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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 414-417

Association of vitamin D serum concentration and oral lichen planus: A randomized controlled clinical trial


1 Department of Oral Medicine and Radiology, Shri. Yashwantrao Chavan Dental College, Ahmednagar, Maharashtra, India
2 Department of Oral Medicine and Radiology, Vokkaligara Sangha Dental College and Hospital, Bengaluru, Karnataka, India
3 Department of Oral Medicine and Radiology, Rajarajeshwari Dental College, Bengaluru, Karnataka, India
4 Department of Public Health Dentistry, Shri. Yashwantrao Chavan Dental College, Ahmednagar, Maharashtra, India
5 Department of periodontics, Vokkaligara Sangha Dental College and Hospital, Bengaluru, Karnataka, India

Date of Submission30-Jul-2021
Date of Decision25-Oct-2022
Date of Acceptance28-Oct-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Vinaya R Pawar
14, “Ashay”, Bhagyalaxmi Nagar, Vasmat Road, Parbhani, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_216_21

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   Abstract 


Introduction: Vitamin D plays a crucial role in regulating immunity by reducing the multiplication of helper T cells, activating regulatory T cells, and inhibiting the release of immunoglobulins. Vitamin D levels must be measured in a disease mediated by the immune system, such as oral lichen planus (OLP). Aim: This study aimed to identify the potential association between vitamin D serum levels and OLP. Material and Methods: A randomized case-control study was conducted with 50 volunteers divided into two groups: 20 case subjects and 30 controls. 2.5 ml of venous blood was extracted from the median cubital vein of both patients and controls. The total quantity of 25-hydroxyvitamin D was determined by an electrochemiluminescence binding assay. Statistical Analysis Used: The independent student's t-test was performed to compare the serum vitamin D levels between the two groups. Results: The mean vitamin D values in OLP patients and healthy controls were 15.11 and 26.10 ng/ml, respectively. In OLP cases, vitamin D3 deficiency was more prevalent than in control subjects. These distinctions were statistically significant (P-value < 0.05). Conclusion: Vitamin D levels might portray a significant factor in the aetiopathogenesis of OLP and could influence the disease's course and prognosis.

Keywords: Deficiency, 25-hydroxyvitamin D, immune response, oral lichen planus
Key Messages: Due to its function in immunological regulation, vitamin D is a key factor in the aetiopathogenesis of oral lichen planus. Therefore, oral lichen planus patients should have their vitamin D levels evaluated and treated accordingly with vitamin D supplements.


How to cite this article:
Pawar VR, Krishna S, Deepak T A, Prarthana G A, Vyavahare S, Jujare RD. Association of vitamin D serum concentration and oral lichen planus: A randomized controlled clinical trial. J Indian Acad Oral Med Radiol 2022;34:414-7

How to cite this URL:
Pawar VR, Krishna S, Deepak T A, Prarthana G A, Vyavahare S, Jujare RD. Association of vitamin D serum concentration and oral lichen planus: A randomized controlled clinical trial. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Feb 2];34:414-7. Available from: http://www.jiaomr.in/text.asp?2022/34/4/414/363026




   Introduction Top


Lichen planus (LP), a persistent, immune-mediated, mucocutaneous illness, has been classified as a potentially malignant disorder (PMD). The majority of affected persons are middle-aged. It favors women more than men, with a male-to-female ratio of 1:3. The global prevalence of oral lichen planus (OLP) ranges from 0.5 to 2.2%.[1] Its occurrence has contributed to an autoimmune pathogenesis wherein autoreactive T cells target antigens that get exposed by the basal cell layer. Vitamin D has been observed to have a direct regulatory effect on T lymphocyte activity. It suppresses the proliferation of Th1 cells and accelerates the production of Th2 cells by directly affecting CD4 cells.[2] Considering the relevance of OLP as a PMD with autoimmune etiology and the potential effect of vitamin D on the immune system, the purpose of this study had been to analyze whether vitamin D could be a probable etiological factor for OLP and to compare vitamin D serum levels in patients with OLP and healthy people.


   Subjects and Methods Top


Fifty participants were separated into two groups for the case-control study: twenty cases diagnosed with OLP and thirty controls. These volunteers were of the same age and gender. The participants provided their informed, written consent. The approval from the institution's ethics committee was acquired on November 10, 2018, with the reference number KIMS/IEC/D17/2018. The study was done by the Helsinki Declaration. No treatment was administered, and the patient's personal information was kept private. The laboratory tests were provided free of charge to the patients. Cases with tobacco smoking or chewing habits, the development of lichenoid lesions, the use of any drugs, or the presence of any systemic disorders were excluded. An intraoral clinical examination and an incisional biopsy were conducted on the lesion site. A histological examination was performed on the tissue sample to confirm the diagnosis of OLP. The median cubital vein was then venipunctured to obtain 2.5 ml of blood under asepsis. The blood sample was centrifuged to separate the serum. Then, the electrochemiluminescence-binding assay was utilized to quantify the total amount of 25-hydroxy vitamin D.

Normative values for vitamin D

Levels of vitamin D 30 ng/mL (75 nmol/L) have been considered normal, whereas levels of vitamin D 20 ng/mL (50 nmol/L) and 30 ng/mL have been considered deficient and considerate.

Sample size determination

Using the G power program (3.1.9.2), effect size = 0.95, alpha error = 0.05, power = 0.95, and allocation ratio of cases: Controls = 1.5, the sample size was calculated to be: Group 1 = 21, Group 2 = 31, which was then rounded to 20 and 30.

Analytical statistics

The statistical software SPSS Version 20.0 Armonk, NY: IBM Corp; 2011 was used to analyze the data, and P 0.05 was deemed significant. Calculated descriptive statistics included mean, standard deviation, and confidence interval. The independent student's t-test was performed to compare the serum vitamin D levels between the two groups.


   Results Top


According to the data, all instances with OLP (>20 ng/ml) were vitamin D deficient. The vitamin D levels of OLP patients did not differ significantly according to geography, clinical type, or gender. Thirty controls participated in the study; three men (13%) and seven women (30.4%) had normal blood vitamin D levels (30 ng/mL), respectively. Eight women (34.7%) and five men (21.7%) had vitamin D levels below 20 ng/mL. This found that females have greater vitamin D deficiency and insufficiency than males. According to statistical analysis, serum vitamin D levels differed significantly between the case and control groups.


   Discussion Top


LP has been considered to be relatively prevalent with its inflammatory, immune-mediated pathogenesis. It has been identified as having an undefined risk of conversion into malignancy, hence, it has been classified as a potentially malignant condition.[1],[3] Manifested clinically on the skin, nails, and hair as well as on mucous membranes. They were reported with an annual malignancy potential of 0.2%, with their prevalence and incidence estimated to be 0.89% globally. Clinical variants of OLP include reticular, papular, plaque-like, bullous, atrophic, and erosive.[4] The immune system has been held solely and primarily responsible for developing OLP.[2],[5]

Vitamin D has been observed to significantly influence the commensal and the severity of OLP by controlling the immune mechanisms of the human body. It has been documented that more than 80% of the production of Vitamin D3 occurs when the skin gets exposed to ultraviolet rays wherein 7-dehydrocholesterol gets converted to pre-vitamin D3 in the epidermis, which gets simultaneously converted to Vitamin D3. 1,25-dihydroxyvitamin D3 is the most active form of Vitamin D physiologically which gets synthesized from 25-hydroxyvitamin D3 in the liver and 1,25-dihydroxy vitamin D3 in the kidney.

A deficiency of 1,25(OH) 2D3 has been observed to have diverse effects on the functioning of immune cells; they promote innate immunity and suppress adaptive immunity.[6] Based on the type of skin, geographic location, and climatic condition, 5–30 min of moderate sun exposure three times a week on the limbs has been recommended.[1],[7] Vitamin D deficiency attenuates the production of T cells which are involved in inflammatory pathways, particularly Th1 and Th17 cells, that could cause more injuries in inflammatory conditions such as LP.[8] Hence, monitoring the vitamin D levels of patients with LP is mandatory.

Recent studies have shown that vitamin D modulates the immune system. In addition to enhancing the chemotaxis and phagocytic capacities of innate immune cells, the combination of calcitriol, Vitamin D receptor, and retinoid X receptor directly increases the transcription of antimicrobial peptides such as defensin 2 and cathelicidin antimicrobial peptide (hCAP18).[9],[10],[11],[12] T cells, the other major class of adaptive immune cells, are also thought to be an important target for the immunomodulatory effects of various vitamin D forms.[13]

The plausible methods by which vitamin D could regulate the functioning of T cells are by either direct endocrinal effects mediated by systemic calcitriol on T cells or by T cells directly converting 25(OH) D to calcitriol intracranially. It has been observed that calcitriol has indirect effects on antigen presentation to T lymphocytes that are mediated by localized APC.[13]

All existing treatments for OLP attempt to eliminate the disorder's symptoms. Topical medicines including corticosteroids, retinoids, calcineurin inhibitors (cyclosporine and tacrolimus), and ultraviolet phototherapy have been suggested. Among these, topical steroid pastes, such as 1% triamcinolone acetonide, are routinely used and recognized as the most effective treatment. It is reasonable to use systemic steroids to treat symptoms produced by resistant lesions. The suggested dosage is 1 mg per kilogram per day for seven days, followed by a reduction to 10 mg per day. A topical steroid maintenance dose may be initiated during the reduction of systemic steroid dosage.[5] The present investigation evaluated the serum vitamin D levels of the control group and OLP patients. The results demonstrated a statistically significant difference between the serum vitamin D levels of the two groups (p = 0.001*) with an odds ratio of 1.25 [Figure 1] and [Table 1].
Figure 1: Comparison of serum vitamin D levels between cases and ontrols

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Table 1: Comparative evaluation of vitamin D levels between cases and controls- descriptive and inferential statistics

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The present study comprised participants between the ages of 18 and 80, with a mean age of 45.5; between the ages of 41 and 50 years, the prevalence of OLP was determined to be 45% [Table 1] and [Table 2]. Gonzalez-Moles et al.[14] reported that the risk of having OLP is 3.43 times greater for patients over 40 years than for those under 40 years worldwide, whereas Varghese et al.[15] showed its prevalence range between the 30- and 60-year age group in the South Indian population.
Table 2: Age and gender distribution among OLP group

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In the present study, males (n = 11, 55%) were more likely to be affected than females (n = 9, 45%) to exhibit prevalence [Table 1] and [Table 2], which was found to be similar to the results reported by Sachdev et al.,[16] which comprised 102 validated OLP cases, 77 (75.4%) of which were male and 25 (24.5%), female. In studies conducted by Gupta et al.[1] and Bahramian et al.[2] The prevalence of OLP was 64.7% in females and 22.8% in males, respectively, whereas a study conducted by Varghese et al.[15] suggested a higher prevalence rate in females (64.7% vs. 35.2%) than in males.

The present study suggested buccal mucosa to be the most common site involved by OLP with the highest prevalence (n = 12, 60%), followed by the marginal and attached gingiva (n = 3, 15%), buccal mucosa and attached gingiva (n = 3, 15%), and attached gingiva (n = 2, 10%) [Table 1] and [Table 3]. Results were similar to that reported by Varghese et al.[15] wherein bilateral involvement of the buccal mucosa had been observed to be more prevalent (77.0%). Gonzalez-Moles et al.[14] also reported buccal mucosa as the prevalent site (67.15%).

In comparison to bullous LP and erosive LP, reticular LP (n = 13, 65%) is the most common type observed in our study [Table 2] and [Table 3]. Similar to the study by Varghese et al.,[15] in which reticular LP was shown to be the most prevalent form (61.5%). Reticular LP is the most common variant of OLP (46% of cases), as per reported by Gonzalez-Moles et al.'s,[14] with its presentation as lacy white streaks surrounded by sharply defined erythematous borders.
Table 3: Location and clinical type distribution among OLP group

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The frequency of vitamin D deficiency among both controls and patients makes it difficult to compare vitamin D serum levels between the two groups. To clarify the function of vitamin D as an OLP etiological factor, additional studies with bigger sample numbers are required.


   Conclusion Top


Vitamin D significantly regulates both innate and adaptive immune system cells. It plays a substantial role in the aetiopathogenesis of the disease or could portray as one of the prime factors that could influence the duration, progression, and outcome of OLP. Further studies should be conducted with a larger sample size to determine vitamin D's association with the occurrence of LP.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gupta A, Mohan RP, Kamarthi N, Malik S, Goel S, Gupta S. Serum vitamin D concentration in patients with oral lichen planus in Northern India: A case-control study. J Dermatol Res Ther 2017;1:19.  Back to cited text no. 1
    
2.
Bahramian A, Bahramian M, Mehdipour M, Falsafi P, Khodadadi S, Tabriz FD, et al. Comparing the vitamin D levels of people with oral lichen planus to those of healthy individuals. J Dent 2018;19:212-6.  Back to cited text no. 2
    
3.
Georgakopoulou EA, Achtari MD, Achtaris M, Foukas PG, Kotsinas A. Oral lichen planus as a preneoplastic inflammatory model. J Biomed Biotechnol 2012;1:759626. doi: 10.1155/2012/759626.  Back to cited text no. 3
    
4.
Gorouhi F, Davari P, Fazel N. Cutaneous and mucosal lichen planus: A comprehensive review of clinical subtypes, risk factors, diagnosis, and prognosis. Scient World J 2014;30:742826. doi: 10.1155/2014/742826.  Back to cited text no. 4
    
5.
M. Burket's Oral Medicine. 12th ed. USA: Glick PMPH; 2015. p. 104-8.  Back to cited text no. 5
    
6.
Hart PH, Gorman S. Sunlight's UV wavelengths suppress immunity. What role does UV-induced vitamin D3 play as a mediator? Clin Biochem Rev 2013;34:3-13.  Back to cited text no. 6
    
7.
Tabbakh T, Wakefield M, Dobbinson SJ. Concerns about vitamin D and sun exposure behavior among Australians. Health Promot J Aust 2021;32:399-406.  Back to cited text no. 7
    
8.
Prietl B, Treiber G, Pieber TR, Amrein K. Vitamin D, and immune function. Nutrients 2013;5:2502-21.  Back to cited text no. 8
    
9.
Tak MM, Chalkoo AH. Vitamin D deficiency- A possible contributing factor in the aetiopathogenesis of oral lichen planus. J Med Dent Sci 2017;6:4769-73.  Back to cited text no. 9
    
10.
Zhao B, Li R, Yang F, Yu F, Xu N, Zhang F, et al. LPS-induced vitamin D receptor decrease in oral keratinocytes is associated with oral lichen planus. Sci Rep 2018;8:763.  Back to cited text no. 10
    
11.
Martens PJ, Gysemans C, Verstuyf A, Mathieu C. Vitamin D's effect on immune function. Nutrients 2020;12:1248. doi: 10.3390/nu12051248.  Back to cited text no. 11
    
12.
Hewison M. An update on vitamin D and human immunity. Clin Endocrinol 2012;76:315-25.  Back to cited text no. 12
    
13.
Ao T, Kikuta J, Ishii M. The effects of vitamin D on the immune system and inflammatory diseases. Biomolecules 2021;11:1624. doi: 10.3390/biom11111624.  Back to cited text no. 13
    
14.
González-Moles MÁ Warnakulasuriya S, González-Ruiz I, González-Ruiz L, Ayen A, Lenouvel D, et al. Worldwide prevalence of oral lichen planus: A systematic review and meta-analysis. Oral Dis 2021;27:813-28.  Back to cited text no. 14
    
15.
Varghese SS, George GB, Sarojini SB, Vinod S, Mathew P, Mathew DG, et al. Epidemiology of oral lichen planus in a cohort of south Indian population: A retrospective study. J Cancer Prev 2016;21:55-9.  Back to cited text no. 15
    
16.
Sachdev R, Mukerjee S, Garg K, Singh G. Demographic prevalence of oral lichen planus in males: A retrospective study. Acta Sci Dent Sci 2019;3:111-4.  Back to cited text no. 16
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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