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Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 2  |  Page : 267-270
Low level laser therapy in the treatment of aphthous ulcer


1 Department of Periodontics, Babu Banarasi Das College of Dental Sciences, Babu Banarasi Das University, Chinhat, Lucknow, Uttar Pradesh, India
2 Department of Prosthodontics, Sardar Patel Post Graduate Institute of Medical and Dental Science, Lucknow, Uttar Pradesh, India

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Date of Submission23-Feb-2012
Date of Decision08-Aug-2012
Date of Acceptance04-Nov-2012
Date of Web Publication20-Aug-2013
 

   Abstract 

Recurrent aphthous stomatitis (RAS) is one of the most common and painful ulcerative lesions of the oral cavity, but until now no cure has been recognized for it. Two patients diagnosed with minor RAS were treated in a single sitting with low level laser therapy using 940-nm diode laser. The lesions healed completely within 3-4 days and a follow-up for 1 showed no recurrence in these patients. According to the results of this study, low level laser therapy can decrease the healing time, pain intensity, size, and recurrence of the lesion in patients with minor RAS, and hence can be considered the most appropriate treatment modality for minor RAS, with greatest clinical effectiveness.

Keywords: Aphthous ulcer, diode laser, healing, low level laser therapy, pain

How to cite this article:
Anand V, Gulati M, Govila V, Anand B. Low level laser therapy in the treatment of aphthous ulcer. Indian J Dent Res 2013;24:267-70

How to cite this URL:
Anand V, Gulati M, Govila V, Anand B. Low level laser therapy in the treatment of aphthous ulcer. Indian J Dent Res [serial online] 2013 [cited 2020 May 28];24:267-70. Available from: http://www.ijdr.in/text.asp?2013/24/2/267/116691
Ulceration is a breach in the oral epithelium, which typically exposes nerve endings in the underlying lamina propria, resulting in pain or soreness. Aphthous ulcerations, commonly referred to as "canker sores," are the most prevalent oral mucosal lesions affecting more than 20% of population. The term "aphthous" is derived from a Greek word "aphtha" which means ulceration. Recurrent bouts of solitary or multiple shallow, small, round, or ovoid painful ulcers, with circumscribed margins, having yellow or gray floors surrounded by erythematous halo in patients who are otherwise well characterize recurrent aphthous stomatitis (RAS). RAS has been described under three different clinical variants as classified by Stanley in 1972. [1] Minor RAS also known as Miculiz's aphthae or mild aphthous ulcers, major RAS also known as periadenitis mucosa necrotica recurrens or Sutton's disease, and Herpeti form ulceration characterized by recurrent crops of multiple ulcers which may be up to 100 in number. [1] Various treatment options are available which should be guided by the severity of the disease (the amount of pain), the frequency of ulceration, and the potential adverse effects of the medications. If an underlying disorder is present, effective treatment of the condition may result in the remission of the ulcers. However, in the absence of a clearly defined cause, the treatment for RAS is symptomatic, the goals being to decrease pain, healing time, number and size of the ulcer, and to increase disease-free periods which include topical agents, systemic and topical steroids, corticosteroids, cauterization, antibiotics, mouth rinses containing active enzymes, etc. [2] Currently, low level laser therapy (LLLT) has been employed for the treatment of RAS because of its biomodulation and analgesic effect by stimulation of the healing process and promoting immediate relief of pain without an overdose of medication or side effects. Hence, in the current case series, patients diagnosed with RAS were treated with LLLT using diode laser.


   Case Reports Top


Two patients with the chief complaint of recurrent painful ulcers in the oral cavity came to the Department of BBDCODS. On intraoral examination, small round ulcers with erythematous halo were seen on the tongue, labial and buccal mucosa. The diagnosis of minor RAS was made on the basis of history and clinical criteria proposed by Natah et al. in 2004. [2] A detailed medical history was taken to rule out other ulcerative disorders and conditions such as Crohn's disease, celiac disease, neutropenia, HIV infection, and Behcet's syndrome. A written informed consent was taken from the patient. One of the patients gave a history of recurrence of these extremely painful ulcers since 8 years. The patient had been undergoing treatment for the same since 7 years and had used various chemotherapeutic agents like topical anaesthetics, steroids, etc., which took around 7-10 days for the lesions to heal but still the lesion recurred every 2-3 months [Figure 1] and [Figure 2]. The patients were treated for minor RAS with only LLLT using 940-nm diode laser (Ezlase, Biolase, Irvine, California). The laser was started using a bleaching tip in a defocussed mode 5-8 mm from the lesion and advanced slowly toward the area ending up 2-3 mm away from the lesion, moving continuously from the periphery of the lesion to the center, "painting" the entire area, and moving away from the lesion if the patient felt warmth [Figure 3] and [Figure 4]. The setting was initially put at 0.6 W CW (1.2 W pulsed) for 30-45 seconds. A refractory period of 15-20 seconds between laser "passes" was given to allow the tissue to cool down. The area was rubbed with a wet gloved finger to determine if a decrease in pain was felt by the patient. A second and third pass with the laser was further applied to decrease the pain of the area on palpation. A second pass was done with the setting of 0.7 W CW (1.4 W pulsed) for 30-45 seconds, and a third and final pass was completed with 0.8 W CW (1.6 W pulsed) for a similar period of time. After each pass, the area was checked with palpation, but a maximum time of 2 min of total laser energy was employed. Only a single sitting treatment was given. Patients were given log diaries and instructed to record the details of ulcers (the number of ulcers, intensity of pain, the period of healing, and the frequency of recurrence). Pain was assessed using Visual Analogue Scale (VAS). The recordings were made just before the treatment, immediately after treatment, and every 2 days thereafter for a period of 2 weeks. The patients reported that ulcers started healing earlier than in previous attacks; there was also early reduction in pain. Healing was uneventful and all the patients experienced spontaneous reduction in pain as recorded on VAS immediately after treatment. The lesions healed completely within 3-4 days [Figure 5]. A follow-up for 1 year showed no recurrence in these patients.
Figure 1: A cluster of aphthous ulcers

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Figure 2: Aphthous ulcer on tongue

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Figure 3: Lesion treated with 940-nm diode laser

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Figure 4: Lesion treated with 940-nm diode laser

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Figure 5: Postoperative on third day

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   Discussion Top


RAS is one of the most painful oral mucosal inflammatory ulcerative conditions causing pain on eating, swallowing, and speaking. Various treatment modalities like steroids, mouthwashes, etc., have numerous side effects, require patient compliance, and are relatively expensive. On the contrary, LLLT not only provided instant pain relief but was also cost-effective and provided time benefit as single sitting was sufficient. Though in the cases described here semiconductor diode laser, which is sometimes referred to as "cold" or "soft" laser, was used, some of the "hard" or "hot" surgical lasers (such as CO 2 , Nd: YAG) have also been used for providing LLLT. Zand et al. in 2009 employed a low-intensity, non-thermal, single session of CO 2 laser for the treatment of minor RAS and reported dramatic and immediate pain reduction in the patients after irradiation. [3] Similar results were also demonstrated by Iris Brader (2008) when Nd: YAG laser was used in a noncontact mode for the treatment of minor RAS. [4] Yet, diode lasers have an edge over their high-powered "hard" surgical laser counterparts, as they do not cause thermal injury to hard tissues, are compact, low-cost devices, and have very high electrical and optical efficiencies. [5] Apart from treating apthous ulcers, LLLT has also been successfully employed in dentistry for the promotion of wound healing, neuronal regeneration, and for the management and treatment of mucositis, pulpotomy, post-herpetic neuralgia, Temporo-mandibular joint pain, oral lichen planus, pemphigus vulgaris, and multiple chronic ulcers such as mucus membrane pemphigoid, epidermolysis bullosa, etc. [5],[6] Healing, highlighted as one of the main effects of LLLT, is characterized by three main factors. [7] First, there is an increment of adenosine triphosphate (ATP) production, as laser is considered to raise the production of ATP, leading to a boost in mitotic activity and to an increase in protein synthesis by mitochondria, resulting in greater tissue regeneration in the repair process. Second, there is a stimulus to microcirculation, which increases the delivery of nutritional elements associated with increased speed of mitosis, facilitating cell multiplication. Finally, new vessels are formed from pre-existing vessels. [7] [Table 1] reveals various possible mechanisms involved in the acceleration of wound healing by LLLT, as given by Walsh. [5] Furthermore, in the cases presented here, the time required for complete healing of lesions was 3-4 days, which is significantly quicker as compared to the longer healing periods with pharmaceutical methods, also demonstrated by Bladowski et al. in 2010. [8] It is also in agreement with the results from the study performed by De Souza et al. in 2010 who revealed that 75% of the patients reported a reduction in pain in the same session after laser treatment and total regression of the lesion occurred after 4 days, whereas total regression in the corticoid group took 5-7 days. [9] Khademi et al. also found similar benefits of quicker healing and reduced pain after using low levels of laser treatment on RAS. [10] Hence, it can be concluded and validated that LLLT is the most appropriate treatment modality for minor RAS. However, long-term comparative studies are needed to further substantiate the advantages of LLLT in the treatment of oral lesions.
Table 1: Possible mechanisms involved in the acceleration of wound healing by LLLT


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   Conclusion Top


LLLT employed as a treatment modality for the management of minor recurrent apthous ulcers in the current case report not only provided instant pain relief with a rapid decrease in the size of the lesion but also no recurrence was seen even after 1 year of follow-up. Since no medications were required, their side effects and risk of overdosage could also be prevented. Hence, it can be concluded that LLLT is a safe and clinically effective therapy for treating minor RAS, which also provides time and cost benefit to the patients.

 
   References Top

1.Stanley HR. Aphthous lesions. Oral Surg Oral Med Oral Pathol 1972;30:407-16.  Back to cited text no. 1
    
2.Natah SS, Konttinen YT, Enattah NS, Ashammakhi N, Sharkey KA, Hayrinen Immonen R. Recurrent aphthous ulcers today: A review of growing knowledge. Int J Oral Maxillofac Surg 2004;33:221-34.  Back to cited text no. 2
    
3.Zand N, Ataie-Fashtami L, Djavid GE, Fateh M, Alinaghizadeh MR, Fatemi SM, et al. Relieving pain in minor aphthous stomatitis by a single session of non-thermal carbon dioxide laser irradiation. Lasers Med Sci 2009;24:515-20.  Back to cited text no. 3
[PUBMED]    
4.Brader I. The treatment of aphthosis with the Nd: YAG laser. Quintessenz J 2008;2:77-86.  Back to cited text no. 4
    
5.Walsh LJ. The current status of low level laser therapy in dentistry. I. Soft tissue applications. Aust Dent J 1997;42:247-54.  Back to cited text no. 5
    
6.Basirat M. The effects of the low power lasers in the healing of the oral ulcers. J Lasers Med Sci 2012;3:79-83.  Back to cited text no. 6
    
7.Rocha AM Jr, Vieira BJ, de Andrade LC, Aarestrup FM. Effects of low-level laser therapy on the progress of wound healing in humans: The contribution of in vitro. J Vasc Bras 2007;6 Suppl 3:258-66.  Back to cited text no. 7
    
8.Bladowski M, Konarska Choroszucha H, Choroszucha T. Comparison of treatment results of recurrent aphthous stomatitis (RAS) with low-and high-power laser irradiation vs. pharmaceutical method (5-year study). J Oral Laser Appl 2004;4:191-209.  Back to cited text no. 8
    
9.De Souza TO, Martins MA, Bussadori SK, Fernandes KP, Tanji EY, Mesquita Ferrari RA, et al. Clinical evaluation of low-level laser treatment for recurring aphthous stomatitis. Photomed Laser Surg 2010;28 Suppl 2:S85-8.  Back to cited text no. 9
    
10.Khademi H, Shirani AM, Nikegbal F. Evaluation of low level laser therapy in recurrent aphthous stomatitis. J Dent Shiraz Univ Med Sci 2009;10 Suppl 2:160-2.  Back to cited text no. 10
    

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Correspondence Address:
Vishal Anand
Department of Periodontics, Babu Banarasi Das College of Dental Sciences, Babu Banarasi Das University, Chinhat, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.116691

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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