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2 0 0 9 V O L 1 7, N O . 3
or muscle relaxation, are all sensi-
tive to different irradiances or
doses. An example of this is the
stimulation of fibroblasts; a dose of
5 J/cm2 will stimulate the cellular
activity of fibroblasts, whereas
higher doses inhibit cell viability
and proliferation.8 Thus, for wound
healing, the clinician should ideally
use a dose lower than 5 J/cm2. |
The biostimulatory and
JOU R NAL OF L ASER DENTI STRY
Dry Socket
Tunr and Hode describe the bene-
fits of PBM in helping to prevent
alveolitis after a tooth extraction.14
Figure 2: Arndt-Schultz curve. The horizontal axis depicts an increasingly higher dose The following case study illustrates
from left to right, and indicates that biostimulation occurs with relatively smaller doses PBM treatment for a painful dry
when compared to the higher doses that cause bioinhibition socket.
The importance of dose should Many procedures a dental surgeon Oral Mucositis
always be kept in mind when using performs, especially extraction of Oral mucositis, presenting as an
PBM; if the clinician is not molars, create an acute inflamma- open sore over the oral soft tissue,
achieving the anticipated response tory response that can result in is a life-altering condition that is a
to laser treatment, the dose should edema, bruising, and pain. side effect of chemotherapy and
be re-evaluated to ensure it is Currently, the primary method of radiation therapy. Laser therapy
within the optimal range. dealing with the pain and discom- has been investigated as a preven-
Additionally, treatments may need fort of the surgical procedures is tative application to mucositis and
to be modified over time to ensure prescription of pain analgesics, as a treatment modality for healing
the practitioner is achieving the many of which carry side effects or erupted sores, with positive
2 0 0 9 V O L 1 7, N O . 3
ideal effect from the laser dose decreased mental alertness. Studies results.15 A 2006 study by Corti et
(pain relief vs. wound healing). have demonstrated that PBM in al., using a light-emitting diode
acute pain reduction compares well device with an emission of 645 15
Acute vs. Chronic Pain to standard nonsteroidal anti- nm, demonstrated that PBM accel-
Treatment dose and duration will inflammatory drug (NSAID) erated the healing rate of oral
largely be governed by the status of treatment, with a better risk- mucositis by 117% to 164%.16
the injury. PBM can effectively benefit profile.10 Healing is also Often, oral mucositis can be so
speed the resolution of acute accelerated by stimulation of fibrob- debilitating for patients that they
inflammation and pain, conditions lasts and osteoblasts, which cannot continue their cancer treat-
that should be treated frequently produce soft tissue and bone, ments, so a tool that can treat or
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prevent the sores will have consid- Dental Infections C fibers, the fibers that carry
erable clinical importance. For infections and edema, PBM has pulpal pain; and increases oxygena-
Consultation with the oncologist been reported to dilate lymphatic tion and lymphatic drainage, which
should always be done prior to vessels and reduce the permeability are responsible for pain relief after
commencing laser treatments. of blood vessels.20 Figure 5 demon- the first minutes of tissue irradia-
strates the application to the tion.6, 21-22
Fractures and Orthognathic Surgery lymph nodes using a PBM device.
PBM accelerates healing of bone
after fractures or orthognathic Primary Tooth Restorations
surgery through the stimulation of A variety of factors contribute to
osteoblasts. A 2005 study in rats the analgesic effect produced by
demonstrated that laser irradiation PBM which allows dental practi-
resulted in an increase in bone tioners to perform many primary
neoformation, with better quality tooth restorations without anes-
bone on the irradiated groups when thesia. Small animal studies show
compared to the control group, who that laser irradiation promotes a
received no radiation.11 release of endorphins and sero- Figure 4: LLLT treatment of a soft tissue
tonin; inhibits the conduction of lesion
Soft Tissue Lesions
Soft tissue lesions, such as herpes
simplex, denture sores, and angular C AS E ST U DY : D RY SO C K ET
cheilitis respond positively to low- Treating Dentist: Dr. Gerald Ross
level laser irradiation. Schindl and A 45-year-old male patient had a lower first molar extracted.
Neumann investigated the effect of During the postoperative instructions, the patient (a smoker) was
LLLT on recurrent herpes simplex advised to avoid smoking cigarettes for a minimum of 2 days. The
and demonstrated that 10 daily patient presented the following day with dry socket and admitted to
irradiations significantly lowered smoking the previous evening.
the incidence of local recurrence An 830-nm PBM device was used. The intraoral light guide was
and is a beneficial treatment alter- placed in the socket and the socket was irradiated until pain relief
native to commonly used drugs was felt by patient (in this case 48 J/cm2 of energy was applied before
such as acyclovir and famciclovir.17 the patient started to experience a reduction in discomfort). A
Further, the author has clinically dressing was placed into the socket and the patient was sent home
observed that laser irradiation of without any pain medications. The patient returned the next day for
2 0 0 9 V O L 1 7, N O . 3
herpes simplex decreases the inci- a dressing change and the laser was applied into the socket using 4
dence of lesion recurrence. Marei et J/cm2 before application of the new dressing for stimulation of the
al. examined the effect of laser epithelium in the socket. The patient did not require any additional
irradiation on denture sores and treatments and the area healed in 7 days.
noted that LLLT eased the pain
caused by denture lesions, while at
4 weeks post-treatment the laser-
irradiated areas showed clinically C AS E ST U DY : O R A L M U CO S I T I S
superior healing, and histological Treating Dentist: Dr. Gerald Ross
epithelialization and vasculariza- A 61-year-old female patient undergoing chemotherapy for terminal |
tion of the lesion.18 Tunr and Hode cancer presented with numerous sores over the inside of her mouth.
JOU R NAL OF L ASER DENTI STRY
report successful treatment of The patient could not eat, drink, or swallow without extreme pain.
angular chelitis with PBM, but Treatments (mouth rinses) assigned by the oncologist had no effect
warn of its recurrence if the funda- on healing of the sores. A visible red laser (660 nm) was applied
mental cause is not dealt with.19 It intraorally overlapping throughout the mouth for 2 days in a row.
is advantageous to treat any soft When the patient came in on the second day, the pain was markedly
tissue lesion in its most acute decreased and she was able to eat soup. By the fourth day, she was
stage. For example, herpetic lesions able to eat normally. The patient passed away in the following month
are most susceptible to LLLT but no sores returned during that time.
during their prodromal stage. NOTE: Prior to laser treatment, the dentist contacted the oncolo-
Figure 4 demonstrates the treat- gist who was willing to try any treatment that could work on the
ment of a lesion on the lip using an mucositis.
830-nm PBM device.
H7, LU9, and P6 are the parasym- Figure 7: A graphic diagram of three
pathetic calming points and parasympathetic calming acupuncture
stimulation of these points can be points for reduction of nausea and
Figure 5: Application of low-level laser to very effective in reducing anxiety. gagging. Courtesy of Donald J. Coluzzi, DDS.
the submandibular lymph nodes A 1998 report in the British Adapted from Atlas of acupuncture points. Point
Journal of Anaesthesia investigated locations [Internet]. Published by
Laser irradiation is applied to the effectiveness of laser irradiation www.AcupunctureProducts.com, 2007. [Cited
the apex of each root for analgesia to the P6 acupuncture point on post- 2009 Dec 28.] 39 p. Available from:
and again after the tooth has been operative vomiting. In the laser http://chiro.org/acupuncture/ABSTRACTS/
prepared for reduction of pain and stimulation group, the incidence of Acupuncture_Points.pdf.
inflammation, as shown in Figure vomiting was significantly lower
6. Distraction techniques are (25%) than in the placebo group a significantly greater amount of
recommended to help the patient (85%), and the patients were quite mature bone, a better distribution
deal with the mental fears or receptive to the painless procedure.24 of bone, and more organization of
anxiety surrounding the dental bone after laser irradiation, when
appointment. Dental analgesia does Uptake and Elimination of compared to the control group that
not seem to be as effective in Anesthesia received no laser irradiation.25
permanent teeth because of the Based on the mechanisms of PBM Another study used rats to
2 0 0 9 V O L 1 7, N O . 3
increased size and sensitivity of the therapys ability to increase blood examine the effect of laser therapy
dental pulp; however, it has been circulation,4 the author has found on bone and demonstrated that the
shown clinically to be effective for that there is an increase in uptake laser group had an abbreviated
pain relief during crown cementa- and elimination of anesthesia. PBM initial inflammatory response and
tions and decreased sensitivity is applied to the submandibular a rapid stimulation of bone matrix
during scaling appointments. lymph nodes and the site of injec- formation at 15 and 45 days.26 An
tion after the injection and upon earlier rabbit study showed that
Nausea and Gagging completion of the dental appoint- bone healing is improved and those
Application of the laser to the P6 ment, for uptake and elimination, authors concluded that it is
(Pericard 6) acupuncture point on respectively. possible to reduce the loading time
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the nausea and gagging some Implant Placement humans from 4 months to approxi-
patients feel during impression- Three papers indicate that PBM mately 2 months and 24 days, and
taking or X-ray procedures. As can reduce inflammation following in the maxilla, from 6 months to 4
shown in Figure 7, the P6 is located implant placement, help speed the months and 6 days.27
on the underside of the wrist, integration of the implant into the
approximately 1 inch from the bone, and improve the quality of Orthodontics
distal palmar crease (approxi- the bone around the implant. A Orthodontic treatments are lengthy
mately the width of the distal study using rabbits utilized Raman and often painful for many patients.
thumb phalanx).23 For patients who spectroscopy and electronic As mentioned previously, Gerbi et
are extremely nauseous or anxious, microscopy to investigate the effect al. have shown that PBM irradia-
application to three acupuncture of infrared light on the loading tion on bone increases osteoblastic
points in the wrist can be effective; time of dental implants, and found proliferation, collagen deposition
and bone neoformation when contour, and mucosa healing when Laser Therapy as a Diagnostic Tool
compared to non-irradiated bone.11 compared with non-laser treated Occasionally, a patient will present
A 2008 study investigating the area, which served as a control.32 To to a dental practitioner with exces-
effect of laser therapy on orthodontic further exemplify these positive sive tooth pain, the source of which
movement showed that the velocity responses, a study by Ozcelik et al. cannot be accurately identified.
of canine movement was signifi- demonstrated that LLLT enhanced Traditional diagnostic methods
cantly higher in the laser-irradiated epithelialization and improved such as thermal or electrical
teeth compared to teeth that wound healing after gingivectomy stimuli often do not show any indi-
received no irradiation. In addition, and gingivoplasty operations.33 cation of the problem, making the
the pain intensity was also at a Figure 8 shows an 830-nm PBM diagnosis and treatment stressful
lower level in the lased group device being used to irradiate a for both the patient and the doctor.
throughout the entire retraction closed incision. As stated previously, PBM irradia-
period.28 Histological observations tion increases circulation, thus a
made during another study on Endodontics patient with a hyperemic pulp will
rabbits showed that both osteoblasts PBM is effective for reducing pain feel a sharp pain when the laser is
and osteoclasts remained more and inflammation after endodontic applied to a tooth.35 Figure 9 shows
active on the lased side which could treatments, for dentin hypersensi- a diagnostic outline that could be
account for the accelerated move- tivity, and as a diagnostic tool for used in endodontics.
ment.29 Finally, Turnhani et al. pulp hyperemia.34
showed that a single application of Dentin Hypersensitivity
LLLT reduced the pain at 6 and 30 A study by Marsilio et al. demon-
hours after banding treatment.30 strated that LLLT treatment of
dentin hypersensitivity in two
Periodontics different groups of patients was
The use of PBM as a treatment effective for 86% to 88% of all the
modality in periodontics is effec- participants.36 Another study
tive, either as a treatment method compared LLLT to topical fluoride
on its own or as an adjunct to the varnish application for treatment
increasingly popular surgical of dentinal hypersensitivity and
lasers. A recent study investigated found that 86% of the laser irradia-
the gingival inflammatory response tion group achieved absence of pain
and dental plaque reduction compared to 27% of the fluoride
following scaling and root planing Figure 8: LLLT irradiation after flap surgery group.37
2 0 0 9 V O L 1 7, N O . 3
combined with PBM in 60 patients.
The authors found a significant
decrease in the clinical indices
(plaque, gingival, and sulcular
bleeding), which they thought could
be beneficial in the treatment of
chronic advanced periodontitis.31
Periodontal Surgery
Healing after periodontal surgery |
is often a lengthy and painful
JOU R NAL OF L ASER DENTI STRY
TMJ and Facial Pain cells that are damaged will respond evolving technology. With every
When treating temporomandibular to PBM better than cells that are passing day, more is being discov-
joint (TMJ) or facial pain, PBM is a healthy and functioning normally. ered about the mechanisms of laser
useful tool to add to the therapeutic However, there are precautions therapy, doses, treatment locations,
arsenal. From simple acute cases all laser users should take and areas and diseases in which a laser will
like facial pain after long appoint- to avoid treating when using PBM. have an effect. At our hands is a
ments to chronic TMJ cases, laser Specifically, those include avoiding tool that can reduce pain, stimulate
therapy will help reduce pain and exposure to the thyroid gland, to wound healing, and modulate the
inflammation, and significantly pregnant women, and to radiation inflammatory response.
resolve muscle trismus. In a system- therapy patients.40 Also important to Photobiomodulation can be used
atic review of postoperative pain note is that the laser will be ineffec- effectively in dental specialties to
relief in patients after undergoing tive if the patient has had a steroid better manage treatments that are
third molar extraction, a PBM irra- injection in the last six months.41 All often deemed painful by patients,
diation was shown to be beneficial in laser users should consult their without prescribing pharmaceuti-
reducing acute inflammatory pain.13 laser manufacturer for any ques- cals that often have a number of
In a clinical study of 74 patients tions regarding contraindications side effects. All healthcare profes-
complaining of TMJ pain, 64% were and appropriate treatment doses, as sionals, including dentists and
pain-free or had improvement in well as for instructions about safety dental specialists, should further
comfort after 12 PBM sessions over eyewear for everyone within the investigate photobiomodulation to
a six-week period.38 Pinheiro and nominal hazard zone of the beam. enhance their clinical treatments
colleagues analyzed the effect of Photobiomodulation is an and outcomes.
PBM on maxillofacial disorders by
irradiating 141 female and 24 male
patients twice a week for 6 weeks. C A S E S T U D Y : T M J PA I N
At the end of the treatment 72% of Treating Dentist: Dr. Gerald Ross
patients were aymptomatic and 15% A 55-year-old patient presented with pain in the left temporo-
had improved considerably.39 mandibular joint and a limited ability to open the mouth. The
computed tomography (CT) tomogram (R = right, SMV = submental
Neuropathic Pain vertex, L = left) showed degenerative joint disease (osteoarthritis) of
Neuropathic facial pain is a debili- the left TMJ with no disc present.
tating condition for a patient that Six applications of the laser were performed over a three-week period,
results in their living with excruci- with treatment applications to the joint, joint capsule, and the lateral
ating pain or with a continuous pterygoid muscle. This treatment resulted in the patient being pain-free
2 0 0 9 V O L 1 7, N O . 3
dose of prescription analgesics. As for the last two years and with the ability to open the mouth wider.
stated above in the study by
Bjordal et al.,13 PBM permits many
patients to live a life free from
discomfort or with less pain.
CO N C LU S I O N
Although PBM has been available
to health care professionals since
the 1960s, low-level laser therapy
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2 0 0 9 V O L 1 7, N O . 3
South Africa. He is currently a board redox mechanisms. Photomed Laser
11. Gerbi MEM, Pinheiro ALB, Marzola
Surg 2008;26(4):323-328.
member of the North American C, Limeira Jnior Fde A, Ramalho
Association for Laser Therapy 2. Karu TI. Low-power laser therapy. LMP, Ponzi EAC, Soares AO,
(NAALT) and is helping with Chapter 48 in: Vo-Dinh T, editor. Carvalho LCB, Lima HV, Gonalves
numerous studies on photobiomodu- Biomedical photonics handbook. TO. Assessment of bone repair asso-
lation. Dr. Ross may be contacted by Boca Raton, Fla.: CRC Press, ciated with the use of organic bovine
e-mail at ddsross@rogers.com. 2003:48-1 48-25. bone and membrane irradiated at
830nm. Photomed Laser Surg
Alana Ross, BScH, graduated 3. Hamblin MR, Demidove TN.
2005;23(4):382-388.
with an honors degree in Biomedical Mechanisms of low level light
Science from the University of therapy. In: Hamblin MR, Waynant 12. Aras MH, Gngrms M. The effect |
Guelph in Ontario, Canada. In 2004, RW, Anders J, editors. Mechanisms of low-level laser therapy on trismus
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2007;22(4):303, abstract O50. dental care. Gen Dent 2008;56(7): 2006;24(5):588-594.
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14. Tunr J, Hode L. Laser therapy: 33. Ozcelik O, Cenk Haytac M, Kunin A,
Clinical practice and scientific back- 24. Schlager A, Offer T, Baldissera I. Seydaoglu G. Improved wound
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vomiting in children undergoing A controlled pilot study. J Clin
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