pathologically simulate OLP, but do not represent a truly autoimmune reaction against epithelial factors (Cheng et al., 2016). Thus, aiming to provide better clinical approach guidelines and to refine inclusion and exclusion criteria for research within these diseases, strict diagnosis criteria were proposed both in clinical and pathologic levels (Cheng et al., 2016). Kurt et al. superficially describe the differentiation of OLP from other OLL as oral lichenoid reactions (OLR) associated to amalgam dental restorations on their discussion. However, the diagnosis of the cases described are hardly supported by the most recent diagnosis criteria, as proposed on a position paper released by the American Academy of Oral and Maxillofacial Pathology (Cheng et al., 2016). In Cases 1 and 2 (Kurt, Kolsuz, & Eren, 2019), extensive amalgam restorations were in close contact with the lesions. After the replacement of the amalgam for composite resin, the lesions regressed substantially. Although not reaching total healing 1 month after the initial approach, a chronic inflammation as those might take longer periods to reach complete healing, and that does not support the diagnosis of OLP. In our clinical experience, the diagnosis of OLP might take long periods to differentiate OLP from OLR, and moreover, equivocated diagnosis of OLP might change to OLR years later. Case 3 (Kurt et al., 2019) is the one that more closely might represent a true OLP. However, for all the three cases, there is a severe lack on the description of medical history and use of systemic medications, which might influence on the differentiation of OLP from OLR (Boñar-Alvarez et al., 2019). Besides the lack in clinical criteria for the diagnosis of OLP, there is no description or illustration of the histologic characteristics of these lesions. Although we consider the intralesional injection of corticosteroid pertinent to improve the remission process of the lesions, the diagnosis of all three cases might be equivocated. Huge efforts were given by researchers along many years to better understand the OLP and OLL, especially given the malignant potential of OLP and oral lichenoid dysplasia (Shearston, Fateh, Tai, Hove, & Farah, 2019). Most recent scientific publications have considered strict diagnosis criteria and results from these researches are showing more accurate results regarding malignant potential, and clinicopathological behavior of these diseases (Cheng et al., 2016; Shearston et al., 2019). From that, better clinical approach protocols might be developed. When dealing with cases as those described by Kurt et al., clinicians must be aware that a pool of diseases might manifest with a similar characteristic; therefore, the attention to detail and to strictly follow the diagnosis criteria proposed in literature are mandatory. In the cases described by Kurt et al., the good response to the intralesional corticosteroid injection might be by OLRs and not by OLP.