Oral lichen planus: the white striae the hygienist sees before anyone else

Oral lichen planus is among the mucosal lesions hygienists encounter most often, and in many cases it is whoever performs the hygiene who notices it first.

The commonest form is reticular: a pattern of fine interlacing white striae, known as Wickham's striae, on otherwise normal mucosa.

The typical site is the posterior buccal mucosa, bilaterally. Bilaterality is an important element: the lesions are generally symmetrical, and this helps distinguish them from other conditions.

In the reticular form the patient has no symptoms and often does not know they have it. It requires no treatment, but it does require recognition and documentation.

The erosive form is different and symptomatic. Red, ulcerated, painful areas appear, making acidic or spiced food difficult and complicating home hygiene.

The distinction matters because the erosive form requires medical management, while the reticular one only needs monitoring over time.

The principal differential concerns other white lesions. Pseudomembranous candidiasis wipes away with gauze leaving an erythematous surface; lichen does not, because it lies within the thickness of the epithelium.

Leukoplakia typically presents as a homogeneous plaque rather than a network, and is more often unilateral.

Morsicatio buccarum, the lesion from chronic cheek biting, has a shredded irregular appearance, sits along the occlusal line, and relates to a habit the patient confirms when asked.

The designation of oral lichen as a potentially malignant lesion carries a practical obligation: the lesions must be documented and followed over time, and changes reported.

Photographing at the outset and at every review is the simplest way to make comparable an appearance that memory cannot.

On hygiene, the practical point is that plaque accumulation worsens the symptoms of erosive forms, so hygiene matters more here than elsewhere, and at the same time the patient avoids it because it hurts.

Management means gentle instrumentation, a very soft brush, toothpastes without sodium lauryl sulphate and without strong flavourings, and avoiding alcohol-containing mouthwashes that increase burning.

In summary: the reticular form is bilateral, symptomless and monitored, the erosive form is symptomatic and needs medical management, candidiasis wipes away with gauze while lichen does not, photographic records make progression comparable, and hygiene must be made tolerable because it matters more here.