10.59987/ads/2015.1.15-20
Background. Chronic periodontitis affects 47% of adult population over the age of 30. The first phase of periodontal treatment is always represented by scaling and root planning (SRP), that is a causal, non-surgical therapy that recognizes as primary aims the control of bacterial infection and the reduction of periodontal plaque-associated inflammation. Yet, another innovative causal therapy is represented by the irradiation of periodontal pockets with laser.
Aim. To evaluate the effect of a 940-nm diode laser as an adjunct to SRP in patients affected by periodontitis.
Materials and methods. Sixty-eight adult patients with moderate-to-severe periodontitis were sequentially enrolled and undergone to periodontal examination (V1) in order to detect gingival index (GI), plaque index (PI) and probing depth (PD). The patients were randomly divided into two groups: the first (n=34) received SRP treatment alone, the control group (n=34) received SRP and 940-nm diode laser therapy.
Results. Data were analyzed by Student’s t-test, with two tails; for all clinical parameters, both groups reported statistically significant differences compared to basal values (p&lt;0.0001). Both procedures were effective in improving GI, PI and PD, but the use of diode laser was associated with more evident results.
Conclusions. Considered the better clinical outcomes, diode laser can be routinely associated with SRP in the treatment of periodontal pockets of patients with moderate-to-severe periodontitis.
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Annali di stomatologia
root planning
Effectiveness of a diode laser in addition to non-surgical periodontal therapy: study of intervention
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Original Article
2022-08-12
2022-08-12
2015-03-01
2023-12-04
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Ann Stomatol (Roma)
R. Del Giudice
2015
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root planning
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Effectiveness of a diode laser in addition to non-surgical periodontal therapy: study of intervention
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                                                                                                     Original article



    Effectiveness of a diode laser in addition
    to non-surgical periodontal therapy:
    study of intervention




                                                                                                       i
                                                                                                     al
                                                                                                  on
    Antonio Crispino, DDS, PhD                                Conclusions. Considered the better clinical out-
    Michele Mario Figliuzzi, DDS, PhD                         comes, diode laser can be routinely associated
    Claudio Iovane, DDS                                       with SRP in the treatment of periodontal pockets
    Teresa Del Giudice, MD                                    of patients with moderate-to-severe periodontitis.
    Simona Lomanno




                                                                                         zi
    Delfina Pacifico, DDS                                     Key words: periodontal diseases, diode laser,
    Leonzio Fortunato, MD                                     scaling, root planning.
    Roberto Del Giudice, DDS




                                                                           na
                                                              Introduction
    Department of Periodontics and Oral Sciences,
    “Magna Graecia” University, Catanzaro, Italy              The periodontal disease is a chronic inflammatory
                                                              process, characterized by bacterial etiology and cyclic




                                                                er
                                                              evolution, which determines a progressive, site-specif-
    Corresponding author:                                     ic destruction of the supporting tissues of the tooth,
    Antonio Crispino                                          and proceeds from the superficial periodontium (gum)
    Department of Periodontics and Oral Sciences,


                                                        t     to the deep periodontium (alveolar bone, periodontal
    “Magna Graecia” University
    Via Tommaso Campanella, 115
                                                     In       ligament, cementum), resulting in typical pathological
                                                              lesions (periodontal pockets, gingival recessions, ver-
    88100 Catanzaro, Italy                                    tical and/or horizontal bone resorption, bifurcation le-
    E-mail: crispino@unicz.it                                 sions) to the loss of the dental element (1).
                                                              From the epidemiological point of view, in the United
                                                 ni
                                                              States of America chronic periodontitis affects 47% of
    Summary                                                   the adult population over the age of 30, distributed in
                                                              mild (9%), moderate (30%) and severe (8%) (2).
                                     io

    Background. Chronic periodontitis affects 47% of          Although a number of risk factors can influence the
    adult population over the age of 30. The first phase of   start, progression and prognosis of periodontitis (age,
    periodontal treatment is always represented by scal-      sex, cigarette smoking, hormonal changes, immune
    ing and root planning (SRP), that is a causal, non-sur-   system disorders, systemic diseases, diabetes, stress)
                           iz



    gical therapy that recognizes as primary aims the         (3-5), the main etiological factor is represented by den-
    control of bacterial infection and the reduction of pe-   tal plaque and in particular by anaerobic gram-nega-
    riodontal plaque-associated inflammation. Yet, anoth-     tive bacilli (6). For that reason, the first phase of peri-
           Ed




    er innovative causal therapy is represented by the ir-    odontal treatment is always represented by the initial
    radiation of periodontal pockets with laser.              preparation, which is a type of etiological, non-surgical
    Aim. To evaluate the effect of a 940-nm diode             therapy, which recognizes as primary aims the elimina-
    laser as an adjunct to SRP in patients affected by        tion or reduction of bacterial infection and the control of
    periodontitis.                                            periodontal plaque-associated inflammation (7). We
    Materials and methods. Sixty-eight adult patients         choosed to use laser therapy to personally verify the
IC




    with moderate-to-severe periodontitis were se-            actual efficiency, where the literature talks to us for a
    quentially enrolled and undergone to periodontal          long time, of this treatment option in the treatment of
    examination (V1) in order to detect gingival index        periodontally compromised patients and to evaluate
    (GI), plaque index (PI) and probing depth (PD).           their satisfaction. In addition to SRP the use of laser
C




    The patients were randomly divided into two               therapy, as shown by several studies, appears to im-
    groups: the first (n=34) received SRP treatment           prove and facilitate the healing of treated sites. Re-
    alone, the control group (n=34) received SRP and          cently, Yilmaz et al. (2013) have shown that in the
    940-nm diode laser therapy.                               sites treated with the use of laser Er:YAG in addition to
                                                              SRP, reached statistically significant improvements in
©




    Results. Data were analyzed by Student’s t-test,
    with two tails; for all clinical parameters, both         terms of attachment gain and reduction in PD com-
    groups reported statistically significant differ-         pared to sites treated with only srp or only topical
    ences compared to basal values (p<0.0001). Both           gaseous ozone (8). Other study that compares, like
    procedures were effective in improving GI, PI and         treatment options, Nd:YAG laser alone, SRP alone,
    PD, but the use of diode laser was associated             and Nd:Yag plus SRP has demonstrated that the last
    with more evident results.                                option of treatment is the best in term of reduction of

    Annali di Stomatologia 2015; VI (1): 15-20                                                                        15
    A. Crispino et al.


    PI, GI, PPD and GCF volume values (9). Another type           GI and PI were detected on 6 index teeth: 12, 16, 24,
    of laser (KTP: potassium-titanyl-phosphate) has shown         32, 36, 44.
    to be a significant help in SRP, like demonstrated in a       It was then measured the pocket depth (PD), which
    study of Romeo et al. (2010). In this study, treated          consists in measuring the distance in mm between
    sites are divided into four groups and the best results       the free gingival margin and the base of the pocket,




                                                                                                           i
    were obtained in the groups in which the laser has            making six records for each dental element: mesial,




                                                                                                         al
    been used (10). A diode laser has a wavelength of             central and distal probing of the buccal and lingual-
    810-980 Nm, and there are many different laser used           palatal sides of all teeth (14). The values in mm of
    in periodontology with a different wavelength; Ktp laser      the survey were then converted into a score called




                                                                                                      on
    has a wavelength of 532 Nm, Nd:YAG laser of 1064              T-score:
    Nm, Er:Yag of 2940 Nm and CO2 laser of 9600-10600             • 0 = PD between 0 and 2 mm
    Nm (11). We used diode laser cause has an easier              • 1 = PD between 2 and 4 mm
    learning curve and a more affordable price than others.       • 2 = PD between 4 and 6 mm
                                                                  • 3 = PD over 6 mm.




                                                                                            zi
                                                                  After having filled a complete medical records, pa-
    Aim of the study                                              tients were randomly divided into two treatment
                                                                  groups.




                                                                               na
    To check and compare the possible improvement of              The patients of the first group (n=34) received initial
    the periodontal indices in two groups of patients with        preparation. It consists in the mechanical instrumen-
    periodontal disease: the first group undergone to             tation of the root surface, in order to make it biologi-
    SRP, the second one to SRP with the addition of               cally compatible with the healing of periodontal tis-




                                                                    er
    laser therapy.                                                sues; that is made possible by two fundamental pro-
                                                                  cedures:
                                                                  • scaling, which consists in removing mucobacterial
    Materials and methods                                             plaque and tartar from supragingival and subgin-



                                                            t         gival tooth surfaces, generally through the use of
    At the Department of Dentistry of the University Hos-
    pital “Mater Domini” of Catanzaro, sixty-eight adult
                                                         In           inserts fixed on an ultrasonic scaler;
                                                                  • root planning, which consists in the removal of
    patients (mean age of 56,3 years) with moderate-to-               deposits of subgingival calculus, granulation tis-
    severe periodontal disease were sequentially enrolled             sue and softened, infected or necrotic cementum,
    on a voluntary basis.Totally 1224 sites with periodon-            eliminating the irregularities of the root surface to
                                            ni
    tal disease are treated.                                          make it smooth and hard, typically through the
    The selected cases were based on the following inclu-             use of manual tools such as the curettes.
    sion criteria: 1) patients 18 or older; 2) single or multi-   The second group of patients (n=34) received the
                                  io

    rooted teeth; 3) patients that received the same laser        same therapy did in the first group, but with the ad-
    treatment including: laser settings, procedural steps and     dition of laser therapy through a 940 nm diode
    technique; 4) patients who undergone, after 4 months,         laser (ezlase™ soft tissue diode laser - Biolase
    to follow-up and 5) patients that had no surgery for 12       Technology Inc.). This laser is extremely compact
                         iz



    months prior to treatment. There was no exclusion of          and easy to handle; the active medium is a semi-
    smokers or patients with medical conditions.                  conductor and the pumping system is an electric
    After having obtained a thorough medical and den-             current (15); the wavelength’s laser of 940 nm
          Ed




    tistry anamnesis and the underwriting of a specific in-       makes it considerably affine to molecules of hemo-
    formed consent, all the patients underwent a peri-            globin and melanin (16).
    odontal examination (V1), in order to detect the most         The operating protocol of the treatment of periodontal
    common indices of periodontal health. The experi-             pockets in by 940 nm diode laser provides for the ap-
    mentation has followed the principles of Declaration          plication of the following dosimetric values:
    of Helsinki.                                                  • power: 3 W
IC




    The degree of gingival inflammation was assessed by           • pulse frequency: 15 Hz
    gingival index (GI) of Löe and Silness (1967) (12),           • fluence: 1,2 J/mm2
    measured from 0 to 3 on each tooth:                           • emission mode of laser light: pulsed
    • 0 = healthy gingiva                                         • on time (pulse duration): 10 ms
C




    • 1 = mild inflammation, absence of bleeding on               • time-off (relaxation time): 20 ms
             probing                                              • average power: 1 W
    • 2 = moderate inflammation, bleeding on probing              • optical diameter fiber and tips: 300-400 μ.
    • 3 = severe inflammation, spontaneous bleeding.              The pulsed emission has two important clinical ad-
©




    The level of hygiene was assessed by plaque index             vantages:
    (PI) of Silness and Löe (1964) (13):                          • enables the thermal relaxation during the time-off,
    • 0 = absence of plaque                                           avoiding the overheating and charring of radiated
    • 1 = presence of plaque detectable with probe                    tissues;
    • 2 = moderate accumulation of plaque, which is vi-           • allows to operate without the use of anesthesia.
             sible to the naked eye                               Treatment should not begin before all the people in
    • 3 = abundant accumulation of plaque.                        the room have not been wearing protective glasses.

    16                                                                               Annali di Stomatologia 2015; VI (1): 15-20
    Effectiveness of a diode laser in addition to non-surgical periodontal therapy: study of intervention


    After connecting all the components (pedal and opti-             Results
    cal fiber), it is essential to activate the tip on a dark
    cardboard (e.g., blue articulation paper) and check              The biggest difference was found relatively to the av-
    that the spot of the light guide designs a perfect cir-          erage gingival index (GI). In the group of patients un-
    cle, making sure that it has not a star-shaped appear-           dergoing initial preparation alone, such clinical para-




                                                                                                                 i
    ance; the activated tip presents a blackened and, at             meter decreased from the value of 1.6 to the value of




                                                                                                               al
    this point, the laser is ready for use. Given the high           0.9, with a reduction of 44% as average, while in the
    affinity of the 940 nm diode laser for dark colors, we           group of subjects treated with diode laser, the aver-
    were able to increase the bactericidal effect just irri-         age gingival index was turned from the value of 1.5 to




                                                                                                            on
    gating the site to be treated with an exogenous chro-            0.3, demonstrating a decrease of 80%; therefore the
    mophore, that is a pigmented substance that makes                addition of the laser-therapy allows to reduce the av-
    the tissues more suscettible to the light of the diode           erage gingival index than double the SRP alone (80
    laser. Substances such as povidone-iodine (Beta-                 vs 44%).
    dine®) and methylene blue contribute to reduce the               Plaque index and probing depths were reduced by a




                                                                                                 zi
    bacterial load due to their disinfectant power; more-            mean of 57 and 58% in the group of patients receiv-
    over these pigments bind to the cytoplasmic mem-                 ing SRP alone, while in the group of patients under-
    brane of bacteria, making them darker (17, 18). So               going SRP + laser therapy, PI and PD underwent a




                                                                                   na
    you have just to irrigate the quadrant to be treated             mean percentage decrease of 67 and 76%.
    with such substances and wait 30 seconds, without                Ultimately, the results of this study clearly shows that
    rinsing. Therefore fit the tip within the periodontal            both procedures are effective in improving periodon-
    pocket, keeping at about 1 mm from the bottom of the             tal indices (GI, PI, PD) compared to basal values, but




                                                                        er
    same and in the parallel direction to the long axis of           the association of the diode laser to the initial prepa-
    the tooth to be treated. The tips have a metal core              ration allows to obtain clinical results more evident
    which allows their inclination according to the needs            than the single procedure of SRP (Tabs. 1, 2).
    of the operator and to the spatial arrangement of the
    pocket. Once the light beam is activated, the tip must


                                                             t       Table 1. Results of Group I (SRP therapy).
    be moved within the pocket in both horizontal and
    vertical directions, as to draw a pattern, with rapid
                                                          In         Parameter                  Middle Value          P
    movements, leading the tip toward the inner wall of              Average PI (V1)            2,1
    the pocket, in order to remove junctional epithelium                                                              < 0.0001
                                                                     Average PI (V4)            0,9
    migrated and induce bleeding necessary for the for-
                                                 ni
    mation of a clot. It is recommended to make for each             Average GI (V1)            1,6
                                                                                                                      < 0.0001
                                                                     Average GI (V4)            0,9
    pocket 3 cycles of irradiation, each lasting 30 sec-
    onds. It is important during the treatment to maintain           Average PD (V1)            2,6
                                                                                                                      < 0.0001
                                     io

    the aspirator near the site, to avoid overheating.               Average PD (V4)            1,1
    When you remove the tip from the pocket, it might
    have residues of sulcular epithelium and infected                Table 2. Results of Group II (SRP and laser therapy).
    granulation tissue, in which case you need to clean it
                           iz



    up with a gauze soaked in disinfectant before pro-               Parameter                  Middle Value          P
    ceeding to the next pocket.
                                                                     Average PI (V1)            1,5
    The clinical follow-up has been executed, in both                                                                 < 0.0001
           Ed




                                                                     Average PI (V4)            0,5
    groups, after 4 months of treatment (V4). After an ap-
    propriate causal non-surgical therapy and an ade-                Average GI (V1)            1,5
                                                                                                                      < 0.0001
    quate oral hygiene at home by the patient, periodon-             Average GI (V4)            0,3
    tal tissues undergo a healing process that is complet-           Average PD (V1)            1,7
    ed after an average of 3 months. In particular, it as-                                                            < 0.0001
                                                                     Average PD (V4)            0,4
    sists to:
IC




    • reduction in probing depth (PD), due to recolla-
         genation of the supracrestal fibers, obviously in           Discussion
         function variable depending on the depth of initial
         probing (19,20);                                            The remarkable difference between the two proce-
C




    • reduction in gingival index (GI) and bleeding on               dures in improving periodontal variables is attribut-
         probing, due to the reduction of the inflammatory           able to the benefits from the use of diode laser in ad-
         infiltrate;                                                 dition to the traditional procedures of SRP in the
    • reduction in the plaque index (PI) and change of               treatment of periodontal pockets (23, 24). They are:
©




         supra- and subgingival bacterial flora, with a de-          • bactericidal effect;
         crease of Gram-negative and an increase Gram-               • curettage effect;
         positive (21, 22).                                          • bio-stimulating effect.
    Data were analyzed by Student’s T test with two tails.           Combining laser therapy with conventional proce-
    For all clinical parameters considered, both treatment           dures is in fact achieved a more effective decontami-
    groups reported statistically significant differences            nation of the pocket, with also a recolonization slower
    compared to baseline (p <0.0001).                                than sites treated only mechanically (25-29); some

    Annali di Stomatologia 2015; VI (1): 15-20                                                                               17
    A. Crispino et al.


    Authors attribute this phenomenon to clot formation in      in vivo in addition to SRP procedures, analyzing the
    the pocket, that would act as a seal to it.                 following parameters: residual debris, root surface
    Thanks to curettage effect, the laser eliminates the        morphology, thermal side effects; he concluded that
    sulcular epithelium infected in a total and complete        the laser therapy does not cause any mechanical al-
    way than conventional methods of treatment with             teration or thermal damage to the cementum (47).




                                                                                                                i
    manual tools (30), without any kind of damage to the        Regarding the tolerance and compliance of the patient,




                                                                                                              al
    underlying connective tissue and reducing the bac-          the laser therapy of periodontal pockets does not in-
    terial load of Actinobacillus actinomycetemcomitans         volve discomfort or intraoperative pain, nor requires,
    and Porphyromonas gingivalis (31), which easily             as a rule, the execution of loco-regional anesthesia,




                                                                                                           on
    penetrate within the sulcular epithelium. Further-          since the power values provided are relatively low (3
    more there is a scientific evidence on the direct an-       W) and the energy is supplied in pulsed mode (41).
    timicrobial effect of diode laser against levels of Tar-    While recognizing these indisputable results, it should
    geted Periodontal Pathogens (32). According to              be stressed, however, that the laser acts only as an
    Kreisler (2005) the greatest reduction in the degree        adjunct to etiological non-surgical periodontal thera-




                                                                                                zi
    of tooth mobility and probing depth in the group of         py, not being able to replace traditional mechanical
    patients who underwent SRP + laser therapy can be           procedures of SRP; in this regard, the study of Kam-
    mainly attributed not to the killing of bacteria in peri-   ma et al. (2009) showed that combining mechanical




                                                                                na
    odontal pockets, but rather to the complete removal         treatment (SRP) with diode laser therapy produces
    of infected sulcular epithelium, which leads to             better results than the laser therapy alone, both in
    greater attack of the connective tissue (33). Further-      clinical (probing depth and clinical attachment level)
    more, the removal of granulation tissue infected pro-       and bacteriological terms (total bacterial count of pe-




                                                                  er
    motes the healing of connective tissue with a de-           riodontal pathogens) (20).
    crease in probing depth, gingival index and tooth
    mobility and a recovery of clinical attacks signifi-
    cantly higher compared to the initial preparation only      Conclusions
    (33-36); these results, in addition to being the best,


                                                          t
    are longer lasting and more stable over time (37).
    However, according to De Micheli (2011) the results
                                                       In       The results show the adjunctive benefits that diode
                                                                laser treatment can provide when it is used as an ad-
    of the two therapeutic procedures are similar with          junct to non surgical periodontal treatment.
    regard to plaque index and bleeding on probing, for         Considered the better clinical results, the laser diode
    which laser therapy does not lead to additional ben-        can be routinely associated with the traditional me-
                                           ni
    efits (38). Also according to Dukic (2012) the results      chanical non-surgical therapy (SRP) in the treatment
    of the two treatments are similar in terms of plaque        of periodontal pockets of patients with moderate-to-
    index, bleeding on probing and clinical attachment          severe chronic periodontitis.
                                 io

    level: the addition of laser therapy showed a marked        The results of such studies encourage us in hoping
    improvement in PD, but only in periodontal pockets          that the use of complementary low power laser in the
    of moderate depth (from 4 to 6 mm) (39).                    future will become a part of the standard protocol of
    Finally, because of the biostimulant effect (29,40-42),     non-surgical periodontal therapy.
                         iz



    laser therapy induces the acceleration of mitotic
    processes within the irradiated tissues, without caus-
    ing structural and/or functional alterations. According     References
          Ed




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