Photobiomodulation in Tooth Surgery: Comparison
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The surgical extraction of the lower third molars is widely practiced in oral surgery. Subsequent inflammatory complications such as pain, facial swelling, and trismus can negatively affect the quality of life of the patients. Non-medication methods used to minimize tissue injury after third-molar extraction and without side effects include the use of photobiomodulation.

  • photobiomodulation
  • laser
  • low level laser therapy
  • tooth extraction
  • oral surgery
  • pain
  • swelling
  • trismus

1. Introduction

The surgical extraction of the third mandibular molars is the most frequent procedure in oral and maxillo-facial surgery[1].
An impacted third molar can cause different consequences such as pericoronitis, distal caries and periodontal pocket of the second molar, odontogenic abscesses, and the development of follicular cysts[2].
The healing period following the surgical extraction of an impacted third mandibular molar is associated with an intense inflammatory response. This process is responsible for postoperative pain, facial swelling, and trismus, which negatively affect the quality of life of the patients during 7–10 days after the surgery[3]. These signs and symptoms are a consequence of the surgical wound and the duration of the surgery itself[4], as the result of a direct trauma on the blood and lymphatic vessels[5]. After local anesthesia wears off, the pain usually reaches maximum intensity 3 to 5 h after surgery, continuing for 2 to 3 days, and gradually diminishing until the seventh day[6][7]. Swelling reaches peak intensity in 12 to 48 h, influencing facial esthetics and social interactions. It usually resolves between the fifth and seventh days. Trismus may be considered initially as having a protective function by encouraging the patient to rest the surgical site and permit healing. However, it may lead to difficulty in eating and functioning if it persists for more than a few days.
Piezoelectric devices, which can be used instead of conventional burs, may be beneficial for surgeries at complex anatomical sites because they can preferentially cut mineralized structure[8]; furthermore, some authors reported a reduction in postoperative sequelae using the piezoelectric surgical technique in third molar extraction[9][10].
The standard therapeutic approach to reduce the postoperative complications is the administration of medications such as non-steroidal anti-inflammatories (FANS), corticosteroids (CS), and analgesics. However, even if they are effective, these drugs present some important adverse effects such as the tendency to systemic bleeding, gastrointestinal irritation, and allergic reactions. In addition, antibiotics reduce the risk of postoperative infection and alveolitis, but the possibility of developing bacterial resistance makes their administration indicated only in selected cases[11].
These considerations justify the effort to find alternative and innovative methods for the resolution of the symptomatology that follows the surgical extraction of the impacted mandibular third molars, possibly without adverse effects. Non-medication methods used to minimize the postoperative after third molar extraction include cryotherapy, acupuncture, and photobiomodulation (PBM)[12][13][14].
PBM is the application of near-infrared (NIR) light for therapeutic purpose. The “optical window” in which the effective penetration of light into tissues is maximized is between approximately 600 and 1200 nm. Low-energy laser light produces photochemical effects whereby it penetrates the mucosa without overheating or producing other side effects[15].
In literature, the conclusions of the effectiveness of PBM after third molars surgical extractions are controversial. The current evidence on the effect of PBM on pain, swelling, and trismus after third molars surgery are summarized and reported.

2. Description of the Studies

A detailed flow chart of the selection process is shown in Figure 1. 
Oral 02 00004 g001 550
Figure 1. Flow chart illustrating the search strategy.
A total of 1833 subjects participated across the 41 studies. Nine studies did not record participants’ gender; in the other studies, there were 727 female participants and 1106 male participants.
The characteristics of the included studies are presented in Table 1 and Table 2.
Table 1. Characteristics of the included studies.
  Authors and Year of Publication Laser Properties Outcomes Sample Size
 
Table 2. Method of evaluation of the outcomes and main results of the included studies.
  Method of Evaluation Comparison Results
  (nm) (mW) (J/cm2)    
      Pain Swelling Trismus
  Asutay et al. (2018)[16] 810 300 4 pain, trismus, swelling Reduction Not statistically significant45
Not statistically significant   Hamid et al. (2017)
[17][17] 810 100 32, 86 pain 30
VAS vs. placebo Reduction       Landucci et al. (2016)[18] 780 10 7, 5 pain, trismus, swelling
[22
18] VAS, NRS vs. placebo Not statistically significant Reduction Reduction   Sierra et al. (2015)
[19][19] 660, 808 100 VAS, FDM, MO106 pain 60
vs. placebo Reduction  
[20Sierra et al. (2016)[20] 660, 808 ]100 106 FDM, MO 808 nm vs. 660 nm   808 Reductionpain 60
808 Reduction   Pol et al. (2016)[21] 650, 904 8–500, 70 no reported pain, swelling 25
[21] VAS, FDM vs. placebo Reduction Reduction     Abdel-Alim et al. (2015)[22]
[22830 ] MO, Bello’s FSA4 no reported pain, trismus, swelling 80
vs. delayed PBM Reduction Reduction Reduction   Fabre et al. (2015)[23] 660 35 5 pain, trismus, swelling 10
[23] VAS, FDM, MO vs. placebo Reduction Reduction Reduction  
[24Merigo et al. (2015)[24] 650, 910 ]no reported 480, 31 pain, swelling 59
VAS, FDM vs. placebo Reduction Reduction     Ferrante et al. (2013)[25] 980 300 no reported pain, trismus, swelling 30
[25] VAS, FDM, MO vs. placebo Reduction Reduction   Koparal et al. (2018)[26] 810 300 4 pain, trismus, swelling 45
Reduction
[26] VAS, MO, 3dMD FP vs. placebo Reduction Not statistically significant Not statistically significant   Raisesian et al. (2017)[27] 980 300 18 pain, trismus, swelling 44
[27   Petrini et al. (2017)[28] 980 300 no reported pain, trismus, swelling 45
]   Kahraman et al. (2017)[29] 830 100 3 pain 53
  Alan et al. (2016)[30] 810 300 4 pain, trismus, swelling 15
VAS, FDM, MO   Eroglu et al. (2016)[31] 940 no reported 4 pain, trismus, swelling 35
vs. drug therapy Reduction Not statistically significant Not statistically significant
[28] VAS, FDM, MO vs. drug therapy Reduction Reduction Not statistically significant
[29] VAS intraoral vs. extraoral Reduction    
[30] VAS, MO, 3dMD FP vs. placebo Reduction Not statistically significant Not statistically significant
[31] VAS, FDM, MO vs. placebo Not statistically significant Not statistically significant Not statistically significant  
[32Eshghpour et al. (2016)[32] 660 ]200 85, 7 pain, swelling 40
VAS, ECE vs. placebo   Kazancioglu et al. (2014)[33] 808 100 4 pain, trismus, swelling 60
Reduction Reduction  
[33] VAS, FDM, MO vs. ozone therapy Reduction Reduction   Tuk et al. (2017)[34] 660 198 67,5 pain 163
Reduction
[34] HR, SR, Questionnaire vs. placebo Not statistically significant       Farhadi et al. (2017)[35] 550 100 5 pain, trismus, swelling 48
[35   Pedreira et al. (2016)[36] 808 no reported 2 pain, trismus, swelling 24
]Not statistically significant   Lopez Ramirez et al. (2012)[37] 810 500
[37] VAS, FDM, MO vs. placebo5 pain, trismus, swelling 20
Not statistically significant Not statistically significant Not statistically significant   Amarillas et al. (2010)[38] 810 c100 4 pain, trismus, swelling 30
VAS, FDM, MO
[38] VAS, FDM, MO vs. placebo Not statistically significant Not statistically significant Not statistically significant   Roynesdal et al. (1993)[39] 830 40 no reported pain, trismus, swelling 25
[39] VAS, FS, MO vs. placebo Not statistically significant Not statistically significant Not statistically significant   Fernando et al. (1993)[40] 830 30 no reported pain, swelling 52
vs. placebo
[40] VAS, Swelling scale vs. placebo Not statistically significant Not statistically significant    
[41]Markovic et al. (2007)[41] 637 50 4 swelling 120
Not statistically significant FDM vs. placebo   Reduction  100 4 swelling, trismus 32
[42] Amin Laskin FS, MO vs. placebo   Reduction Reduction   Aras et al. (2010)[43] 808 100 4
[43] Amin Laskin FS, MOswelling, trismus 48
Not statistically significant intraoral vs. extraoral   Feslihan et al. (2019)[44] 810 300 6 pain, trismus, swelling 30
  Santos et al. (2020)[45] 780 70 52, 5 pain 32
Not statistically significant
[36] VAS, FDM, MO vs. placebo Not statistically significant Not statistically significant   Aras et al. (2009)[42] 808   Reduction Reduction
[44] VAS, FDM, MO vs. methylprednisolone Not statistically significant Not statistically significant Not statistically significant
[45] VAS vs. split mouth Reduction       Lakshmi et al. (2021)[46]
[980 300 no reported 46]pain, trismus, swelling 100
VAS, FS, MO vs. placebo Not statistically significant   El Saeed et al. (2020)[47] 980 500 4 pain, trismus, swelling 20
Reduction Reduction
[47] VAS, FS, MO vs. placebo Reduction Reduction Reduction   Nejat et al. (2021)[48] 660, 980 200
[48]1.5, 6 pain 80
VAS vs. placebo Reduction       Kamal et al. (2021)[49] 980 100 no reported pain, trismus, swelling
[4924
] VAS, FS, MO vs placebo Reduction Reduction Reduction   Bianchi de Moraes et al. (2020)[50] 660 30 10, 30 pain, trismus, swelling 57
[50] VAS, MO, 3dMD FP 10 J/cm2 vs. 30 J/cm2 vs. placebo Not statistically significant   Kumar Gulia et al. (2021)[51] 940 500 10 pain, trismus, swelling 32
  Scarano et al. (2021)[52] 1064 1000 no reported pain, swelling 20
  Momeni et al. (2021)[53] 940 500 10 pain, trismus, swelling 25
  Hadad et al. (2021)[54] 810 Fraga et al. (2020)[55] 808 100 133
[16] VAS, MO, 3dMD FP vs. placebo
Not statistically significant
Not statistically significant
[
51
]
VAS, FS, MO
vs. placebo
Reduction
Not statistically significant
Not statistically significant
[
52
]
VAS, FS
vs. placebo
Reduction
Reduction
 
[
53] VAS, FS, MO vs. placebo Reduction Not statistically significant Not statistically significant
100 212 pain, trismus, swelling 13
[54] VAS, FS, MO vs. placebo Reduction Reduction Not statistically significant  
[pain, swelling 55]40
VAS, FS LLLT + aPDT vs. placebo Reduction Not statistically significant   Mohajerani et al. (2020)[56] 810, 632 500 5, 2 pain, trismus, swelling 40
 
[
56
]
VAS, FS, MO
vs. split mouth
Reduction
Reduction
Not statistically significant
Legend: aPDT, antimicrobial photodynamic therapy, FDM, facial distance measuring, FS, facial swelling, MO, maximum mouth opening, NRS, numeric rating scale, PRS, pain rating scale, VAS, visual analog scale, 3dMD FP, 3dMD face photogrammetric.
 

3. Efficacy of PBM

3.1. Pain

Twenty-five studies reported a reduction of pain when compared to placebo[16][17][19][21][22][23][24][25][26][27][28][29][30][32][33][45][46][47][51][52][53][54][55][56]. In these studies, lasers were used both intraorally and extraorally, and the laser’s parameters were as follows: wavelengths ranged from 632 to 1064 nm; powers were between 4 and 1000 mW; energy densities were between 3 and 212 J/cm2. Eleven articles reported no statistically significant difference of PBM on reducing pain in comparison with placebo[18][31][34][35][36][37][38][39][40]. The lasers used in these studies were diode lasers with wavelengths of 660 nm, 810 nm, and 980 nm, different powers (30–500 mW) and energy densities (2–60 J/cm2). The most successful wavelengths in reducing pain were 810 and 980 nm (Figure 2).
Oral 02 00004 g002 550
Figure 2. Histograms showing the pain outcome according to the wavelengths of the included studies. Legend: NR, no reduction, NSSR, no statistically significant results.

3.2. Facial Swelling

Facial swelling was assessed in 36 studies[16][18][21][22][23][24][25][26][27][28][35][36][37][38][39][40][41][42][44][46][49][50][51][52][53][54][55][56]. Nineteen articles reported significant decrease in facial swelling after PBM application when compared with placebo[18][20][21][22][23][24][25][32][33][41][42][43][46][47][49][52][54][56]. The laser’s parameters of the included articles were as follows: wavelengths ranged from 650 to 1064 nm; powers were between 4 and 1000 mW; energy densities were between 2 and 480 J/cm2. The wavelength of 810 nm induced the smallest facial swelling reduction (Figure 3).
Oral 02 00004 g003 550
Figure 3. Histograms showing the swelling outcome according to the wavelengths of the included studies. Legend: NR, no reduction, NSSR, no statistically significant results.

3.3. Trismus

Twenty-eight studies assessed the impact of PBM on postoperative trismus. Eleven studies reported reducing of trismus with PBM[19][20][22][23][25][33][42][43][46][47][49]. In the included studies, wavelengths ranged between 660 and 980 nm, power ranged between 4 and 500 mW, and energy densities were between 4 and 212 J/cm2. As for swelling, the wavelength of 810 nm was the one that induced the worst outcome. Instead, the wavelength of 980 nm determined the better reduction of trismus (Figure 4).
Oral 02 00004 g004 550
Figure 4. Histograms showing the trismus outcome according to the wavelengths of the included studies. Legend: NR, no reduction, NSSR, no statistically significant results.

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