Effects of 980 Diode Laser Treatment Combined with Scaling and. Root Planing on Periodontal Pockets in Chronic Periodontitis.

Effects of 980 Diode Laser Treatment Combined with Scaling and Root Planing on Periodontal Pockets in Chronic Periodontitis Abstract: Patients Alireza Fallah, DDS, M.Sc., PhD Candidate Aachen Institute for Laser Dentistry Objective: This study compared the effect of 980 Diode laser + scaling and root planing (SRP) versus SRP alone in the treatment of chronic periodontitis. Method: 21 healthy patients with moderate periodontitis with a probing depth of at least 5mm were included in the study. A total of 42 sites were treated during 6weeks with a combination of 980 Diode laser and SRP (21 sites) or SRP alone (21 sites). The gingival index (GI), probing pocket depth (PPD) and bleeding on probing (BOP) were examined at the baseline and after 6 weeks after the start of treatment. Results: Both groups showed statistically significant improvements in GI, BOP and PPD after treatment. The results also showed significant improvement from laser+ SRP group to SRP alone group. Conclusion: The present data suggest that treatment of chronic periodontitis with either 980 Diode laser + SRP or SRP alone results in statistically significant improvements in the clinical parameters. The combination of 980 Diode laser irradiation in the gingival sulcus and SRP, was significantly better as compared to SRP alone. Introduction Periodontal diseases (gingivitis and periodontitis) are chronic bacterial infections, with a remarkably high prevalence and morbidity. Periodontitis, in contrast to gingivitis, is not reversible, is associated with certain bacterial species and affects all of the soft tissue and bone that support teeth. Periodontitis is moderately to rapidly progressive and is clinically diagnosed on the basis of gingival inflammation, pocket formation, loss of gingival attachment, bone resorption and the number of teeth involved. 1 In early stages of periodontitis close curettage with conventional scaling and root planing is used and in more progressive cases the use of open curettage is needed. Conventional treatments are helpful but not adequate enough always for inhibiting the situation not to reach the need of open curettage. In recent years, the use of lasers has been expected as an alternative or adjunctive Lasers in Dentistry XVI, edited by Peter Rechmann, Daniel Fried, Proc. of SPIE Vol. 7549, 75490D 2010 SPIE CCC code: 1605-7422/10/$18 doi: 10.1117/12.846838 Proc. of SPIE Vol. 7549 75490D-1

treatment to traditional periodontal therapy using hand instruments. Various laser systems such as carbon dioxide (CO2) 2, 3, neodymium: YAG (Nd: YAG) 2-11, diode 2, 3, 12-16 and the erbium group 2,3,17-22 have been studied for their possible use in periodontal treatment. Most of these studies had controversial results from undesired surface changes 23-25 4, 6, and no result 12 to better treatment results. 11, 14 Lots of these researches seem to be done with inappropriate setting or procedure. A new type of diode lasers are now commercialized and more used by dentists which has 980nm wavelength and the manufacturers promises good result in periodontitis treatments. Higher absorption in water and hemoglobin comparing with 810nm diodes seems to lead to better effects. But the literatures about this wavelength are not too much. 15 As most of the treatments with laser solely ended with no result we preferred to set an adjunct laser-srp protocol for periodontitis treatment. The purpose of the present study was to compare the effects of 980 diode laser on the periodontal pockets treatment plus SRP, with SRP alone by evaluating the clinical parameters. 21 healthy patients with chronic periodontits with a total of 42 sites with periodontal pockets divided into 2 test and control groups. The control group had laser+ SRP and the test group got only SRP and the clinical parameters were assessed after 6 weeks. Review of literature Controversial results accompanied with poor understanding of laser tissue reaction made a lot of undesirable result in the field of laser assisted periodontal treatment. Showing the mistakes in the literature and using correct laser protocol seems to end in acceptable results. This researched shows that the adjunct use of laser with conventional therapy has better results than laser alone. Ryden et al. in 1994 used Total dose of 1 J/cm2 over 4 minutes from a GaAs diode laser on test group. Controls were untreated. They showed that laser did not influence the inflammatory reaction of the marginal gingival in an experimental human gingivitis model. No statistical difference between treatment groups in subgingival Bacteria decrease and BOP was seen. 12 The problem was that without solving the original problem no treatment will be effective or will relapse and using Low Level Laser Therapy in an infectious site can not be useful. Our aim must be using high power of laser to reduce the bacteria in the infectious site or activating oxidating agents with low power laser to eliminate the bacteria. Moritz et al. in 1998 used 2.5 W and 50 Hz GaAs diode laser with 10- microsecond pulse duration. Controls were scaled followed by H 2 O 2 rinsing at 1 week, 2months and 4 months. Tests were scaled plus lased at 1 week and at 2 and 4 months. Papillary bleeding index improved in 97% of lased cases but 67% of controls. Mean reduction in PD in test group was 1.30mm versus 0.40mm in control groups. Subgingival Bacteria was insignificantly reduced more in laser group than control group. 14 The set up seems to be good but there is no reason to use pulsed laser as pulses of diode laser has no characteristic of a real pulse and are just gating the outgoing light. Yilmaz et al. GaAs diode in 2002 used GaAs diode in a research with 4 groups: laser only versus laser + SRP versus Proc. of SPIE Vol. 7549 75490D-2

SRP alone versus oral hygiene instructions alone. Laser was used at power density of 1.6 J/cm2 on days 1, 2, 4, 7, 9, and 11 using methylene blue dye as a photosensitizer. Percentage of BOP decrease was 17% for laser only; 50% for SRP only; 60% for laser +SRP and Mean Reduction in PD was 0.23mm for laser only; 0.49mm for SRP only; 0.66mm for laser + SRP. 13 the study shows good understandings of Yilmaz team from the difference between low level effects and high power laser effects which made them use the photosensitizer and also the frequency of treatment which can stabilize the effects. Borrajo et al. used InGaAsP diode with 2 W, 100-millisecond pulse length, 50 Hz, 2-mm-diameter optical fiber plus SRP in test group against SRP alone controls. Although BOP reduced very good (72%) in comparison with SRP alone group (53%) but it could not help the CAL (0.81mm in test group versus 0.85mm in controls). 15 it seems the diameter of the fiber is too much which makes the energy density very low and also reaching the deep parts of pockets impossible. In some researches, the scientists preferred to use Nd:YAG laser which is important for us because the wavelength we choose is nearer to Nd:YAG than the old diode systems. Ben Hatit et al. in 1996 used Nd:YAG in their research with 5 treatment groups: 0.8 W at 10 Hz and 100 mj/pulse versus 1.0 W at 10 Hz and 100 mj/pulse versus 1.2 Watt 12 Hz and 100 mj/pulse versus 1.5 W at 15 Hz and 100 mj/pulse versus scaling only (control). Pulse duration was 150 microseconds, and laser was fitted with 0.3-mm-diameter optical fiber. No significant difference was seen in Subgingival Bacteria. 4 It is obvious the power used, is low and even in this situation it is gated which as mentioned, makes the mean energy too low to have any effect. Radvar et al. in 1996 made the same mistake. 6 The energy they use is in the Low Level Laser Therapy range which can not be useful here because of presence of chronic infection. In 2002 Gutknecht et al. used Nd:YAG laser 100 mj and 20 Hz, 100-microsecond pulse duration, 0.32-mm-diameter optical fiber, and energy density of 124 J/cm2 at fiber tip once per week for 3 weeks. Control was untreated. They showed slight progress in laser groups 0.85mm versus 0.80mm in PD reduction and 85% versus 75% in BOP. 10 May be continuous and higher power of laser can lead to better results with bigger difference from conventional treatments. One year later Miyazaki et al. used nearly the same settings and the result were also nearly the same in BOP and PD reduction but the CAL gain was not good in laser treatments. They also showed that Nd:YAG results are much better than CO2 laser results. 8 in 2005 Noguchi et al. used a higher dose of Nd:YAG plus antibiotics. They used 200 mj and 10 Hz for 90 seconds with 0.4-mmdiameter optical fiber. Treatment groups were laser only, laser + local minocycline, laser + povidone-iodine irrigation, and sham procedure (control). Each treatment was done every week for 1 month. The results were very promising. Mean Reduction in PD was 1.57mm for laser; 2.39mm for laser+ minocycline; 1.60mm for laser+ irrigation and there was no change in control group. Mean Gain in CAL was 1.52mm for laser; 2.36mm for laser + minocycline; 1.62mm for laser+ irrigation and again no change in control group. Decrease percentage of BOP was 63% for laser; 77% for laser + minocycline; 65% for laser + irrigation and 19% for control group. 11 These researches shows that correct setting, protocol and wavelength can lead to desirable result from lasers but as an adjunct process to conventional treatments. Proc. of SPIE Vol. 7549 75490D-3

Materials and methods 21 patients seeking periodontal care with chronic periodontits diagnosis at a private dental clinic were selected for participation in this clinical trial. 11men and 10 women ranging from 34 to 54 year old were among our patients. The purpose and design of the study were explained and the patients signed an informed consent form for ethical concerns. The patient s selection criteria were: 1) Free of systemic complications which could interfere with periodontal healing; 2) No use of antibiotics during the 3 months prior to treatment; 3) No periodontal treatment during the previous 6 months; and 4) Presence of periodontal pockets of at least 5mm. All patients were evaluated at baseline and 6 weeks after treatment. All patients learned basic oral hygiene care like correct teeth brushing and flossing and admitted that they did as what we explained during 6weeks. A total of 42 sites from our 21 patients were randomly assigned to the following treatments: 1) 980 diode laser+ SRP (test) 2) SRP alone (control). Both groups were treated with SRP at time zero by an expert periodontist. SRP was performed using Ultrasound systems followed by Gracey curettage. The instrumentation for both test and control teeth was performed until the operator felt that the root surface were adequately debrided and planed. Test group got first shot of laser by dentist a trained for laser applications. We used 980nm diode laser (cheese TM, Gigaa optronics Ltd., Wuhan, China) with 2.5W, continuous mode, 400nm fiber, and 1 mm/sec sweeping motion from the depth of pocket upward to the margin. Each pocket took nearly 20 sec. and the whole laser process was done twice with a 2 min. gap. Every 7days for 5 weeks (total 6 dental treatment session) the laser treatment on the test group was performed again on the same site. The whole laser process was performed as sham for the control group during the 6 weeks. Both groups were treated under local anesthesia. Third examiner measured the following clinical parameters at baseline and after 6weeks (day 42): gingival index (GI) 16, probing pocket depth (PPD). Bleeding on probing (BOP) was recorded as either absent (0) or present (1). Measurement of PPD was made using a plastic constant pressure probe with a 20 g controlled probing force (PDT sensor probe, Pro-Dentex, Batesville, AR USA) and customized acrylic stents with a guiding groove. The examiner was not aware of the treatments the patients were undergone. Proc. of SPIE Vol. 7549 75490D-4

Statistical analysis A software package (SPSS version 14.0) was used for the statistical analysis. Comparisons for BOP (yes/no data) were made by Chi-square test and P< 0.05 was considered significant. We present the data in the tables and diagram by percentage and number. We used Fisher's Exact Test for the accuracy control. Comparisons for GI and PPD were made by Independent Samples Test with 95% Confidence Interval of the Difference and again P< 0.05 was considered significant. We present the data in the tables and diagram as the mean with respect to the standard deviation. Results The mean changes and Standard Deviation in GI and PPD from the baseline to 6 weeks are shown in Table 1.GI was significantly reduced in both groups at 6 weeks examination compared to baseline (P <0.01) (Figure 2). PPD also reduced significantly in both groups at 6 weeks examination compared to the baseline (P<0.01) (Figure3). In both GI and PPD, the reduction in case group was significantly higher than control group. At the baseline examination, the percentages of the BOP were 100% in the both groups. An improvement of the percentages of the BOP was observed at 6 weeks in both groups but again the improvement was better in the case group. (90.4%of the test group and 57.1%of the control group). (Table 2 & Figure 1) These data are confirmed by chi-square test (P< 0.05). (Table 3) Figure 1. Improvement of the BOP from day 1 to day 42 Proc. of SPIE Vol. 7549 75490D-5

Figure 2. Improvement of the GI from day 1 to day 42 Figure 3. Improvement of the PPD from day 1 to day 42 Proc. of SPIE Vol. 7549 75490D-6

casecontrol N Mean Std. Deviation Std. Error Mean GI1 case 21 2.28571.462910.101015 control 21 2.23810.436436.095238 GI42 case 21.5238.67964.14831 control 21 1.1905.81358.17754 PPD1 case 21 6.2857 1.18924.25951 control 21 6.1905.92839.20259 PPD42 case 21 3.5238.74960.16358 control 21 4.8095.87287.19048 Table 1. Mean changes in GI and PPD from the baseline to 6 weeks BOP42 Total no yes casecontrol case Count 19 2 21 % of Total 90.4% 9.6% 100.0% control Count 12 9 21 % of Total 57.1% 42.9% 100.0% Table2. Improvement of the percentages of the BOP Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Pearson Chi-Square 6.035(b) 1.014 Continuity Correction(a) 4.434 1.035 Likelihood Ratio 6.413 1.011 Fisher's Exact Test.032.016 Linear-by-Linear Association 5.891 1.015 N of Valid Cases 42 Table 3. Chi-Square Tests results for BOP Proc. of SPIE Vol. 7549 75490D-7

Discussion Several studies have reported the application of leasers in the treatment of periodontal pockets but there are not too many clinical study using 980nm diode laser in periodontal treatment. 15 Other diode lasers and Nd:YAG systems which have nearest wavelength comparing to our system, was used for researches in the past 2 decade 12-22. Some results indicated that there were no statistically significant differences using lasers and ultrasonic scaling in the clinical parameters. 4,6,12 But on the other hand Moritz et al. in 1998 used 2.5 W of 810nm diode laser and showed improvement in BOP and PPD 14 and in 2002 Gutknecht et al. used Nd:YAG laser and proved the same result 10 so in the present study, we compared the effectiveness of a combination treatment of 980nm diode laser and SRP to SRP alone on periodontal pockets and we supposed with correct setting, wavelength and treatment protocol, much better results will be achieved. With regard to the clinical parameters we chose, both groups showed statistically significant improvements in GI, BOP and PPD after treatment. The results also showed significant improvement from laser+ SRP group to SRP alone group. The results of the present study are partially in agreement with a clinical study reported by Moritz et al. 14 and Gutknecht et al. 10. Like our study they both showed improvement in PPD and BOP from the baseline and from the control group. Their results, however, showed that there were no statistically significant differences in gingival bacteria decrease and there was a statistically significant improvement BOP and PPD following treatment compared to baseline. In our study we didn t measure the gingival bacteria but we assessed the GI which showed significant improvement in both group and also significant improvement from laser+ SRP group to SRP alone group. The length of their studies was 175 and 180 days but our study was only 6weeks (42days). But there were researches with no significant improvement using a laser. 4,6,12 These discrepancies specially in BOP and PPD could be explained mainly by differences in the modality of irradiation that is due to both the setting and the fiber diameter. Using low levels of laser without any photosensitizing agent can end without improvement of the periodontal disease. Also the irradiation protocol must be continuous in some weeks which we chose 6weeks for the chronic patients. Using very large fiber diameters may cause improper results as it decrease the energy density at the fiber tip. As the pulses of diode lasers does not have the characteristic of a real pulse, using pulsed (gated) diode laser just decreases the average power and is useless. The results came out of this study shows that our hypothesis was correct within the limits of this study. Proc. of SPIE Vol. 7549 75490D-8

Er:YAG and CO 2 lasers were common lasers in the market but very expensive and Nd:YAG laser are not so common because of small range of usage. New generations of diode lasers are going to find their place in the dental offices as they are perfect for soft tissue management and marketed with low price. The accessibility to periodontal pocket is better than any other laser mainly because of using optical fiber system. Within the limits of this study, the present data suggest that treatment of chronic periodontitis with 980 diode laser+ SRP and SRP alone results in statistically significant improvements in clinical parameters such as BOP, GI, and PPD. But the most important result is that the combination treatment of 980 diode laser irradiation in the periodontal pocket+ SRP appears to provide additional effects on the treatment outcomes compared to SRP alone and improves the healing process of chronic periodontal pockets. The result of this study within its limits, may suggest that using 980 diode lasers with the protocol mentioned above, as an adjunct tool with conventional SRP can help patient and dentist to reach better treatment results. It must be mentioned here that we had full cooperation of the patients which can directly influence the outcomes. We suggest some researches with longer treatment period, bigger test and control groups and also assessment of clinical attachment level to be done. References 1) Horz HP, Conrads G (2007) Diagnosis and anti-infective therapy of periodontitis. Expert Rev. Anti Infect. Ther. 5(4), 703 715 2) Pick RM, Colvard, MD (1993) Current status of lasers in soft tissue dental surgery. J Periodontol. 64: 589-602 3) Rossman JA, Cobb CM (1995) Lasers in periodontal therapy. Periodontology 2000. 9:150-164 4) Ben Hatit Y, Blum R, Severin C, Maquin M, Jabro MH (1996) The effects of a pulsed Nd:YAG laser on subgingival bacterial flora and on cementum: An in vivo study. J Clin Laser Med Surg 14:137-143 5) Neill ME, Mellonig JT. Clinical effects of the Nd:YAG laser for combination periodontitis therapy. Pract Periodontics Aesthet Dent 1997;9(Suppl. 6):1-5 6) Radvar M, MacFarlane TW, MacKenzie D, Whitters CJ, Payne AP, Kinane DF (1996) An evaluation of the Nd:YAG laser in periodontal pocket therapy. Br Dent J 180:57-62 7) Liu CM, Hou LT, Wong MY, Lan WH (1999) Comparison of Nd:YAG laser versus scaling and root planing in periodontal therapy. J Periodontol 70:1276-1282 8) Miyazaki A, Yamaguchi T, Nishikata J, Okuda. K, Suda S, Orima K (2003) Effects of Nd:YAG and laser treatment and ultrasonic scaling on periodontal pocket of chronic periodontitis patients. J Periodontol, 74:175-180 9) Harris DM, Gregg RH II, McCarthy DK, Colby LE, Tilt LV (2004) Laserassisted new attachment procedure in private practice. Gen Dent 52:396-403 Proc. of SPIE Vol. 7549 75490D-9

10) Gutknecht N, Radufi P, Franzen R, Lampert F (2002) Reduction of specific microorganisms in periodontal pockets with the aid of an Nd:YAG laser An in vivo study. J Oral Laser Appl 2:175-180 11) Noguchi T, Sanaoka A, Fukuda M, Suzuki S, Aoki T (2005) Combined effects of Nd:YAG laser irradiation with local antibiotic applications into periodontal pockets. J Int Acad Periodontol 7:8-15 12) Ryden H, Persson L, Preber H, Bergstro m J (1994) Effect of low level energy laser irradiation on gingival inflammation. Swed Dent J 18:35-41 13) Yilmaz S, Kuru B, Kuru L, Noyan U, Argun D, Kadir T (2002) Effect of gallium arsenide diode laser on human periodontal disease: A microbiological and clinical study. Lasers Surg Med 30:60-66 14) Moritz A, Schoop U, Goharkhay K (1998) Treatment of periodontal pockets with a diode laser. Lasers Surg Med 22:302-311 15) Borrajo JL, Varela LG, Castro GL, Rodriguez-Nunez I, Torreira MG (2004) Diode laser (980 nm) as adjunct to scaling and root planing. Photomed Laser Surg 22:509-512 16) Qadri T, Miranda L, Tuner J, Gustafsson A (2005) The short-term effects of low-level lasers as adjunct therapy in the treatment of periodontal inflammation. J Clin Periodontol 32:714-719 17) Schwarz F, Sculean A, Georg T, Reich E (2001) Periodontal treatment with an Er:YAG laser compared to scaling and root planing. A controlled clinical study. J Periodontol 72:361-367 18) Schwarz F, Sculean A, Berakdar M, Georg T, Reich E, Becker J (2003) Clinical evaluation of an Er:YAG laser combined with scaling and root planing for nonsurgical periodontal treatment. A controlled, prospective clinical study. J Clin Periodontol 30:26-34 19) Schwarz F, Sculean A, Berakdar M, Georg T, Reich E, Becker J (2003) Periodontal treatment with an Er:YAG laser or scaling and root planinng. A 2- year follow-up split-mouth study. J Periodontol 74:590-596 20) Sculean A, Schwarz F, Berakdar M, Romanos GE, Arweiler NB, Becker J (2004) Periodontal treatment with an Er:YAG laser compared to ultrasonic instrumentation: A pilot study. J Periodontol 75:966-973 21) Schwarz F, Sculean A, Georg T, Becker J (2003) Clinical evaluation of the Er:YAG laser in combination with an enamel matrix protein derivative for the treatment of intrabony periodontal defects: A pilot study. J Clin Periodontol 30:975-981 22) Sculean A, Schwarz F, Berakdar M, Windisch P, Arweiler NB, Romanos GE (2004) Healing of intrabony defects following surgical treatment with or without an Er:YAG laser. J Clin Periodontol 31:604-608 23) Israel M, Cobb CM, Rossman JA, Spencer P (1997) The effects of CO 2, Nd:YAG and Er:YAG lasers with and without surface coolant on tooth root surfaces. J Clin Periodontol. 24:595-602 24) Sasaki KM, Aoki A, Masuno H, Ichinose S, Yamada S, Ishikawa I (2002) Compositional analysis of root cementum and dentin after Er:YAG laser Proc. of SPIE Vol. 7549 75490D-10

irradiation compared with CO 2 lased intact roots using Fourier transformed infrared spectroscopy. J Periodontal Res, 37:50-59 25) Tucker D, Cobb CM, Rapely JW, Killoy WJ (1996) Morphologic changes following in vitro CO 2 laser treatment of calculus-ladened root surfaces. Lasers Surg Med, 18:150-156 Proc. of SPIE Vol. 7549 75490D-11