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Benefits of laser phototherapy on nerve repair

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Lasers Med Sci
DOI 10.1007/s10103-014-1531-6
REVIEW ARTICLE
Benefits of laser phototherapy on nerve repair
Renata Ferreira de Oliveira &
Daniela Miranda Richarte de Andrade Salgado & Lívia Tosi Trevelin &
Raquel Marianna Lopes & Sandra Ribeiro Barros da Cunha &
Ana Cecília Correa Aranha & Carlos de Paula Eduardo &
Patricia Moreira de Freitas
Received: 16 September 2013 / Accepted: 20 January 2014
# Springer-Verlag London 2014
Abstract Post-traumatic nerve repair represents a major chal-
lenge to health sciences. Although there have been great
advances in the last few years, it is still necessary to find
methods that can effectively enhance nerve regeneration. La-
ser therapy has been widely investigated as a potential method
for nerve repair. Therefore, in this article, a review of the
existing literature was undertaken with regard to the effects
of low-power laser irradiation on the regeneration of
traumatically/surgically injured nerves. The articles were se-
lected using either electronic search engines or manual tracing
of the references cited in key papers. In electronic searches, we
used the key words as “paresthesia”, “laser therapy”, “low-
power laser and nerve repair”, and “laser therapy and nerve
repair”, considering case reports and clinical studies. Accord-
ing to the findings of the literature, laser therapy accelerates
and improves the regeneration of the affected nerve tissues,
but there are many conflicting results about laser therapy. This
can be attributed to several variables such as wavelength,
radiation dose, and type of radiation. All the early in vivo
studies assessed in this research were effective in restoring
sensitivity. Although these results indicate a potential benefit
of the use of lasers on nerve repair, further double-blind
controlled clinical trials should be conducted in order to
standardize protocols for clinical application.
Keywords Nerve repair . Low-power laser therapy . LLLT
(low-level laser therapy)
R. F. de Oliveira : D. M. R. de Andrade Salgado : L. T. Trevelin :
R. M. Lopes : S. R. B. da Cunha : A. C. C. Aranha :
C. de Paula Eduardo : P. M. de Freitas (*)
Department of Restorative Dentistry, Special Laboratory of Lasers in
Dentistry (LELO), School of Dentistry, University of São Paulo,
São Paulo, Brazil
e-mail: pfreitas@usp.br
Introduction
Nerve tissue injuries may occur during various dental and
routine surgical procedures, resulting in classic paresthesia.
This deficiency is characterized as a sensory neural loss, and is
an abnormality that may or may not be transitory; it implies a
sensory disorder in which the patient reports a decrease or lack
of sensitivity, tingle in the tongue, lips or cheeks, and change
in taste, among other manifestations [1–4]. The main iatro-
genic causes of paresthesia in dentistry include the removal of
impacted third molars, endodontic treatments, inferior alveo-
lar nerve block (local anesthesia), orthognathic surgery, im-
plants, surgical removal of cysts or tumors, and facial trauma
[5–10].
For the treatment of nerve tissue injuries, the following
therapies have been proposed: systemic drugs administration
(vitamins B and C, steroidal anti-inflammatory agents), local
physiotherapy, electrical stimulation, acupuncture, and moxi-
bustion. The prognosis for recovery as a result of these treat-
ments varies considerably, depending on the extent of the
nervous/nerve tissue injuries and the suggested treatment
[11–13]. However, there is no therapy that promotes the total
recovery and normalization of the injured tissue.
First described in 1978 [14] as an alternative for the regen-
eration of the traumatized nerves, low-power laser has been
extensively studied and great advances have been achieved in
the last three decades. Some of the effects of phototherapy are
an increase in cellular metabolism and an increase in DNA
and RNA synthesis in the cell nucleus, with consequent cell
proliferation and protein synthesis, for example, collagen
fibers produced by fibroblasts [15–19], cell differentiation
(fibroblasts into myoblasts) [20], changes in nervous/nerve
cell action potential [21], effects on the immune system (lym-
phocyte activation) [22, 23], microcirculation stimulation and
capillary formation [24], stimulation of the release of growth
factors, and increase in leukocyte activity [25, 26].

Some studies have assessed the effects of the phototherapy
in sciatic crush injury in rats considering several parameters,
such as the morphological and electrophysiological aspects,
and functional recovery after nerve injury, and they concluded
that phototherapy proved to be efficient in promoting neural
recovery independent of having been performed
transcutaneously or directly [14, 27–33].
However, although laser therapy has been shown to accel-
erate or improve the regeneration of the affected nervous/
nerve tissue injuries [31–42], the studies described in the
literature showed differences with respect to wavelength, ir-
radiation parameters, and dosimetry used, making it difficult
to obtain clear and objective information to facilitate clinical
application by the dental professional/dentist. In 2005 [30], a
literature review was released about the use of the photother-
apy to increase peripheral nerve repair. However, in the last
8 years, other trial studies have been published, highlighting
important aspects of laser therapy in paresthesia. Thus, it is
important to make a critical evaluation of the data obtained to
date, showing which treatment protocols are most used, and
which are capable of providing positive results in repairing
injured nervous/nerve tissue, thereby providing professionals
with guidance in selecting the appropriate treatment.
For this purpose, we performed a search of the literature in
the electronic databases of Medline/Pubmed, BVS and Sci-
ence Direct, using the key words “paresthesia”, “laser thera-
py”, “low-power laser and nerve repair”, and “laser therapy
and nerve repair”, considering case reports and clinical studies
(in animal models and humans).
Paresthesias derived from nervous/nerve tissue injury
There are several iatrogenic causes of nerve tissue injuries that
lead to sensorineural deficiency (paresthesia) [5–10]. The
damage to nerve fibers, especially the sensory type, can be
classified according to the method proposed by Seddon and
Sunderland [43, 44], as described in Tables 1 and 2,
respectively.
A peripheral nerve trauma can result in a deficiency rang-
ing from total loss of sensitivity to a discrete change in clinical
condition, which can persist for days, weeks, or become
Table 1 Seddon’s classification (1943) of the degree of involvement of the nervous tissue, according to clinical intervention [43]
Classification Nomenclature Definition
First degree Neuropraxia A conduction block without axonal degeneration.
Second degree Axonotmesis A more severe injury.
Third degree Neurotmesis The most severe injury, with complete anatomical
Fourth degree section of the neurovascular bundle or extensive
Fifth degree avulsion or crush injury.
Lasers Med Sci
permanent [45, 46]. The spontaneous reversal may take place
within a few days or months, depending mainly on the degree
of injury sustained, location, and individual capacity for re-
covery [47]. Sensation may return in less severe cases
(neuropraxis) [48], and it is known that in more than 96 %
of the cases, spontaneous return of sensitivity may occur in up
to 24 months [8]. As regards the inferior alveolar nerve, the
return of neurosensory function depends on regeneration of its
fibers and elimination or remission of the secondary causes of
the paresthetic condition, such as hemorrhage, edema, local
inflammation, compressive tumor lesion, development of fi-
brous scar tissue, or infection. If there is compression due to
the presence of a foreign body after a surgical procedure,
surgical re-intervention may be necessary to eliminate this
foreign body [4, 49, 50].
Conventional treatment
The treatment offered for cases of paresthesia are dependent
on the degree of nerve tissue impairment/injury.
Neuropraxis
In cases in which nerve compression only occurs due to post-
traumatic edema, it is recommended to wait for the gradual
return of sensitivity [46, 48, 51]. If this is not successful,
the use of a corticoid or a surgical decompression is recom-
mended [47, 51].
The majority of dentists prescribe conventional drug treat-
ment consisting of antineuritic medication (vitamins B and C)
and steroidal anti-inflammatory substances, in order to try to
restore the electric flow of the nerve fiber and decrease the
duration of the pathology [48].
One of the most indicated therapies is to use vitamin B1
associated with strychnine at the dose of 1 mg/ampoule, in
12 days of intramuscular injections. Another procedure is to
use cortisone (100 mg) every 6 h, during the first 2 or 3 days
so that if there is improvement, there is a distance between the
initial doses.
However, there is no effective treatment for paresthesia.
The symptoms tend to regress within 1–2 months; however,
Intervention
A microsurgical intervention is not indicated.
Regeneration can take place several months later
without surgical intervention.
A microsurgical intervention is generally indicated.
Lasers Med Sci

Table 2 Sunderland’s classification (1951) of the degree of involvement of the nervous tissue, according to the prognosis of regeneration [44]

Classification Definition Prognosis

First degree Nerve conduction is physiologically interrupted;
however, there is no broken axon.
Second degree Evident rupture of the axon with distal and proximal
Wallerian degeneration for one or more nodal segments.
Third degree Rupture of axon and endoneurial tubes, preserving
the perineum.
Fourth degree Axons and endoneurial tubes are completely disrupted, in addition
to part of the epineurium; however, the integrity of part of the
epineurium is maintained, and complete section of the entire
trunk does not occur. Continuity nervosa is only maintained by
scar tissue.
Fifth degree There is complete transection of the nerve trunk with a variable
distance between neural stumps.
There is no degeneration, and the spontaneous recovery
occurs in a few days or weeks.
The integrity of the endoneurial tube is maintained,
favoring the course of the regeneration process.
Disorganization of the internal architecture of the
funiculus hinders regeneration by stimulating fibrosis
during the process, obstructing the growth of axons.
Regeneration is more difficult than it is in the second
and third degrees.
The possibilities of regeneration and return
of function are remote.

there is improvement with the use of histamine or vasodilator
drugs [4].
Axonotmesis or neurotmesis
In cases of sectioning of neural tissue, however, neurorrhaphy
techniques that consist of the coaptation of an injured nerve
segment may be used in order to restore the sensory loss or
motor function [47, 52, 53]. The sooner decompression is
performed, the greater will be the probability of regeneration
occurring, because there will be a smaller quantity of scar
tissue [47, 52, 54]. The indications for neural repair by
neurorrhaphy include the following: observation of, or
suspected laceration or transection of the nerve (the anesthesia
does not improve 3 months after surgery); pain resulting from
neuroma formation; and pain caused by a foreign object or
deformity of the duct, in addition to progressive decrease in
sensitivity or increase in pain [53]. Sensitivity may be recov-
ered in approximately 01 (1 year) [4]. Neurorraphy may,
however, be a very invasive method, and is indicated as the
last option in the treatment of sensorineural loss, and only
when there is complete nerve transection, so that the treatment
of first choice is medication [48].
Other therapies currently used for the treatment of paresthe-
sias of the orofacial region, such as neuropraxis and
axonotmesis of different etiologies, are the following:
neurorehabilitation, which seeks to restore or upgrade the sen-
sorial processors and motor function [55]; eletroacupuncture,
which is based on the same principles as acupuncture, however,
using the needles connected to an electric appliance that pro-
duces electrical stimuli with an analgesic effect, when it is
switched on [11]; and moxibustion, which is a type of thermal
acupuncture that consists of applying heat in body points or
regions [56, 57]. However, in the scientific literature, there are
still no longitudinal clinical studies that prove effectiveness of
these three therapies.
Among many methodologies offered to improve nerve
repair, laser therapy has received increasing attention as a
noninvasive technique [30] over the two last decades, and in
some cases, the use of drugs has not been necessary [58, 59].
Although studies on the effects of laser therapy on peripheral
nerve regeneration were published towards the end of 1970, it
was only in the late 1980s that scientific interest began to be
shown in the therapeutic approach to this technique, leading to
the publication of a series of studies showing positive effects
of laser therapy on nerve regeneration [14, 15, 28, 30–33, 41,
42, 60–82].
Mechanism of action of low-level lasers
Low-level laser therapy consists of releasing energy from
photons absorbed through photochemical, photophysical
and/or photo biological effects on cells and tissues that do
not generate heat [78, 83–85].
Many effects of LLLT (low-level laser therapy) at a cellular
level have now been well elucidated, such as the stimulation
of mitochondrial activity, stimulation of DNA and RNA syn-
thesis, the variation of intra and extracellular pH, acceleration
of metabolism, increased protein production and modulation
of enzymatic activity [86–89]. In spite of the photochemistry,
photo physical and photo biological effects of low-level laser
therapy having been proved [78, 84, 85, 90], some authors
agree that future studies should be conducted on low-level
laser therapy as a noninvasive treatment modality in different
diseases and peripheral nerve injuries, in order to obtain
protocols based on the literature, for wide acceptance and
standardization of this technique in clinical therapy [73, 74,
76, 81, 82].
Low-level laser acts by decreasing inflammation, and thus,
sensitivity to pain [86, 87, 90–93]. It stimulates circulation and
cell activity, acts in biomodulation due to the increase in

production of mitochondrial ATP, and leads to an increase in
the threshold of nerve terminal excitability that results in an
analgesic effect [88, 89, 94]. The mechanism whereby low-
level laser exerts its effects is based on the stimulation of the
Na+/K+ pump in the cell membrane [95, 96]. This stimulation
hyperpolarizes the membrane, increasing the nerve impulses
and pain threshold [97]. The analgesic effect is due to the
increase of ß endorphins in the cerebrospinal fluid [98], and
others, such as anti-inflammatory, vascular, myorelaxing, and
healing effects, have been attributed to the use of low-power
laser. They induce arteriolar and capillary vasodilatation and
neovascularization, leading to increased blood flow in the
irradiated area [78, 84, 85, 99].
Laser therapy on nerve tissue
The literature points out three main goals of the use of low-
power lasers in the treatment of paresthesia: (1) it accelerates
injured nerve tissue regeneration; (2) it stimulates adjacent or
contralateral nerve tissues, causing them to play the role of the
sectioned nerve; and (3) it biomodulates the nervous/nerve
response leading to normality of the action potential threshold.
After this, we will discuss the effects of low-intensity laser
therapy in these three processes in greater detail.
Accelerates injured nerve tissue regeneration
In peripheral nerve injury occurring after axon transection, the
distal part of the axon disintegrates and undergoes Wallerian
degeneration dues to loss of contact with the cell body.
Calcium-dependent proteases are activated in axon distal to
injury, leading to a proteolytic process that disintegrates axo-
plasm [100, 101]. The remainders of the distal part of such
axons, including myelin debris, are digested by Schwann cell
proliferation and macrophage invasion [102, 103]. Schwann
cell myelination through partitioning-defective 3 (PAR3) pro-
tein (or protease-activated receptor 3) can be regulated by a
positive sign of the injured axon or the absence of a signal
normally provided by intact axons. The importance of
Schwann cells and macrophages in removing myelin may
vary over time after the injury [102]. After the lesion,
Schwann cells proliferate [104], and develop very early after
a neural injury [105], with the response being faster in non
myelinating Schwann cells [106].
Studies have shown that laser therapy accelerates and
improves the regeneration of affected nerve tissue, since irra-
diation with laser acts in activating and/or stimulating axon
sprouting, and acts directly on axons and/or on Schwann cells
[34–37, 41, 82]; accelerates the myelination of the regenerated
nerve fibers by increasing cells metabolism; and stimulates
Schwann cells proliferation and inhibits cell degeneration
[38–40].
Lasers Med Sci
Stimulating adjacent nervous/nerve tissues
It is believed that laser has the potential to regenerate nerves
and/or stimulate nearby innervations in order to play the role
of compromised innervations. Another hypothesis about the
role of low-power laser therapy in paresthesia is based on its
potential to increase microcirculation at the irradiated site,
which has been scientifically proven [107, 108]. A possible
hypothesis mentioned in a paper published in 1996 [64] is that
laser irradiation can stimulate the reinervation of the tissue, by
penetrating into axons or adjacent Schwann cells, the metab-
olism of the damaged sensorineural tissue, and the production
of growth-associated proteins by adjacent non-injured nerves.
Similar findings were found in the study of Dahlin in 2004
[109].
Biomodulates the nervous/nerve response
The beneficial effect of phototherapy with low-power laser
has been shown not only in nerves treated with laser but also
in the corresponding segments of the spinal cord, where
treatment with laser significantly decreased the degenerative
changes in neurons, and the proliferation induced by both
astrocytes and oligodendrocytes. This suggests a higher rate
of metabolism in neurons, and an enhanced capacity to pro-
duce myelin under the influence of a laser treatment [30].
Some studies [14, 28, 31, 69] have assessed the
histomorphometric evolution to determine the total surface
area of the fascicle, mean axon diameter, and axonal density
in the proximal, middle, and distal segments of the nerve. This
examination was performed using a computerized system
with an operating microscope and a video camera connected
to a monitor and a computer screen with specific software that
allows the quantification of myelinated and unmyelinated
fibers, as well as individual evaluation of axons with determi-
nation of the radius, circumference, diameter, and area [69]. It
was found that there was an increase in axon density and an
increase in peroxidase enzyme in the nucleus of the motor
facial nerve [15] in the groups treated with laser, when com-
pared with the control groups (not submitted to laser
therapy)—these are findings consistent with those of other
studies [34–40].
Many studies have reported conflicting results concerning
laser therapy. This may be attributed to many variables, such
as wavelengths, dose, and type of radiation [14, 15, 28, 30–33,
41, 42, 61–82, 110, 111]. The present study considered 32
published articles in literature, including 3 clinical case re-
ports, 22 in vivo studies in animal models, 3 in vitro studies, 4
in vivo studies in humans (Table 3). The differences in out-
comes were found to be based on the different lasers used and
parameters selected to perform treatment of paresthesia. These
variables are described individually below, pointing out their
relevance in each of the findings.
Table 3 Summary of experimental studies of phototherapy effects on nerve regeneration

Ref. Year Type of study No. of Affected site Time of study Wavelength (nm) Dose (J/cm2) Power density Irradiation time Outcome measure Results/effects
samples
Lasers Med Sci

Animal trials
14 1987 In vivo – Sciatic nerve Approx. 1 year 632.8 – – 14 min Eletrophysiological and Positive
morphological
28 1987 In vivo – Sciatic nerve – 632.8 – – 7 min Eletrophysiological and Positive
morphological
61 1992 In vivo 12 rabbits Peronial nerve 15 days 632.8 3.82 – 3 min Eletrophysiological Positive
15 1993 In vivo 87 rats Facial nerve 14 days 361, 457,514, – – 13–120 min Counting the no. of HRP Effective
633,720,1064
63 1995 In vivo 20 rats Sciatic nerve 28 days 820 48 550 mW/cm2 85 s (per point) SFI, neurophysiological and Effective
histological
66 2001 In vivo 17 rats Sciatic nerve 21 days 632 180 – – CMAPs Effective
injury
68 2001 In vivo 24 rats Sciatic nerve 10 weeks 780 – – 15 min (per area) Eletrophysiological, Effective
somatosensorial and histologic
69 2002 In vivo 5 rabbits Mentual nerve 15 weeks 820–830 6 – 90 s (per point) Histomorphometric Effective
110 2003 In vivo 24 rats Sciatic nerve Approx. 21 days 904 0.31/2.48/19 – 15 min Eletrophysiological and Null
morphological
70 2003 In vivo 20 rats Sciatic nerve 5 weeks 650 – – 5 min Motor test Effective
71 2004 In vivo 16 rats Median nerve Approx. 808 29 – 39 s Functional, optical and electronic Effective
injury 2 months 905 40 – 1’12 s microscopy
111 2005 In vivo – Sciatic nerve Approx. 8 weeks 905 – – 72 s Eletrophysiological and Negative
904 2 min morphological
73 2007 In vitro 24 rats Fibular nerve 8 weeks 901 nm – 10 m/W 10 min Histopathological Effective
74 2007 In vivo 20 rats Sciatic nerve 3 months 780 nm – 200 m/W 15 min SFI, electrophysiological Effective
Morphology,
42 2008 In vivo 16 rats Inferior alveolar 3 weeks – 5 – 1 min Histological analyses Effective
nerve
76 2009 In vivo 12 rats Sciatic nerve 21 days 660 4 0.0413 W/cm2 96.7 s (per point) SFI, histological and Positive (histomorphometric
histomorphometric changes) null (functional
recovery)
77 2009 In vivo 12 rats Sciatic nerve 20 days 660 4 0.0413 W/cm2 – SFI Effective
injury
78 2010 In vivo 27 rats Sciatic nerve 21 days 660 10 – 20 s SFI 660 nm more effective than
injury 830 10 38.66 s 830 nm
79 2010 In vivo 64 rats Sciatic nerve 10 days 660/780 10/60/120 – 0.3 a 2 min SFI Effective
injury
33 2010 In vivo 40 rats Sciatic nerve 12 weeks 660 – 24 mW – Tibialis anterior muscle weight; Effective
electrophysiology;
immunohistochemistry;
histopathological observation;
RT-PCR
Table 3 (continued)

Ref. Year Type of study No. of Affected site Time of study Wavelength (nm) Dose (J/cm2) Power density Irradiation time Outcome measure Results/effects
samples

81 2011 In vivo 36 rats Median nerve 16 weeks 810 175 21 mW/cm2 1,182 s Grip strength test; Effective
electrophysiology;
immunohistochemistry;
82 2011 In vivo 12 rats Sciatic nerve 8 weeks 660 3.84 0.0032 W/cm2 5 min SFI, eletrophysiological and Positive
histomorphometric
31 2011 In vitro 20 rats Sciatic nerve 21 days 904 nm 4 J/cm2 0.0413 W/cm2 32 s per point Histological; analyzed and Effective
quantified Schwann cells,
myelinic axons with large
diameter and neurons
32 2012 In vivo 50 rats Sciatic nerve 15 days 660 e 808 10 ou 50 30 mW 9 s (10 J/cm2) e 47 s SFI, histological and Positive
(50 J/cm2) histomorphometric
Clinical trials and case reports (On patients)
62 1993 In vivo 40 patients Inferior, mentual 20 weeks 830 6 437 mW/cm2 90 s (per point) VAS, objective and subjective tests Effective
and lingual (tingling and numbness)
alveolar nerve
64 1996 In vivo 13 patients Inferior, alveolar Around 36– 820 48 550 mW/cm2 85 s (per point) mechanoreceptor and temperature Effective
nerve and 69 days tests (mechanoreceptor) null
lingual nerve (temperature)
65 2000 In vivo 6 patients Inferior and 35 days 820–830 – 550 mW/cm2 90 s (per point) VAS, temperature and objective Effective
mentual tests (2 points)
alveolar nerve
67 2001 Case report 6 patients Lingual nerve 165 days 780 – – – VAS, temperature, Effective
mechanoreceptor
72 2006 In vivo 4 patients Lips, chin, gum Approx. 7 weeks 820–830 – – 90 s VAS, objective tests Effective
and oral
region
75 2008 Case report 1 patient Nerve Approx. 670 7 – – Not informed Effective
4 months
80 2011 Case report 25 patients Not informed Around 8– 660/690 4/140 – – Not informed Effective
201 days 790/830 4/140 – –
41 2012 In vitro – Sural nerve 20 days 810 1e4 50 mW 8 s (1 J/cm2) e 32 s MTT assay and real-time PCR Positive
(4 J/cm2) analysis
Lasers Med Sci
Lasers Med Sci
Variables that influence laser therapy
Wavelength
Among the studies analyzed in this critical review, the wave-
lengths most frequently used in the repair of nerve tissue
ranged between the red and near infrared (660–905 nm) spec-
tral bands. From an analysis of studies, it was determined that
in the past, helium–neon laser (He–Ne), emitted in the red
region of electromagnetic spectrum, was the most studied
wavelength used in biomodulation of the nervous/nerve re-
sponse in the neural repair process [30, 58]. At present, new
wavelengths are being used, with lasers emitting radiation at
the wavelength of 650–950 nm, since both red and
infrared wave lengths have shown significant results in
neural regeneration [32, 66, 71, 81].
In general, considering the in vivo (animal models) and
in vitro results of this review [14, 15, 28, 31–33, 41, 42, 61,
63, 66, 68–71, 73, 74, 76–79, 81, 82, 110, 111], the wave-
lengths used vary from 361 to 1,064 nm and the majority of
the results have proved that laser therapy was effective. In the
study of Begis et al. [110], laser therapy showed null results, in
other words, no statistical significance was observed in stud-
ied groups. The authors explained that although earlier studies
suggested that laser stimulates the cell proliferation, the effect
on nerve regeneration is debatable. According to the authors,
the biological effects of laser may not only be related to the
nerve lesion injury but also to the wavelength, the irradiation
dose, and beam emission mode (continuous or pulsed), and
because different procedures have been used in different stud-
ies, the results were not similar.
In the work of Reis et al. [76], the result of the action of
low-power laser therapy at wavelength 660 nm was positive
when the histomorphometric changes in myelin sheath area
were observed, in which there was a statistically significant
increase, when compared with the control group. However, in
the functional analysis (Sciatic Functional Index), this study
did not achieve significant improvement in the study group
compared with the control group. According to the authors,
this was because, after neural cell injury, there is the onset of
degeneration processes, characterized by an engorgement of
the cells. These changes, in spite of the production of neuro-
transmitters with the aim of increasing protein synthesis (actin
and tubulin), are related to the regeneration of the cytoskeleton
axons, and affect intracellular transport and the growth cone. It
is probable that the period of 7 days after the lesion would be
marked by these events, but the use of laser therapy within
24 h of the injury could reduce the immediate loss of the
function, confirming the allegation of Dahlin et al. [109];
however, this did not occur in the above-mentioned study.
In the work of Chen et al. [11], the result of the laser
therapy was negative. The authors reported that the treatment
with pulsed laser at a wavelength of 904 and 905 nm, with the
emission time of 72 s at 905 nm and 2 min at 904 nm, not only
decreased the success rate of regeneration but also inhibited
the axonal growth of the nerve. They also reported that ac-
cording to the literature and their study, laser irradiation shows
two effects: it may promote nerve regeneration and may also
prevent nerve recovery, demonstrating the importance of
using safe stimulation protocols; otherwise, inappropriate la-
ser stimulation may irreversibly damage some nervous/nerve
tissues, retarding the nerve regeneration process.
Laser at a wavelength in the red spectrum was used in
various studies in humans and in animal models [14, 15, 28,
32, 33, 66, 67, 70, 75, 77, 78, 80, 82]. The red laser wave-
length ranged from 632.8 to 690 nm, and in 90 % of the
studies in which it was used, the results showed the effective-
ness of the laser for the treatment of paresthesia. In only one
study [76], conducted with an animal model (in vivo), laser
therapy showed null results for SFI (sciatic functional index)
in the evaluation period, as described above.
Studies that compared laser at the red and infrared wave-
lengths reported distinct and inconclusive results [32, 78, 80];
however, in one of them [80], there was no difference among
the treatments and in the other, two [32, 78] phototherapy at
the red and infrared wavelengths (660, 808, and 830 nm) were
effective, but the best result was expressed with the wave-
length of 660 nm [32, 78].
Laser in the infrared spectral range was also used in both
human and animal models (in vivo) and (in vitro) [15, 31, 32,
41, 61–65, 69, 71–74, 78, 81, 110, 111]. Wavelengths ranged
from 790 to 1,064 nm, and in some of the studies analyzed, the
result obtained showed the effectiveness of laser for the treat-
ment of paresthesia. Some authors [71] reported that laser
induces a faster increase in the rate of recovery of injured
function, in addition to a faster increase in the rate of recovery
of muscle mass and nerve fiber regeneration. The studies
conducted by Bagis et al. [110] may have shown the result
of the null effect of laser therapy for the same reason previ-
ously mentioned, in other words, due to the type of lesion
induced in the sample. The study conducted by Chen et al.
[111], however, did not show positive results for the laser
treatment on nerve repair possibly due to the use of a pulsed
laser (wavelength at 904 and 905 nm) with a power output that
may have oscillated and interfered in the neural regeneration.
However, this hypothesis must be assessed in future studies,
because this condition was described and assessed only in this
study. In the study of Gigo-Benato et al. [71], both types of
emission were used, and better results were shown in the
continuous emission mode. Considering that without excep-
tion, all published studies that used continuous emission led to
positives results, this type of light emission must be the first
choice for promoting peripheral nerve repair [30]. Neverthe-
less, this hypothesis cannot be confirmed, since further studies
should still be conducted to prove the real effectiveness of
laser with the emission in continuous mode in comparison

with the pulsed mode. Based on literature review that was
carried out in this article, we can only say that up to now, in the
majority of published studies, laser was used in the continuous
mode and was shown to have positive results. Therefore, this
mode is the first choice for promoting peripheral nerve repair.
Nervous/nerve tissue affected
In human studies, the sites most affected were the inferior
alveolar nerve, mental nerve, and lingual nerve, and in one of
the studies, paresthesia in the lower lip, chin, and gum was
assessed. The in vivo studies in animal models show a ten-
dency to evaluate injury in the sciatic, median, and facial
nerves. Only one of the selected articles [80] did not report
the site/location affected by the injury.
Although many studies reported greater difficulty in recov-
ery from paresthesia after neurotmesis [10], in one of the
in vivo, animal model studies assessed [68], the use of infrared
laser was effective after complete transection and anastomosis
of the sciatic nerve, in agreement with the findings of other
studies about total neural injury and sensory recovery post-
trauma [52–54]. In an in vivo study (animal model) [15], laser
was used to repair induced injury to the facial nerve, using
different wavelengths (361, 457, 633, 720, and 1,064 nm),
power (from 8.5 to 40 mW), and irradiation times (13–
120 min) and the authors concluded that the best result was
obtained at the following parameters: wavelength of 633 nm,
8.5 mW, 90 min, 45.9 J, and 162.4 J/cm2. In addition, it was
concluded that the laser emitting in the red spectral band is
more efficient than infrared laser, and this finding coincides
with those of other studies analyzed in this review [32, 78].
Neurosensory tests
As regards neurosensory tests conducted to evaluate treat-
ment, the most frequently used were VAS (visual analog scale)
[62, 65, 67, 72, 76–78], SFI (sciatic functional index) [32, 63,
64, 77–79], temperature tests [64, 65, 67], needle-stick test
[62, 65], mechanoreceptor test [65, 67], and other tests, such
as the two points discrimination [65], motor and muscle
function test [70, 81], analyzing the degree of tingling and
numbness [62], and computer analysis [31, 41, 71, 75, 76, 81,
82], counting the degree of peroxidase (Horse Radish Perox-
idase or HRP) [15], Compound Muscle Action Potentials or
CMPs [66], neurophysiological [63], electrophysiological
[14, 28, 33, 61, 68, 79, 81, 82, 109, 110], both objective and
subjective tests [62, 65, 72], and histomorphometric [14, 28,
31, 32, 69, 76] and histopathological [31–33, 41, 73] analyses.
Only two studies did not mention the type of tests performed
[75, 80]. Each clinical test is specific for different nervous/
nerve fibers, and these tests are extremely important because
they are able to quantify the evolution of the paresthesia
within a determined period of time [47, 54, 112].
Lasers Med Sci
Subjective clinical tests to assess the functionality of the
trigeminal nerve branches are divided into two categories: the
mechanoceptive tests (connected to tactile stimuli), which are
based on the patient’s decision-making capacity, in a blind
test, to identify the contact simultaneously at two close points,
or describe the trajectory of a brush tip passing over the
surface of the skin; and the nociceptive tests (connected to
potential pain causing stimuli), which include thermal tests, or
light punctures of the skin or mucosa, and pulp vitality test
[54, 113]. Neuroelectrical tests can be used to evaluate disor-
ders of the inferior alveolar nerve, allowing a satisfactory
measurement of the degree of nerve involvement and assess
which groups of nerves were most affected [113]. Lee et al.
[114] reported that thermal images are an effective and safe
way to diagnose a state of paresthesia.
A study published by Khullar et al. [64] has highlighted the
need for standardization of neurosensory testing to evaluate
the results promoted by laser therapy. The authors conducted
two tests—mechanoreceptor and temperature tests—to assess
the effectiveness of infrared laser in the treatment of paresthe-
sia caused by injury to the inferior alveolar and lingual nerves.
When using mechanoreceptor tests, infrared laser therapy was
found to be effective, but when using the temperature test,
there was no significant difference in improvement between
the two groups (treated/or not treated with low-power laser).
Irradiation parameters
When evaluating the irradiation parameters described in se-
lected articles, it was found that some data, such as the
repetition rate (Hz), the frequency of application, the time of
exposure, and the diameter of the laser output beam (equip-
ment spot size), were not described. Power was one of the
parameters that varied widely from 5 to 416 mW in animal
studies [15, 31–33, 41, 63, 66, 68–71, 73, 74, 76–79, 81, 82].
Yet in human studies, there was no significant variation, with
70 mW being the power most used [62, 64, 65, 72] and the
lowest being 3 mW [67].
The energy density used varied widely in both human
studies and animal models. The highest energy density used
in a study with human beings was 140 J/cm2 and the lowest
was 4 J/cm2, and both the highest and lowest densities were
shown to be effective in repairing nerve tissue [80]. In studies
using an animal model, the energy density was higher than
180 J/cm2 [66], and the lowest was 3.84 J/cm2 [82]. In some
studies, the use of low densities of 0.31–19 J/cm2 in laser
treatment showed that the effect was null [76, 109]. On the
other hand, in the study by Gigo-Benato et al. [79], the results
showed that the use of low or moderate energy density,
considered from 10 to 60 J/cm2, at a wavelength of 660 nm,
were shown to be more effective than the energy density of
120 J/cm2, which is used at the wavelength of 780 nm, when
the parameter for the prevention of muscle atrophy was
Lasers Med Sci
evaluated. In the literature, the energy density of <10–150 J/
cm2 and the time between <1 and 90 min [30, 79] have been
shown to be effective in promoting nerve regeneration.
Another important fact to consider as regards sensorineural
recovery with laser therapy is the time of treatment. In one
study [84], a crush injury was performed in the peroneal nerve
of rabbits. It was observed that 15 daily transcutaneous laser
irradiations at 632.8 nm on the injured nerve, starting on the
first day after operation, allowed significant increase in neural
recovery in the group treated with laser, after motor-evoked
potential evaluation, when compared with the control group,
as shown in other studies [15, 25, 28, 61, 68, 70, 71, 73, 74,
78, 79, 81, 82, 110, 111]. In another study [63], 20 rats were
submitted to sciatic nerve injury (axonotmesis), of which 10
received daily treatment with 830-nm laser for a period of
28 days. After SFI (Sciatic Functional Index) evaluation, it
was observed that laser therapy promoted a functional in-
crease in the nerve; however, in the motor-evoked potential
assessment, no significant differences in improvement were
found when compared with the control group. In the study of
Reis et al. [76], 12 rats were subjected to sciatic nerve injury
(neurotmesis). Of these, six received daily treatment with 660-
nm laser for a period of 20 consecutive days.
Histomorphometric evaluation showed that positive results
in nerve regeneration were obtained, with a statistically sig-
nificant increase in the area of the myelin sheath when com-
pared with the control group. However, the SFI (Sciatic Func-
tional Index) test showed no improvement in the study group
in comparison with the control group.
In the in vivo retrospective studies evaluated in this re-
search, all were shown to be effective in the recovery of
sensitivity [32, 33, 42, 62, 64, 65, 67, 72, 75, 80]; however,
when the temperature test was evaluated in the study [72], no
significant differences were observed.
The follow-up periods in the studies reviewed in this re-
search ranged from 8 to 201 days. Eight days was the mini-
mum time observed to obtain significant clinical improvement
in the return of sensitivity (8 days), and 201 days was the
maximum time observed to achieve sensory recovery after
treatment with laser therapy [80]. In this study of Yoshimoto
et al. [80], the author stated that infrared laser at a wave-
length of 790–820 nm was used during post-operative
control, and recommended that it should start on the day
after surgery, and continue on alternate days during the
period of nervous/nerve tissue repair. However, in his
study, it is not clear whether laser irradiation was per-
formed during the period of 8 days in the shortest time
observed for neural recovery, and it is also not clear
whether he used laser therapy up until 201 days in the
case in which the longest sensorineural recovery time was
observed. Information about the frequency of laser thera-
py irradiations that were applied during the total period
observed in the study was also not explained.
Some authors reported that in patients who used no tech-
nique to accelerate sensory return, and who took only the
conventional medication, such as corticosteroid therapy, it
may take up to approximately 6.6 months to acquire complete
sensory normality [8, 47, 48]. Studies affirmed that milder
cases of neural lesion (neuropraxic), associated with the de-
gree of injury sustained, location, and individual capacity of
recovery, help and influence spontaneous neural return [8,
45–48, 109].
Final considerations
Finally, in the literature, it may be seen that there are many
differences among the results found, especially with respect to
the lasers used and parameters selected for use in paresthesia.
However, there is a large body of evidence that laser therapy
accelerates and improves the regeneration of affected nerve
tissues. The literature still lacks protocols and double-blind
controlled clinical trials verifying these effects, and this should
be the focus of future research.
Acknowledgement The authors would like to thank the Department of
Restorative Dentistry of the School of Dentistry of the University of São
Paulo (USP) for providing the financial support for the English revision
of the current manuscript. They also thank the National Counsel of
Technological and Scientific Development (CNPq—Grants # 304198/
2010-2 and # 307375/2010-2).
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