The use of low-level lasers in the treatment of oral lichen planus (OLP) – a review of the literature

Piotr Zdziebło¹, Ewelina Machała-Ćwikła², Urszula Łapińska³, Kamila Machała², Dominika Machała², Piotr Ćwikła⁴

¹Medical University of Lublin, Faculty of Dentistry, Lublin, Poland, ²University of Rzeszów, College of Medical Sciences, Rzeszów, Poland, ³Wrocław Medical University, Faculty of Dentistry, Wrocław, Poland, ⁴Independent Public Healthcare Centre in Leżajsk, Psychiatric Ward, Leżajsk, Poland

Corresponding author: Ewelina Machała-Ćwikła, MD, E-mail: ew.machala@gmail.com

How to cite this article: Zdziebło P, Machała-Ćwikła E, Łapińska U, Machała K, Machała D, Ćwikła P. The use of low-level lasers in the treatment of oral lichen planus (OLP) – a review of the literature. Our Dermatol Online. 2024;15(e):e43.

Submission: 02.04.2024; Acceptance: 26.06.2024

DOI: 10.7241/ourd.2024e.43

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ABSTRACT

A laser is a device that emits radiation in the visible light, ultraviolet or infrared range, using the phenomenon of forced emission. The name is an acronym for Light Amplification by Stimulated Emission of Radiation. The main characteristics of a laser beam include: monochromaticity, coherence, parallelism and intensity. By power, we can divide lasers into 2 groups: high-energy (hard) lasers with emission power above 1 W and low-energy (<1 W) lasers. Lasers are used in medicine, industry, military technology, telecommunications, surveying and construction, among other fields. Lichen planus is a chronic disease of the mucous membranes and skin with a fairly common occurrence, characteristic clinical picture and unclear etiology. The therapy of lichen planus of the mucous membranes, especially its oral form (OLP), is still a major problem despite continuous medical advances. To date, a fully effective treatment regimen has not been developed. Current methods are mainly based on pharmacotherapy. With advances in technology, the search for alternative forms of treatment has begun. In recent years, an increasing number of reports have suggested the validity of using Low Level Laser Therapy (LLLT) to treat oral lichen planus. The use of this treatment may reduce the incidence of side effects observed with traditional corticosteroid (CS) therapy, sulfones or immunosuppressants.

Key words: OLP, Oral lichen planus, Low-level-laser therapy, LLLT, Oral lichen planus treatment

INTRODUCTION

The lesions in the form of oral lichen planus take on a characteristic clinical picture [1,2]. The most common form of lichen planus is the reticular form, which is characterized by whitish streaks surrounded by well-defined reddened borders. There are other clinical subtypes of OLP: plaque-like, popular, atrophic/erosive, ulcerative and bullous. The lesions are most often localized on mucosa of cheek, on tongue and gums [2]. Patients may report pain, difficulty in eating certain foods, especially foods with a sharp or sour taste [3–5]. The disease can also be asymptomatic [1]. OLP generally occurs in middle-aged people, slightly more often among women [2,6]. The problem is believed to affect 1-2 % of the population [2]. Recent studies report that OLP is a localized lesion, with an autoimmune basis, that progresses with T-lymphocyte dysfunction [7]. General diseases that most commonly coexist with oral lichen planus include hypertension, diabetes and heart diseases [4]. A higher occurence of lichen has also been observed in the course of active chronic hepatitis caused by HCV infection [8]. A study by Fitzpatrick et al. found that the risk of OLP lesions become malignant to squamous cell carcinoma was 1.09 %. The study was conducted on a group of 7806 patients diagnosed with OLP. Most often, these lesions were localized on the tongue [9]. Given this fact, it is extremely important to control and treat lichen planus localized in the oral mucosa [3,10]. The side effects of topical and systemic steroid therapy used in traditional treatment regimens have prompted researchers to search for alternative treatments for OLP [3]. In recent years, there have been many studies confirming the effectiveness of low-level lasers in the treatment of oral lichen planus [11]. The purpose of this paper is to discuss the use of laser therapy in the treatment of the oral form of oral lichen planus (OLP).

MATERIALS AND METHODS

The purpose of creating a review paper was to analyze studies on laser therapy published in the PubMed database. The following keywords were used in the search: oral lichen planus treatment, OLP, low-level-laser therapy, LLLT. Based on the content of the retrieved papers and their conclusions, a selection of scientific articles and a comparative analysis were made.

ETHICS STATEMENT

This study was conducted in accordance with the Declaration of Helsinki.

DISCUSSION

Use of low-level lasers in the treatment of lesions on the oral mucosa

Studies have shown the biostimulatory effects of low-level lasers on tissues [12]. The laser beam, characterized by monochromaticity and strong focus, has the ability to penetrate tissue to a depth of up to 6 cm [11,13]. The biological effects of low-level lasers are multidirectional. Their photo- and bio-stimulatory properties affect, among other things, the proliferation of macrophages, lymphocytes, fibroblasts, endothelial cells, keratinocytes, an increase in ATP synthesis, the release of growth factors and cytokines, the transformation of fibroblasts into myofibroblasts and collagen synthesis [13–15]. As a result, therapy with low-level lasers can be extremely useful in diseases involving the oral mucosa with painful symptoms [16,17]. Based on the study, the validity of using LLLT to treat OLP was demonstrated [18–25].

Low-level laser therapy (LLLT) as an alternative to refractory local OLP variants

Hanaa M. Elshenawy et al. conducted a study on a group of 10 patients experiencing pain and burning sensation due to OLP who did not respond to topical corticosteroid treatment. These patients were treated with diode laser therapy (LLLT) with a wavelength of 970 nm. The altered mucosa was irradiated with a calibrated diode (30 Hz, 180 J). In one session, the lesion was irradiated four times for 2 minutes with 1-minute breaks in between to relax the mucosa. Patients were treated with laser therapy once a day, twice a week, for 2 months, receiving a maximum of 10 sessions. Assessment of lesions and pain was evaluated before, during and after the study using a visual analog scale (VAS) and clinical observation of each patient. As a result, there was a significant reduction in the size of the patients’ mucosal lesions and a significant reduction in pain and burning sensation. The severity of positive treatment effects correlated with the number of treatment sessions performed. No side effects of the therapy were observed during treatment [18]. Carlo Fornaini described the case of an 84-year-old woman with a painful lesion localized on her tongue with OLP. The patient was treated with a topical steroid and an anti-fungal drug (0.05 % Clobetasol with nystatin) for one month. Due to the lack of efficacy of the therapy, it was decided to start a new treatment with LLLT. The treatment was performed with a KTP diode laser with a wavelength of 532 nm. Six separate sessions (twice a week) were performed, each lasting 4 minutes (1 minute of exposure and a 30 second interval between exposures). After three sessions, the patient reported a reduction in pain and discomfort. A decrease in lesions on the mucosa of the tongue was observed. Tests performed after the end of treatment and one-month follow-up presented significant improvement [19]. A study was conducted in Boston on a group of nine patients with histopathologically confirmed OLP who did not respond to conventional treatment. The therapy was performed with a 308 nm excimer laser. The effects of the therapy were presented as excellent in 5 patients, mediocre in 2, one patient responded poorly, and another failed to complete the therapy due to hospitalization. Treatment proceeded without pain and was well tolerated [20].

LLLT as a stand-alone treatment for OLP

Mahdavii et al. described 2 clinical cases in which the 630-nm laser was proven effective in treating erosive/ulcerative lesions of OLP without dysplasia. The diagnosis was confirmed by histopathological examination. Treatment sessions were held at three-day intervals, for one month, using a 630 nm, 10 mW, 1.5 J/cm2 laser. The exposure time was 150 seconds for the lesion. The changes were photographed after each session. Patients were followed up for 3 months. Pain was monitored using a visual analog scale (VAS) during and after treatment. A histopathological examination carried on one month after laser treatment, showed a change from the erosive form to the keratotic form in both cases, as well as a significant reduction in pain. At 3-month follow-up, both patients showed no visible changes on mucosa or recurrence of pain [21]. Derikvand et al. described the case of a 46-year-old woman with oral lichen planus. Previous treatment with topical steroid application in combination with chlorhexidine and nystatin has been ineffective. The patient was offered treatment with laser therapy. In order to be able to evaluate the efficacy of the laser, the patient was asked to discontinue her medications 3 months prior to the therapy. The therapy was divided into a photomodulation phase and a surgical phase. In both phases a 980-nm diode laser was used, with changes of the mode settings. As a result, clinical symptoms began to disappear after a week. After a month of treatment, the symptoms disappeared completely. At follow-up one month after the end of treatment, no relapse was noted and no side effects were reported [22].

Use of LLLT in combination therapy

In a randomized single-blind study, Kalagi G. Panchal et al. compared the efficacy of LLLT therapy with concurrent topical steroid application, with therapy based on topical steroid application alone, in the treatment of symptomatic OLP. Patients were randomized to Group A (LLLT + topical steroid application) and Group B (topical steroid only). Patients participating in the study met the following criteria: being 18 years of age or older, pain and burning sensation within the lesion on the oral mucosa, and histologically confirmed erosive nature of the OLP-like lesion. Each patient participating in the study was subjectively assessed for pain intensity and lesion size using vernier caliper. Both A and B groups of subjects applied a topical ointment containing a steroid (0.1 % triamcinolone acetonid) until the lesion disappeared, for a maximum of 28 days (application 5 times a day on the affected mucosa). In Group A patients, during standard topical steroid therapy, mucosal lesions were irradiated with LLLT, in the form of a 10-minute session using an 810 nm, 0.8-0.9 W laser for 10 minutes, in 9 sessions, twice a week. Patients were monitored at 7-day intervals during the first month of the study, followed by 15-day intervals for the next 2 months. During follow-up, it was found that patients in group A (LLLT+ topical steroid) had significantly less pain and the size of the mucosal lesions compared to group B (topical steroid only), and the differences in the efficacy of the two therapies were better observed with time [23].

Comparison of the efficacy of LLLT with the traditional OLP treatment regimen

Reem Kamal Mohamed et al. conducted a randomized controlled trial on a group of 44 patients with the erosive form of oral lichen planus. The patients were divided into two groups. A control group of 22 study participants used a topical steroid with an anti-fungal drug (0.1 % triamcynolone acetonid- 3 times a day and myconazole in gel form once a day). The experimental group was subjected to laser therapy (980 nm diode laser, 300 mW, twice a week for 5 weeks). The patients’ condition was assessed at 6 and 12 weeks after treatment. Using the Mann-Whitney test, the two study groups were compared in terms of pain, lesion size, and salivary malondialdehyde (MDA) level as an indicator of oxidative stress. Results in both study groups showed a significant reduction in pain, a decrease in lesion size and a decrease in salivary MDA level. The results of the study in both groups were statistically similar to each other. Both therapies were found to be effective. There was no significant difference in treatment efficacy between the control and experimental groups [24]. In a randomized controlled clinical trial conducted on 42 patients with symptomatic erosive or atrophic OLP, the efficacy of a laser-based therapy (InGaAIP- 660 nm, 3 sessions per week over 30 days) was compared with a conventional one involving topical steroid application (0.05 % clobetasol propionate, 3 applications per week over 30 days). Patients were divided into 2 groups. Nystatin was used for anti-fungal prevention in all subjects. In the evaluation of the effectiveness of the treatment, the following were taken into account: the size of the lesions on the mucosa, the sensation of pain, the functionality of the masticatory organ, resolution of the lesions and their recurrence, the evaluation of anxiety among patients. Observations of patient were conducted at weekly intervals during the active treatment phase. The checks were made 30 and 60 days after the end of therapy. After the end of treatment, considerable improvements were noted in all evaluated criteria in both groups of patients. Subsequent observations found better persistence of positive treatment effects in patients treated with the laser [25].

CONCLUSION

Nowadays, we are seeing rapid development in medicine. Current treatments under development are focused on improving the effectiveness of new therapies, making them more non-invasive and reducing side effects. Laser therapy, by meeting these requirements, appears to be a promising treatment method. Other advantages of using lasers include the simplicity of the procedures performed, their painlessness and increasing availability.

Low-level lasers do not have a causal effect on lichen-like lesions, but have the effect of modulating the body’s natural tissue repair processes. The use of LLLT in the treatment of OLP-like lesions, due to its proven efficacy, seems to be as justified as possible. The low-level lasers can be used either as an independent method or as a supportive treatment. A number of studies have proven the effectiveness of LLLT in reducing pain and burning sensation in the oral cavity, and have shown a significant effect on reducing lesion size in symptomatic and treatment-resistant varieties of OLP. Clinically proven effectiveness, with the absence of adverse effects, fully justify the use of low-level lasers.

The first use of lasers in medicine was relatively recent. Thus, it is necessary to conduct studies on a larger number of patients in order to better understand the effects of laser therapy on the human body, analyze the benefits of using laser beams in medicine, as well as the possible dangers of doing so.

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