Low-level laser treatment of burning mouth syndrome: a systematic review and meta-analysis
Review Article

Low-level laser treatment of burning mouth syndrome: a systematic review and meta-analysis

Chen Sun1,2,3, Wei-Wen Jiang1,2,3

1Department of Oral Mucosal Diseases, Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China; 2National Clinical Research Center for Oral Diseases, Shanghai 200011, China; 3Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai 200011, China

Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study material or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Wei-Wen Jiang. Department of Oral Mucosal Diseases, Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 639 Zhi-Zao-Ju Road, Shanghai 200011, China. Email: wwjiang33@hotmail.com.

Abstract: Burning mouth syndrome (BMS) is a chronic disease that consists of pain or a burning sensation on the oral mucosa in the absence of clinical or laboratory signs. The aim of this study was to compare the efficacy of low-level laser (LLL) treatment with different wavelengths on patients with BMS to provide an optimized approach for clinical management. The PubMed and Wanfang databases were searched for studies in English or Chinese until September 30, 2018 using “burning mouth syndrome” and “laser” as keywords. Fifteen clinical trials were analyzed for data extraction. LLL treatment for BMS was effective. A LLL with a wavelength of 790 nm showed the greatest efficiency. However, the parameters in the trials, such as wavelength (650–980 nm), power (20–1,500 mW), energy density (0.53–200 J/cm2), time (10 s–15 min), sessions (1–20 s), and irradiated frequency, varied widely. More randomized controlled trials (RCTs) are needed to draw a clear conclusion to provide evidence for optimized clinical management.

Keywords: Burning mouth syndrome (BMS); low-level laser (LLL)

Received: 30 June 2019; Accepted: 15 October 2019; Published: 29 November 2019.

doi: 10.21037/fomm.2019.10.02

Introduction

Burning mouth syndrome (BMS) is a chronic intraoral pain disorder with numbness or a burning or tingling sensation where no medical or dental cause can be identified (1,2). Patients with BMS possibly have mucosa dryness or taste alteration (3). The symptoms of BMS trends to increase from day to night and could be occurred on the tongue, lip or the entire oral mucosa. BMS is seen more frequently in pre- and postmenopausal women (4,5). The etiology of BMS is not clear, and the therapy is aimed at relieving symptoms (6-9). Evidence has shown that BMS is associated with peripheral or central neuropathic disturbances (10). Clonazepam and antidepressants have reduced the symptoms of pain and burning sensation for patients with BMS (10). Recently, the use of low-level laser (LLL) treatment has been used to reduce pain and burning sensation in patients with BMS.

Biological effects occur in organisms under the influence of LLL therapy. LLL therapy has the potential to reduce pulpal inflammation, preserve dental pulp vitality and improve healing (11-16). LLL produces an analgesic effect by decreasing endogenous opiates, increasing the pain threshold and regulating the release of pain mediators, such as bradykinin and histamine (17-20). Sugaya et al. reported that 46.2% of patients with BMS benefited from LLL with 790 nm, 20 mW, and 6 J/cm2 (21). Likewise, Arbabi-Kalati et al. showed that laser group with 630 nm, 30 mW, and 1 J/cm2 on symptom relief was superior to placebo group (20). Although Al-Maweri et al. reviewed 10 clinical trials of LLL treatment and concluded that majority of the studied showed effective in reducing symptom of BMS, the parameters of LLL in those studies were widely variable (3). Our study updated the clinical trials of LLL treating BMS till September 30, 2018 and was focused on the treating parameters of LLL therapy patients with BMS.

Methods

Criteria for considering studies for this review

All clinical trials using LLL treating patients with BMS were included.

The type of studies was clinical trial. The type of participants was patients diagnosed with BMS. The intervention was LLL with or without placebo. The outcome was measured by relief of pain/burning sensation.

Search methods for identification of studies

A literature search was conducted in the PubMed and Wanfang databases until September 30, 2018 by using the following keywords: “BMS” and “laser”. Studies could be in either Chinese or English. The titles and abstracts were screened from the initial searches to select trials for treating the local oral mucosa on BMS patients with LLL. The full report was screened and assessed when inadequate information of the titles and abstracts was hard to decide whether a trial fulfilled the inclusion criteria.

Data collection and analysis

The data collected included author, year of publication, participants, assessment criteria, effect, wavelength of LLL therapy, power, irradiation session, energy density, time and irradiation frequency. The treatment efficiency was calculated as [visual analog scale (VAS) baseline − VAS final session]/VAS baseline. If the trial did not mention the baseline of VAS, the treatment efficiency was analyzed as the number of improved patients/numbers of total patients. RevMan version 5.3 was used to perform meta-analysis. The heterogeneity acrossing studies was analyzed by the I2 statistic, whose value of 25%, 50%, and 75% corresponding to low, moderate, and high heterogeneity, respectively (22). If I2>25%, a sensitivity analysis was conducted to explore the source of significant heterogeneity (23).

Assessment of quality

The quality of randomized controlled trial (RCT) was assessed following the Cochrane Collaboration’s tool for 7 aspects of bias, including random sequence generation (selection bias), allocation concealment(selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and others bias (6). The overall risk of bias following these criteria: when having all low risk of bias, the RCT was deemed as an overall low risk of bias; when having at least one unclear risk of bias and had no high risk of bias, the RCT was deemed to have an unclear overall risk of bias; when having a high risk of bias, the RCT was deem as an overall high risk of bias.

Results

The search

The initial search yielded a total of 36 studies from all databases. Of 36 articles, no articles were removed after screening for duplication. A total of 11 articles were excluded after reading the titles and abstracts, and the full-text articles of the remaining 25 studies were reviewed. At this full-text analysis, 10 studies were excluded because they did not meet our inclusion criteria. A total of 15 studies were processed for final review and meta‐ analysis (20,21,24-36). The process of study selection is described in Figure 1.

Figure 1 Flow chart of progress for systematic review.

Included studies

Six of the 15 studies were randomized trials with 101 participants (25-30). Nine studies were RCTs with 427 participants (20,21,24,31-36). Among the RCTs, 8 RCTs compared the efficacy between the LLL group and the placebo group, which consisted of a laser with no energy (20,21,31-36) and 1 RCT compared the effects of the LLL group and the clonazepam group (24).

Characteristics of participants

All participants were diagnosed with BMS, which is persistent oral mucosal pain with no dental or medical cause. In total, 451 women (85.4%) and 77 men (14.6%) were included. The mean age for trials was ranged from 46.9 to 70.9 years (Table 1).

Table 1

General characteristics of subjects

Author Subjects (number) Mean age Gender (F/M) Type of study Country
Barbosa et al. (36) 52 60.2 52/0 RCT Brazil
Valenzuela et al. (32) 44 65.5 41/ 3 RCT Spain
Cui et al. (34) 90 55.3 81/ 9 RCT China
Sugaya et al. (21) 30 59.7 21/ 2 RCT Brazil
Arduino et al. (24) 33 67.1 25/ 8 RCT Italy
Arbabi-Kalati et al. (20) 20 46.9 20/ 0 RCT Iran
Spanemberg et al. (33) 78 62.8 67/ 11 RCT Spain
Santos-Lde et al. (29) 20 63.2 17/ 3 RT Brazil
Brailo et al. (25) 16 70.9 14/ 2 RT Croatia
Pezelj-Ribaric et al. (35) 40 60.7 27/ 13 RCT Croatia
Santos-Lde et al. (28) 10 65.8 9/ 1 RT Brazil
Vukoja et al. (31) 40 57-85 40/ 0 RT Croatia
Yang et al. (30) 17 50.6 13/ 4 RT China
Kato et al. (26) 11 64.0 10/ 1 RT Brazil
Romeo et al. (27) 25 / 16/ 9 RT Italy

RCT, randomized controlled trial; RT, randomized trial.

Parameters of intervention

All trials used a diode laser. The parameters of LLL therapy varied widely with the wavelength of laser, power, energy density, irradiation times, irradiation sessions, mode, number of point, energy for point, and laser distance (Table 2). Fourteen trials used unitary wavelengths (20,21,24-26,28-36). A double gallium arsenide (GaAs) laser with wavelengths of 650 and 910 nm was utilized in one study (27). Four trials used the same wavelength of 660 nm and similar other parameters, and the greatest improvement was 58.2% (25,28,29,36). The irradiation time ranged from 10 s to 15 min. One study did not mention the time of irradiation (23). The participants in 14 trials received constant sessions (20,21,24-29,31-36). The treatment session number in Yang et al. ranged from 1 to 7, and treatment ended when patients felt they no longer needed treatment (30).

Table 2

Parameters of LLL treatment for patients with BMS

Trail Wave length (nm) Power (mw) Energy density (J/cm2) Time (s) Session (times) Frequency Mode Number of point Energy for point (J) Laser distance (cm)
(36) 660 30 3 10 4 1/week C V / 1
(32) 815 1,000 133.3 / 4 1/week C 10 4 0
815 1,000 200 / 4 1/week C 10 6 0
(34) 810 500 3 10 20 1/day C V 5 0
810 500 3 10 10 1/2 days C V 5 0
(21) 790 20 6 300 4 2/week C V 6 0
(24) 980 300 10 10 10 2/week C V / 0.2
(20) 630 30 1 10 4 2/week / 10 / /
(33) 830 100 176 50 10 1/week C 47 5 /
830 100 176 50 9 3/week C 47 5 /
685 35 72 58 9 3/week C 47 2 /
(29) 660 40 10 10 10 1/week / V 0.4 1
(25) 660 50 1.5–2 900 8 1/2 days / 12 / /
(35) 685 30 3 100 20 5/week C / 3 0
(28) 660 40 20 10 10 1/week C V 0.4 0
(31) 685 20 2 900 10 5/week P / / /
(30) 800 1,500 105 70 1–7 1/week P V / 0
(26) 790 120 6 10 3 1/2 weeks C V 1.2 0
(27) 650 & 910 40 0.53 900 8 2/week / V / 0

C, continuous; P, pulsed; V, variable according to irradiated area.

Relief of pain or burning sensation

All 15 trials were evaluated the reduction of pain on patients with BMS. Thirteen of these trials used the VAS to evaluate pain relief (Table 3) (21,24-26,28-36). The numeric rating scale (NRS) was applied in 2 trials (Table 3) (20,27). Fifteen trials showed 15.6% to 80.4% relief of pain or burning sensation after LLL treatment. The clinical trial by Kato et al. with 790 nm wavelength and energy density 6 J/cm2 showed the greatest efficiency (Table 3) (26). Eight out of 9 RCTs showed significant differences between LLL therapy and controls (Table 3) (20,21,24,31-34,36).

Table 3

Efficacy and adverse reaction of LLL treatment for patients with BMS

Trial Group Adverse reaction Method Efficacy P
(36) 660 nma No VAS 66.7%c *
ALAa headache and nausea 70.0%c *
660 nmb No 70.0%c *
ALAb No 16.75c *
Placebo No NA Ref
(32) 815 nm No VAS 15.7%c *
815 nm No 15.6%c *
Placebo No 7.3%c Ref
(34) 810 nm NA VAS 75.8%c *
810 nm NA 72.7%c *
Placebo NA 41.5%c Ref
(21) 790 nm NA VAS 46.2%d *
Placebo NA 40.0%d Ref
(24) 980 nm No VAS 60.0%c *
Clonazepam No 34.3%c Ref
(20) 630 nm NA NRS 55.0%c *
Placebo NA 2.5%c Ref
(33) 830 nm NA VAS 62.5%c *
830 nm NA 62.5%c *
685 nm NA 47.0%c >0.05
Placebo NA 32.8%c Ref
(29) 660 nm NA VAS 75.0%c *
(25) 660 nm NA VAS 56.9%c *
(35) 685 nm NA VAS 14.3%c *
Placebo NA NA Ref
(28) 660 nm NA VAS 58.2%c *
(31) 685 nm NA VAS 66.6%c >0.05
Placebo NA 50.0%c Ref
(30) 800 nm No VAS 47.6%c *
(26) 790 nm No VAS 80.4%c *
(27) 650 & 910 nm NA NRS 34%c *

a, burning mouth syndrome; b, secondary oral burning; c, compared with baseline; d, compared with no baseline; *, <0.05. ALA, alpha-lipoic acid; Ref, reference; NA, not available.

Four studies were qualified for meta-analysis using a random-effects model (20,22-24). The effect of LLL treatment was found significantly higher than placebo (standard mean difference, 2.32; 95% CI, 1.17 to 3.46). However, we found significant heterogeneity across the included studies (I2=89%; P<0.00001) in Figure 2. Therefore, we performed a sensitivity analysis by excluding one study at a time. The I2 was 74%, 93%, 93%, and 85%, respectively (P>0.0.5). The results indicated that the sensitivity of heterogeneity was low and the meta-analysis was robust and credible.

Figure 2 Summary of bias risk. L, low risk of bias; U, unclear risk of bias; H, high risk of bias.

Adverse effects

Of the 15 included trials, 5 reported no adverse reactions on patients undergoing LLL treatment (24,26,30,32,36); however, the remaining 10 studies did not mention whether there were any adverse effects (Table 3) (20,21,25,27-29,31,33-35). Sugaya et al. reported that 2 and 5 participants were dropped from the experimental group and the control group, respectively, with no further explanation (Table 3) (21). Barbosa et al. mentioned that 11 patients did not complete the treatment for personal reasons unrelated to the study, and 1 patient with alpha-lipoic acid discontinued the study due to adverse headache and nausea (36).

Risk of bias

Risk of bias was assessed in 9 RCTs. Four RCTs showed a low overall risk of bias in Figure 3 (20,21,24,32). However, 3 studies had an unclear overall risk of bias in Figure 3 (33-35). RCTs by Barbosa et al. and Vukoja et al. were marked as an overall high risk of bias in Figure 3 (31,36).

Figure 3 Meta-analysis of the relationship between LLL and BMS. CI, confidence interval; IV, inverse variance; SD, standard deviation; LLL, low-level laser; BMS, burning mouth syndrome.

Discussion

Most clinical trials reported that LLL treatment was effective and can reduce the symptoms of pain and burning sensation for patients with BMS. LLL treatment could be an alternative treatment option with the non-invasive and non-drug characters. However, successful treatment with LLL depends on the use of correct parameters and irradiation of LLL (37). Of 15 trials reviewed, LLL with 630 nm, 30 mW and 1 J/cm2 showed the highest efficacy among 4 RCTs meta-analyzed.

Patients with BMS have burning sensation or pain in the tongue or oral mucosa, without accompanying clinical and laboratory findings. The lack of unified criteria led the diagnosis of BMS difficult. In 1994, the International Association for the Study of Pain (IASP) defined BMS as burning tongue or other mucous membranes. It usually bilateral, dysgeusic taste, altered taste perception, dry mouth, denture intolerance (38). Two of 15 trials used IASP definition (20,34). In 2013, the International Classification of Headaches (ICH) addressed the definition of BMS as an inter-oral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day over more than 3 months, without clinically evident causative lesions (39). This definition clearly describes the minimum time of symptom for BMS diagnosis. Two trials utilized ICH diagnostic criteria of BMS (16,36). Although 3 of 15 trials cited neither IASP nor ICH definitions, the diagnosis of BMS criteria were described in their inclusion criteria (25,30,33). Spanemberg et al. mentioned their enrolled BMS patients suffering oral burning/pain at least 4–6 months (33). In addition, 8 of 15 trials did not refer to the diagnostic criteria of BMS (21,24,26-29,31,35). The lack of diagnostic criteria might made the studies inferior quality. As well, the difference of diagnosis criteria may lead to poor comparability of results.

In terms of gender distribution, the majority of the analyzed studies contained both females and males. Three studies, however, enrolled only female patients (11,17,22). BMS is seen more frequently women, while men could also be diagnosed with BMS.

The desired outcome of LLL treatment for BMS was to reduce the symptom of pain or burning sensation. Of 15 trials reviewed, VAS and NRS were performed in 13 (21,24-26,28-36) and 2 studies (20,27), respectively. Evaluation of pain includes NRS, VAS, verbal rating scale (VRS), and faces pain rating scale (FPS) (40). VAS is similar to the NRS as it provides a measure of pain intensity and is accurate in assessment of the effects of a treatment, which is less influenced by the subjectivity of pain than is the VRS or FPS (40).

With a longer course and chronic persistence, BMS recurs easily and generally difficult to heal. LLL therapy may reduce acute and chronic pain by changing mitochondrial signaling and reducing ATP availability. It blocks and modulates neurotransmitters of Aδ and C nociceptors (21). LLL treatment of BMS has attracted attention as an approach for pain relief on patients with BMS. Most of trials applied LLL treatment at least 4 sessions (20,21,24-29,31-36). Sugaya et al. suggested that the effect of LLL therapy was temporary when a laser was applied in a single session, but these effects lasted longer when laser irradiation was performed in several sessions (21).

More RCTs are needed to draw a clear conclusion to provide evidence for optimized clinical management.

Acknowledgments

Funding: This work was supported by National Natural Science Foundation of China [No. 81671036], and the National Construction Project of Clinical Key Specialized Department [(2013)544].

Footnote

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.org/article/view/10.21037/fomm.2019.10.02/coif). The authors have no conflicts of interest to declare.

Ethical Statement: All the authors are accountable for all aspects of the work, and the questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/fomm.2019.10.02
Cite this article as: Sun C, Jiang WW. Low-level laser treatment of burning mouth syndrome: a systematic review and meta-analysis. Front Oral Maxillofac Med 2019;1:10.

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