|Year : 2015 | Volume
| Issue : 1 | Page : 49-53
Versatility of diode lasers in low-level laser therapy for the management of recurrent aphthous stomatitis
Butchi Babu1, Uday Kiran Uppada2, Bassel Tarakji3, Khaja Amjad Hussain3, Saleh Nasser Azzeghaibi4, Ibrahim Alzoghaibi4
1 Consultant Periodontist, FMS Dental Hospital, Hyderabad, Telangana, India
2 Consultant Oral Maxillofacial Surgeon, FMS Dental Hospital, Hyderabad, Telangana, India
3 Department of Oral Maxillofacial Sciences, Al-Farabi College of Dentistry and Nursing, Riyadh, Saudi Arabia
4 Director, Al-Farabi College of Dentistry and Nursing, Riyadh, Saudi Arabia
|Date of Web Publication||20-May-2015|
Dr. Butchi Babu
Consultant Periodontist, FMS Dental Hospital, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Recurrent aphthous stomatitis (RAS) is a painful condition, often leading to impairment of the basic functions such as mastication, speech, and brushing. Several treatment modalities have been advocated in the past, but none hasve been proven efficacious. A novel treatment modality in the form of low-level laser therapy (LLLT) has evolved in recent years. LLLT also known as "cold laser" works on the principle of biostimulation. This biomodulatory effect plays a pivotal role in accelerating the healing process and provides analgesia. Hence, it constitutes an alternative to processes that present pain and inflammatory reaction. The present series of cases throw light regarding the use of diode laser for LLLT as an effective and quick tool in the painless management of recurrent aphthous ulcers.
Keywords: Diode laser, low-level laser therapy, recurrent aphthous stomatitis
|How to cite this article:|
Babu B, Uppada UK, Tarakji B, Hussain KA, Azzeghaibi SN, Alzoghaibi I. Versatility of diode lasers in low-level laser therapy for the management of recurrent aphthous stomatitis. J Orofac Sci 2015;7:49-53
|How to cite this URL:|
Babu B, Uppada UK, Tarakji B, Hussain KA, Azzeghaibi SN, Alzoghaibi I. Versatility of diode lasers in low-level laser therapy for the management of recurrent aphthous stomatitis. J Orofac Sci [serial online] 2015 [cited 2019 Dec 7];7:49-53. Available from: http://www.jofs.in/text.asp?2015/7/1/49/157392
| Introduction|| |
A laser is a device with an active medium consisting of solid, liquid or gaseous substances which produces a light beam when excited by a source of energy. This device is categorized into two types: High-power lasers or surgical lasers, possessing photothermal effects with cutting, vaporization and hemostasis properties and low power lasers or therapeutic lasers, with analgesic, anti-inflammatory and biostimulation properties. 
The biological effects caused by low power lasers in tissues consist of light energy which is deposited on the tissues and becomes vital energy, thus producing primary effects (direct), secondary effects (indirect) and general therapeutic effects which in turn promote analgesic, anti-inflammatory and healing reactions.  When laser light interacts with cells and tissues in an appropriate dosage, certain cell functions can be stimulated, among them are stimulation of lymphocytes, mast cell activation, increase of mitochondrial adenosine triphosphate (ATP) production and proliferation of several types of cells, thus promoting anti-inflammatory effects. 
The principle of biostimulation promoted by therapeutic lasers was introduced gt;20 years ago. It was first applied in dermatology, especially supplementing the repair process of skin wounds. Later, it was suggested that biostimulation could also be useful in accelerating the healing of wounds inside the oral cavity. Recurrent aphthous stomatitis (RAS) is one among the many that falls into the wide spectrum of clinical applications of a therapeutic laser.
Recurrent aphthous stomatitis (recurrent aphthous ulcers, canker sores) comprises a group of chronic, inflammatory, ulcerative diseases of the oral mucosa.  According to Stanley, RAS is described under three different clinical variants: Minor RAS, major RAS, and herpetiform ulcerations.  Prevalence of RAS in Indian population is 21.7% with slight female predilection.  The etiopathogenesis of the disease is unknown, and the appropriate concept still remains unconquered. It is widely accepted that stress is the most common predisposing factor followed by nutritional deficiency.  Most common locations of the lesions coincide with the areas covered with nonkeratinized oral mucosa.  Clinically there are three main types of RAS: Minor aphthae, major aphthae, and herpetiform aphthae. ,, The most common type of RAS is the minor aphthae, which can be described as erosion smaller than 1 cm in diameter, surrounded by erythematous halo. It heals with no scar formation and lasts no longer than 2 weeks. 
Treatment of RAS is symptomatic, the prime goal being to relieve pain and enhance the healing process. It may be accomplished by the usage of topical agents, systemic and topical steroids, cauterization, antibiotics, mouth rinses containing active enzymes, etc., but none of them have been proven to be efficacious. ,, This paper is intended to emphasize the efficacy of low-level laser therapy (LLLT) in the treatment of RAS based on the principle of bio modulation.
| Case Reports|| |
A 40-year-old male patient reported to our hospital with the chief complaint of pain associated with an ulcer over his left lower labial mucosa. He gave a history of undergoing a crown lengthening procedure with respect to his lower left quadrant as part of the perio-restorative treatment plan. Next day, he noticed an ulcer in his left lower labial mucosa. The ulcer was <1 cm exhibiting central erosion surrounded by an erythematous halo [Figure 1]a. Based on the clinical presentation and anatomical location of occurrence, it was suggestive of a minor aphthous ulcer.
|Figure 1: Management of minor aphthae on the lower left labial mucosa: (a) Preoperative view of the lesion (b) low level laser therapy using an 808 nm diode laser (c) surface of the ulcer being rubbed by a ball burnisher to evaluate pain perception (d) postoperative view of the lesion after 72 h|
Click here to view
In order to reduce the discomfort and pain associated with the ulcer, a treatment strategy was designed, and the patient was treated with LLLT using an 808 nm diode laser (Sunny, MSI, Bangalore). An informed consent regarding the laser treatment was taken. A special hand piece with a 600 nm beam diameter was used in a defocused mode. The laser setting was 1W in a continuous mode, which was the biostimulation mode, suggested by the manufacturer. With the above-mentioned settings, the laser hand piece was passed over the ulcer in a scanning motion in a defocused mode from about 8 mm away and eventually approaching within 2 mm range of the ulcer for about 30 s [Figure 1]b.
To evaluate the patient perception of pain, a ball burnisher was used to rub the surface of the ulcer [Figure 1]c, and the patient was enquired about any reduction of pain. Second and third passes were required as there was not much reduction of pain. A relaxing period of 10-15 s was given between each pass. The postoperative view of the lesion after 72 h is shown in [Figure 1]d.
A young female patient was referred to our hospital with the chief complaint of spacing between her teeth and bleeding while brushing. She also complained of pain associated with an ulcer over her left upper labial mucosa close to the lip commissure. The ulcer was <1 cm exhibiting central erosion surrounded by an erythematous halo [Figure 2]a. Based on the clinical presentation and anatomical location of occurrence, it was suggestive of a minor aphthous ulcer. The patient was explained the intended laser treatment protocol, and an informed consent of the patient was taken.
|Figure 2: Management of minor aphthae on the left upper labial mucosa: (a) Preoperative view of the lesion (b) low level laser therapy using an 810 nm and 400 mm fiber diode laser (c) surface of the ulcer being rubbed by a ball burnisher to evaluate pain perception (d) postoperative view of the lesion after 72 h|
Click here to view
A diode laser (Picasso, Dentsply) with an 810 nm wavelength and a 400 μm fiber and a noninitiated tip was used. The power setting of the laser was set at 0.6W and was used in a defocused mode, starting at a distance of 10 mm away from the lesion and slowly approaching the lesion within a range of 2 mm for about 30 s for the first pass [Figure 2]b. The pain perception of the patient was then evaluated using a plastic filling instrument [Figure 2]c. Since the patient reported no significant reduction in pain, two more passes with the power setting of 0.7W and 0.8W with duration of 30 s each were applied. A cooling interval of 20 s was given between the passes. The total duration of laser exposure was <2 min. The postoperative view of the lesion after 72 h is shown in [Figure 2]d.
A female patient reported to our hospital with the chief complaint of pain associated with speech and chewing. She presented with an ulcer on the tip of her tongue which she noticed 48 h earlier. The ulcer was >1 cm exhibiting central erosion surrounded by an erythematous halo [Figure 3]a. Based on the clinical presentation and anatomical location of occurrence, it was suggestive of a major aphthous ulcer. An informed consent regarding the laser treatment was taken.
|Figure 3: Management of major aphthae on the tip of the tongue: (a) Preoperative view of the lesion (b) low level laser therapy using a 940 nm diode laser (c) postoperative view of the lesion after 72 h|
Click here to view
A diode laser (Ezlase, Biolase) with a 940 nm wavelength was used. The tip of the laser was removed, and only the hand piece was used, thus increasing the beam diameter from 300 μm to 4 mm. The power setting of the laser was set at 1W and was used in a continuous defocused mode in a scanning motion, starting at a distance of 8-10 mm away from the lesion and slowly approaching the lesion within a range of 2 mm for about 30-40 s for the first pass as shown in [Figure 3]b. The patient required a second pass of 1.2W power, after a 20 s interval, for about 30-40 s, after which she showed relief from pain. The postoperative view of the lesion after 72 h is shown in [Figure 3]c.
A male patient reported to our hospital with intense pain associated with multiple recurrent ulcers in the oral cavity. On examination, a cluster of ulcers was found over the right maxillary gingiva [Figure 4]a. These ulcers measured 2-3 mm in diameter exhibiting central erosion surrounded by an erythematous halo. Based on the clinical presentation and anatomical location of occurrence, it was suggestive of herpetiform type of RAS. An informed consent was taken prior to the laser treatment.
|Figure 4: Management of herpetiform ulcers on the right maxillary gingiva: (a) Preoperative view of the lesion (b) low level laser therapy using a 940 nm diode laser (c) postoperative view of the lesion after 72 h|
Click here to view
Taking into account the vast area covered by the multiple ulcers, a diode laser (Ezlase, Biolase) of a 940 nm wavelength was opted with a bleaching hand piece having a beam diameter of 12 mm so as to cover the entire affected area in a scanning motion. The power setting of the laser was set at 2W and was used in a continuous defocused mode in a scanning motion, starting at a distance of 8-10 mm away from the lesion and slowly approaching the lesion within a range of 2 mm for about 30-40 s for the first pass as shown in [Figure 4]b. Whenever the patient complained of warmth, the distance was suitably increased. The patient required two more passes of 2.2W and 2.4W, for about 30-40 s each. A cooling interval of 20 s was given in between the passes. The postoperative view of the lesion after 72 h is shown in [Figure 4]c.
| Discussion|| |
Recurrent aphthous stomatitis is characterized by 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, at intervals of few months to few days in patients who are otherwise normal. , The etiology of RAS is still uncertain, but the precipitating factors are stress, mechanical injury, hormonal changes, gastrointestinal diseases, vitamins, and trace element deficiencies.  Systemic conditions include genetic predisposition and immunodeficiency. These intrinsic factors pose a challenge to the clinician in the management of RAS.
Various pharmaceutical modalities like steroids, mouthwashes, etc., have been tried in the past with varied success. In addition, they have numerous side effects, require patient compliance, and are relatively expensive. , With evolving technology, lasers have indeed proven to be a boon as they provide immediate pain relief and aid in rapid healing compared to any other available treatment options.
Low level laser therapy is recognized with various terminologies such as "biostimulator," "cold laser," "soft laser," "low intensity laser therapy," "photobiomodulating lasers" and "laser phototherapy" etc., and the wavelength of these diode lasers ranges from 630 to 910 nm. , In addition to its role in the management of RAS, it has a wide spectrum of clinical applications which include herpes labialis, angular cheilitis, trismus, paresthesia, dentine hypersensitivity, temporomandibular joint pain, and in the postoperative phase. 
Low-level laser therapy was considered as a prime treatment modality for managing RAS in our present case series to provide immediate pain relief to the patient and augment healing of the lesion. The possible mechanisms for immediate reduction in pain in our present case series might be attributed to the fact that LLLT stimulates the production of ß-endorphins, which are considered as our body's natural pain killer, thus causing pain relief. It has a profound effect on C fibers leading to a decreased activity of these fibers and altering the pain threshold. 
Agarrwal et al. proposed that the usage of LLLT inhibits the conduction of nerve fibers. They suggested that the inhibition of nerve conduction caused by LLLT was not because of a permanent damage caused to the nerve, but due to a reversible conformational change in the voltage-gated Na-K channels, similar to the action of local anesthetic agents.  Similar studies conducted by De Souza revealed that 75% of the study population reported reduction in pain immediately after a single session of laser treatment.  Khademi et al. in a double-blind clinical trial treated twelve patients with minor RAS using a diode laser and reported that with the use of LLLT there was a decrease in the healing time and pain intensity in patients with aphthae. 
Our present case series also highlighted the healing capabilities of LLLT. The time required for complete healing of lesions was 3-4 days in our series of cases, which was significantly quicker when compared to the longer healing periods with pharmaceutical agents. These results are in accordance with the study of Bladowski et al.  The possible mechanisms which have enhanced a rapid healing might be attributed to the fact that LLLT enhances ATP synthesis leading to an increase in mitotic activity that results in increase in protein synthesis by mitochondria, resulting in greater tissue regeneration in the repair process. , LLLT also provides a stimulus to microcirculation, which increases the delivery of nutritional elements associated with an increased rate of mitosis, leading to neoangiogenesis. 
A thorough review of the literature has proven that lasers aid in a quicker healing compared to other treatments such as topical corticosteroids etc., through varied mechanisms.  When it is delivered in appropriate dosage, energy of the photons from the LLLT is converted into photochemical, photophysical, and photobiological effects. These effects include lymphocyte stimulation, activation of mast cells, and also the proliferation of various types of cells such as fibroblasts and macrophages. All these factors synergistically promote anti-inflammatory effects and bio stimulatory effects, thus enhancing wound healing. 
Low-level laser therapy tends to increase fibroblast proliferation and differentiation by stimulating the production of basic fibroblast growth factor.  In addition, LLLT aids in the transformation of fibroblasts into myofibroblasts, which are responsible for wound contraction thus helping in the rapid healing of the ulcer.  Secondary clinical effects associated with LLLT are a decrease in the levels of histamine, bradykinins, and substance P, which reduces the inflammation.  This effect was clearly evident as the erythematous halo surrounding the ulcers had completely resolved by the 3 rd day post LLLT.
It can be concluded based on the results of the present study and thorough review of the existing literature that LLLT can decrease the healing time, pain intensity, size, and recurrence of the lesion in RAS, and hence can be considered the most appropriate treatment modality for RAS, with the greatest clinical effectiveness.
| Conclusion|| |
Many treatment modalities have been tried in the past for the management of RAS with varied success. The topics pertaining to the appropriate treatment modality for the management of RAS still remain as a never-ending debate in the field of dentistry. LLLT gains an edge over the other existing treatment modalities due to its localized effects resulting in no harm to the adjacent tissues and no systemic toxicity. It is noninvasive with good patient compliance having no mutagenic effects and can repeatedly be used without risk. However, long-term comparative studies are needed to further substantiate the advantages of LLLT in the treatment of oral lesions.
| References|| |
Yarak S, Okamoto OK. Biostimulation effects of low-power laser in the repair process. An Bras Dermatol 2010;85:849-55.
Slebioda Z, Szponar E, Kowalsk A. Recurrent aphthous stomatitis: Genetic aspects of etiology. Postepy Dermatol Alergol 2013;2:96-102.
Stanley HR. Aphthous lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1972;30:407-16.
Patil S, Reddy SN, Maheshwari S, Khandelwal S, Shruthi D, Doni B. Prevalence of recurrent aphthous ulceration in the Indian Population. J Clin Exp Dent 2014;6:e36-40.
Pedersen A. Psychologic stress and recurrent aphthous ulceration. J Oral Pathol Med 1989;18:119-22.
Ship JA. Recurrent aphthous stomatitis. An update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:141-7.
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.
Scully C, Gorsky M, Lozada-Nur F. The diagnosis and management of recurrent aphthous stomatitis: A consensus approach. J Am Dent Assoc 2003;134:200-7.
Barrons RW. Treatment strategies for recurrent oral aphthous ulcers. Am J Health Syst Pharm 2001;58:41-50.
Scully C, Porter S. Oral mucosal disease: Recurrent aphthous stomatitis. Br J Oral Maxillofac Surg 2008;46:198-206.
Tuner J, Hode L. Biostimulation. Ch. 3. p. 61-114. The mechanisms. Ch. 11. p. 333-64. Laser Therapy: Clinical Practice and Scientific Background. Gransgesberg, Sweden: Prima Books, AB; 2002.
Walsh LJ. The current status of low level laser therapy in dentistry. Part 1 soft tissue applications. Aust Dent J 1997;42:247-54.
Aggarwal H, Singh MP, Nahar P, Mathur H, Gv S. Efficacy of low-level laser therapy in treatment of recurrent aphthous ulcers: A sham controlled, split mouth follow up study. J Clin Diagn Res 2014;8:218-21.
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.
Khademi H, Shirani AM, Nikegbal F. Evaluation of low level laser therapy in recurrent aphthous stomatitis. Shiraz Univ Dent J 2009;10:160-2.
Bladowski M, Choroszucha HK, Choroszucha T. Comparison of treatment results of recurrent aphthous stomatitis with low and high power laser irradiation versus pharmaceutical method. J Oral Laser Appl 2004;4:191-209.
Yu W, Naim JO, Lanzafame RJ. The effect of laser irradiation on the release of bFGF from 3T3 fibroblasts. Photochem Photobiol 1994;59:167-70.
Pourreau-Schneider N, Ahmed A, Soudry M, Jacquemier J, Kopp F, Franquin JC, et al.
Helium-neon laser treatment transforms fibroblasts into myofibroblasts. Am J Pathol 1990;137:171-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]