Ultrasound stimulation attenuates root resorption of rat replanted molars and impairs tumor necrosis factor-α signaling in vitro

Attenuation of orthodontically induced inflammatory root resorption by using low-intensity pulsed ultrasound as a therapeutic modality- a systematic review

Ultrasound is an effective tool for both diagnostic and therapeutic applications. As an imaging tool, ultrasound has mostly been used for real-time noninvasive diagnostic imaging. As ultrasound propagates through a material, a reflected radio-frequency (RF) signal is generated when encountering a mismatch in acoustic impedance. While traditionally recognized for its diagnostic imaging capabilities, the application of ultrasound has broadened to encompass therapeutic interventions, most notably in the form of Low-Intensity Pulsed Ultrasound (LIPUS). Low-Intensity Pulsed Ultrasound (LIPUS) is a form of mechanical energy transmitted transcutaneously by high-frequency acoustic pressure waves. The intensity of LIPUS (30 mW/cm2) is within the range of ultrasound intensities used for diagnostic purposes (1-50 mW/cm2) and is regarded as non-thermal, non-destructive, permeating living tissues and triggering a cascade of biochemical responses at the cellular level. The LIPUS device produces a 200 µs burst of 1.5 MHz acoustic sine waves, that repeats at a modulation frequency of 1 kHz and provides a peak pressure of 30 mW/cm2. Low-intensity pulsed ultrasound (LIPUS) forms one of the currently available non-invasive healing-enhancing devices besides electro-stimulation (pulsed electro-magnetic field, PEMF). This modality has been leveraged to enhance drug delivery, expedite injury recovery, improve muscle mobility, alleviate joint stiffness and muscle pain, and enhance bone fracture healing. Although LIPUS has been embraced within various medical disciplines, its integration into standard dental practices is still in its nascent stages, signifying an unexplored frontier with potentially transformative implications. Low-intensity pulsed ultrasound (LIPUS) has emerged as an attractive adjuvant therapy in various dental procedures, such as orthodontic treatment and maxillary sinus augmentation. Its appeal lies in its simplicity and non-invasive nature, positioning LIPUS as a promising avenue for clinical innovation. One particular area of interest is orthodontically induced inflammatory root resorption (OIIRR), an oftenunavoidable outcome of the orthodontic intervention, resulting in the permanent loss of root structure. Notably, OIIRR is the second most common form of root resorption (RR), surpassed only by root resorption related to pulpal infection. Given the high prevalence and potential long-term consequences of OIIRR, this literature review seeks to evaluate the efficacy of LIPUS as a therapeutic approach, with an emphasis on assessing its capacity to reduce the severity of OIIRR to a level of clinical significance. To conduct this systematic review, a comprehensive automated literature search was executed across multiple databases, including MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, SciELO, Cochrane, PubMed, trials registries, 3ie, and Google Scholar. Both forward and backward citation tracking was employed, encompassing studies published from database inception through January 2009 to April 2023. The review focused on randomized controlled trials (RCTs) that specifically evaluated the effects of low-intensity pulsed ultrasound therapy on orthodontically induced inflammatory root resorption (OIIRR), without restrictions of publication date. A stringent selection criterion was applied, and only studies demonstrating high levels of statistical significance were included. Ultimately, fourteen studies met the inclusion criteria and were subjected to further analysis. The overall quality of the included randomized controlled trials (RCTs) was rigorously assessed utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. This analysis revealed certain methodological limitations that posed challenges in drawing definitive conclusions from the available evidence. Despite these constraints, the review offers invaluable insights that can inform and guide future research. Specifically, it delineates recommendations for targeted populations, necessary interventions, appropriate outcome measures, suitable study designs, and essential infrastructure to facilitate further investigations. The synthesis of these insights aims to enhance the development and application of low-intensity pulsed ultrasound therapy within the field of dentistry, thereby contributing to improved patient outcomes.

Prevention and repair of orthodontically induced root resorption using ultrasound: a scoping review

INTRODUCTION

This review summarizes the available recent literature on different mechanisms and parameters of pulsed ultrasound (US) that have been used during orthodontic treatments to prevent and repair root resorption.

AREAS COVERED

A literature search was conducted between January (2002) and September (2022) in the following databases: PubMed, Google-Scholar, Embase and The-Cochrane-Library. After exclusions, a total of 19 papers were included in the present review. The most used US parameters with positive outcomes were frequency of 1.5 MHz, pulse repetition frequency of 1000 Hz, output intensity of 30 mW/cm2, duration of application of 20 mins and total number sessions were 14 with a repetition interval of 1day. The suggested mechanisms induced by US were alteration of cementoblasts, osteoblasts, osteoclasts, alkaline-phosphatase (ALP), runt-related-gene-2 (Runx2), osteoprotegerin (OPG), type-I-collagen (Col-I), C-telopeptide-type-I-collagen (CTX-I), hepatocyte-growth-factor (HGF), bone morphogenetic protein-2 (BMP-2), cyclooxygenase-2 (Cox-2), calcium (Ca2+), receptor activator of nuclear factor-kappa-B ligand (RANKL), and receptor activator of nuclear factor-kappa-B (RANK).

EXPERT OPINION

Understanding mechanisms and deciding which parameters of US that can be used during orthodontic treatment to prevent and repair root resorption is a great challenge. This work summarizes all the available data that can aid this process and suggest that US is an effective noninvasive method not only in prevention and repairing of orthodontic induced root resorption but also in accelerating teeth movement.

Low-intensity pulsed ultrasound attenuates replacement root resorption of avulsed teeth stored in dry condition in dogs

This study aimed to investigate the effects of low-intensity pulsed ultrasound (LIPUS) on replacement root resorption after replantation of avulsed teeth stored in a dry condition in dogs. A total of 73 premolar roots from four male mongrel dogs were intentionally avulsed with forceps and divided into four groups—HN, HL, DN, and DL—according to storage conditions and whether or not they received LIPUS treatment. Thirty-eight roots were kept in Hanks’ Balanced Salt Solution for 30 min (HN and HL groups), whereas the remaining 35 roots were left to dry in the air for an hour (DN and DL groups) prior to replantation. Following replantation, the roots in the HL and DL groups (21 and 18 roots, respectively) received a 20-min daily LIPUS treatment for 2 weeks. The animals were euthanized 4 weeks after the operation. Micro-computed tomography images were acquired for each root and the amount of replacement root resorption was measured three-dimensionally. Histological assessments were also carried out. There was significantly less replacement root resorption for the roots in the DL group compared to the DN group (p < 0.01). Histological findings in the DN group demonstrated evident replacement root resorption, whereas the DL group revealed less severe resorption compared to the DN group. Within the limitations, these results suggest that LIPUS could attenuate the replacement resorption of avulsed teeth stored in a dry condition, thereby improving their prognosis.

Effect of Low Intensity Pulsed Ultrasound (LIPUS) on Tooth Movement and Root Resorption: A Prospective Multi-Center Randomized Controlled Trial

The aim of this study was to evaluate the possible effect of low intensity pulsed ultrasound (LIPUS) on tooth movement and root resorption in orthodontic patients. Twenty-one patients were included in a split-mouth study design (group 1). Ten additional patients were included with no LIPUS device being used and this group was used as the negative control group (group 2). Group 1 patients were given LIPUS devices that were randomly assigned to right or left side on upper or lower arches. LIPUS was applied to the assigned side that was obtained by randomization, using transducers that produce ultrasound with a pulse frequency of 1.5 MHz, a pulse repetition rate of 1 kHz, and average output intensity of 30 mW/cm². Cone-beam computed tomography (CBCT) images were taken before and after treatment. The extraction space dimensions were measured every four weeks and root lengths of canines were measured before and after treatment. The data were analyzed using paired t-test. The study outcome showed that the mean rate of tooth movement in LIPUS side was 0.266 ± 0.092 mm/week and on the control side was 0.232 ± 0.085 mm/week and the difference was statistically significant. LIPUS increased the rate of tooth movement by an average of 29%. For orthodontic root resorption, the LIPUS side (0.0092 ± 0.022 mm/week) showed a statistically significant decrease as compared to control side (0.0223 ± 0.022 mm/week). The LIPUS application accelerated tooth movement and minimized orthodontically induced tooth root resorption at the same time.

A preliminary study of effects of low-intensity pulsed ultrasound (LIPUS) irradiation on dentoalveolar ankylosis

The purpose of this experiment was to investigate whether low-intensity pulsed ultrasound (LIPUS) irradiation can inhibit dentoalveolar ankylosis in transplanted rat teeth. LIPUS irradiation (the pulsed ultrasound signal had a frequency of 3.0 MHz, a spatial average intensity of 30 mW/cm², and a pulse ratio of 1:4) was performed on the face over the re-planted teeth of rats for 4 weeks. After the rats were euthanized, we measured mobility (Periotest value [PTV]) of the transplanted and control teeth using a Periotest. Finally, we performed histological evaluation to detect ankylosis. PTVs tended to be significantly lower for re-planted teeth than for control teeth. Histological evaluation revealed that the roots of all re-planted teeth were coalescent with alveolar bone. Furthermore, no ankylosis was observed in three-fifths of the re-planted teeth following LIPUS irradiation. These results indicate the potential efficacy of LIPUS to inhibit dentoalveolar ankylosis.

Effects of Low-Intensity Pulsed Ultrasound on Orthodontic Tooth Movement and Orthodontically Induced Inflammatory Root Resorption in Ovariectomized Osteoporotic Rats

This study investigated the effects of low-intensity pulsed ultrasound (LIPUS) on orthodontic tooth movement (OTM) and orthodontically induced inflammatory root resorption (OIRR) in ovariectomized osteoporotic rats. Forty-eight 28-d-old female Wistar rats were divided into ovariectomized and intact groups. In both groups, animals were left untreated; treated with 50 g mesially directed orthodontic force on the maxillary first molars using nickel-titanium closed-coil springs for 28 d; or treated with the same orthodontic protocol along with a 20-min LIPUS application on alternate days for 28 d. Extent of OTM and amount of OIRR of mesial roots were measured on three-dimensionally reconstructed micro-computed tomography images. Ovariectomy increased OIRR (p < 0.05). LIPUS reduced root volumetric loss regardless of ovariectomy status (p < 0.05); only ovariectomized animals had decreased OTM (p < 0.05). LIPUS normalizes OTM and attenuates OIRR in ovariectomized osteoporotic rats. It may therefore be beneficial in women with postmenopausal osteoporosis.

Low-intensity pulsed ultrasound in dentofacial tissue engineering

Oral and maxillofacial diseases affect millions of people worldwide and hence tissue engineering can be considered an interesting and clinically relevant approach to regenerate orofacial tissues after being affected by different diseases. Among several innovations for tissue regeneration, low-intensity pulsed ultrasound (LIPUS) has been used extensively in medicine as a therapeutic, operative, and diagnostic tool. LIPUS is accepted to promote bone fracture repair and regeneration. Furthermore, the effect of LIPUS on soft tissues regeneration has been paid much attention, and many studies have performed to evaluate the potential use of LIPUS to tissue engineering soft tissues. The present article provides an overview about the status of LIPUS stimulation as a tool to be used to enhance regeneration/tissue engineering. This review consists of five parts. Part 1 is a brief introduction of the acoustic description of LIPUS and mechanical action. In Part 2, biological problems in dentofacial tissue engineering are proposed. Part 3 explores biologic mechanisms of LIPUS to cells and tissues in living body. In Part 4, the effectiveness of LIPUS on cell metabolism and tissue regeneration in dentistry are summarized. Finally, Part 5 relates the possibility of clinical application of LIPUS in orthodontics. The present review brings out better understanding of the bioeffect of LIPUS therapy on orofacial tissues which is essential to the successful integration of management remedies for tissue regeneration/engineering. To develop an evidence-based approach to clinical management and treatment of orofacial degenerative diseases using LIPUS, we would like to be in full pursuit of LIPUS biotherapy. Still, there are many challenges for this relatively new strategy, but the up to date achievements using it promises to go far beyond the present possibilities.

Estimation of diffraction effect in ultrasonic attenuation by through-transmission substitution technique

Measurement of ultrasonic attenuation is important in clinical and industrial applications. The overall goal of this research was to characterize the diffraction effect in ultrasonic attenuation. We have followed a systematic approach, beginning with the theoretical analysis of the calculation method using the transfer function of the signal spectrum, moving on to numerical computations and experimental confirmation. The relation of sample thickness to pulse duration is presented and the transmission coefficient of the sample for different propagation modes is discussed. Particular attention is paid to the diffraction effect which is easy to be neglected but a potential source of artifacts. Numerical computations demonstrated that lower frequencies, shorter transducer distances and larger velocity difference can result in significant diffraction effect. Due to the complexity of determining interface loss in Single Sample Substitution Method (SSM), Two Samples Substitution Method (TSM) was proposed to avoid this drawback. Comparison experiment with SSM illustrates that the proposed diffraction correction model is sound in theory and feasible in practice.

Ultrasound stimulation attenuates resorption of tooth root induced by experimental force application

Root resorption is an adverse outcome of orthodontic tooth movement. However, there have been no available approaches for the protection and repair of root resorption. The aim of this study was to evaluate the effects of low-intensity pulsed ultrasound (LIPUS) on root resorption during experimental tooth movement and the effects of LIPUS in the RANKL/OPG mechanism in osteoblasts and cementoblasts in vitro. Twenty four Wistar strain male rats of 12-week-old were used in this study. The upper first molars were subjected to experimental movement in the mesial direction for 1-3weeks. Through the experimental periods, the right upper first maxillary molar was exposed to LIPUS (LIPUS group) every day for 1, 2 or 3weeks. The nature of root resorption was observed and then quantified by histomorphometric analysis. In the 2weeks period, significantly greater amount of tooth movement was observed in the LIPUS group (p<0.05). In addition, LIPUS group showed less root resorption lacunae and lower number of odontoclasts. In the period of 3weeks, LIPUS group presented significantly shorter length of root resorption lacunae and smaller amount of root resorption area (p<0.01). The number of odontoclasts and osteoclasts was also significantly lower in the LIPUS group (p<0.01 and p<0.05, respectively). However, no significant differences could be found regarding the amount of tooth movement. It is shown that LIPUS exposure significantly reduced the degree of root resorption during tooth movement without interrupting tooth movement. In vitro experiments showed that MC3T3-1 constitutively expressed higher levels of RANKL and RANTES mRNA comparing to OCCM-30. However, OPG mRNA expression was much higher in OCCM-30. LIPUS stimulation significantly increased the mRNA expression of RANKL in MC3T3-E1 at 4 (p<0.01) and 12h (p<0.05), although OPG mRNA expression was not affected by LIPUS. In contrast, the expression of RANKL and OPG mRNAs were both significantly increased by LIPUS in OCCM-30 at 12h (p<0.01). Moreover, LIPUS application suppressed the up-regulation of RANKL mRNA induced by compression force in OCCM-30, but no similar effect could be observed in MC3T3-E1. In conclusion, it is suggested that LIPUS exposure significantly reduces root resorption by the suppression of cementoclastogenesis by altering OPG/RANKL ratio during orthodontic tooth movement without interfering tooth movement. LIPUS may be an effective tool to prevent root resorption during tooth movement and is applicable to clinical use in near future.

Current status of low intensity pulsed ultrasound for dental purposes

Over the past few years, tissue engineering applied to the dental field has achieved relevant results. Tissue engineering can be described by actions taken to improve biological functions. Several methods have been described to enhance cellular performance and low intensity pulsed ultrasound (LIPUS) has shown to play an important role in cell metabolism. The present article provides an overview about the current status of LIPUS as a tissue engineering tool to be used to enhance tooth and periodontal regeneration.