J Bagh College Dentistry Vol. 23(2), 2011 Clinical evaluation of

Transcription

1 Clinical evaluation of laser in the treatment of chronic periodontitis in comparison with that of hand and ultrasonic treatment Fahad Al Dabbagh B.D.S., M.Sc. (1) Khulood Al Safi B.D.S., M.Sc., Ph.D. (2) ABSTRACT Background: The use of lasers for treatment of periodontal diseases has become a topic of much interest in periodontal therapy, based on its various characteristics, such as tissue ablation, homeostasis and sterilization effect. Materials and methods:a total of 72 periodontal pockets were selected and randomly grouped into three groups; treated by Er:YAG laser (160mJ 15Hz), ultrasonic scaling device and hand instruments respectively. Clinical periodontal assessments (PI, BOP, PPD and RAL) were performed before starting treatment and after three months. Numerical rating scale was used to evaluate pain level that the patient experience during each type of treatment. Results: The results show statistically significant (P < 0.05) reduction in all periodontal clinical parameters at the second visit in all groups, but the group treated by Er:YAG laser shows most significant improvement when compared with other two groups, also less pain was felt during treatment by Er:YAG laser with a mean of (1.166), followed by ultrasonic instrument (mean = 4.916), while treatment by hand instruments are regarded as the most painful one with a mean of (8.166). Conclusion:It was concluded that Er:YAG laser (of 160mJ energy at 15Hz pulse repetition rate) could be used as an alternative to conventional non surgical periodontal treatment (ultrasonic and hand instruments). Key words: chronic periodontitis, Er:YAG laser, hand instruments, ultrasonic instruments. (J Bagh Coll Dentistry 2011;23(78-83). INTRODUCTION Scaling and root planing (SRP) is generally the first treatment employed for periodontitis and it is considered as a nonsurgical procedure, root planing involves cleaning and smoothing the root surface of an infected tooth so that the gingival tissue can heal, shrinking the tissue and reducing the depth of the pocket that had formed, thus making the root surfaces biologically compatible with optimal healing and reattachment of epithelium to the root surface, scaling may be performed with hand instruments alone or with the aid of an ultrasonic scaler. (1) Recently, the use of laser light has been suggested as an alternative to the conventional mechanical treatment,it was proposed that laserbased root surface treatment might lead to improved periodontal therapy due to relatively conservative removal of tooth substance as well as to the bactericidal effect towards periopathogenic bacteria,also it has been annotated in the literature that application of laser in periodontal treatment provides a more comfortable patient experience with less trauma and post-operative complications as well as a decreased healing time. (2) The Erbium-doped: Yttrium Aluminum Garnet laser (Er:YAG), emitting at a wavelength of 2940 (1) MSc Periodontics, Department of Periodontics, College of Dentistry, Baghdad University (2) Professor, Department of Periodontics, College of Dentistry, Baghdad University nm, possesses suitable properties not only for soft tissue therapy but also for hard tissue treatment due to its characteristic wavelength that is highly absorbed by water. (3) MATERIALS AND METHODS A total of twelve patients (with age range from years) were asked to participate in this clinical trial. Study goals and Full description of the entire procedure were explained to each patient and an informed consent was obtained from each of them. Inclusion criteria were: 1- Male patient (to obtain maximum standardization of sample and exclude any possible external variables effect) with chronic periodontitis having at least 6 teeth with pockets of 5mm. 2- The patients shouldn't have: - Systemic diseases that could affect the periodontal condition. - Recent (3months) periodontal treatment. - Recent (3 months) antibiotics taking. The affected teeth for each patient are randomly categorized into three groups. The first one received nonsurgical Er:YAG laser treatment of (160mJ, 15Hz) settings, the second received ultrasonic non surgical periodontal treatment, while the third one treated by hand instruments. Periodontal clinical parameters were recorded for each patient before starting treatment and after three months from treatment. Oral and Maxillofacial Surgery and Periodontology 78

2 KaVo KEY Laser III upgraded, piezoelectric ultrasonic scaler Piezon Master 400 with supragingival and subgingival scaling tips and Universal and Gracey curette, were used for in this study. Clinical periodontal parameters include: a- Plaque Index (4) A dental mirror and a periodontal probe or dental explorer was used after drying of the teeth included in the study to assess plaque amount; see table 1. b- Bleeding on Probing: The selected sites were gently probed with a WHO periodontal probe to the deepest point. If bleeding occurs within 30 seconds after probing, the site was given a positive score, while a negative scoreis given for non bleeding sites. c- Clinical Probing Pocket Depth: The distance from gingival margin to the most apical extent of the probe inserted into the gingival crevice as close as to the long axis of the tooth was recorded to the nearest half millimeter; the probe had been allowed to fall without exerting excessive pressure. d- Relative Attachment Level: An occlusal stents were fabricated for each patient, then these stents adjusted to fit on teeth. Vertical grooves corresponding to the probing direction for each site were made by using a fine fissure dental stone bur, these grooves provided a reproducible reference points for the paths of insertion and theangulations of probing at each site. The distance from the base of the pocket to the lower periphery of the stent was considered as a relative attachment level. PI, PPD and RAL were assessed by using a periodontal probe having William's graduations, with 0.4 mm tip diameter, which modified to increase its graduation to 14mm. e- Pain level: In this study, NRS was used to evaluate pain intensity during each type of treatment for each patient, were each one learned carefully how to use this scale. In this scale the 0 represent no pain, while 10 represent the maximum pain, then the patient asked to record the corresponding value for pain that he felt immediately after each treatment type. Treatment procedures conducted in this manner: 1. Hand instrument nonsurgical periodontal therapy: Hand instrumentation was done by using universal curette with G11-12,G13-14 used for posterior teeth while Gracey curette G3 - G4 was used for anterior teeth. The hand curettes were sharpened before instrumentation each tooth. 2. Ultrasonic nonsurgical periodontal therapy: Ultrasonic nonsurgical periodontal therapy is accomplished by applying a light touch and light pressure. Keeping the tip of scaler parallel to tooth surface and constantly in motion, the working tip kept in contact with all aspects of the root surface to ensure thorough removal of deposits and toxins, and this was achieved by a series of focused, overlapped strokes which ensure complete root coverage. Water irrigation was used according to the operator preference. The debridement was performed until the operator felt that the root surfaces are smooth and hard by mean of dental explorer. 3. laser nonsurgical periodontal therapy: Before starting laser therapy a protective eyeglasses were wearied by operator and patient for safety from laser hazard. Er:YAG laser device was adjusted on 160mJ as energy level and 15Hz as frequency, while water irrigation was used according to the operator preference. The instrumentation performed from coronal to apical in parallel paths, with an inclination of the fiber tip of 150 to 200 to the root surface, consequently, the energy density of the laser light reaching the root surface. The debridement was performed until the operator felt that the root surfaces are smooth and hard by mean of dental explorer. Post treatment instructions:all the patients were instructed not to use any type of antibiotics or mouth rinse during the research period (to exclude their effect on research results), also they instructed to use the same method of brushing (Modified Bass technique). Statistical analysis SPSS version 11 was used for analysis of data collected and to obtain both descriptive and inferential statistics. Bleeding on probing expressed as a ratio. Statistical analysis of difference between mean scores before treatment and their value after three months from treatment were undertaken using the paired sample Student t-test (Intra group comparison), also differences between the groups (inter group comparison) was assessed using the same test. Chi-square test was used for comparing the percentage of bleeding on probing. The comparison was done at a 5% significant level. RESULTS 1. Plaque Index: Intra-group comparison of mean at baseline visit and second visit revealed very high significance reduction for all groups, figure 1; Oral and Maxillofacial Surgery and Periodontology 79

3 Inter-group comparison of mean for the three method show significant differences between groups treated by Er:YAG laser and the other two groups. The difference was insignificance between group treated by ultrasonic instrument and that treated by hand instruments, table Bleeding On Probing: All three groups show BOP at the baseline visit. Groups treated by laser and hand instruments show very highly significant reduction in the bleeding sites, while group treated by ultrasonic instrument comes in next by 63.63% reduction in bleeding sites, which is non significant one, figure 2; tables Probing Pocket Depth: The values of pocket depth show very high significant reduction in means between two visits for all groups. The highest reduction is recorded in the group treated by Er:YAG laser followed by group treated by hand instruments, group treaded by ultrasonic instrument fall in the last place by minimum reduction in pocket depth. Figure 3 show the difference of pocket depth means for three groups at two visits. The difference between Er:YAG laser group and hand instrument treated group was not significant, but it is significant with ultrasonic group, table Relative Attachment Level: Intra-group comparison of mean values for all groups between visits reveals very high significant reduction in RAL. Again the Er:YAGtreated group success in achieving the greatest reduction, followed by hand instrument treated group and finally ultrasonic treated one, figure 4. Inter-group comparison reveals no significant difference in the values of mean for three groups at the second visit, table 5 declares that. 5. Pain level (by NRS): At the baseline visit, and after finishing each type of treatment, the patient asked to chose the most appropriate value that correspond pain level that he felt during treatment, the recorded data proved that sites treated by Er:YAG laser show the minimum amount of pain as compared to those treated by ultrasonic instrument or hand instruments, figure 5. The difference between three groups was very highly significant regarding pain level during treatment, table 6. DISCUSSION In fact, hand or ultrasonic Instrumentation is regarded as mechanical means for pathological deposits removal, while Er:YAG laser therapy removes these deposits by photothermal mechanism; the rapid subsurface expansion of the interstitially trapped water within the mineral substrate causes a massive volume expansion, and this expansion causes the surrounding material to be exploded away; due to the water spray and the short pulse duration, there is a minimal amount of heat transferred to the remaining and adjacent tooth structure. (5) As mentioned by Gronqvist et al. (6), thermal evaporation of water and organic components would be the major process in the ablation of bacterial biofilms with the Er:YAG laser, as with other hard lasers. Also Er:YAG laser shows antimicrobial effects against periodontopathic bacteria and the removal of lipopolysaccharides. (7) The favorable short-term (three months) improvement as assessed by clinical parameters could be a reflection of a reduction of the bacterial load after laser treatment. (8) Other study revealed that the Er:YAG laser had a significant decontamination effect on periodontally diseased root surfaces and also had a significantly better decontamination effect than that of the ultrasonic scaler with respect to the total numbers of Colony forming units (CFUs) of aerobic and anaerobic microbes, these bacteria would be devitalized and detoxified by thermal denaturation of the bacterial substances, study also shows that the remaining biofilms on the boundary of treated areas of ultrasonically scaled root surface completely retained their original form of bacterial flora, whereas the remaining biofilms at the marginal region on the lasertreated surface showed a zone with a denatured appearance in the SEM examination. (9) (10) Pourzarandianet at. was shown that Er:YAG laser induces cyclooxygenase-2 expression to produce prostaglandin E2 in a laserenergy-dependent manner, suggesting that cyclooxygenase-2-dependent prostaglandin E2 by laser irradiation may play an important role in the acceleration of gingival fibroblast proliferation; this probably explain, at least in part, the successful healing following Er:YAG non-surgical periodontal treatment as described in numerous clinical studies. Another study shown that predominantly flat cells were found on laser and ultrasonically instrumented root surfaces; In contrast, the scaled and root planed specimens exhibited considerable fewer attached and more round cells, these findings may be supported by the results from controlled clinical trials, which have shown that nonsurgical periodontal treatment with an Er: YAG laser resulted in a statistically significant higher gain of clinical attachment than SRP with hand instruments. (11) The records obtained by using NRS for assessing pain level reveal a significance Oral and Maxillofacial Surgery and Periodontology 80

4 reduction in pain level during Er:YAG laser treatment. An explanation for pain reduction during treatment might be the disruption of nerve terminals in the dentin tubules, combined with a degeneration of nerve terminals between the odontoblasts, which were demonstrated by using transmission electron microscopy. (12) REFERENCES 1. Bonito Arthur, Lohr Kathleen, Lux Linda, Sutton Sonya. Effectiveness of antimicrobial adjuncts to scaling and root-planing therapy for periodontitis (Evidence Report/Technology Assessment). Agency for Healthcare Research and Quality, US department of health and human services 2004; 88: Kelbauskiene Solveiga and Maciulskiene Vita. A pilot study of Er,Cr:YSGG laser therapy used as an adjunct to scaling and root planing in patients with early and moderate periodontitis. Baltic Dental and Maxillofacial J 2007; 9(1): Takasaki Aristeo Atsushi, Aoki Akira, Mizutani Koji, Kikuchi Shigenari, Oda Shigeru, Ishikawa Isao. Er:YAG laser therapy for peri-implant infection (a histological study). J Lasers Med Sci 2007; 22: Silness J, LoeH. Periodontal disease in pregnancy (II): Correlation between oral hygiene an periodontal conditions. Acta Odontol Scand 1964; 22: Freiberg RJ, Cozean C. Pulsed erbium laser ablation of hard dental tissue: the effects of atomized water spray versus water surface film. Lasers in dentistry 2002; 4610: Gronqvist A, Wistrom J, Axner O, Monsen TJ. Bactericidal effect of pulsed 1,064 nm Nd:YAG laser light on Staphylococcus epidermidis is of photothermal origin (in vitro study). Lasers Surg Med 2000; 27: Folwaczny M, Mehl A, Aggstaller H, Hickel R. Antimicrobial effects of 2.94 micron Er:YAG laser radiation on root surfaces (in vitro study). J Clin Periodontol 2002; 29(1): Eberhard J, Ehlers H, Falk W, Acil Y, Albers HK, Jepsen S. Efficacy of subgingival calculus removal with Er:YAG laser compared to mechanical debridement (in situ study). J Clin Periodontol 2003; 30: Akiyama Fumihiko, Aoki Akira, Miura-Uchiyama Mako, Sasaki Katia, Ichinose Shizuko &Umeda Makoto, Ishikawa Isao, Izumi Yuichi. In vitro studies of the ablation mechanism of periodontopathic bacteria and decontamination effect on periodontally diseased root surfaces by erbium: yttrium aluminum garnet laser. Lasers Med Sci 2010; Pourzarandian A, Watanabe H, Ruwanpura SM, Aoki A, Noguchi K, Ishikawa I. Er:YAG laser irradiation increases prostaglandin E production via the induction of cyclooxygenase-2 mrna in human gingival fibroblasts. J Periodontal Res 2005; 40: Schwarz Frank, Aoki Akira, Sculean Anton, Georg Thomas, Scherbaum Werner, Becker Ju rgen.in Vivo Effects of an Er:YAG Laser, an Ultrasonic System and Scaling and Root Planing on the Biocompatibility of Periodontally Diseased Root Surfaces in Cultures of Human PDL Fibroblasts. J Lasers Surg Med 2003; 33: Inoue H, Izumi T, Ishikawa H, Watanabe K.Shortterm histomorphological effects of Er:YAG laser irradiation to rat coronal dentin-pulp complex. Oral Surg Oral Med Oral Pathol 2004; 97: Schwarz Frank, Aoki Akira, Sculean Anton, Georg Thomas, Scherbaum Werner, Becker Ju rgen. In Vivo Effects of an Er:YAG Laser, an Ultrasonic System and Scaling and Root Planing on the Biocompatibility of Periodontally Diseased Root Surfaces in Cultures of Human PDL Fibroblasts J Lasers Surg Med 2003; 33: Silness J, Loe H. Periodontal disease in pregnancy (II): Correlation between oral hygiene an periodontal conditions. Acta Odontol Scand 1964; 22: Takasaki AristeoAtsushi, Aoki Akira, Mizutani Koji, Kikuchi Shigenari, Oda Shigeru, Ishikawa Isao. Er: YAG laser therapy for peri-implant infection (a histological study). J Lasers Med Sci 2007; 22: Score 0 Table 1: Silness and Loe plaque index No Plaque A film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may Score 1 be seen in situ only after application of disclosing solution or by using the probe on the tooth surface. Moderate accumulation of soft deposits within the gingival pocket, or on the tooth and gingival Score 2 margin, which can be seen with the naked eye. Score 3 Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin Table 2: Paired sample t-test of Plaque Index Ultrasonic Hand Oral and Maxillofacial Surgery and Periodontology 81

5 Figure 1: Difference of Plaque Index mean for three groups between two visits Figure 4: Difference of Relative Attachment Level mean for three groups between two Figure 2: Difference of Bleeding On Probing percentage for six groups between Figure 5: Difference of Pain Level for three groups Figure 3: Difference of pocket depth mean for three groups between two visits Table 3: Chi-Square test of Bleeding On Probing for six groups Chi -Square Sign Oral and Maxillofacial Surgery and Periodontology 82

6 Table 4: Paired sample t-test of pocket depth for three groups Ultrasonic Hand Table 5: Paired sample t-test of Relative Attachment Level for three groups at the second visit Ultrasonic Hand Table 6: Paired sample t-test of Pain Level for three groups Ultrasonic Hand Oral and Maxillofacial Surgery and Periodontology 83