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the erosive form. The World Health Orga- Clinical: In general, this is a fairly straight- will not be aware of the habit or they may
nization classifies oral lichen planus as a forward clinical diagnosis. Some patients be bruxing or grinding their teeth at night.
premalignant condition (Figures 26-28). may not be aware that they are chewing on Traumatic lesions can also be treated with
their mucosa, however most are. In differ- ‘magic’ mouth rinses or topical mid-level
steroids.

Oral Lichen Planus vs. Cheek Biting
When comparing lesions of lichen planus
and cheek biting/tissue trauma it is im-
portant to separate the two through clinical
presentation and laboratory tests, if needed.
Lichen planus occurs all over the mouth on
movable and non-movable tissues as op-
Figure 27. Oral lichen planus Figure 28. Oral lichen planus posed to cheek biting which only develops
Figure 26. Erosive oral plaque. Wickham striae. on the buccal mucosa/occlusal plane or in
lichen planus. the area of potential trauma from the teeth.
Lichen planus frequently presents on the
Age/Sex/Race: Oral lichen planus is more entiating the lesions, it is important to look attached alveolar mucosa, on the hard and
prevalent in females and Caucasians. It typ- at the tongue as well as the cheeks, since it soft palates, and may present with a posi-
ically presents in adults. is quite difficult to chronically chew on the tive Nikolsky sign. Patients presenting with
cheeks without also chewing on the tongue trauma from habitual biting or chewing of
Treatment: Once the diagnosis has been (Figures 29-31). the mucosa will only present with lesions
confirmed, it is important to inform the pa- where the teeth are contacting the muco-
tient that oral lichen planus cannot be cured sa, the lips, cheek and tongue. Often with
trauma the tissue looks like it is thickened
and is only treated palliatively. Treatment is and peeling, however the tissue tears will
palliative by corticosteroids, topical if pos- line up with the cusp tips. Cheek biting
sible, and immunosuppressant medications most frequently presents on the commis-
as needed. Systemic steroids can be used in sures and the buccal mucosa, and these
difficult to treat cases or recalcitrant cases. tissue tears give the affected area a shaggy
Patients should be informed of the slight appearance. An incisional biopsy will help
potential for malignant change, should be separate the two clinical presentations;
monitored, and should be biopsied if there however, you can also talk with the patient
are any changes clinically. about the habit and see if they realize that
they are in fact chewing on the mucosa.
Cheek Chewing (Morsicatio Buccarum) Cheek biting is not considered premalig-
nant and will heal quickly when the patient
Etiology: Unintentional biting of the oral stops irritating the tissue. No treatment is
mucosa is a common problem leading to necessary, however a mild steroid may help
potential mucosal trauma and painful ulcer- the tissue heal faster. A biopsy diagnosis of
ations. These lesions are acute and normal- lichen planus is different in that it cannot
ly heal within a few days without scarring be cured; it can only be palliatively treated
or complications provided the patient does and there is a slight increased incidence of
not habitually chew on the area. Chronic squamous cell carcinoma in these patients.
habitual biting of the mucosa may lead to Therefore, a patient with an erosive lichen
white patches, a shaggy irregular ulceration planus diagnosis needs to be followed up,
of the affected mucosa with a macerated ap- re-biopsied every three to five years, and
pearance on the affected tissue, or desqua- Figures 29-31. Cheek chewing. seen in the office yearly at a minimum to
mation of the traumatized mucosa. There is confirm that the tissue has not changed in
no malignant potential with these lesions appearance. If the patient is uncomfortable,
even though they can appear as leukopla- Age/Sex/Race: These lesions tend to be they can be treated with a mild to moderate
kia. These lesions are called “morsicatio seen in both young patients as well as pa- level topical steroid, to be used only if they
buccarum” when they occur on the buccal tients in their twenties to forties, although are in pain. Since lichen planus cannot be
mucosa. The buccal mucosa and tongue are any age can be affected. Race and sex are cured, it is essential that the patient under-
the most common sites affected, however not clinically relevant. stand this and that they only apply medi-
tissue trauma may present in mucosa that cation as needed. Patients without erosion
is easily reached by and traumatized by the Treatment: Discuss the habitual biting do not need to be treated at all. Occasion-
teeth. It is more common on the lower lip with the patient, explain the etiology of the ally some patients may complain that their
cheeks feel rough, but if there are no ero-
than the upper lip as it is easier to chew on oral lesions, and reassure the patient that sion, steroids will not help the patient. A
the lower lip. the lesions will resolve if they stop trauma-
tizing the mucosa. Occasionally, the patient biopsy is needed to confirm the diagnosis.

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