Journal of Photochemistry & Photobiology, B: Biology 170 (2017) 1–5

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Journal of Photochemistry & Photobiology, B: Biology

journal homepage: www.elsevier.com/locate/jphotobiol

Treatment of recurrent aphthous stomatitis with Er,Cr:YSGG laser

irradiation: A randomized controlled split mouth clinical study

Hasan Guney Yilmaz a,⁎, Mohammed Rateb Albaba a, Ayse Caygur a, Esra Cengiz b,
Fatma Boke-Karacaoglu c, Hayriye Tumer a
a
Department of Periodontology, Faculty of Dentistry, Near East University, Mersin, Turkey
b
Department of Restorative Dentistry, Faculty of Dentistry, Mersin University, Mersin, Turkey
c
Department of Periodontology, Faculty of Dentistry, Ankara University, Ankara, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: The present randomized controlled split mouth clinical study aimed to investigate the efficacy of Er,Cr:YSGG laser
Received 11 January 2017 irradiation on pain reduction and healing rate of recurrent aphthous stomatitis. 40 patients with RAS were re-
Received in revised form 7 March 2017 cruited for this study and RAS ulcerations of each patient were randomly assigned to the control or test group.
Accepted 16 March 2017
In the test group, Er,Cr:YSGG laser with non-contact mode was used to irradiate RAS lesions. In the placebo
Available online 22 March 2017
group, RAS lesions were irradiated with the same device without laser emission. Pain was evaluated with visual
Keywords:
analog scale (VAS) while a clinician graded healing of RAS (HRAS). In the placebo group at immediate; scores of
Aphtous ulceration VAS presented no statistically significance; in the test group, laser application showed significant pain reducing,
Stomatitis at 1st day control. In the test group, a significantly healing effect at 1st day control was observed and this effect
Er,Cr:YSGG laser was maintained throughout the study. In the placebo group, scores of HRAS were statistically significant at con-
trols on 3, 7, 10 days. Statistically significant difference between the scores of VAS and HRAS was found for all
control days except day 10 according to the intergroup comparisons. Based on these findings, Er,Cr:YSGG laser
application at 0.25 W without water may be appropriate to reduce pain and also accelerate the healing of RAS.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction
Recurrent aphthous stomatitis (RAS) is a common clinical condition
that is characterized with recurrent small, ovoid or round non-infec-
tious, non-vesicular and immunologically mediated ulcers with
circumscribed margins which was surrounded by an erythematous
halo in oral cavity [1]. Approximately 5–25% of the general population
is affected by RAS with onset ranging from childhood to adolescence.
RAS is classified into 3 types, as the minor, major and herpetiform
aphthous ulcerations [2,3]. Minor aphthous ulceration is the most com-
mon form of RAS and the minor form is respectively followed by major
and herpetiform ulceration [1–4]. Although RAS is the most common ul-
ceration affecting the oral mucosa; the etiology and pathogenesis of RAS
is still not known. As causative agents; many factors including local, sys-
temic, microbiological, allergic, nutritional, and genetic factors have
been proposed [2–6].
Although patients have spontaneous healing within a week, RAS
causes many problems for the patient owing to pain, such as difficulties
in eating, drinking, and maintaining oral hygiene [5,6]. There is no cure
⁎ Corresponding author.
E-mail address: guneyyilmaz@hotmail.com (H.G. Yilmaz).
available for RAS. A wide variety of topical therapies which includes
avoiding certain foods, treatment with local anesthetics (lidocaine gel,
benzydamine), protective bioadhesives (cyanoacrylate), antiseptic or
anti-inflammatory therapies (chlorhexidine gluconate, triclosan,
amlexanox), local antibiotics (tetracycline, chlortetracycline), and topi-
cal steroids (triamcinolone acetonide) or systemic agents (colchicine,
pentoxifylline, corticosteroids, dapsone, thalidomide, cyclosporine,
and infliximab) have been suggested for the treatment of these ulcers
over the years [5,6]. Reducing healing time and pain for RAS improve
patient ability to swallow, eat, and talk which restores patient's life
quality. Thus, optimal treatment modalities to obtain a rapid reduction
of pain and healing time of RAS are needed.
With the development of laser technology, lasers may be use in the
treatment of RAS because laser irradiation reported to accelerate the
wound healing [7–11]. Also, the use of lasers may eliminate the possible
side effects of drugs [7–11]. Er,Cr:YSGG lasers are widely used for dental
applications such as oral surgery, preventive dentistry, periodontics and
endodontics. However, to the best of our knowledge, no clinical data ex-
ists in the literature regarding the outcomes of Er,Cr:YSGG laser use on
the treatment of RAS lesions. The purpose of this randomized controlled
clinical study was to assess the clinical effectiveness of Er,Cr:YSGG laser
irradiation on healing rate and reducing pain of RAS at a 10 days period.

http://dx.doi.org/10.1016/j.jphotobiol.2017.03.011
1011-1344/© 2017 Elsevier B.V. All rights reserved.
2 H.G. Yilmaz et al. / Journal of Photochemistry & Photobiology, B: Biology 170 (2017) 1–5
2. Material and Methods
Forty (24 male 16 female) patients with the age range of 18 to 58
(mean age: 26 ± 9.2 years) with a chief complaint of minor RAS were
included in the study (between January 2015–March 2016). For inclu-
sion, every patient had to have one pairs of minor RAS lesions in the
buccal or labial nonkeratinized oral mucosa with duration of 3 days or
less. Patients with a known systemic disease (e.g., Behçet disease) that
predisposed them to have RAS, or who have any major herpetic lesions,
traumatic ulcers, ulcers caused by topical or systemic medications, or
undergoing systemic or local treatment for have RAS were excluded.
This study was approved by the Ethics Committee of Near East Univer-
sity Ethics Committee (YDU-2015-28-149). Registration number of this
study is NCT02925182 (clinicaltrials.gov). After patients were verbally
informed about the treatment plan, potential risks of the treatment
and possible discomforts, they were requested to sign the informed con-
sent form.
For each patient, 2 ulcerations with the dimension of approximately
4–10 mm as measured by the same investigator, and located on the dif-
ferent parts of oral cavity were selected. Patients were requested to
score their pain and discomfort level for each RAS lesion by marking a
point on a visual analog scale (VAS) with 10 cm. For each subject, select-
ed RAS lesions were randomly assigned by the toss method to 2 groups:
test (Fig. 1) or the control group in this split-mouth study. Afterwards,
half of the RAS lesions were irradiated with Er,Cr:YSGG laser (Waterlase
MD, Biolase, Irvine, CA, USA) on hard tissue mode using a mg6 sapphire
tip (600 μm diameter, 6 mm length) at an energy level of 0.25 W with a
repetition rate of 20 kHz, pulse duration of 140 μs without water and
10% air at 5 J/cm2 energy density with non-contact mode (Fig. 2). The
laser application time by scanning the RAS lesion area was 20 s per sur-
face. In the placebo group, RAS was irradiated by the same Er,Cr:YSGG
laser without laser emission. All treatments (laser and placebo) were
performed by the same investigator only at the first visit. The patients
were adviced not to take any topical or systemic medications or prod-
ucts from day 0 to day 7, although they could have been taking such
medicines before entering the study. The scores of VAS were recorded
immediately and at 4 control sessions, at adys1, 3, 7 and 10 after treat-
ment. The process of healing of RAS (HRAS) lesions were assessed on
these follow-up periods by the investigator on a four-point scale
(range 1–4) at which grade 1 means totally healing, grade 2 represents
moderate healing (N 50% of RAS lesions was healed and epithelialized),
grade 3 defines slightly healing (b50% of RAS lesions was healed and
epithelialized) and grade 4 means no healing.
For all groups, mean values of the VAS scores were calculated. The
normal distribution of all scores was evaluated with the Kolmogarov-
Smirnov test. One-way repeated analysis of variance (ANOVA) was
Fig. 1. Preoperative clinical view of recurrent aphthous stomatitis in the mucosa of the
lower lip.
Fig. 2. Clinical view of recurrent aphthous stomatitis immediately after Er,Cr:YSGG laser
irradiation.
performed to assess the changes over time within the groups. When sig-
nificance was detected, Tukey's test was performed for post hoc com-
parisons. A paired t-test was performed to compare the study groups
at each follow-up periods. Values of p b 0.05 were accepted as statisti-
cally significant.
3. Results
All 40 subjects (with totally 80 minor RAS lesions) completed the
10 days test period (Table 3). No complications or adverse reactions
were observed. The mean scores of VAS and HRAS before and after
Er,Cr:YSGG laser irradiation were presented in Tables 1 and 2, respec-
tively. In the test group, laser application showed significant pain reduc-
tion immediately after treatment in compassion to the control group.
Also, this effect was maintained throughout the study (p b 0.01, Table
1). In the placebo group, there were no statistically significant differ-
ences among the baseline VAS scores at immediate, 1 and 3 days after
treatment. The VAS scores at immediate,1 and 3 days after treatment
showed statistically significant differences according to the intergroup
comparisons (p b 0.01, Table 1). In the test group, at first day control;
laser treatment showed a significant healing effect and this effect was
maintained throughout the study (p b 0.01, Table 2). The HRAS scores
were statistically significant at 3, 7, 10 days in the control group (p b
0.05, Table 2). Statistically significant differences between the VAS and
HRAS scores were found for all control days except for day 10 according
to the intergroup comparisons (p b 0.01, Table 2).
4. Discussion
Since the etiology and pathogenesis of RAS is still unknown, many
therapies and drugs have been evaluated in an attempt to palliate the
symptoms [5,6]. There is no agreement in the treatment of RAS in the
literature. In all RAS cases, management is symptomatic, that aims to re-
duce inflammation of the aphthae resulting in pain reduction by admin-
istering topical or systemic treatments. The traditional treatment of RAS
is included glucocorticoids and antimicrobial therapy. These medica-
tions have been applied as topical pastes, mouthrinses, intralesional in-
jections and systemically by the oral route [5,6]. All systemic
medications recommended for the treatment of RAS have an anti-in-
flammatory component. Their usage should be considered in relation
to the patient's disease activity because all of these medications may
have significant side effects [2–6]. Also some alternative therapies
have been used to treat RAS however results of this clinical trials are
conflicting [12].
Lasers have been considered as an alternative treatment method due
to some of their promising abilities as absorbing water perfectly and
their effective absorption by biological tissues with minimal damage
 H.G. Yilmaz et al. / Journal of Photochemistry & Photobiology, B: Biology 170 (2017) 1–5
Table 1
Mean degree of VAS scores and standard deviation in both groups over 10 days.
Baseline Immediate
Laser 8.3 ± 2,1a 0.2 ± 0.5b,⁎
Placebo 8.1 ± 2.4a 7.8 ± 2.1a,⁎
Different letters show statistical significance at intragroup comparisons, p b 0.05, repeated ANOVA.
VAS, visual analog scale.
⁎ The differences immediately, and 1, 3, and 7 days after treatment were statistically significant between the laser group and the control group; p b 0.05, paired t-test.
of surrounding tissues. For the treatment of different types of mucosal
lesions; many laser types such as galium–aluminium–arsenide
(GaAlAs) [13,14], neodymium-doped: yttrium, aluminium and garnet
(Nd:YAG) [7,15], and carbon dioxide (CO2) [11,13,16] lasers have been
used. However, there are limited clinical data available in the literature
regarding the outcome of the use of CO2, NdYAG, diode laser therapy
and low level laser therapy (LLLT) for the treatment of RAS [17,18].
Zand et al. [11] investigated the pain relief effect of non-thermal CO2
irradiation on minor RAS lesions at 4 days period in their study. They re-
ported that, the use of CO2 laser at 1w power at the de-focused contin-
uous mode decreased the pain levels of RAS compared to placebo. After
this study, authors evaluated the wound healing effect of CO2 with the
same settings in minor RAS lesions in another study and they showed
that the healing period was significantly shorter in ulcers treated by
CO2 laser than in those treated with placebo [19]. In an another study
[20], which examined the possible efficacy of the high-power CO2
laser for pain reduction in RAS, a CO2 laser with a power output of
4 W was used to irradiate painful minor RAS lesions. During laser treat-
ment, removing as much necrotic tissue as possible was proposed. After
anesthetic resolution, most of the patients in that study recorded no
pain. Also none of the patients asked for post-operative medication for
pain reduction. In that study [20], it was concluded that CO2 laser
might be an alternative treatment modality for minor RAS lesions, be-
cause of its ability of reduction or elimination of pain. Tezel et al. [7]
compared the effects of Nd:YAG laser irradiation and medication treat-
ment on the degree of post-treatment pain, discomfort, and eating and
speech complications on 20 patients at 7 days period. They stated that,
Nd:YAG laser treatment group showed less post-treatment pain and
fewer functional complications. In that study, immediate reduction of
pain and faster healing in comparison to the medication group were re-
ported. Albrektson et al. [21] evaluated the analgesic effect of LLLT in
acute minor RAS lesions at 40 patients. They showed that LLLT provided
reduction in pain and reduced the discomfort while eating, drinking,
and brushing teeth for patients that have RAS, in comparison to placebo.
Recently, Er,Cr:YSGG lasers have been currently used with a wide
range of dental applications, such as oral surgery, preventive dentistry,
periodontics and endodontics [22–28]. Er,Cr:YSGG laser can provide
precise hard and soft tissues cut by the interaction of laser energy
with atomized water droplets on the interface of tissue leading to the
ablation of the tissue. Not only existing water in tissue, but also exoge-
nous water was used by Er,Cr:YSGG laser for ablation. Considering
this, Er,Cr:YSGG laser was applied without water to avoid ablation in
the present study. Higher water absorption coefficient which causes
rapid vaporization and micro-explosions leads to high pressure on the
surrounding structures. Er,Cr:YSGG laser (2780 nm) has the advantage
Table 2
Mean degree of HRAS scores and standard deviation in both groups over 10 days.
Baseline Day 1 Day 3 Day 7
Laser 4 ± 0a 3.1 ± 0.4b,⁎ 1.2 ± 1.4c,⁎ 1 ± 0d,⁎
Placebo 4 ± 0a 4 ± 0a,⁎ 3.2 ± 1.6b,⁎ 1.6 ± 1.2c,⁎
Different letters show statistical significance at intragroup comparisons, p b 0.05, repeated
ANOVA.
HRAS, healing of recurrent aphthous stomatitis.
⁎ The differences at 1, 3 and 7 days after treatment were statistically significant between
the laser group and the control group, p b 0.05, paired t-test.
3
Day 1 Day 3 Day 7 Day 10
0.8 ± 0.6b,⁎ 0.4 ± 0.2b,⁎ 0.1 ± 0.3b,⁎ 0.0 ± 0b
7.4 ± 1.8a,⁎ 4.7 ± 1.6b,⁎ 1.1 ± 0.8c,⁎ 0.0 ± 0d
of creating minimal tissue distortion due to the less thermal deep or lat-
eral damage as the heat escapes by means of vaporization when com-
pared to near infrared (810 nm to 1064) and Nd:YAG lasers.
Therefore, on the lesion surface a relatively thin coagulation layer was
produced by Er,Cr:YSGG laser due to the penetration and thermogenesis
of the laser. This coagulation layer may cause desensitization of the un-
derlying tissues. It was also reported that reactive oxygen species which
can be created by erbium lasers in irradiated tissue have sterilization ef-
fects. And this effect may stimulate fibroblasts, collagen, and formation
of extracellular matrix [29,30]. The high bactericidal potential of
Er,Cr:YSGG laser [31] should also be considered since bacteria have
the ability to decrease pain thresholds at injured tissues due to the in-
creased synthesis of inflammatory mediator and infection. It is also
noteworthy that Er,Cr:YSGG laser has effect on the TRPVl neural recep-
tor that is stimulated by heat [32]. This effect may be another possible
mechanism of reduction reduction with the use of Er,Cr:YSGG laser
since thermal-sensitive TRPs in nerves may act as pain sensors as re-
ported. Ryu et al. [33] evaluated the efficacy of Er,Cr:YSGG laser on cul-
tured trigeminal neurons and cell cultures overexpressing TRPVl with
similar energy level which was applied in the present study. The laser
was irradiated on the capsaicin injected hindpaw of TRPV1-knockout
mice vs. control mice. In the control group, capsaicin caused intense
linking/shaking responses on hindpaw. At the laser-irradiated mice
group, significant pain reduction related behavior was observed. It is
has been suggested that the affected effects directly the function of
TRPV channel in sensory neurons instead of damaging cells. Taking
into consideration of these findings, it may be suggested that the use
of Er,Cr:YSGG laser can provide analgesia via inhibition of TRPVl. In a
previous randomized controlled clinical study; Kurtulmus-Yilmaz et
al. [22] evaluated the efficacy of Er,Cr:YSGG laser on pain reduction
and healing process of traumatic ulcerations (TU) after placing new
complete dentures on a 2-week period at 30 patients. They stated that
laser irradiation provided significant pain reduction immediately and
significant healing effect after treatment. Consistent with these results;
in the current research, Er,Cr:YSGG laser therapy showed significant
pain reduction immediately after treatment in comparison to the con-
trol group and accelerated healing of RAS lesions significantly 1 day
after treatment. This effect was maintained throughout the study with-
out any adverse reaction.
In this study the VAS evaluation was done for each single lesion
however considering the difficulty for the patients to discriminate the
values in so small lesions, patients who had lesions smaller than 4 mm
were not included in the study.
According to the results of this randomized controlled clinical study,
it may be recommended that the application of Er,Cr:YSGG laser with
0%water at 0.25 W, could be appropriate to reduce pain and accelerate
the healing process of RAS.
Conflict of Interests
Day 10
1 ± 0d
The authors declare that they have no conflict interests.
1 ± 0d
Funding
This research was supported by YDU Centre of Excellence (# CE018-
2015).
4 H.G. Yilmaz et al. / Journal of Photochemistry & Photobiology, B: Biology 170 (2017) 1–5
Table 3
Dimensions and localizations of RAS lesions.
Patient number RAS size (mm) RAS localization
1 5 Mandibula anterior
6 Mandibula posterior
2 4 Maxilla posterior
5 Maxilla anterior
3 5 Mandibula anterior
5 Maxilla anterior
4 6 Maxilla anterior
4 Mandibula anterior
5 4 Mandibula anterior
4 Maxilla premolar
6 7 Maxilla anterior
5 Maxilla posterior
7 5 Maxilla premolar
6 Mandibula premolar
8 5 Mandibula anterior
6 Maxilla anterior
9 5 Maxilla premolar
7 Mandibula premolar
10 5 Mandibula anterior
6 Mandibula posterior
11 8 Maxilla anterior
5 Maxilla premolar
12 6 Mandibula premolar
5 Maxilla anterior
13 9 Mandibula anterior
7 Mandibula premolar
14 4 Mandibula anterior
7 Maxilla anterior
15 5 Maxilla posterior
7 Mandibula anterior
16 6 Maxilla premolar
9 Mandibula premolar
17 5 Mandibula anterior
4 Mandibula posterior
18 4 Maxilla premolar
4 Mandibula premolar
19 6 Mandibula anterior
4 Maxilla anterior
20 4 Maxilla anterior
5 Mandibula anterior
21 6 Maxilla anterior
6 Mandibula anterior
22 4 Maxilla anterior
7 Mandibula anterior
23 5 Mandibula premolar
4 Mandibula anterior
24 6 Mandibula posterior
7 Maxilla anterior
25 5 Maxilla anterior
6 Mandibula anterior
26 5 Maxilla premolar
4 Mandibula anterior
27 6 Mandibula premolar
4 Maxilla anterior
28 5 Mandibula posterior
5 Maxilla anterior
29 6 Mandibula premolar
5 Maxilla anterior
30 7 Mandibula anterior
4 Maxilla anterior
31 4 Maxilla anterior
4 Maxilla posterior
32 6 Maxilla premolar
5 Mandibula anterior
33 4 Mandibula premolar
6 Maxilla anterior
34 4 Maxilla premolar
7 Mandibula anterior
35 9 Maxilla premolar
7 Mandibula anterior
36 6 Maxilla premolar
6 Mandibula posterior
37 4 Mandibula premolar
6 Maxilla anterior
38 5 Maxilla posterior
Table 3 (continued)
Patient number RAS size (mm) RAS localization
5 Maxilla premolar
39 6 Mandibula anterior
8 Mandibula posterior
40 5 Maxilla anterior
6 Mandibula premolar
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