February 01, 2016

Can shining a light on teeth with photobiomodulation make them move faster? A new method of speeding up orthodontic treatment.

Can shining a light on teeth make them move faster?  A new method of speeding up orthodontic treatment.

We would all like to make teeth move faster and complete our orthodontic treatment in a shorter time. I have previously posted about several recent developments that aim to reduce treatment times which are being marketed without much evidence. This post is concerned with a recent study about photobiomodulation in which low-level light energy is applied to the alveolar bone with the aim of speeding up orthodontic treatment.

Before we look at the paper, I would like to point out that my blog reached a milestone last month. As regular readers know, all the posts last month were about orthodontic extractions. This must have been interesting to people because the blog was accessed 26,000 times by 12,500 visitors. It looks as though this is becoming surprisingly popular..

This week’s post is on a paper that was spotted by Nick Pandis from Corfu, Greece. Nick has been a great support to me on this blog and has provided me with some statistical information on this post.

Intraoral photobiomodulation-induced orthodontic tooth alignment : a preliminary study.

Shaughnessy, T., Kantarci, A., Kau, C. H., Skrenes, D., Skrenes, S., & Ma, D. (2016).

BMC Oral Health, 1–9. doi:10.1186/s12903-015-0159-7

This paper was published in the open access journal BMC Oral Health. This is a relatively new Journal but has an established editorial board. It does not publish many orthodontic studies.

I have published several posts on methods of making teeth move faster.  I have pointed out that current knowledge shows us that developments in “magic” wires and “special” brackets do not seem to have an effect on the rate of tooth movement. Nevertheless, work on the stimulation of bone remodelling in the individual patient may show some promise and is certainly very interesting. Unfortunately, recent evidence suggests that using vibration does not appear to be effective and injection of substances and surgical injury to bone may not be acceptable to our patients.

An alternative appears to be photobiomodulation (PBM). In this technique the alveolar bone is exposed to low-level light therapy. This activates the cellular mechanism that increase blood flow and this leads to optimal tooth movement. This theory is supported by some animal experiments.

This study is a preliminary study that aims to assess the feasibility and impact of an intra-oral PBM device. The manufacturers of the device supported the study but most of the authors were independent and they declared all conflicts.

They tested the null hypothesis that there will be no difference in the rate of orthodontic anterior alignment between PBM and a control group.

What did they do?

They enrolled 19 participants (11-18 years old) who attended a private practice for treatment in the USA. The patients were treated between September 2011 and September 2013.

This was not a randomised trial. The first 8 patients enrolled in the study were in the control group and the subsequent 11 participants received additional treatment with the PBM device. It is important to note that the patients in the control group started treatment before the PBM patients. There was also a change in the type of bracket used in the practice. This meant that the control group was bonded with 018 slot self-ligating speed brackets. But most of the PBM group were treated with 018 slot conventional ligated brackets.

Study casts were taken at

  • T0 before bonding
  • T1 when the Little’s index was visually detected to be less than 1mm.

They then calculated the weekly rate of crowding resolution. I am not sure how they did this because they did not state when they saw the patients for review appointments.

They carried out a power calculation They also subjected the data to a wide battery of statistical tests.

What did they find?

There was no difference at the start of treatment between the groups for Little’s index scores. They found significant differences in tooth movement between the groups For the PBM group the average rate of tooth alignment was 1.27 mm/week. For the control group this was 0.44mm/week.

What did I think?

I thought that this was an interesting paper that may lead to further studies which could provide us with clinically important information. But we need to be careful in interpreting this study for the following reasons:

  • There was an imbalance between the groups in that the PBM group had 44% mandibular arches and the control had 70%.  This may be a considerable confounder because there may be differences in the rate of alignment between arches. However, they did account for this, to a degree, in their analysis.
  • The participants were not randomly allocated
  • The two groups were treated with different brackets!
  • The participants were only followed until initial alignment and we do not know the effect of PBM on treatment time to the end of treatment.
  • This was a small-scale pilot study with a small sample size. The literature is full of pilot studies suggesting a treatment effect, but when a larger study was carried out the effect disappeared.

It was good to see that the authors drew attention to these issues in their discussion and suggested further work was certainly necessary. This was unlike the recent Acceledent study that showed “positive” results.

So before we all go out buying PBM and selling it to our patients, all we can conclude at the moment is that this new technique may work. In this respect, this was a useful study. Let’s hope that the manufacturers have not started advertising.

Oh no too late….

I looked at their web-based clinical dossier, this includes animal studies, publications in review and low circulation journals which show “positive” effects of this treatment. This then leads to claims that PBM reduces treatment time.

I take it back…. In the land of no evidence; the Salesman is King.

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Have your say!

  1. I just hope that the Acceleration lasts till finishing. Anyway , especilly teenage patients will be motivated further by a faster unravelling of crowding.

  2. Let us hope that the “light will shine on the truth of PBM” with further research. I am skeptical but worth a look!

  3. Thanks Kevin for taking the time to review these articles. It would be nice if the PBM did decrease treatment time. It would also be neat if it reduced treatment discomfort. Then again with the way marketing seems to be taking us by simply paying an extra $19.95 you can upgrade to the deluxe model with which you can speed up your orthodontics, reduce your wrinkles and remove unwanted body hair (with a note to consumers to clean the appliance appropriately between each application)

  4. My university ( Mahidol ) did some clinical trial with orthopulse when I was doing my master.
    From what the teacher told me ( Yes I know not so evidence based comment ), the speed was faster than the control group for the levelling but not so much difference after that.
    Plus the patient has to come back to the practice for doing the light session, take time for the patient and take time for the clinician (or assistant ) so I do not see this a a very practical option. My adults patient complain that they have to come to see to often already.
    If they develop a DIY at home option perhaps.

  5. It is such a pity that they rushed into this study (as also occurred with the original vibrational and SL bracket studies) rather than conducting a prospective RCT as this paper does not answer the question for us. As you pointed out Kevin, the use of different brackets can influence the result. A narrower SL bracket controls rotation less than a twin bracket and so there can be less/slower reduction in the irregularity index. They also combined the upper and lower arches and there was a disproportionate number of upper arches in the experimental group. The irregularity index can be greater in the upper arch (larger teeth so displacement of contacts is greater when crowded) and also allows for a greater reduction in irregularity so it ‘seems’ they move faster. This happened in the very first clinical paper on vibration by one of these authors where he reported upper arch irregularity and the larger decrease they claimed to be due to the appliance causing more rapid movement. However when compared with another paper reporting upper arch irregularity reduction (and no appliance) it was actually the same. For all these reasons this paper is just confusing the issue and why it is not appearing in one of our leading orthodontic journals – it just would not be accepted for publication.

  6. It’s a fact that teeth move faster when you shine a light onto them because otherwise the brackets fall off.

  7. Whats next? Tickling teeth to move faster??? Oh hey maybe teeth can dance better to Rock and Roll music :/

  8. With all due respect Peter, the SPEED self ligating bracket is not the same as a traditional single wing bracket with respect to your comment on rotational control. I am not promoting any particular bracket, however, the nickel titanium clip combined with a NiTi AW will fully and efficiently de-rotate the tooth. And honestly, if you do not believe that, place one in an over-corrected position on your next patient and see what happens! The evidence does not support one bracket system, e.g., Damon, Smart Clip, moving teeth any faster than another bracket system. There is no evidence demonstrating that teeth move slower with the SPEED bracket system. So, it seems disingenuous to me when folks on this blog in particular, who know very well what the evidence says, write that “they even used a different bracket!” in their control group! Yes we did (for reasons I can explain, and I did not hide the fact that I did so) and it happens to be a bracket that some would tout as being able to move teeth faster-but that is not evidence based. We cannot have it both ways. We either respect the evidence or we don’t.

    Why did we publish our paper in a low circulation journal? Because the high circulation journals are NOT going to touch it. They do not want another Acceledent, Damon, situation where they might be seen as promoting a commercial product-or a commercial company using them to do so. I understand that very well and respect it. My prediction is that the only Acceledent article that will be published in the AJO-DO or EJO will be one that shows no evidence for vibration. Full disclosure, I do not use the technology in my practice and have no vested interest in whether it works or not—just like the OrthoPulse.

    Some of the points you and Kevin raise are valid, and we address them in the paper. We reported what we found. We agree that RCTs will ultimately provide the evidence. We introduced the idea, and the potential for light therapy as a way of enhancing the biology of tooth movement in this pilot study. We do not work for Biolux. We sincerely do not have anything at stake in reporting what we find, statistically significant or not. If the next RCT shows no clinically significant evidence for speeding tooth movement with LLLT, every clinician needs to consider that evidence in deciding whether they are willing to incorporate the technology in their office.

    Respectfully, Tim

  9. Tim, thanks for the helpful comments. As you know I felt that your paper was interesting but can you tell us why your team carried out a study in which the two intervention groups were treated with different brackets? As you stated this was a significant co founder, and it certainly must have an effect on the findings and makes the interpretation of the study very difficult.

    I am not sure that I agree on your comments about the major journals not taking papers that show an effect of new technology. I think that the reason that they are now publishing trials on self ligation that show no effect are that the studies have been carried out to a sufficient high standard for publication. There is a long history of low quality studies showing an effect of treatment and higher quality studies finding that this effect is not found. Did you try and publish your study in the AJO-DDO?

    • Thank you Kevin for posting my response, and actually for your fair and balanced comments directed toward the authors. In our previous paper evaluating the velocity of alignment with the earlier version extra-oral delivery system, I collected control data on a SPEED group. These patients were coming into my office every 2 weeks for photos and impressions and it was time consuming in my private practice clinic. So, I predominantly used this same control data ( but added a few more new pts ) when Biolux came out with the intra-oral protype device which I tested in this pilot study, basically because it was already available and yes convenient, and made for a bigger N. Wish we hadn’t now, and do wish a Control group treated at the same time with the same bracket system was used. Very fair point. But I also thought, ok, folks are claiming faster tooth movement (not evidence based) with passive self ligating brackets and the SPEED bracket is passive in any wire less than .016″ in the .018″ slot so I thought the orthodontic community might accept it because this would (if anything) tilt things against finding any significance. Interestingly enough, the rate of alignment with the extra-oral, and first intra-oral devices were similar—by comparison to the same control group. A similar dose could be obtained in a fraction of the time given that the light was closer to the source with the intra-oral device.

      I did not submit to the AJO-DO because they rejected a paper based on a Masters Thesis project of my colleague in Abu Dhabi, Said Samara. His RCT was so much more than ours, in that he evaluated the rate of en-masse (never been done before) extraction site space closure in ~130 quadrants, found some statistical significance (did not claim clinical significance). He spent 2 years doing the project, it was so well controlled (NiTi springs on 19×25 SS AWs, supervised by Jon Artun for demanding treatment consistentcy, photos and models every 4 weeks, etc). I know Said to be an honest and relentless worker and his effort was incredible. After every review (a total of 4), his paper would be sent to new reviewers conflicting with requests from previous reviewers. He was asked to use a different method of statistics after the first review; he complied and it made the findings a bit stronger. He changed everything they asked him to change and after almost a year, it was rejected. A few months ago, the AJODO published a pain evaluation study with a flash of light following separator placement. It did not compare to Said’s monumental project. I just got the impression that the high circulation journals simply did not want to put themselves in a bad position of being used by King Salesman. In the third review, Said was asked to spend more time in the discussion differentiating clinical significance from statistical significance and he went out of his way to make no claims of clinical significance. (I thought it was our job as readers of an article to determine that for ourselves as well). Bottom line, Said did a study and reported what he found, a small statistical difference in rate of space closure with light, not unlike what has been found in the rat model by Alp Kantarci. But I genuinely think Said was penalized because Biolux provided the lights.

      Those are my thoughts and I surely could be wrong Kevin. I just didn’t think we stood a chance of getting our paper published in the AJO-DO, or EJO. I agree that new technology stuff gets published, but the recent climate with marketing, hype, unjustifiable claims, etc does indeed make these different and troubling times. I give Biolux credit though; unlike others peddling devices on the market right now, they sure have sponsored a lot of studies and have accumulated lots of data by comparison. Again, we will see if this technology falls by the wayside like many others have before it, or is proven to be effective.

      Best to you, and I enjoy the blog!


    • I meant to add Kevin, one of the reviewers of Said Samara’s space closure paper wrote: “I can just see it now, this study shows a ~25% increase in the rate of space closure with the addition of light. The manufacturer will claim a 25% reduction in treatment time—if they can resist the temptation to claim 50%”. That is why I thought Said was being penalized for Biolux providing the light for his study. And maybe even a little for what some other manufacturers had done with little evidence and lots of hype>

  10. A local orthodontist is also studying ultrasound’s effects and it ‘sounds’ like it may reduce the risk of root resorption.

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