Laser therapy for recurrent aphthous stomatitis: an overview

A Novel Therapeutic Approach of 980 nm Photobiomodulation Delivered with Flattop Beam Profile in Management of Recurrent Aphthous Stomatitis in Paediatrics and Adolescents-A Case Series with 3-Month Follow-Up

Background/Objectives: Recurrent aphthous stomatitis (RAS) is one of the most common oral mucosal lesions and a very debilitating lesion, especially in paediatric and adolescent patients. The current pharmacotherapy offers a pain relief but not without side effects, and therefore photobiomodulation (PBM) can be an alternative therapy. To the authors' best knowledge, no published study has explored the efficacy of λ 980 nm laser PBM in the management of all RAS subtypes in paediatric and adolescent patients, and therefore, this prospective observational clinical study was conducted to bridge this gap by evaluating λ 980 nm laser PBM efficacy in symptomatic RAS management in paediatric and adolescent patients. The objectives were to evaluate (1) pain intensity alleviation; (2) wound healing rate; (3) wound size closure; (4) a complete resolution; (5) evidence of recurrence; and (6) patients' treatment satisfaction. Methods: The study's variables were assessed at the following timepoints: T0: pre-treatment; T1: immediately after first PBM session; T2: 5 hours (h) post first PBM session (via telephone call); T3: immediately after second PBM session (three days post first PBM session); T4: three-day follow-up (after complete PBM treatments); T5: two-week follow-up; and T6: three-month follow-up. The following PBM dosimetry and treatment protocols were employed: λ 980 nm; 300 mW; 60 s; 18 J; CW; flattop beam profile of 1 cm2 spot size; 18 J/cm2; and twice-a-week irradiation (72 h interval). Results: At T1, significant immediate pain intensity relief was reported. 33.33% recorded "4" and 66.67% reported "5" on the quantitative numeric pain intensity scale (NPIS), and this continued to improve significantly (83.33%) at T2. All the subjects reported "0" on the NPIS at T3, T4, T5 and T6. There was a significant reduction in the lesion surface area (>50% complete healing) at T3 compared to T0. Complete healing (100%) with no evidence of scarring and lesion recurrence observed at T4, T5 and T6. Very good patients' satisfaction was reported at all timepoints. Conclusions: This is the first report demonstrating λ980 nm efficacy in all RAS subtype management in paediatric and adolescent patients with a 3-month follow-up, whereby its PBM dosimetry and treatment protocols were effective from scientific and practical standpoints, and hence multicentre RCTs with large data are warranted to validate its reproducibility and to enrich the knowledge of PBM application in all RAS subtypes.

Immune-mediated oral mucosal pathology: a comprehensive review and update for clinicians - part II

The oral mucosa can be involved in a wide variety of mucocutaneous conditions that may present primarily in the mouth or affect other cutaneous or mucosal sites. Many of these conditions are immune mediated and typically present as inflammatory mucosal pathology. Patients experiencing such conditions usually seek medical evaluation and treatment due to the associated pain and discomfort, and occasionally taste disturbance or dysphagia and the overall deterioration in the oral health-related quality of life. These conditions share some common features and there could be some overlap in their clinical presentation, which can lead to delays in diagnosis and proper management of patients. Clinicians dealing with such disorders, including dermatologists, need to be aware of the oral manifestations of mucocutaneous conditions, their clinical features, underlying mechanisms, diagnostic approaches, and treatment options, as well as the recent advances in the research on these conditions. This review provides a comprehensive, evidence-based reference for clinicians, with updated insights into a group of immune mediated conditions known to cause oral mucosal pathology. Part one will cover oral lichen planus, erythema multiforme and systemic lupus erythematosus, while part two will cover recurrent aphthous stomatitis, pemphigus vulgaris and mucous membrane pemphigoid, in addition to the less common disorders linear IgA disease, dermatitis herpetiformis and epidermolysis bullosa.

Histological effects of photobiomodulation on delayed tooth replantation: a systematic review

This systematic review evaluated preclinical studies to assess whether PBM has a more favorable histological response than other treatments used before delayed replantation of avulsed teeth. This review followed the PRISMA checklist and was registered in PROSPERO. MEDLINE (PubMed), Embase, Scopus and Web of Science were searched from their inception to July 14, 2022. Data were independently extracted by two reviewers. Data were collected about species, number of animals, number and type of teeth, groups evaluated, extra-alveolar time, parameters for PBM and other study groups, presence and characteristics of containment, observation time points, evaluation methods, characteristics evaluated, and significant results. The ARRIVE and SYRCLE tools were used to assess the methodological quality and risk of bias (RoB) of the studies. After screening, six studies were included in the review synthesis. Three of the four studies that evaluated root resorption as an outcome found that PBM decreases its occurrence after delayed tooth replantation. A meta-analysis was not conducted because some data were missing in the included studies. Half of the studies evaluating ankylosis found an increase in its occurrence after PBM. Two studies evaluated inflammatory responses and found a reduction of inflammation after PBM. In general, studies had high methodological heterogeneity, intermediate reporting quality and high RoB. Despite the methodological quality and RoB limitations of the studies, the histological responses after delayed tooth replantation were more favourable in the PBM groups. Preclinical studies supported by guidelines should define laser parameters for future clinical studies.

Determinants and inequality of recurrent aphthous stomatitis in an Indonesian population: a cross sectional study

INTRODUCTION

Recurrent Aphthous Stomatitis (RAS) is the most common type of ulceration in the oral cavity which can occur due to several factors.

AIMS

To determine the factors related to the incidence of RAS and examine the social class inequality in RAS among the Indonesian population using data from the fifth wave of the Indonesian Family Life Survey (IFLS5) in 2014.

METHODS

This study is a descriptive study with a cross-sectional design using secondary data from IFLS5 data in 2014 (n = 28,410). Socio-economic position (SEP) was calculated by Adult Equivalent Scale and categorized into 4 classes. Outcome is RAS. Mediating factors were psychosocial (stress), eating behavioral (food consumption), and systemic diseases. Descriptive analysis, chi-square and a series of logistic regressions were performed to analyze the data. Odds ratio (OR) and 95% confidence interval (CI) were used to report the results.

RESULTS

Only 18.39% of IFLS5 respondents experienced the incidence of recurrent aphthous stomatitis in 2014. The bivariate (chi-square) results showed that there was a relationship between the incidence of RAS and the related independent variables. Logistic regression showed the highest possibility of RAS in respondents aged 18-34 years, female, unmarried, high school education level, living in the city, having frequent stress levels, having food habits that frequently drinking soda, sweet foods, chili sauce, fried food and has systemic diseases such as, asthma, cancer, rheumatism, and digestion. The lowest SEP group had the highest probability of occurrence of RAS over the other groups among the different models.

CONCLUSIONS

There are several factors that determine the incidence of RAS. There was a monotonic gradient of inequality in RAS according to SEP group. This study might be useful to provide information regarding the relationship of determinants factors with the incidence of RAS to prevent it and promote oral health in the future.

Systematic review and meta-analysis of oxidative stress and antioxidant markers in recurrent aphthous stomatitis

BACKGROUND

We performed this systematic review and meta-analysis to synthesize all studies that reported the level of oxidative and antioxidative markers in recurrent aphthous stomatitis (RAS) patients compared to controls.

METHODS

We registered our study in PROSPERO (CRD42023431310). PubMed, ProQuest, Scopus, EMBASE, Google Scholar, and Web of Science were searched to find relevant publications up to June 5, 2023. The standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated. We included 30 articles after multiple stags of screening.

RESULTS

We found that erythrocyte superoxide dismutase and Glutathione peroxidase activity were significantly lower in patients with RAS compared to healthy controls (SMD = - 1.00, 95%CI = -1.79 to -0.21, p = 0.013, and SMD = - 1.90, 95%CI = -3.43 to -0.38, p = 0.01, Respectively). However, there was not any difference between patients with RAS and healthy controls in erythrocyte Catalase (SMD = - 0.71, 95%CI = -1.56-0.14, p = 0.10). The total antioxidant status (TAS) level, in serum was significantly lower in patients than healthy controls (SMD = - 0.98, 95%CI = -1.57 to -0.39, p = 0.001). In addition, RAS patients had higher levels of serum Malondialdehyde (MDA), Serum total oxidant status, and serum oxidative stress index than healthy controls (SMD = 2.11, 95%CI = 1.43-2.79, p < 0.001, SMD = 1.53, 95%CI = 0.34-2.72, p = 0.01, and SMD = 1.25, 95%CI = 0.25-2.25, p = 0.014, Respectively); However, salivary MDA and TAS, and serum uric acid, vitamin E and C, and reduced glutathione levels of patients with RAS were not different from that of healthy controls.

CONCLUSIONS

The relationship between oxidative stress and RAS is well established in this meta-analysis. Although the molecular processes underlying the etiology of this pathology remain unknown, evidence indicating oxidative stress has a significant role in the pathogenesis of RAS has been revealed.

COMPARATIVE EFFICACY OF THERAPEUTIC INTERVENTIONS FOR THE MANAGEMENT OF RECURRENT APHTHOUS ULCERS: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

BACKGROUND

Recurrent aphthous ulceration (RAU) is an oral condition cavity affecting 2.5 billion people worldwide. We aimed to assess the comparative efficacy and safety of available interventions in the management of RAU.

MATERIALS AND METHODS

An electronic search of 3 databases (Medline, CENTRAL, Scopus) was performed to identify randomized control trials evaluating the efficacy of RAU interventions published until December 2022. A network meta-analysis (NMA) was conducted on 4 outcomes: reduction in pain, duration of ulceration, the diameter of ulceration, and area of ulceration. The interventions are then arranged using the surface area under cumulative ranking (SUCRA).

RESULTS

A total of 38 trials involving 2773 patients were included were included in quantitative synthesis by NMA. Our analysis showed that Diode laser [MD, -4.865 ± 1.951 (95%CI = (-8.690, -1.041)] was the most effective in reducing the pain score followed by Amlexanox [MD, -2.673 ± 1.075 (95%CI = -4.779, -0.566)]. Iralvex performed the best in reducing the duration of ulceration [MD, -6.481 ± 1.841 (95%CI = -10.090, -2.872)]. Diode laser, acacia nilotica with licorice formulation, and amlexanox were the most effective interventions for reduction of ulcer diameter. Majority of the trials reported absence of any adverse effects and those reported were mild.

CONCLUSION

Our NMA has identified several interventions to be more effective than a placebo. Laser therapy may be an option for promoting pain management, however, most have only been tested in 1 or 2 trials. Further studies with rigorous methodology on larger samples are recommended to strengthen the current evidence.

Effectiveness of Photobiomodulation in Reducing Pain of Oral Mucosal Diseases: A Case Series

Introduction

Pain management becomes important in the treatment of oral mucosal diseases since it can impair the quality of life. Photobiomodulation (PBM) as an alternative therapy, has potency in reducing pain through several mechanisms targeting peripheral nerves in the target tissue.

Purpose

To discuss the effectiveness of PBM in the management of four cases of oral mucosal diseases.

Case

Four patients, two females and two males, with an age ranging from 24 to 63 years came to the Oral Medicine Department complaining of painful lesions in their oral cavity. Three cases showed ulceration of the oral mucosa and had been diagnosed with recurrent aphthous stomatitis, recalcitrant chronic ulcer, and non-specific chronic sialadenitis. One patient who complained of intense pain and swelling on the right side of the face was diagnosed with post-herpetic neuralgia (PHN).

Case Management

PBM was administered in all four cases (976 nm diode laser, three cases with spot size 0.01 cm², fluency 10 J/cm², and one case with spot size 0.5 cm²; fluency 3 J/cm²). Visual analog scale (VAS) control was performed before and after the PBM at each visit. The recorded VAS results show a reduction in pain that started at the post-laser time, with VAS before PBM ranging from 5 to 7 and after PBM ranging from 0 to 4. Three patients were given triamcinolone acetonide 0.1%, chlorhexidine gluconate 0.2% mouthwash, petroleum jelly, and multivitamins. One patient was given mefenamic acid and multivitamins.

Conclusion

PBM can be a useful adjunctive treatment to relieve the pain of oral mucosal diseases due to its ability to reduce pain intensity.

Healing of Recurrent Aphthous Stomatitis by Non-Thermal Plasma: Pilot Study

Recurrent aphthous stomatitis (RAS) is a common disease in the oral cavity characterized by recurrent ulcers (RU). Usually, these cause acute pain without definitive treatment. The present study determines the efficacy of non-thermal plasma (NTP) for treating RU. NTP is applied to the patient's RU using a radiofrequency generator connected to a point reactor. The power density applied to the ulcer is 0.50 W/cm², less than 4 W/cm², which is the maximum value without biological risk. Each patient received two treatments of three minutes each and spaced 60 min apart at a distance of 5 mm from the RU. From a sample of 30 ulcers in patients treated for RU with an average age of 37 years, they stated that the pain decreased considerably and without the need for ingestion of analgesics and antibiotics. Regeneration took place in an average of three days. The NTP proved to be an excellent therapeutic alternative for the treatment of RU since it has a rapid effect of reducing pain and inflammation, as well as adequate tissue regeneration.

A Narrative Review on Means to Promote Oxygenation and Angiogenesis in Oral Wound Healing

Oral mucosa serves as the primary barrier against pathogen invasions, mechanical stresses, and physical trauma. Although it is generally composed of keratinocytes and held in place by desmosomes, it shows variation in tissue elasticity and surface keratinization at different sites of the oral cavity. Wound healing undergoes four stages of tissue change sequences, namely haemostasis, inflammation, proliferation, and remodelling. The wound healing of oral hard tissue and soft tissue is largely dependent on the inflammatory response and vascular response, which are the targets of many research. Because of a less-robust inflammatory response, favourable saliva properties, a unique oral environment, and the presence of mesenchymal stem cells, oral wounds are reported to demonstrate rapid healing, less scar formation, and fewer inflammatory reactions. However, delayed oral wound healing is a major concern in certain populations with autoimmune disorders or underlying medical issues, or those subjected to surgically inflicted injuries. Various means of approach have been adopted to improve wound tissue proliferation without causing excessive scarring. This narrative review reappraises the current literature on the use of light, sound, mechanical, biological, and chemical means to enhance oxygen delivery to wounds. The current literature includes the use of hyperbaric oxygen and topical oxygen therapy, ultrasounds, lasers, platelet-rich plasma (PRP)/platelet-rich fibrin (PRF), and various chemical agents such as hyaluronic acid, astaxanthin, and Centella asiatica to promote angiogenesis in oral wound healing during the proliferation process. The arrival of a proprietary oral gel that is reported to improve oxygenation is highlighted.

A Randomized controlled clinical trial on dose optimization of thalidomide in maintenance treatment for recurrent aphthous stomatitis

BACKGROUND

Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease, and ulcer-free periods are a major concern for patients. Thalidomide has been shown to be an effective systemic drug in the treatment of RAS, but the value of undertaking a trial to evaluate various maintenance doses was warranted.

METHODS

We performed this randomized controlled clinical trial with a two-stage design. Firstly, all the 125 cases of RAS received prednisone at a starting dose of 15 mg/d for one week as an initial therapeutic drug. Secondly, the 100 cases of RAS in the experimental group received thalidomide (50 mg/d vs. 25 mg/d) as a maintenance drug to observe its efficacy and safety.

RESULTS

During maintenance medication at the fourth and eighth weekend, the two doses (50 and 25 mg/d) of thalidomide were equivalent in reducing the incidence of ulcers, ulcer number, and ulcer pain, respectively (all p > 0.05). Notably, the ulcer-free period in the group using 25 mg/d thalidomide for eight weeks was longer (mean, >3 months) than those in the other groups (all p < 0.05). Importantly, the total adverse events in the group using 25 mg/d thalidomide were significantly less than those in the group using 50 mg/d (p < 0.001). Moreover, the effect of 50 mg/d thalidomide on the levels of various salivary cytokines was not superior to 25 mg/d medication (p > 0.05).

CONCLUSION

This dose optimization study concluded that 25 mg/d thalidomide had a long-term effect on extending the recurrence interval of RAS with better safety.

Crosstalk between the oral microbiota, mucosal immunity, and the epithelial barrier regulates oral mucosal disease pathogenesis

Oral mucosal disease (OMD), which is also called soft tissue oral disease, is described as a series of disorders or conditions affecting the mucosa and soft tissue in the oral cavity. Its etiology is unclear, but emerging evidence has implicated the influence of the composition of the oral mucosa and saliva-resident microbiota. In turn, this dysbiosis effects the immune response balance and epithelial barrier function, followed by the occurrence and progression of OMD. In addition, oral microbial dysbiosis is diverse in different types of diseases and different disease progressions, suggesting that key causal pathogens may exist in various oral pathologies. This narrative literature review primarily discusses the most recent findings focusing on how microbial dysbiosis communicates with mucosal adaptive immune cells and the epithelial barrier in the context of five representative OMDs, including oral candidiasis (OC), oral lichen planus (OLP), recurrent aphthous ulcer (RAU), oral leukoplakia (OLK), and oral squamous cell carcinoma (OSCC), to provide new insight into the pathogenetic mechanisms of OMDs.

Analysis of the psychopathological profile, quality of life, and cost-effectiveness of oral lichen planus patients treated with photobiomodulation

OBJECTIVES

To evaluate the effect of PBM on the psychological profile and quality of life of patients with oral lichen planus (OLP) in comparison to corticoid and to investigate the cost-effectiveness of both treatments.

MATERIALS AND METHODS

Patients were randomized into two groups: Control (clobetasol propionate 0.05%) and Photobiomodulation (660 nm, 100mW, 177 J/cm², 5 s, 0.5 J) twice a week for 30 days. The Hospital Anxiety and Depression Scale (HADS) and OHIP-14 were used in different treatment time points and at follow-up. The cost-effectiveness was calculated using the improvement in OHIP-14 after treatment.

RESULTS

OLP patients showed detected levels of anxiety, depression, and poor quality of life at baseline. No improvement in anxiety and depression was noticed after treatments. However, PBM and corticoid significantly improved the quality of life of OLP patients, considering the OHIP-14-T and the physical pain domain. The treatment with corticoid was more cost-effective than PBM.

CONCLUSIONS

Psychological distress was not improved after both treatments and PBM is as effective as corticoids in promoting a better quality of life in OLP patients, despite its higher cost.

CLINICAL RELEVANCE

This study highlights the need for additional therapeutic interventions in OLP patients, to early recognize and to manage the alterations in their psychological profile. Moreover, PBM is an effective therapy in OLP patient's quality of live and although it was a more expensive, the advantage of being a minimally invasive therapy associated with no side effects must be considered in clinical practice, especially in those patients with refractory disease.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov; the registration number is NCT03320460, registered in 17/10/2017.

Evaluation of diode laser versus topical corticosteroid in management of Behcet's disease-associated oral ulcers: a randomized clinical trial

OBJECTIVES

The current trial was conducted to assess the effect of diode laser therapy compared to topical corticosteroid in management of oral ulcers of BD.

MATERIALS AND METHODS

Fifty patients were divided randomly into two parallel groups. The first group received 980 nm diode laser; the second group received topical corticosteroid (0.1% triamcinolone acetonide). The outcome measures included oral ulcer activity index (composite index), pain (VAS), number of oral ulcers, healing time, and oral health-related quality of life (OHIP-14). The collected data were analyzed for any statistical significance.

RESULTS

A statistically significant difference was detected between laser and corticosteroid groups favoring laser on comparing composite index and VAS scores on the first and third days and on comparing number of ulcers on the third and fifth days. A statistically significant difference was detected between laser and corticosteroid groups on comparing scores of the questions assessing discomfort with eating food, irritability with other people, taste worsening, unsatisfactory diet, and painful aching on the first and/or third days. No adverse effects were reported by participants of both groups.

CONCLUSIONS

Diode laser is efficient safe treatment modality for management of BD-associated oral ulcers. Diode laser was more efficient than triamcinolone acetonide in controlling pain and reducing oral ulcer activity.

CLINICAL RELEVANCE

Laser therapy is efficient safe modality that could spare BD patient from adding a new medication to their long list, being just one visit compared to other regular daily regimen medications.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT03771768.

Photobiomodulation therapy drives massive epigenetic histone modifications, stem cells mobilization and accelerated epithelial healing

Emerging evidence indicates the clinical benefits of photobiomodulation therapy (PBMT) in the management of skin and mucosal wounds. Here, we decided to explore the effects of different regiments of PBMT on epithelial cells and stem cells, and the potential implications over the epigenetic circuitry during healing. Scratch-wound migration, immunofluorescence (anti-acetyl-Histone H3, anti-acetyl-CBP/p300 and anti-BMI1), nuclear morphometry and western blotting (anti-Phospho-S6, anti-methyl-CpG binding domain protein 2 [MBD2]) were performed. Epithelial stem cells were identified by the aldehyde dehydrogenase enzymatic levels and sphere-forming assay. We observed that PBMT-induced accelerated epithelial migration and chromatin relaxation along with increased levels of histones acetylation, the transcription cofactors CBP/p300 and mammalian target of rapamycin. We further observed a reduction of the transcription repression-associated protein MBD2 and a reduced number of epithelial stem cells and spheres. In this study, we showed that PBMT could induce epigenetic modifications of epithelial cells and control stem cell fate, leading to an accelerated healing phenotype.

Low-power lasers on bacteria: stimulation, inhibition, or effectless?

Clinical protocols based on low-power lasers have been widely used for inflammation process resolution improvement, pain relief, wound healing, and nerve regeneration. However, there are concerns if exposure to such lasers could have negative effects on infected organs and tissues. There are experimental data suggesting exposure to radiations emitted by low-power lasers either induces stimulation, inhibition, or it is effectless on bacterial cultures. Thus, this review aimed to carry out a review of studies and to propose a hypothesis to explain why exposure to low-power lasers could stimulate, inhibit, or have no effect on bacteria. A literature search was carried out for assessment of published reports on effect of low-power lasers on bacteria. The experimental data suggest that keys for determining laser-induced effects on bacteria are specific physical laser and biological parameters. Final consequence on bacterial cells could depend on exposure to low-power laser which could either cause more stimulation of endogenous photoacceptors, more excitation of endogenous photosensitizers, or a balance between such effects.

The clinical efficacy and safety of traditional Chinese medicine in the treatment of recurrent aphthous stomatitis: A protocol of systematic review and meta-analysis

BACKGROUND

The objective of this meta-analysis was to summarize and identify the available evidence from studies to estimate the clinical value of traditional Chinese medicine (TCM) in the treatment of recurrent aphthous stomatitis (RAS) and provides clinicians with evidence on which to base their clinical decision making.

METHODS

This review will include all studies comparing clinical efficacy of TCM in the treatment of RAS. The search strategy will be performed in 9 databases. We will not establish any limitations to language and publication status, published from inception to the August 2020. Two reviewers will screen, select studies, extract data, and assess quality independently. Outcome is clinical efficacy, pain relief, duration of wound healing, effect on wound healing, rate of recurrence, adverse events, and safety. The methodological quality including the risk of bias of the included studies will be evaluated. We will carry out statistical analysis using RevMan 5.3 software.

RESULTS

This study will summarize current evidence to assess the efficacy and safety of TCM in the treatment of RAS.

CONCLUSION

The findings of this study will provide helpful evidence for the clinician, and will promote further studies, as well as studying the value of TCM.

REGISTRATION NUMBER

INPLASY202080126 (DOI number: 10.37766/inplasy2020.8.0126).