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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
Original article / research
Full Version
Evaluation of Postoperative Pain in Periodontal Flap Surgery with and without Photobiomodulation using Diode LASER: A Split-mouth Randomised Controlled Study
Correspondence Address :
Neeraj Chandrahas Deshpande,
Room No. 7, Department of Periodontology, K.M. Shah Dental College and Hospital, Piparia, Waghodia, Vadodara-391760, Gujarat, India.
E-mail: drneeraj78@gmail.com
Introduction: Flap surgery is used to treat deep periodontal pockets and recent innovations like Low-level LASER Therapy (LLLT), or Photobiomodulation (PBM), help reduce postsurgical pain. LLLT works by emitting red or infrared light at wavelengths between 660 and 940 nm, which penetrates tissues and interacts with cytochrome c oxidase to modulate immune responses, reduce inflammation and ease pain, promoting faster healing.
Aim: To evaluate and compare postoperative pain in periodontal flap surgery with and without PBM using a diode laser.
Materials and Methods: A split-mouth randomised controlled study was carried out in the Department of Periodontology at KM Shah Dental College and Hospital, Vadodara, Gujarat, India. The study took place from August 2023 to January 2024. Based on the inclusion and exclusion criteria, 14 participants (28 sites) with bilateral pocket probing depths of 5-7 mm diagnosed with generalised periodontitis stage II grade A were treated with open flap debridement. After open flap debridement, the test group (Group A) received PBM using a diode LASER (940 nm in a continuous mode with 0.5 W for 112 seconds) applied with a whitening handpiece at a 3 mm distance to the flap surfaces, whereas the contralateral arch, or control group (Group B), received no LASER treatment. The parameters assessed for postoperative pain following flap surgery included the Visual Analogue Scale (VAS) to track the patients’ pain levels and the amount of analgesics they took throughout the first week following surgery. For inter group comparison of the amount of analgesics taken and assessing the VAS score, the Mann-Whitney U test was used. Data analysis was done using IBM Statistical Package for Social Sciences (SPSS) Statistics 20.0 (IBM Corporation, Armonk, NY, USA), with the level of significance set at p=0.05.
Results: The mean age of the participants was 41.14±2.95 years. Patients in the test group had statistically significant differences in their VAS scores from the day of surgery (day 0) to day 7 compared to the control group. The number of analgesics taken on day 1 postsurgery did not show statistically significant results, as the number of analgesics taken was similar in both the control group as well as LASER group (p-value 0.063). However, patients receiving LASER treatment used fewer analgesics on days 2, 3, 4, 5 and 6 than the control group, with a p-value of less than 0.05, indicating statistically significant findings in this regard.
Conclusion: Based on the present study’s findings, it can be concluded that the 940 nm diode LASER has the potential to greatly minimise postoperative discomfort and reduce the quantity of analgesics that patients require following flap surgery.
Light amplification by stimulated emission of radiation, Pain management, Photobiomodulation therapy, Semiconductor
The outcome of a periodontal flap surgery depends on a number of factors, including the incision design, the degree of tissue invasion, the instruments used, the length of time the patient experiences discomfort and the recovery time following the procedure. These factors can turn it into a stressful treatment stressful, resulting in varying degrees of pain and disabling responses depending on the level of discomfort (1).
Various techniques have been employed to reduce postoperative pain, including the surgical blocking of pain-transmitting neurons, non opioid medications, Non Steroidal Anti-inflammatory Medicines (NSAIDs), opioid analgesics, Patient-controlled Analgesia (PCA) and epidural analgesia. Recently, novel strategies for lessening postoperative pain have emerged, among which Low-level Light Amplification by Stimulated Emission of Radiation (LASER) Therapy (LLLT), also known as Photobiomodulation (PBM) therapy, has garnered significant interest and is increasingly being used in dentistry and medicine (2).
According to previous research, 30 percent of patients who underwent periodontal surgery reported pain in the first week post-treatment (3). Numerous strategies have been employed to regulate the release of inflammatory mediators. NSAIDs are the most frequently used medications to prevent and treat postsurgical pain; however, these medications can potentially cause gastric issues and abnormal platelet function (4).
The PBM uses low-power LASER light with wavelengths between 632 and 1064 nm and a power range of 1 to 1000 mW to induce a biological response (5). There is no vibration, sound, or heat. generated by these LASERS. LLLT causes a photochemical reaction in the cell known as biostimulation or PBM. The absorption and scattering of light within the tissue depend on tissue chromophores and wavelength. Proteins such as flavins, cytochromes, porphyrins and nuclear chromatin excessively absorb wavelengths less than 600 nm excessively, whereas water in the tissue absorbs wavelengths longer than 1150 nm excessively. The range between 600 and 1150 nm is referred to as the “optical window” for PBM, which is the range of practical and useable wavelengths for this application (6).
The PBM is the process of using light, usually from a low-power LASER or Light Emitting Diode (LED) light source, to promote analgesia, lessen inflammation and aid in tissue repair.
It transfers energy to intracellular mitochondrial chromophores, which comprise molecules that absorb light, including endogenous porphyrins and enzymes like Cytochrome-C Oxidase (CCO). Near-infrared light can be absorbed by CCO due to its two heme-iron and two copper cores. Cellular photodissociation of Nitric Oxide (NO) from CCO can be induced by Low-level LASER Therapy (LLLT). When cells are under stress, oxygen in CCO is replaced by NO generated by mitochondrial NO synthase. This replacement lowers cellular respiration and, as a result, lowers the synthesis of molecules that store energy, such as ATP. LLLT inhibits the displacement of oxygen by dissociating NO from CCO, allowing for continuous cellular respiration (7).
Furthermore, it causes the mitochondria to release Reactive Oxygen Species (ROS), which activate Nuclear Factor Kappa B (NF-κB), a transcription factor that serves as a redox sensor (8). Enhanced redox processes and increased production of Adenosine Triphosphate (ATP) causes neuronal membranes to repair and the transmission of pain (7).
The efficiency of these LASERS is probably influenced by several parameters, including the stability of the neural cell membrane, enhancement of the cellular resuscitation system, enhanced ATP synthesis and decreased levels of prostaglandin E2. Reduced nociceptor signal transduction (8).
The rationale for using Photobiomodulation (PBM) in periodontal flap surgery is based on its ability to enhance healing, reduce pain and inflammation and improve tissue regeneration. Although the reported results of some studies have generated controversy, they have demonstrated a significant impact of PBM on improving wound healing and reducing postoperative discomfort following periodontal procedures (9),(10). There is convincing evidence that LASERS with wavelengths of 820 nm, 940 nm and 660 nm can induce mast cell degranulation (9).
Nonetheless, there are not many case studies (11),(12) discussing how PBM affects pain after periodontal flap surgery. Therefore, the aim of the present study was to evaluate and compare postoperative pain in periodontal flap surgery with and without PBM using a diode LASER to determine the efficacy of PBM.
A split-mouth randomised controlled study was carried out between August 2023 and January 2024 in the Periodontology Department of KM Shah Dental College and Hospital in Vadodara, Gujarat, India. The Institutional Ethics Committee approved the study (SVIEC/ON/DENT/SRP/22077).
Sample size calculation: The following assumptions were used to determine the sample size: The readings in Groups A and B were 0.857 and 1.306, respectively (10), with an alpha error of 5% and a beta error of 20%. The Standard Deviation (SD) considered was 0.42 (10). Thus, the minimal sample size needed for each category was determined to be 14 (http://powerandsamplesize.com).
Inclusion criteria: Patients with age group between 18 and 65 years with bilateral periodontal pockets with depths of 5 to 7 mm and similar affected teeth on both sides of the maxilla and mandible were included in the study.
Exclusion criteria: Pregnant and lactating women, patients with a history of long-term use of antibiotics and corticosteroids, smokers, tobacco chewers and patients who are not willing to undergo treatment were excluded from the study.
Study Procedure
The study involved 14 patients (28 sites), with ages ranging from 18 to 65. The patients were diagnosed with generalised periodontitis stage II grade A (13), and had bilateral pocket probing depths of 5-7 mm. While performing quadrant-wise flap surgery, a coin toss approach was used; one side of the quadrant was treated with Photobiomodulation (PBM) utilising a 940 nm diode laser following flap debridement, while no laser was applied (Sham Laser) to the contralateral quadrant after flap debridement. The number of teeth included for flap surgery was the same in both the test and control groups.
Presurgical procedure: During the first visit, medical records and patient data were collected and oral hygiene recommendations were reinforced. Hand and ultrasonic scalers were used for both root planing and scaling. Patients were observed two times a week for the first month and after verifying their cooperation and plaque management, they were added to the research.
Surgical procedure: Using a double-blind method, neither the patient nor the primary investigator knew which side of the quadrant received the diode LASER PBM. After procuring written consent from the patient, the guide/secondary investigator used the coin toss method for randomisation, allotted one side of the quadrant to Group A (PBM with flap surgery) and the other side to Group B (flap surgery alone).
Following the administration of local anaesthesia (2% lidocaine; 1/100,000 epinephrine), the UNC-15 Probe was used to measure the depths of the pockets. Next, a full-thickness Kirkland flap procedure was performed. A crevicular incision was given using a No. 12 blade and the flap was reflected using periosteal elevators, exposing the underlying bone. The root surface was then scaled and polished and a thorough debridement was carried out. Both flap surfaces were treated with a 940 nm diode LASER (Biolase, USA) (Table/Fig 1),(Table/Fig 2) in continuous mode with 0.5 W power for 112 seconds, using a whitening hand-piece at a distance of 3 mm. The flap surgery was finished by positioning the flap borders where the bone and root surface met and it was sutured using 3-0 silk suture.
In the control group (Group B), all the steps of flap surgery were followed and the LASER was applied in an off mode to comply with the double-blinded protocol. One surgeon performed all the surgeries and a one-month time interval was kept between the two surgeries (Table/Fig 3).
Postsurgery instructions: All patients were advised to take analgesics after surgery (Ibuprofen 400 mg) and whenever they felt pain until one week post-surgery (up to 3 tablets in 24 hours). Furthermore, a 0.2% chlorhexidine rinse and 500 mg of amoxicillin were recommended (every eight hours) for five days.
The two techniques utilised to record the degree of pain were the visual analogue scale (9) {no pain (0) to severe pain (10)} and the amount of analgesics the patient took from the day of the operation to one week later. To gauge their level of pain during the day and to keep track of how many analgesics they had taken, patients were asked to log their level of pain prior to going to bed each night.
(Table/Fig 4) shows the Consolidated Standards of Reporting Trials (CONSORT) flow diagram is shown in (Table/Fig 4).
Statistical Analysis
The data were analysed using IBM SPSS Statistics 20.0 (IBM Corporation, Armonk, NY, USA) and the results were presented in graphs and tables. The significance of the research parameters between the two groups was evaluated using the Mann-Whitney U test, as part of the data did not follow a normal distribution; hence non parametric Mann-Whitney U test was used. A p-value of 0.05 or less was considered statistically significant, with p=0.05 acting as the threshold of significance.
A total of 14 patients (28 sites), with a mean age of 41.14±12.95 years (ranging from 28 to 54 years), completed the procedures and follow-up sessions in this split-mouth randomised controlled clinical trial. The VAS scores for the LASER group and the control group were compared using the Mann-Whitney U test. From day 0 to day 7, the VAS score findings showed statistically significant differences between the LASER and control groups, with the LASER group experiencing significantly less severe pain (p<0.05). The pain experiences during the first week after surgery for both the control and LASER groups are presented in detail in (Table/Fig 5).
Day 0 refers to the day of surgery. The amount of analgesics taken by the patients on Days 0, 2, 3, 4, 5 and 6 showed statistically significant results, indicating that patients treated with LASER consumed less number of analgesics compared to the control group (p<0.05). However, the number of analgesics taken on Day 1 did not show statistically significant results, as the amount of analgesics taken was similar in both the control group as well as LASER groups (p=0.063). Also, at Day 7 postoperatively, no statistically significant results were seen when comparing the two groups.
The patients’ analgesic intake during the first week following surgery for both the control and LASER groups is presented in detailed (Table/Fig 6).
The purpose of the study was to evaluate the effect of PBM using 940 nm diode LASER on pain after Kirkland flap surgery. This split-mouth randomised controlled trial’s primary goal was to assess how PBM affected postoperative pain following traditional flap surgery. PBM LASERS have the ability to reduce pain by modulating inflammation in a dose-dependent way. Compared to LASERS with visible spectrum wavelengths, the LASER employed in this investigation had a deeper penetration depth because of its 940 nm infrared wavelength (14).
The VAS score and the quantity of analgesics consumed by the patient consumed were employed to assess the patient’s pain perception because they are simple to use, yield results quickly and make it easier to comparisons of the patient’s experience with those of other studies that have been done in a comparable fields (11),(12).
In the current study, the outcomes showed that the PBM LASER may considerably reduce pain from the day of surgery to the sixth day following surgery, with little to no change observed on the seventh day. Additionally, compared to the control group, the LASER group required less analgesics on days 0, 2, 3, 4, 5 and 6 of the procedure.
Similar results were obtained by Sanz-Moliner JD et al., using an 810-nm diode LASER and repeating the emission with a power of 0.1 W to reduce pain following Modified Widman Flap (MWF) surgery (12). Compared to a 940 nm LASER, an 810 nm LASER has a deeper penetration. The VAS score and the quantity of analgesics used were used to determine the patients’ level of pain. They conclusion that PBM LASERS can help reduce pain following surgery (12).
The PBM lasers lower biochemical markers, oxidative stress, inflammation and swelling. Bjordal JM et al., conducted a systematic review to study the effects of PBM and their key parameters, revealed that these effects are dose-dependent, with the highest effective doses occurring between 0.3 and 19 J/cm2 and the lowest effective dose occurring at 7.5 J/cm2 (15). Higher doses of PBM LASERS should be applied within 72 hours of surgery and should then be gradually followed by lower doses to speed up the healing process.
The positive outcomes in the VAS score in the LASER group on the day of surgery can be related to the action of PBM, as it stimulates the production of endorphins, which are natural pain-relieving compounds in the body. It also lessens the transmission of pain signals by modulating nerve conduction. The outcomes also show that patients in the LASER group took fewer analgesics overall than those in the control group (16),(17).
There are three overlapping phases in the complex and dynamic process of wound healing. Tissue damage triggers the inflammatory phase, which is the initial stage. The second phase, also known as the fibroblastic phase, involves fibroblasts that produce collagen and tropocollagen (18),(19).
In relation to the several phases of wound healing, PBM appears to be more successful during the fibroblastic phase, which includes increased angiogenesis, fibroblast activity and epithelial proliferation. Previous literature has noted the effects of PBM on fibroblasts, such as enhanced growth factor release, increased proliferation and conversion into myofibroblasts (20).
Merigo E et al., assessed the influence of impacted wisdom teeth surgery on pain, oedema and trismus using a 940-nm diode LASER applied extraorally and intraorally, similar to the one utilised in this investigation (21). The parameters were set at a total dose of 50 J, a spot size of 2.8 cm2 and a power density of 0.5 W/cm2. Furthermore, a bleaching handpiece was used for beam emission every 12 hours for three days. In contrast to the current study, the VAS questionnaire score, which was collected on days 2 and 7 following surgery, revealed no statistically significant difference between the LASER-treated and sham groups. Clinically, however, fewer cases of trismus, oedema and discomfort were recorded.
In a meta-analysis and comprehensive review, Zhao H et al., sought to determine how well LLLT worked as an adjunct to periodontal surgery for treating wound healing and postoperative pain (14). At day three after surgery, there was a substantial difference in pain reduction between the groups, but at day seven, there was no difference. Additionally, the mean analgesic intake of the LLLT group during the first week was much lower than average: MD -0.60 (95% CI -0.97 to -0.22); (p=0.002). Day 14 results from free gingival graft operations demonstrated markedly faster re-epithelialisation and improved wound healing in palatal donor sites when LLLT was used as an adjuvant. The findings showed that LLLT improved postoperative pain management when used in conjunction with periodontal surgery.
The application of diode LASERS for early healing as PBM has a positive effect on fibroblast proliferation and migration. This can be repeated in future studies using similar LASER settings as those used in the current study across various periodontal surgeries to determine the efficacy of PBM.
Limitation(s)
Further well-conducted research with larger samples and in various settings seems necessary to draw comprehensive conclusions regarding the effect of PBM LASERS on postsurgery symptoms. Also, to find out how PBM affects different cellular levels and to better comprehend the mechanisms of PBM on pain, more histological research is needed.
The present study shows that the 940 nm diode LASER settings utilised in this study could greatly minimise the amount of analgesics the patient needs to take after surgery, as well as reduce the level of postoperative pain. The future perspectives are that more patient-centered clinical investigations are required to evaluate the effects of PBM utilised in various periodontal surgical procedures from a histological perspective and to gain a deeper understanding of the mechanisms by which PBM reduces pain.
DOI: 10.7860/JCDR/2024/73471.20327
Date of Submission: Jun 11, 2024
Date of Peer Review: Aug 06, 2024
Date of Acceptance: Sep 18, 2024
Date of Publishing: Nov 01, 2024
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? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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