Millisecond flashes of light phase delay the human circadian clock during sleep

Circadian Mechanisms in Brain Fluid Biology

The brain is a complex organ, fundamentally changing across the day to perform basic functions like sleep, thought, and regulating whole-body physiology. This requires a complex symphony of nutrients, hormones, ions, neurotransmitters and more to be properly distributed across the brain to maintain homeostasis throughout 24 hours. These solutes are distributed both by the blood and by cerebrospinal fluid. Cerebrospinal fluid contents are distinct from the general circulation because of regulation at brain barriers including the choroid plexus, glymphatic system, and blood-brain barrier. In this review, we discuss the overlapping circadian (≈24-hour) rhythms in brain fluid biology and at the brain barriers. Our goal is for the reader to gain both a fundamental understanding of brain barriers alongside an understanding of the interactions between these fluids and the circadian timing system. Ultimately, this review will provide new insight into how alterations in these finely tuned clocks may lead to pathology.

Moving time zones in a flash with light therapy during sleep

In humans, exposure to continuous light is typically used to change the timing of the circadian clock. This study examines the efficiency of a sequence of light flashes ("flash therapy") applied during sleep to shift the clock. Healthy participants (n = 10) took part in two 36-h laboratory stays, receiving a placebo (goggles, no light) during one visit and the intervention (goggles, 2-ms flashes broad-spectrum light for 60 min, delivered every 15 s, starting 30 min after habitual sleep onset) during the other. Circadian phase shift was assessed with changes in salivary dim light melatonin onset (DLMO). Sleep, measured with polysomnography, was analyzed to assess changes in sleep architecture and spectral power. After 1 h of flashes, DLMO showed a substantial delay (1.13 ± 1.27 h) compared to placebo (12 ± 20 min). Two individuals exhibited very large shifts of 6.4 and 3.1 h. There were no substantive differences in sleep architecture, but some evidence for greater instability in sleep. 1 h of flash therapy during sleep evokes large changes in circadian timing, up to 6 h, and does so with only minimal, if any, impact on sleep. Flash therapy may offer a practical option to delay the circadian clock in shift workers and jet travelers.

Controlled light exposure and intermittent fasting as treatment strategies for metabolic syndrome and gut microbiome dysregulation in night shift workers

The mammalian circadian clocks are entrained by environmental time cues, such as the light-dark cycle and the feeding-fasting cycle. In modern society, circadian misalignment is increasingly more common under the guise of shift work. Shift workers, accounting for roughly 20% of the workforce population, are more susceptible to metabolic disease. Exposure to artificial light at night and eating at inappropriate times of the day uncouples the central and peripheral circadian clocks. This internal circadian desynchrony is believed to be one of the culprits leading to metabolic disease. In this review, we discuss how alterations in the rhythm of gut microbiota and their metabolites during chronodisruption send conflicting signals to the host, which may ultimately contribute to disturbed metabolic processes. We propose two behavioral interventions to improve health in shift workers. Firstly, by carefully timing the moments of exposure to blue light, and hence shifting the melatonin peak, to improve sleep quality of daytime sleeping episodes. Secondly, by timing the daily time window of caloric intake to the biological morning, to properly align the feeding-fasting cycle with the light-dark cycle and to reduce the risk of metabolic disease. These interventions can be a first step in reducing the worldwide burden of health problems associated with shift work.

Human circadian rhythm studies: Practical guidelines for inclusion/exclusion criteria and protocol

As interest in circadian rhythms and their effects continues to grow, there is an increasing need to perform circadian studies in humans. Although the constant routine is the gold standard for these studies, there are advantages to performing more naturalistic studies. Here, a review of protocols for such studies is provided along with sample inclusion and exclusion criteria. Sleep routines, drug use, shift work, and menstrual cycle are addressed as screening considerations. Regarding protocol, best practices for measuring melatonin, including light settings, posture, exercise, and dietary habits are described. The inclusion/exclusion recommendations and protocol guidelines are intended to reduce confounding variables in studies that do not involve the constant routine. Given practical limitations, a range of recommendations is provided from stringent to lenient. The scientific rationale behind these recommendations is discussed. However, where the science is equivocal, recommendations are based on empirical decisions made in previous studies. While not all of the recommendations listed may be practical in all research settings and with limited potential participants, the goal is to allow investigators to make well informed decisions about their screening procedures and protocol techniques and to improve rigor and reproducibility, in line with the objectives of the National Institutes of Health.

luox: validated reference open-access and open-source web platform for calculating and sharing physiologically relevant quantities for light and lighting

Light exposure has a profound impact on human physiology and behaviour. For example, light exposure at the wrong time can disrupt our circadian rhythms and acutely suppress the production of melatonin. In turn, appropriately timed light exposure can support circadian photoentrainment. Beginning with the discovery that melatonin production is acutely suppressed by bright light more than 40 years ago, understanding which aspects of light drive the 'non-visual' responses to light remains a highly active research area, with an important translational dimension and implications for "human-centric" or physiologically inspired architectural lighting design. In 2018, the International Commission on Illumination (CIE) standardised the spectral sensitivities for predicting the non-visual effects of a given spectrum of light with respect to the activation of the five photoreceptor classes in the human retina: the L, M and S cones, the rods, and the melanopsin-containing intrinsically photosensitive retinal ganglion cells (ipRGCs). Here, we described a novel, lean, user-friendly, open-access and open-source platform for calculating quantities related to light. The platform, called luox, enables researchers and research users in vision science, lighting research, chronobiology, sleep research and adjacent fields to turn spectral measurements into reportable quantities. The luox code base, released under the GPL-3.0 License, is modular and therefore extendable to other spectrum-derived quantities. luox calculations of CIE quantities and indices have been endorsed by the CIE following black-box validation.

Objective sleep assessments for healthy people in environmental research: A literature review

To date, although many studies had focused on the impact of environmental factors on sleep, how to choose the proper assessment method for objective sleep quality was often ignored, especially for healthy subjects in bedroom environment. In order to provide methodological guidance for future research, this paper reviewed the assessments of objective sleep quality applied in environmental researches, compared them from the perspective of accuracy and interference, and statistically analyzed the impact of experimental type and subjects' information on method selection. The review results showed that, in contrast to polysomnography (PSG), the accuracy of actigraphy (ACT), respiratory monitoring-oxygen saturation monitoring (RM-OSM), and electrocardiograph (ECG) could reach up to 97%, 80.38%, and 79.95%, respectively. In terms of sleep staging, PSG and ECG performed the best, ACT the second, and RM-OSM the worst; as compared to single methods, mix methods were more accurate and better at sleep staging. PSG interfered with sleep a great deal, while ECG and ACT could be non-contact, and thus, the least interference with sleep was present. The type of experiment significantly influenced the choice of assessment method (p < 0.001), 85.3% of researchers chose PSG in laboratory study while 82.5% ACT in field study; moreover, PSG was often used in a relatively small number of young subjects, while ACT had a wide applicable population. In general, researchers need to pay more attention at selection of assessments in future studies, and this review can be used as a reliable reference for experimental design.

Sleep Deprivation Does Not Influence Photic Resetting of Circadian Activity Rhythms in Drosophila

Previous investigations in humans and rodent animal models have assessed the interplay of sleep in the circadian system’s phase responses to nighttime light exposure. The resulting data have been mixed, but generally support a modulatory role for sleep in circadian photic resetting (not an absolute requirement). Drosophila have been historically used to provide important insights in the sleep and circadian sciences. However, no experiments to date have evaluated how immediate sleep need or recent sleep history affects their pacemaker’s phase readjustments to light. We did so in the current study by (1) forcing separate groups of animals to stay awake for 1 or 4 h after they were shown a broadspectrum pulse (15 min during the first half of the night, 950 lux), or (2) placing them on a restricted sleep schedule for a week before light presentation without any subsequent sleep disruption. Forced sleep restriction, whether acute or chronic, did not alter the size of light-induced phase shifts. These data are consistent with observations made in other diurnal animals and raise the possibility, more broadly, that phototherapies applied during sleep—such as may be necessary during the winter months—may still be efficacious in individuals experiencing sleep-continuity problems such as insomnia.

Investigation of the aging clock's intermittent-light responses uncovers selective deficits to green millisecond flashes

The central pacemaker of flies, rodents, and humans generates less robust circadian output signals across normative aging. It is not well understood how changes in light sensitivity might contribute to this phenomenon. In the present study, we summarize results from an extended data series (n = 5681) showing that the locomotor activity rhythm of aged Drosophila can phase-shift normally to intermittently spaced episodes of bright polychromatic light exposure (600 lx) but that deficits emerge in response to 8, 16, and 120-millisecond flashes of narrowband blue (λ_m, 452 nm) and green (λ_m, 525 nm) LED light. For blue, phase-resetting of the activity rhythm of older flies is not as energy efficient as it is in younger flies at the fastest flash-exposures tested (8 milliseconds), suggesting there might be different floors of light duration necessary to incur photohabituation in each age group. For green, the responses of older flies are universally crippled relative to those of younger flies across the slate of protocols we tested. The difference in green flash photosensitivity is one of the most salient age-related phenotypes that has been documented in the circadian phase-shifting literature thus far. These data provide further impetus for investigations on pacemaker aging and how it might relate to changes in the circadian system's responses to particular sequences of light exposure tuned for wavelength, intensity, duration, and tempo.

A longitudinal study of morning, evening, and night light intensities and nocturnal sleep quality in a working population

We aimed to investigate whether higher light intensity in the morning is associated with better nocturnal sleep quality and whether higher light intensities in the evening or night have the opposite effect. Light intensity was recorded for 7 consecutive days across the year among 317 indoor and outdoor daytime workers in Denmark (55-56° N) equipped with a personal light recorder. Participants reported sleep quality after each nocturnal sleep. Sleep quality was measured using three parameters; disturbed sleep index, awakening index, and sleep onset latency. Associations between increasing light intensities and sleep quality were analyzed using mixed effects models with participant identity as a random effect. Overall, neither white nor blue light intensities during morning, evening, or night were associated with sleep quality, awakening, or sleep onset latency of the subsequent nocturnal sleep. However, secondary analyses suggested that artificial light during the morning and day contrary to solar light may increase vulnerability to evening light exposure. Altogether, we were not able to confirm that higher morning light intensity significantly improves self-reported sleep quality or that higher evening or night light intensities impair self-reported sleep quality at exposure levels encountered during daily life in a working population in Denmark. This suggests that light intensities alone are not important for sleep quality to a degree that it is distinguishable from other important parameters in daily life settings.

Long-term cumulative light exposure from the natural environment and sleep: A cohort study

We analysed (A) the association of short-term as well as long-term cumulative exposure to natural light, and (B) the association of detailed temporal patterns of natural light exposure history with three indicators of sleep: sleep duration, sleep problems, and diurnal preference. Data (N = 1,962; 55% women; mean age 41.4 years) were from the prospective Young Finns Study, which we linked to daily meteorological data on each participant's neighbourhood natural light exposure using residential postal codes. Sleep outcomes were self-reported in 2011. We first examined associations of the sleep outcomes with cumulative light exposure of 5-year, 2-year, 1-year, and 2-month periods prior to the sleep assessment using linear and Poisson regression models adjusting for potential confounders. We then used a data-driven time series approach to detect clusters of participants with different light exposure histories and assessed the associations of these clusters with the sleep outcomes using linear and Poisson regression analyses. A greater cumulative light exposure over ≥1 year was associated with a shorter sleep duration (β = -0.10, 95% confidence interval [CI] -0.15 to -0.04), more sleep problems (incident rate ratio [IRR] 1.04, 95% CI 1.0-1.07) and diurnal preference towards eveningness (β = -0.09, 95% CI -0.14 to -0.03). The data-driven exposure pattern of "slowly increasing" light exposure was associated with fewer overall sleep problems (IRR 0.93, 95% CI 0.88-0.98) compared to a "recently declining" light exposure group representing the "average-exposure" group. These findings suggest that living in an area with relatively more intense light exposure for a longer period of time influences sleep.

Barriers to sleep in acute hospital settings

OBJECTIVE

This study aimed to examine the environmental and operational factors that disrupt sleep in the acute, non-ICU hospital setting.

DESIGN, SETTING AND PARTICIPANTS

This was a prospective study of adult patients admitted to an acute tertiary hospital ward (shared versus single room) and sleep laboratory (single room conducive to sleep).

MAIN OUTCOME MEASURES

This study measured ambient light (lux) and sound (dB), number of operational interruptions, and questionnaires assessing sleep and mental health.

RESULTS

Sixty patients were enrolled, 20 in a double bedroom located close to the nursing station ('shared ward'), 20 in a single bedroom located distant to the nursing station ('single ward') and 20 attending the sleep laboratory for overnight polysomnography ('sleep laboratory'). Sleep was disturbed in 45% of patients in the shared and single ward groups (Pittsburgh Sleep Quality Index > 5). Light levels were appropriately low across all 3 locations. Sound levels (significant effect of room F(1.38) = 6.452, p = 0.015) and operational interruptions (shared ward 5.6 ± 2.5, single ward 6.2 ± 2.9, sleep laboratory 2.7 ± 2.1 per night, p < 0.05 wards compared to sleep laboratory) were higher in the shared and single ward group compared to the sleep laboratory but not compared to each other. Noise was rated as the greatest environmental disturbance by 70% of ward patients compared to 10% in the sleep laboratory.

CONCLUSION

Higher noise levels and frequent operational interruptions are potential barriers to sleep and recovery on an acute medical ward which are not ameliorated by being in a single bedroom located distant to the nursing station.

luox: novel validated open-access and open-source web platform for calculating and sharing physiologically relevant quantities for light and lighting

Light exposure has a profound impact on human physiology and behaviour. For example, light exposure at the wrong time can disrupt our circadian rhythms and acutely suppress the production of melatonin. In turn, appropriately timed light exposure can support circadian photoentrainment. Beginning with the discovery that melatonin production is acutely suppressed by bright light more than 40 years ago, understanding which aspects of light drive the 'non-visual' responses to light remains a highly active research area, with an important translational dimension and implications for "human-centric" or physiologically inspired architectural lighting design. In 2018, the International Commission on Illumination (CIE) standardised the spectral sensitivities for predicting the non-visual effects of a given spectrum of light with respect to the activation of the five photoreceptor classes in the human retina: the L, M and S cones, the rods, and the melanopsin-containing intrinsically photosensitive retinal ganglion cells (ipRGCs). Here, we described a novel, lean, user-friendly, open-access and open-source platform for calculating quantities related to light. The platform, called luox, enables researchers and research users in chronobiology, sleep research and adjacent field to turn spectral measurements into reportable quantities. The luox code base, released under the GPL-3.0 License, is modular and therefore extendable to other spectrum-derived quantities. luox has been endorsed by the CIE following black-box validation.

Environmental exposures and sleep outcomes: A review of evidence, potential mechanisms, and implications

Environmental exposures and poor sleep outcomes are known to have consequential effects on human health. This integrative review first seeks to present and synthesize existing literature investigating the relationship between exposure to various environmental factors and sleep health. We then present potential mechanisms of action as well as implications for policy and future research for each environmental exposure. Broadly, although studies are still emerging, empirical evidence has begun to show a positive association between adverse effects of heavy metal, noise pollution, light pollution, second-hand smoke, and air pollution exposures and various sleep problems. Specifically, these negative sleep outcomes range from subjective sleep manifestations, such as general sleep quality, sleep duration, daytime dysfunction, and daytime sleepiness, as well as objective sleep measures, including difficulties with sleep onset and maintenance, sleep stage or circadian rhythm interference, sleep arousal, REM activity, and sleep disordered breathing. However, the association between light exposure and sleep is less clear. Potential toxicological mechanisms are thought to include the direct effect of various environmental toxicants on the nervous, respiratory, and cardiovascular systems, oxidative stress, and inflammation. Nevertheless, future research is required to tease out the exact pathways of action to explain the associations between each environmental factor and sleep, to inform possible therapies to negate the detrimental effects, and to increase efforts in decreasing exposure to these harmful environmental factors to improve health.

Lesion of intergeniculate leaflet GABAergic neurons attenuates sleep in mice exposed to light

Light has immediate effects on sleep in rodents, but the neural pathways underlying the effect remain to be elucidated. The intergeniculate leaflet (IGL) containing GABAergic neurons receives direct retinal inputs. We hypothesized that IGL GABAergic neurons may mediate light-induced sleep. EEG/electromyogram recording, immunohistochemistry, electrophysiology, optogenetics, fiber photometry, behavioral tests, and cell-specific destruction were employed to investigate the role of IGL GABAergic neurons in the regulation of acute light-induced sleep. Here, EEG/electromyogram recordings revealed that acute light exposure during the nocturnal active phase in mice induced a significant increase in non-rapid eye movement and rapid eye movement sleep compared with controls. Immunohistochemistry showed that acute light exposure for 2 hours in the active phase induced an increase in c-Fos expression in the IGL, whereas lights-off in the rest phase inhibited it. Patch clamp coupled with optogenetics demonstrated that retinal ganglion cells had monosynaptic functional connections to IGL GABAergic neurons. Calcium activity by fiber photometry in freely behaving mice showed that light exposure increased the activity of IGL GABAergic neurons. Furthermore, lesion of IGL GABAergic neurons by caspase-3 virus significantly attenuated the sleep-promoting effect of light exposure during active phases. Collectively, these results clearly indicated that the IGL is one of key nuclei mediating light-induced sleep in mice.

luox: novel open-access and open-source web platform for calculating and sharing physiologically relevant quantities for light and lighting

Light exposure has a profound impact on human physiology and behaviour. For example, light exposure at the wrong time can disrupt our circadian rhythms and acutely suppress the production of melatonin. In turn, appropriately timed light exposure can support circadian photoentrainment. Beginning with the discovery that melatonin production is acutely suppressed by bright light more than 40 years ago, understanding which aspects of light drive the 'non-visual' responses to light remains a highly active research area, with an important translational dimension and implications for "human-centric" or physiologically inspired architectural lighting design. In 2018, the International Commission on Illumination (CIE) standardised the spectral sensitivities for predicting the non-visual effects of a given spectrum of light with respect to the activation of the five photoreceptor classes in the human retina: the L, M and S cones, the rods, and the melanopsin-containing intrinsically photosensitive retinal ganglion cells (ipRGCs). Here, we described a novel, lean, user-friendly, open-access and open-source platform for calculating quantities related to light. The platform, called luox, enables researchers and research users in chronobiology, sleep research and adjacent field to turn spectral measurements into reportable quantities. The luox code base, released under the GPL-3.0 License, is modular and therefore extendable to other spectrum-derived quantities.

Circadian Responses to Light-Flash Exposure: Conceptualization and New Data Guiding Future Directions

A growing number of studies document circadian phase-shifting after exposure to millisecond light flashes. When strung together by intervening periods of darkness, these stimuli evoke pacemaker responses rivaling or outmatching those created by steady luminance, suggesting that the circadian system's relationship to light can be contextualized outside the principle of simple dose-dependence. In the current review, we present a brief chronology of this work. We then develop a conceptual model around it that attempts to relate the circadian effects of flashes to a natural integrative process the pacemaker uses to intermittently sample the photic information available at dawn and dusk. Presumably, these snapshots are employed as building blocks in the construction of a coherent representation of twilight the pacemaker consults to orient the next day's physiology (in that way, flash-resetting of pacemaker rhythms might be less an example of a circadian visual illusion and more an example of the kinds of gestalt inferences that the image-forming system routinely makes when identifying objects within the visual field; i.e., closure). We conclude our review with a discussion on the role of cones in the pacemaker's twilight predictions, providing new electrophysiological data suggesting that classical photoreceptors—but not melanopsin—are necessary for millisecond, intermediate-intensity flash responses in ipRGCs (intrinsically photosensitive retinal ganglion cells). Future investigations are necessary to confirm this “Cone Sentinel Model” of circadian flash-integration and twilight-prediction, and to further define the contribution of cones vs. rods in transducing pacemaker flash signals.

Naturalistic Intensities of Light at Night: A Review of the Potent Effects of Very Dim Light on Circadian Responses and Considerations for Translational Research

In this review, we discuss the remarkable potency and potential applications of a form of light that is often overlooked in a circadian context: naturalistic levels of dim light at night (nLAN), equivalent to intensities produced by the moon and stars. It is often assumed that such low levels of light do not produce circadian responses typically associated with brighter light levels. A solid understanding of the impacts of very low light levels is complicated further by the broad use of the somewhat ambiguous term “dim light,” which has been used to describe light levels ranging seven orders of magnitude. Here, we lay out the argument that nLAN exerts potent circadian effects on numerous mammalian species, and that given conservation of anatomy and function, the efficacy of light in this range in humans warrants further investigation. We also provide recommendations for the field of chronobiological research, including minimum requirements for the measurement and reporting of light, standardization of terminology (specifically as it pertains to “dim” light), and ideas for reconsidering old data and designing new studies.

Effects and mechanisms of action of light-emitting diodes on the human retina and internal clock

White light-emitting diodes (LEDs) will likely become the most used lighting devices worldwide in the future because of their very low prices over the course of their long lifespans which can be up to several tens of thousands of hours. The expansion of LED use in both urban and domestic lighting has prompted questions regarding their possible health effects, because the light that they provide is potentially high in the harmful blue band (400-500 nm) of the visible light spectrum. Research on the potential effects of LEDs and their blue band on human health has followed three main directions: 1) examining their retinal phototoxicity; 2) examining disruption of the internal clock, i.e., an out-of-sync clock, in shift workers and night workers, including the accompanying health issues, most concerningly an increased relative risk of cancer; and 3) examining risky, inappropriate late-night use of smartphones and consoles among children and adolescents. Here, we document the recognized or potential health issues associated with LED lighting together with their underlying mechanisms of action. There is so far no evidence that LED lighting is deleterious to human retina under normal use. However, exposure to artificial light at night is a new source of pollution because it affects the circadian clock. Blue-rich light, including cold white LEDs, should be considered a new endocrine disruptor, because it affects estrogen secretion and has unhealthful consequences in women, as demonstrated to occur via a complex mechanism.

Association between circadian disruption and diseases: A narrative review

Circadian rhythms play an important role in a wide range of human physiology and pathology. Individuals increasingly experience situations such as night-shift work schedules, likely leading to circadian disruption. Recent studies have also demonstrated that patients with other diseases often show symptoms of circadian disruption as manifested by the sleep-wake cycle and other biological rhythms. Circadian disruption often results in changes to the phase, period, and amplitude of the sleep-wake cycle, melatonin rhythm, and core body temperature. Several cardiometabolic, psychiatric, and neurodegenerative diseases are closely related to circadian disruption. Several interventions are also available, including phototherapy, exogenous melatonin, and exercise. The cumulative findings suggest that circadian disruption can increase risk for some cardiometabolic diseases. Circadian disruption also acts as a concomitant symptom of several psychiatric and neurodegenerative diseases. More attention should be paid to evaluating the impact of circadian disruption on these related diseases, as well as the benefits of the mitigation interventions for both circadian disruption and related diseases.

Characterizing the temporal Dynamics of Melatonin and Cortisol Changes in Response to Nocturnal Light Exposure

We studied the dynamics of melatonin suppression and changes in cortisol levels in humans in response to light exposure at night using high-frequency blood sampling. Twenty-one young healthy participants were randomized to receive either intermittent bright (~9,500 lux) light (IBL), continuous bright light (CBL) or continuous dim (~1 lux) light (VDL) for 6.5 h during the biological night (n = 7 per condition). Melatonin suppression occurred rapidly within the first 5 min and continued until the end of each IBL stimuli (t1/2 = ~13 min). Melatonin recovery occurred more slowly between IBL stimuli (half-maximal recovery rate of ~46 min). Mean melatonin suppression (~40%) and recovery (~50%) were similar across IBL stimuli. Suppression dynamics under CBL were also rapid (t1/2 = ~18 min), with no recovery until the light exposure ended. There was a significant linear increase of cortisol levels between the start and end of each IBL stimulus. Under CBL conditions cortisol showed trimodal changes with an initial linear activating phase, followed by an exponential inhibitory phase, and a final exponential recovery phase. These results show that light exposure at night affects circadian driven hormones differently and that outcomes are influenced by the duration and pattern of light exposure.

Effect of Light Flashes vs Sham Therapy During Sleep With Adjunct Cognitive Behavioral Therapy on Sleep Quality Among Adolescents: A Randomized Clinical Trial

IMPORTANCE

Owing to biological, behavioral, and societal factors, sleep duration in teenagers is often severely truncated, leading to pervasive sleep deprivation.

OBJECTIVE

To determine whether a novel intervention, using both light exposure during sleep and cognitive behavioral therapy (CBT), would increase total sleep time in teenagers by enabling them to go to sleep earlier than usual.

DESIGN, SETTING, AND PARTICIPANTS

This double-blind, placebo-controlled, randomized clinical trial, conducted between November 1, 2013, and May 31, 2016, among 102 adolescents enrolled full-time in grades 9 to 12, who expressed difficulty going to bed earlier and waking up early enough, was composed of 2 phases. In phase 1, participants were assigned to receive either 3 weeks of light or sham therapy and were asked to try to go to sleep earlier. In phase 2, participants received 4 brief CBT sessions in addition to a modified light or sham therapy. All analyses were performed on an intent-to-treat basis.

INTERVENTIONS

Light therapy consisted of receiving a 3-millisecond light flash every 20 seconds during the final 3 hours of sleep (phase 1) or final 2 hours of sleep (phase 2). Sham therapy used an identical device, but delivered 1 minute of light pulses (appearing in 20-second intervals, for a total of 3 pulses) per hour during the final 3 hours of sleep (phase 1) or 2 hours of sleep (phase 2). Light therapy occurred every night during the 4-week intervention. Cognitive behavioral therapy consisted of four 50-minute in-person sessions once per week.

MAIN OUTCOMES AND MEASURES

Primary outcome measures included diary-based sleep times, momentary ratings of evening sleepiness, and subjective measures of sleepiness and sleep quality.

RESULTS

Among the 102 participants (54 female [52.9%]; mean [SD] age, 15.6 [1.1] years), 72 were enrolled in phase 1 and 30 were enrolled in phase 2. Mixed-effects models revealed that light therapy alone was inadequate in changing the timing of sleep. However, compared with sham therapy plus CBT alone, light therapy plus CBT significantly moved sleep onset a mean (SD) of 50.1 (27.5) minutes earlier and increased nightly total sleep time by a mean (SD) of 43.3 (35.0) minutes. Light therapy plus CBT also resulted in a 7-fold greater increase in bedtime compliance than that observed among participants receiving sham plus CBT (mean [SD], 2.21 [3.91] vs 0.29 [0.76]), as well as a mean 0.55-point increase in subjective evening sleepiness as compared with a mean 0.48-point decrease in participants receiving sham plus CBT as measured on a 7-point sleepiness scale.

CONCLUSIONS AND RELEVANCE

This study found that light exposure during sleep, in combination with a brief, motivation-focused CBT intervention, was able to consistently move bedtimes earlier and increase total sleep time in teenagers. This type of passive light intervention in teenagers may lead to novel therapeutic applications.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01406691.

Effects of light on human circadian rhythms, sleep and mood

Humans live in a 24-hour environment, in which light and darkness follow a diurnal pattern. Our circadian pacemaker, the suprachiasmatic nuclei (SCN) in the hypothalamus, is entrained to the 24-hour solar day via a pathway from the retina and synchronises our internal biological rhythms. Rhythmic variations in ambient illumination impact behaviours such as rest during sleep and activity during wakefulness as well as their underlying biological processes. Rather recently, the availability of artificial light has substantially changed the light environment, especially during evening and night hours. This may increase the risk of developing circadian rhythm sleep-wake disorders (CRSWD), which are often caused by a misalignment of endogenous circadian rhythms and external light-dark cycles. While the exact relationship between the availability of artificial light and CRSWD remains to be established, nocturnal light has been shown to alter circadian rhythms and sleep in humans. On the other hand, light can also be used as an effective and noninvasive therapeutic option with little to no side effects, to improve sleep,mood and general well-being. This article reviews our current state of knowledge regarding the effects of light on circadian rhythms, sleep, and mood.

Circadian Responses to Fragmented Light: Research Synopsis in Humans

Light is the chief signal used by the human circadian pacemaker to maintain precise biological timekeeping. Though it has been historically assumed that light resets the pacemaker's rhythm in a dose-dependent fashion, a number of studies report enhanced circadian photosensitivity to the initial moments of light exposure, such that there are quickly diminishing returns on phase-shifting the longer the light is shown. In the current review, we summarize findings from a family of experiments conducted over two decades in the research wing of the Brigham and Women's Hospital that examined the human pacemaker's responses to standardized changes in light patterns generated from an overhead fluorescent ballast. Across several hundred days of laboratory recording, the research group observed phase-shifts in the body temperature and melatonin rhythms that scaled with illuminance. However, as suspected, phase resetting was optimized when exposure occurred as a series of minute-long episodes separated by periods of intervening darkness. These observations set the stage for a more recent program of study at Stanford University that evaluated whether the human pacemaker was capable of integrating fragmented bursts of light in much the same way it perceived steady luminance. The results here suggest that ultra-short durations of light-lasting just 1-2 seconds in total-can elicit pacemaker responses rivaling those created by continuous hour-long stimulation if those few seconds of light are evenly distributed across the hour as discreet 2-millisecond pulses. We conclude our review with a brief discussion of these findings and their potential application in future phototherapy techniques.

Circadian Rhythm Sleep-Wake Phase Disorders

This article reviews delayed and advanced sleep-wake phase disorders. Diagnostic procedures include a clinical interview to verify the misalignment of the major nocturnal sleep episode relative to the desired and social-normed timing of sleep, a 3-month or greater duration of the sleep-wake disturbance, and at least a week of sleep diary data consistent with the sleep timing complaint. Treatment options include gradual, daily shifting of the sleep schedule (chronotherapy); shifting circadian phase with properly timed light exposure (phototherapy); or melatonin administration. Future directions are discussed to conclude the article.

Resetting the late timing of 'night owls' has a positive impact on mental health and performance

BACKGROUND

There is conflict between living according to our endogenous biological rhythms and our external environment, with disruptions resulting in negative consequences to health and performance. This is often documented in shift work and jet lag, but 'societal norms' (eg, typical working hours) can create profound issues for 'night owls', people whose internal biological timing predisposes them to follow an unusually late sleep-wake cycle. Night owls have also been associated with health issues, mood disturbances, poorer performance and increased mortality rates.

METHODS

This study used a randomized control trial design aimed to shift the late timing of night owls to an earlier time (phase advance), using non-pharmacological, practical interventions in a real-world setting. These interventions targeted light exposure (through earlier wake up/sleep times), fixed meals times, caffeine intake and exercise.

RESULTS

Overall, participants demonstrated a significant advance of ∼2 h in sleep/wake timings as measured by actigraphy and circadian phase markers (dim light melatonin onset and peak time of the cortisol awakening response), whilst having no adverse effect on sleep duration. Notably, the phase advance was accompanied by significant improvements to self-reported depression and stress, as well as improved cognitive (reaction time) and physical (grip strength) performance measures during the typical 'suboptimal' morning hours.

CONCLUSIONS

Our findings propose a novel strategy for shifting clock timing towards a pattern that is more aligned to societal demands that could significantly improve elements of performance, mental health and sleep timing in the real world.

Light Modulation of Human Clocks, Wake, and Sleep

Light, through its non-imaging forming effects, plays a dominant role on a myriad of physiological functions, including the human sleep–wake cycle. The non-image forming effects of light heavily rely on specific properties such as intensity, duration, timing, pattern, and wavelengths. Here, we address how specific properties of light influence sleep and wakefulness in humans through acute effects, e.g., on alertness, and/or effects on the circadian timing system. Of critical relevance, we discuss how different characteristics of light exposure across the 24-h day can lead to changes in sleep–wake timing, sleep propensity, sleep architecture, and sleep and wake electroencephalogram (EEG) power spectra. Ultimately, knowledge on how light affects sleep and wakefulness can improve light settings at home and at the workplace to improve health and well-being and optimize treatments of chronobiological disorders.

Impact of an Individually Tailored Light Mask on Sleep Parameters in Older Adults With Advanced Phase Sleep Disorder

Objective: This study investigated whether light delivered through the eyelids of sleeping persons might create phase delay in older adults who are adversely affected by advanced sleep phase disorder. Participants: Thirty-two cognitively intact, community-dwelling participants aged ≥ 50 years (20 females, 12 males) with Pittsburgh Sleep Quality Index scores ≥ 5 (poor sleep) completed the study. Methods: This within-subjects, randomized, two-treatment crossover design study exposed participants to an active "blue" (λ_max  =  480 nm) lighting intervention or a placebo "red" (λ_max = 640 nm) control through closed eyelids during sleep for 8 weeks. Conditions were administered 1 hr after bedtime using custom-built light masks delivering a train of 2-s duration light pulses presented every 30 s for ≤ 2 hr (approximately 240 pulses/night). Dependent variables were subjective measures of sleep and depression (questionnaires) and objective measures of sleep (wrist actigraphy), analyzed using linear mixed models with treatment, period, and carryover as fixed effects. Results: The actigraphy analysis found no effect of the intervention or the control condition on sleep start time, total sleep time, number of sleep bouts, or sleep efficiency, either compared to baseline or to one another. Subjective responses of study participants, however, indicated statistically significant (p < 0.05) improvement in seven of eight reported measures of sleep quality with both the intervention and the control condition, but no difference between the two conditions. Conclusions: The participants reported improvement in sleep quality, but the intervention did not confer additional advantages after adjusting for period and carryover effects.

Suppression of salivary melatonin secretion under 100-Hz flickering and non-flickering blue light

Background

Bright light at night is known to suppress melatonin secretion. Novel photoreceptors named intrinsically photosensitive retinal ganglion cells (ipRGCs) are mainly responsible for projecting dark/bright information to the suprachiasmatic nucleus and thus regulating the circadian system. However, it has been shown that the amplitude of the electroretinogram of ipRGCs is considerably lower under flickering light at 100 Hz than at 1–5 Hz, suggesting that flickering light may also affect the circadian system. Therefore, in this study, we evaluated light-induced melatonin suppression under flickering and non-flickering light.

Methods

Twelve male participants between the ages of 20 and 23 years (mean ± S.D. = 21.6 ± 1.5 years) were exposed to three light conditions (dim, 100-Hz flickering, and non-flickering blue light) from 1:00 A.M. to 2:30 A.M., and saliva samples were obtained just before 1:00 A.M. and at 1:15, 1:30, 2:00, and 2:30 A.M.

Results

A repeated measures t test with Bonferroni correction showed that at 1:15 A.M., melatonin concentrations were significantly lower following exposure to non-flickering light compared with dim light, whereas there was no significant difference between the dim and 100-Hz flickering light conditions. By contrast, after 1:30 A.M., the mean melatonin concentrations were significantly lower under both 100-Hz flickering and non-flickering light than under dim light.

Conclusion

Although melatonin suppression rate tended to be lower under 100-Hz flickering light than under non-flickering light at the initial 15 min of the light exposure, the present study suggests that 100-Hz flickering light may have the same impact on melatonin secretion as non-flickering light.

A systematic review of the amount and timing of light in association with objective and subjective sleep outcomes in community-dwelling adults

Light is considered the dominant environmental cue, or zeitgeber, influencing the sleep-wake cycle. Despite recognizing the importance of light for our well-being, less is known about the specific conditions under which light is optimally associated with better sleep. Therefore, a systematic review was conducted to examine the association between the amount and timing of light exposure in relation to sleep outcomes in healthy, community-dwelling adults. A systematic search was conducted of four databases from database inception to June 2016. In total, 45 studies met the review eligibility criteria with generally high study quality excepting for the specification of eligibility criteria and the justification of sample size. The majority of studies involved experimental manipulation of light (n = 32) vs observational designs (n = 13). Broad trends emerged suggesting that (1) bright light (>1000 lux) has positive implications for objectively assessed sleep outcomes compared to dim (<100 lux) and moderate light (100-1000 lux) and (2) bright light (>1000 lux) has positive implications for subjectively assessed sleep outcomes compared to moderate light (100-1000 lux). Effects due to the amount of light are moderated by the timing of light exposure such that, for objectively assessed sleep outcomes, brighter morning and evening light exposure are consistent with a shift in the timing of the sleep period to earlier and later in the day, respectively. For subjectively assessed sleep outcomes, brighter light delivered in the morning was associated with self-reported sleep improvements and brighter evening light exposure was associated with worse self-reported sleep.

Responses to Intermittent Light Stimulation Late in the Night Phase Before Dawn

The circadian clock is comprised of two oscillators that independently track sunset (evening) and sunrise (morning), though little is known about how light responses differ in each. Here, we quantified the morning oscillator’s responses to 19 separate pulse trains, collecting observations from over 1300 Drosophila at ZT23. Our results show that the advances in activity onset produced by these protocols depended on the tempo of light administration even when total exposure was conserved across a 15-min window. Moreover, patterns of stimulation previously shown to optimize the evening oscillator’s delay resetting at ZT13 (an hour after dusk) were equally effective for the M oscillator at ZT23 (an hour before dawn), though the morning oscillator was by comparison more photosensitive and could benefit from a greater number of fractionation strategies that better converted light into phase-shifting drive. These data continue to build the case that the reading frames for the pacemaker’s time-of-day estimates at dusk and dawn are not uniform and suggest that the “photologic” for the evening versus morning oscillator’s resetting might be dissociable.

Multiplexing Visual Signals in the Suprachiasmatic Nuclei

The suprachiasmatic nuclei (SCN), the site of the mammalian circadian (daily) pacemaker, contains thousands of interconnected neurons, some of which receive direct retinal input. Here, we study the fast (<1 s) responses of SCN neurons to visual stimuli with a large-scale mathematical model tracking the ionic currents and voltage of all SCN neurons. We reconstruct the SCN network connectivity and reject 99.99% of theoretically possible SCN networks by requiring that the model reproduces experimentally determined receptive fields of SCN neurons. The model shows how the SCN neuronal network can enhance circadian entrainment by sensitizing a population of neurons in the ventral SCN to irradiance. This SCN network also increases the spatial acuity of neurons and increases the accuracy of a simulated subconscious spatial visual task. We hypothesize that much of the fast electrical activity within the SCN is related to the processing of spatial information.

On-orbit sleep problems of astronauts and countermeasures

Sufficient sleep duration and good sleep quality are crucial to ensure normal physical and mental health, cognition and work performance for the common people, as well as astronauts. On-orbit sleep problem is very common among astronauts and has potential detrimental influences on the health of crewmembers and the safety of flight missions. Sleep in space is becoming a new medical research frontier. In this review we summarized on-orbit sleep problems of astronauts and six kinds of causes, and we presented the effects of lack of sleep on performance as well as mental and physical health, then we proposed seven kinds of countermeasures for sleep disturbance in spaceflight, including pharmacologic interventions, light treatment, crew selection and training, Traditional Chinese Medicine and so on. Furthermore, we discussed and oriented the prospect of researches on sleep in space.

Circadian phase-shifting by light: Beyond photons

Circadian entrainment to the solar light:dark schedule is thought to be maintained by a simple photon counting method. According to this hypothesis, the pacemaker adjusts the phase of the body's endogenous rhythms in accordance to the intensity and duration with which it encounters a perceived twilight signal. While previous data have generally supported the hypothesis, more recent analysis has codified other factors besides irradiance that influence the magnitude of resetting responses to light delivered within the same phase of the circadian cycle. In particular, the frequency with which light is alternated with darkness, or whether it's packaged in millisecond flashes versus continuous blocks, can significantly alter the dose-response relationship. Here, we used a drosophilid model to test whether circadian photon-counting trends can be broken with light administration protocols spanning just 15 minutes. In the early part of the delay zone, a 15-min continuous light pulse was fragmented until it could no longer produce a full-magnitude shift of the flies' locomotor activity rhythms. The remaining exposure was then reorganized along various fractionation schemes that employed pulses with different widths and interstimulus intervals. Our results suggest that the pacemaker integrates the phase-shifting effects of equiluminous light differently depending on the stimulus pattern with which light is made available. For example, despite having fewer photons, certain ratios of light and darkness could be optimized on a timescale of seconds and minutes so as to achieve pacemaker resetting close to par with steady luminance. These data provide further evidence that the circadian pacemaker's responses to light entail more than photon counting and motivate continued discussion on how phototherapy can be best optimized in clinical practice to improve conditions linked to circadian impairment.

Precision Light for the Treatment of Psychiatric Disorders

Circadian timekeeping can be reset by brief flashes of light using stimulation protocols thousands of times shorter than those previously assumed to be necessary for traditional phototherapy. These observations point to a future where flexible architectures of nanosecond-, microsecond-, and millisecond-scale light pulses are compiled to reprogram the brain's internal clock when it has been altered by psychiatric illness or advanced age. In the current review, we present a chronology of seminal experiments that established the synchronizing influence of light on the human circadian system and the efficacy of prolonged bright-light exposure for reducing symptoms associated with seasonal affective disorder. We conclude with a discussion of the different ways that precision flashes could be parlayed during sleep to effect neuroadaptive changes in brain function. This article is a contribution to a special issue on Circadian Rhythms in Regulation of Brain Processes and Role in Psychiatric Disorders curated by editors Shimon Amir, Karen Gamble, Oliver Stork, and Harry Pantazopoulos.

The impact of temporal modulations in irradiance under light adapted conditions on the mouse suprachiasmatic nuclei (SCN)

Electrophysiological responses of SCN neurons to light steps are well established, but responses to more natural modulations in irradiance have been much less studied. We address this deficit first by showing that variations in irradiance for human subjects are biased towards low temporal frequencies and small magnitudes. Using extracellular recordings we show that neurons in the mouse SCN are responsive to stimuli with these characteristics, tracking sinusoidal modulations in irradiance best at lower temporal frequencies and responding to abrupt changes in irradiance over a range of commonly encountered contrasts. The spectral sensitivity of these light adapted responses indicates that they are driven primarily by cones, but with melanopsin (and/or rods) contributing under more gradual changes. Higher frequency modulations in irradiance increased time averaged firing of SCN neurons (typically considered to encode background light intensity) modestly over that encountered during steady exposure, but did not have a detectable effect on the circadian phase resetting efficiency of light. Our findings highlight the SCN’s ability to encode naturalistic temporal modulations in irradiance, while revealing that the circadian system can effectively integrate such signals over time such that phase-resetting responses remain proportional to the mean light exposure.

A novel intrinsic electroretinogram response in isolated mouse retina

Since the discovery of intrinsic photosensitive retinal ganglion cell (ipRGC) was reported in 2002, many features specific to this cell type have been described. However, scare information is available on the retinographic components directly reflecting ipRGC activity. In this study, we identified the electroretinogram (microERG) that reflects the photoresponses by ipRGCs in ex vivo preparations of the mouse retina, in which classical photoreceptors (cones and rods) were ablated mechanically and photochemically. MicroERG consisted of three components: a large transient ON response, a small and lazy hump 19s after the onset of the light, and a large transient OFF response. A complete microERG recording required at least 30s of light exposure. MicroERG showed the highest spectral photosensitivity at 478nm. This wavelength corresponds to the peak wavelength in the ipRGCs' photosensitive curve. The psychophysical test using a blue light-emitting diode (LED) light (470nm) revealed that the absolute threshold illuminance for microERG was greater than 12.26 log photons/s/cm² in both ON and OFF responses, whereas microERG was not adapted for dark. The amplitude of microERG increased linearly with irradiance. The sensitivity of temporal frequency was high in microERG (at least 100Hz), as suggested by the study on melatonin suppression by flickering light in human subjects (Zelter et al., 2014). Melatonin secretion was suppressed by light via ipRGCs and the suprachiasmatic nucleus. These properties of the photoresponse indicate that microERG may reflect the functions of ipRGC as a luminance detector in the mouse retina.

Disruption of Circadian Rhythms by Light During Day and Night

PURPOSE OF REVIEW

This study aims to discuss possible reasons why research to date has not forged direct links between light at night, acute melatonin suppression or circadian disruption, and risks for disease.

RECENT FINDINGS

Data suggest that irregular light-dark patterns or light exposures at the wrong circadian time can lead to circadian disruption and disease risks. However, there remains an urgent need to: (1) specify light stimulus in terms of circadian rather than visual response; (2) when translating research from animals to humans, consider species-specific spectral and absolute sensitivities to light; (3) relate the characteristics of photometric measurement of light at night to the operational characteristics of the circadian system; and (4) examine how humans may be experiencing too little daytime light, not just too much light at night.

SUMMARY

To understand the health effects of light-induced circadian disruption, we need to measure and control light stimulus during the day and at night.

Responses to Spatial Contrast in the Mouse Suprachiasmatic Nuclei

A direct retinal projection targets the suprachiasmatic nucleus (SCN) (an important hypothalamic control center). The accepted function of this projection is to convey information about ambient light (irradiance) to synchronize the SCN’s endogenous circadian clock with local time and drive the diurnal variations in physiology and behavior [1, 2, 3, 4]. Here, we report that it also renders the SCN responsive to visual images. We map spatial receptive fields (RFs) for SCN neurons and find that only a minority are excited (or inhibited) by light from across the scene as expected for irradiance detectors. The most commonly encountered units have RFs with small excitatory centers, combined with very extensive inhibitory surrounds that reduce their sensitivity to global changes in light in favor of responses to spatial patterns. Other units have larger excitatory RF centers, but these always cover a coherent region of visual space, implying visuotopic order at the single-unit level. Approximately 75% of light-responsive SCN units modulate their firing according to simple spatial patterns (drifting or inverting gratings) without changes in irradiance. The time-averaged firing rate of the SCN is modestly increased under these conditions, but including spatial contrast did not significantly alter the circadian phase resetting efficiency of light. Our data indicate that the SCN contains information about irradiance and spatial patterns. This newly appreciated sensory capacity provides a mechanism by which behavioral and physiological systems downstream of the SCN could respond to visual images [5].

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Many SCN units have receptive fields optimized for spatial discrimination

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A large majority of SCN neurons track changes in spatial patterns

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Spatial patterns can enhance SCN-maintained firing, but not circadian phase resetting

Association between light at night, melatonin secretion, sleep deprivation, and the internal clock: Health impacts and mechanisms of circadian disruption

Exposure to Artificial Light At Night (ALAN) results in a disruption of the circadian system, which is deleterious to health. In industrialized countries, 75% of the total workforce is estimated to have been involved in shift work and night work. Epidemiologic studies, mainly of nurses, have revealed an association between sustained night work and a 50-100% higher incidence of breast cancer. The potential and multifactorial mechanisms of the effects include the suppression of melatonin secretion by ALAN, sleep deprivation, and circadian disruption. Shift and/or night work generally decreases the time spent sleeping, and it disrupts the circadian time structure. In the long run, this desynchronization is detrimental to health, as underscored by a large number of epidemiological studies that have uncovered elevated rates of several diseases, including cancer, diabetes, cardiovascular risks, obesity, mood disorders and age-related macular degeneration. It amounts to a public health issue in the light of the very substantial number of individuals involved. The IARC has classified shift work in group 2A of "probable carcinogens to humans" since "they involve a circadian disorganization". Countermeasures to the effects of ALAN, such as melatonin, bright light, or psychotropic drugs, have been proposed as a means to combat circadian clock disruption and improve adaptation to shift and night work. We review the evidence for the ALAN impacts on health. Furthermore, we highlight the importance of an in-depth mechanistic understanding to combat the detrimental properties of exposure to ALAN and develop strategies of prevention.

Circadian-Based Therapies for Circadian Rhythm Sleep-Wake Disorders

This review summarizes recent developments relevant to the treatment of circadian rhythm sleep-wake disorders. The clinical practice guidelines for the treatment of intrinsic circadian rhythm sleep-wake disorders is described, followed by recent treatment studies for delayed sleep-wake phase disorder, non-24 hour sleep-wake disorder, irregular sleep-wake disorder and shift work. New methods to estimate circadian phase, including home saliva collection to estimate the dim light melatonin onset, circadian questionnaires and general rules to guide light and exogenous melatonin treatments are described. New developments in light treatment are detailed, including light flashes during sleep and wearable light devices. Substances such as caffeine and alcohol, and devices such as electronic tablets are also considered for their potential to shift circadian timing. Finally, an update on melatonin supplements in the US is discussed, along with the controversy surrounding the use of melatonin supplements in patients with prediabetes or diabetes.

Craniofacial Wound Healing with Photobiomodulation Therapy: New Insights and Current Challenges

The fundamental pathophysiologic response for the survival of all organisms is the process of wound healing. Inadequate or lack of healing constitutes the etiopathologic basis of many oral and systemic diseases. Among the numerous efforts to promote wound healing, biophotonics therapies have shown much promise. Advances in photonic technologies and a better understanding of light-tissue interactions, from parallel biophotonics fields such as in vivo optical imaging and optogenetics, are spearheading their popularity in biology and medicine. Use of high-dose lasers and light devices in dermatology, ophthalmology, oncology, and dentistry are now popular for specific clinical applications, such as surgery, skin rejuvenation, ocular and soft tissue recontouring, and antitumor and antimicrobial photodynamic therapy. However, a less well-known clinical application is the therapeutic use of low-dose biophotonics termed photobiomodulation (PBM) therapy, which is aimed at alleviating pain and inflammation, modulating immune responses, and promoting wound healing and tissue regeneration. Despite significant volumes of scientific literature from clinical and laboratory studies noting the phenomenological evidence for this innovative therapy, limited mechanistic insights have prevented rigorous and reproducible PBM clinical protocols. This article briefly reviews current evidence and focuses on gaps in knowledge to identify potential paths forward for clinical translation with PBM therapy with an emphasis on craniofacial wound healing. PBM offers a novel opportunity to examine fundamental nonvisual photobiological processes as well as develop innovative clinical therapies, thereby presenting an opportunity for a paradigm shift from conventional restorative/prosthetic approaches to regenerative modalities in clinical dentistry.