Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : ZE25 - ZE30 Full Version

Photobiomodulation and its Effect on Stability of Orthodontic Mini-implants: A Systematic Review and Meta-analysis of Randomised Controlled Trials


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53306.16282
Reshma Mohan, Ravindra Kumar Jain, Arthi Balasubramaniam

1. Postgraduate, Department of Orthodontics and Dentofacial Orthopaedics, Saveetha Dental College and Hospital, Chennai, Tamil Nadu, India. 2. Associate Professor, Department of Orthodontics and Dentofacial Orthopaedics, Saveetha Dental College and Hospital, Chennai, Tamil Nadu, India. 3. Senior Lecturer, Department of Public Health Dentistry, Saveetha Dental College and Hospital, Chennai, Tamil Nadu, India.

Correspondence Address :
Ravindra Kumar Jain,
Saveetha Dental College and Hospital, Saveetha Institute of Medical and
Technical Sciences, Saveetha University 162, Poonamallee High Road,
Chennai-600077, Tamil Nadu, India.
E-mail: ravindrakumar@saveetha.com

Abstract

Introduction: The influence of Photobiomodulation (PBM) on the field of orthodontics has been of recent interest. The PBM has a promising effect on acceleration of tooth movement, alleviation of pain during orthodontic treatment and Mini-Implant (MI) stability.

Aim: To systematically report on the effectiveness of PBM on the stability of orthodontic MI.

Materials and Methods: This systematic review was conducted during January 2021 and February 2021. Literature search was conducted in five electronic databases for human trials published between January 2000 to February 2021 on the effectiveness of PBM therapy for stability of orthodontic MI. Cochrane review manager software (Revman version 5.4) and Cochrane Risk Of Bias (ROB) 2 tool were used for bias assessment. The primary outcome measured was the stability of MI using Resonance Frequency Analysis (RFA) or Periotest Value (PTV). The secondary outcomes measured were pain and inflammation around the peri-implant area. Also, Interleukin-1β (IL-1β) was also measured in gingival crevicular fluid.

Results: A total of six Randomised Controlled Trials (RCTs) were included in the review. Out of the six studies, two showed low Risk Of Bias (ROB) whereas three showed some concerns and one showed high ROB. Quantitative analysis was done for four studies with a random effects model to assess the MI stability measured by periotest at 30 days and 60 days. A significant mean difference of -3.31 (95% Confidence Interval [CI]-5.15, -1.47) between PBM and controls for mini-implant stability at 30 days and a significant mean difference of -3.47 (95% CI-4.58, -2.36) between PBM and controls at 60 days with low heterogeneity was obtained. Three studies reported on the pain response after PBM and both groups showed no significant difference. A decrease in gingival inflammation was reported in one study whereas other study showed no significant change in IL-1β in gingival crevicular fluid.

Conclusion: Majority of the studies included in this review reported improved secondary stability with PBM. The low heterogeneous nature of the quantitative studies also supports the data obtained. However, the results should be concluded with caution.

Keywords

Bone implant interactions, Laser, Light accelerated orthodontia

Stability of the MI is a critical factor that determines the clinical success of orthodontic treatment and is dependent on many factors. According to Baek SH et al., MI failures usually occur during the first week after loading. Therefore, enhancing early stabilisation could be an essential step in increasing the stability of MI (1). Loading MI immediately after treatment does not give specific time for tissue healing (2). An important factor responsible for the long-term clinical success of an implant is the quality of bone and its volume. The biomechanical stability of MI depends on bone formed at the bone-implant interface (2). Mechanical retention in sufficiently dense bone provides sufficient primary stability for MI (3).

The PBM is a non invasive procedure used in orthodontics for accelerating tooth movement and alleviating pain during treatment. It is also known as Light Accelerated Orthodontia (LAO) therapy or Low-Level Light Therapy (LLLT) as it uses low energy light or laser in the red to near infrared range of about 600-1000 nm (4). It induces a non thermal photochemistry effect on the cellular level following an increase of Adenosine Triphosphate (ATP) production in mitochondria (4).

Inflammation of the peri-implant region is one of the main reasons for failure and is manifested as redness, swelling of tissues around the neck of the screws (5). Immediately after loading, the area of placement suffers from ischaemic injury, altered oxygen supply and lack of nutrients; which can lead to apoptosis of the injured cells in the peri-implant area (6). The healing process involves inflammation, tissue formation, and tissue remodelling which in turn maintains tissue integrity (7). However, inflammation can deteriorate the bone surrounding the neck of MI. PBM therapy has been proposed to show a beneficial effect on tissue growth and regeneration. It has been used in many areas such as wound healing, pain relief, antiinflammatory effect and accel-erating orthodontic tooth movement (8). This therapy uses non ionising light sources in the visible and near infrared spectrum promoting non thermal biological processes over tissues (9). This light is capable of affecting cell behaviour with significant heating effects, among other benefits (10). PBM promotes an increase of the vascularisation; modulation of the inflammatory processes; proliferation of fibroblasts, keratinocytes, chondrocytes, and osteoblasts; and cytokine expression that induce matrix synthesis, improving the bone repair process (11),(12),(13).

Many studies have reported increased stability of orthodontic MI with the use of PBM therapy (14),(15),(16),(17),(18),(19),(20). The aim of the current systematic review is to systematically analyse the available literature and report on the effectiveness of PBM therapy for improving the stability of orthodontic MI.

Material and Methods

Protocol registration: The systematic review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement (21). This systematic review was conducted during January 2021 and February 2021. The review was registered with the PROSPERO database (CRD42020218813).

Search strategy: A systematic search of the medical literature produced from January 2000 to February 2021 was performed to identify all peer-reviewed articles potentially relevant to the review’s question. The following databases were searched: PubMed, Cochrane library, Lilacs, Embase and Google Scholar. The search was attempted to gather all articles relevant to the study with no time and language restriction in order to eliminate bias (Table/Fig 1).

Data collection process: PICO (patient/population, intervention, comparison and outcomes) analysis along with eligibility criteria is mentioned in (Table/Fig 2). All studies meeting the selection criteria were included in the review. The selection process of included studies was reported in the PRISMA flow chart (Table/Fig 3). A table for describing the ‘study characteristics’ of the included articles was made that included the following information: first author, year of publication, study design, sample size, control group, intervention group, outcomes in the studies (i.e., stability, displacement, pain assessment, etc.,), parameters assessed and the statistical tests done.

Risk of Bias (ROB): The ROB was assessed using Cochrane ROB-2 tool (22). The risk of the included studies are assessed in five domains according to the tool- bias due to randomisation process, deviations from intended intervention, missing outcome data, measurement of outcome and selection of reported results. Each RCT was assigned at high risk (>1 domains showed high), some concerns (>1 domains showed some concerns) or low risk (no domains showed high or some concerns). Two authors (RM and RKJ) performed the ROB independently and a third author (ABS) resolved the disparities. The Cohen’s kappa test (κ) test was used to assess the level of agreement between the reviewers.

Quantitative assessment: Meta-analysis was performed on studies reporting the stability of MI that were assessed by PerioTest Value (PTV) units at 30 days and at 60 days using random effects model where heterogeneity was high [I2 >50%]. Cochrane review manager software (Revman version 5.4) was used for meta-analysis and the studies involving both RFA groups were not taken into consideration as one study measured mobility in Hertz and the other measured it in Implant Stability Quotients (ISQ) grading.

Level of evidence: The certainty of the scientific evidence was assessed using the GRADEpro (Grading of Recommendations Assessment, Development, and Evaluation) guidelines (23). The stability of MI between the two groups after 30 and 60 days of loading in the studies involved for quantitative analysis were assessed for their study design, ROB, inconsistency, indirectness, imprecision and publication bias if any.

Results

Search strategy: The electronic search identified a total of 2,242 studies. After removal of duplicates, there were a total of 605 articles, which were then subjected to further screening. After screening through titles and abstracts, a total of eight articles were assessed for eligibility. From this, based on the inclusion criteria, two articles were excluded. Only six relevant studies were identified and were included for the qualitative analysis. Total of four studies out of six were included for quantitative analysis. The results of the search are illustrated in the PRISMA flow chart (Table/Fig 3).

The studies included were all of the split mouth design. A total of 104 participants were involved, all of whom were treated with PBM or LLLT on the experimental side.

Characteristics of the intervention: All included studies assessed the effect of PBM on the stability of MI and their information is given in (Table/Fig 4) (14),(15),(16),(17),(18),(19).

In the included studies of this review, the protocol of laser application was different. In the study by Ekizer A et al., PBM with energy density of 20 mW/cm2 was applied on the test side and pseudo application was done on the placebo side for a period of 21 successive days (20 minutes per day) (16). The primary stability was assessed with RFA using an Osstell ISQ RFA device. Flieger R et al., in their study used a 635 nm laser with a dose of 10 J for 100 seconds at two points each (buccal and palatal side of the alveolus/implant) (14). The total energy per session was 20 J/cm2. The laser application was done on 0, 3, 6, 9, 12, 15, and 30 days after implant placement and the total energy for all therapeutic sessions together was 140 J. The implant stability was measured using a Periotest device (PTV). Matys J et al., in their two studies used two different laser emission parameters that is 635 nm (19) and 808 nm (15). In both the studies, they irradiated with diode laser at two points (palatal and buccal peri-implant area) with 4 J energy per point for 40 seconds. The total energy applied was 56 J after all the sessions. The periotest device was used to assess the stability of the implant. Osman A et al., used a 910 nm diode laser using 0.7 watts for 60 seconds over the MI insertion area without any contact with the mini-screw (18). The stability was assessed before and after loading at different time periods (immediately, 7, 14, 21, 30, and 60 days) with a PTV device. Abohabib AM et al., used a diode laser with 940 nm wavelength at 0, 7, 14 and 21 days after the placement of the MI, where the stability was measured using RFA (17).

The results of most of the included studies have shown an increase in the implant stability after 30 days of loading of the MI, except for Osman A et al., who demonstrated no significant difference in improvement of MI stability after application of PBM (Table/Fig 5) (14),(15),(16),(17),(18),(19).

Risk Of Bias (ROB) of the included studies (Table/Fig 6): Out of the six studies, only two had a low ROB (16),(17) whereas one showed high risk (18) and three showed some concerns (14),(15),(19). Flieger R et al., Matys J et al., and Matys J et al., had not mentioned how they had blinded their participants and personnel showing bias in the randomisation process. In the study by Matys J et al., reporting bias was observed. One microimplant in the control group was lost during the 60 day frame and the results still included the failed microimplant group (14),(15),(19). The study by Osman A et al., showed bias due to deviation from intended interventions and outcome measurement (18).

Meta-analysis: The results of the meta-analysis for mini-implant stability after 30 days of loading between PBM and control group showed significant (p-value=0.0004) mean difference of -3.31 (95% CI -5.15, -1.47) and a low heterogeneity (I²=35%) in the included studies (Table/Fig 7).

The results of the meta-analysis for mini-implant stability after 60 days of loading between PBM and control group showed significant (p-value <0.00001) mean difference of -3.47 (95% CI -4.58, -2.36) and no heterogeneity (I²=0%) in the included studies (Table/Fig 8).

Assessment of certainty of evidence (Table/Fig 9): The quality of available evidence of MI stability between the groups after loading at 30 days and 60 days was assessed using GRADEpro (23). The certainty of evidence on the effect of PBM on MI stability after 30 and 60 days of loading was found to be ‘low’ owing to the high ROB associated with one study (18) and some concerns with three studies (14),(15),(19) included for the quantitative analysis. Also, a small sample size and fewer number of studies contribute to risk of imprecision which further downgrades the level of evidence from the RCTs.

Discussion

Summary of evidence: This systematic review included six RCTs which assessed the stability of the orthodontic mini-implants after low level laser diode application. All included studies (14),(15),(16),(17),(18),(19) reported higher mini-implant secondary stability after application of PBM in the peri-implant area and a statistically significant increase in the stability was noted in five (14),(15),(16),(17),(19) of the six studies. None of the studies reported significant reduction in pain experience after laser application. All of the six studies were split mouth RCTs, the laser application protocols and dosages varied among the studies. Since, one of the included studies had reported a high ROB (18) and three showed some concerns (14),(15),(19), a higher mini-implant stability following treatment with PBM should be carefully considered. In the present review, meta-analysis to assess the MI stability reported a significant mean difference of -3.31 and -3.47 between PBM and control groups concluding a significantly improved mini-implant stability after subjecting to PBM at 30 days and 60 days. A low heterogeneity of the included studies was noted at both 30 and 60 days.

Costa ACF et al., has recently published a systematic review on the stability of MIs when subjected to PBM (24). They have included both randomised and non randomised trials in their SR and have reported that two studies had low ROB and three had unclear ROB. In this review a high ROB was noted in 1 study (18) and some concerns in three studies (14),(15),(19); and it is supported by the inter-reviewer agreement. Also, the method of conversion of PTVs to RFA values as mentioned by Costa ACF et al., in their review is questionable as it is just a plain inversion of values whereas a method of proper conversion is reported in the literature (25). In this review, meta-analysis of only the PTV values reported in 4 of the articles included was done.

All studies included in this review (14),(15),(16),(17),(18),(19) have reported using 8-10mm long and 1.5 mm diameter implants. The loading protocol is one important factor which influences the stability of mini-implants. It was uniform in all the six studies included in the review and a delayed loading after two weeks was done. The site of placement is also an important factor affecting mini-screw stability and all the studies reported placement in the attached gingiva between second premolar and first molar in maxilla (14),(18),(19). In none of the studies, stent was used for placing mini-implants. Hence, many factors affecting the stability of mini-implants were matched and standardised. The measurement tool used to assess the stability of the mini-screws was either RFA or Periotest. Both these are established methods for analysing implant stability and a significant correlation between the two has been reported in the literature (26).

All of the included studies reported a higher mini-implant stability following administration of PBM except for the study by Osman A et al., which reported a non significant reduction in the mobility of the mini-screws after PBM therapy when compared to untreated controls (18). On bias assessment, this study reported a high ROB due to deviation from intended interventions and outcome measurements. The authors did not mention the method of mini-screw placement and the total energy dosage of laser application. Since, there are some methodological deficiencies reported in the study, the results of the study should be considered with caution.

Three studies had reported on the pain response of patients after mini-implant placement in both control and study groups (14),(19),(27). No significant differences in pain experience between the both groups were reported. All subjects experienced pain after the first 2-4 hours following placement of the MIs. The initial pain remained over the first 24 hours then subsided over the week. The efficacy of laser application for relieving pain after MI placement is not significant in the three studies. However, since the three studies are conducted by the same authors the results should be considered with caution.

Gingival inflammation was reported in the study by Osman A et al., They reported less inflammatory changes in the PBM treated group (18). In the control group, they reported inflammation in three patients by the end of one month. This was resolved with proper oral hygiene instructions. However, the gingival inflammation increased by the end of two months in the control group; whereas the experimental group showed no signs of inflammation throughout treatment. The results by Osman A et al., suggested that laser therapy seems to modulate the inflammatory response which in turn increases the inflammatory cytokines which reabsorb the traumatised bone and improves bone metabolism (18). These results are consistent with an animal study by Yanaguizawa MS et al., where they suggested that the lack of gingival inflammation observed in the lower level laser therapy group could be attributed to the decreasing level of IL-8 on laser therapy stimulation (28). Boyce B et al., study has shown that IL-1 and tumor necrosis factor played an important role during bone remodelling by osteoclast formation and activation (29). Studies have shown that IL-1ß levels are involved with bone resorption and inhibition of apposition during orthodontic movement of teeth (30),(31),(32). Ekizer A et al., suggested that PBM treatment had no effect on IL-1 levels in the gingival crevicular fluid of tooth and peri-implant crevicular fluid during canine distalisation (16).

Limitation(s)

The limitations of this review include different laser application protocols reported in the selected studies which can affect the results. Inclusion of a small number of studies for the meta-analysis can also be considered a limitation. The quality of the included studies was moderate thus, limiting the clinical application of the review findings. Therefore, considering all these limitations further clinical trials with better methodology are required.

Conclusion

Based on the evidence provided by this systematic review, it is suggested that PBM therapy is effective in enhancing the primary stability of MIs. It is also observed that PBM has no effect on pain experience after MI placement. However, due to the low quality evidence, we recommend well-designed studied with standard protocols to be conducted in the near future.

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DOI and Others

DOI: 10.7860/JCDR/2022/53306.16282

Date of Submission: Nov 15, 2021
Date of Peer Review: Jan 12, 2022
Date of Acceptance: Feb 03, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 23, 2021
• Manual Googling: Jan 11, 2022
• iThenticate Software: Feb 17, 2022 (14%)

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