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Case 4

 

“Outside the box”

By: Scott Manhart, DDS, MS
Billings, MT

The patient is a 58 y.o.  Caucasian female referred to the clinic in January of 2013 for evaluation and treatment of a symptomatic oral ulcerative condition.  The patient states the condition developed during the late fall and progressed for several weeks. She sated the pain was always present. She described the sensation as a deep burning pain, particularly on the right, that ranged between 4-7 on a pain scale of 0-10.   The patient also complained of some general oral sensitivity.   She visited the referring dentist office for evaluation at which time they placed her on Nystatin oral rinse and a Maalox based mouthwash containing steroid, and antihistamine.  This therapy produced minimal improvement.

Medical history was negative for autoimmunity.  Current medical conditions include mild hypertension, managed with a diuretic and acid reflux managed with omeprazole. On oral examination, a mild lichenoid change in the alveolar mucosa was noted. One severe area of ulceration was observed on the buccal mucosa near tooth #31.  This site had been the site of origin for the condition and produced most of her discomfort.

A biopsy was obtained for light and immunochemistry analysis.   Results indicated findings consistent with erosive lichen planus.  Intense lymphocytic infiltrate of the laminia propria was observed.  Staining was negative for all antibodies but intense for fibrinognen at the basement membrane. 

Treatment consisted of daily application of Clobetasol cream to the symptomatic lesion b.i.d.  The patient was also instructed to use Alpha-Lipoic Acid supplement at 600 mg /day for 1 month then decreasing to 200mg/day and an daily vitamin E rinse to reduce the overall sensitivity of the oral mucosa.

The patient was compliant with the recommended therapy for the next 6 months.  Overall tissue sensitivity improved.  The ulceration in the #31 area persisted and remained symptomatic.  At this point several treatment options were considered including referral to intra-lesional injection of steroids, referral to dermatology for more aggressive systemic medication therapy or use of an Nd-YAG laser for biostimulaiton.  Given the potential drawbacks of systemic medication the patient elected trying the laser treatment. 

In mid July 2013, the patient presented for biostimulation.   Laser settings for the procedure were 100uS, 3.6Watt, 20Hz: 300 uJ were delivered to the lesion in a non-contact mode.   The patient was not anesthetized so that she could provide feedback regarding discomfort so that overheating of the tissues could be avoided.  The patient reported not discomfort during the procedure. 

Immediately following biostimulation the patient reported that the pain level had decreased by half.  No other treatment was recommended and the patient instructed to forgo steroid application on the lesion for 1 week.

At her 1-week post operative visit the patient reported that within 2 days of the treatment the site was visually healing and by 5 days she was considering not coming for her appointment because she was symptom free and could no longer see the lesion. 

Clinically the site had healed substantially in the intervening week.    There was a halo of deep inflammation still present but the surface had covered with a layer that appears to be the hyperkeratosis usually seen in plaque-like lichen planus.

To date the patient remains symptom free and the lesion continues to resolve. 

Discussion

Lichen planus (LP) is a disease of the skin and/or mucous membranes. It is thought to be the result of an autoimmune process with an unknown initial trigger. Where the trigger is known, the term lichenoid lesion is used instead. There is no cure, but many different medications and procedures have been used to control the symptoms.

Topical and systemic steroids have been the mainstay of therapy.  Retinoids, Dapsone and other immune-modulatory agents have been employed in severe cases, particularly where oral and cutaneous lichen is present (1).  Side effect profiles of these agents can range from mild to severe, with some patients stating that the “cure can be as bad as the disease.”  

Given that there is no cure for this condition, symptomatic relief has always been viewed as a successful clinical endpoint for treatment.   Utilizing the Nd-YAG laser in this case provided a high level of relief for the patient while risking no significant side effects.  Further, the cost for biostimulation is on par with the cost of the medications usually used for management of this condition. 

This case provided certain advantages over more typical Lichen Planus cases in that there was a single, clearly identifiable symptomatic ulceration.   This allowed the clinician to be focused with the application of laser energy.   Most patients present with a more generalized pattern several symptomatic sites.  This potentially could lead to application of the laser energy over a wider area and possibly leading to a dilution of overall effect.  A review of articles and posting regarding the application of laser biostimulaiton in LP reveals this case to be  unusually successful in resolving the lesion utilizing the single treatment non-contact energy dose applied.   While most other reports show alleviation of symptoms, the resolution of lesions appears to be variable.  This may be due to lack of a full understanding of the mechanism of action and defined protocols (2, 3, 4, 5). 

The mechanism of action of ND-YAG lasers in controlling pain and or initiating healing is still not clear.  A study conducted by NASA concluded the gravity dependent proliferation of human cells could be compensated for in weightless conditions by the application of infrared laser energy.  This effect was attributed to activation of mitochondrial chromophores and cytochrome systems (6). 

Several studies have suggested that infrared laser energy reduces pain perception and stimulates fibroblasts in vitro (7,8).    Others have noted decreased inflammatory reactions and accelerated wound healing by altering the expression of genes encoding cytokines in vivo (9,10).  While these studies provide an insight into the possible mechanisms of action, future studies should continue elucidate this phenomenon and evaluate effect of titrated energy dosing on reducing symptoms as well as attaining lesion resolution.

This case suggests a non-pharmacologic approach to addressing inflammatory conditions such as oral lichen planus utilizing the Periolase Nd:YAG laser.  These conditions can be challenging to treat successfully due to the chronic nature of the condition, poor patient compliance and physical drawback associated with applying and maintaining medications on the oral mucosa.  In this case the Nd:YAG laser produced significant reduction in symptoms but also aided in healing a persistent ulceration that had been resistant to standard modalities of treatment.  Biostimulation with the Nd:YAG laser  should be considered an adjunctive option to managing  erosive lichen planus cases with steroids alone.

References

  1. Bagan J, Compilato D, Paderni C, Campisi G, Panzarella V, Picciotti M, Lorenzini G, Di Fede O. Topical therapies for oral lichen planus management and their efficacy: a narrative review.   Curr Pharm Des. 2012; 18(34):5470-80.
  2. Cafaro A, Arduino PG, Massolini G, Romagnoli E, Broccoletti R.  Clinical evaluation of the efficiency of low-level laser therapy for oral lichen planus: a prospective case series. Lasers Med Sci. 2013 Apr 3.
  3. Agha-Hosseini F, Moslemi E, Mirzaii-Dizgah I.  Comparative evaluation of low-level laser and CO₂ laser in treatment of patients with oral lichen planus.  Int J Oral Maxillofac Surg. 2012 Oct;41(10):1265-9.
  4. Fornaini C, Raybaud H, Augros C, Rocca JP.  New clinical approach for use of Er:YAG laser in the surgical treatment of oral lichen planus: a report of two cases.  Photomed Laser Surg. 2012 Apr;30(4):234-8.
  5. Jajarm HH, Falaki F, Mahdavi O.A comparative pilot study of low intensity laser versus topical corticosteroids in the treatment of erosive-atrophic oral lichen planus. Photomed Laser Surg. 2011 Jun;29(6):421-5.
  6. Whelan HT et al. Light emitting diode medical applications from deep space to deep sea.  NASA . J Clin Laser Med Surgery 2001: 2: 110
  7. Kreisler M. et al. Effect of low level laser therapy in reducing postoperative pain after endodontic therapy- a randomized double blind clinical study, Int  J Oral Maxollfac Surg 2004: 33: 38-41
  8. Kreisler M. et al. Effects of low-level GaA1As laser irradiation on the proliferation rate of human periodontal ligament fibroblasts: an in vitro study.  J Clin Periodontol 2003:30:353-358
  9. Pourzarandian. A et al. Histological and TEM examination of early stages of bone healing after Er:YAG laser irradiation.  Photomed Laser Surgery 2004:  22: 342-350
  10. Safavi, SM et al. Effects of low-level He-Ne laser irradiation on the gene expression of IL-1beta, TNF-alpha, IFN-gamma, TGF-beta, and PDGF in rats’s gingiva.  Lasers Med Sci 2007 23 331-335

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