Original Article. Direct Immunofluorescence in Clinically Diagnosed Oral Lichen Planus

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1 JOMP Journal of Oral Medicine and Pain Original Article pissn eissn J Oral Med Pain 2016;41(1): Direct Immunofluorescence in Clinically Diagnosed Oral Lichen Planus Kyung-Eun Lee 1,2, Bong-Jik Suh 1,2 1 Department of Oral Medicine, School of Dentistry, Chonbuk National University, Jeonju, Korea 2 Institute of Oral Bioscience, Chonbuk National University, Jeonju, Korea Received February 16, 2016 Revised March 14, 2016 Accepted March 14, 2016 Correspondence to: Bong-Jik Suh Department of Oral Medicine, School of Dentistry, Chonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju 54896, Korea Tel: Fax: yonam@jbnu.ac.kr This paper was supported by Clinical Fund of Chonbuk National University Hospital. Purpose: Oral lichen planus (OLP) is relatively common mucosal disease in clinical dentistry. OLP is intractable and regarded having malignant potential. Until now, there is some debate on how far OLP can be malignant, and which characteristics can be a risk factor for malignant transformation. Clinician need to know some differences between OLP and lesions similar to OLP to manage properly and suppose prognosis correctly. Therefore, the aim of this study was to divide clinical OLP into two groups and to compare the results of direct immunofluorescence (DIF) between two groups. Methods: This study was conducted on outpatients who visited at the department of Oral Medicine in Chonbuk National University Hospital from January 2007 to November Patients with DIF result were retrospectively reviewed. The selected patients were classified clinical typical of OLP (CTO) or clinical compatible with OLP (CCW) by modified World Health Organization diagnostic criteria of OLP and oral lichenoid lesion. Results: DIF were classified by deposition intensity or pattern of anti-human antibody and fibrinogen. The classification of fluorescence pattern in each specimen was graded as positive, possibly positive or negative. Conclusions: Both CTO and CCW had positive and possibly positive pattern. Prevalence of positive pattern was 68.8% in CTO and 52.6% in CCW and that of possibly positive pattern was 9.4% in CTO and 5.3% in CCW. Prevalence of negative was 21.8% in CTO and 42.1% in CCW. Key Words: Direct immunofluorescence; Fibrinogen; Fluorescent antibody technique, direct; Lichen planus, oral INTRODUCTION Lichen planus (LP) is a chronic immune-mediated mucocutaneous disease which can affect oral mucosa, skin, genital mucosa, scalp and nail. 1) When LP is found in the oral cavity without associated dermatologic lesions, it is referred to as oral lichen planus (OLP). Patients diagnosed with skin LP are 50% to 70% more likely to develop oral lesions, whereas patients diagnosed with OLP are only 15% more likely to show skin lesions. 2) The prevalence of OLP has varied from 0.5% to 3% by estimated articles. 3-5) Recent review article reported that an overall age standardized prevalence of 1.27% (0.96% in men and 1.57% in women) could be calculated. 6) One of the most important issues concerning OLP, common mucosal disease in oral cavity, is its potential for malignant transformation into oral squamous cell carcinoma. Some authors concluded that OLP had been considered as malignant potential disorders based on retrospective and prospective epidemiologic data. 7-10) Whereas, van der Meij et al. 11) proposed the modification of World Health Organization (WHO) diagnostic criteria for OLP to differentiate from oral lichenoid lesion (OLL) clinically and histopathologically. By applying modified WHO diagnostic criteria of OLP and OLL, they reported that patients with OLL had an increased risk of oral cancer, but this increased risk Copyright C 2016 Korean Academy of Orofacial Pain and Oral Medicine. All rights reserved. CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Kyung-Eun Lee et al. DIF in Clinically Diagnosed OLP 17 was not detected in patients with OLP. 11) Although uniform criteria for OLP and OLL lack clinically and histologically, 12) it is thought that differential diagnosis of OLP and OLL is important. Several studies suggested that immunopathological finding may occasionally be additional markers in the diagnosis of OLP as it showed fibrinogen deposition at the mucosalsubmucosal interface ) Authors wondered whether the oral lesions which are clinically similar to OLP but not to be matched to clinical diagnostic criteria correctly have differences in immunopathology or not. So we evaluated the prevalence and intensity or pattern of immunofluorescence in groups between clinical typical of OLP (CTO) and clinical compatible with OLP (CCW). MATERIALS and METHODS white lines (reticular pattern), erosive, atrophic, bullous, and plaque type lesions. When the clinical features included the aforementioned criteria, we classified the oral lesions as CTO. The term CCW was used for lesions that do not complete criteria (Table 1). 3. Examination and Diagnostic Classification of Direct Immunofluorescence DIF assays using commercially obtained anti-human antibody (immunoglobulin G [IgG], IgA, IgM, C3) and fibrinogen. Results of DIF were classified by intensity or pattern of anti- human antibody and fibrinogen deposition. The classification of fluorescence deposition in each specimen was graded as positive, possibly positive or negative. Positive pattern (Fig. 1) was defined as intensity that was clearly and consistently greater than the background intensity or as pattern presented linear-to-fibrillary shaggy deposition 1. Patients Selection This study was conducted on outpatients who visited at the department of Oral Medicine in Chonbuk National University Hospital from January 2007 to November 2015 (Jeonju, Korea). Patients with direct immunofluorescence (DIF) result were retrospectively reviewed. Patients who had diagnosed as OLP clinically and performed biopsy from buccal mucosa were selected. 2. Clinical Classification by Modified WHO Diagnostic Criteria of OLP and OLL The selected patients were classified by clinical criteria described on modified WHO diagnostic criteria proposed by van der Meij and van der Waal 17) in The clinical criteria included the presence of bilateral, mostly symmetrical lesions, presence of lace-like network of slightly raised Fig. 1. Positive pattern: direct immunofluorescence stained section shows deposition of fibrinogen along the basement membrane in fibrillary shaggy pattern and clearly and consistently greater intensity than the background. Table 1. Clinical criteria of modified World Health Organization diagnostic criteria of OLP and OLL 17) Clinical criteria Presence of bilateral, more or less symmetrical lesions Presence of a lace-like network of slightly raised gray-white lines (reticular pattern) Erosive, atrophic, bullous and plaque-type lesions are only accepted as a subtype in the presence of reticular lesions elsewhere in the oral mucosa In all other lesions that resemble OLP but do not complete the aforementioned criteria, the term clinically compatible with should be used OLP, oral lichen planus; OLL, oral lichenoid lesion. Cited from the article of van der Meij and van der Waal (J Oral Pathol Med 2003;32: ). 17)

3 18 J Oral Med Pain Vol. 41 No. 1, March 2016 of fibrinogen along the basement membrane (BMZ). In the possibly positive pattern (Fig. 2), the observable intensity was only slightly greater than the background or homogenous linear pattern of fibrinogen was along the BMZ. Negative fluorescence was defined when no observable intensity greater than the background fluorescence was noted ,18) RESULTS A total of 51 outpatients were selected. Of 51 patients, 19 patients were males and 32 patients were females. The overall mean age was years. The youngest patient was 17 years and the oldest was 72 years (Table 2). The most commonly affected site was buccal mucosa followed by buccal fold, buccal gingiva. The distribution of lesions was bilateral in 32 patients and unilateral in 19 patients. All patients had lesions of whitish striae with/without atrophic and erosive lesions (Table 3). Therefore, patients diagnosed as CTO were 32 persons and patients diagnosed as CCW were 19 persons (Table 3). The results of DIF were reviewed through the pictures taken under a fluorescent microscope. Fibrinogen deposition was found in 36 of 51 patients. Both CTO and CCW had positive and possibly positive pattern. Prevalence of positive pattern was 68.8% in CTO and 52.6% in CCW and that of possibly positive pattern was 9.4% in CTO and 5.3% in CCW. Prevalence of negative was 21.8% in CTO and 42.1% in CCW (Table 4). DISCUSSION DIF can be a valuable tool for the diagnosis of a group of mucosal diseases that often difficult to separate clinically and histologically. Location and pattern of fluorescent antibody (IgG, IgA, IgM, fibrinogen) reactions in oral mucosal Table 2. Age and sex distribution of 51 patients Age group (y) Male (n=19) Female (n=32) Fig. 2. Possibly positive pattern: direct immunofluorescence stained section shows deposition of fibrinogen along the basement membrane in homogenous linear pattern and slightly greater intensity than the background Values are presented as number only. Table 3. The outcome of clinical assessment and diagnosis by modified World Health Organization diagnostic criteria of OLP and OLL Clinical state Yes No Clinical feature 1. Presence of bilateral, more or less symmetrical lesions Presence of a lace-like network ) Only presence of a lace-like network 2 0 2) Presence of a lace-like network with erosive, atrophic, bulbous and plaque-type lesions 49 0 Clinical diagnosis Clinically typical of OLP 32 Clinically compatible with OLP 19 OLP, oral lichen planus; OLL, oral lichenoid lesion. Values are presented as number of patients.

4 Kyung-Eun Lee et al. DIF in Clinically Diagnosed OLP 19 Table 4. Comparison of the outcome of clinical diagnosis and direct immunofluorescence assessment Deposition of fibrnogen Clinically typical of OLP (n=32) Clinically compatible with OLP (n=19) Total (n=51) Positive 22 (68.8) 10 (52.6) 32 (62.7) Possibly positive 3 (9.4) 1 (5.3) 4 (7.8) Negative 7 (21.8) 8 (42.1) 15 (29.4) Values are presented as number (%). specimens can be helpful to confirm diagnostic impressions. Specific diseases for which DIF can be helpful include the following: the diagnoses of LP, lupus erythematous, pemphigus vulgaris, mucous membrane pemphigoid, chronic ulcerative stomatitis, and linear IgA. 18) According to several studies of DIF in OLP, the prevalence of positive pattern along the BMZ revealed various finding ranging from about 62% to 100%. Most common DIF pattern was shaggy fibrinogen deposition along the BMZ with or without positive IgM and colloid body ,19,20) Laskaris et al. 13) reported that all thirty five biopsy specimens of patients with OLP demonstrated deposition of fibrinogen at the BMZ in a linear pattern or, more often, in a broad band from which numerous threadlike outgrowths extended into the connective tissue. Firth et al. 14) reported that 84% with patients of OLP were positive in staining with anti-fibrinogen in the BMZ, the staining of colloid bodies with immunoreactive proteins with C3. Buajeeb et al. 21) showed that the prevalence of positive DIF in Thai OLP patients was 82.9%. The most common finding and typical pattern was shaggy fibrinogen at BMZ. However, authors didn t describe clinical criteria of OLP detailedly though these studies were performed in specimens diagnosed as only OLP clinically. 13,14) Buajeeb et al. 21) examined specimens that erosive or atrophic lesion without white striae were misdiagnosed as OLP otherwise known as features of OLP. In our study, we selected clinical OLP with reticular pattern, one of the most important factors in clinical criteria and subdivided into 2 groups the one is as CTO and the other as CCW by modified WHO diagnostic criteria proposed by van der Meij and van der Waal. 17) We could find that positive or possibly positive deposition of fibrinogen at the BMZ represented in both CTO and CCW. Prevalence of positive pattern was 68.8% in CTO and 52.6% in CCW and that of possibly positive pattern was 9.4% in CTO and 5.3% in CCW. Raghu et al. 16) diagnosed OLP and OLL histopathologically unlike our study and concluded that the pattern of fluorescence was more ragged and fibrillary in OLP, while it was more homogenous and less intense in suspected OLL although deposition of fibrinogen at the BMZ was present in both OLP and suspected OLL. In the present study, we could not support that there was difference of fluorescence pattern between CTO and CCW. The reasons is thought because histopathogical findings were not included and lichenoid drug reactions that appeared the same immunofluorescence finding as OLP 22) were not considered. The purpose of this study was to classify patients who had diagnosed as OLP newly by modified WHO diagnostic criteria by van der Meij and van der Waal 17) and to find whether difference of features in DIF was in CTO and CCW or not. But, we were unable to find that there was difference of fluorescence pattern between CTO and CCW. The findings in this study should be considered as preliminary observation, because lesions of patients were classified and analyzed by only clinical criteria. Further study should be investigated to include the evaluation of histopathologic finding and medication with more experimental specimens. There is no specific test to identify between OLP and OLL at the present. In the future, study using other investigative approaches will have to be performed. CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. References 1. Sugerman PB, Savage NW, Walsh LJ, et al. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002;13: Nico MM, Fernan des JD, Lourenço SV. Oral lichen planus. An Bras Dermatol 2011;86:

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