The effects of low level laser therapy on the management of

Original scientific article/Izvorni znanstveni članak
doi: 10.21860/medflum2017_173373
The effects of low level laser therapy on
the management of chronic idiopathic
orofacial pain: trigeminal neuralgia,
temporomandibular disorders and burning
mouth syndrome
Učinak mekog lasera u liječenju kroničnih idiopatskih bolova
orofacijalne regije: trigeminalne neuralgije, temporomandibularnih
poremećaja i sindroma pekućih usta
Robert Antonić1, Martina Brumini2*, Ivana Vidović2, Miranda Muhvić Urek3, Irena Glažar3,
Sonja Pezelj-Ribarić3
Department of Prosthodontics, Faculty of
Medicine, University of Rijeka, Rijeka
1
Abstract. Aim: To investigate the efficacy of different wavelengths of low level laser therapy
(LLLT) in the management of orofacial pain by measuring the pain reduction using visual
analogue scale (VAS). Materials and methods: Study involved 20 patients with trigeminal
neuralgia (TN), 20 with temporomandibular disorders (TMD) and 40 with burning mouth
syndrome (BMS). 50 % of the patients in each syndrome group were treated with 660 nm
laser, and other 50 % with 810 nm laser. Orofacial pain was quantified by the VAS. Results:
VAS was significantly lower after the application of LLLT, in all subjects and for both applied
wavelengths (P < 0.05). Efficacy of 810 nm laser compared to 660 nm laser was significantly
higher for all patients and in both the TN and TMD groups (P < 0.001; P = 0.005; P = 0.024).
Conclusions: LLLT has proven to be an effective intervention in reducing pain in TN, TMD and
BMS patients. Better results can be achieved with higher wavelengths.
Department of Endodontics, Faculty of
Medicine, University of Rijeka, Rijeka
2
Department of Oral Medicine and
Periodontology, Faculty of Medicine,
University of Rijeka, Rijeka
3
Key words: burning mouth syndrome; facial pain; lasers; pain measurement; temporomandibular joint disorders; trigeminal neuralgia
Sažetak. Cilj: Ispitati učinke različitih valnih duljina mekog lasera (ML) u liječenju orofacijalnog
bola mjerenjem prijavljenog bola na vizualno-analognoj skali (VAS). Materijali i metode: U
istraživanju je sudjelovalo 20 ispitanika s trigeminalnom neuralgijom (TN), 20 s
temporomandibularnim poremećajima (TMP) i 40 sa sindromom pekućih usta (SPU). 50 %
ispitanika u svakoj skupini liječeno je laserom 660 nm, a preostalih 50 % laserom 810 nm.
Orofacijalni bol određen je prema VAS-u. Rezultati: Nakon primjene ML-a prijavljeni bol bio
je značajno manji za sve ispitanike (P < 0,05). Značajno veće smanjenje bola ostvareno je
primjenom lasera 810 nm za sve pacijente te za TN i TMP grupu (P < 0,001; P = 0,005; P =
0,024). Zaključci: ML pokazao se učinkovitom metodom smanjenja bola kod TN-a, TMP-a i
SPU-a. Bolji rezultati ostvaruju se primjenom veće valne duljine.
Ključne riječi: bol lica; laseri; mjerenje bola; poremećaji temporomandibularnog zgloba;
sindrom pekućih usta; trigeminalna neuralgija
Corresponding author:
Martina Brumini, DMD
Department of Endodontics
Faculty of Medicine, University of Rijeka
Braće Branchetta 20, 51 000 Rijeka
e-mail: martina.brumini@gmail.com
*
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medicina fluminensis 2017, Vol. 53, No. 1, p. 61-67
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R. Antonić, M. Brumini, I. Vidović et al.: The effects of low level laser therapy on the management of chronic idiopathic...
INTRODUCTION
Chronic idiopathic pain management is a growing
challenge for both primary care physicians and
specialists1. In the orofacial region, the most
common forms of chronic idiopathic pain are
trigeminal neuralgia (TN), temporomandibular
joint disorders (TMD) and burning mouth syndrome (BMS). In recent papers discussing the
management of chronic idiopathic orofacial pain,
authors state that it is crucial to have a multidi-
A great number of patients suffering from chronic idiopathic orofacial pain are not satisfied with medical therapy because of incomplete control of pain or
drug-related side effects. Surgical treatment is often invasive and its results depend on many variables. Unsatisfactory therapeutic results necessitates finding
alternative treatment.
mensional approach which includes pain specialists, headache neurologists, neurosurgeons, oral
surgeons, liaison psychiatrists, physiotherapists,
clinical psychologists and radiologists2,3. According to Zakrzewska, a combination of antidepressants and cognitive behaviour therapy gives the
best results in the management of chronic idiopathic orofacial pain3. Although medication is often the first line of treatment, tolerance may
develop as the treatment period and the need
for extra dosage increase, which leads to more
side effects. A great number of patients suffering
from chronic idiopathic orofacial pain are not satisfied with medical therapy because of incomplete control of pain or drug-related side
effects4,5. When drug therapy fails to control the
pain, surgical treatment is usually proposed, especially in cases of TN pain5. Surgical treatment is
often invasive and its results depend on many
variables: experience, expertise and correct selection of technique of neurosurgery team. Unsatisfactory therapeutic, whether medicinal or
surgical results necessitates finding alternative
treatment.
Low level laser therapy (LLLT) uses low-powered
laser light in the range of 1-1000 mW, at wavelengths from 632-1064 nm, to stimulate a biolog-
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ical response. These lasers emit no heat, sound,
or vibration and act by inducing a photochemical
reaction in the cell, a process referred to as biostimulation or photobiomodulation6. Its basic effects are biostimulative, regenerative, analgesic
and antiinflammatory7. Laboratory studies suggest that irradiation stimulates collagen production, alters DNA synthesis, and improves the
function of damaged neurological tissue. It is a
treatment modality that is becoming widely
known because it is a noninvasive, quick, safe
nonpharmaceutical intervention8.
The aim of this study was to investigate the efficacy of different wavelengths of laser irradiation
in the management of orofacial pain by measuring the pain reduction using visual analogue scale
(VAS).
MATERIALS AND METHODS
The study protocol has been approved by the
Ethical Committee of the Medical Faculty, University of Rijeka and Clinical Hospital Centre Rijeka.
All subjects were informed of the aims and procedures of research, as well as the fact that their
medical data would be used in research. Only
those subjects who gave written permission in
the form of informed consent were included.
Participants
The study involved 80 patients with diagnosed
chronic idiopathic orofacial pain syndrome: 20 of
them with TN, 20 with TMD and 40 with BMS. Patients were examined at the Oral Medicine Unit
and Prosthetic Dentistry Unit, Clinical Hospital
Centre Rijeka, Faculty of Medicine, University of
Rijeka. The criteria for inclusion in the study
were: diagnosis of chronic idiopathic orofacial
pain syndrome, absence of any systemic diseases
that might be involved, absence of any local oral
factors that might be involved, orofacial pain during the last 14 days, no other therapy one month
before and during the study. The diagnosis for
TMD was made through a standard comprehensive clinical examination based upon the Research Diagnostic Criteria for Temporomandibular
Disorders (RDC/TMD)9. The study included subjects suffering from myofascial pain with/without
limited mouth opening. Classical TN was diag-
medicina fluminensis 2017, Vol. 53, No. 1, p. 61-67
R. Antonić, M. Brumini, I. Vidović et al.: The effects of low level laser therapy on the management of chronic idiopathic...
nosed according to the International Classification of Headache Disorders Criteria10 and the
duration of illness ranged from 6 to 12 months.
The criteria for inclusion in the BMS group was:
BMS diagnosis and the absence of any systemic
diseases or local oral factors that might be involved in the sensation of mouth burning. The
individuals underwent complementary examinations (complete blood count, blood glucose level
and estrogen level) and only those with normal
values took part in the study. After medical, dental and social histories of each participant were
collected, clinical examination was performed according to the standard clinical criteria. Each patient was evaluated according to subjective pain
reporting: 0-10 VAS. Orofacial pain was quantified by the VAS, where 0 inidicated “no pain” and
10 indicated “the worst possible pain”6.
Methods
The effect of the laser light was evaluated after
the final treatment.
Statistical analysis
Statistical analyisis of the data was performed using Statistica 10.10 (StatSoft Inc., Tulsa, SAD). The
normal distribution of age was checked by Kolmogorov-Smirnov test. Data of age were presented as median and (5th-95th) percentile boundaries,
LLLT stimulates collagen production and improves the
function of damaged neurological tissue. Better results
can be achieved with higher wavelenghts. It is also important for reducing coasts of treatment, as we have less
need for surgical treatment or medicine use. Because
only 6-10 applications are necessary to achieve pain relief, LLLT may also have a positive psychological effect.
Research was conducted during 2014. The patients were treated with LLLT 5 days per week for
4 consecutive weeks with a 660 nm or 810 nm
Ga-Al-As (Gallium-Aluminum-Arsenide) diode laser (Medio LASER Combi Dental, Iskra Medical,
Ljubljana, Slovenia). In each syndrome-group,
50 % of the participants were treated with
660 nm laser and 50 % of them with 810 nm laser: 10 participants of TN group, 10 participants
of TMD group and 20 participants of BMS group
were treated with 660 nm laser; and 10 participants of TN group, 10 participants of TMD group
and 20 participants of BMS group were treated
with 810 nm laser. During each session, the laser
light was delivered to the tissue by a straight optical fiber with a 2 mm spot size and the output
power was measured at the fiber aperture. The
laser output power was monitored weekly using
analogue power meters provided by the manufacturer. The output power of the laser was
measured for 7 min and found to be practically
constant. The treatment areas, each one being a
1 cm2 surface were used on tender points diagnosed at the start of the treatment. The laser
was applied for approximately 10 minutes
(810 nm or 660 nm, continuous wave, 30 mW
output power, 3.0 J/cm2). The treatment time (t)
for each application point was calculated using
the following equation11:
medicina fluminensis 2017, Vol. 53, No. 1, p. 61-67
minimum and maximum. Differences in age between participants were checked using KruskalWallis test. The analysis of the presence gender
was performed using χ2 test. Data of VAS were
presented as median and (5th-95th) percentile
boundaries. Results of VAS before and after LLLT
were compared using the Wilcoxon test. Statistical
analysis of VAS before and after LLLT at each wavelength was performed using Mann-Whitney test.
All statistical values were considered significant
at P = 0.05.
RESULTS
Demographic characteristics of all participants
are shown in Table 1. There was no significant
difference between groups regarding the age of
the patients (P = 0.149). There were significantly
more female than male patients (P = 0.007). In
the BMS group there were significantly more female than male patients (P = 0.004).
In all 3 groups, for both 660 nm and 810 nm applied wavelength, VAS after LLLT was significantly
lower than before LLLT. In all 3 groups, 810 nm laser
showed better results assessed through VAS reduction. Efficacy of 810 nm laser compared to 660 nm
laser was significantly higher in TN group and in
TMD group (P = 0.005 and P = 0.024); (Table 2).
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R. Antonić, M. Brumini, I. Vidović et al.: The effects of low level laser therapy on the management of chronic idiopathic...
Table 1. Demographic characteristics of participants
N
Age* / years (min-max)
Male / n ( %)
Female / n ( %)
P
Trigeminal
neuralgia
20
53 (32-71.5)
27-72
12 (60)
8 (40)
0.392
Temporomandibular
disorders
20
44.5 (28-60)
27-63
9 (45)
11 (55)
0.662
Burning mouth
syndrome
40
51 (29.5-75.5)
25-80
9 (22.5)
31 (77.5)
0.004
All
80
50 (28.5-72)
25-80
30 (30.7)
50 (62.5)
0.007
P
0.149
*data are presented as median (5th-95th) percentile boundaries, minimum and maximum
Table 2. Efficacy of different wavelenghts assessed through VAS reduction
Trigeminal neuralgia
10
10
Laser wavelenght
(nm)
660
810
Temporomandibular disorders
10
10
660
810
Burning mouth syndrome
20
20
660
810
40
40
80
660
810
Orofacial pain syndrome
All
All
N
VAS before*
VAS after*
P
7 (2-9)
7 (5-10)
0.940
6.5 (3-10)
7 (4-10)
0.762
7 (2-9.5)
6 (3.5-9)
0.508
7 (2-9.5)
6 (4-10)
0.736
6.5 (2-8)
4 (1-5)
0.005
6 (2-9)
3 (1-8)
0.024
4.5 (1-8)
4 (1-6.5)
0.460
5.5 (1-8)
3.5 (1-6.5)
< 0.001
0.043
0.005
0.018
0.005
0.001
< 0.001
< 0.001
< 0.001
*data are presented as median (5th-95th) percentile boundaries
DISCUSSION
Results of this study showed that subjective pain,
measured using VAS, after the use of LLLT was
significantly lower in patients with TN, TMD and
BMS, for both 660 nm and 810 nm lasers. By performing searches on Medline database using:
LLLT, TN, TMD and BMS as keywords non of the
research was found. Therefore, we concluded
that this was the first research that investigated
different wavelenghts of LLLT in the treatment of
TN, TMD and BMS.
One of the studies on the use of LLLT in the management of different disorders of orofacial region, performed by Pinheiro et al. showed
reduction of pain in TMD, TN, inflammation,
tooth hypersensitivity and aphtae after the application of LLLT. Authors suggested that the reduction of pain in TMD patients may be due to an
increased release of β-endorphins, whereas the
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reduction of pain in TN patients may be a result
of a recovery of the neuronal activity and function12.
A majority of the studies on the use of LLLT in the
management of chronic idiopathic orofacial pain
involved TMD. Statistically significant reduction
of pain in the laser group in relation to the placebo was observed in research by Gray et al.13, Bertolucci and Grey14, Fikácková et al.15, Mazzetto et
al.16, Öz S et al.17, Çetiner et al.18 and Venezian et
al.19. Some of the studies reported both reduction of pain as well as a significant improvement
in the range of mandibular movements and decreased tenderness of masticatory muscles20-22.
Previous studies suggest that both idiopathic TN
and idiopathic BMS may be of neuropathic origin.
Several authors suggested that pathogenesis of
TN may involve axon and myelin changes23,24.
Tongue biopsies in BMS patients showed a significant reduction of epithelial nerve fibres versus
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R. Antonić, M. Brumini, I. Vidović et al.: The effects of low level laser therapy on the management of chronic idiopathic...
control group25,26. The treatment of neuropathic
pain conditions often involves a variety of medicines with many side effects and, as the treatment continues, the need for extra dosage
increase27,28. Medicinal management often includes antidepressants but, as studied by Tammialia-Salonen et al. antidepressants did not
effectively relieve BMS associated symptoms29.
Effectiveness of LLLT in peripheral nerve regeneration was demonstrated in several studies30-32.
Nerve regeneration and acceleration of axonal
growth was observed in rats after the application
of 780 nm laser30. In another study, rabbits who
were treated with 901 nm laser showed thicker
nerve fibers, clearer Ranvier nodes and more regular myelin layers, compared to control group31.
In a study by Romeo et al. 68 % of BMS patients
reported significant relief after LLLT32. Statistically
significant reduction in the salivary levels of
proinflammatory cytokines TNF-α and IL-6 was
observed after the application of LLLT in BMS patients27. In the treatment of TN, LLLT has proven
effective in several studies33-35. Vernon and Hasbun reported no pain after 12 sessions35 and a
study by Eckerdal and Bastian proved LLLT efficacy at one-year follow up34. Taken together, these
results indicate that LLLT biostimulative effects
may play an important role in the management
of neuropathic pain conditions, such as idiopathic TN and idiopathic BMS.
In all 3 groups, greater VAS reduction was observed after the application of 810 nm laser compared to 660 nm laser. In a study by Carvalho et
al., it was observed that greater laser wavelength
was associated with greater pain reduction36.
Previous research showed that the effectiveness
of LLLT is greater when used in the spectrum of
780 to 904 nm because of increased penetration.
Greater laser photobiomodulation is linked to
higher irradiation protocols as well as to a greater number of sessions and frequency of application37,38.
In some of the studies, LLLT did not show as effective in the management of orofacial pain conditions39,40. López-Ramírez et al. used 810 nm
laser to treat pain, facial swelling and trismus after surgical removal of impacted lower third molar39. We suppose the reason why LLLT did not
show as effective is because it was appliaed in 1
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session only. Research by León et al. showed that
6-10 applications were necessary to achieve pain
relief in TMD patients41. Carrasco et al. reported
less TMD symptoms and greater masticatory efficiency after 8th laser session42. In another study,
Amanat et al. aimed to evaluate the efficacy of
LLLT in the treatment of TN, myofascial pain dysfunction syndrome and atypical facial pain40. Authors reported no significant differences between
laser group and control group, and suggested
there is no significant efficacy for LLLT in the
management of orofacial pain conditions.
We assume the reason why LLLT failed to show
its efficiency is because all patients received
pharmaceutical treatment as well. This adds support for the hypothesis that pain reduction from
LLLT is achieved through an antiinflammatory action. Kim et al. reported greater pain relief in TN
patients treated with LLLT alone compared to TN
patients treated with a combination of LLLT and
medications43. In previous mentioned study, León
et al. compared LLLT to drug therapy in TMD patients. LLLT group showed better results assessed
through VAS41.
CONCLUSIONS
LLLT with its biostimulatory, antiinflammatory
and analgesic effects has proven to be an effective intervention in reducing pain in TN, TMD and
BMS patients. Nevertheless, LLLT still has not
been included in every day dental practice in the
treatment of chronic idiopathic orofacial pain.
One of the reasons might be a lack of standardization of treatment protocol for LLLT. Therefore,
one of the aims of this paper was to contribute in
developing specific guidelines for the use of LLLT
in patients with TN, TMD and BMS. Our research
suggests that better results can be achieved with
higher wavelenghts. LLLT might also be important
for reducing coasts of treatment, as we have less
need for surgical treatment or medicine use. Because only 6-10 applications are necessary to
achieve pain relief, LLLT may also have a positive
psychological effect, especially on patients suffering from chronic pain conditions, such as TN,
TMD and BMS.
Conflicts of interest statement: The authors report no
conflicts of interest.
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