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Archives of Oral Sciences & ResearchUse of Diode LASER for the Treatment of Periodontal Pocket: A NovelapproachSneha Puri * , Kaustubh Takare * , Manohar Bhongade *ABSTRACTObjective: The aim of the present study was to evaluate the effectiveness of diode laser in thetreatment of periodontal pocket.Material and Methods: A total of 20 sites with probing depth ≥5 mm were randomly assignedto test sites (10) while other to control sites (10) with the help of coin flip. The test sites weretreated with diode laser, whereas control sites were treated by scaling and root planing. Clinicalparameters recorded at baseline and at 3 months were plaque index (PI), papillary bleeding index(PBI), probing pocket depth (PPD), clinical attachment level (CAL) and gingival recession (GR).The diode LASER was used with a thin flexible light guide with a diameter of 0.4 mm and awavelength of 810 Nm at an output power of 0.8 W.Results: The mean PPD at 3 months post operatively in the test group was reduced to 3.32±0.30mm whereas in control group it was reduced to 2.03±0.10 mm. The mean CAL gain at 3 monthspost operatively was 2.25±0.09 mm in test group and 1.58±0.25 mm in control group.Conclusion: The comparison of both the groups showed that diode LASER has an additionalbenefit in reducing probing pocket depth possibly by reducing bacterial load which will help toresolve inflammation.AOSR 2013; 3(1): 1-12Key words – Periodontitis; Laser; Periodontal regeneration.* Department of Periodontics and Implantology, Sharad Pawar Dental College, Sawangi (M),Wardha - 442005INTRODUCTIONRe-establishment of connective tissuesurface of teeth with a history of periodontaldisease is the major goal of periodontaltherapy. Periodontally affected root surfacesare hypermineralized and contaminated withcytotoxic and other biologically activesubstances 1,2 especially endotoxins 2 whichplay a pivotal role in preventing newconnective tissue attachment to the exposedroot surface. Usually, in the initial phase ofperiodontal therapy, debridement of thediseased root surface is nonsurgically treated1

Diode laser for periodontal pocket treatmentby mechanical scaling and root planing,primarily by using manual or power-driveninstruments. However, following rootplaning the instrumented root surface isinvariably covered by a smear layer, 3containing remnants of dental calculus,contaminated root cementum, bacterialendotoxin, and subgingival plaque.Furthermore, conventional mechanicaldebridement using curettes is stilltechnically demanding and time consumingand power scalers sometimes causediscomfort and stress in patients as a resultof noise and vibration.In recent years, the use of laser irradiationhas been expected to serve as an alternativeor an adjunctive treatment to conventional,mechanical periodontal therapy. Variousadvantageous characteristics, such ashaemostatic effects, selective calculusablation, or bactericidal effects againstperiodontopathic pathogens might lead towavelengths of the laser most commonlyused in periodontics, which includesemiconductor diode lasers, the Nd:YAGlaser (Neodymium doped: Yttrium,aluminium and garnet), the Er:YAG laser(erbium doped: yttrium, aluminium andgarnet), and the carbon dioxide (CO 2 ) laser,range from 635 to 10,600 nm.Diode LASERs (810) have been used in thetreatment of periodontal diseases as well asperiimplant therapy because of thecharacteristic antibacterial effects 7 withoutinducing dramatic changes in the underlyingtissue. The diode LASER reveals abactericidal effect and helps to reduceinflammation in the root canal and in theperiodontal pocket in addition to scaling.Furthermore amongst various LASERsystems Diode LASER radiation is absorbedby superficial layer while as other LASERsystems are absorbed by deeper tissuelayers. Thus they have a better effect onimproved treatment outcomes.4,5,6Thesites affected by periodontal disease. Laser2

Sneha Puri et al.therapy, or laser-assisted pocket therapy,may be promising new approaches inperiodontics.hygiene (PI>1) and patients with history ofperiodontal surgical therapy of the selectedsite were excluded from the study.Therefore the present study was carried outwith basic aim of evaluating the effect ofdiode LASERs in the treatment ofperiodontal pocket.MATERIAL AND METHODS20 sites in 2 patients with moderate to severeperiodontitis were selected from theoutpatient department of Periodontics. Thepatients who were included in the studywere systemically healthy patients, hadpresence of bilaterally atleast one or twosites with PPD ≥ 5 mm and CAL ≥ 5 mmfollowing initial therapy, radiographicevidence of marginal bone loss ≥ 30%affecting atleast 50% of dentition.Patients with antibiotic therapy during last 3months, pregnant females or lactatingmothers, smokers or who use any tobaccoproducts, patients with unacceptable oralAn informed consent was signed by thepatients agreeing to the treatment. The studyprotocol was approved by ethical committeeof Datta Meghe Institute of MedicalScience, Sawangi (Meghe), Wardha.Information concerning their dietary status,mouth cleaning habits, gingival andperiodontal status along with other routineclinical data was recorded in the speciallydesigned chart. Patients were examinedunder good illumination.Study design:The split mouth, controlled clinical trial wascarried out over a period of 3 months. Atotal of 20 sites in 2 patients were found tobe suitable after supragingival andsubgingival scaling with each site having apocket depth of ≥5 mm. One quadrant ineach patient was randomly assigned to testgroup while other to control group with the3

Diode laser for periodontal pocket treatmenthelp of coin flip. The test sites underwentirradiation with diode LASER. While ascontrol group was treated by scaling androot planning using hand and rotaryinstrument.Clinical measurements recorded were plaqueindex (Turskey, Gilmore, Glickmannmodification of Quigley Hein plaque index,1970) 8 as an expression of the level of fullmouth supragingival plaque accumulation.Gingival inflammation was assessed byPapillary bleeding index (PBI). 9Clinical parameters recorded at baseline andat 3 months post operatively were PPD,CAL, and GR by using periodontalprobe † .These probing measurements wererecorded only on the teeth to be treated.Treatment Procedure:Initially full mouth supragingival andsubgingival scaling was performed by usingultrasonic unit (EMS+mini PIEZON) in all† Williams periodontal probe, Hufriedy, U.S.Acases. After 6 week in the test group, rootplaning was performed by using Hoescalers& standard Gracey Currettes underlocal anesthesia. Instrumentation was carriedout until the root surface was consideredsmooth and clean according to the operator’sclinical judgement. All the pocket sites werethen irradiated with the diode LASER.Diode LASER having a thin flexible lightguide with a diameter of 0.4 mm and awavelength of 810 Nm at a power of 0.8Wwas used for lasing.Each tooth was subdivided into 4 sites, eachof which was lased separately as follows:The tip of the optical fiber is inserted in thebottom of the pocket. Illumination wasstarted by keeping optical fibre parallel tothe root surface. The fibre was passed bothin vertical and horizontal directions coveringboth the epithelial surface and connectivetissues. Vaporizing the necrotized tissueseliminates the bacterial flora. The durationof lasing depended on the depth of the4

Sneha Puri et al.respective periodontal pocket. The pocketdepth in mm corresponds to the exposuretime in seconds. Therapy was terminatedwhen there was light bleeding. The sites inthe control group were treated by onlyscaling and root planing without use of laserfor the irradiation of periodontal pocket.STATISTICAL ANALYSIS:For each visit, duplicate recordings of PPD,CAL and GR averaged for each site. Thedifferences in PPD, CAL and GR among theexperimental sites at baseline and at3months examinations were assessed bymeans of paired t-test. Reduction in PPD,gain in CAL and increase in GR in test andcontrol group were assessed by usingstudents' unpaired t-test. Comparison PI &GBI at baseline and 6 weeks was carried outby using students paired t-test.A parametric analysis was performedfollowing the required assumptions verified.RESULTS:During the course of the study, woundhealing was uneventful. None of the selectedpatients dropped out before the terminationof the study.In general, patients showed good oralhygiene throughout the study. In test groupat baseline mean full mouth PI score was0.94 ± 0.60, which at 3-month, decreased to0.56. ± 0.28 Mean PBI score dropped from1.72 ± 0.42 at baseline to 0.8 ± 0.26 at 3-month. In control group at baseline meanfull mouth PI score was 0.96 ± 0.05, whichat 3-month, decreased to 0.58 ± 0.24.Likewise, the mean PBI score dropped from1.84 ± 0.44 at baseline to 0.86 ± 0.10 at 3-months (Table 1).Statistical analysis was performed by usingsoftware ‡ .‡ SPSS Version 14.0, SPSS @ inc., Chicaco IL, USA5

Diode laser for periodontal pocket treatmentTable 1: Mean Plaque (PI) and Papillary bleeding Index (PBI) scores between Baseline, 3months (Mean SD).Parameters Group Baseline 3 months Difference P-valuePIPBITest 0.94±0.06 0.56±0.28 0.38±0.22 0.002*Control 0.96 ±0.05 0.58 ±0.24 0.36±0.19 0.000*Test 1.72 ±0.42 0.80 ±0.26 0.90±0.37 0.000*Control 1.84 ±0.44 0.86 ±0.1 0.98±0.33 0.000**p

Sneha Puri et al.recession between the test and control groups (p>0.05). (Table 2)Table 2: Comparison of Clinical parameters of Test and Control sites at 3 month (Mean ± SD)ParametersTest SiteControl SiteDifferenceP- valuePPD reduction(mm)3.32 ±0.33 2.03 ± 0.13 1.29±0.11 0.000*CAL gain(mm)3.80 ±0.23 4.45 ±0.30 0.65±0.12 0.000*GR increase(mm)1.19 ±0.20 1.25 ±0.18 0.06±0.08 0.477*p

Diode laser for periodontal pocket treatmentforms of periodontal therapy are influencedby general level of oral hygiene.In the present study the mean probingpocket depth reduction in the test group was3.32 (2.6 mm from 5.6 mm) at 3 monthswhereas in control group it was 2.03 mm(3.19 mm from 5.73 mm) at 3 months.Results of our study are similar to a study byCrispi et al, (2007) 13 in which there wasstatistically significant differences in PDbetween the test and control groups forpockets of 1 to 4 mm, 5 to 6 mm, and ≥7mm. Also in a study by Schwarz et alwas 0.94mm only. The possible reason forsignificant reduction in the probing pocketdepth in LASER group may be due to thereduction in periodontopathic bacteria likeAggregatibacter actinomycetemcomitans,Porphyromonas gingivalis and PrevotellaIntermedia as well as increase in number ofcocci and non-motile rods and a decrease inthe amount of motile rods and spirochetes(Schwarz et al 2006). 14The effectiveness of scaling and root planingin the treatment of periodontal disease toreduce bacterial plaque on the root surface is(2006) 14 showed that the mean value of theuniversally accepted.16Sbardone et alPD decreased in the laser group from 4.9mm at baseline to 2.9 mm after 6 monthsand in the SRP group from 5.0 mm atbaseline to 3.4 mm after 6 months. Howeverseveral studies are not in accordance to thepresent study, as a study by Rafael et al(2007) 15 showed only 1.43mm mean PDdecrease in the photodynamic therapy (PDT)group after 3 months and in SRP group it(1990) 17 reported that diseased sites treatedwith a single episode of scaling and rootplaning was repopulated with potentiallypathogenic microbes at 21 day aftertreatment. However, the sites treated withdiode laser were not repopulated withpotentially pathogenic microbes even after28 days. Pick et al (1985) 18 showed in astudy that LASER light not only eliminates8

Sneha Puri et al.bacteria but also inactivates bacterial toxinsincreased to 1.25 mm at 3 months.Thediffused with root cementum. Diode LASERis expected to have a disinfecting thermaleffect on the bacteria that is basically limitedto root surface.In the present study, the mean clinicalattachment level gain was 2.25 mm in thetest group whereas in the control group itwas 1.58 mm. These findings are supportedby similar studies by Schwarz et al (2006) 14showed that mean value of the CALdecreased in the laser group from 6.3 mm atbaseline to 4.4 mm after 3 months and in theSRP group from 6.5 mm at baseline to 5.5after 3 months. In a study by Crispi et al(2007) 13 showed that mean RCAL decreasedin the PDT group from 9.93 mm at baselineto 8.74 mm after 3 months, and in the SRPgroup, from 10.53 mm at baseline to 9.01mm after 3 months. Mean gingival recessionwas 0.39 which was increased to 1.19 mm at3 months in the test group whereas in thecontrol group it was 0.32 mm which wasreason for more gain in CAL in the testgroup may be because of the ability ofDiode LASER to enhance epithelialremoval, leading to retardation of epithelialmigration, which enhances connective tissueattachment. In addition because of adequatecoagulation provided by use of LASERs, 19damage to the surrounding healthy tissues isreduced which may stimulate new boneformation if applied in the correct way.These results may justify the interest in theapplication of the laser in general, to thefield of periodontology. Because the effectsof laser treatment of periodontal tissuebasically depends on the wavelength, pulseenergy, frequency, and spot size used, whenthese factors are taken in account diode lasercan be considered as an interestingalternative to conventional scaling and rootplaning in periodontal treatment.Furthermore amongst various LASERsystems Diode LASER radiation is absorbed9

Diode laser for periodontal pocket treatmentby superficial layer while as other LASERsystems are absorbed by deeper tissuelayers. Thus have a better effect on sitesaffected by periodontal disease.CONCLUSIONS:From the analysis of the results, and withinthe limitations of the present study,following conclusions were drawn:-1) Both the treatment group resulted insignificant reduction in Probingpocket depth (PPD), and gain inClinical Attachment level (CAL).2) LASERs in combination with localperiodontal therapy may represent anew approach in long termmanagement of periodontal pocketwith chronic periodontitis.REFERENCES:1. Aleo JJ, De Renzis FA, Farber PA,Varboncocur AP. The presence andbiological activity of cementumbound endotoxins. J Periodontol1974; 45: 672–675.2. Hatfield CG, Baumhammers A.cytotoxic effects of periodontallyinvolved surfaces of human teeth.Arch Oral Biol, 1971; 16: 465-468.3. Blomlof JP, Blomlof LB, LindskogSF. Smear removal and collagenexposure after non surgical rootplaning followed by EDTA gelpreparation. J Periodontol 1996; 67:841-845.4. Ando Y, Aoki A, Watanabe H,Ishikawa I. Bactericidal effect oferbium YAG laser onperiodontopathic bacteria. LasersSurg Med 1996; 19: 190–200.5. Aoki A, Ando Y, Watanabe H,Ishikawa I. In vitro studies on laserscaling of subgingival calculus withan erbium:YAG laser. J Periodontol1994; 65: 1097–1106.10

Sneha Puri et al.6. Aoki A, Sasaki KM, Watanabe H,Ishikawa I. Lasers in nonsurgicalperiodontal therapy. Periodontol2000 2004; 36: 59–97.periodontal pockets throughirradiation with a diode laser: a pilotstudy. J Clin Laser Med Surg 1997;15: 33-37.7. Moritz A, Schoop U, Goharkay K etal. Treatment of periodontal pocketwith a diode laser. Laser Surg Med1998; 22: 302-3118. Turesky S, Gilmore, Glickman.Reduced plaque formation by thechloromethyl analogue of vitamin C.J Periodontal 1970; 41: 41-3.9. 9.Muhlemann H.R. Psychologicaland chemical mediators of gingivalhealth. J Prev Dent 1977; 4: 6-1710. Gutknecht N, Fischer J, Conrads G etal: Bactericidal effect of theNd:YAG lasers in laser supportedcurettage. Proc SPIE 1997;2973:221-223.11. Moritz A, Gutknecht N, DoertbudakO et al: Bacterial reduction in12. Bach G and Neckel C: A 5 yearcomparative study on conventionaland laser assisted therapy forperiimplantitis. Proc SPIE 2000;3910: 12-17.13. Crespi R, Cappare P, Toscanelli I,Gherlone E, Romanos GE. Effects ofEr:YAG laser compared to ultrasonicscaler in periodontal treatment: a 2-year follow-up split-mouth clinicalstudy. J Periodontol 2007; 78: 1195–1200.14. Schwarz F, Bieling K, Nuesry E,Sculean A, Becker J. Clinical andhistological healing pattern of periimplantitislesions following nonsurgicaltreatment with an Er:YAGlaser. Lasers Surg Med 2006; 38:663–671.11

Diode laser for periodontal pocket treatment15. Rafael R. de Oliveira, Humberto O,Schwarz-Filho, Arthur B Novaes JRand Mario Taba Jr. antimicrobialphotodynamic therapy in the nonsurgical treatment of aggressiveperiodontitis: A preliminaryrandomized controlled clinical study.J Periodontol 2007; 78: 965–973.16. Badersten A, Nilveus R, Engelberg J.Effect of nonsurgical periodontaltherapy. II Severely advancedperiodontitis. J clin Periodontol1987; 10: 63-73.17. Sbardone L, Ramaglia L, Gulletta E,Iacono V. Recolonization ofsubgingivalmicroflora after scalingand root planing in humanperiodontitis. J Periodontol 1990;61: 579-584.18. Pick RM, Pecaro BC, Silberman CJ.The laser gingivectomy. The use ofCO 2 laser for the removal ofphenytoin hyperplasia. J Periodontol1985; 56: 492-496.19. Rastegar S, Jacques S.L, MotamediM et al. Theoretical analysis ofequivalency of high-power diodelaser (810nm) and Nd:YAG laser(1064 nm) for coagulation oftissue:predictions for prostatecoagulation. Proc SPIE 1992; 1646:150-156.CORRESPONDENCEDr. Sneha PuriPost graduate studentDept. of Periodontics and Implantology,Sharad Pawar Dental College, Sawangi (M), Wardha - 442005E-mail – smiling.sneha3@yahoo.in12