PBM and pediatric dentistry
By Jan Tunér
Too many persons have a fear of dentistry and kids are no exception. The introduction of lasers has meant a lot to many kids since several therapies can be performed more or less painlessly. The only problem is that there are so few laser dentists! The most well-known laser for pediatric use is the Erbium laser, known to be able to “drill” cavities. Indeed it can, but this is only one of the many assets of this laser. Less known are the “low level” lasers and what they can do for the kids.
One useful indication is to anesthetize a tooth. This works well in deciduous teeth (milk teeth) and young teeth, applying 3-4 J over the crown and 3-4 over the apices. Does not always produce 100% analgesia but generally enough to be a good experience.
Another very good indication is for pulp capping and deep cavities. This is performed when there is an accidental opening from the tooth cavity into the vital pulp. The “over-capping” aims at creating a new dentinal bridge over the opening without compromising the pulp. Several studies have shown the beneficial effect of PBM for this indication.
Dr. Martin Kaplan has a dental clinic in Stoughton, MA, USA, offering general dentistry but focused on pedodontics, thus the name of the clinic – Kid Care Dental. Dr. Kaplan has been practicing laser dentistry for more than 15 years, including PBM – photobiomodulation. The following clinical case highlights the benefits of using PMB in pedodontics.
This is the case of a 7 year old female who fell off of a rocking horse and fell approximately 2 - 3 feet onto her face. The tooth #8 was immediately placed in 2% milk and the patient was rushed to the dental office. She presented as very anxious (she had a history of requiring oral conscious sedation to complete dental care 6 month prior to the injury). The patient was immediately brought into the operatory for a neurological exam. All signs were intact for time, place, person, balance, eye movement, balance and squeezing of the hands. The tooth was immediately removed by its crown and placed in “Save-A-Tooth” (Hank’s balanced salt Solution HBSS) for approximately 30 minutes, while the patient was being evaluated by Panoramic x-ray and being calmed down with Nitrous Oxide Oxygen analgesia. Intraoral evaluation confirmed that #8 was the exfoliated tooth and #9 was partial vertically avulsed with mobility ¾, #C was mobile 2+/4. The tooth was re-implanted and LLLT 4J over the lip and 4 J over the apex of the re-implanted tooth was performed. The two teeth were stabilized by Ribbond.
Prior to releasing the patient, a call was made to the patient’s physician to report the injury and the clinical signs and symptoms of the dental and physical injury and a report of a neurological test. Taking into account the type of fall, the physician was satisfied that there was no need to have the patient re-evaluated. A discussion of the current immunizations was held and no indications presented to have any additional immunization. Analgesia of Tylenol was prescribed and no narcotics were given so as not to mask any possible concussion or other neurological effect of the injury. A prescription of Amoxicillin was written, 250 mg TID x 10 days to provide for infection coverage of the open wound socket and the dental pulp (per AAPD and AAED guidelines). Post-op call to family indicated no pain.
24 hour follow-up was 4 J of LLLT on lip and under lip and 2 J on the apex of 8 & 9 (2 J to as not to be additive to the 4 J the day before. This protocol was repeated on day 3 and on day 7 the protocol was changed to 2 J lip and 2 J #8 and 2J #9. Day #9 was the same protocol. Then 5 days (due to weekend and days off the patient returned and was healing well. The splint remained on #8 & #9 for 7 weeks due to the damaged socket. On day 14 when the splint was removed form C & H 2 J of LLLT was applied to 8 & 9. A periapical x-ray was taken to confirm that the re-implanted tooth was properly in the socket (clinically it appeared so). For the next several days on the 3rd day LLLT was applied to the teeth at 2 J. On day 17, the entire splint was removed and an additional x-ray was taken. Follow–up on month 3 and 6 reveals intact normal mobility, white coloration, healing gingiva and root formation is continuing.
Relevant literature
Paschoud Y et al. Effet du soft-laser sur la néofromation d´un pont dentinaire après coiffage pulpaire direct de dents humaines à l’ hydroxyde de calcium. Rev Mens Suisse Odont-Stomatol. 1988; 98 (4): 345-356.
Kurumada F. The effect of laser irradiation on the activation of inflammatory cells and the vital pulpotomy. A study of the application of Ga-As semiconductor laser to endodontics. J Clinical Pediatric Dentistry. 1995; 19: 232.
Utsunomiya T. A histopathological study of the effects of low-power laser irradiation on wound healing of exposed dental pulp tissues in dogs, with special reference to lectins and collagens. J Endod. 1998; 24 (3): 187-193.
Godoy B M, Arana-Chavez V E, Nunez S C, Ribeiro M S. Effects of low-power red laser on dentine-pulp interface after cavity preparation. An ultrastructural study. Arch Oral Biol. 2007 Sep; 52 (9): 899-903.
Shigetani Y, Sasa N, Suzuki H, Okiji T, Ohshima H. GaAlAs laser irradiation induces active tertiary dentin formation after pulpal apoptosis and cell proliferation in rat molars. J Endod. 2011; 37 (8): 1086-1091.
Matsui S, Tsujimoto Y, Matsushima K. Stimulatory effects of hydroxyl radical generation by Ga-Al-As laser irradiation on mineralization ability of human dental pulp cells. Biol Pharm Bull. 2007; 30 (1): 27-31.
Fernandes A P, Lourenço Neto N, Teixeira Marques N C, Silveira Moretti A B, Sakai V T, Cruvinel Silva T, Andrade Moreira Machado M A, Marchini Oliveira T. Clinical and radiographic outcomes of the use of Low-Level Laser Therapy in vital pulp of primary teeth. Int J Paediatr Dent. 2014 [Epub ahead of print]
Arany P R, Cho A, Hunt T D, Sidhu G, Shin K, Hahm E, Huang G X, Weaver J, Chen AC, Padwa B L, Hamblin M R, Barcellos-Hoff M H, Kulkarni A B, J Mooney D. Photoactivation of Endogenous Latent Transforming Growth Factor-beta1 Directs Dental Stem Cell Differentiation for Regeneration. Sci Transl Med. 2014; 28 6 (238): 238ra69.
Toomarian L, Fekrazad R, Tadayon N, Ramezani J, Tunér J. Stimulatory effect of low-level laser therapy on root development of rat molars: a preliminary study. Lasers Med Sci. 2012; 27 (3): 537-542.
Fekrazad R, Seraj B, Ghadimi S, Tamiz P, Mottahary P, Dehghan M M. The effect of low-level laser therapy (810 nm) on root development of immature permanent teeth in dogs. Lasers Med Sci. 2014 [Epub ahead of print]