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Previously Published

Review analysis & evaluation

The Effectiveness of Lasers to Reduce Dentinal


Hypersensitivity Remains Unclear

Article Title and


Bibliographic Information

Effectiveness of laser in dentinal


hypersensitivity treatment:
a systematic review.
Sgolastra F, Petrucci A,Gatto R, MonacoA.
J Endod 2011;37(3):297-303.
Reviewer

Asbjorn Jokstad, DDS, PhD


Purpose/Question

Do patients with dentinal


hypersensitivity subjected to laser
light application compared to
placebo light experience reduced
hypersensitivity or any adverse
outcomes?
Source of Funding

Information not available

Type of Study Design

Systematic review

Level of Evidence

level 2

Limited-quality, patientoriented evidence

Strength of
Recommendation Grade

Inconsistent or limitedquality
patient-oriented evidence

Reviewer: Asbjorn Jokstad, DDS, PhD; Professor


and Head, Prosthodontics, University of Toronto
Faculty of Dentistry, 124 Edward Street, Room
356, M5G 1G6 Toronto, Canada;Tel:1 416 979
4930 ext 4427; Fax.1 416 979 4769
E-mail: a.jokstad@dentistry.utoronto.ca
Originally Published in:
J Evid Base Dent Pract
2011;11:178179
1532-3382/$36.00
2011 Elsevier Inc. All rights reserved.
doi: 10.1016/j.jebdp.2011.09.009

SUMMARY

Selection Criteria
Studies were located in a wide spectrum of bibliographic databases including Medline, Science Direct, Cochrane Clinical Trials Register, Cochrane Reviews, ISI Web of
Science, LILACS, and IADR. Manual hand searches supplemented the digital search.
No language restrictions applied. Independent screening was performed by 2 reviewers before coming to a forced decision of inclusion or exclusion. Kappa statistics were used for measuring agreement. Corresponding authors were contacted
for verication of study details if needed.

Key Study Factor


The review was limited to randomized controlled trials (RCTs) on adult patients
with hypersensitive dentin comparing laser intervention versus using a placebo
with a follow-up of more than 3 months.

Main Outcome Measure


A reference is made to a requirement of the included studies to have used an
assessment of hypersensitivity by scale and the data reported with a mean and
standard deviation. It is not entirely clear whether this should be interpreted as
limited to use of VAS scales only, in contrast to categorical Likert-like scales or
nominal descriptors. Regardless, the list of excluded studies in the original Table 3
does not include any studies that were excluded because of the lack of fullling
this requirement.

Main Results
Out of several thousand titles and abstracts, 63 full-text articles were examined,
and 6 of these were identied as RCTs. Three of these reported on less than 3
months, leaving only 3 articles for data extraction. No metaanalyses were done on
this limited and somewhat heterogeneous data material. The methodological quality was considered, leaving the authors to conclude that the estimated risk of bias
was high for all 3 studies. An exception was one of the studies where the authors
were contacted and apparently had produced an inadequate article, but otherwise
allegedly had conducted an exemplary trial.

Conclusions
Laser treatment appears to reduce dentin hypersensitivity, but the evidence for this
effectiveness is weak, and the placebo effect cannot be ruled out. No pulp damage
or major adverse effects were reported in the 3 identied studies.

231

September 2012

Journal of evidence-based dental practice Special IssuePeriodontal and Implant Treatment

COMMENTARY AND ANALYSIS

an RCT, which in fact seems also to be the case.2 The study


compared laser versus a curing light used as a placebo and
found no effects of the laser at the follow-up examination
6 weeks later. Perhaps the RCT simply disappeared from
Table 3, because it was clearly identied by the authors as
their reference 25.

his review had 2 stated objectives, the rst of which was


to address the clinical effect of laser application and the
second to survey literature related to the safety of laser applications. These are conceptually 2 different

research questions. The rst is a question of relative efcacy


and is best answered by an RCT, whereas the second is a
question of causal association that requires a far broader basis of clinical data for judgment and estimation. The reviewer
believes that only the rst objective has been addressed in
this article by virtue of the pre hoc decision to limit the review to RCTs. This part of the review was, however, good,
and the authors should be commended for their thoroughness in the search for evidence and for a good critical appraisal of the limited amount of information available for
review. Unfortunately, the poor quality of the evidence, ie, 3
potentially biased RCTs, negate making any conclusions with
regard to determining whether laser use has any effects, positive or negative, on dentin hypersensitivity. Clearly, the same
applies to the question about the safety of laser application.
One needs to be aware that the conclusion that no side effects, adverse reactions, or pulp damage were reported at
the energy and power settings used is based solely on these
3 potentially biased RCTs and no other study data.
One may question why the authors of this review limited
the inclusion to studies with a minimum of a 3-month followup observation period instead of, say, 1 week, 2 months, or
6months. Given the cyclic nature of dentin hypersensitivity,
one may argue that any RCT, regardless of follow-up time,
that addresses the issue of whether laser works or not should
have been appraised. One recommendation for acceptable
time for evaluation of efcacy of chemical desensitizers is to
assess after 6 to 8 weeks.1
In the 3 identied articles, the placebo intervention was not
an alternative light source but a simulated use of the laser
device. One study referred to a routine in which the laser
was used for 30 seconds without water coolant followed
by 90 seconds with water coolant, and the description of
patient blinding was that the beam was switched off, but
with coolant running. In the second article, a reference was
made to use the same melody and without laser emission,
and in the third article, the laser device was positioned but
not activated. Because further details of the experimental
setting are lacking, it is difcult to appraise whether these settings were adequate or not for blinding the patients. Another
issue that could have potentially biased the ndings is that 3
different lasers were used in the reviewed RCTs. One study
used a GaAlAs laser, another used an Nd:YAG laser, and the
third used both an Nd:YAG and an Er:YAG laser.

Given the limited amount of information available, the use of


lasers to address dentinal hypersensitivity should continue to
be considered as experimental therapy.

REFERENCES

A small detail, perhaps, but in the reference list of one of


the 3 identied articles a particular study was referred to as

Volume 12, Supplement 1

Conducting an RCT of patients with dentin hypersensitivity


is fraught with methodological problems, especially if limiting
a trial to a single-intervention approach. The rst issue is to
identify the main etiological factor for the patients condition, which may be associated with friction and/or corrosive
intraoral milieu3 (eg, the multifactorial etiology behind hypersensitive occlusal surfaces is clearly different from the Class
V tooth-surface loss lesions. Second, dentists always have
a professional obligation to advise their patient about the
likely cause of their condition to minimize further damage.
Recommendations for reducing the symptoms of hypersensitivity may be, for example, to reduce corrosive food and
drink intake, alter tooth-brushing habits, change toothpaste
formulation, or to stop particular habits such as chewing gum.
It is questionable whether a simplistic laser treatment can
and should replace the multi-intervention approach used by
dentists in real life.4 In fact, the 3 studies that were identied
in the review are likely to have been heavily biased by these
hidden confounding variables; moreover, for the same reason,
it is unfeasible from a research ethics perspective to conduct a trial on dentinal hypersensitivity using only a singleintervention approach. Complex multilevel statistical models
can in theory be used where multiple intervention factors
come to play in a trial, necessitating the use of advanced biostatistical expertise. Whether these experts are available or
even interested in studying a relatively minor medical condition such as dentinal hypersensitivity given todays medical
research climate is another question.

232

1.

Gillam DG, Orchardson R, Nrhi MVO, Kontturi-Nrhi V. Present and


future methods for the evaluation of pain associated with dentine
hypersensitivity. In: Addy M, et al. editors. Tooth wear and sensitivity.
London: Martin Dunitz; 2000. p. 283-97.

2.

Gentile LC, Greghi SL. Clinical evaluation of dentin hypersensitivity


treatment with the low intensity Gallium-Aluminum-Arsenide laser
AsGaAl. J Appl Oral Sci 2004;12:267-72.

3.

Grippo JO, Simring M, Schreiner S. Attrition, abrasion, corrosion and


abfraction revisited: a new perspective on tooth surface lesions. J Am
Dent Assoc 2004;135:1109-18.

4.

Cunha-Cruz J, Wataha JC, Zhou L, Manning W, Trantow M, Bettendorf


MM, et al. Treating dentin hypersensitivity: therapeutic choices made
by dentists of the northwest PRECEDENT network. J Am Dent Assoc
2010;141:1097-105.