Journal of Evaluation in Clinical Practice:Volume 16(1)February 2010p 111113

Quality of life in patients with oral lichen planus

LpezJornet, Pa PhD MD DDS1; CamachoAlonso, Fabio PhD MDS2 1 Dean Professor and 2 Assistant Professor, Department of Oral Medicine, Faculty of Medicine and Dentistry, University of Murcia, Murcia, Spain Accepted for publication: 30 September 2008 Correspondence Dr Pa LpezJornet, Clnica Odontolgica Universitaria, Medicina Bucal, Hospital Morales Meseguer, Adv. Marques de los Velez s/n, Murcia 30008, Spain, Email: majornet@um.es Keywords: oral disease; Oral Health Impact Profile; oral lichen planus; quality of life Abstract Background: Oral lichen planus (OLP) can seriously affect the quality of life ofpatients because it has a strong impact on social relations, psychological status and daily activities. Objective: To study the quality of life using the Oral Health Impact Profile (OHIP49) (validated Spanish version) in patients with OLP. Patients and methods: A total of 74 patients with a minimum age of 18 years who had lichen planus were recruited into the study, along with 74 healthy subjects matched by sex and age who acted as control. Both groups completed the OHIP49. Results: Higher scores were obtained on the OHIP49 index in patients with OLP for all the subgroups and for the overall total than in the control group. Furthermore, there were statistically significant differences in the items concerning psychological discomfort, social disability and handicap in patients with OLP. Conclusions: The study shows that the quality of life in patients with OLP is reduced and that patientcentred measures should be considered in the management of patients with OLP. Introduction Oral lichen planus (OLP) is a relatively common mucocutaneous disease affecting about 0.1 4% of the population, depending on the study population. OLP is primarily an adult disease and is more common in women, with a femaletomale prevalence of about 2:1 [1 3]. Lichen planus commonly affects the oral mucosa, usually without skin lesions. If present, mucosal lesions are usually multiple and almost always have a bilateral, symmetrical distribution. OLP has a number of forms including reticular, erosive, atrophic and plaque

types. More than one form may be present at the same time and in the same location [1,2]. There is controversy in the literature as to carcinogenicity of OLP lesions. There are several longterm prospective studies that show a malignant transformation rate of 1% over a mean period of 5 years [1,4]. Patients with erosive lichen planus suffer from symptoms that are severe and may even be lifethreatening, preventing the patients from eating and dinking, and influencing the patient's daily life in many ways. The importance of embracing patients' views in assessing oral health needs and in treatment planning has been widely advocated. To that end, a number of different patientcentred oral health status measures have been developed over the last decade, to assess the physical, social and psychological consequences of oral health and thus the impact of oral health status on quality of life. These measures are recommended to complement traditional clinical oral health status measures, to improve communication between patients and their clinical attendants, and to provide greater understanding of the consequences of oral disease upon daytoday living and the quality of life [2,5]. The Oral Health Impact Profile (OHIP49) was developed for detailed measurement of the levels of dysfunction, discomfort and disability associated withoral disorders. Some of these measures are used routinely in national epidemiological studies and are also commonly used among various oral health specialties, particularly those involving oral rehabilitation and oral cancer. However, it is little used in oral diseases such as viral infections, candida, lichenplanus, and so on [6]. The aim of this study was to investigate the dimensional structure of oral healthrelated quality of life measured by the validated Spanish version of the OHIP49 [7] in patients diagnosed in accordance with the World Health Organization (WHO) criteria for OLP and to evaluate the OHIP49. Material and methods The study was carried out between January and November 2006. Consecutive patients from the Department of Oral Medicine, University of Murcia (Spain), with OLP, according to the WHO criteria [8], were included in the study. All patients were informed that OLP is a chronic disease and a premalignant condition. All the patients were Caucasian, aged more than 18 years; the presence of any other oral mucosa condition and skin lichen planus were the exclusion criteria. All patients with OLP were diagnosed in the University Dentistry Clinic and presented the same sociocultural characteristics. The interviewer (previously trained) presented herself and provided information about the study, as well as the time needed (30 minutes). The interview was carried out once informed consent had been granted by the patient. The validated Spanish version was used, which contains 49 items [7]; individuals were asked how frequently they had experienced any impact of the disease in the last month. This is a patientcentred outcome measure based on the WHO's diseaseimpairmentdisability handicap model. This questionnaire was then completed by 74 consecutive patients with

OLP. In our group of patients with OLP (n = 74), 68 patients (91.89%) were treated with topical steroids and six (8.11%) with systemic steroids. The control group was composed of healthy patients of the same age, sex and sociocultural characteristics as the study. The OHIP49 is a model for measuring oral health. In the OHIP49, each item was scored: never 0; hardly ever 1; occasionally 2; fairly often 3; very often 4. El OHIP49 is divided into seven different parts, and the possible score range for each of these is: functional limitation (9 items) from 0 to 36; physical pain (9 items) from 0 to 36; psychological discomfort (5 items) from 0 to 20; physical disability (9 items) from 0 to 36; psychological disability (6 items) from 0 to 24; social disability (5 items) from 0 to 20; handicap (6 items) from 0 to 24; and finally overall OHIP score (49 items) from 0 to 196. In this model, the higher the scores, the poorer state of health. The study was performed according to the principles of the Helsinki Declaration and was approved by the local ethics committee. Data were analysed using the SPSS 12.0 statistical program (SPSS Inc., Chicago, IL, USA). A descriptive study was made of each variable. The KolmogorovSmirnov normality test and Levene variance homogeneity test were applied, and the data were seen not to show a normal distribution. Statistical analysis was performed using a nonparametric ranking test, while the MannWhitney Utest was used in comparisons between groups. Statistical significance was accepted for P 0.05. Results The group of patients with OLP (n = 74) was made up of 16 man (21.62%) and 58 women (78.38%). The average age was 53.23 13.13 (range 2078) years. The control group (n = 74) consisted of 23 men (31.08%) and 51 women (68.92%), with an average age of 48.07 14.01 (range 2885) years. As regards the validated Spanish OHIP49, we found higher scores in all patients and subgroups than in the control group. Furthermore, significant differences were found in the subgroups of psychological discomfort (P = 0.011), social disability (P = 0.028) and handicap (P = 0.017) for the patients with OLP (Table 1).

Table 1 Comparison between the Spanish healthy control and 74 patients with oral lichen Whitney Utest was used in comparisons between groups) Discussion Quality of life is increasingly acknowledged as a valid, appropriate and significant indicator of service need and intervention outcomes in contemporary public health research and practice. Healthrelated qualityoflife measures, including objective and subjective assessments, are especially useful for evaluating efforts to prevent disabling chronic diseases and assessing their effectiveness [5]. The OHIP is a questionnaire designed to measure selfreported dysfunction, discomfort and disability attributed to oral conditions and is based on a conceptual oral health model outlined by Locker et al. [5]. The original instrument has 49 items representing seven domains (functional limitation, physical pain, psychological

discomfort, physical disability, psychological disability, social disability and handicap) and has been shown to be reliable and sensitive to changes and to exhibit suitable crosscultural consistency. Traditionally, the most frequently used method has been the selfadministered questionnaire, and Robinson et al. [9] found no difference in the scores obtained for the OHIP between those carried out via interview and those that are selfadministered. Patientbased outcome measures are not routinely incorporated into the clinical decisionmaking process. The shift towards evidencebased medicine means that the patients' perceptions of quality of lifecould be included in this process. This would increase the clinician's awareness of how the patients' disease affects them from day to day. Clinical measures alone do not provide an accurate representation of the impact of oral health on an individual's quality of life, and basing treatment only on physiological factors may not give as effective relief from symptoms as when taking into account all aspects of health [6]. Our results are in agreement with those obtained by Llewellyn and Warnakulasuriya [6]. For other diseases of the oral mucosa, Mumcu et al. found thatpatients with Behet's disease, recurrent stomatitis aphthosa and oral ulcers enjoy a poor quality of life [10]. Hegarty et al. found that increased pain, as evaluated by visual analog scale (VAS), was associated with a poor oral healthrelated quality of life in patients with lichen planus [3]. Lundqvist et al. found that the erosive lichen planus is a severe disease with symptoms and complications affecting the patient's life [11]. According to the literature, oral health problems can result in pain and discomfort and can lead to problems in eating, interpersonal relationships, appearance and the individual's positive selfimage [12]. From investigating patients with erosive lichen planus, we conclude that it is necessary to treat the patients as a whole and not to ignore the psychological wellbeing, even though physical symptoms and complaints are severe. Other authors, such as Jensen et al. [13], also obtained very dispersed results. In our study, the quality of life of a reticular OLP was really higher than the control group. Furthermore, significant differences were found in the subgroups of psychological discomfort (P = 0.011), social disability (P = 0.028) and handicap (P = 0.017). We recognize that there are several limitations inherent to this study. First, our sample included only patients from southeast Spain, which limits generalization. The prevalence of hepatitis C virus (HCV) in patients with OLP in Spain is 20% [14], which may influence the psychological discomfort felt by them. However, the prevalence of HCV in our group was very low and we observed no difference between those with and without HCV. The present study is the first to evaluate quality of life in Spanish patients with OLP using the validated Spanish OHIP49 questionnaire. We believe these results support the use of qualityoflife measures in the field of oral medicine.

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