Can Diode Laser 810 decrease Post Endodontic Pain in Patients with Asymptomatic Necrotic Maxillary Incisors? A Four-Arm Randomized Controlled Trial

doi:10.21203/rs.3.rs-3139987/v1

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Can Diode Laser 810 decrease Post Endodontic Pain in Patients with Asymptomatic Necrotic Maxillary Incisors? A Four-Arm Randomized Controlled Trial

https://doi.org/10.21203/rs.3.rs-3139987/v1

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Background and aim:

In light of the development of modern technologies and the insertion of laser in the context of endodontic treatment, this study aimed to find the best method for applying the 810 diode laser to relieve post-endodontic pain on necrotic maxillary incisors with periapical lesions within a single-visit treatment.

Methods:

Eighty patients with a necrotic incisor, diagnosed with asymptomatic periodontitis, received standardized cleaning and shaping procedures, then divided equally into four groups: G1: control group with no laser application, G2: applying the diode laser as an irrigation activation system (IAS), G3: applying the diode laser from the buccal and palatal mucosa, G4: applying the diode laser as an IAS and from buccal and palatal mucosa. The postoperative pain (PP) was assessed using the visual analog scale (VAS) 1, 3, 7, and 14 days after the treatment. The mean values of the VAS score were statistically analyzed.

Results:

During 14 days after treatment, there was a statistically significant difference between mean values of VAS scores in the four groups (P value < 0.05); G1 scored the highest score, whereas G4 showed the lowest one. Moreover, G4 showed favorable outcomes compared with G2 and G3 during the first three days after treatment.

Conclusion:

Diode laser reduced the PP after necrotic teeth with large-sized apical lesion treatment, whereas using diode laser either as an IAS or LLLT reduced the PP compared with the control group. Moreover, the usage of a diode laser in both previous techniques represents the best protocol for PP relieve during 14 days of treatment.

Health sciences/Health care

Health sciences/Medical research

Endodontic treatment

Diode laser 810

Low-level laser therapy

Irrigation activation system

Post-operative pain

Low-level laser therapy (LLLT) with diode laser incorporates the application of non-heating non-invasive red light which can penetrate biological tissue deep to 5 mm, interact with cells, and promote oxidative metabolism in the mitochondria leading to an increase in the synthesis of endogenous endorphins, modify the pain threshold,

decrease bradykinin synthesis, prostaglandin synthesis, and histamine release, with the target of decreasing inflammation, improving tissue repair and wound healing, and producing analgesia [1–6]. Moreover, LLLT is a very useful non-invasive therapy for patients who are needle phobic or for those whom they are contraindicated to take non-steroidal anti-inflammatory drugs [7].

The diode laser has been used widely in many domains of medicine and dentistry [8]. It can be used to disinfect the root canal due to its ability to eliminate bacteria and seal the dentinal tubules [9]. In addition, several endodontic-related studies have reported the possibility of using a diode laser as LLLT, as it is more profound than the blue-visible or red-visible spectrum[10], and thus it is eligible to be applied externally to the periapical tissues to relieve pain and flair-up following endodontic treatment in the mechanism mentioned previously [11] [12].

Moreover, a diode laser can be used to agitate the irrigation solution, where it causes a vapor bubble formation which occurs very fast, causing very rapid turbulence in the irrigant solution throughout the whole canal and thus it enhances the effectiveness of cleaning process during root canal treatment and reduces the post-operative pain (PP) and flair-up [13–15].

Flair-up is one of the most problems facing clinicians which arises especially in the first hours or days after treating necrotic teeth with peri-apical lesions as pain and/or swelling requiring emergency clinical visit [16] and occurs with an incidence of 3%-58% [17].

The inflated levels of inflammatory mediators, which exist in the damaged periapical tissue, engender the activation or sensitization of peripheral nociceptors and cause peripheral hyperalgesia [17, 18].

Many factors could be correlated with the incidence of flare-ups included: the number of visits to complete the treatment, factors related to the host (age and gender), the existence of pre-operative pain, the condition of the pulp (vital or necrotic), and the peri-radicular tissues, and the extrusion of the debris and the medicaments beyond the apex during the treatment [19–21].

There are many protocols to relieve the PP including pharmaceutical and non-pharmaceutical strategies. The pharmaceutical strategies aim to minimize the symptoms by using drugs such as acetaminophen [22], steroidal and non-steroidal drugs [23], anti-inflammatory [24], and a combination of 2 drugs [25]. Non-pharmaceutical strategies depend on reducing the PP with the aid of stress-lowering approaches[26], intra-canal cryotherapy [27], intra-canal dressing, and using the diode laser as LLLT or as an Irrigation activation system.

After reviewing several dental literatures, studies about the best protocol for applying the diode laser in the context of pain relief after endodontic treatment was not sufficient, so this study aimed to evaluate the effect of using the diode laser either in IAS or LLLT or the combination of both previous techniques on PP after endodontic treatment of necrotic teeth with apical lesions. The null hypothesis suggests that there are no differences between diode laser application in three ways compared to the control group in which no laser was used.

Study design, settings, and ethical approval

This randomized double-blinded clinical trial (RCT) has utilized a four-arm parallel superiority design with a 1:1:1:1 allocation ratio. This study was conducted from January 2020 and January 2023 at the Endodontic Department Faculty of Dentistry, Damascus University, Damascus, Syria. This study was conducted respecting the ethical guidelines of the Declaration of Helsinki. The research project was ethically approved by the Local Research Ethics Committee of the Faculty of Dentistry, Damascus University (UDDS-98-07022019/SRC-1734). The project was self-funded and it was registered at the ISRCTN registry under ID number: ISRCTN99457940 in 17/11/2022. This RCT has been written according to CONSORT 2010 guidelines [28].

Sample size calculation

The sample size was calculated using G* Power 3.1.9.4 (Heinrich-Heine-Universität, Düsseldorf, Germany). It was estimated depending on the study of Naseri et al. [11] which described the changes in a Visual Analog Scale (VAS) value after 24 hours of endodontic treatment with LLLT. A minimum total sample size of 80 patients (20 in each group) was found to be sufficient for a level of significance of 0.05, power of 95%, and 0.37857 as effect size f (using the mean and standard deviation of the groups in the previous study).

Recruitment and Eligibility Criteria

Two hundred seventy-five patients aged between 25 and 44 years were referred to the Endodontic Department during the study period because the presence of apical lesions in their teeth was investigated by the principal research (M.T.A). The principal investigator searched for patients with at least one or more maxillary incisors (central or lateral) with large-sized periapical lesions > 5mm (S3) according to Venskutonis classification [29]. Preoperative periapical radiographs were taken to assess incisor anatomy, periapical lesion size, apex diameter, and the cause of periapical lesion to determine the included incisors. Those who met this condition were one hundred and forty patients. Sixty patients were considered unsuitable for inclusion due to the presence of systemic diseases that compromised their general immune status, un-restorable incisors, teeth with symptomatic periodontitis, lidocaine hypersensitivity, open-apex incisors, incisors with multi-canals, internal or external resorptions, patients with advanced periodontitis (more than 5 mm periodontal attachment and bone loss), or incisors with unsuccessful previous endodontic treatment.

Therefore, eighty patients were included in the current research. All included patients, who accepted to participate in this study, signed an informed consent sheet after explaining all the details about the trial and the therapeutic part of it.

Randomization

Incisors were assigned to no laser application group, diode laser as an IAS group, diode laser in LLLT or the diode laser as an IAS and LLLT group together using the simple randomization method at an allocation ratio of 1:1:1:1, and a random sequence was created using the website www.random.org, which was accessed on 1 January 2020.

Cards with different diode laser application methods were placed into opaque and sealed envelopes (20 envelopes per study group), and the patients were instructed to randomly select an envelope. Thus, patients were assigned to four groups: Group 1 (control group): no laser application (n = 20), Group 2: diode laser as an IAS (n = 20), Group 3: diode laser in LLLT (n = 20), and Group 4: diode laser as an IAS and LLLT together (n = 20).

Blinding

As the current study was an interventional study, the treating clinician could not be blinded regarding the diode laser application method during treatment. However, the involved patients were completely blinded. The assessment of treatment outcomes was completed by two trained researchers (two Ph.D. students) who were calibrated to the evaluation criteria and blinded to the diode laser application method.

Clinical procedure

Under local anesthesia and rubber dam isolation, all caries and previous restorations were removed. The access cavity was refined using an Endo-Z bur (Dentsply Maillefer, Tusla, Oklahoma, USA). The canal orifice was prepared using an orifice opener file (ORODEKA LTD. Xincheng, Jining, China). The working length was determined with an apex locator (C-smart-1, COXO, Fushan, China) using K-file #10, and confirmed radially.

After achieving the glide path, the canal was shaped using Plex V ORODEKA rotary files (ORODEKA LTD. Xincheng, Jining, China). The final apical file was #25 to #40 concerning the initial size of canals. The canal was irrigated copiously with sodium hypochlorite (NaOCl) 5.25% using a 30-gauge endodontic irrigating needle (Sybron Endo, Crop, Orange, CA, USA) between files. After instrumentation, the sample was divided into four groups according to the method of diode laser application: (G1) No laser application (control group), (G2) diode laser as an IAS, (G3) diode laser in LLLT and (G4) diode laser as an IAS and LLLT together.

Group 1 (No laser application):

The canals were filled up with sodium hypochlorite, and then intermittent ultrasonic irrigation was used, where a #25 U-file ultrasonic tip (U-file, Zipperer Co., Munchen, Germany), mounted on an ultrasonic handpiece (Woodpeker, Guilin, China), was inserted inside the filled canal 2 mm before the apex without wall contact. The NaOCl was activated for 45 seconds at the medium power setting (30-kHz) with a push-and-pull movement for each 2 mL of irrigant, which was repeated until achieving 40 mL of NaOCl within 15 min in total. Then, all canals were irrigated with normal saline, filled with 2 mm of EDTA 17% (Produits Dentaires SA, Vevey, Switzerland), and activated with the U-file in the same previous settings for 15 seconds, and the procedure was repeated twice. Finally, all canals were irrigated with normal saline, filled with 2 mm of CHX 2% (Maquira, Maringa, Brazil), and activated with the U-file in the same previous settings for 15 s, and that was repeated twice. The previous method of irrigant activation was similar to the one described by Liapis [30], and Prada [31].

Group 2 (Diode laser as an IAS):

The canals were filled up with sodium hypochlorite, and then the laser irradiation was performed using an 810-nm diode laser (Mercury G10; Wuhan Pioon Technology Co., Ltd., Wuhan City, China) coupled with an optical fiber tip (200 µm). The tip was inserted 2 mm before the apex and operated at the following settings: an average power of 1.2 W with a lower frequency of 50 Hz and an energy of 12 J (each cycle) in pulsed mode. Then, the tip was removed using a slow helical movement in the apicoronal direction. Each 2 mL was activated for 45 seconds and repeat until 40 mL of NaOCl was activated within about 15 min in total (Fig. 1). Then, all canals were irrigated with normal saline, filled with 2 ml of EDTA 17%, and activated with a diode laser in the same previous settings for 15 seconds, and the procedure was repeated twice. Finally, all canals were irrigated with normal saline, filled with 2 ml of CHX 2%, and activated with a diode laser for 15 seconds, and that was repeated twice. The previous method of irrigant activation with a diode laser was similar to the one described by Coelho [32] and Kaplan [33].

All canals in G1 and G2 were dried using sterilized paper points (Gabadent, Guangdong, China) and obturated using gutta-percha (Gabadent, Guangdong, China) and AH plus sealer (Dentsply Sirona, Charlotte, NC, USA) in the warm vertical compaction technique, and the canals were restored with suitable resin bonded restorations (Fig. 2 and Fig. 3).

Group 3 (Diode laser in LLLT):

Patients in G3 received no laser application during final irrigation as described in G1. After restoring the teeth, an 810-nm diode laser (Mercury G10; Wuhan Pioon Technology Co., Ltd., Wuhan City, China) coupled with an optical fiber laser tip (8 mm) was positioned 3 mm away from the oral mucosa and perpendicular to soft tissue with the beam focused on the apical location of the targeted tooth which was estimated based on the working length of the incisor. Diode laser exposure was carried out using a continuous mode with 10 Hz frequency, and power of 100 mW. The tip was applied both at the buccal and the palatal side for 80 s each (Fig. 4). The previous method of LLLT was similar to the one described by Naseri [11].

Group 4 (Diode laser as an IAS and LLLT together):

Patients in G4 received diode laser activation during final irrigation as described in G2, and after restoring the teeth, they get LLLT with diode laser as described in G3.

Outcomes measures

Patients of all groups were recalled at 1 day, 3 days, 7 days, and 14 days of treatment, and PP was recorded using a VAS scale, where patients chose their pain levels by pointing along a 10-cm continuous line between two endpoints, ranging from the absence of pain to unbearable pain.

The CONSORT flow chart of the study was described in Fig. 5.

Statistical analysis

The collected data were tabulated and analyzed using SPSS software (Version 20, IBM SPSS Inc., Chicago, IL, USA). Shapiro–Wilk test was used to evaluating if the quantitative measurements showed normal distribution, so the comparison between groups regarding PP was performed using the Kruskal–Wallis test, and the pairwise comparisons were performed using the Mann-Whitney U test. The level of significance was set at 0.05.

A total of 80 necrotic incisors in 80 patients (42 males and 38 females) aged between 25 and 44 years (\(\stackrel{-}{x}\) = 27.5) were included in the study. No significant differences were reported between the groups regarding the age (P = 0.335) and gender (P = 1.000) of the treated patient, indicating that the allocation of patients into study groups was randomized.

Table 1 and Fig. 2 summarize the mean, the standard deviation, the range, and the Kruskal-Walis test results of the VAS scores of the pre-operative pain and the PP after 1, 3, 7, and 14 days of treatment in the groups. The Kruskal-Wallis test showed a significant difference between the groups (No laser application, diode laser as an IAS, diode laser in LLLT and diode laser as an IAS and LLLT together) after 1,3,7, and 14 days of treatment (P = 0.000, P = 0.000, P = 0.000, and P = 0.001 respectively). Meanwhile, there were no significant differences between the groups before the treatment (P = 0.525), indicating that pre-operative pain levels of the asymptomatic patients were similar.

Table 1

Descriptive statistics of the VAS scores in groups and the P-values of significance testing.
Studied Period	Method of using Diode Laser	Number	Mean ± Std. Deviation	Range	Chi Square	*P value
Before Treatment	No laser application	20	0.53 ± 0.52	0–1	0.902	0.825
	Diode laser as IAS	20	0.60 ± 0.51	0–1
	Diode laser in LLLT	20	0.60 ± 0.51	0–1
	Diode laser as IAS and LLLT together	20	0.73 ± 0.59	0–2
After 1 day	No laser application	20	5.00 ± 2.14	3–9	45.339	0.000^
	Diode laser as IAS	20	1.60 ± 0.74	1–3
	Diode laser in LLLT	20	0.80 ± 0.68	0–2
	Diode laser as IAS and LLLT together	20	0.27 ± 0.46	0–1
After 3 days	No laser application	20	2.80 ± 1.86	1–6	39.035	0.000^
	Diode laser as IAS	20	0.60 ± 0.74	0–2
	Diode laser in LLLT	20	0.20 ± 0.41	0–1
	Diode laser as IAS and LLLT together	20	0 ± 0	0–0
After 7 days	No laser application	20	0.80 ± 0.86	0–3	24.235	0.000^
	Diode laser as IAS	20	0.13 ± 0.35	0–1
	Diode laser in LLLT	20	0 ± 0	0–0
	Diode laser as IAS and LLLT together	20	0 ± 0	0–0
After 14 days	No laser application	20	0.33 ± 0.49	0–1	16.091	0.001^
	Diode laser as IAS	20	0 ± 0	0–0
	Diode laser in LLLT	20	0 ± 0	0–0
	Diode laser as IAS and LLLT together	20	0 ± 0	0–0
* Kruskal-Walis test ^ Signigicant differences

The Mann-Whitney U test was used to detect differences in pairwise comparisons in Table 2, where it showed that after one day of the treatment, the four groups have significant differences in pairwise comparisons (P < 0.05 in each pairwise comparisons); the no laser application group (G1) had the highest mean of VAS scores (\(\stackrel{-}{x}\) = 5.00(, then the diode laser as an IAS group (G2) (\(\stackrel{-}{x}\) = 1.60), then the diode laser in LLLT group (G3) (\(\stackrel{-}{x}\) = 0.80), and the diode laser as an IAS and LLLT together (G4) had the lowest mean of VAS scores (\(\stackrel{-}{x}\) = 0.27(. Similarly, after 3 days of treatment, the four groups have significant differences in pairwise comparisons (P < 0.05 in each pairwise comparisons); the no laser application group (G1) had the highest mean of VAS scores (\(\stackrel{-}{x}\) = 2.80(, then the diode laser as an IAS group (G2) (\(\stackrel{-}{x}\) = 0.60), then the diode laser in LLLT group (G3) (\(\stackrel{-}{x}\) = 0.20), and the diode laser as an IAS and LLLT together (G4) had the lowest mean of VAS scores (\(\stackrel{-}{x}\) = 0.00(.

After 7 days of treatment, there was no significant differences between diode laser as an IAS group (G2) (\(\stackrel{-}{x}\) = 0.13(, diode laser in LLLT group (G3) (\(\stackrel{-}{x}\) = 0.00(, and the diode laser as an IAS and LLLT together (G4) (\(\stackrel{-}{x}\) = 0.00( (P < 0.05, in each pairwise comparisons) regarding the mean of VAS score. However, the no laser application group (G1) had the highest mean value of VAS score (\(\stackrel{-}{x}\) = 0.80(, and there were significant differences between G1 and G2, G3, and G4 ( P = 0.008, P = 0.000, and P = 0.000 respectively). Similarly, After 14 days of treatment, there was no significant differences between diode laser as an IAS group (G2) (\(\stackrel{-}{x}\) = 0.00(, diode laser in LLLT group (G3) (\(\stackrel{-}{x}\) = 0.00(, and the diode laser as an IAS and LLLT together (G4) (\(\stackrel{-}{x}\) = 0.00( (P < 0.05, in each pairwise comparisons) regarding the mean of VAS score. However, the no laser application group (G1) had the highest mean value of VAS score (\(\stackrel{-}{x}\) = 0.33(, and there were significant differences between G1 and G2, G3, and G4 ( P = 0.016 for each comparisons).

Table 2

Descriptive statistics of pairwise comparisons between the groups and the P-values of significance testing.
Studied Period	Irrigant Activation Technique (I)	Irrigant Activation Technique(J)	Mean Difference (I-J)	U value	*P-Value
After 1 day	Diode laser as IAS	No laser application	-3.40	4.0	0.000*
		Diode laser as an IAS and LLLT together	1.33	16.0	0.000*
		Diode laser in LLLT	0.80	53.0	0.007*
	Diode laser as an IAS and LLLT together	No laser application	-4.73	0	0.000*
	Diode laser as an IAS and LLLT together	Diode laser in LLLT	-0.53	63.5	0.022*
	Diode laser in LLLT	No laser application	-4.20	0	0.000*
After 3 days	Diode laser as IAS	No laser application	-2.20	25.5	0.000*
		Diode laser as an IAS and LLLT together	0.60	60.0	0.003*
		Diode laser in LLLT	0.40	79.5	0.098*
	Diode laser as an IAS and LLLT together	No laser application	-2.80	0	0.000*
	Diode laser as an IAS and LLLT together	Diode laser in LLLT	-0.20	90.0	0.073*
	Diode laser in LLLT	No laser application	-2.60	7.5	0.000*
After 7 days	Diode laser as IAS	No laser application	-0.67	58.0	0.008*
		Diode laser as an IAS and LLLT together	0.13	97.5	0.150
		Diode laser in LLLT	0.13	97.5	0.150
	Diode laser as an IAS and LLLT together	No laser application	-0.80	45.0	0.000*
	Diode laser as an IAS and LLLT together	Diode laser in LLLT	0	112.5	1.000
	Diode laser in LLLT	No laser application	-0.80	45.0	0.000*
After 14 days	Diode laser as IAS	No laser application	-0.33	75.0	0.016*
		Diode laser as an IAS and LLLT together	0	112.5	1.000
		Diode laser in LLLT	0	112.5	1.000
	Diode laser as an IAS and LLLT together	No laser application	-0.33	75.0	0.016*
	Diode laser as an IAS and LLLT together	Diode laser in LLLT	0	112.5	1.000
	Diode laser in LLLT	No laser application	-0.33	75.0	0.016*
* Mann-Whitney U test. ^ significant difference.

The current study had special importance, although the last systematic review recommended conducting more studies on the LLLT [12], this study evaluated the effect of both intra-canal and extra-canal 810 diode laser application with standardized parameters in comparison with conventional endodontic treatment without the use of laser in the term of PP in single-rooted teeth presenting with necrotic pulps and periapical lesion performed in a single visit within a subgroup of Syrian patients. Our results reject the null hypothesis, as the three ways of diode laser application (IAS, LLLT, and combination of IAS and LLLT) reduced the PP in comparison with the control group (no laser application) during 14 days of the treatment of necrotic maxillary incisors in single visit treatment.

Although the rotary preparation systems reduce the extrusion of the debris beyond the apex, they do not eliminate this phenomenon [34], which increases the PP, especially in necrotic teeth, where the microorganisms within the root canal system are expelled with the debris into the periapical tissues [35] [16]. This may explain the use of different methods to reduce PP after necrotic teeth treatment.

Previous studies used a diode laser in wavelength between 808–910 as a non-invasive way to reduce PP [3]. A lot of studies have focused on the use of diode lasers in activating irrigants as a potential method for reducing PP [36] [37], other studies have concentrated on its use in the context of low-level laser therapy [11] [38], and one study has compared both of these techniques on the PP [39], but to the best of our knowledge, this is the first study to compare the use of these two techniques together on PP.

This study was carried out on healthy participants having asymptomatic periodontitis in maxillary incisors with a large-sized periapical lesion. Patients having a previous history of pain were not involved to reduce all potential pre-operative factors. Moreover, patients with disseminated oral pain were not included, as pain in one tooth may affect other teeth [40].

A specific methodology was used in the present study to minimize PP as much as possible, where all canals were kept gently patent with a small instrument (#10 K file), and the WL was determined with the apex locator and confirmed by a radiograph to be 1 mm before the radiographic apex to avoid further periodontal ligament damage. Moreover, the canals were prepared as appropriate for the initial apex size measurement, and care was taken to avoid over-instrumentation of the root canal system to avoid increasing the PP in necrotic teeth [41]. In addition, irrigation protocols are very contrasting through in-vivo studies due to many available irrigation procedures and tooth statutes [42]. For example, the activation time, NaOCl concentration, and total volume were increased to make the irrigation protocol suitable for the treatment of necrotic teeth with large-sized periapical lesions to minimize the bacteria virulence in the root canal system. Nevertheless, continuous replenishment during the activation of the three irrigants was done to maintain their efficacy [43, 44].

The PUI was adopted in the control group because this method is commonly and widely used as an IAS in laboratory, bacteriological, and clinical studies related to endodontics [45] [46] [47]. It was also mentioned that PUI can reduce the PP compared to conventional irrigation [48].

It is noteworthy that both PUI and diode laser activation didn’t increase the apical extrusion of irrigants in comparison with conventional needle irrigation [49]. Diode Laser activation of hypochlorite enhances biofilm removal from the infected dentinal root and helps to eliminate enterococci faecalis by 98% [50, 51]. Nevertheless, diode Laser activation of EDTA enhances removing the smear layer from the apical third of the root canal [52]. Moreover, diode laser activation of CHX increased its penetration through dentinal tubes [53]. The previous enhancement in irrigants features, which increased in disinfecting and cleaning of the root canal system rather than the healing characters of the diode laser itself [54], may reflect in pain decreasing in patients of diode laser as an IAS group in comparison with the control group through all follow-up periods.

The previous results are in agreement with several studies that diode laser relieves the PP compared to the control group [36] [37]. However, although the difference in the mean values of VAS scores between the two groups was relatively small, the significant differences in the laser activation group lasted for two weeks compared to previous studies that showed significant differences for only one day.

The application of diode laser in the LLLT (third and fourth groups) was adopted to be irradiated on the buccal and palatal surface because it represented the best protocol for this type of treatment compared to the buccal application alone during the first hours after the end of treatment, as irradiating on only the buccal surface, the periapical region close to the palatal surface may receive lower energies than the periapical region close to the buccal surface and vice versa [11].

The results indicated that the LLLT group showed improvement in mean values of VAS scores compared with the no laser application group through follow-up periods. These results met the previous studies that using a diode laser in LLLT reduced the PP [11][38]. Moreover, the application of a diode laser in LLLT showed superior improvement to the mean value of VAS scores in the IAS group during the first 3 days of treatment. The previous result can be explained by the diameter of the optic fiber of the device used (200 µm for the IAS group and 8 mm for the LLLT group), as the application of the laser in LLLT included a wider area than its application within the canal. The previous result differed from Ismail's study, where the previous study found that the application of the diode laser in LLLT was better than its application as an IAS only on the first day of treatment [39].

The group of diode laser as an IAS and LLLT together showed the best PP decreasing compared to the LLLT group alone and IAS group alone through three days of treatment, and compared to the no laser application group through fourteen days of treatment, which means that the greater the area of exposure by different methods of diode laser, the more optimal the reduction of PP.

Although both forms of intra-canal and extra-canal laser application have the same effect in relieving PP after 3 days of treatment, the intra-canal application seems to be easier because it also activates the irrigants and thus shortens the treatment steps. However, in the case of a tooth with a curved canal, it may be difficult to enter the tip inside the canal and therefore pain relief by the external application may be easier. When appropriate, both internal and external application of the diode laser is the optimal protocol to reduce PP.

Despite our best attempts to standardize the criteria of the patients included in the current study, there were problems represented in the pain of the infiltration anesthesia and gingival pain resulting from the rubber dam clamp, which may have affected pain assessment, especially on the next day after treatment. Moreover, since the previous study was a clinical study, it was not possible to standardize the apical diameters of the teeth included in the patients, so we only relied on expanding the apical foramen to three measurements of its basic diameter, and therefore the amount of expansion was not associated with the severity of PP. In addition, not all cases of asymptomatic necrotic incisors were suitable for single-visit treatment, as some cases were not filled in the same session because the canals were not dried; these cases required a calcium hydroxide dressing that could mask the pain caused by irrigants activation [33], which forced us to exclude these cases from the current study.

Further studies are required to assess the relationship between the diode laser application method used and periapical lesion healing of necrotic teeth.

Within the above-mentioned limitations of this randomized clinical trial, the results showed that diode laser can reduce the PP of necrotic teeth with large-sized apical lesions; diode laser as an IAS has favorable effects in reducing PP compared to no laser application during three days of treatment. Moreover, diode laser in LLLT has favorable effects in reducing PP compared to IAS during three days of treatment, and the usage of both techniques together represents the best protocol for PP relieve during fourteen days of treatment.

Funding: This research received no external funding.

Conflicts of Interest: The authors declare no conflict of interest.

Author Contributions: Mohammad Tamer Abbara and Ghina Mahayni conceptualized the idea, provided the treatment, and contributed to the writing and documenting. Samar Akil and Omar Hamadah conceptualized the idea and supervised the PhD thesis for Mohammad Tamer Abbara. Yasser Alsayed Tolibah contributed to the interpretation of data and the revision, formatting, and re-editing of the manuscript. All authors read and agreed to the published version of the manuscript.

Data availability: The datasets used and analyzed during the current study available from the corresponding author on reasonable request

Acknowledgments: The presented research is part of the PhD study of Mohammad Tamer Abbara approved by the Local Research Ethics Committee of the Faculty of Dentistry (UDDS-98-07022019/SRC-1734).

Chung, H., et al., The nuts and bolts of low-level laser (light) therapy. Annals of biomedical engineering, 2012. 40: p. 516-533.
Asnaashari, M. and N. Safavi, Application of low level lasers in dentistry (endodontic). Journal of lasers in medical sciences, 2013. 4(2): p. 57.
He, W., et al., A systematic review and meta-analysis on the efficacy of low-level laser therapy in the management of complication after mandibular third molar surgery. Lasers in medical science, 2015. 30: p. 1779-1788.
de Freitas, L.F. and M.R. Hamblin, Proposed mechanisms of photobiomodulation or low-level light therapy. IEEE Journal of selected topics in quantum electronics, 2016. 22(3): p. 348-364.
Bashkatov, A.N., et al., Optical properties of human skin, subcutaneous and mucous tissues in the wavelength range from 400 to 2000 nm. Journal of Physics D: Applied Physics, 2005. 38(15): p. 2543.
Bouillaguet, S., et al., Production of reactive oxygen species from photosensitizers activated with visible light sources available in dental offices. Photomedicine and laser surgery, 2010. 28(4): p. 519-525.
Carroll, J.D., et al., Developments in low level light therapy (LLLT) for dentistry. Dental Materials, 2014. 30(5): p. 465-475.
Metin, R., U. Tatli, and B. Evlice, Effects of low-level laser therapy on soft and hard tissue healing after endodontic surgery. Lasers in medical science, 2018. 33: p. 1699-1706.
Moritz, A., et al., In vitro irradiation of infected root canals with a diode laser: results of microbiologic, infrared spectrometric, and stain penetration examinations. Quintessence Int, 1997. 28(3): p. 205-9.
Huang, Y.-Y., et al., Biphasic dose response in low level light therapy. Dose-response, 2009. 7(4): p. dose-response. 09-027. Hamblin.
Naseri, M., et al., Effect of Low-level Laser Therapy With Different Locations of Irradiation on Postoperative Endodontic Pain in Patients With Symptomatic Irreversible Pulpitis: A Double-Blind Randomized Controlled Trial. J Lasers Med Sci, 2020. 11(3): p. 249-254.
Guerreiro, M.Y.R., et al., Effect of low-level laser therapy on postoperative endodontic pain: An updated systematic review. Complementary Therapies in Medicine, 2021. 57: p. 102638.
Hibst, R., et al., Mechanism of high-power NIR laser bacteria inactivation. J Biophotonics, 2010. 3(5-6): p. 296-303.
Koch, J.D., et al., Irrigant flow during photon-induced photoacoustic streaming (PIPS) using Particle Image Velocimetry (PIV). Clinical oral investigations, 2016. 20: p. 381-386.
Yoon, H.S., et al., Akkermansia muciniphila secretes a glucagon-like peptide-1-inducing protein that improves glucose homeostasis and ameliorates metabolic disease in mice. Nature Microbiology, 2021. 6(5): p. 563-573.
Walton, R.E., Interappointment flare‐ups: incidence, related factors, prevention, and management. Endodontic Topics, 2002. 3(1): p. 67-76.
Sathorn, C., P. Parashos, and H. Messer, The prevalence of postoperative pain and flare‐up in single‐and multiple‐visit endodontic treatment: a systematic review. International endodontic journal, 2008. 41(2): p. 91-99.
Nath, R., et al., Efficacy of corticosteroids for postoperative endodontic pain: A systematic review and meta-analysis. Journal of dental anesthesia and pain medicine, 2018. 18(4): p. 205-221.
DiRenzo, A., et al., Postoperative pain after 1- and 2-visit root canal therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2002. 93(5): p. 605-10.
Walton, R. and A. Fouad, Endodontic interappointment flare-ups: a prospective study of incidence and related factors. Journal of endodontics, 1992. 18(4): p. 172-177.
Arias, A., et al., Relationship between postendodontic pain, tooth diagnostic factors, and apical patency. Journal of endodontics, 2009. 35(2): p. 189-192.
Torabinejad, M., et al., Effectiveness of various medications on postoperative pain following complete instrumentation. Journal of Endodontics, 1994. 20(7): p. 345-354.
Arslan, H., E.C. Gündoğdu, and M. Sümbüllü, The effect of preoperative administration of antihistamine, analgesic and placebo on postoperative pain in teeth with symptomatic apical periodontitis: a randomized controlled trial. Eur Endod J, 2016. 1(1): p. 1.
Attar, S., et al., Evaluation of pretreatment analgesia and endodontic treatment for postoperative endodontic pain. Journal of endodontics, 2008. 34(6): p. 652-655.
Menhinick, K.A., et al., The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double‐blind, placebo‐controlled study. International endodontic journal, 2004. 37(8): p. 531-541.
Gatchel, R.J., Managing anxiety and pain during dental treatment. J Am Dent Assoc, 1992. 123(6): p. 37-41.
Keskin, C., et al., Effect of intracanal cryotherapy on pain after single-visit root canal treatment. Aust Endod J, 2017. 43(2): p. 83-88.
Cuschieri S. The CONSORT statement. Saudi J Anaesth. 2019 Apr;13(Suppl 1):S27-S30
Venskutonis, T., et al., Periapical and endodontic status scale based on periapical bone lesions and endodontic treatment quality evaluation using cone-beam computed tomography. Journal of endodontics, 2015. 41(2): p. 190-196.
Liapis, D., et al., Postoperative pain after ultrasonically and laser‐activated irrigation during root canal treatment: a randomized clinical trial. International Endodontic Journal, 2021. 54(7): p. 1037-1050.
Prada, I., et al., Update of the therapeutic planning of irrigation and intracanal medication in root canal treatment. A literature review. Journal of clinical and experimental dentistry, 2019. 11(2): p. e185.
Coelho, M.S., L. Vilas-Boas, and P.Z. Tawil, The effects of photodynamic therapy on postoperative pain in teeth with necrotic pulps. Photodiagnosis and photodynamic therapy, 2019. 27: p. 396-401.
Kaplan, T., S.S. Kaplan, and G.P. Sezgin, The effect of different irrigation and disinfection methods on post-operative pain in mandibular molars: a randomised clinical trial. BMC Oral Health, 2022. 22(1): p. 1-9.
Tanalp, J. and T. Güngör, Apical extrusion of debris: a literature review of an inherent occurrence during root canal treatment. International endodontic journal, 2014. 47(3): p. 211-221.
Siqueira Jr, J.F., Microbial causes of endodontic flare‐ups. International endodontic journal, 2003. 36(7): p. 453-463.
Omar, Z.M., H. El Shinawy, and G. Eid, Effect of diode laser activated irrigation on postoperative pain in single visit endodontic treatment: a randomized controlled trial. Acta Scientific Dental Sciences, 2020. 4(2): p. 1-6.
Erkan, E., et al., Postoperative pain after SWEEPS, PIPS, sonic and ultrasonic-assisted irrigation activation techniques: a randomized clinical trial. Odontology, 2022. 110(4): p. 786-794.
Pawar, S.S., et al., Postendodontic treatment pain management with low-level laser therapy. Journal of Dental Lasers, 2014. 8(2): p. 60.
Ismail, H.H., M. Obeid, and E. Hassanien, Efficiency of diode laser in control of post-endodontic pain: a randomized controlled trial. Clin Oral Investig, 2023. 27(6): p. 2797-2804.
Ramamoorthi, S., M.S. Nivedhitha, and M.J. Divyanand, Comparative evaluation of postoperative pain after using endodontic needle and EndoActivator during root canal irrigation: A randomised controlled trial. Australian Endodontic Journal, 2015. 41(2): p. 78-87.
Junior, J.A.C., et al., The effect of foraminal enlargement of necrotic teeth with the reciproc system on postoperative pain: a prospective and randomized clinical trial. Journal of endodontics, 2016. 42(1): p. 8-11.
Tonini, R., et al., Irrigating solutions and activation methods used in clinical endodontics: a systematic review. Frontiers in oral health, 2022. 3: p. 838043.
Moorer, W. and P. Wesselink, Factors promoting the tissue dissolving capability of sodium hypochlorite. Int Endod J, 1982. 15(4): p. 187-96.
Zehnder, M., Root canal irrigants. Journal of endodontics, 2006. 32(5): p. 389-398.
Orlowski, N.B., et al., Smear layer removal using passive ultrasonic irrigation and different concentrations of sodium hypochlorite. Journal of endodontics, 2020. 46(11): p. 1738-1744.
Kluge, M., et al., Improving the microbial sampling and analysis of secondary infected root canals by passive ultrasonic irrigation. Clinical Oral Investigations, 2022. 26(6): p. 4575-4586.
Tolibah, Y.A., et al., Comparison of MTA versus Biodentine in apexification procedure for nonvital immature first permanent molars: a randomized clinical trial. Children, 2022. 9(3): p. 410.
Salim, A., A. Darrag, and W. Ghoneim, Post-Operative Pain after Single-Visit Endodontic Treatment Using Different Root Canal Irrigation Activating Techniques. Egyptian Dental Journal, 2021. 67(4): p. 3719-3730.
Helvacıoğlu Kıvanç, B., et al., Apical extrusion of sodium hypochlorite activated with two laser systems and ultrasonics: a spectrophotometric analysis. BMC Oral Health, 2015. 15(1): p. 1-5.
Ordinola‐Zapata, R., et al., Biofilm removal by 6% sodium hypochlorite activated by different irrigation techniques. International endodontic journal, 2014. 47(7): p. 659-666.
Sarda, R., et al., Antimicrobial efficacy of photodynamic therapy, diode laser, and sodium hypochlorite and their combinations on endodontic pathogens. Photodiagnosis and photodynamic therapy, 2019. 28: p. 265-272.
Arslan, H., et al., Effect of agitation of EDTA with 808-nanometer diode laser on removal of smear layer. Journal of endodontics, 2013. 39(12): p. 1589-1592.
Iselinni, C., R. Meidyawati, and N. Djauharie, Effects of a 980-NM diode laser’s activation of 2.5% NaOCL and 2% chlorhexidine antifungal irrigation solutions on Candida albicans biofilms. International Journal of Applied Pharmaceutics, 2017. 9(Special Issue 2): p. 14-16.
Dawood, M.S. and S.D. Salman, Low level diode laser accelerates wound healing. Lasers in medical science, 2013. 28: p. 941-945.

No competing interests reported.

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Can Diode Laser 810 decrease Post Endodontic Pain in Patients with Asymptomatic Necrotic Maxillary Incisors? A Four-Arm Randomized Controlled Trial

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