Pain Perception Following Periodontal Decontamination Treatment with Laser Therapies: Comparison between Oxygen High-Level Laser Therapy (OHLLT) and Laser-Assisted New Attachment Procedure (LANAP)
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsGood topic analyzing the perceived pain levels following periodontal decontamination treatment with laser therapies. The paper needs some revisions. Lot of missing citations. Lot of missing details in the methods. Most importantly no results of PCR test were shared completely. Because of the missing results not sure if all the conclusions are fully supported by data. Please refer to comments and make necessary changes.
Abstract:
Line 35: If there was no significant difference at baseline shouldn’t the p-value be greater than 0.05? Please verify
Introduction:
Line 62-65: Missing citation for “Multiple studies”.
Line 80-83: Seems little out of place. Most of the information about Nd:YAG laser was anyways discussed in the next paragraph
Line 129-133: What literature is being referenced here “Scientific literature has provided evidence”
Line 136-138: Missing citation for “Several studies”
Methods:
How was the sample size of 20 chosen for the study?
Lot of measuring units were used to describe the characteristics of lasers. For example: W, mj, ms and Hz. Please provide full form when using them for first time.
What is the basis of this treatment protocols employed in the study? Any references?
Please confirm how many providers were involved in providing the care. What training did they have? What steps were taken to avoid any provider bias?
Line 319-321: Was no chlorhexidine soaked guaze used for group 2?
Results:
Please share the demographic distribution between the two groups. How many males vs females and mean age of each group? Was there any statistical difference between the groups?
What does IC in the table 1 stand for? Is it CI? Please confirm
It also says (min- max) under the median in the table 1. But only one value was shared so is it the difference of two values?
In the abstract it was mentioned as “The quantity of periodontal bacteria seen seven days post-treatment exhibited statistical equivalence between both groups, and was found to be statistically decreased compared to the pre-treatment levels.” But no actual data or results of. PCR -Real time test results for both the groups were shared except for line 343 “Group 1 exhibited a reduction of 80.3%, while Group 2 shown a reduction of 81.4%.”.
Line 345: “statistically equivalent reductions” What statistical tests were used to test the difference.
Line 369: There is no table 2 presented in the paper.
Figure 2: What does these results represent exactly? Proportions in one patient or group of patients?
Discussion:
A lot of discussion was about PCR-real time and its findings and relevance. But since the results from PCR-real time test were not shared it hard to validate those claims. For example, line 426-428 “the proportions of P. gingivalis, T. forsythia, and T. forsythia were comparable in the sample groups (groups 1 and a) following one week of therapy.” No proportions by each species were shared except for a pie diagram. Who are in group “a”?
Please discuss the limitations of the study.
Conclusions:
Many of the statements are not fully supported by the data shared in the manuscript.
Author Response
Dear reviewer,
Thank you for your kind review and helpful suggestions on how to improve our paper.
All questions regarding statistics have been decided by the statisticians of our department, we do not believe that revisions are necessary.
As now better outlined in the text, the results of the microbiological part are exposed in our already published article (reference 38).
All your other requests were carried out and underlined in red in the text, as were those of the other reviewers.
We hope you will consider our work suitable for publication in Applied Sciences in the current form.
Best regards,
The Authors
Reviewer 2 Report
Comments and Suggestions for AuthorsThe study is a randomised trial to assess the subjective experience of post-operative pain among patients who underwent the LANAP procedure and those who underwent the OHLLT protocol. The LANAP protocol uses a solid-crystal, digitally pulsed, yttrium aluminum garnet dental laser with neodymium doping (Nd:YAG), is introduced into the periodontal pocket and is meant to selectively induce photodepolarization of the inflamed follicular epithelium, to initiate the formation of a surgical access flap in the gingiva, and to eliminate bacteria within the pocket. The OHLLT protocol involves the utilization of a diode laser in conjunction with a hydrogen peroxide-based solution. While there was an earlier study by the same group indicating that both laser techniques exhibited increased effectiveness in terms of periodontitis treatment, there are no studies evaluating pain perception. The purpose of this study is pertinent as LANAP is associated with potential thermal burns to the patient if not utilised properly.
The aim of the study is to record pain differences. The numerical scale rate (NRS) was used as a single, one-dimensional scale to detect pain differences.
Please outline references that validate its use - Is there test-retest reliability, and internal consistency? What are the patients’ own abilities to cope with pain that will affect the reliability of the measure? Were any other questionnaires or interviews done to assess the patients’ PROs.
Improvements to the manuscript should include whether the NRS is validated, and a discussion of its limitations.
Other comments:
Page 1
Line 24. What is third degree periodontitis? Please use the 2018 EFP/AAP terminology. Similarly Page 4 Line 182-183.
Page 3
Line 108. Reference does not describe LANAP protocol
Please attach CONSORT guidelines, ethical board reference. Was the trial registered beforehand?
How were the patients randomised?
10 patients per group – are they adequately powered to detect statistical differences
Author Response
Dear reviewer,
Thank you for your kind review and helpful suggestions on how to improve our paper.
We have added the limitations of the study regarding the sample and the reliability of the NRS, we have no other data to report in this regard.
All your other requests were carried out and underlined in red in the text, as were those of the other reviewers.
We hope you will consider our work suitable for publication in Applied Sciences in the current form.
Best regards,
The authors
Reviewer 3 Report
Comments and Suggestions for AuthorsGeneral comment
In this paper, the authors compared two treatments for periodontal diseases mainly focusing on pain after treatment, and concluded Oxygen High Level Laser Therapy caused less pain than laser-assisted new attachment procedure, but there weren’t significant difference between two groups in the quantity of periodontal bacteria.
I think this study focused on interesting point, however there are still several issues to be addressed.
Specific comments
1. Authors showed only one pain scale based on subjective symptom and the criteria is obscure. This is the biggest problem in this paper. I think adding some objective symptoms data relating pain must be required.
2. The authors should show breakdown of each groups. (Ex. Age, sex, periodontitis stage, history of smoking etc.).
3. Also, multivariate regression analysis is needed. This is also applicable comment 1.
4. Table 1 and Fig 7 showed only mean value, S.D. values of each should be shown in table and fig.
5. Authors said that the quantity of periodontal bacteria seen seven days post-treatment exhibited statistical equivalence between both groups, and was found to be statistically decreased compared to the pre-treatment levels. However there aren’t any figures that we can recognize that.
6. Fig. 2 is not suitable, that must be improved. Authors should show the graph of before and after of the treatments in each group groups. Also non-English language is used in Fig. 2.
7. General data like BoP, P.I.,P.D. of each group should be provided.
8. Adding graphical explanation of LANAP and OHLLT including their mechanism will be helpful for readers.
Author Response
Dear reviewer,
Thank you for your kind review and helpful suggestions on how to improve our paper.
All questions regarding statistics have been decided by the statisticians of our department, we do not believe that revisions are necessary.
Unfortunately we do not have more objective data regarding pain to show.
As now better outlined in the text, the results of the microbiological part (including periodontal indices) are exposed in our already published article (reference 38).
All your other requests were carried out and underlined in red in the text, as were those of the other reviewers.
We hope you will consider our work suitable for publication in Applied Sciences in the current form.
Best regards,
The Authors
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsThe paper looks better after the corrections. However, there are still some major concerns that may need some clarifications. In the manuscript the authors discuss about different proportions of bacteria noticed in Oxygen High Level Laser Therapy (OHLLT) and Laser Assisted New Attachment Procedure (LANAP) groups but actual results of bacterial counts between the groups were not clearly shared in the manuscript. But just claim that the results were shared in a previously published study (Reference #32). Without the actual results many of the conclusions could not be verified.
Abstract:
Based on the results shared in the current study the following sentence couldn’t be verified “The quantity of periodontal bacteria seen seven days post-treatment exhibited statistical equivalence between both groups, and was found to be statistically decreased compared to the pre-treatment levels”
Methods:
Line 177: No explanation of how was the sample size of 20 decided upon.
Line 205: What steps were taken to avoid provider bias. Please explain what training did the clinician have in providing the treatment. Was the clinician a general dentist or periodontist? Any specialized training received in using the lasers?
2.2 Operative protocols: Figure 8: Please explain how were treatment protocols for the groups developed? Was it based on any previous research or researchers personal experience?
Results:
Line 356-358: When checked the results from the study (reference #32) no statistical results comparing the different proportions of bacteria between the groups and different time intervals were shared. Only a graph with bacterial count was noticed.
Table 1: Headings were updated to CI 95% but only 1 value was shared. No actual confidence interval values are shared.
Figure 2: Are these PCR -Real test results of both the groups involved in the study? Or is it just one group? At what time frame were these bacterial counts measured.
Discussion:
Line 439-444: The discussion goes in detail about different proportions of bacterial counts noticed in the study. Without sharing the results of both the groups in the current study, it is not possible verify the statements.
Conclusions:
Conclusions are not fully supported by data shared in the study.
Author Response
Dear reviewer,
Thank you for your kind review. We have tried to fix the paper according to your suggestions:
- Abstract: we have modified the sentence excluding to claim statistically evidence;
- Methods: we have explained how we selected patients and the skills of the clinician;
- Results: we have delated claims of statistically evidence regarding bacterial analysis, which is not the main focus of this paper; we have added information to table and figure;
- Discussion: we have delated the part you did not think is verified by the study;
- Conclusions: we have tried to improve it.
We hope that you will consider the paper eligible to be published in Applied Sciences in the current form.
Best regards,
The Authors
Reviewer 2 Report
Comments and Suggestions for AuthorsThe authors have clarified that the NRS (a single, one-dimensional scale) was used to detect pain differences, but no pilot was carried out to test the reliability. They have given a one-line statement at the end of the manuscript highlighting that it is a limitation.
As this is the primary aim of the study, I find this to be a major flaw in the methodology, unless the authors can adequately address this.
Comments on the Quality of English LanguageCan be improved with some editing.
Line 482-483
'by the not complete reliability of the NRS.' - not grammatically correct.
Author Response
Dear reviewer,
Thank you for your kind review. We have already underlined the limitations of the study. We hope you will consider the paper eligible to be published in Applied Sciences in the current form.
Best wishes,
The Authors
Reviewer 3 Report
Comments and Suggestions for AuthorsAuthors answered and wrote that the full results and statistics of the microbiological analysis (including periodontal indexes) are presented in the previously published paper by the same authors. If it is so, the original new data in this paper is limited only one pain scale based on subjective symptom from patients at a current revised version. In that case, this paper seems not to match to the aims of Applied Science, and thus this paper is recommended to be submitted to another journals that have case presentation style and so on.
Author Response
Dear reviewer,
Thank you for your kind review.
The focus of this paper is to compare post-treatment pain in LANAP and OHLLT protocols. We think it is suitable for Applied Sciences in the special issue we applied to "Photodynamic Therapy and Other Innovative Techniques or Materials in Dental Clinical Practice and Research"
We hope you will judge our work elegible to be published.
Best wishes,
The Authors
Round 3
Reviewer 1 Report
Comments and Suggestions for AuthorsEven though the corrections make it better, many of the statements in the discussion, claiming from the study, still could not be verified. The conclusions of the current paper are similar to the previous study that was already published by the same authors.
Line 355-357: The results of another published study are just being referenced here as the results of the current study.
Lines 437-445: None of the statements could be verified even after referring to the cited study #32. The cited study only shows the total bacterial count in percentage but nothing about the individual bacterial counts.
Due to multiple self-citations and considering that there is nothing new being added to the current literature on this topic, I think the current study may have to be rejected
Author Response
Dear reviewer,
We have tried to improve our paper according to your suggestions. We are sorry that it seems it is not enough for you. We disagree about not being an interesting topic to add to Literature.
Best wishes,
The Authors
Reviewer 2 Report
Comments and Suggestions for AuthorsThe authors have highlighted the limitations of the study and the manuscript can be accepted in its current form.
Author Response
Dear reviewer,
Thank you for your kind review and for accepting our paper.
Best wishes,
The Authors
