Comparison of Low-Level Laser Therapy Versus Ozone Therapy in the Treatment of Oral Lichen Planus
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Laser and Ozone Therapies, and OLP Ann Dermatol Vol. 27, No. 5, 2015 http://dx.doi.org/10.5021/ad.2015.27.5.485 ORIGINAL ARTICLE Comparison of Low-Level Laser Therapy versus Ozone Therapy in the Treatment of Oral Lichen Planus Hakki Oguz Kazancioglu, Merve Erisen1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem Vakif University, 1Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University, Istanbul, Turkey Background: The treatment options for oral lichen planus Symptom improvement was achieved after treatment with (OLP) are numerous and include topical and systemic agents. LLLT, ozone, and corticosteroid (p<0.05). The efficacy in- Intralesional and systemic corticosteroids are used; however, dices were significantly higher in the ozonated and cortico- the therapeutic results are often disappointing. Objective: To steroid-treated groups. Conclusion: Ozone and cortico- compare the influence of ozone, laser, and topical cortico- steroid therapies were more effective than 808-nm LLLT in steroid therapies in the treatment of OLP. Methods: One hun- the treatment of OLP. (Ann Dermatol 27(5) 485∼491, 2015) dred twenty adult patients with ≤3 cm atrophic-erosive bi- opsy-proven OLPs in the tongue or buccal mucosa were re- -Keywords- cruited into the study. They were randomly assigned, by pre- Dentistry, Lasers, Lichen planus, Pain, Ozone operative envelope drawing, to be treated with low-level la- ser therapy (LLLT group), ozone therapy (ozonated group), and topical corticosteroid therapy (positive control group). A INTRODUCTION placebo treatment containing base ointment without the ac- tive corticosteroid component was administered to patients Lichen planus is a common chronic mucocutaneous dis- in the negative control group. Response rate scores were de- ease of uncertain origin that has been shown to affect termined on the basis of changes in the appearance score and 0.5% to 2.2% of the studied populations1-8. The oral lichen pain score of the lesions between baseline and after each planus (OLP) affects approximately 2% of the population2,3. treatment. Results: The study subjects consisted of 56 male OLP, in general, may arise in >70% of persons with skin and 64 female OLP patients with a combined mean age of lesions. The frequency of malignant change ranges from 42.6±8.3 years (range, 28∼55 years). No statistically sig- 0.4% to 3.3%, with the periods of observation being from nificant difference was detected in clinical severity among 0.5 to >20 years4. the groups. The sign scores decreased in almost all scoring Six clinical forms of OLP have been described: reticulated, groups; however, statistically significant improvement was plaque-like, erosive, papular, atrophic, and bullous4. Re- found in the ozonated and corticosteroid-treated groups. ticular OLP is the most common form and is relatively asymptomatic. On the other hand, the erosive, atrophic, and bullous forms are typically the most symptomatic, of- Received November 6, 2013, Revised November 27, 2013, Accepted ten debilitating, and prompt the patient to seek care. Com- for publication January 27, 2014 pared with self-limiting cutaneous lesions, most OLP le- Corresponding author: Hakki Oguz Kazancioglu, Department of Oral sions are chronic, rarely undergo spontaneous remission, and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem Vakif 5,6 University, Adnan Menderes Bulvarı, 34390 Fatih, Istanbul, Turkey. and are difficult to treat completely . Tel: 90-212-453-1700, Fax: 90-212-533-2326, E-mail: dt_oguz@ OLP is seen worldwide, mostly in the fifth to sixth decades yahoo.com of life, and is twice as prevalent in women as in men1,4. This is an Open Access article distributed under the terms of the The differential diagnosis of erosive OLP includes squ- Creative Commons Attribution Non-Commercial License (http:// amous cell carcinoma, chronic candidiasis, benign mu- creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, cous membrane pemphigoid, pemphigus vulgaris, chronic provided the original work is properly cited. cheek chewing, lichenoid reaction to dental amalgam or Vol. 27, No. 5, 2015 485 HO Kazancioglu and M Erisen drugs, hypersensitivity mucositis, and systemic disease with LLLT (laser group), ozone therapy (ozonated group), such as erythema multiforme, graft-versus-host disease, and or topical corticosteroid (positive control group). A place- discoid lupus erythematosus3,4,7. bo treatment containing base ointment without the active The treatment options for OLP are numerous and include corticosteroid component was administered to patients in topical and systemic agents. Intralesional and systemic the negative control group. Each group consisted of 30 corticosteroids are used but with often disappointing ther- patients. apeutic results4,8. Topical corticosteroids remain the main- The exclusion criteria were as follows: 1. Presence of sys- stay of therapy; however, their long-term use may cause temic diseases that may cause OLP, such as hepatitis C; 2. some adverse effects such as candida overgrowth, thin- age <20 years; 3. pregnant or breastfeeding; 4. use of li- ning of the oral mucosa, and discomfort on application. chenoid reaction-inducing drugs such as antihyperten- Gorsky et al.9 showed that candidal lesions were found in sives, diuretics, nonsteroidal anti-inflammatory drugs, anti- 32% of OLP patients who received corticosteroid therapy. convulsants, and drugs for treating tuberculosis; 5. pres- In addition, some patients may not respond effectively to ence of histologic signs of dysplasia in the biopsy speci- only topical corticosteroid application. men; 6. previous OLP treatment within 1 month before Low-level laser therapy (LLLT) has potential biostimulating the beginning of the study; 7. lesions adjacent to the amal- effects when applied to oral mucosal tissues. LLLT seems gam filling site; and 8. systemic corticosteroid use. to offer some benefits in controlling the inflammatory All patients were informed about the potential complica- process by promoting the healing of the tissues, but with- tions of laser, ozone, and corticosteroid treatments and out undesired adverse effects, and also by reducing phar- each gave written consent on an institutionally approved macologic support after a surgery10. form. This study followed the medical protocol and ethics The anti-inflammatory effect of LLLT could be due to an of the Declaration of Helsinki. Ethical approval was ob- increase of phagocytic activity, an increase in the number tained from Bezmialem Vakif University’s ethical commit- and diameter of lymphatic vessels, a decrease in the per- tee (IRB No. 34/16). meability of blood vessels, and a restoration of micro- Laser therapy capillary circulation, normalizing the permeability of vas- cular walls and decreasing edema11,12. LLLT has also gained Patients in the LLLT group were treated with laser irradi- acceptance for the treatment of premalignant oral mucosal ation (exposure time, 2.5 min; fluence, 1.5 J/cm2 per ses- lesions such as leukoplakia and OLP. Many types of laser sion; irradiance, 10 mW/cm2; no. of illumination point, 1; are now used for the treatment of various diseases. A few area, 1 cm2). A diode laser (808 nm, 0.1 W, continuous literature reports demonstrated the use of a diode laser for wave; Fotona XD-2; Fotona, Ljubljana, Slovenia) was used the treatment of OLP13,14. as a light source. A light exposure dose of 120 J/cm2 was Another nonmedication method used to treat OLP in den- used for 2.5 min. The lesions and 0.5 cm of their sur- tistry is ozone therapy15. Ozone reacts with blood compo- rounding tissue were illuminated with a spot size of 1 nents (erythrocytes, platelets, leukocytes, and endothelial cm2. Laser irradiation was done two times a week (once cells) and induces oxygen metabolism, cell energy, im- every third day) for a maximum of 10 sessions. In each munomodulatory changes, the antioxidant defense system, session, the laser used was not in contact with the tissues. and microcirculation in tissues16. Such effects resemble The application distance was 0.5∼1 cm; because at this the biostimulatory property of LLLT that has been widely distance, the difference in application distance did not af- studied10,17. fect the spot size with the handpiece that was used. Large The aim of this study is to compare the influence of lesions were illuminated with multiple spots. ozone, laser, and topical corticosteroid therapies in the Ozone therapy treatment of atrophic-erosive OLP. Ozone therapy was performed by using an ozone gen- MATERIALS AND METHODS erator (Ozonytron; Biozonix GmbH, Munich, Germany) with a tissue probe (alveolar probe) (Fig. 1). The ozone Patients generator was applied intraorally with an intensity of 60% One hundred twenty adult patients with atrophic-erosive for 10 s, according to information given by the manu- OLP (≤3 cm) in the tongue or buccal mucosa were re- facturer. Irradiation was done twice a week (once every cruited into the study. The OLP was diagnosed clinically third day) for a maximum of 10 sessions (Fig. 2). When the and histopathologically. The patients were randomly as- tip of the probe is placed in contact with the body, it emits signed, by preoperative envelope drawing, to be treated energy around the treated area and splits environmental 486 Ann Dermatol Laser and Ozone Therapies, and OLP Fig. 2. Application of ozone treatment. lesions were scored from 0 to 1 (0=no white striations, Fig. 1. Ozone device and application probes. 1=appearance of white striations); erosive/erythematous areas were scored from 0 to 3 according to area of in- diatomic oxygen into singular atomic oxygen and ozone. volvement (0=no lesion, 1=lesions <1 cm2, 2=lesions The concentration of ozone in the operation field is 10∼ from 1 to 3 cm2, 3=lesions >3 cm2); and ulcerative areas 100 μg/ml. were scored from 0 to 3 according to area of involvement (0=no lesion, 1=lesions <1 cm2, 2=lesions from 1 to 3 Control groups cm2, 3=lesions >3 cm2).