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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 142-144

Treatment-resistant gingivitis responding to photobiomodulation in pemphigus vulgaris


1 Department of Dermatology, St. George and Sutherland Clinical School, University of New South Wales, Sydney, Australia; Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Dermatology, St. George and Sutherland Clinical School, University of New South Wales; Department of Dermatology, Faculty of Medicine, University of New South Wales; Department of Dermatology, The George Institute for Global Health, Sydney, Australia

Date of Submission29-Apr-2021
Date of Decision23-Sep-2021
Date of Acceptance10-Nov-2021
Date of Web Publication01-Jul-2022

Correspondence Address:
Dedee F Murrell
Department of Dermatology, St. George Hospital, University of New South Wales, Sydney, Australia. Faculty of Medicine, University of NSW, Sydney, Australia. The George Institute for Global Health, Sydney
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_29_21

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  Abstract 


Gingivitis is a chronic inflammatory condition of the maxillary and mandibular gingiva due to poor hygiene of the gums. A 91-year-old woman with a prior diagnosis of pemphigus vulgaris and persistent gingivitis for 11 years was treated using photobiomodulation (PBM), red 650 nm laser light, 150 mW, 2 J/Cm2 in 16 sessions for 6 weeks. Redness and pain decreased significantly not long after photobiomodulation was commenced and healed completely in 16 sessions. In follow-up after 3 months, her situation was still stable. PBM can be used as an effective, noninvasive, safe, and cost–benefit treatment.

Keywords: Gingivitis, low-level laser therapy, pemphigus vulgaris, photobiomodulation


How to cite this article:
Kazemikhoo N, Murrell DF. Treatment-resistant gingivitis responding to photobiomodulation in pemphigus vulgaris. J Oral Res Rev 2022;14:142-4

How to cite this URL:
Kazemikhoo N, Murrell DF. Treatment-resistant gingivitis responding to photobiomodulation in pemphigus vulgaris. J Oral Res Rev [serial online] 2022 [cited 2022 Aug 16];14:142-4. Available from: https://www.jorr.org/text.asp?2022/14/2/142/349706




  Introduction Top


Pemphigus as an autoimmune bullous disorder characterized by circulating autoantibodies against the keratinocytes cell surface has three primary subsets: (1) pemphigus vulgaris (PV), (2) pemphigus foliaceus, and (3) paraneoplastic pemphigus. PV is the most common and important variant with an incidence of 0.5–3.2/100,000 population. Loss of tolerance to the desmosomal protein desmoglein-3 (Dsg3), production of autoantibodies directed against cellular adhesion molecules, involvement of autoreactive T-cells in the induction and maintenance of antibody production, and cytokine alteration seem to play a crucial role in the pathogenesis of PV. The clinical manifestations are superficial oral mucosal erosions and ulcerations leading to friable, thin vesicles.[1] Direct immunofluorescence microscopy is the gold standard diagnosis for PV, which detects tissue-bound autoantibodies. Treatment modalities include rituximab and short-course corticosteroids. Gingivitis may be a part of pemphigus, but more commonly, it relates to dental disease and is very difficult to cure.

Photobiomodulation (PBM) which previously was called low-level laser therapy is a noninvasive treatment which stimulates tissue healing, reduces inflammation and pain, and is an effective treatment for different oral cavity disorders as well as other parts of the body.[2] Several clinical trials suggest the efficacy of PBM on oral wound healing following gingivectomy wound healing and postoperative pain after gingival grafting[3] and connective tissue graft for root coverage.[4]

PBM affects tissue regeneration, collagen synthesis, cellular proliferation, and growth factors released from various cells.[5] It seems that PBM interferes with mitochondrial-membrane potential, ATP synthesis, and altered cellular metabolism. Such capabilities enable PBM to enhance and stimulate the wound healing process. It seems that PBM has immunoregulatory effects and can decrease inflammatory markers in activated inflammatory cells.[2]


  Case Report Top


The patient was a 91-year-old woman with a history of biopsy-proven PV mostly confined to the mouth since 2008. Prednisone started at 50 mg daily in June 2008, was tapered to 5 mg in 2009, and was stopped in November 2013. She was suffering from arthritis, sleeping problems, and easy bruises while using prednisone. Since 2013, she was in complete remission with no medications and denied lesions. Her Dsg1 and 3 ELISA became negative. Since the beginning of her pemphigus, she was suffering from persistent desquamative gingivitis on the upper gingiva and was using dexamethasone swish and spit with minimal effects. A biopsy was done from the upper gingiva in July 2012, and the results confirmed nonspecific ulceration represented of gingivitis rather than pemphigus. She was reviewed by an oral surgeon and denist. They determined that the gingivitis related to teeth dead underneath and major surgery would be needed to eliminate it, but the patient could not afford such surgery. She was advised to continue using corticosteroid mouthwash and using Biotin toothpaste, salted water rinses, alpha-lipoic acid which irritated her gums, sucralfate 2% which made her gums, worse, Bonjela mouth ulcer gel which was not effective by other dentists she visited during these years. Just using doxycycline 50 mg twice daily which was used June 2016–January 2019 made some improvement. She had been using fish oil, Vitamin D, and Seretide in the past 1 year before starting PBM. In terms of past medical history, she had breast cancer (1973), chronic obstructive pulmonary disease, hypertension (2011), hyperlipidemia, and hay fever.

Treatment

When she was referred for PBM, her upper gingiva was erythematous and her Visual Analog Scale (VAS) for gum pain was 4/10. She was treated using a portable laser probe, 650 nm, 150 mW, radiation area 0.25 cm2, power density 0.6 W/cm2, contact (using cling wrap to avoid contamination), continuous mode, 2 J/cm2 (Canadian Optic and Laser Centre, COL Centre, Canada), every other day for 10 sessions and twice a week for 6 more sessions.


  Results Top


After 4 sessions, her VAS pain score decreased to 0/10, but treatment was continued to eliminate the erythema and inflammations as well until 16 sessions. The patient was reviewed 3 months later, and her situation was stable without any pain and inflammation.


  Discussion Top


PBM has been used in the treatment of various disorders during the past 40 years. Here, we report a case of using red 650 nm laser light on healing of gingivitis mimicking PV in a 91-year-old patient who was suffering from this condition for 11 years. Although her condition was resistant to the classic treatments, her gums healed completely after 16 sessions of PBM.

Several studies suggest that PBM reduces pro-inflammatory cytokine levels in activated inflammatory cells. Lim's study on human gingival fibroblasts showed that red 635 nm light LED reduced the inflammatory markers including prostaglandin E2 (PGE2), cyclooxygenase-2 (COX2), and granulocyte colony-stimulating factor and had regulatory effects on activated normal T-cell expression.[2] In another study using the same wavelength, they showed a reduction of interleukin (IL)-6, IL8, p38 phosphorylation, and increased JNK phosphorylation on the human gingival fibroblasts.[5] Sakurai et al. reported similar inhibitory effects and reduction of the levels of COX2 and PGE2 and also downregulation in the expression of the IL-1β in the human gingival.[6],[7] Katagiri et al. reported modulation of mitochondrial retrograde signaling, and effects on the intracellular calcium and reactive oxygen species in T-cells. They suggested that binding of nitric oxide (NO) to cytochrome c oxidase after illumination of the T-cells with near infrared laser could result in the NO release, which seems to be involved in these changes.[8]

This inhibitory effect on the inflammatory markers might be beneficial in other autoimmune disorders too. In a study by Yamaura et al., they reported the reduction of mRNA and protein levels of tumor necrosis factor-alpha and IL-1β, and IL-8 after PBM on synoviocytes isolated from rheumatoid arthritis patients.[9] Another study by Hwang et al. showed that PBM has an inhibitory effect on IL8 expression and IL6 in the intervertebral disc degeneration.[10] Further research is warranted to determine the optimal frequency duration of PBM treatment for gingivitis.

Financial support and sponsorship

Australian Blistering Disease Foundation.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Venugopal SS, Murrell DF. Diagnosis and clinical features of pemphigus vulgaris. Dermatol Clin 2011;29:373-80.  Back to cited text no. 1
    
2.
Lim W, Choi H, Kim J, Kim S, Jeon S, Zheng H, et al. Anti-inflammatory effect of 635 nm irradiations on in vitro direct/indirect irradiation model. J Oral Pathol Med 2015;44:94-102.  Back to cited text no. 2
    
3.
Heidari M, Paknejad M, Jamali R, Nokhbatolfoghahaei H, Fekrazad R, Moslemi N. Effect of laser photobiomodulation on wound healing and postoperative pain following free gingival graft: A split-mouth triple-blind randomized controlled clinical trial. J Photochem Photobiol B 2017;172:109-14.  Back to cited text no. 3
    
4.
da Silva Neves FL, Silveira CA, Dias SB, Santamaria Júnior M, de Marco AC, Kerbauy WD, et al. Comparison of two power densities on the healing of palatal wounds after connective tissue graft removal: Randomized clinical trial. Lasers Med Sci 2016;31:1371-8.  Back to cited text no. 4
    
5.
Choi H, Lim W, Kim I, Kim J, Ko Y, Kwon H, et al. Inflammatory cytokines are suppressed by light-emitting diode irradiation of P. gingivalis LPS-treated human gingival fibroblasts: Inflammatory cytokine changes by LED irradiation. Lasers Med Sci 2012;27:459-67.  Back to cited text no. 5
    
6.
Sakurai Y, Yamaguchi M, Abiko Y. Inhibitory effect of low-level laser irradiation on LPS-stimulated prostaglandin E2 production and cyclooxygenase-2 in human gingival fibroblasts. Eur J Oral Sci 2000;108:29-34.  Back to cited text no. 6
    
7.
Nomura K, Yamaguchi M, Abiko Y. Inhibition of interleukin-1beta production and gene expression in human gingival fibroblasts by low-energy laser irradiation. Lasers Med Sci 2001;16:218-23.  Back to cited text no. 7
    
8.
Katagiri W, Lee G, Tanushi A, Tsukada K, Choi HS, Kashiwagi S. High-throughput single-cell live imaging of photobiomodulation with multispectral near-infrared lasers in cultured T cells. J Biomed Opt 2020;25:1-18.  Back to cited text no. 8
    
9.
Yamaura M, Yao M, Yaroslavsky I, Cohen R, Smotrich M, Kochevar IE. Low level light effects on inflammatory cytokine production by rheumatoid arthritis synoviocytes. Lasers Surg Med 2009;41:282-90.  Back to cited text no. 9
    
10.
Hwang MH, Shin JH, Kim KS, Yoo CM, Jo GE, Kim JH, et al. Low level light therapy modulates inflammatory mediators secreted by human annulus fibrosus cells during intervertebral disc degeneration in vitro. Photochem Photobiol 2015;91:403-10.  Back to cited text no. 10
    




 

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