ARTICLE IN PRESS

Photobiomodulation lasers in dentistry

Robert A. Convissar, and Gerald Ross

When dentists hear the word “laser”, their minds always go to surgical devi-
ces that can incise, excise and ablate tissue. An entirely different class of
lasers exist that are non-surgical; that is, they are incapable of cutting tissue,
but work quite well for palliative procedures. Photobiomodulation (PBM)
lasers have been used in both human and veterinary medicine for decades.
These devices are now becoming much more commonplace in the dental
operatory. The use of PBM lasers in orthodontic therapy is described here.
(Semin Orthod 2020; &:1–5) © 2020 Elsevier Inc. All rights reserved.

Photobiomodulation lasers in shape of dental composite curing lights (FIG. ONE

orthodontics HERE)

P
hotobiomodulation (PBM) lasers are devices
that use coherent, collimated, monochromatic
light energy (the three defining qualities of lasers)
to perform therapeutic procedures. The term pho-
tobiomodulation describes how these devices work:
they use photons (light energy) to modulate biologi-
cal processes. Unlike surgical lasers, such as the
more well known Erbium, Carbon Dioxide, Neo-
dymium YAG (Nd.YAG) and surgical diode lasers,
which are used routinely in dental offices worldwide
to cut, incise, and excise soft and hard tissues, PBM
lasers are unable to perform any surgical proce-
dures. They are non-surgical and are used primarily
for pain management/palliative treatments. Only
recently have they shown the ability to affect tooth
movement and bone growth, a critically important
facet of orthodontic therapy. Photobiomodulation
therapy (PBMT) is the term used to describe the
use of these lasers. PBM lasers have also been called
Low Level Lasers (LLL); Cold Lasers; Therapeutic
Lasers, and Soft Lasers. All of these older terms
have been supplanted by the term PBM. It must be
emphasized here once again that PBM lasers are
used for palliative/pain reduction treatments, not
surgical procedures. These devices use laser energy,
usually (but not always) produced by semiconductor
diodes between 0.1 W and 0.5 W to perform their
treatment. The devices are roughly the size and
Diplomate, American Board of Laser Surgery 200 Park Avenue
South Suite 1414, New York 10003, United States; DDS 22 Queen
Street North Box 190 Tottenham, Ontario L0G 1W0, Canada.
Corresponding author. E-mail: LaserBobDDS@gmail.com
© 2020 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2020.06.005
PBM lasers have been used in all facets of medi-
cine and dentistry for palliative/pain reduction
treatments. A recent (March 2020) National
Library of Medicine/NIH literature search (pub
med) using the terms “low level lasers and pain
control” resulted in 279 papers that discuss the use
of this modality for everything from pain reduction
post cesarean section1 to post-herpetic neuralgia2
to fibromyalgia3 to nipple pain during breastfeed-
ing4 to carpal tunnel syndrome,5 and much
more.6-8 One of the most comprehensive textbooks
on the subject, by Tuner and Hode9 lists a large
number of procedures for which PBM lasers are
indicated in dentistry. These procedures include:
alveolitis, anaesthesia, pericorinitis, hypersensitive
dentin, mucositis, and TMJ disorders.
PBM to control gagging
The first step in orthodontic therapy is data gath-
ering, in the form of radiographs and study mod-
els, two procedures that may induce gagging
and/or vomiting in children. Elbay10 studied
whether PBMT could prevent gagging in chil-
dren undergoing intraoral maxillary radiogra-
phy. Twenty-five children with moderate to
severe gag reflexes were evaluated. Both mean
and median gagging scores were higher in the
control (non-laser) group. Patients unable to tol-
erate the control radiograph were able to toler-
ate the procedure after PBMT. For this study, the
laser was placed on the P6 (Nei Guan) acupunc-
ture point on the wrist. This correlates well with a
study by Sari11 that used acupuncture at the P6
acupuncture point to successfully prevent

Seminars in Orthodontics, Vol &, No &, 2020: pp 1 5 1

 ARTICLE IN PRESS

2 Convissar and Ross

Fig. 1. Typical PBM laser.

gagging in orthodontic patients undergoing
maxillary alginate impressions. PHOTO TWO
HERE
PBMT and pain control in orthodontics
Nobrega12 performed a placebo controlled ran-
domized double-blind study that showed that
PBMT was effective in reducing the pain from sepa-
rators placed on first molars. Dominguez and
Velasquez13 showed PBMT to be effective in reduc-
ing pain during the final stage of arch wire place-
ment with several different bracket systems. They
used an 830 nm diode laser at a power of 0.1 W
with a dose of 80 J/cm2 placed buccally and lin-
gually in one arch while the opposing arch was
used as control. Bicakci et al.14 showed significant
reductions in both pain levels and PGE2 levels
when PBM lasers were used to reduce orthodontic
post-adjustment pain. The laser used was 820 nm
wavelength, 50 mW, at 4points surrounding the
first molar while the molar on the contralateral
side acted as a control. Maximum effect was
reported at 24 h post activation of the arch wires.
Gingival fluid was collected before and after to
measure Prostaglandin E2 level. De Sousa et al.15

Fig. 2. PBM laser at P6 acupuncture point.

 ARTICLE IN PRESS
Photobiomodulation lasers in dentistry
published a systematic literature review of PBMT
during orthodontic movement and pain control in
humans. They concluded that PBMT had demon-
strated efficacy in reducing orthodontic pain. In
their discussion of pain control they attribute two
different mechanisms: increased production of B-
endorphin, and repression of the conduction of
nerve impulses in peripheral nerve ends, impairing
transmission of the local pain impulses. The most
effective parameters were 2 8 Joules per tooth
applied 1 5 days per month.
PBM lasers have also been shown to be effec-
tive in palliation of recurrent aphthous ulcers
and other gingival irritations that occur during
orthodontic treatment. Zand16 used a non-ther-
mal CO2 laser a 1 W defocused to treat these
lesions. Half of the patients were treated with the
laser, with the control group treated by waving
the laser over the lesion but without any laser
energy leaving the unit. They concluded that
using the CO2 laser in a PBM setting for a single
session promoted wound healing in minor aph-
thous ulcers with no visible side effects. Pin-
heiro17 gathered 165 patients with various
maxillofacial disorders, including TMJ pain, tri-
geminal neuralgia, aphthous ulcers, and other
disorders. They were all treated with PBMT.
Their results revealed that of the 165 patients,
120 were asymptomatic at the end of treatment,
20 improved considerably, and only 20 were
symptomatic. Dos Santos18 published a systematic
review of laser therapy for recurrent aphthous
stomatitis. The conclusion of the systematic
review was that laser therapy is an effective tool
to treat recurrent aphthous stomatitis.
PBMT and orthodontic movement
A good deal has been published in the literature
regarding the use of PBMT to increase the speed
of orthodontic treatment, first in rats, and then
in human studies. A few highlights are discussed
here. Gomes19 published a study on rats that eval-
uated the effects of PBMT on periodontal tissues
and alveolar bone remodelling. Four groups of
15 rats each were studied. The groups were: 1)
normoglycemic rats; 2) diabetic rats; 3) laser
treated normoglycemic rats; 4) laser treated dia-
betic rats. He concluded that the PBMT strongly
stimulated alveolar bone remodelling and fav-
oured continuous reorganization of the soft peri-
odontal tissues, leading to the maintenance and
3
integrity of the periodontal microstructure
under orthodontic force, especially in uncon-
trolled diabetic rats. Altan20 evaluated the effects
of PBMT on osteoblastic and osteoclastic activity
on rats with maxillary incisors moved with a heli-
cal spring with a force of 20 gs. They concluded
that PBMT accelerates the bone remodelling
process by stimulating osteoblastic and osteoclas-
tic cell proliferation and function during ortho-
dontic tooth movement. Yang21 evaluated both
660 nm and 830 nm PBM lasers with respect to
orthodontic movement. Tooth movement was
analysed with a stereomicroscope. The number
of osteoclasts was determined by tartrate resistant
acid phosphatase (TRAP) and bone-remodelling
factors evaluated immunohistochemically. They
concluded that tooth movement over 14 days was
significantly higher in both PBMT groups com-
pared to the controls and both promoted alveo-
lar bone remodelling on the compression side.
Tori22 reported positive effects of PBMT on
speed of tooth movement when compared with
control and placebo groups. Varella23 investi-
gated the effects of PBMT on interleukin 1-B lev-
els in gingival crevicular fluid and its correlation
with orthodontic tooth movement. They con-
cluded that PBMT accelerated orthodontic tooth
movement and increased the levels of interleu-
kin 1-B in crevicular fluid. Other researchers,
notably Ureturk,24 Ekizer,25 Yassael, ,26 and Qam-
ruddin27found similar results. Caravalho-
Lobato28 published a meta-analysis of papers that
discuss the effect of PBMT on tooth movement
in both animals and humans. The paper
included 5 human studies with canine tooth
retraction and 11 animal studies. Four of the 5
human studies and 8 of the 11 animal studies
showed statistically significant positive changes
when PBMT was used.
Rapid palatal expansion
Fazilat et al.29 split and expanded rabbit mandibles
and studied the effect of PBMT on the speed of
bone healing. The greatest change in the amount
of bone healing when compared to control mandi-
bles was found at day 10 of the study. This corre-
lates well with an implant placement study
performed by Campanha30 showing significant
changes in bone formation 15 days post implant
placement when PBM laser were used to irradiate
the implant placement site. Rosa31 took 20 adult
 ARTICLE IN PRESS
4 Convissar and Ross
male rats and divided them into 4 groups: 1) con-
trol no treatment; 2) rapid maxillary palatal
expansion; 3) rapid maxillary palatal expansion
and PBMT; 4) rapid maxillary palatal expansion
and LED (light emitting diode) therapy. Raman
spectroscopy was carried out at the midpalatal
suture line. A statistically significant difference was
found between the control (non laser/non LED
groups) and the laser/LED groups. Cepera32
divided 27 children, aged 8 12 years into 2 groups:
Rapid maxillary expansion with PBMT and rapid
maxillary palatal expansion without PBMT. Occlu-
sal radiographs were digitized and submitted to
imaging software to measure optical density of the
area. Results showed a statistically significant
increase in bone density and accelerated healing
of the midpalatal area. Angeletti33 studied 13
patients ranging in age from 18 to 33 years of age
with a maxillary transverse deficiency more than
7 mm. After undergoing a LeFort 1 osteotomy with
separation of the pterygomaxillary suture followed
by activation of a Hyrax expander activated in the
operating room, half of the patients underwent
PBMT along the midpalatal suture, with the other
half serving as controls. The patients underwent
digital radiography at 1,2,3,4 and 7 months postop-
eratively and compared the results to the preopera-
tive digital radiographs. The results showed a
statistically significantly higher bone mineralization
in the PBMT group than in the control group.
Conclusion
PBMT has been used in medicine and dentistry for
decades as a palliative/pain reducing modality. In
the past decade, researchers and clinicians alike
have used PBMT to decrease pain, increase speed
of tooth movement, and increase bone deposition
during rapid maxillary palatal expansion. Though
much more research needs to be done, prelimi-
nary research shows promising findings when
orthodontic therapy is enhanced with PBM lasers.
Declaration of Competing Interest
None.
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