|Year : 2014 | Volume
| Issue : 1 | Page : 19-23
Psychiatric morbidity in oral lichen planus: A preliminary study
Abhishek Ranjan Pati1, Mubeen Khan2, Vijayalakshmi Konaajji Ramachandra2, Rajat Panigrahi1, Soumik Kabasi3, Swati Saraswata Acharya4
1 Departments of Oral Medicine and Radiology, Institute of Dental Sciences, Siksha O Anusandhan (SOA) University, Bhubaneswar, Odisha, India
2 Department of Oral Medicine and Radiology, Government Dental College, Bangalore, Karnataka, India
3 Department of Public Health Dentistry, Institute of Dental Sciences, Siksha O Anusandhan (SOA) University, Bhubaneswar, Odisha, India
4 Department of Orthodontics, Institute of Dental Sciences, Siksha O Anusandhan (SOA) University, Bhubaneswar, Odisha, India
|Date of Submission||14-Jun-2014|
|Date of Acceptance||03-Aug-2014|
|Date of Web Publication||26-Sep-2014|
Abhishek Ranjan Pati
Room No. 101, Department of Oral Medicine and Radiology, Institute of Dental Sciences, K-8 Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To study the clinical types and association of psychological factors in patients with Oral Lichen Planus (OLP). Materials and Methods: An analytical age- and sex-matched study involved 30 patients with oral lichen planus (group 1) and 30 control subjects (group 2). We applied the following psychometric tests to both groups: General Health Questionnaire (GHQ) and Hospital Anxiety and Depression Scale (HADS). Results: The patients with OLP were found to exhibit statistically significant higher anxiety, insomnia, and social dysfunction with the tests that were used (GHQ 24 and HADS) than the control group (P > 0.05). The study group likewise exhibited greater depression and somatic symptoms. The mean total of the GHQ and HAD scores were found to be higher in the study group than in the controls (P > 0.05). Among the various types of OLP, patients with the erosive type had higher mean scores for anxiety and insomnia, social dysfunction and depression. Conclusion: In most patients psychiatric morbidity was strongly associated with OLP, which could support its role in the etiopathogenesis of the disease. The higher scores of the General Health Questionnaire and Hospital Anxiety and Depression Scale gave an insight into the hypothesis that psychological factors are associated with the causation of OLP.
Keywords: Anxiety, oral lichen planus, psychiatric morbidity, stress
|How to cite this article:|
Pati AR, Khan M, Ramachandra VK, Panigrahi R, Kabasi S, Acharya SS. Psychiatric morbidity in oral lichen planus: A preliminary study
. J Indian Acad Oral Med Radiol 2014;26:19-23
|How to cite this URL:|
Pati AR, Khan M, Ramachandra VK, Panigrahi R, Kabasi S, Acharya SS. Psychiatric morbidity in oral lichen planus: A preliminary study
. J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2020 Jan 27];26:19-23. Available from: http://www.jiaomr.in/text.asp?2014/26/1/19/141833
| Introduction|| |
Lichen Planus is a relatively common mucocutaneous disease. Although the prevalence is unknown, studies suggest an incidence of 0.02 to 0.22% among the Indian population.  The exact etiology of Oral Lichen Planus (OLP) is still not understood. It has been suggested that OLP may have a psychological component in its etiology, and indeed, patients often relate the onset or an exacerbation of their condition to stressful life events.  It has been shown, that the emotional arousal resulting from stress leads to activation of the autonomic nervous system and release of neuropeptides from cutaneous sensory nerve fibers, which may be responsible for the initiation and exacerbation of the inflammatory response in the skin. 
Although a number of epidemiological studies have been carried out in western countries, very little is known about its nature in the Indian population, hence, a sincere effort has been made to assess the status of OLP in a selected hospital-based population, in order to obtain data such as prevalence, distribution according to age, sex, clinical types, intraoral locations, and the association of psychological factors with OLP.
| Materials and Methods|| |
The study was conducted on 60 patients, who comprised of the study group (group 1, n = 30) having OLP and age- and sex-matched controls (group 2, n = 30) reporting to the Department of Oral Medicine and Radiology, Government Dental College and Research Institute and to the Department of Psychiatry, Bangalore Medical College (which worked in collaboration), from September 2011 to February 2012. They were in an age group ranging from 21-70 years. The subjects were explained in detail about the procedure of the study and each subject gave an informed written consent for inclusion in the study.  A thorough history taking and clinical examination was done and the study group was selected based on the following inclusion criteria:
a. Patients with OLP (group 1) exhibited the characteristic clinical features of the disease, with histopathological confirmation (basal layer hydropic degeneration and a profuse infiltration of lymphoid cells within the limits of the basal zone),  and were not taking psychoactive drugs. The patients with known systemic diseases and on drugs were excluded from the study.
b. Control subjects (group 2), who were selected from the same city, presented no oral mucosal lesions or any other systemic diseases and were not known to have undergone psychosomatic alterations or to be receiving psychoactive medication.
Patients with OLP were selected based upon the clinical criteria given by the World Health Organization (WHO).  The Modified WHO diagnostic criteria of OLP and Oral Lichenoid Lesion (OLL)  clinical criteria are:
1. Presence of bilateral, more or less symmetrical lesions.
2. Presence of a lacelike network of slightly raised gray-white lines (reticular pattern).
3. Erosive, atrophic, bullous, and plaque-type lesions are accepted only as a subtype in the presence of reticular lesions elsewhere in the oral mucosa.
In our study OLP were clinically divided into erosive and non-erosive types according to the classification by Eisen.  A shorter 28-item General Health Questionnaire (GHQ) proposed by Goldberg and Hillier  was used as a screening instrument to detect those with a diagnosable psychiatric disorder, consisting of four subscales: Somatic symptoms; anxiety and insomnia; social dysfunction; and severe depression. The Hospital Anxiety and Depression Scale was used for identifying and quantifying the two most common forms of psychological disturbances in patients, namely, anxiety and depression. 
| Statistical Analysis|| |
Statistical analysis was done using the SPSS version 9.0 (Statistical Package for the Social Sciences, Chicago, Illinois, USA). The Kruskall Wallis H Test was used as a nonparametric equivalent to one-way analysis of variance (ANOVA), to test several independent samples assuming that the underlying variable has a continuous distribution. The Mann Whitney U Test was used as a nonparametric equivalent to the t-test for two independent samples from the same population. A P value < 0.05 was considered as significant.
| Results|| |
In a comparison between the OLP subjects and the control group, we obtained the following results:
Out of 30 OLP patients, 15 (50%) were males and 15 (50%) females. The mean age of the OLP patients was 39.97 ± 7.48 years, where in male patients it was 41 years as compared to 39 years for females. A male female ratio of 1:1 was observed. The mean age was found to be slightly higher in the study group compared to the control group, but the difference between them was not statistically significant (P > 0.05). Out of 30 patients in the study group, we found fourteen (47%) cases with an erosive form, eight (27%) with a reticular form, five (17%) with an annular form, two (7%) with a plaque form, and one (3%) with a hypertrophic type [Graph 1] [Additional file 1].
In our study of 30 patients, 56% had normal anxiety, 33% had borderline anxiety, and 3.33% had morbid anxiety on a Hospital Anxiety Scale. For depression in our study, 73.33% were normal and 26.26% had mild depression [Table 1], [Graph 2] [Additional file 2].
|Table 1: Table showing comparison of OLP and control patients upon individual scores obtained in Hospital Anxiety & Depression scale|
Click here to view
The mean scores of anxiety and insomnia, social dysfunction, GHQ, and Hospital Anxiety were found to be higher in the study group compared to the control group, and the difference between them was found to be statistically significant (P < 0.05) [Graph 3] [Additional file 3]. A higher mean hospital depression score was recorded in the study group compared to the control group, but the difference between them was not statistically significant (P > 0.05). Among the various types of OLP, the erosive type had the highest prevalence (47%). We used the Kruskal-Wallis chi-square test to correlate the various psychological factors with the types of OLP, and found that higher mean somatic symptoms, anxiety and insomnia, social dysfunction, and depression were found in the erosive type.
| Discussion|| |
First described by Erasmus Wilson, in 1869, Oral Lichen Planus is a disease that affects the skin, scalp, nails, and mucosa. , Lichen planus is a chronic inflammatory epidermal and mucosal disease, reportedly affecting 0.5 to 2.0% of the general population, with a mean age of onset in the fourth to fifth decade, with a higher mean age in males,  which was in accordance with our study. A majority of the studies revealed a female predominance. Thorn et al.,  in 1988, found male:female ratio to be 1:2. Silverman et al.,  in 1985, found 67% of their patients to be females. Eisen,  in 1999, also found 70 and 30% occurrence in females and males, respectively. However, according to McCarthy and Shklar,  OLP had equal predilection for males and females, which was consistent with our study. This increase in the male population may be due to the fact that the study was conducted in a closed dental setting.
In a majority of the reported studies and surveys, OLP could present with various clinical forms and at multiple oral sites. , Out of 30 OLP subjects in our study, twenty-one cases (70%) had lesions on the buccal mucosa, three cases (10%) had lesions on the tongue, five cases (16.66%) had lesions on the gingiva, and one case (3.33%) had lesions on the palate. No cases in the present study had lesions on the lip or floor of the mouth. Lichen planus isolated to a single oral site other than the gingiva was an infrequent occurrence. Isolated lip lesions were reported by Allan and Buxton. 
Our findings correlate with the study by Shklar and McCarthy,  where they found the highest involvement site (80%) in the buccal mucosa. Scully and el-Kom  noted that approximately 10% of the patients with OLP have the disease confined to the gingiva. The prevalence of isolated gingival lichen planus in this study was higher (16%). Gingival lichen planus may be more difficult to diagnose than other characteristic clinical forms of the disease. When lichen planus is confined to the gingiva, the clinical appearance of lichen planus in the form of desquamative gingivitis shares many clinical features with vesiculoerosive diseases. When gingival lichen planus presents as small, raised, white, lacy papules or plaques, it may resemble keratotic diseases such as leukoplakia. Furthermore, the histopathological features of gingival lichen planus are often non-diagnostic, as they are altered by superimposed gingivitis. 
Oral Lichen Planus can present in a variety of clinical forms - the most common among this is the reticular form. , Our observation was in contrast with the other studies. ,, In the present study, we found approximately fourteen (47%) cases in the erosive form, eight (27%) in the reticular form, five (17%) in the annular form, two (7%) in the plaque form, and one (3%) of the hypertrophic type. This variation can be accounted for, as the study was conducted in a closed dental setting.
An attempt has been made to associate OLP with a variety of systemic maladies such as diabetes mellitus, rheumatic collagen diseases, chronic stress syndrome, hypertension, viral infections, human leukocyte antigen (HLA) predispositions, and idiosyncratic drug reactions.
However, these associations have relied primarily on anecdotal evidence, as the true cause of lichen planus remains poorly defined.  Since the description of the disease by Wilson, attention has been drawn to the importance of psychosomatic factors. Anderson pointed out, in 1968, that patients with OLP were found to be in a state of stress and anxiety, with emotional changes. 
Two of the conditions known to be intermediate agents leading to many somatic malfunctions, stress, and anxiety, are the combined result of environmental and social factors. Both these factors have a potential effect on oral health.  Preda et al., based on psychological investigations, have reported that the oral mucosa is an erogenic zone and is an extremely complex and vulnerable region, that is, very reactive to certain psychological influences. These authors have also included OLP as one of the psychosomatic diseases.  It has been shown that the emotional arousal resulting from stress leads to activation of the autonomic nervous system and release of neuropeptides from the cutaneous sensory nerve fibers, which may be responsible for the initiation and exacerbation of the inflammatory response in the skin. 
Mental disturbance has been discussed as one of the causative factors of lichen planus. , We found a higher mean score of somatic symptoms, anxiety, and depression in the erosive type of OLP when compared to other clinical types. Investigators have tried to distinguish the importance of the psychological factors in relation to the different types of OLP, with no clear results. McCartan  found a high level of anxiety in cases of non-erosive OLP, whereas, Lowental and Pisanti  established them in the erosive-bullous form, which was in accordance with our study.
In our study of 30 patients, 56% had normal anxiety, 33% had borderline anxiety, and 3.33% had morbid anxiety on the Hospital Anxiety Scale, which was similar to the results obtained by McCartan,  where 50% had normal, 24% had borderline, and 13% had morbid anxiety, based on scores obtained on the Hospital Anxiety Scale.
With regard to depression, in our study, 73.33% were normal and 26.26% had mild depression. This was in accordance with other studies of McCartan,  where 88% had no depression, 6% had borderline, and 6% had morbid depression, however, we did not find any patient with morbid depression, since the study was carried out in a closed dental setting.
We found a higher mean HAD and GHQ score in the study group compared to the control group. Our results were similar to a study done by Hampf et al.,  who found that the OLP patients were more disturbed as compared to the controls as seen in our study. Burkhart et al.,  assessed the medical history, lifestyle, and health habits, and pointed out the occurrence of stressful events at the onset of OLP in 51% of the subjects. More recently Rojo-Moreno et al.,  in a controlled study on 100 patients, using different psychometric tests, found greater anxiety and depression in OLP patients than in the controls. On the contrary, Allen et al.  and Mcleod  reported that there was no relationship between the patients with this condition and the stressing events or symptoms of anxiety experienced by them; they concluded that the psychological factors were not important in its etiology nor in the severity of the OLP.
A hypothesis can be proposed that psychosomatic factors may be related to the oral lesions of OLP, in the sense that patients with erosive and atrophic lesions exhibit greater anxiety and other psychological alterations. Such disorders could represent an etiological cofactor in OLP; contrarily, the disease and its lesions could be responsible for the psychological problems. Extensive longitudinal studies would be required to make such a distinction in different setups.
| Conclusion|| |
From this study, we can conclude that along with the conventional therapy for OLP patients, it may be beneficial to advocate psychiatric services as an aid in the possible prevention of disease exacerbations and to avoid the occurrence of somatisation. The present study represents a cross-sectional survey and extensive longitudinal studies would be required to establish the role of stress, anxiety, and depression in the etiopathogenesis of Oral Lichen Planus. Our findings merely reflect the psychological status of our patients with OLP; no further interpretations or generalizations are possible on the basis of the results obtained.
| References|| |
|1.||Shah B, Ashok L, Sujatha GP. Evaluation of salivary cortisol and psychological factors in patients with oral lichen planus. Indian J Dent Res 2009;20:288-92. |
|2.||Eisen D. The clinical features, malignant potential, and systemic associations of oral lichen planus: A study of 723 patients. J Am Acad Dermatol 2002;46:207-14. |
|3.||Peterson LJ. Institutional review board (IRB) and informed consent. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:125. |
|4.||Scully C, el-Kom M. Lichen planus: Review and update on pathogenesis. J Oral Pathol 1985;14:431-58. |
|5.||Rad M, Hashemipoor MA, Mojtahedi A, Zarei MR, Chamani G, Kakoei S, et al. Correlation between clinical and histopathologic diagnoses of oral lichen planus based on modified WHO diagnostic criteria. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:796-800. |
|6.||Goldberg DP, Hillier VF. A scaled version of the general health questionnaire. Psychol Med 1979;9:139-45. |
|7.||Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70. |
|8.||Rojo-Moreno JL, Bagán JV, Rojo-Moreno J, Donat JS, Milián MA, Jiménez Y. Psychologic factors and oral lichen planus. A psychometric evaluation of 100 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:687-91. |
|9.||Chaudhary S. Psychosocial stressors in oral lichen planus. Aust Dent J 2004;49:192-5. |
|10.||Myers SL, Rhodus NL, Parsons HM, Hodges JS, Kaimal S. A retrospective survey of oral lichenoid lesions: Revisiting the diagnostic process for oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:676-81. |
|11.||Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ. Course of various clinical forms of oral lichen planus. A prospective follow-up study of 611 patients. J Oral Pathol 1988;17:213-8. |
|12.||Silverman S Jr, Gorsky M, Lozada-Nur F. A prospective follow-up study of 570 patients with oral lichen planus: Persistence, remission, and malignant association. Oral Surg Oral Med Oral Pathol 1985;60:30-4. |
|13.||Eisen D. The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:431-6. |
|14.||McCarthy PL, Shklar G. Diseases of the oral mucosa. 2 nd ed. Philadelphia: Lea and Febiger; 1980. p. 203. |
|15.||Xue JL, Fan MW, Wang SZ, Chen XM, Li Y, Wang L. A clinical study of 674 patients with oral lichen planus in China. J Oral Pathol Med 2005;34:467-72. |
|16.||Allan SJ, Buxton PK. Isolated lichen planus of the lip. Br J Dermatol 1996;135:145-6. |
|17.||Seoane J, Romero MA, Varela-Centelles P, Diz-Dios P, Garcia-Pola MJ. Oral lichen planus: A clinical and morphometric study of oral lesions in relation to clinical presentation. Braz Dent J 2004;15:9-12. |
|18.||Vincent SD, Fotos PG, Baker KA, Williams TP. Oral lichen planus: The clinical, historical and therapeutic features of 100 cases. Oral Surg Oral Med Oral Pathol 1990;70:165-71. |
|19.||Lowental U, Pisanti S. Oral lichen planus according to the modern medical model. J Oral Med 1984;39:224-6. |
|20.||Ivanovski K, Nakova M, Warburton G, Pesevska S, Filipovska A, Nares S, et al. Psychological profile in oral lichen planus. J Clin Periodontol 2005;32:1034-40. |
|21.||Kimyai-Asadi A, Usman A. The role of psychological stress in skin disease. J Cutan Med Surg 2001;5:140-5. |
|22.||Wilson E. On lichen planus. J Cutan Med Dis Skin 1869;3:117-32. |
|23.||McCartan BE. Psychological factors associated with oral lichen planus. J Oral Pathol Med 1995;24:273-5. |
|24.||Hampf BG, Malmström MJ, Aalberg VA, Hannula JA, Vikkula J. Psychiatric disturbance in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol 1987;63:429-32. |
|25.||Burkhart NW, Burkes EJ, Burker EJ. Meeting the educational needs of patients with oral lichen planus. Gen Dent 1997;45:126-32; quiz 143-4. |
|26.||Allen CM, Beck FM, Rossie KM, Kaul TJ. Relation of stress and anxiety to oral lichen planus. Oral Surg Oral Med Oral Pathol 1986;61:44-6. |
|27.||Mcleod RI. Psychological factors in oral lichen planus. Br Dent J 1992;173:88. |