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Lasers may reduce pain arising from dentin hypersensitivity James Bader, Ben Balevi, Paul Farsai, Carlos Flores-Mir, John Gunsolley, Debora Matthews, Katherine Vig and James Zahrowski JADA 2014;145(4):e1-e2 10.14219/jada.2013.56 The following resources related to this article are available online at jada.ada.org (this information is current as of June 29, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/4/e1
Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Downloaded from jada.ada.org on June 29, 2014
ORIGINAL CONTRIBUTIONS
Critical Summaries
Lasers may reduce pain arising from dentin hypersensitivity A critical summary of Sgolastra F, Petrucci A, Severino M, Gatto R, Monaco A. Lasers for the treatment of dentin hypersensitivity: a meta-analysis. J Dent Res 2013;92(6):492-499.
James Bader, DDS, MPH; Ben Balevi, BEng, DDS, Dip EBHC(Oxford), MSc; Paul Farsai, DMD; Carlos Flores-Mir, DDS, Cert Ortho, DSc; John Gunsolley, DDS, MS; Debora Matthews, DDS, Dip Perio, MSc; Katherine Vig, BDS, MS, FDS, DOrth; James Zahrowski, DMD, MS, PharmD
Systematic review conclusion. Erbium:yttrium-aluminum-garnet (Er:YAG), neodymium:yttrium-aluminum-garnet (Nd:YAG) and gallium-aluminum-arsenide (GaAlAs) lasers appear to be efficacious in reducing dentin hypersensitivity (DH). However, given the high degree of heterogeneity of the included studies, future adequately powered randomized controlled trials (RCTs) are needed to confirm these results. Critical summary assessment. The authors assessed 13 RCTs providing limited evidence that Er:YAG, Nd:YAG and GaAlAs lasers could be efficacious in reducing DH when compared with no treatment; however, they did not compare the results with those for studies of alternative treatments. Evidence quality rating. Limited. Clinical question. In adults with dentin hypersensitivity (DH), do certain lasers, compared with placebo or no treatment, effectively reduce DH? Review methods. Two independent reviewers searched seven electronic databases through Feb. 10, 2013, with no language restrictions. The reviewers considered only randomized controlled trials (RCTs) involving adult participants in which investigators compared laser treatment for DH with placebo or no treatment. The reviewers combined the change in pain level from baseline to follow-up in a meta-analysis to determine efficacy. The reviewers assessed risk of bias. Main results. The reviewers included in the meta-analyses 13 RCTs that involved 373 adults
and four types of lasers: erbium, chromium:yttrium-scandiumgallium-garnet (Er,Cr:YSGG) versus placebo, erbium:yttrium-aluminumgarnet (Er:YAG) versus placebo, neodymium:yttrium-aluminumgarnet (Nd:YAG) versus placebo, and gallium-aluminum-arsenide (GaAlAs) versus placebo. The reviewers reported no statistically significant differences for Er,Cr:YSSG versus placebo (standardized mean difference [SMD], 2.49; 95 percent confidence interval [CI], −0.25 to 5.22; P = .07) but did report statistically significant differences in favor of lasers for Er:YAG versus placebo (SMD, 2.65; 95 percent CI, 1.25 to 4.05; P = .0002), Nd:YAG versus placebo (SMD, 3.59; 95 percent CI, 0.49 to 6.69; P = .02) and GaAlAs versus placebo (SMD, 3.40; 95 per-
cent CI, 1.93 to 4.87; P < .00001). The reviewers rated three trials as being at low risk of bias and the remaining 10 as being at high risk of bias. The reviewers found substantial clinical heterogeneity among each group of studies, including variation in how DH was stimulated (air blasts of varying duration and tactile stimulation) as well as in how pain was recorded (visual analog scale and verbal rating scale). Conclusions. All lasers (Er:YAG, Nd:YAG and GaAlAs) except Er,Cr:YSGG appear to be efficacious in reducing DH; however, considering the important limitations of the evidence, no clinical recommendation can be given. No sources of funding for this systematic review were listed.
JADA 145(4) http://jada.ada.org April 2014 e1 Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 29, 2014
ORIGINAL CONTRIBUTIONS
COMMENTARY Importance and context. DH is a common condition that is characterized by short, sharp pain arising from exposed dentin in response to thermal, evaporative, tactile, osmotic or chemical stimuli. Its pathogenesis remains unclear, but it is thought to be caused by changes in fluid pressure in dentinal tubules in response to these stimuli. Several treatment alternatives, including laser therapy, have been proposed and have had variable degrees of efficiency. Several types of lasers are used; however, the effectiveness of laser therapy remains unknown. Strengths and weaknesses of the systematic review. The reviewers in this systematic review examined only one means of desensitization, lasers, in comparison with placebo, and they did not compare lasers with alternative treatments. The reviewers also did not form a conclusion about which laser type is preferable, because they did not compare results between laser types. The reviewers conducted a comprehensive search with adequate inclusion and exclusion criteria, and they evaluated only RCTs. They performed random-effects meta-analyses for each treatment arm but did not stratify trial outcomes on the basis of symptoms and disease severity, a measure that would have minimized heterogeneity. They treated all outcome measurements similarly, without any assessment or consideration of the reliability and accuracy of the outcome measurement used. They summarized the magnitude of the reductions in discomfort in terms of SMDs, making it difficult to determine the clinical significance of these results. Strengths and weaknesses of the evidence. Study designs varied substantially, particularly in elements that might influence outcomes, such as exposure time and methods of stimulation and measurement. Similarly, the amount of time between treatment and final assessment varied extensively, from immediately to six months after treatment. When these studies were synthesized, both latency and delay of treatment effect became possible confounding variables. The reviewers did not attempt to detect any temporal effects, electing simply to analyze the effects over the longest period assessed. In addition, most or all of the included studies had a high risk of bias (10 of 13), were split-mouth studies (nine of 13) and had small sample sizes (13 of 13). There were only a few studies in each laser category. Because the reviewers found a high degree of heterogeneity, one should consider the conclusions cautiously. Implications for dental practice. The results of this systematic review are of limited value to clini-
cians because they do not provide information about which laser is best, and the reviewers also did not compare lasers with other existing desensitizing treatments. Three lasers (Er:YAG, Nd:YAG and GaAlAs), but not a fourth (Er,Cr:YSGG), appear to be efficacious in reducing DH. However, because the magnitudes of the effects of each laser were not reported in a more clinically relevant manner, and because the results varied between the studies, it is difficult to determine the usefulness of lasers in the treatment of DH in clinical practice. Before recommending laser therapy over other modalities such as oxalates and desensitizing toothpaste, dentists should consider the clinical context, the scientific evidence, the patient’s values and the cost-benefit relationship. n
doi:10.14219/jada.2013.56
Dr. Bader is a research professor, Department of Operative Dentistry, University of North Carolina at Chapel Hill. He also serves The Journal of the American Dental Association as its associate editor for evidence-based practice and is a member of the ADA Critical Review Panel. Dr. Balevi maintains a private practice in general dentistry in Vancouver, British Columbia, Canada, and is an associate with the faculty of medicine, University of British Columbia, Vancouver. He also is a member of the American Dental Association Critical Review Panel. Dr. Farsai is an associate professor, Goldman School of Dental Medicine, Boston University. He also is a member of the American Dental Association Critical Review Panel. Dr. Flores-Mir is an associate professor and the division head, Orthodontics, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmondton, Alberta, Canada. He also is a member of the American Dental Association Critical Review Panel. Dr. Gunsolley is a professor, Department of Periodontics, School of Dentistry, Virginia Commonwealth University, Richmond. He also is a member of the American Dental Association Critical Review Panel. Dr. Matthews is the assistant dean, Research, Faculty of Dentistry, Dalhousie University, Halifax, Nova Scotia, Canada. She also is a member of the American Dental Association Critical Review Panel. Dr. Vig is an emeritus faculty member, Division of Orthodontics, College of Dentistry, The Ohio State University, Columbus. She also is a member of the American Dental Association Critical Review Panel. Dr. Zahrowski maintains a private practice in orthodontics in Tustin, Calif. He also is a member of the American Dental Association Critical Review Panel. Address correspondence to Dr. Zahrowski at 13372 Newport Ave. #E, Tustin, Calif. 92780, e-mail JJZahrowski@ gmail.com. Disclosure. None of the authors reported any disclosures. These summaries, published under the auspices of the American Dental Association Center for Evidence-Based Dentistry, are prepared by practitioners trained in critical appraisal of published systematic reviews who work under the mentorship of experts. The summaries are not intended to, and do not, express, imply or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. For more information on the evidence quality rating provided above and additional critical summaries, please visit http://ebd.ada.org.
e2 JADA 145(4) http://jada.ada.org April 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Lasers may reduce pain arising from dentin hypersensitivity James Bader, Ben Balevi, Paul Farsai, Carlos Flores-Mir, John Gunsolley, Debora Matthews, Katherine Vig and James Zahrowski JADA 2014;145(4):e1-e2 10.14219/jada.2013.56 The following resources related to this article are available online at jada.ada.org (this information is current as of June 29, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/4/e1
Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Downloaded from jada.ada.org on June 29, 2014
ORIGINAL CONTRIBUTIONS
Critical Summaries
Lasers may reduce pain arising from dentin hypersensitivity A critical summary of Sgolastra F, Petrucci A, Severino M, Gatto R, Monaco A. Lasers for the treatment of dentin hypersensitivity: a meta-analysis. J Dent Res 2013;92(6):492-499.
James Bader, DDS, MPH; Ben Balevi, BEng, DDS, Dip EBHC(Oxford), MSc; Paul Farsai, DMD; Carlos Flores-Mir, DDS, Cert Ortho, DSc; John Gunsolley, DDS, MS; Debora Matthews, DDS, Dip Perio, MSc; Katherine Vig, BDS, MS, FDS, DOrth; James Zahrowski, DMD, MS, PharmD
Systematic review conclusion. Erbium:yttrium-aluminum-garnet (Er:YAG), neodymium:yttrium-aluminum-garnet (Nd:YAG) and gallium-aluminum-arsenide (GaAlAs) lasers appear to be efficacious in reducing dentin hypersensitivity (DH). However, given the high degree of heterogeneity of the included studies, future adequately powered randomized controlled trials (RCTs) are needed to confirm these results. Critical summary assessment. The authors assessed 13 RCTs providing limited evidence that Er:YAG, Nd:YAG and GaAlAs lasers could be efficacious in reducing DH when compared with no treatment; however, they did not compare the results with those for studies of alternative treatments. Evidence quality rating. Limited. Clinical question. In adults with dentin hypersensitivity (DH), do certain lasers, compared with placebo or no treatment, effectively reduce DH? Review methods. Two independent reviewers searched seven electronic databases through Feb. 10, 2013, with no language restrictions. The reviewers considered only randomized controlled trials (RCTs) involving adult participants in which investigators compared laser treatment for DH with placebo or no treatment. The reviewers combined the change in pain level from baseline to follow-up in a meta-analysis to determine efficacy. The reviewers assessed risk of bias. Main results. The reviewers included in the meta-analyses 13 RCTs that involved 373 adults
and four types of lasers: erbium, chromium:yttrium-scandiumgallium-garnet (Er,Cr:YSGG) versus placebo, erbium:yttrium-aluminumgarnet (Er:YAG) versus placebo, neodymium:yttrium-aluminumgarnet (Nd:YAG) versus placebo, and gallium-aluminum-arsenide (GaAlAs) versus placebo. The reviewers reported no statistically significant differences for Er,Cr:YSSG versus placebo (standardized mean difference [SMD], 2.49; 95 percent confidence interval [CI], −0.25 to 5.22; P = .07) but did report statistically significant differences in favor of lasers for Er:YAG versus placebo (SMD, 2.65; 95 percent CI, 1.25 to 4.05; P = .0002), Nd:YAG versus placebo (SMD, 3.59; 95 percent CI, 0.49 to 6.69; P = .02) and GaAlAs versus placebo (SMD, 3.40; 95 per-
cent CI, 1.93 to 4.87; P < .00001). The reviewers rated three trials as being at low risk of bias and the remaining 10 as being at high risk of bias. The reviewers found substantial clinical heterogeneity among each group of studies, including variation in how DH was stimulated (air blasts of varying duration and tactile stimulation) as well as in how pain was recorded (visual analog scale and verbal rating scale). Conclusions. All lasers (Er:YAG, Nd:YAG and GaAlAs) except Er,Cr:YSGG appear to be efficacious in reducing DH; however, considering the important limitations of the evidence, no clinical recommendation can be given. No sources of funding for this systematic review were listed.
JADA 145(4) http://jada.ada.org April 2014 e1 Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 29, 2014
ORIGINAL CONTRIBUTIONS
COMMENTARY Importance and context. DH is a common condition that is characterized by short, sharp pain arising from exposed dentin in response to thermal, evaporative, tactile, osmotic or chemical stimuli. Its pathogenesis remains unclear, but it is thought to be caused by changes in fluid pressure in dentinal tubules in response to these stimuli. Several treatment alternatives, including laser therapy, have been proposed and have had variable degrees of efficiency. Several types of lasers are used; however, the effectiveness of laser therapy remains unknown. Strengths and weaknesses of the systematic review. The reviewers in this systematic review examined only one means of desensitization, lasers, in comparison with placebo, and they did not compare lasers with alternative treatments. The reviewers also did not form a conclusion about which laser type is preferable, because they did not compare results between laser types. The reviewers conducted a comprehensive search with adequate inclusion and exclusion criteria, and they evaluated only RCTs. They performed random-effects meta-analyses for each treatment arm but did not stratify trial outcomes on the basis of symptoms and disease severity, a measure that would have minimized heterogeneity. They treated all outcome measurements similarly, without any assessment or consideration of the reliability and accuracy of the outcome measurement used. They summarized the magnitude of the reductions in discomfort in terms of SMDs, making it difficult to determine the clinical significance of these results. Strengths and weaknesses of the evidence. Study designs varied substantially, particularly in elements that might influence outcomes, such as exposure time and methods of stimulation and measurement. Similarly, the amount of time between treatment and final assessment varied extensively, from immediately to six months after treatment. When these studies were synthesized, both latency and delay of treatment effect became possible confounding variables. The reviewers did not attempt to detect any temporal effects, electing simply to analyze the effects over the longest period assessed. In addition, most or all of the included studies had a high risk of bias (10 of 13), were split-mouth studies (nine of 13) and had small sample sizes (13 of 13). There were only a few studies in each laser category. Because the reviewers found a high degree of heterogeneity, one should consider the conclusions cautiously. Implications for dental practice. The results of this systematic review are of limited value to clini-
cians because they do not provide information about which laser is best, and the reviewers also did not compare lasers with other existing desensitizing treatments. Three lasers (Er:YAG, Nd:YAG and GaAlAs), but not a fourth (Er,Cr:YSGG), appear to be efficacious in reducing DH. However, because the magnitudes of the effects of each laser were not reported in a more clinically relevant manner, and because the results varied between the studies, it is difficult to determine the usefulness of lasers in the treatment of DH in clinical practice. Before recommending laser therapy over other modalities such as oxalates and desensitizing toothpaste, dentists should consider the clinical context, the scientific evidence, the patient’s values and the cost-benefit relationship. n
doi:10.14219/jada.2013.56
Dr. Bader is a research professor, Department of Operative Dentistry, University of North Carolina at Chapel Hill. He also serves The Journal of the American Dental Association as its associate editor for evidence-based practice and is a member of the ADA Critical Review Panel. Dr. Balevi maintains a private practice in general dentistry in Vancouver, British Columbia, Canada, and is an associate with the faculty of medicine, University of British Columbia, Vancouver. He also is a member of the American Dental Association Critical Review Panel. Dr. Farsai is an associate professor, Goldman School of Dental Medicine, Boston University. He also is a member of the American Dental Association Critical Review Panel. Dr. Flores-Mir is an associate professor and the division head, Orthodontics, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmondton, Alberta, Canada. He also is a member of the American Dental Association Critical Review Panel. Dr. Gunsolley is a professor, Department of Periodontics, School of Dentistry, Virginia Commonwealth University, Richmond. He also is a member of the American Dental Association Critical Review Panel. Dr. Matthews is the assistant dean, Research, Faculty of Dentistry, Dalhousie University, Halifax, Nova Scotia, Canada. She also is a member of the American Dental Association Critical Review Panel. Dr. Vig is an emeritus faculty member, Division of Orthodontics, College of Dentistry, The Ohio State University, Columbus. She also is a member of the American Dental Association Critical Review Panel. Dr. Zahrowski maintains a private practice in orthodontics in Tustin, Calif. He also is a member of the American Dental Association Critical Review Panel. Address correspondence to Dr. Zahrowski at 13372 Newport Ave. #E, Tustin, Calif. 92780, e-mail JJZahrowski@ gmail.com. Disclosure. None of the authors reported any disclosures. These summaries, published under the auspices of the American Dental Association Center for Evidence-Based Dentistry, are prepared by practitioners trained in critical appraisal of published systematic reviews who work under the mentorship of experts. The summaries are not intended to, and do not, express, imply or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. For more information on the evidence quality rating provided above and additional critical summaries, please visit http://ebd.ada.org.
e2 JADA 145(4) http://jada.ada.org April 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
