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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 155-161

Comparative efficacy of laser and topical corticosteroid in the management of aphthous stomatitis


1 Department of Oral Medicine and Radiology, DMIMS, Wardha, Maharashtra, India
2 Lokmanya Tilak Municipal Medical College and Hospital, Sion, Mumbai, Maharashtra, India
3 Public Health Dentistry, DMIMS, Wardha, Maharashtra, India

Date of Submission04-May-2019
Date of Decision20-Jun-2019
Date of Acceptance15-Jul-2019
Date of Web Publication2-May-2020

Correspondence Address:
Dr. Neha Agrawal
Sharad Pawar Dental College, Sawangi (M) Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_31_19

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  Abstract 


Background: There are different modalities for the management of aphthous stomatitis. Laser therapy and topical corticosteroid are among these treatment options. The main focus of all these treatment modalities is toward the symptomatic relief and decrease in the duration of ulcer. Objectives: The aim of this study was to compare the efficacy of laser of 810 nm wavelength with topical corticosteroid in the management of aphthous stomatitis. Materials and Methods: A prospective clinical study comprised 77 patients ranging in the age group 20–40 years. Patients were divided into two groups – Group I patients were treated with laser therapy (810 nm) on the 1st day of the visit, while Group II patients underwent single local corticosteroid treatment (triamcinolone acetonide 0.1% in orabase). Size measurement, pain score, functional disability, and the level of erythema were measured immediately after application and on the 3rd day. Results: On follow-up visit, there was a significant statistical difference in pain score and functional disability in Group I patients. The level of erythema was significantly decreased in both the groups, more in Group II. Conclusion: Laser treatment showed superiority over corticosteroid in terms of instant pain relief and functional disability caused by the ulcer. However, both the therapies resulted in significant relief in symptoms at the end 3rd day.

Keywords: Aphthous stomatitis, laser therapy, triamcinolone acetonide


How to cite this article:
Agrawal N, Dangore S, Bhowate R, Agrawal S, Reche A. Comparative efficacy of laser and topical corticosteroid in the management of aphthous stomatitis. J Datta Meghe Inst Med Sci Univ 2019;14:155-61

How to cite this URL:
Agrawal N, Dangore S, Bhowate R, Agrawal S, Reche A. Comparative efficacy of laser and topical corticosteroid in the management of aphthous stomatitis. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 May 28];14:155-61. Available from: http://www.journaldmims.com/text.asp?2019/14/3/155/283586




  Introduction Top


Recurrent aphthous stomatitis (RAS) is a common condition affecting 5%–25% of the general population.[1] Traditionally, the management of RAS is directed toward symptomatic pain relief. Many therapeutic agents including topical steroids, tetracycline mouth rinses, antibiotics, and local anesthetic gels are commonly used for the same. Among these, a topical corticosteroid is considered as the first treatment of choice. However, therapeutic laser, an emerging modality, can be used in the management of RAS.[2]

A number of studies mentioned about the use of lasers in RAS, and the various lasers used are neodymium-doped yttrium aluminum garnet (Nd:YAG), CO2, and diode lasers with the wavelength of 660 nm, 830 nm, 904 nm, etc., However, scarce data are reported in the literature relevant to the utility of therapeutic lasers with the wavelength of 810 nm in the management of RAS. In the previous studies by Albrektson et al. (2014) and Aggarwal et al. (2014), laser with a similar wavelength was used, but they did not compare the effects of laser with any other treatment modality.[3],[4] In the present study, the efficacy of therapeutic lasers with wavelength of 810 nm was evaluated by comparing with one of the well-documented treatment options in the management of RAS. Furthermore, in this study, laser was used in noncontact mode.

The advantages of 810-nm diode laser are the convenience of its application, the ability for large areas to be treated in a single application, acceptable healing of the lesions with minimal adverse effect, the possibility of precise control of laser fluence in all areas of the mouth, and cost-effectiveness.[5] Furthermore, the laser did not require dependency, while in the case of topical application (TA), there is a total dependency on the patients for appropriate management of ulcers.[6],[7] Thus, the present study was designed to compare the efficacy of laser therapy (810 nm) and TA in the management of RAS.


  Materials and Methods Top


The present Institutional Ethics Committee-approved study was conducted in the Department of Oral Medicine and Radiology, Sharad Pawar Dental College and Hospital DMIMS (DU), Wardha. The study included 100 clinically diagnosed patients of RAS which were considered for inclusion after obtaining written informed consent from them.

The patients were divided into two equal groups, i.e., Group A (50 patients treated with Laser [810 nm]) and Group B (50 patients treated with TA). Inclusion criteria were patients having one or more recurrent ulcers, duration of ulcer not more than 48 h on presentation, not taking medication for oral ulcers, and no history of any systemic disease which is known to cause oral ulcers. The patients presenting with chronic nonhealing ulcers, denture wearer, pregnant women, or lactating mothers were the exclusion criteria.

Aphthous ulcers were diagnosed based on the history of recurrence and clinically characteristic painful ulcers that were small, round-to-ovoid, affecting nonkeratinized oral mucosa, and surrounded by a distinct erythematous halo.[2]

A detailed case history and various parameters such as pain, size of ulcer, erythema, duration, and functional disability were recorded to evaluate the efficacy of both the treatment modalities. All these parameters were evaluated on the 1st day before the treatment, immediately after the treatment, and after 3 days.

To measure pain, Visual Analog Scale (VAS) was used while the maximum diameter of the ulcer was assessed with a Williams calibrated periodontal probe as shown in [Figure 1].
Figure 1: Size of ulcer measured using William's caliberated periodontal probe

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The degree of erythema was evaluated on a 4-point scale ranging from 0 to 3 based on the method of Bhat and Sujatha[2] [Figure 2]: 0 – no Erythema, 1 – light red/pink, 2 – red but not dark in color, and 3 – very red/dark in color.
Figure 2: Four point scale to calculate degree of erythema 0 – No Erythema, 1 – Light red/pink, 2 – Red but not dark in colour, 3 – Very red/dark in colour

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Functional disability involved the evaluation of the effect of oral ulcers on tasting, speaking, and eating/swallowing which was assessed by Likert-type scale:[8] 0 – when none of the time; 1 – little of the time; 2 – some of the time; 3– most of the time; and 4 – all the time.[8]

To measure efficacy indices for ulcer size, pain improvement and erythema level following formula was used.

EI = ([V3 - V]/V) ×100% and ([V1 - V]/V) ×100%.[9]

According to this, V3 refer to the values measured at day 3 visit, V1 refers to the values measured immediately after application, while V refers to the baseline value measured before the study entry.

The EI was evaluated on a 4-rank scale: (1) heal: EI = 100%; (2) marked improvement: 100% >EI ≥70%; (3) moderate improvement: 70% >EI ≥30%; and (4) no improvement: EI <30%.[9]

Group I patients were treated by ZOLAR 810 nm Diode LASER which was used in a defocused mode 5–8 mm away 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. The setting initially was put at 0.6 W CW for 30–45 s. A refractory period of 15–20 s between laser “passes” was given to allow the tissue to cool down. Then, the area was rubbed with a wet, gloved finger to determine if a decrease in pain is felt by the patient. A second and third pass 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 for 30–45 s, and a third and final pass was completed by 0.8 W CW for a similar period. 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.

For Group II, TA was applied to ulcer on the 1st day by drying the area of ulcer with the help of sterile gauze and allowed to remain for 4–5 min. They were advised to apply 0.1% of TA oral ointment directly on the ulcer four times a day for 3 days. They were asked to squeeze out approximately ¼ inch (0.5 cm) of the paste from the tube on a clean fingertip and apply to the site of the ulcer, after drying the ulcer with clean cotton. The patient was asked to take care not to eat or drink 20 min after application. A comparison of the size of aphthous ulcer on the 1st and 3rd days is shown in [Figure 3].
Figure 3: Comparison of aphthous size on day 1 (a) and day 3 (b)

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All variables from the study were statistically analyzed for the mean values, standard deviation, frequency, percentage, and “P” value, and the results obtained were statistically analyzed using Chi-square test and ANOVA test. Evaluation of results and statistical analysis was carried using SPSS Software version 23.0 (IBM Corp, Armony, NY).


  Results Top


The prevalence of RAS was more in the second decade 51 (66.23%) as compared to the third decade 26 (33.76%) and observed to be more in females as compared to males. Labial mucosa was the most common site affected, while least affected site was the floor of the mouth. In this study, there were 5.26% major ulcers and 18.42% herpetiform ulcers and 76.31% minor ulcers.

The mean ulcer size at the baseline in Group A was 4.12 + 2.33 mm and in Group B was 4.57 ± 2.58 mm and that on the 3rd day in Group A was 1.00 ± 1.39 mm and in Group B was 1.21 ± 1.78 mm. On the application of Student's unpaired t-test, t-value was 0.57 and P value was found to be 0.21, suggesting a statistically insignificant difference in both the groups on the 3rd day. However, when compared within the two groups between the baseline and on the 3rd day, the value of P got to be 0.002 and 0.003 subsequently, which shows that ulcer size was reduced significantly in both the groups [Table 1] and [Table 2].
Table 1: Comparison of size (mm) of ulcer at the baseline and after 3 days between the two groups applying Studentfs unpairedt-test

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Table 2: Comparison of size (mm) of ulcer between the two groups at the baseline and after 3 days (Studentfs paired t-test)

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Observations about pain score between the baseline, immediately after application, and after 3 days in group A were significant as shown in [Table 3]. In Group A, the mean pain score on the VAS was 2.64 ± 0.98, 0.43 ± 0.75, and 0.07 ± 0.03 and that for Group B was 2.74 ± 1.01, 2.74 ± 1.01, and 0.89 ± 0.98 for the baseline, immediately after application, and after 3 days, respectively. When the comparison was made between the two groups by applying Student's t-test, it showed a statistically significant difference. Both [Table 3] and [Table 4] show that there was a prominent reduction in the pain score after 3 days and also more effective treatment was given in Group A as compared to Group B.
Table 3: Comparison of pain on the Visual Analog Scale at the baseline, immediately after application, and after 3 days between the two groups (Studentfs unpaired t-test)

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Table 4: Comparison of pain score on the Visual Analog TA group, as shown in Graphs 3-5- Scale between the two groups at baseline, immediately after application, and after 3 days (Studentfs paired t-test)

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The findings relevant to functional disability scores were suggestive of significant immediate effects in reducing functional disability score on the application of laser and also after 3 days. Although there was no immediate effect of TA in the functional disability score, a significant reduction in functional disability score was noticed after 3 days [Table 5] and [Table 6].{Table 5}
Table 6: Comparison of functional disability score between two the groups at the baseline, immediately after application, and after 3 days (studentís paired t-test)

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There was a reduction of erythema level in both the groups on the 3rd day, but a significant reduction in the erythema level was observed in the triamcinolone group (P < 0.0001). In the present study, no significant difference was observed on comparison of grading of efficacy index for size of ulcer between the two groups [Graph 1].



The prominent reduction in the pain score was observed on the application of laser and also after 3 days, showing a statistically significant difference between pain score before treatment, immediately after, and after 3 days (P < 0.0001). However, no immediate effect of TA in the pain reduction was observed. Comparative efficacy of two treatment options with reference to pain relief showed better results of laser than TA [Graph 2]. Concerning the reduction in ulcer size, both the treatment modalities were observed to be effective after 3 days.



Grading of pain scores between both the groups presented the best results for the laser as compared to TA. The grading of degree of erythema level showed that TA had significantly decreased the erythema. In contrast to this, grading of functional disability showed good results in laser group than TA group, as shown in [Graph 3],[Graph 4], [Graph 5].



Duration of the ulcer has been significantly decreased in both the groups on the 3rd day as compared to the baseline, but there were nonsignificant results when the comparison was made between both the groups [Graph 6].




  Discussion Top


The laser has been widely used in the health field, mainly for therapeutic purposes or for biostimulation because of its characteristics of low-level energy and wavelengths capable of penetrating tissues. Many studies have demonstrated the anti-inflammatory capacity of laser light as well as its action in the reduction of pain and stimulus for tissue repair.[7]

Few studies demonstrated the utility of lasers in RAS. However, the present study assessed the comparative effect of lasers in noncontact mode with a drug routinely considered as the first drug of choice, that is topical corticosteroid, and that was the rationale behind performing this study.

In age-wise distribution, of 77 patients, maximum patients were in the second decade. Findings are comparable to the previous study by Natah et al.[10] Studies by El-Haddad et al.[11] and Mohamed and Al-Douri[12] showed that the age ranged between 28 and 42 years.

Concerning the gender predilection, the findings of the present study are comparable to a few previous studies.[11] Malayil et al. stated that the female predilection may be due to some hormonal reasons such as the luteal phase of the menstrual cycle, association with progesterone levels in pregnancy and much more.[13] According to the survey by Chattopadhyay and Chatterjee, the incidence of RAS was greater in men.[14] Gichki et al. reported equal sex predilection in their study.[15]

In the present study, the labial mucosa was the most common site, and other common sites were the corner of the mouth, soft palate, and lingual mucosa. Studies by Porter et al.[16] and Scully[17] also mentioned the same thing.

Concerning the type of ulcers, the findings of the present study are comparable to the previous study by Natah et al.[10] Natah et al. showed that the prevalence of minor ulcers was approximately 80%, major were 10%, and herpetiform ulcer showed the rarest form and Mohamed and Al-Douri reported 10% cases of herpetiform aphthous ulcers.[10],[12]

After 3 days of application, both the treatment options are observed to be good for the reduction of ulcer size. Regarding the size modulation, Hopkins et al. suggested an indirect mechanism of action of lasers on the surrounding tissue of the wound, enhancement of contraction wound leading to the reduction in ulcer size.[18]

With reference to the healing of ulcer and its size reduction, the findings of the present study are comparable to the previous studies.[19],[20],[21] Similarly, Anand et al. and Misra N et al. reported that the most appropriate treatment modality with the greatest clinical effectiveness for RAS is therapeutic lasers.[22],[23]

According to Walsh, lasers are effective in healing and reduction in ulcer size, which is due to biostimulation. It causes an increase in fibroblast and its migration, collagen organization, and anti-inflammatory effect. Reduction in the neutrophil infiltrate and promotion of growth factors and other substances in the bloodstream is observed.[24]

According to the present study, on the application of laser, immediate reduction in the pain score was observed. On the 3rd day, both the treatment modalities were observed to be effective, though laser was comparatively more effective. Similar findings are observed in the studies performed by Prasad and Pai and Zand et al.[19],[20] Even Tezel et al.[25] also found comparative results, but they used Nd:YAG laser.

Various mechanisms resulting in immediate analgesic effects after therapeutic laser application are (1) stabilization of depolarizing potential of nerve fibers or effects on the cellular and biochemical processes of the inflammatory responses;[26] (2) reduction of the destructive interleukins and tumor necrotizing factor-α production; and (3) the improvement of the immune system function.[27] Elad et al.[28] described two interesting case reports with the beneficial merits of CO2 laser application in a nonablative manner in oral lesions of graft versus host disease and RAS. However, Howell et al.[29] used an HeNe laser and found no significant difference between 66 untreated patients and 46 laser-treated patients.

The present study showed that functional disabilities such as difficulty in eating, brushing, and drinking were reduced immediately as the laser was applied; findings are comparable to the study by Aggarwal H et al.[4]

In the present study, the mean erythema level on the 3rd day after the treatment showed a statistically significant difference between both the groups (P = 0.0001). Two modes of action such as anti-inflammatory action and specific blocking effect of T-lymphocyte epithelial cell interaction are responsible for the reduction in the erythema level, which points toward the effects such as decrease in erythema, pain score, reduction in duration of ulcer, and functional disability after 3–4 days of its regular use.[6] Tezel et al.[25] found the same results as that of the present study. Kamath and Nayak[21] conducted a study in which significant reduction in erythema level was found in diode laser more than the control group.

In the present study, among corticosteroids, TA was used for comparison in the management of aphthous ulcer. However, in the previous study by Al-Na'mah et al., significant results are reported of dexamethasone in faster healing and decreasing the adverse effects as compared to TA. This shows that other corticosteroids such as dexamethasone can also be used in the management of RAS with more safety.[30] Femiano et al. conducted a study in which they observed that steroids were effective in accelerating ulcer healing by reducing the erythema and pain score effectively.[31]

One of the reasons for marked improvement or healing aphthous ulcer on the 3rd day using laser could be laser therapy increases mast cell activation, leading pro-inflammatory cytokines release; this promotes local leukocyte infiltration of tissues. Mast cell has a vital role in leukocyte functions; the different activities of mast cells after laser therapy are helpful in the promotion of wound healing in the oral cavity.[24]

Overall findings of the study showed more efficacy of laser to get immediate pain relief as well as reducing the functional disability. The limitation of the study was the patients were not followed for a longer duration for observation regarding recurrence. However, a study can be conducted by considering the prevalence of recurrence rate in laser-treated patients as one of the parameters, in addition to the parameters used in the present study.


  Conclusion Top


Therapeutic laser is best for relieving pain and functional disability immediately after application which are the main reasons for discomfort to a patient in RAS. However, the use of TA which is traditionally considered as the first-line treatment cannot be underestimated as Laser and TA are equally effective in the management of RAS. Erythema level was reduced more significantly with TA.

Acknowledgment

We are thankful to Datta Meghe Institute of Medical Sciences (Deemed to be University) for providing the facilities to carry out this research work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 6], [Table 6]



 

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