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\begin{document}

\title{Use of Photobiomodulation for Anesthesia Puncture Pain Reduction: A Case
Report}



\author[1]{Anna Carolina  Horliana}%
\author[1]{Giovanna Fontgalland Ferreira}%
\author[1]{Glaucia Gonçales Abud Machado}%
\author[1]{Vinicius Leão Roncolato}%
\author[1]{Sandra Bussadori}%
\author[1]{Lara  Jansiski Motta}%
\author[1]{Cinthya Cosme Gutierrez Duran}%
\author[1]{Kristianne Fernandes}%
\author[1]{Raquel Agnelli Mesquita-Ferrari}%
\affil[1]{Universidade Nove de Julho}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\selectlanguage{english}
\begin{abstract}
The objective of this study is to evaluate the effect of
photobiomodulation (PBM) on pain control during pterygomandibular
puncture. A patient received anesthesia on both sides of the mouth in a
randomized manner. On the right side, an 808nm infrared low-level laser
was applied before local anesthesia. On the left side, a sham laser was
applied using the same technique. There was a 50\% reduction in pain
levels on the PBM-treated side compared to the sham PBM side, as
measured by the visual analog scale. Sensitivity tests revealed that
anesthesia was more effective on the PBM side. There was no significant
difference in blood pressure before and after anesthesia on either side.
While these findings are based on a single case report, they suggest
that photobiomodulation before anesthesia may alleviate puncture pain
associated with anesthesia. Nevertheless, further well-designed clinical
trials are necessary to confirm the effectiveness of this complementary
therapy.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Dental fear and phobia are highly prevalent in adults worldwide.
Generally, this fear can be linked to trauma and is directly associated
with dental care. Anxious patients have lower treatment adherence, which
can lead to oral health issues and reduced quality of life {[}1,2{]}.
Pain is commonly cited as the primary reason for this fear, with local
anesthetic injection being the procedure most dreaded by patients
{[}3,4{]}.

The pterygomandibular is a challenging technique. Some students and
novice professionals may struggle to identify anatomical landmarks
accurately. Additionally, anatomical variations of the mandibular
foramen can sometimes occur. Consequently, it is frequent to repeat or
supplement anesthesia, increasing patient fear.

Other techniques have been developed to alleviate pain puncture.
However, there is currently no standardized injection method or
established protocol {[}5,6,7{]}.

Photobiomodulation is a technique that employs low-level lasers for
therapeutic purposes, serving as a complementary therapy across multiple
health specialties {[}8,9{]}. In dentistry, it can be applied to many
procedures, but its most effective effect is on pain management. This
technique is safe and lacks contraindications or adverse effects. Some
wavelengths were tested for this protocol {[}10,11,12,13,14,15{]},
however, the lack of evidence on this topic, highlights the need for
randomized and controlled clinical trials.

This study aims to provide a case report detailing the use of
photobiomodulation as an adjunct for pain control during
pterygomandibular puncture.

\textbf{CASE REPORT}

Patient M.R.F, male, 54 years old, with controlled systemic
hypertension. He presented subgingival calculus and scaling, and root
planning was performed. Bilateral pterygomandibular anesthesia was
performed by the same operator. This study was accepted by the Ethics
Committee (5.598.425) and followed CARE checklist (Figure 1)

\textbf{Clinical features}

The patient has expressed fear and discomfort with the anesthetic
procedure since he was a child. In their own words, they stated, ''I
would prefer to feel pain during cleaning and restoration than to take
anesthesia.''

It used a carpule with a backflow prevention mechanism, two long
needles, two tubes of Mepivacaine 2\% with epinephrine 1:100,000, a
low-power laser device (MMOptics\textsuperscript{TM}), and protective
eyewear. (Figure 2-A).

To eliminate any potential placebo effect, the patient was blind to the
procedures. A website \emph{https://www.sealedenvelope.com} was employed
to determine the initial treatment on the right side. Therefore, the
right side was laser sham, while the left side was effective laser.

Figure 2- A) Materials used; B) Positioning of the laser; C) Puncture
site

\textbf{Photobiomodulation}

It was observed that most studies used the infrared laser with high
energy doses {[}10,11, 12,13,14,15{]}. Thus, the protocol of choice was
adapted and described in Table 1 {[}13{]}. The laser was applied before
anesthesia at the indicated site (Figure 2-B) and then anesthetized at
the same site (Figure 2-C).

Table 1 -- Dosimetric parameters

\textbf{Pain assessment}

The pain was measured using the visual analog scale (VAS), which
consists of a 10cm line, from 0 (no pain) to 10 (the worst pain). The
patient was instructed to mark a vertical line at the point that best
matched the intensity of pain at that exact moment after the injection,
on both sides.

\textbf{Anesthetic Latency Time}

To measure the beginning of the anesthesia effect, a digital stopwatch
was used by an assistant who measured the results about sensibility in 2
and 5 minutes, according to professional orientation and the perception
that the patient reported.

\textbf{Blood Pressure}

For safety reasons, blood pressure was measured before and after the
procedure by the dental surgeon with a manual sphygmomanometer.

\textbf{RESULTS}

On the laser side, the pain sensation was 4,2 cm on VAS scale while on
the sham side, it was 8,4 cm, 50\% reduction in the pain sensation on
the photobiomodulation side (Figure 3).

Figure 3- VAS (Visual Analog Scale)

A) Laser sham side: 8,4cm (VAS); B) Laser side: 4,2cm (VAS)

Supplementary anesthesia was not necessary on any side. The patient felt
discomfort during the procedure on the sham side, while on the laser
side, it was not reported. Concerning anesthesia duration time, on the
laser side, the anesthetic latency time was better, the sensation of the
lip, mucosa, and pulp test, and the time to anesthesia was quickly
compared to the A-laser sham side.

No difference could be observed between blood pressure before and after
anesthesia at either time point.

All the results obtained are shown in the table below (Table 2).

Table 2- Case report results

\textbf{DISCUSSION}

There is a demand for pre-procedure local anesthesia therapy to address
the fear and trauma experienced by many patients during this procedure.
This therapy should provide a safe, side-effect-free solution that
effectively alleviates pain caused by needle punctures and eliminates
the need for repeated anesthesia {[}2{]}.

The effectiveness of the use of Photobiomodulation is already proven,
and numerous well-designed studies have obtained positive results,
especially in pain control. However, to date, there are no well-designed
studies on the relationship between photobiomodulation and its action in
local anesthesia {[}8,9{]}.

This study found a 50\% improvement in the patient's perception of pain,
in line with other studies with anesthesia that have shown positive
results. Sensitivity tests showed that anesthesia was more effective on
the laser side, and there was no difference in blood pressure before and
after anesthesia.

Given all other the studies found, it was not possible to find other
outcomes evaluated, that is, it was not possible to compare results
about anesthetic latency or the possible change in blood pressure.
Studies that evaluate more than one outcome and not only pain are
necessary since this is an area of application of photobiomodulation
where there is a shortage of studies.

Even though this case report had positive results, we cannot state that
the application of photobiomodulation before anesthesia is determinant
to reduce pain and increase the effectiveness of local anesthesia since
it also depends on the technique performed and possible anatomical
changes of the patient, and this case, we evaluated only one patient.
For this reason, more studies are needed to evaluate the mechanism of
action of photobiomodulation in anesthesia and well-designed clinical
studies to prove this possible effect.

\textbf{Acknowledgments}

The project received a governmental grant from the National Council for
Scientific and Technological Development process (CNPq:3146682020-9).

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https://doi.org/10.1007/s41547-021-00120-3\selectlanguage{english}
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