Effect of frequent laser irradiation on orthodontic pain A single-blind randomized clinical trial

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1 Originl Article Effect of frequent lser irrdition on orthodontic pin A single-blind rndomized clinicl tril Won Te Kim ; Mohmed Byome b ; Jun-Beom Prk c ; Je Hyun Prk d ; Seung-Hk Bek e ; Yoon-Ah Kook f ABSTRACT Objective: To nlyze the effect of low-level lser therpy (LLLT) on perception of pin fter seprtor plcement nd compre it with perceptions of control nd plcebo groups using frequent irrdition protocol. Mterils nd Methods: Eighty-eight ptients were rndomly llocted to lser group, lightemitting diode (LED) plcebo group, or control group. Elstomeric seprtors were plced on the first molrs. In the lser nd LED groups, first molrs were irrdited for 30 seconds every 12 hours for 1 week using portble device. Pin ws mrked on visul nlog scle t predetermined intervls. Repeted mesure nlysis of vrince ws performed for sttisticl nlysis. Results: The pin scores of the lser group were significntly lower thn those of the control group up to 1 dy. The pin scores in the LED group were not significntly different from those of the lser group during the first 6 hours. After tht point, the pin scores of the LED group were not significntly different from those of the control. Conclusions: Frequent LLLT decresed the perception of pin to nonsignificnt level throughout the week fter seprtor plcement, compred with pin perception in the plcebo nd control groups. Therefore, LLLT might be n effective method of reducing orthodontic pin. (Angle Orthod. 2013;83: ) KEY WORDS: Low-level lser therpy (LLLT); Light-emitting diode (LED); Orthodontic pin; Elstomeric seprtor; Plcebo; Visul nlog scle (VAS); Lser irrdition Former grdute student, Grdute School of Clinicl Dentl Science, The Ctholic University of Kore, Seoul, Kore. b Reserch Assistnt Professor, Deprtment of Orthodontics, The Ctholic University of Kore, Seoul, Kore. c Clinicl Assistnt Professor, Deprtment of Periodontics, Seoul St Mry s Hospitl, College of Medicine, The Ctholic University of Kore, Seoul, Kore. d Associte Professor nd Chir, Postgrdute Orthodontic Progrm, Arizon School of Dentistry & Orl Helth, AT Still University, Mes, Ariz, nd Adjunct Professor, Grdute School of Dentistry, Kyung Hee University, Seoul, Kore. e Professor, Deprtment of Orthodontics, School of Dentistry, Seoul Ntionl University, Seoul, Kore. f Professor, Deprtment of Orthodontics, Seoul St Mry s Hospitl, The Ctholic University of Kore, Seoul, Kore. Corresponding uthor: Yoon-Ah Kook DDS, MSD, PhD, Deprtment of Orthodontics, Seoul St Mry s Hospitl, College of Medicine, The Ctholic University of Kore, 222, Bnpodero, Seocho-gu, Seoul , Republic of Kore (e-mil: kook2002@ctholic.c.kr) Accepted: November Submitted: August Published Online: December 14, 2012 G 2013 by The EH Angle Eduction nd Reserch Foundtion, Inc. INTRODUCTION Pin or discomfort during orthodontic tretment is mjor concern for clinicins nd ptients. It my discourge ptients from seeking or continuing tretment. 1 The incidence nd severity of pin hve been reported to be higher thn those of extrctions. 2 Severl ptients hve reported tht orthodontic pin disturbed their sleep during the first week fter initil wire plcement. 3 The pek of pin occurred pproximtely 24 hours fter seprtor/initil wire plcement nd decresed over the next 6 to 8 dys. 2,4 7 To control the pin, nlgesics or nti-inflmmtory gents hve been prescribed, nd the initil rch wire hs often been limited to light force only. 8,9 Preemptive ibuprofen significntly reduced the pin 2 hours fter seprtor plcement compred with plcebo. However, significnt mount of pin ws reported t 24 hours. 6 Another option, the use of nonsteroidl ntiinflmmtory drugs, is still controversil becuse of their potentil influence on tooth movement nd their dverse systemic side effects Recently, low-level lser therpy (LLLT) hs been used to control pin becuse of its nti-inflmmtory DOI: /

2 612 KIM, BAYOME, PARK, PARK, BAEK, KOOK properties nd regenertive effect on neurons These effects hve been ttributed to photobioctive rection tht stimultes the prolifertion nd differentition of cells. 18 Previous studies hve shown tht LLLT my increse the blood supply nd promote recovery of dentl tissue. 19 In ddition, severl studies hve shown tht LLLT reduced orthodontic pin Other studies showed no significnt reduction of pin with lsers compred to plcebo. 16,23 Moreover, lser therpy hd no impct on time of pin initition nd mximum pin. 21 Interestingly, in previous LLLT studies, clinicins directly performed single-session lser irrdition in their office. 17,21,24 Other studies reclled the prticipnts to the office severl times for lser ppliction. 20,25 This limittion might hve decresed the efficcy of the therpy. It is hypothesized tht more frequent ppliction of lser therpy during the pin/discomfort period might led to greter reduction in the perception of pin in orthodontic ptients. However, no study hs evluted the effect of frequent LLLT. Currently, compct, bttery-operted, hndheld device tht produces low-level luminum-glliumindium-phosphide semiconductor (AlGInP) lser hs been developed for use by ptients t home. These devices hve been found to be sfe nd effective in the mngement of dentin hypersensitivity. 26 The purpose of this study ws to nlyze the effect of more frequent LLLT protocol on the perception of pin from immeditely up to 7 dys fter seprtor plcement nd to compre it to the perception of pin in control nd plcebo groups. MATERIALS AND METHODS One hundred nd twenty ptients were ssessed in privte clinic from My 2010 to Jnury Of these, 88 ptients (23 mles, 65 femles; men ge, 22.7 yers) met the following inclusion criteri: complete eruption of the second molrs nd no open interproximl contcts of the first molr. In ddition, ptients with previous orthodontic tretment, metbolic nd periodontl diseses, or mediction were excluded. The study ws pproved by the institutionl review bord of the Ctholic University of Kore. Smple-size clcultion ws performed bsed on previous results. 20 Subjects were ssigned rndomly to three test groups: lser irrdition group (n 5 28), light-emitting diode (LED) group s plcebo (n 5 30), nd control group receiving no irrdition (n 5 30). Subjects ssigned to the lser nd LED groups were blinded to their ssignment. A low-level medicl semiconductor lser device with n AlGInP diode, wvelength of 635 nm, energy of 10 mj, field dimeter of 5.6 mm, nd output potency of Figure 1. A compct, bttery-operted, hndheld AlGInP lser device for home use. (A) Disssembled. (B) Activted. 6 mw (Figure 1) nd n LED device with wvelength of 635 nm nd output of 12.9 mw of the sme exterior design (Dentl.M, M&H Co, Hwseong, Kore) were used. After plcement of 2.1 mm elstomeric seprtors (Dentlstics Seprtors, Denturum, Ispringen, Germny) mesilly nd distlly on both mxillry first molrs, subjects in the lser nd LED groups were tught to use the device nd sked to pply it for 30 seconds on ech re immeditely then every 12 hours for 1 week with close contct between the tip nd mucos to irrdite the mesiobuccl, mesiolingul, distobuccl, nd distolingul res. The three groups were sked to mrk pin severity on questionnire contining 11 copies of 10 cm visul nlog scle (VAS) t 5 minutes, 1 hour, 6 hours, 12 hours nd then t dys 1, 2, 3, 4, 5, 6, nd 7 fter the seprtors were pplied. Sttisticl Anlysis Sttisticl evlution ws performed by SPSS 16.0 (SPSS Inc, Chicgo, Ill). Two-wy nlysis of vrince (ANOVA) ws performed to compre ge of subjects ccording to group nd gender. Repeted mesures ANOVA ws conducted to evlute the differences in pin scores t ech time point s the within-subjects vrible nd between groups nd gender s the between-subjects vribles. Age ws used s covrint. The lph level ws RESULTS There were no significnt differences in ge mong the lser, LED plcebo, nd control groups (P 5.069) or between genders (P 5.094). Also, no significnt

3 EFFECT OF FREQUENT LLLT ON ORTHODONTIC PAIN 613 Tble 1. Descriptive Dt for the Lser, LED, nd Control Groups Totl Mle Femle P Vlue* Lser group 28 ( ) 7 ( ) 21 ( ).094 LED group 30 ( ) 7 ( ) 23 ( ) Control group 30 ( ) 9 ( ) 21 ( ) Totl 88 ( ) 23 ( ) 65 ( ) P vlue {.069 Dt presents number of subjects (men ge 6 stndrd devition); two-wy ANOVA compring ge ccording to gender (*) nd group ({); no significnt interction between group nd gender. interction between groups nd gender ws found (P 5.30) (Tble 1). There ws significnt difference in pin perception mong the three groups (P 5.004). The lser group showed sttisticlly significnt decrese in pin scores compred with the control group (P 5.003). The plcebo group demonstrted no significnt differences from the lser nd control groups (P 5.28 nd P 5.26, respectively; Figure 2). However, gender hd no significnt effect on scores of pin perception (P 5.81; Figure 3). In ddition, there ws borderline significnce of the interction between the gender nd groups (P 5.05). The mximum level of pin ws reched 1 dy fter seprtor plcement. The lser group showed mximum level of ( ), which ws significntly lower thn those of the LED plcebo nd control groups ( nd , respectively) (Tble 2 nd Figure 2). During the first 6 hours, the pin scores in the plcebo group were not significntly different from those of the lser group. Furthermore, t 12 nd 24 hours fter plcement of seprtors, the pin scores of the plcebo group were not significntly different from those of the control group. From dy 2 to dy 7 fter seprtors plcement, the pin scores of ll three groups decresed. Pin scores were still lower t dy 2 in the lser group; however, the difference ws not sttisticlly significnt. A decrese ws seen in the control nd plcebo groups, which reched level tht ws not significntly different from the lser group (Tble 2 nd Figure 2). In the lser group, there were no significnt differences between pin scores t different time points. However, in the plcebo group, the mximum pin score occurred t 1 dy nd ws significntly higher thn t 5 minutes, 1 hour, 6 hours, or dy 6 or 7; wheres in the control group it ws higher thn t 5 minutes nd t dys 5, 6, nd 7 (Tble 2). Becuse of the borderline significnce (P 5.05) of interction between groups nd gender, the groups were compred within ech gender independently. In mle subjects, the pin scores in the lser group were lower thn those in the plcebo nd control groups, which showed similr pin perception trend. In femle subjects, pin scores in the plcebo group Figure 2. Comprison of men pin scores on the VAS mong the lser, LED, nd control groups over time. Figure 3. Comprison of men pin scores on the VAS between mle nd femle subjects over time.

4 614 KIM, BAYOME, PARK, PARK, BAEK, KOOK Tble 2. Pin Perception Scores of the Lser, LED, nd Control Groups t Ech Time Point,b 5 min 1 h 6 h 12 h 1 d 2 d Lser group LED group Control group P vlue NS Multiple comprison C. L (0.020) nd LED (0.025) C. L (0.006) nd LED (0.001) C. L (0.001) nd LED (0.10) C. L (0.005) C. L (0.003) Repeted mesures ANOVA with Bonferroni post hoc for multiple comprison. b C indictes control; L, lser; LED, light-emitting diode; NS, nonsignificnt. showed similr trend to those in the lser group (Figure 4). DISCUSSION The im of this study ws to evlute the effect of frequent lser irrdition on the perception of pin cused by orthodontic forces. The pin perception rnged widely depending on individulized pin thresholds, ge, nd gender. 2 5,27,28 In greement with previous studies, pin reched mximum level 24 hours fter seprtor plcement. 14,22,28 The mximum pin level in the lser group ws similr to the initil pin level in the control group. The pin scores were decresed nd were not significntly different mong ll time points. This might indicte the lser blunts the pek of the pin compred with the pek pin experienced by the plcebo nd control groups (Figure 2). It ws presumed tht score of 0 to 30 score is the mild pin rnge, wheres score of 31 to 69 is moderte pin. 29 In our study, the lser group s pin ws 20 scores lower thn pin scores in the other groups. This decrese tht chnges the level of pin from moderte to mild might be cliniclly significnt. Less pin nd fster recovery hve been reported with the CO 2 lser thn with the Nd:YAG lser group, suggesting longer-lsting nlgesic effect with CO 2 lser therpy. 30 Menwhile, Dilsiz et l. 31 demonstrted tht the Nd:YAG lser ws more effective in desensitizing teeth thn the 685 nm diode lser. In our study, the AlGInP diode lser ws pplied wheres in severl studies gllium-luminum-rsenide diode lser ws used. 19,24,32 Thus fr, no study hs compred the effect of different lser types with different tretment settings. In our study, the LED group showed lower pin scores thn the control group during the first 6 hours, nd then the scores incresed nd showed no significnt difference from those of the control group. The decresed scores could be ttributed to the plcebo effect. Severl mechnisms hve been suggested to explin the plcebo effect, such s emotionl modultion nd reduction of subjective stress during pinful stimultion. 33 In previous study, pin reduction ws reported by 39% of the subjects fter dministrtion of nlgesic plcebo. 34 However, the incresed fer of pin fter previous plcebo experience ws found to reduce the Figure 4. Comprison of men pin scores on the VAS mong lser, LED, nd control groups over time ccording to gender. (A) Mle subjects. (B) Femle subjects.

5 EFFECT OF FREQUENT LLLT ON ORTHODONTIC PAIN 615 Tble 2. Extended 3d 4d 5d 6d 7d P Vlue Multiple Comprison NS d. 5 min, 1 h, 6 h, 6 d, nd 7 d d. 5 min, 5 d, 6 d, nd 7 d NS NS NS NS NS Repeted mesures ANOVA with Bonferroni post hoc for multiple comprison. b C indictes control; L, lser; LED, light-emitting diode; NS, nonsignificnt. plcebo nlgesic effect. 35 This might explin the incresed pin scores in our study fter the second LED ppliction. In ddition, evidence supported the hypothesis tht plcebo nd tretment effects re not cumultive nd tht they hve mutully exclusive mechnisms. 36 Esper et l. 23 showed tht pin scores decresed significntly in the LED group between 2 nd 120 hours compred with scores of the control nd lser groups. They ttributed their result to the high-potency nd high-energy LED (0.1 W nd 7 J, respectively) pplied in their study. Consequently, this inconsistency between the investigtions might be due to the differences in the properties of the LED nd lser used. In our study, the pttern of the plcebo effect over time seemed different between genders. The pin scores in mle subjects in the plcebo group followed the sme pttern s the control group wheres in femles, pin scores ppered to more closely follow the trend in the lser group. In greement, Sxon et l. 37 reported tht femle ptients were more ffected by plcebo tretment, lthough n effective response to the nlgesic plcebo tretment ws demonstrted in mles only. 38 Another study demonstrted no gender dimorphism in reltion to the plcebo nlgesic effect. 39 Nevertheless, our results should be interpreted with cution due to the reltively smll size of the mle group. In concordnce, no significnt difference ws reported in the discomfort level fter plcement of seprtors nd initil rch wire, ccording to ge nd gender. 7,28 A group of environmentl, socioculturl, nd genetic fctors re responsible for these differences Therefore, the present study might hve been ffected by these individul vritions. A future study pplying split-mouth method might be required to remove bis. Also, study evluting the effect of lser ppliction on the pin produced by the initil wire is recommended. In ddition, comprison between the pin tht resulted from seprtor plcement nd from rch wire chnge is wrrnted. CONCLUSIONS N The lser group showed significnt min effect compred with the control group only. N The perception of pin ws not significntly different bsed on ge or gender. However, the effect of lser irrdition ws more pronounced in mle subjects. N The plcebo tretment ws more effective fter the first irrdition thn fter the following sessions nd ws more effective in femle subjects thn in mles. N Therefore, frequent low-level lser irrdition my be n effective wy to reduce orthodontic pin during the first dy fter seprtor plcement. REFERENCES 1. Oliver RG, Knpmn YM. Attitudes to orthodontic tretment. Br J Orthod. 1985;12: Jones ML, Chn C. Pin in the erly stges of orthodontic tretment. J Clin Orthod. 1992;26: Jones M, Chn C. The pin nd discomfort experienced during orthodontic tretment: rndomized controlled clinicl tril of two initil ligning rch wires. Am J Orthod Dentofcil Orthop. 1992;102: Jones ML. An investigtion into the initil discomfort cused by plcement of n rchwire. Eur J Orthod. 1984;6: Scheurer PA, Firestone AR, Burgin WB. Perception of pin s result of orthodontic tretment with fixed pplinces. Eur J Orthod. 1996;18: Steen Lw SL, Southrd KA, Lw AS, Logn HL, Jkobsen JR. An evlution of preopertive ibuprofen for tretment of pin ssocited with orthodontic seprtor plcement. Am J Orthod Dentofcil Orthop. 2000;118: Wilson S, Ngn P, Kess B. Time course of the discomfort in young ptients undergoing orthodontic tretment. Peditr Dent. 1989;11: Bird SE, Willims K, Kul K. Preopertive cetminophen vs ibuprofen for control of pin fter orthodontic seprtor plcement. Am J Orthod Dentofcil Orthop. 2007;132: Bernhrdt MK, Southrd KA, Btterson KD, Logn HL, Bker KA, Jkobsen JR. The effect of preemptive nd/or postopertive ibuprofen therpy for orthodontic pin. Am J Orthod Dentofcil Orthop. 2001;120: Kyrknides S, O Bnion MK, Subtelny JD. Nonsteroidl nti-inflmmtory drugs in orthodontic tooth movement: metlloproteinse ctivity nd collgen synthesis by endothelil cells. Am J Orthod Dentofcil Orthop. 2000;118: Wlker JB, Buring SM. NSAID impirment of orthodontic tooth movement. Ann Phrmcother. 2001;35: Gmeiro GH, Pereir-Neto JS, Mgnni MB, Nouer DF. The influence of drugs nd systemic fctors on orthodontic tooth movement. J Clin Orthod. 2007;41:73 78; quiz 71.

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