DENTINO
JURNAL KEDOKTERAN GIGI Vol IX. No 1. March 2024
ELSABAGH SCORING SYSTEM FOR ASSESSING SEVERITY AND TREATMENT IMPROVEMENT IN MULTIPLE ORAL LICHEN PLANUS
Ayu Permatasanti1), M. Hasan Hapid1), Wahyu Hidayat2)
1)Oral Medicine Residency Program, Faculty of Dentistry, Universitas Padjadjaran
2)Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran
ABSTRACT
Introduction: Lichen planus (LP) is a mucocutaneous, chronic, autoimmune disease, with various clinical manifestations, often involving the oral mucosa, and commonly occurs in adults 30-60 years old. Among the various scoring systems for oral lichen planus, the Elsabagh scoring system is valid, accurate, relatively easier to teach, relatively faster to master, and does not require complex calculations.
Objective: This paper aimed to report and evaluate the successful therapy given based on using the Elsabagh scoring system in oral lichen planus. Case: A 53-years-old woman came to the Department of Oral Medicine with a main complaint of pain in the upper gums and lower right left a year ago. The pain got worse when eating highly spiced and spicy foods. She felt pain when brushing her teeth. Extra oral examination revealed multiple white plaques on the vermilion border. Intra-oral examination revealed erosive, erythema, accompanied by white plaques mesh-like shaped, irregular, and painful, on the upper labial, right and left buccal mucosa, posterior teeth of the mandible that extend into the mucobuccal fold, and gingiva, palate, and posterior gingiva of the right and left maxillae. Amalgam fillings were found on teeth 37 and 46 with plaque and calculus. Based on clinical features, the patient was diagnosed with Multiple Oral Lichen Planus of Erosive and Reticular type. Case management: The patient received topical and systemic corticosteroids, mouthwashes, and supplements. She was advised to stop eating highly spiced and spicy foods, replace amalgam filling with tooth-colored filling, scaling, and replace removable dentures with permanent dentures. The evaluation result using the Elsabagh scoring system showed an improvement from the value of 8 on the initial visit to 3 on the last visit. There was an improvement in the patient's condition after treatment based on evaluation using the Elsabagh scoring system in this case. The Elsabagh scoring system can correlate disease severity with subjective symptoms, allowing comparisons between the initial evaluation of lesions and treatment efficacy or disease progression in oral lichen planus.
Keywords: Autoimmune, Elsabagh Scoring System, Oral Lichen Planus
Correspondence: Wahyu Hidayat, Department of Oral Medicine, Universitas Padjadjaran, Jl. Sekeloa Selatan No. 1, Bandung, West Java, Indonesia 40132; Tel: +62-22-2533044; Email corresponding author:
INTRODUCTION
Lichen planus (LP) is a mucocutaneous, chronic, autoimmune disease, with various clinical manifestations, often involving the oral mucosa.1,2 Prevalence of Oral Lichen Planus (OLP) in adult populations is 0,5-2%. The male-to-female sex ratio is 2: 11 and the onset is between 30-60 years old. 1,3 Other literature states that OLP is two to three times more common in women.3,4 There have been reports of OLP cases occurring in children.1
The most common type is a reticular shape with a characteristic slender white stripe (Wickham striae), erosive/ulcerative, and plaque-like.1 Reticular lesions are often asymptomatic in patients, but atrophic (erythematous) or erosive (ulcerative) OLP is sometimes accompanied by a burning sensation, sensitivity of the oral mucosa to hot or spicy foods, and pain or discomfort in the oral mucosa.4,5
Predilection often occurs mainly in the buccal, gingival mucosa, and mucobuccal fold; rarely occurs on the lips, tongue, and palate.5
Scoring systems have been widely used to evaluate the severity and activity of OLP.6,7 Based on Unnikrishnan et al., there are various OLP scoring systems, namely Thongprasom, Escudier, Reticular Erosive Ulcerative (REU), Reticular Atrophic Erosive (RAE), Malhotra, Modified Oral Mucositis Oral (MOMI), Modified Escudier Index, Siponen and Salo, White Erosive Atrophic Modified (WEA- MOD), Elsabagh, and Reticulation Hyperemia Ulceration (RHU) scoring systems.8
This case report described the use of the Elsabagh scoring system in OLP. The Elsabagh scoring system is a scoring system that was first published in the year 2021.8,9 The Elsabagh scoring system can be a valid, reproducible, and sensitive tool
to accurately assess OLP severity. In addition, the system is easy to teach, relatively faster to master, and does not require complicated calculations.9
This paper aimed to report and evaluate the successful therapy given based on using the Elsabagh scoring system in oral lichen planus.
CASE
A 53-years-old woman came to the Department of Oral Medicine with a main complaint of pain in the upper gums and lower right left a year ago. Initially, the patient went to the general dentist but only did scaling and felt more pain afterward. There was a recovery period of a week. The pain got worse when eating highly spiced and spicy foods. She felt pain when brushing her teeth.
There were no similar lesions in other parts of the body. No history of systemic diseases. No history of smoking, drinking alcohol, taking drugs, or having free sex. The patient's job is martial arts instructor.
She has been married.
CASE MANAGEMENT
A series of examinations have been carried out on the patient. Extra oral examination revealed dry upper and lower lip, desquamation, with white plaque lesions, multiple, at the vermilion border, and pain.
Intra-oral examination as in (Figure 1) revealed an erosive lesion, erythema, accompanied by white plaque mesh-like shaped, irregular, and painful, on the upper labial mucosa, right and left buccal mucosa, posterior teeth of the mandible that extend into the mucobuccal fold and gingiva, palate, and posterior gingiva of the right and left maxillae. The Dorsum tongue revealed a white plaque lesion on the 2/3 posterior of the dorsum tongue, which could be scrapped without left erythema and was painless.
Amalgam fillings were found on teeth 37 and 46 with plaque and calculus. She used a removable denture on the right upper anterior tooth.
Figure 1. Clinical features of the initial visit
Serum cortisol examination revealed normal results (8,5 μg/dL); whereas vitamin D3 examination revealed deficiency (11,6 ng/mL). Based on clinical features, the patient was diagnosed with Multiple Oral Lichen Planus of Erosive and Reticular type.
Elsabagh's total score on the first visit was 8.
On the first visit, therapy is given as topical corticosteroid prednisone 5mg in the form of mouthwash, zinc patented mouthwash, and chlorhexidine gluconate mouthwash 0,2%. The
patient was instructed to brush her teeth and tongue twice a day, increase in eating of vegetables and fruits, meet daily fluid needs, get enough rest, avoid excessive stress, as well as avoid eating highly spiced and spicy foods. We made a referral to the Prosthodontics Department to replace removable dentures with permanent dentures.
On the second visit for control, 21 days after the first visit, The patient's condition improved but still felt painful when eating. She could brush her teeth normally. Clinically, there was an improvement in the lesion’s condition (Figure 2).
Elsabagh's total score on the secondvisit was 7.
Figure 2. Clinical features of the second visit The therapy at the second visit was still the same as before, but chlorhexidine gluconate 0,2%
mouthwash was stopped. Moreover, we made a referral to the Dental Conservative Department to replace the amalgam filling with a tooth-colored filling; as well as gave vitamin D 1000 IU supplement, taken once a day one tablet each.
Fifteen days later on the third visit, the patient’s condition improved (Figure 3). The pain decreased slightly compared to before. She brushed her teeth normally. She has replaced the amalgam filling with a tooth-colored filling. Elsabagh's total score on the third visit was 6.
Figure 3. Clinical features of the third visit
On this visit, prednisone 5mg mouthwash was stopped and replaced with systemic prednisone 5mg per oral, taken twice a day two tablets each in the morning and evening. Moreover, clobetasol propionate 0,05% ointment was given.
At the fourth visit for control, 14 days later, the pain decreased. Clinically, there was an improvement (Figure 4). Elsabagh's total score on the fourth visit was 5.
Figure 4. Clinical features of the fourth visit
Thirty-five days later, on the fifth visit, the patient felt more pain when eating spicy foods and also felt discomfort when brushing her teeth. The patient's condition worsened (Figure 5). Elsabagh's total score on the fifth visit was 6.
Figure 5. Clinical features of the fifth visit
On the sixth visit, 21 days passed since the previous visit, the pain decreased, and the condition improved (Figure 6). The patient could brush her teeth normally again. She has stopped eating highly spiced and spicy foods. Elsabagh's total score on the sixth visit was 4.
Pharmacological therapy given at the fourth to sixth visit was still the same as the third visit. At the fifth visit, the patient got education again, especially related to avoiding eating highly spiced and spiced foods.
Figure 6. Clinical features of the sixth visit
Approximately eight months later, at the seventh visit (Figure 7), the patient still complained of pain when eating spicy food and brushing her teeth a little rough on the right and left buccal mucosa, as well as upper right and left gingiva. We evaluated the vitamin D3 examination. Elsabagh's total score on the seventh visit was 5.
Figure 7. Clinical features of the seventh visit
Between the sixth visit to the seventh visit, the patient stopped prednisone 5mg per oral. On the seventh visit, oral systemic corticosteroid was replaced with methylprednisolone 8mg, twice a day one tablet each. She also got clobetasol propionate 0,1% ointment in combination with triamcinolone acetonide in orabase, by a ratio of 1: 1.
About a month later from her previous visit, on the eighth visit for control, the lesion improved as in (Figure 8). Vitamin D3 examination revealed insufficiency (27,5 ng/mL). We also did the Depression Anxiety Stress Scale (DASS)-21 test and the result was normal. The patient gave consent and wrote informed consent for this case including images, and the institution has also approved for publication. The case has complied with the Helsinki Declaration.
Figure 8. Clinical features of the eighth visit
DISCUSSION
Studies in the literature have proposed many scoring systems for OLP. Among them, those suggested by Thongprasom et al are the most commonly used. Based on a study by Elsabagh et al, the Elsabagh scoring system shows statistically significant substantial agreement with biopsy results, while the Thongprasom score shows almost no agreement with biopsy results. Diagnostic accuracy is much higher for the Elsabagh scoring system, with non-existent statistical significance for the Thongprasom score. In addition, perfect specificity (100%) from the Elsabagh scoring system compared to the Thongprasom score, guarantees its ability to distinguish patients with low-severity disease with very few cases of false negatives. The presence of pain in the basic construction of the scoring system explains the results of concurrent validity, in which a significant strong correlation was found between the Elsabagh scoring system and numerical rating scale (NRS), while the correlation with Thongprasom scores was weaker.9
Elsabagh's scoring system consists of four categories. Each category is given a subscore, then all subscores are added to get the patient's final total score. These categories are described in (Figure 9).9 Pain scores are recorded subjectively using NRS. Patients were asked to verbally rate pain levels on a scale, the result is recorded, and further categorized into no pain (NRS 0), mild pain (NRS 1-3), moderate pain (NRS 4-6), and severe pain (NRS 7-10).9,10,7 According to the Elsabagh scoring
system, the overall score can vary from 0 to 9, with 9 indicating the worst severity of the disease and 0 indicating complete remission of the condition.9
Figure 9. Elsabagh Scoring System
At the first visit, the patient was given topical corticosteroid therapy prednisone 5mg in the form of mouthwash. Corticosteroids are the gold treatment due to their role in dampening cell-mediated immune activity thereby modulating immune function.1,5,11,12
The patient was also given zinc-patented mouthwash. Zinc patented mouthwash containing zinc. Administration of mouthwash containing zinc is based on the consideration that zinc plays an important role in maintaining reproductive function, immune function, and proper wound healing through the regulation of DNA and RNA polymerase, thymidine kinase, and ribonuclease. By decreasing intercellular adhesion molecule (ICAM)-1 and tumor necrosis factor (TNF) expression, both are keratinocyte activation markers, zinc has been proven to have anti-inflammatory effects.13
We gave chlorhexidine gluconate mouthwash 0,2% and made a referral to the Prosthodontics Department to replace removable dentures with permanent dentures. Oral hygiene and oral dental repair play a major role in OLP management.7,12,14 We also made referrals for cortisol and vitamin D3 examinations.
The first visit revealed a feature of erosive lesions accompanied by white lesions; NRS was 8 (severe pain); the location of the lesion was on the bilateral buccal mucosa, upper labial mucosa, and palate; and involved gingivitis with desquamation involving eight teeth. Assessment according to the Elsabagh scoring system on the first visit of each category as in (Figure 10). Elsabagh's total score on the first visit was 8.
At the second visit, we found that the patient had vitamin D3 deficiency. Furthermore, she was advised to consume daily routine vitamin D3 1000 IU per day. Vitamin D is a fat-soluble vitamin that has both internal and external sources. Vitamin D receptor (VDR) is abundant in T lymphocytes and macrophages and most commonly in immature thymus immune cells and mature TCD8+
lymphocytes.15 Cortisol examination results were normal.
Prednisone mouthwash therapy continued,
however, chlorhexidine gluconate 0,2% mouthwash was stopped. Oral hygiene and oral dental repair play a major role in OLP management.1,5,7,12 This is the basis for consideration of the patient referred to dental conservation. we made a referral to the Dental Conservative Department to replace the amalgam filling with a tooth-colored filling. Elsabagh's scoring from the first visit to the second visit decreased. The decrease occurred in the pain category, where the NRS result was from 8 (severe pain) to 6 (moderate pain). Other clinical features at the second visit were still the same as at the first visit. Assessment according to Elsabagh on the second visit of each category as in (Figure 10). Elsabagh's total score on the second visit was 7.
At the third visit, topical prednisone 5 mg in the form of mouthwash was replaced with Clobetasol propionate 0,05% ointment. Topical corticosteroids are widely used in OLP treatments to reduce pain and anti-inflammatory effects. Topical corticosteroids in the form of an adhesive paste, such as clobetasol propionate and triamcinolone acetonide, have been widely used. Clobetasol propionate in a liquid solution, ointment, or Orabase shows effectiveness against OLP, especially for atrophic, erosive, and ulcerative type OLP.1,5,7,16
The patient received systemic corticosteroid therapy prednisone 5mg orally, twice a day in the morning and evening, two tablets each. Topical corticosteroids may be used along with systemic corticosteroids to reduce systemic side effects or may be used alone. 1,5,7
Elsabagh's scoring from the second visit to the third visit decreased. The decrease occurred in the gingivitis category in the form of gingival desquamation, i.e. from a condition involving eight teeth to four teeth. There was also a decrease in pain intensity from NRS 6 to 5, but still on the same pain scale, which was moderate pain. Another clinical feature based on Elsabagh's assessment from the second visit to the third visit was still the same.
Elsabagh's total score on the third visit was 6.
Assessment according to Elsabagh on the third visit of each category is described in (Figure 10).
At the fourth visit for control, the therapy was still the same as the previous visit. Elsabagh's scoring from the third visit to the fourth visit decreased. NRS results decreased from 5 (moderate pain) to 3 (mild pain). Lesions of the labial mucosa disappeared but were still present in the palate. The other clinical features based on Elsabagh's assessment from the third visit to the fourth visit were still the same.
Elsabagh's total score on the fourth visit was 5.
Elsabagh’s scores on the fourth visit of each category are described in (Figure 10).
At the fifth visit, the patient's condition clinically deteriorated due to eating highly spiced and spicy foods. OLP treatment with topical and systemic corticosteroids, and steroid immunomodulatory drugs, can be successful, although even in patients
receiving recommended therapy, the condition will sometimes flare up.17 Many OLP patients describe certain factors that can cause flare-ups. Dental amalgam, toothpaste, mouthwash, and flavors such as mint and cinnamon are some of the trigger variables mentioned in the literature. These exposures may increase the expression of keratinocyte neo-antigens, triggering acute flares.17 The therapy at the fifth visit was still the same as before. The patient received re- education, especially related to avoiding eating highly spiced and spicy foods.
Elsabagh's scoring from the fourth visit to the fifth visit increased. The increase occurred in the category of pain and gingivitis. An increase in the pain category from NRS 3 (mild pain) to 6 (moderate pain); while in the gingivitis category, from involving four teeth to eight teeth. No lesions on the palate.
The other clinical features based on Elsabagh's assessment from the fourth visit to the fifth visit were still the same. Assessment according to Elsabagh on the fifth visit of each category as in (Figure 10).
Elsabagh's total score on the fifth visit was 6.
On the sixth visit, the patient's condition improved. She felt less pain and could brush her teeth normally. She has stopped eating highly spiced and spicy foods. The therapy given at this visit was the same as the fifth visit.
Elsabagh's assessment from the fifth visit to the sixth visit decreased. The decrease occurred in the category of pain and gingivitis. A decrease in the pain category from NRS 6 (moderate pain) to 3 (mild pain); while in the category of gingivitis, from eight teeth to four teeth. The other clinical features based on Elsabagh's assessment from the fifth visit to the sixth visit were still the same. Assessment based on Elsabagh on the sixth visit of each category as in (Figure 10). Elsabagh's total score on the sixth visit was 4.
At the seventh visit, it was discovered that the patient had stopped taking oral prednisone due to discomfort in the form of palpitations for almost five months. Then the patient was given methylprednisolone 8mg orally, twice a day with one tablet each in the morning and evening.
Methylprednisolone is a class of intermediate-acting corticosteroids, a group with prednisone, but has a higher anti-inflammatory potency18 She got clobetasol propionate 0,1% ointment in combination with triamcinolone acetonide in orabase by a ratio of 1: 1. To enhance the effects of topical treatment, carboxymethylcellulose-based preparations (Orabase) have been used to prevent premature clearance of the drug.4, 19,20 Carboxymethylcellulose (CMC) is a first- generation mucoadhesive, synthetic, water-soluble, and anionic polymer.19,20 Triamcinolone acetonide 0,1% is a Class IV and V topical corticosteroid with medium potency.21,22,23 We made a referral for a vitamin D examination for evaluation at the seventh visit.
Elsabagh's assessment from the sixth visit to the seventh visit increased. An increase occurred in the location category. The increase in the location category was from not involving the palate to involving the palate. Other clinical features according to the Elsabagh scoring system from the sixth visit to the seventh were still the same. Assessment based on Elsabagh on the seventh visit of each category as in (Figure 10). Elsabagh's total score on the seventh visit was 5.
On the eighth visit, the patient's condition was much better than the previous visit. Vitamin D3
examination improvement from deficiency to insufficiency (27,5 ng/mL). Vitamin D helps in the wound-healing process.15 On this eighth visit, we did a DASS 21 test and the results showed all normal as in (Table 1). The reference value of DASS 21 is as in (Table 2).
Table 1. DASS 21 test results
Indicator Result Interpretation
Depression 0 Normal
Anxiety 0 Normal
Stress 2 Normal
Elsabagh's assessment from the seventh visit to the eighth visit decreased. A decrease occurred in the category of shape and location of the lesion. The lesion form at the eighth visit revealed only white lesions without erosive. The location of the lesion was only in the left buccal mucosa. Another clinical feature was that the width of gingival desquamation reduced and involved two teeth, and NRS from 3 to 1 with the same pain intensity i.e. mild pain.
Assessments based on Elsabagh on the eighth visit of each category are described in (Figure 10).
Elsabagh's total score on the eighth visit was 3.
Table 2. The reference value of DASS 2124 Depressio
n Anxiety Stress
Normal 0-9 0-7 0-14
Mild 10-13 8-9 15-18
Moderate 14-20 10-14 19-25 Severe 21-27 15-19 26-33 Extremely
Severe 28 20 34
The assessments of the severity and improvement of therapy in this case from the first visit to the eighth visit based on the Elsabagh scoring system are described in (Figure 10).
Figure 10. The Elsabagh scoring system from the first visit to the eighth visit
CONCLUSION
There was an improvement in the patient's condition after treatment based on evaluation using the Elsabagh scoring system in this case. The Elsabagh scoring system can correlate disease severity with subjective symptoms, allowing comparisons between the initial evaluation of lesions and treatment efficacy or disease progression in oral lichen planus.
ACKNOWLEDGEMENT
We thank the patient for her approval of the publication of this paper.
CONFLICT OF INTEREST
The author reports no conflict of interest in this paper.
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