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SOFT TISSUE APPLICATIONS OF LASERS A REVIEW Rajat Bhandari, Kartesh Singla, Simarpreet Virk Sandhu, AdityaMalhotra, Harmandeep Kaur, Arshdeep Kaur Pannu International Journal of Dental Research, 2 (1) (2014) 16-19 Presented by- Dr. Priyadershini Rangari

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SOFT TISSUE APPLICATIONS OF LASERS

A REVIEW

Rajat Bhandari, Kartesh Singla, Simarpreet Virk Sandhu, AdityaMalhotra, Harmandeep Kaur, Arshdeep Kaur Pannu

International Journal of Dental Research, 2 (1) (2014) 16-19

Presented by- Dr. Priyadershini Rangari

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Lasers are widely used in dentistry for various clinical procedures like cavity preparation, surgical procedures, scaling and root planning etc. Since its first use in 1960, lasers are now evolved to be used in all aspects of dentistry.

The aim of this review is to describe the application of lasers in oral soft tissue procedures. Soft tissue lasers are becoming popular among the clinicians due to their potential value in surgical procedures providing surface sterilization, dry surgical field and increased patient acceptance.

Lasers are effective in ablation of various potentially malignant disorders, obtaining biopsy, periodontal plastic surgeries and providing incisions in surgical conditions.

Introduction

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A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation.

OR Laser, an acronym for light amplification by stimulated emission of radiation, is a

device for generating a high-intensity, ostensibly parallel beam of monochromatic electromagnetic radiation.

This innovative technology works on the principle of stimulated emission theory which was proposed by Einstein in 1917 based on the concept of spontaneous emission theory which was postulated by Neil Bohr in early 1900s.

Based on these concepts Maiman developed the first laser prototype in 1960 using ruby crystals as an active medium. The first experiment with lasers in dentistry was reported in a study about the effects of a pulsed ruby laser on human caries.

Husein A (2006) Applications of lasers in dentistry: a review. Ar-chives of Orofacial Sciences 1, 1-4. Fuller TA (1997) Physical Considerations of Surgical Lasers. (Clayman L, Kuo P eds.) Lasers in Maxillofacial Surgery and Dentis-try, 1st ed. United States of America:

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CLASSSIFICATION OF LASERS

Gas lasers- Argon Carbon dioxide laser

Solid state lasers

Eg: Nd:YAG Laser

Ho:YAG Laser

Er:YAG Laser

DIODE Laser

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SPONTANEOUS AND STIMULATED EMISSION

In general, when an electron is in an excited energy state, it must eventually decay to a lower level, giving off a photon of radiation. This event is called “spontaneous emission,”

When photon causes the electron to decay in such a manner that a photon is emitted at exactly the same wavelength, in exactly the same direction, and with exactly the same phase as the passing photon. This process is called “stimulated emission.”

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EMISSION MODES

☼ Continuous wave:- beam emitted at one power level continuously as long devise is active.

☼ Gated pulse mode:- periodic alteration of laser energy being on or off, similar to blinking of eye. Mode achieved by opening closing of shutter in front of beam path.

☼ Free running pulsed mode(Donat wave mode):- large peak energy of laser light are emitted for short time(microsecond) followed by long time when laser is off.

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Laser effects on tissue

The light energy from a laser can have four different interactions with the target tissue, and these interactions depend on the optical properties of that tissue and wave length used.

Reflection

Laser beam become more divergent as distance from handpiece increases.

Can be dangerous

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Absorption

This effect is the usual desirable effect, and the amount of energy that is absorbed by the tissue depends on the tissue characteristics such as pigmentation and water content, and on the laser wavelength and emission mode.Short wave lengths, from about 500-1000nm are absorbed readily in pigmented tissue.Argon has high affinity for melanin and hemoglobin. .Diode and Nd : YAG have a high affinity for melanin and less interaction with hemoglobin.Longer wavelength are more interactive with water & hydroxyapatite – Erbium , carbon dioxide laser.

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Transmission:

Transmission of laser energy directly through the tissue, with no effect on target tissue.

Water is relatively transparent to Nd:YAG whereas tissue fluids readily absorb carbon di-oxide.

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Scattering Scattering of the laser light causes weakening the

energy and possibly producing no useful biologic effect.

May cause heat transfer to tissue adjacent to the surgical site and unwanted thermal damage can occur.

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Besides photothermal effects there are other effects that lasers have on selected tissue.

Photochemical effects that lasers create to stimulate chemical reactions, such as curing of composite resin.

They can also cause break in chemical bonds, such as in the process of photodyanamic therapy.

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Several laser systems, such as the diode, ruby, Ho:YAG, Er:YAG, Nd:YAG, and yellow light lasers, as well as dye lasers for photo-dynamic therapy, have been used for treating various diseases.

With the recent advances and developments of wide range of laser wavelengths and different delivery systems, lasers could be applied for the dental treatments including periodontal, restorative and surgical treatments.

The aim of this review is to describe the soft tissue applications of lasers in dentistry.

Lee EA (2006) Laser-assisted gingival tissue procedures in esthetic dentistry. Practical Procedures and Aesthetic Dentistry 18, suppl 2-6. Werner JA, Dunne AA, Folj BJ & Lippert BM (2009) Transoral laser microsurgery in carcinomas of the oral cavity, pharynx, and larynx. Cancer Control 9, 379-88.

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Advantages

Dry surgical field and better visualization. Tissue surface sterilization and reduction in bacteria. Decreased swelling, edema and scarring. Decreased pain. Faster healing response. Increased patient acceptance. Minimal mechanical trauma. Negotiates folds in tissues.

Naik VK, Sangeetha S & Victor DJ (2010) Lasers in periodontics- ascientific boon or bane? SRM University Journal of Dental Sciences 1, 91-8.

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Disadvantages

Expensive. Require specialized training. Dental instruments mainly used are both side and end cutting thus; a

modification of clinical technique is required. No single wavelength will optimally treat all dental disease. There is inability to remove metallic and cast-porcelain defective

restorations. Harmful to eyes and skin.

Coluzzi DJ & Swick MD http://www.henryschein.com/usen/images/Dental/ CEHP/LaserinDentistry.pdf (accessed 14 March 2013)

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Soft tissue application of lasers in dentistry

Applications in oral surgery

Hemostasis. Malformations. Preprosthetic surgeries. Precancerous lesions. Cysts. Benign tumors. Scar corrections. Low Level Laser Therapy

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Peripheral Ossifying Fibromas

These occurs solely on the soft tissue overlying the alveolar process. It is a common gingival growth that usually arises from the interdental papilla.

These lesions can be effectively treated with Er,Cr:YSGG.

Iyer VH et al. reported that the outcome was painless experience to the patient, minimal intraoperative bleeding in the surgical field and excellent healing of the operated area in 1 week period.

Iyer VH, Sarkar S & Kailasam S (2012) Use of the Er,Cr:YSGG Laser in the Treatment of Peripheral Ossifying Fibroma. International Jour-nal of Laser Dentistry 2, 51-55.

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Denture-induced fibrous hyperplasia

This is a response of tissues to a chronically ill fitting denture and present as a benign condition which frequently coexists with denture stomatitis.

Kumar NJ et al. successfully treated the case of denture induced fibrous hyperplasia with the help of carbon dioxide laser and concluded that CO2 lasers could be an excellent alternative to conventional modalities.

Kumar NJ & Bhaskaran M (2007) Denture-induced fibrous hyperplas-ia:treatment with carbon dioxide laser and a two year follow-up. I Journal of Dental Research 18, 135-7e.

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Mucoceles

These are benign lesions of the oral cavity that develop due to extravasation or retention of mucous from salivary glands in the subepithelial tissue generally in response to trauma.

Pedron IJ et al. on the basis of findings of their study concluded that laser treatment provides satisfactory results and allowed for a satisfactory histopathological examination of the excised tissue in case of mucocele.

Pedron IG, Galletta VC, (2010) Treatment of mucocele of the lower lip with diode laser in pediatric patients: presentation of 2 clinical cases. Pediatric Dentistry 32, 539-41.

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Hemangiomas

These are benign vascular proliferations consisting of numerous capillary structures usually present on the tongue, lips, mucous membrane and gingiva.

Genovese WJ et al concluded that application of gallium arsenide (GaAs) have high potency diode laser in the treatment of hemangionma reduced bleeding during excisional surgery, with a consequent reduction in operating time and promoted rapid postoperative hemostasis.

Apfelberg DB et al recommended the laser treatment for excisional surgery of hemangioma.

Genovese WJ, dos Santos MT, Faloppa F & de Souza Merli LA (2010) the use of surgical diode laser in oral hemangioma: a case re-port. Photomedicine and Laser Surgery 28,147-51. Apfelberg DB, Maser MR, Lash H & White DN (1985) Benefits of the CO2 laser in oral hemangioma excision. Plastic and Reconstruc-tive Surgery 75, 46-50.

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Lymphangioma

It is often asymptomatic and a slow growing painless cystic mass covered by healthy mucosa. Despite being a congenital benign lesion, lymphangioma may cause severe esthetic deformities, and surgical excision is the main treatment.

Dos Santos et al reported that the use of CO2 laser was practical, easy to carry out and effective on the treatment of oral lymphangiomas, with no lesion recurrence.

dos Santos Aciole GT, Santos NRS, (2010) Surgical Treatment of Oral Lymphangiomas with CO2 Laser: Report of Two Uncommon Cases. Brazilian Dental Journal 21,365-9.

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Premalignant and malignant lesions Laser resection/ablation is recommended for oral dysplasia to prevent not only recurrence

and malignant transformation but also postoperative oral dysfunction encountered by other conventional modalities.

Van der Hem PS et al concluded that leukoplakia or hyperkeratotic lesions cryotherapy

ablation and CO2 laser is used and the operated area heals rapidly. This is an effective, non-morbid, inexpensive, quick, and relatively painless method of managing such condition.

Kok & Ong concluded that the use of CO2 laser in the treatment of oral lichen planus and lichenoid reaction shows positive results in relieving symptoms.

Van der Hem PS, Nauta JM, van der Wal JE & Roodenburg JL (2005) the results of CO2 laser surgery in patients with oral leukoplakia: a 25 year follow up. Oral Oncology 41, 31-7. Kok TC & Ong ST (2001) the effects of CO2 lasers on oral lichen planus and lichenoid reactions. Annals of Dentistry University of Maaya 8, 35-42.

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Infectious lesions

Erbium laser may be used for ablation or decontamination of infective lesions. Lasers are used in treatment of herpetic, candidiasis, and papilloma virus lesions.

Gaeta GM (2013) laser treatment in medicine and oral pathology. Http://www.Giovannimariagaeta.It/laser %20book%202010.Pdf

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Dentigerous cysts

These are benign odontogenic cysts associated with the crown of an unerupted tooth. They can expand the cortical bone and cause displacement of teeth and root resorption in the adjacent teeth.

Boj JR treated a case of dentigerous cyst by preparation of mucous fenestration using an erbium laser followed by drainage of the fluid content and curettage and the injury was success-fully resolved.

Boj JR, Poirier C (2007) Laser-assisted treatment of a dentigerous cyst: case report. Ped dent 29, 521-4.

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Cancer

The CO2 laser currently has the greatest significance in otorhinolaryngology, predominantly in the treatment of carcinomas of the upper aerodigestive tract.

The neoplastic cells can be removed by hyperthermic (cells are destroyed by laser heat or photodynamic combination of special photosensitive drug with specific type of laser) methods.

López-Álvarez F, Rodrigo JP, (2011) Transoral laser microsurgery in advanced carcinomas of larynx and pharynx. Acta Otorrinolaringológica Española 62, 95-102.

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Applications in periodontics

Gingivectomy. Frenectomy. Removal of granulation tissue. Removal of melanin pigmentation and metal tattoos. Subgingival debridement and curettage. Osseous recontouring as well as in implant surgery. Maintenance of implants. Low Level Laser Therapy.

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Gingivectomy:

Lasers offer the potential of increased operator control and minimal damage in the removal of gingival tissue for restorative purposes and for the treatment of gingival hyperplasia.

Diode lasers specifically, operate at a wavelength that is easily absorbed by the gingival tissues, while posing little risk of damaging the tooth structure.

Pick RM et al presented a 12 cases of phenytoin hyperplasia removed surgically by the CO2 lasers and hence suggested that in the future the laser may offer an alternative or an advancement to current procedures now used in dentistry.

Pick RM, Pecaro BC & Silberman CJ (1985) the laser gingivectomy: the use of CO2 laser for the removal of phenytoin hyperplasia. The Journal of Periodontology 56, 492-6

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Crown Lengthening

Lasers have been promoted for clinical crown lengthening without gingival flap reflection for both esthetic and prosthetic reasons.

Cobb CM et al only supports for such applications in non controlled case reports

Cobb CM (2006) Lasers in periodontics: a review of the literature. The Journal of Periodontology. 77, 545-64

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Frenectomy

According to Kafas P et al. diode laser frenectomy may be performed without infiltrated anaesthesia with the optimum healing postsurgically.

Tissue Pigmentation Reduction

Recently, laser has been widely used and is even preferred over the scalpel technique procedures for depigmentation.

Kafas P, Stavrianos C, Jerjes W, Upile T, (2009) Upper-lip laser frenectomy without infiltrated anaesthesia in a paediatric patient: a case report. Cases Journal 2, 7138. Roshna T & Nandakumar K (2005) Anterior Esthetic Gingival Depigmentation and Crown Lengthening: Report of a Case. The Jour-nal of Contemporary Dental Practice 15,139-147.

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Applications in orthodontics Aesthetic gingival recontouring. Soft tissue crown lengthening. Exposure of soft-tissue impacted teeth. Removal of inflamed and hypertrophic tissue. Frenectomy. Tissue removal at the site for mini screw. Low Level Laser Therapy. Lasers are widely used in Orthodontics for aesthetic gingival recontouring, soft tissue

crown lengthening, exposure of soft-tissue over the impacted teeth, removal of inflamed and hypertrophic tissue, frenectomy in case of highly attached frenum causing hindrance to tooth movement in diastema cases, tissue removal at the site for mini screw and Low Level Laser therapy for reduction in pain experienced during the orthodontic therapy.

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Applications in conservative dentistry & endodontics

Dentinal Hypersensitivity. Pulp Capping & Pulpotomy. Cleaning of root canals. Sterilization of the root canals.

Soft tissue lasers have been successfully used for the removal of coronal pulp and immediate pulp capping due to its thermal and hemostatic effect. Lasers causes modification of the tubular structure of dentin by melting and fusing of the hard tissue or smear layer and subsequent sealing of dentinal tubules leading to reduction in sensitivity of teeth. Laser radiation has the ability to remove debris and smear layer from the root canals due to its potential to kill the microorganisms by its thermal effects.

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Diagnosis of lesions

Laser capture microdissection (LCM) greatly improved the efforts in describing the molecular basis of malignancy.

The first commercialized system was devised by Lance Liotta, Emmert-Buck and coworkers in mid 1990s for accurately and efficiently dissection of cells from histological tissue sections of solid tumors.

LCM provides an ideal method for the extraction of cells from specimens in which the exact morphology of both the captured cells and the surrounding tissue are preserved.

When LCM is combined with immunohistochemical staining techniques, more accurate microdissection of cellular subsets can be obtained. This technique variably helps in early detection of oral squamous cell carcinoma by detecting the biomarkers and establishing protein fingerprint models.

Mehrotra R & Gupta DK (2011) Exciting new advances in oral cancer diagnosis: avenues to early detection. Head & Neck Oncoogy 28, 33.

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Low level laser therapy

Low level laser therapy (LLLT) is defined as laser treatment in which the energy output is low enough to produce nonthermal and biostimulatory effects.

The mechanisms of effect of LLLT causing laser analgesia are due to the stabilization of depolarising potential of nerve fibres or effects on the cellular and biochemical processes of the inflammatory responses.

LLLT has effectively used in pain during orthodontic therapy, acceleration of healing process in wound, reduction of bacterial load in ulcerative conditions like apthous ulcer, infections etc.

Hong-Meng L,(1995) A clinical inves-tigation of the efficacy of low level laser therapy in reducing ortho-dontic postadjustment pain. American Journal of Orthodontics and Dentofacial Orthopedics 108, 614-22.

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Effects of LASERs on soft tissues

Laser can lead to warming, welding, coagulation, protein denaturation, drying, vaporization and carbonization causing the histological changes such as intracellular vacuolization, cellular hyperchromatism and loss of intracellular structure, with the degree of charring of the tissues.

Epithelial changes like blisters, clefts, erosions, and any intraepithelial or subepithelial loss of attachment and vascular changes like intraluminal clotted erythrocytes, vascular stasis with presence of gathered erythrocytes and thrombosed or collapsed blood or lymphatic vessels can also occur.

If disease free margins are needed, the pathologist could encounter serious difficulties to evaluate them due to the presence of charred tissue, artifacts and denaturalised, coagulated and disorganized tissue of variable extension around the margins.

Kende P, Gaikwad R, Yuwanati M & Jain B (2011) Application of Diode Laser in Oral Biopsy: Removal of White Patch Over Tongue - A Case Report. Journal of Indian Dental Association 5, 985-7

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MISCELLANEOUS APPLICATIONS

Analgesic effect of the laser

In vivo studies of the analgesic effect of LLLT on nerves supplying the oral cavity have shown that LLLT decreases the firing frequency of the nociceptors, with a threshold effect seen in terms of the irradiance required to exert maximal suppression.

There have been claims that successful analgesia following oral surgery can be achieved with all major LLLT wavelengths from 632 nm to 904 nm. Local CO2 laser irradiation will reduce the pain associated with orthodontic force application, without interfering with tooth movement.

Post surgical pain

A single episode of LLLT (irradiance 0.9-2.7 J) is 100% effective for apical periodontitis following root canal treatment and post-extraction pain. There are conflicting results with regard to pain reduction post extraction by LLLT verses placebo controls.Mezawa S, Iwata K, Naito K, Kamogawa H. The possible analgesic effect of soft-laser irradiation on heat nociceptors in the cat tongue. Arch Oral Biol. 1988;33:693–4

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Nerve repair and regeneration

Low level laser therapy has been seen to reduce the production of inflammatory mediators from injured nerves, and to promote neuronal maturation and regeneration following injury.

The LLLT protocols used, typically involve daily irradiation for prolonged periods, for example, 10 days at 4.5 J per day.

The direct application of this technique to dentistry has yielded positive results in promoting the regeneration of inferior dental nerve (IDN) tissue, damaged during surgical procedures.

Mester AF, Snow JB, Shaman P. Photochemical effects of laser irradiation on neuritic outgrowth of olfactory neuroepithelial explants. Otolaryngol Head Neck Surg. 1991;105:449–56. 84. Solomon A, Lavie V, New surgical approach to overcome the inability of injured mammalian axons to grow within their environment. J Neural Transplant Plast. 1991;2:243–8

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Review of the literature

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Solveiga Kelbauskiene, Vita Maciulskiene, A pilot study of Er,Cr:YSGG laser therapy used as an adjunct to scaling and root planing in patients with early and moderate periodontitis, Stomatologija, Baltic Dental and Maxillofacial Journal, 9:21-26, 2007

Solveiga et al conducted a study on 130 teeth of 10 patients with early to moderate

periodontitis, aged between 30 and 60 years. 78 teeth were treated with laser+SRP (scaling and root planing) and another 52 teeth were treated with only SRP.

At baseline, no plaque was observed in 3,8% of laser+SRP treated teeth, and in 7,7% of SRP treated teeth, respectively.

Marked reduction of the bleeding scores took place in both groups such as 20.5% of teeth in the ‘laser+SRP’ group and 17% of teeth in SRP were recorded with positive BOP score. Reduction of periodontal depth (PD) occurred in both groups, however, it was significantly more pronounced in “Laser+SRP’’ group.

The combined treatment using laser as an adjunct to root planing and scaling seemed to be advantageous when compared to SRP alone, due to more efficient attachment level restoration.

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Clokie C, Bentley KC, Head TW. The effects of the helium neon laser on postsurgical discomfort: A pilot study. J Can Dent Assoc. 1991;57:584–6

Clokie C et al conducted a study to examine the effect of the helium-neon laser on post-surgical discomfort.

Fifteen patients who had surgical removal of bilaterally symmetrical mandibular third molars were evaluated.

Laser therapy was applied to one side of each patient's mouth with the other side serving as the control. A similar technique of application, without activation of the laser beam, was utilized on the control side.

This study has demonstrated that the helium-neon laser (632.8 nanometre (nm) at 10 milliwatt (mW), when applied to the site for three minutes immediately following third molar surgery, reduced postoperative pain on the day of surgery and on the first postoperative day. This finding was statistically significant.

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Raouâa B, Samèh S, Nour BM, (2013) Effects of Low level laser Therapy versus Corticotherapy on Pain, Trismus and Edema after Surgical Removal of Third Mandibular Molars: A Comparative Study. Family Med Medical Sci Res 2: 111.

Raouaa et al conducted a study to compare the effects of low-level laser therapy and corticosteroids on postoperative, pain, trismus and edema following the removal of mandibular third molars.

They were randomly assigned to two groups of thirty patients each. Patients in the LLLT group received 3.3 J intraorally at the operation site and the same dose extraorally. Patients in the corticosteroids group received postoperative parenteral injection of Dexamethasone.

This study demonstrates that there is no significant difference between administration of corticosteroids and LLLT for the reduction of postoperative pain and trismus but dexamethasone was more effective to reduce swelling on seventh postoperative day.

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Mutan Hamdi Aras, Mary Ann Liebert, The Effect of Low-Level Laser Therapy on Trismus and Facial Swelling Following Surgical Extraction of a Lower Third Molar Photomedicine and Laser Surgery, Volume 27, Number 1, 2009, Inc.Pp. 21–24

Mutan Hamid et al conducted a study on 32 patients who were to undergo surgical removal of lower third molars. these were randomly allocated to two groups, LLLT and placebo.

Patients in the LLLT group received 12 J (4 J/cm2) low-level laser irradiation to the operative side intraorally 1 cm from the target tissue, and to the masseter muscle extraorally immediately after surgery. In the placebo group the handpiece was inserted into the operative side intraorally and was applied to the masseter muscle extraorally each for 1 min, but laser power was not activated.

Interincisal opening and facial swelling were evaluated on postoperative days 2 and 7.

It was determined that the trismus and the swelling in LLLT group were significantly less than in the placebo group on postoperative days 2 and 7. It can be concluded that LLLT can be beneficial for the reduction of postoperative trismus and swelling after third molar surgery.

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Conclusion

The application of lasers has been recognized as an adjunctive or alternative approach in soft tissue surgeries. Laser treatments have been shown to be superior to conventional mechanical approaches with regard to easy ablation, decontamination and hemostasis, as well as less surgical and postoperative pain in soft tissue management.

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Thank you