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| CASE REPORT |
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| Year : 2021 | Volume
: 13
| Issue : 2 | Page : 125-128 |
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Photobiomodulation therapy in the treatment of a palatal ulcer
Nivedita Chinam, Aniket Vaidya, Thilak Thomas John
Department of Oral Medicine and Radiology, Goa Dental College and Hospital, Bambolim, Goa, India
| Date of Submission | 08-Sep-2020 |
| Date of Acceptance | 04-May-2021 |
| Date of Web Publication | 22-Jun-2021 |
Correspondence Address:
Nivedita Chinam
Department of Oral Medicine and Radiology, Goa Dental College and Hospital, Bambolim - 403 202, Goa
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jorr.jorr_43_20
Oral mucosa is the most common site for ulcers, and severely painful ulcers of traumatic origin prompt the patient to visit an oral physician to seek necessary treatment. Currently, numerous topical analgesics and anti-inflammatory medications are prescribed to reduce pain and accelerate healing. An alternative to this is low-level laser therapy which is a drug-free and noninvasive therapy and has shown potential results in treatment of oral ulcers. In this paper, we report a case of a patient with palatal ulcer which was successfully treated using a 660-nm (red) laser.
Keywords: Low-level laser therapy, oral ulcer, photobiomodulation, phototherapy
How to cite this article:
Chinam N, Vaidya A, John TT. Photobiomodulation therapy in the treatment of a palatal ulcer. J Oral Res Rev 2021;13:125-8 |
| Introduction | |  |
Wound healing is a dynamic and complex process involving three main overlapping phases which are inflammation, proliferation, and remodeling. Oral ulcers are characterized by damage to both the epithelium and connective tissue, which are usually repaired within weeks if the etiological factor is removed.[1] The most commonly encountered etiologies of oral ulceration are trauma, recurrent aphthous stomatitis, mucocutaneous disease, microbial infections, systemic disorders, and drug therapy.[2] Numerous therapeutic protocols, such as analgesics, corticosteroids, anti-inflammatory agents, and phytotherapy, are known to accelerate the wound healing process and reduce pain.[1] An alternative approach to this is the use of photobiomodulation (PBM), commonly referred to as low-level laser therapy (LLLT) which is a drug-free, noninvasive therapy and uses light energy to elicit biological responses from the cell and normalize cell function.[3],[4] As the light is of low energy density and it interacts with the tissue cells without thermal effects due to photon beam exposure, this type of laser radiation is also called a soft laser or cold laser.[5] In this article, we report a case of a traumatic ulcer on the palate which showed significant improvement following treatment with low-level laser.
| Case Report | | |
A 57 year old female patient visited the department of oral medicine and radiology with a complaint of pain and ulcer in the mouth for the past 10 days. The pain was of severe intensity and increased during mastication. The patient's past history indicated trauma to anterior maxilla which resulted in dentoalveolar fracture 6 months ago and was subsequently managed by open reduction and internal fixation with a miniplate under general anesthesia. On intraoral examination, the patient presented with a well-defined, irregular-shaped ulceration over the anterior hard palate measuring about 2 cm × 1.5 cm. The margins were erythematous with sloping edges and floor covered with yellowish-white slough [Figure 1]. The region of the ulcer appeared to be elevated, and the surrounding mucosa was inflamed. Radiographic evaluation with intraoral periapical radiograph [Figure 2] revealed a miniplate with screws over the palatal bone corresponding to the area of the ulcer. As there was no radiographic evidence of any infection around the bone plate, we believe that the relatively thin palatal mucosa must have ulcerated secondary to repeated trauma during mastication. Thus, a provisional diagnosis of traumatic ulcer was given. Laser therapy was administered with a handheld diode laser (NLase by IndiLase, Medsol) [Figure 3] of 660-nm (visible red) wavelength at four different points [Figure 4] over the ulcer in continuous wave and contact mode. The energy density was 6 J/cm2 with an output power of 50 mW. The exposure time on each point of the ulcer was 30 s, hence the total energy delivered per point was 1.5 J. LLLT was carried out for four consecutive sessions with an interval of 48 hours. During the third sitting [Figure 5] the total dose administered was 4.5 J/cm2 and in the fourth visit [Figure 6] it was 3 J/cm2. By the third visit, there was a remarkable reduction in the pain scale and decrease in the size of the ulcer with reduction in inflammation and re-epithelialization. In the third and fourth visit the number of points for laser administration were reduced and was limited to the area where the ulcer was persistent. In the fifth visit, the ulcer healing was satisfactory and the patient was able to eat without any discomfort. After complete healing of the palatal ulcer, the patient was rehabilitated with a partial denture using a soft liner to provide relief and protect the underlying area from any trauma. | Figure 1: Image showing irregular shaped ulceration over the anterior hard palate
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 | Figure 2: Intraoral periapical radiograph showing evidence of a miniplate with screws over the palatal bone
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 | Figure 4: Image showing points of laser administration at the site of ulcer
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 | Figure 6: Significant resolution of the ulcer with re-epithelialization in the fourth visit
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| Discussion | | |
Endre Mester was the first to describe the “biostimulation” effect of lasers in 1967.[6] As per the consensus obtained at the joint congress of the North American Association for PBM Therapy and the World Association for Laser Therapy in 2014, the term LLLT was replaced by the term PBM therapy.[7] It involves application of red (600–700 nm) and near-infrared light (700–950 nm), usually produced by low-to-mid power coherent lasers or noncoherent light-emitting diodes, over injuries, or any other lesions. Photobiomodulation therapy is known to accelerate wound healing, reduce inflammation, relieve acute or chronic pain and repair nerve damage.[6] The radiation power range of this treatment modality is between 250 and 500 mW or <250 mW.[5] Currently, laser therapy is being investigated as a therapeutic method in multiple orofacial diseases such as oral lichen planus, recurrent aphthous stomatitis, xerostomia, pemphigus vulgaris, bullous pemphigoid, recurrent herpes simplex infection, burning mouth syndrome, medication-related osteonecrosis of the jaws, trigeminal neuralgia, facial nerve paralysis, geographic tongue, and chronic sinusitis.[5]
The primary effect of PBM occurs when light is absorbed in a chromophore called cytochrome C oxidase (CCO), a protein within the mitochondria which plays a crucial role in the cellular response. In the mitochondria of hypoxic cells, nitric oxide (NO) binds to CCO by competitively displacing oxygen, thus inhibiting cellular respiration and decreasing adenosine triphosphate (ATP) production.[6],[8] Thus, when the light photons are absorbed by the chromophore, three basic events occur which are stimulation of ATP synthesis by activation of the electron transport chain, transient stimulation of reactive oxygen species (ROS), and a temporary release of NO from its binding site on CCO.[3] This brings a shift in cell redox potential towards greater oxidation and increased ROS, causing activation of redox sensitive transcription factors, such as necrosis factor ĸβ, which leads to expression of an array of gene products that prevent apoptosis and cell death, stimulates collagen synthesis, angiogenesis, modulates the inflammatory and antioxidant response [Table 1].[6],[8] It also helps in regeneration of damaged peripheral nervous system, stimulation of proliferation of osteoblast cells, and decreased osteoclast activity.[5] The analgesic effect by LLLT is possibly due to the production of neuropharmacological substances, including endogenous endorphins, decrease in C-fiber activity and bradykinin, and alteration of the pain threshold.[9]
The efficacy of PBM is dependent on the wavelength, output power, and energy density and the different cell types affected.[7] The most important variable is the treatment dose which is a measure of amount of energy that is conducted into the tissue and is measured in joules per square centimeter (J/cm2).[3] LLLT exhibits a biphasic dose–response based on the Arndt–Schulz law, which states that mild stimulus excites physiological activity, whereas strong stimulus can exhibit a biosuppressive activity.[1],[8] This dose–response was verified by Wagner et al. in their study on Wistar rats. They observed that faster and more organized re-epithelialization and tissue healing of the oral mucosa were achieved with an energy density of 4 J/cm2 in comparison to 20 J/cm2.[1] For superficial lesions, the frequently used dose in the red wavelengths tends to be 4 J/cm2, with a range of 1–10 J/cm2. For deep-seated disorders, higher doses of the near-infrared wavelengths, that is, in the 10–50 J/cm2 range, are employed. The light treatment is usually repeated either every day or alternate day, and the course of treatment can last for a period of 2 weeks.[6] Amorim dos Santos et al. in their systematic review on the use of LLLT for recurrent aphthous stomatitis suggested different protocols for wound healing and pain relief. For wound healing, a Diode laser with a wavelength of 810 nm, 0.5 W power, applied 4 times with a gap of 30 to 40 seconds between each application in continuous mode and 2-3 mm distance to lesion was recommended. The exposure time was 180 seconds per application in a single session. For pain relief use of GaAIAs laser with 809 nm of wavelengths, 0.06 W power, applied once a day for 2 days in a pulsed mode and direct contact to lesion, with 80 seconds per application was advised.[4] Apart from diode lasers, the use of nonablative CO2 laser therapy and neodymium: doped yttrium aluminum garnet laser (λ =1064 nm) has also been proven to be effective in wound healing of ulcers.[4],[7] A combination of antimicrobial photodynamic therapy and PBM has also been applied for treatment of oral ulcers. Photodynamic therapy with methylene blue dye application in combination with an appropriate wavelength of visible light, initiates free radicals or superoxide ions that oxidize the biological structures such as mitochondria, DNA, and lipid membranes of microbes causing a lethal photochemical reaction leading to irreversible damage with the consequent death of microorganisms. This “microorganism biological cleaning” of the contaminated area, enhances the healing process and reduce the bacterial load in necrotic lesions.[9] Cabras et al. reported a case of hydroxyurea-induced oral ulceration which was successfully treated with an 810-nm laser unit at 100 mW and 6J/cm2.[10] In our case, we used a red laser with wavelength 660 nm and energy density of 6J/cm2 following which pain control and healing was achieved successfully.
| Conclusion | | |
PBM therapy can be considered as a treatment option for oral ulcers as it is a drug-free and noninvasive therapy, thus avoiding the use of analgesics and anti-inflammatory agents. We reported a case of palatal ulcer which was managed successfully only with PBM. Patient's acceptance of the procedure and results were excellent as perceived by the patient. Furthermore, it is suggested to carry out randomized clinical trials to evaluate the efficacy of this light therapy over the current conventional treatment modalities.
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 | | |
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| 2. | Field EA, Allan RB. Review article: Oral ulceration–Aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic. Aliment Pharmacol Ther 2003;18:949-62. |
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| 4. | Amorim Dos Santos J, Normando AG, de Toledo IP, Melo G, de Luca Canto G, Santos-Silva AR, et al. Laser therapy for recurrent aphthous stomatitis: An overview. Clin Oral Investig 2020;24:37-45. |
| 5. | Kalhori KA, Vahdatinia F, Jamalpour MR, Vescovi P, Fornaini C, Merigo E, et al. Photobiomodulation in oral medicine. Photobiomodul Photomed Laser Surg 2019;37:837-61. |
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| 7. | Suter VG, Sjölund S, Bornstein MM. Effect of laser on pain relief and wound healing of recurrent aphthous stomatitis: A systematic review. Lasers Med Sci 2017;32:953-63. |
| 8. | Chung H, Dai T, Sharma SK, Huang YY, Carroll JD, Hamblin MR. The nuts and bolts of low-level laser (light) therapy. Ann Biomed Eng 2012;40:516-33. |
| 9. | Maya R, Ladeira LL, Maya JE, Mail LM, Bussadori SK, Paschoal MA. The combination of antimicrobial photodynamic therapy and photobiomodulation therapy for the treatment of palatal ulcers: A case report. J Lasers Med Sci 2020;11:228-33. |
| 10. | Cabras M, Cafaro A, Gambino A, Broccoletti R, Romagnoli E, Marina D, Arduino PG. Laser Photobiomodulation for a Complex Patient with Severe Hydroxyurea-Induced Oral Ulcerations. Case Rep Den 2016:9810480, 1-4. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1]
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