International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

Clinicopathological Correlation in Diagnosis of Oral Lichen Planus with

Emphasis on Importance of Communication between Clinician and
Pathologist for Correct Diagnosis: An Original Research
Altaf Hussain Chalkoo1, Nusrat Nazir2
1
Professor and Head, 2Post Graduate Student,
Department of Oral Medicine and Radiology, Government Dental College Srinagar, Jammu and Kashmir.
Corresponding Author: Nusrat Nazir

Received: 13/01/2016 Revised: 10/02/2016 Accepted: 12/02/2016

ABSTRACT

Aims: Evaluation of clinical and histopathological correlation between oral lichen planus using
Discrepancy Index with emphasis on importance of communication between clinician and pathologist
for proper diagnosis of oral lichen planus.
Methods and Material: 60 patients diagnosed as cases of oral lichen Planus using Modified WHO
diagnostic criteria were selected from the department of oral Medicine and Radiology and were
divided in two groups of 30 patients each. Incisional biopsy was done in all cases and specimen was
sent for HPE. In group A provisional diagnosis and clinical findings were mentioned on specimen
form where as in group B no such information was provided.
Results: In Group A out of 30 clinically diagnosed cases of OLP using Modified WHO diagnostic
criteria 28 cases (93.33%) were Histopathologically consistent with OLP with a discrepancy index of
6.66% . In Group B out of 30 clinically diagnosed cases of OLP using Modified WHO diagnosed
criteria only 18 cases (60%) were histopathologically consistent with OLP and discrepancy index was
40%.
Conclusions: The findings of the present study suggest that not only clinical and pathologic findings
are important for formulation diagnosis of Oral Lichen Planus but also clarity in clinician-pathologist
communication is equally important in order to reach the correct diagnosis

Keywords: Lichen planus, incisional biopsy, Histopathological examination, clinico-pathologist

communication, Discrepancy index.

Key Messages: Diagnosis of OLP cannot be made merely clinically or histopathologically but
correlation of both is very important for proper diagnosis. Moreover there should be clarity of
communication between clinician and pathologist for correct diagnosis.

INTRODUCTION Clinically, it can present as white

Lichen planus is a chronic striations (Wickham’s striae), white
autoimmune, mucocutaneous disease papules, white plaque, erythema, erosion
which can affect the oral mucosa, skin, or blisters. The buccal mucosa, dorsum of
genital mucosa, scalp and nails. The tongue and gingiva are commonly
disease has most often been reported in affected. OLP usually presents as a
middle-aged patients more commonly in symmetrical and bilateral lesion or
females than males. [1] Oral lichen planus multiple lesions. It can occur in six types
is also seen in children although rare. [2,3] of clinical variants namely reticular,

International Journal of Health Sciences & Research (www.ijhsr.org) 173

Vol.6; Issue: 3; March 2016
papular, plaque like, erosive, atrophic and criteria of OLP (van der Meij 2003)
bullous [4,5] and some variants can co-exist compared with the 1978 criteria .
in the same patient. Burning sensation and Oral Lichen Planus is therefore a
sometimes pain usually accompany the syndrome diagnosis that is based on the
erosive, atrophic or bullous type lesion. presence of several clinical and
There are various lesions that resemble histopathological criteria. Thus, the
lichen planus both clinically and diagnostic approach is best described as a
histopathologically. Usually, these lesions method of pattern recognition both
are referred to as “lichenoid” lesions. Oral clinically and histopathologically. [7] This
lichenoid lesions encompass several indicates that diagnosis cannot be achieved
clinical settings: [6] solely based on the clinical or
(1) Oral lichenoid contact lesions histopathological diagnosis. Confirmation
(OLCL) as a result of allergic contact of the diagnosis of OLP therefore has to be
stomatitis (delayed immune mediated made after the correlation of the clinical
hypersensitivity). They are seen in direct and histopathological diagnoses. However,
topographic relationship to dental few data exist on the correlation between
restorative materials, most commonly clinical and histopathological diagnoses of
amalgam, or other contacted agents, e.g., OLP.
cinnamon.(2) Oral lichenoid drug reactions The aim of the present study was
(OLDR), wherein oral and/or cutaneous therefore to establish a clinical and
lesions arise in temporal association with histopathological correlation in the
the taking of certain medications, e.g., oral diagnosis of OLP with emphasis on
hypoglycemic agents, angiotensin- increased clarity in communication
converting enzyme inhibitors, and between clinician and pathologist for
nonsteroidal anti-inflammatory agents; correct diagnosis of oral lichen planus.
previously, such lesions were seen in
conjunction with the widespread use of MATERIALS AND METHODS
gold salts and penicillamine for the The study sample comprises of 60
management of rheumatoid arthritis. (3) patients who visited the Department of
Oral lichenoid lesions of graft-versus-host Oral Medicine and Radiology in which
disease (OLL-GVHD) in patients with after complete clinical examination,
acute, or more commonly, chronic diagnosis of OLP was made based on
graftversus- host disease (cGVHD). The Modified WHO diagnostic Criteria as
lack of the universal diagnostic criteria for described in Table 1. After the patients had
the diagnosis of oral lichen planus (OLP) provided their consent form a detailed
can be made accountable for the current history was taken from each patient, and
scepticism and controversies for diagnosis the exact location of all lesions were noted
of olp. Van der Meij et al. have stressed down in a case report form. A checklist
for the need of diagnostic criteria to be consisting of demographic data, present
universally adopted for its firm diagnosis. illness history, previous medical history,
[7,8]
A clinical and a histopathological drug history, dental restorations and
definition of OLP was formulated by the clinical characteristics of the lesion were
WHO in 1978. [9] Later, in 2003, van der noted down.
Meij and van der Waal, [10] proposed a All the 60 patients of OLP were
modification in the WHO criteria, stating divided into two groups Group A and
OLP diagnosis should be clinico- Group B consisting of 30 patients each.
pathological. Results of Rad et al.’ s [11] All the procedures of biopsy were
study in 2009 showed higher explained to the patient and a written
clinicopathologic correlation in the consent was obtained from the patient.
diagnosis of OLP based on the modified After performing all the baseline

International Journal of Health Sciences & Research (www.ijhsr.org) 174

Vol.6; Issue: 3; March 2016
investigations and under all aseptic an experienced pathologist. where as in
precautions L A was administered, group B no such information was provided
reticular areas of the lesion were selected to the Pathologist i.e the pathologist was
as the most appropriate site of biopsy. The completely blinded about the patient. At
biopsy of erosive form of OLP was the end histopathological reports were
challenging. A biopsy specimen of analyzed [Figure 3] and results were
predominantly erosive lesions was taken formulated.
few millimeters away from the lesion so
that the specimen’s epithelium and
connective tissue remains intact. A 3mm
incisional biopsy was obtained [Figure 1].

Figure 3: Histopathalogical picture of same patient

RESULTS
Statistical software SPSS [Version
20.0] and Microsoft Excel were used to
carry out the statistical analysis of data.
Figure 1 showing site of biopsy Data was analyzed by means of descriptive
Biopsy specimens were preserved statistics viz, percentages and means.
in 10% buffered formalin solution. Graphically the data was presented by bar
Hemostasis was achieved by placing and chart diagrams. Discrepancy index
sutures [Figure 2] and the specimen was was employed for comparison of findings
sent for HPE on the same day. in both groups.
Discrepancy index [DI]: (the number of
incompatible diagnosis/the number of total
sample) x100
In our study Out of total 60 patients
36 were females and 24 were males
[Graph1].

60%

50%

40%
30%
20%
10%
Figure 2: Biopsy site sutured for achieving heamostasis.
0%
In Group A patients provisional
Females Males
diagnosis along with all the clinical
findings were written on the HPE form
which was sent along with the specimen to Graph 1: Gender distribution in patients of study sample
the pathology department which is under

International Journal of Health Sciences & Research (www.ijhsr.org) 175

Vol.6; Issue: 3; March 2016
 Buccal mucosa was affected most Discrepancy index [DI]: (the number of
commonly in 70% of cases followed by incompatible diagnosis/the number of total
buccal mucosa and Tongue in 20 % of sample) x100
cases. Buccal mucosa and lips were
affected in 13.33 % of cases where as
buccal mucosa, Tongue and Gingiva was
affected in 3.33% of cases [Graph 2] 6.66% 0

clinical and
8000.00%
histopathalogical
7000.00% Agreement

6000.00%
clinical and
93.33% histopathalogical
5000.00% disagreement

4000.00%

3000.00%

2000.00%

1000.00%
Graph 4: Discrepancy Index in Group A
0.00%
Buccal Buccal Buccal Buccal In Group B out of 30 clinically diagnosed
mucosa mucosa mucosa mucosa
and and lips tongue cases of OLP using Modified WHO
tongue and
gingiva
diagnostic criteria only 18 cases (60%)
were histopathologically consistent with
Graph 2: Sites of distribution in patients of study sample
OLP and Discrepancy Index was 40%
50% of cases were affected by [Graph 5].
Reticular Oral lichen Planus followed by
erosive OLP in 36.66% of cases. Annular
and plaque type was seen in 6.66% of case

60% clinical and

histopathalogical
40.00%
Agreement
50%

60.00%
clinical and
40%
histopathalogical
disagreement
30%

20%

10%
Graph 5: Discrepancy Index in Group B
0%
Reticular Erosive Annular Plaque
DISCUSSION
To establish and confirm OLP and
Graph 3: Clinical Types of oral Lichen Planus in study OLL diagnosis by using methods such as
sample clinical examination and histopathological
In Group A out of 30 clinically analysis, which are available in everyday
diagnosed cases of OLP using Modified clinical practice and among wider
WHO diagnostic criteria 28 cases population of patients, sometimes
[93.33%] were histopathologically represents a diagnostic challenge. Earlier
consistent with OLP and Discrepancy reports have shown that while clinical
index was 6.66%. diagnosis depends on a clinician
interpretation, [12,13] histopathological

International Journal of Health Sciences & Research (www.ijhsr.org) 176

Vol.6; Issue: 3; March 2016
diagnosis is strictly dependent on a When the histopathologic features are less
pathologist interpretation as well, [14,15] but obvious, the term “histopathologically
also the choice of biopsy area, [16] clinical compatible with” should be used
severity of the disease, activity or Final diagnosis OLP or OLL
remission of the disease, and the clinical To achieve a final diagnosis,
type of OLP (reticular lesions are clinical as well as histopathologic criteria
considered easier for histopathological should be included
confirmation). [17,18] Pathologists’ lack of OLP; A diagnosis of OLP requires
information on clinical features and fulfillment of both clinical and
distribution of lesions could also influence histopathologic criteria
their judgment. [12,15,19] Having in mind OLL; The term OLL will be used
these parameters, which could affect the under the following
final histopathologic interpretation, the Conditions:
results of our study could partially be 1. Clinically typical of OLP but
explained by possible interobserver bias as histopathologically only compatible
histopathological diagnosis was done by with OLP
different pathologists. This should be 2. Histopathologically typical of OLP but
taken into account in the future clinically only compatible with OLP
prospective studies. Therefore, due to 3. Clinically compatible with OLP and
many variables affecting diagnosis, histopathologically compatible with
histopathological finding is insufficiently OLP
reproducible. [14,15] Results of Rad et al.’s [11] study in 2009
In our study Modified WHO showed higher clinicopathologic
criteria of 2003 was used for clinical correlation in the diagnosis of OLP based
diagnosis of OLP. on the modified criteria of OLP so in our
Table I. Modified World Health study we used Modified WHO diagnostic
Organization diagnostic criteria of OLP clinical criteria for clinical diagnoses of
and OLL [10] OLP and we found that In Group A out of
Clinical Criteria 30 clinically diagnosed cases of OLP using
Presence of bilateral, more or less Modified WHO criteria 28 cases 93.33%
symmetrical lesions were Histopathologically consistent with
Presence of a lacelike network of slightly OLP and Discrepancy index was 6.66%
raised gray-white lines (reticular pattern) [Graph 4]. In Group B out of 30 clinically
Erosive, atrophic, bullous and plaque-type diagnosed cases of OLP using Modified
lesions are accepted only as a subtype in WHO criteria only 18 cases (60%) were
the presence of reticular lesions elsewhere Histopathologically consistent with OLP
in the oral mucosa and Discrepancy Index was 40% ( graph
In all other lesions that resemble OLP but 5).
do not complete the aforementioned The appropriate selection of the
criteria, the term “clinically compatible biopsy site has a vital role in the accurate
with” should be used diagnosis of OLP. Previous studies have
Histopathologic Criteria reported that reticular lesions were
Presence of a well-defined bandlike zone histopathologically diagnosed as OLP
of cellular infiltration that is confined to much more consistently than erythematous
the superficial part of the connective and erosive lesions. [20,21] so in our study
tissue, consisting mainly of lymphocytes we have taken biopsy from reticular
Signs of liquefaction degeneration in the portion of the lesion and in cases of
basal cell layer erosive OLP sample was taken few
Absence of epithelial dysplasia millimeters away from an erosion so that

International Journal of Health Sciences & Research (www.ijhsr.org) 177

Vol.6; Issue: 3; March 2016
the specimen’s epithelium and connective pathologist is equally important. In
tissue remains intact. conclusion, the findings of the present
In a few instances the study emphasize the importance of
histopathological features may not be considering both clinical and pathologic
diagnostic as OLP evolves through a cycle findings in the formulation of a final
of exacerbation and quiescence. Biopsy in diagnosis. It also insists on the need for
any condition helps to differentiate increased clarity in clinician-pathologist
whether the lesion is of inflammatory communication in order to reach the
origin or consists of underlying atypical correct diagnosis.
features in the epithelium. It is always
possible that more than one disease REFERENCES
process can coexist together. Hence it is 1. Sugerman PB, Savage NW, Walsh LJ,
prudent to take multiple biopsies. [22] To Zhao ZZ, Zhou XJ, Khan A, Seymour
confirm the clinical diagnosis of OLP, GJ, Bigby M The pathogenesis of oral
histopathological assessment has to be lichen planus. Crit Rev Oral Biol Med
2002;13:350-365
performed and the final diagnosis has to be 2. Laeijendecker R, Van Joost T, Tank
achieved only after the correlation of B, Oranje AP, Neumann HA . Oral
clinical and histopathological diagnosis. lichen planus in childhood. Pediatr
Instead of so many precautions, Dermatol 2005;22: 299-304
comparison of the results of clinical and 3. Patel S, Yeoman CM, Murphy R Oral
histological assessment of OLP in GROUP lichen planus in childhood: a report of
B shows lack of correlation and a very three cases. Int J Paediatr Dent
high Discrepancy Index. These findings 2005;15:118-122
are compatible with a similar study [22] 4. Andreasen JO Oral lichen planus. 1. A
although the clinicopathologic correlation clinical evaluation of 115 cases. Oral
in our investigation is apparently stronger Surg Oral Med Oral Pathol 1968;
25:31-42
than the aforementioned study. Factors 5. Pindborg JJ, Reichart PA, Smith CJ,
that may have contributed to the lack of van der Waal I (1997) Histological
correlation include pathologist’s typing of cancer and precancer of the
unawareness of clinical information, lack oral mucosa. 2nd ed, Springer, New
of clinician-pathologist communication York, 30
and failure to biopsy properly. 6. Thornhill MH, Sankar V, Xu X-J,
In the final stage of the present Barrett AW, High AS, Odell EW, et
study in group A when clinical al. The role of histopathological
characteristics and provisional diagnosis characteristics in distinguishing
were known to pathologist a substantial amalgam-associated oral lichenoid
increase in clinicopathologic correlation reactions and oral lichen planus. J Oral
Pathol Med 2006; 35:233-40.
was observed. 7. Vander Meij EH, Reibel J, Slootweg
PJ, van der Wal JE, de Jong WF, van
CONCLUSION der Waal I. Interobserver and
It seems that in order to achieve intraobserver variability in the
higher clinicopathologic correlation in the histologic assessment of oral lichen
diagnosis of OLP, besides using modified planus. J Oral Pathol Med 1999;
WHO definition of OLP and OLL, it is not 28:274-7.
only important to include clinical and 8. Vander Meij EH, Schepman KP,
histopathologic findings together with Smeele LE, van der Wal JE, Bezemer
other relevant factors such as history of PD, van der Waal I. A review of the
recent literature regarding malignant
systemic diseases, history of drug use,
transformation of oral lichen planus.
cutaneous lesions, and dental health but
Oral Surg Oral Med Oral Pathol Oral
communication between clinician and Radiol Endod 1999; 88:307-10.

International Journal of Health Sciences & Research (www.ijhsr.org) 178

Vol.6; Issue: 3; March 2016
 9. Kramer IR, Lucas RB, Pindborg JJ, lesions: a preliminary study,” Oral
Sobin LH. Defi nition of leukoplakia Surgery, Oral Medicine, Oral
and related lesions: An aid to studies Pathology, Oral Radiology and
on oral precancer. Oral Surg Oral Med Endodontology. 2005;99:696-703
Oral Pathol 1978;46:518-39. 16. G. W. Gynther, B. Rozell, and A.
10. Vander Meij EH, van der Waal I. Lack Heimdahl, “Direct oral microscopy
of clinicopathologic correlation in the and its value in diagnosing mucosal
diagnosis of oral lichen planus based lesions a pilot study,” Oral Surgery,
on the presently available diagnostic Oral Medicine, Oral Pathology, Oral
criteria and suggestions for modifi Radiology, and Endodontics . 2000;
cations. J Oral Pathol Med 2003; 90:164-170.
32:507-12. 17. M.-J. Cobos-Fuentes, ´ A. Mart´ınez-
11. Rad M, Hashemipoor MA, Mojtahedi Sahuquillo- M´arquez, I.Gallardo-
A, Zarei MR, Chamani G, Kakoei S, Castillo, J.-R. Armas-Padr´on, A.
et al. Correlation between clinical and Moreno-Fern´andez, and P. Bull´on-
histopathologic diagnoses of oral Fern´andez, “Oral lichenoid lesions
lichen planus based on modifi ed related to contact with dental
WHO diagnostic criteria. Oral Surg materials: a literature review,”
Oral Med Oral Pathol Oral Radiol Medicina Oral, Patologia Oral y
Endod 2009;107:796-800. Cirugia Bucal 2009; 14:514-520.
12. E. H. van der Meij and I. van der 18. D. J. Zegarelli, “Lichen planus: a
Waal, “Lack of clinicopathologic simple and reliable biopsy technique,”
correlation in the diagnosis of oral Journal of Oral Medicine 1981;36:18-
lichen planus based on the presently 20.
available diagnostic criteria and 19. L. S. Al-ani, “Oral lichen planus
suggestions for modifications,” clinical study with the
Journal of Oral Pathology and clinicopathological correlation in the
Medicine. 2003;32:507-512 diagnosis of O. L. P,” Journal of
13. M. Juneja, S. Mahajan, N. N. Rao, T. College Dentistry 2005;17:57-60
George, and K. Boaz, “Histochemical 20. Xue JL, Fan MW, Wang SZ, Chen
analysis of pathological alterations in XM, Li Y, Wang L. A clinical study
oral lichen planus and oral lichenoid of 674 patients with oral lichen planus
lesions.,” Journal of oral science. in China. J Oral Pathol Med. 2005;
2006;48:185-193 34:467-72.
14. S. K. S. Hiremath, A. D. Kale, and S. 21. Eisen D. The Clinical features,
Charantimath, “Oral lichenoid lesions: malignant potential and systemic
clinico-pathological mimicry and its association of oral lichen planus: A
diagnostic implications,” Indian study of 723 patients. J Am Acad
Journal of Dental Research.2011; Dermatol. 2002; 46:207-14.
22:827-834. 22. Eisenberg E. Oral lichen planus: A
15. S.-O. Piboonniyom, N. Treister, W. benign lesion. J Oral Maxillofacial
Pitiphat, and S.-B. Woo, “Scoring Surg. 2000; 58:1278-85
system for monitoring oral lichenoid

How to cite this article: Chalkoo AH, Nazir N. Clinicopathological correlation in diagnosis of oral
lichen planus with emphasis on importance of communication between clinician and pathologist
for correct diagnosis: an original research. Int J Health Sci Res. 2016; 6(3):173-179.

***********

International Journal of Health Sciences & Research (www.ijhsr.org) 179

Vol.6; Issue: 3; March 2016