LASER TECHNOLOGY TO MANAGE PERIODONTAL DISEASE- what’s diode laser’ role?

LASER TECHNOLOGY TO MANAGE PERIODONTAL DISEASE- what’s diode laser’s role?

Present day dental lasers can create oral environments conducive for periodontal repair.

With the bacterial etiology of periodontitis and the resulting host inflammatory reaction, clinicians continue to search for therapeutic modalities to assist in the non- surgical management of periodontal disease. Traditional chairside therapies consist of mechanical debridement with manual and/or ultrasonic instrumentation with the objective of removing calculus, biofilm, and endotoxin from tooth root surfaces. Decreasing the microbial stimuli and associated end products decreases the in- flammatory reaction and allows the host an opportunity to regenerate tissue through wound healing. The purpose of this article is to examine whether dental lasers, which have been in use for the past 3 decades, may augment traditional non- surgical periodontal therapy.

Studies utilizing  laser technology  may  demonstrate   positive  effects on 1) selectively decreasing  the biofilm environment,  2) removing   calculus  deposits  and neutralizing endotoxin,  3) removing  sulcular epithelium  to assist  in reattachment and decreased pocket  depth, and 4) biostimulation for enhanced wound  healing. Comparisons of studies to determine the difference between   lasers and their respective effects on the periodontium are difficult to assess due to a wide variation of laser protocols.

INTRODUCTION

The primary objective of periodontal therapy is to maintain the dentition in comfort, function and esthetics. The focus of this management is centered on controlling both bacterial etiology and the host defense system through host modulation. Therapy is generally divided into two categories:  1) surgical and 2) nonsurgical periodontal therapy. The objective of nonsurgical therapy includes plaque biofilm control, supra- and subgingival scaling, root planing, and the adjunctive use of chemical agents. Scaling is defined as instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, and stains from these surfaces. Root planing is a treatment procedure designed to remove cementum or surface dentin that is   rough, impregnated with calculus,   or contaminated with toxins or microorganisms. An additional procedure called curettage has been also included in nonsurgical periodontal therapy and it includes the process of debriding the soft tissue wall of a periodontal pocket.

The objective of this paper is to introduce the role of lasers in accomplishing the objectives of nonsurgical periodontal management   as related   to both the stated goals of procedures within the management process and to investigate additional modalities such as biostimulation.

LASER FUNDAMENTALS

Laser was introduced   into dentistry in the 1980’s, with significant attention for the past three decades. Dental lasers are divided into several categories dependent on wavelength with most for denta use being in the range of 500 nm to 10,000 nm. Several media exist to generate the energy from semi conductors to crystals and each creates a particular wavelength with a particular affinity for a respective target (chromophore) based on absorption coefficients and depth of penetration. A chromophor is the part of a molecule responsible for its color and attracts a particular wavelength. The chromophores found in the oral tissue are melanin, hemoglobin, oxyhemoglobin and water.

Laser wavelengths have an affinity/attraction to targets based on absorption curves.

For the oral cavity, the target tissue for lasers is soft tissue is gingival epithelium and/or hard tissue containing apatite crystals in teeth and osseous structures. The interaction of the different wavelengths on targets   can be photo thermal, photochemical, photomechanical and photo acoustic effects. Since some laser media such as the diode are attracted to pigment they may be used for hemostasis and as an antimicrobial effect.

Lasers are categorized by energy mediums, wavelengths and the resulting targets.

MICROBIOLOGIC EFFECTS

A laser with its ability for irradiation will have an antimicrobial effect and thus the potential as an addition  to traditional periodontal nonsurgical therapy.  All lasers have some photo thermal effect and most periodontal pathogens are eliminated above 50 o C.

Nd:YAG and diode lasers are absorbed  by bacteria, especially those with pigmentation, and therefore  reduce re-colonization organisms are only pigmented when placed on blood cultures, while several other periodontal pathogens are not pigmented. Since diode lasers have an affinity for pigment they therefore can have a significant bactericidal effect when used in the sulcus. This effect has also been seen when the diode was used with scaling and root planing with aggressive periodontitis when P. gingivalis and T. denticola were reduced more in the SRP with diode laser treatment than SRP or laser treatment alone. The erbium lasers also demonstrate some antimicrobial activity in endodontic procedures; this effect is not due to an attraction to bacterial pigment but more likely from a photo acoustic activity. Studies have compared periodontal treatment with Er:YAG versus scaling and root planing. The Er:YAG treatment resulted in greater gains in clinical attachment levels with the most significant difference in increased pocket depths. No differences were detected in the microbiological analysis of the study.

A diode laser tip can be placed interproximally for an antimicrobial and degranulation effect.

Photodynamic therapy (PDT) may have potential as an adjunct to periodontal debridement. Whether using a ‘cold’ (low level) laser or a conventional dental laser as a diode or Nd:YAG, methylene blue dye can be placed in the sulcus as a subgingival irrigant. The laser wavelengths are attracted to the dye and interact with the medicament resulting in the disruption of the bacterial cell walls. The light energy activates the dye, interacts with intracellular oxygen, and destroys the bacterial organisms by lipid per-oxidation and membrane damage. A systematic review and meta analysis of the effect of photodynamic therapy for periodontitis demonstrated that PDT did not provide an additional positive effect in the management of periodontitis over routine scaling and root planing and thus could not be recommended as an adjunct to therapy.

ROOT SURFACE

The Nd:YAG and diode lasers have a limited use in actual hard tissue root therapy for root detoxification or calculus removal since their targets are primarily soft tissue. The Nd:YAG laser produces pitting, charring, craters, and melting, even when applied parallel to the surface in in-vitro studies. Research demonstrates that the Nd:YAG laser could be effective at removing the smear layer without microstructural damages to the hard tissue, but it caused a significant rise in temperature that may cause it to be inappropriate for in vivo use.

A laser wavelength creates vaporization with associated tissue changes based on temperature.

Erbium lasers demonstrate possibilities for root debridement by their effect on calculus and necrotic cementum with reduction of endotoxins.Erbium lasers with water irrigation can remove calculus with little increase in temperature on the associated root surface. These studies have been conducted in both in-vitro and in-vivo environments. Erbium wavelengths also have been reported to remove endotoxin in in-vivo studies. Erbium lasers are as effective in removing calculus as manual/power instrumentation and demonstrate no thermal damage. Limited in-vitro studies demonstrated that, gingival periodontal ligament fibroblasts adhere to lasered root surfaces in both attachment, spreading, and orientation comparably to surfaces treated with manual Gracey instrumentation.

Erbium lasers can have positive effects on both soft tissue (sulcular epithelium) and hard tissue (root surface and calculus).

SOFT TISSUE

Most dental lasers have wavelengths that can remove the epithelium lining the sulcus.  This may result from the photo thermal and/or the photo acoustic effect. Coagulation of the inflamed soft-tissue wall of a periodontal pocket and hemostasis are both achieved at a temperature of 60 oC.  One of the most beneficial treatments in laser therapy is sulcular debridement.  This process can be a complimentary adjunct to conventional root planing and scaling. The soft tissue laser cuts or ‘vaporizes’ soft tissue, referred to as ablation. Lasers can coagulate the tissue; controlled coagulation increases hemostasis and provides physical access. The benefit of laser use for soft tissue laser treatments and management is that the treatments   are many times less invasive than allowing diseased tissue to be treated while maintaining healthy tissue. There is evidence of increased attachment level gain over scaling and root planning due to these effects. The literature is replete with evidence that soft tissue curettage does not contribute to additional gains in attachment   levels versus meticulous   peri- odontal   root planning   in chronic adult periodontitis.Therefore, soft tissue lasers as the Nd:YAG and the diode laser may have limited application in the reattachment process for non-surgical periodontal  therapy  over scaling and  root planing.

a) Preoperative clinical presentation of a periodontal pocket. b) Insertion of a diode laser to decrease periodontal pathogens and removing sulcular epithelium. c) Immediately following diode laser demonstrating some hemostasis. d) Reprobing at 3 months with decreased pocket depth and decreased inflammation.

BIOSTIMULATION

The category of lasers referred to as low level light lasers (LLLT) are recognized   for biostimulation   and photo-bio modulation (PBM). These lasers use laser light energy, rather than heat therapy, to affect biological responses from the cells and cell responses. The laser and LED sources used for LLLT are between 600 and 950 nm (nm).  The PBM affects the mitochondria of the cell, primarily cytochrome-c oxidase in the electron chain and porphyrins on the cell membrane, and increases mitochondria increasing adenosine triphosphate via oxidative phosphorylation and modulation of reactive oxygen. The resulting rise in energy decreases inflammation and enhances would healing.

Studies of biostimulation and periodontal therapy demonstrate changes in both clinical parameters and patient comfort. Studies utilizing photodynamic and LLLT in nonsurgical periodontal therapy demonstrated a decrease in inflammatory parameters including interleukin-1 B over controls of traditional debridement.  Incorporating LLLT into non-surgical peridontal therapy has shown significantly more improvement in sulcus bleeding index (SBI), clinical attachment   level, and probing depth (PD) levels compared to the control group, but no differences in decrease of growth factor-b1 levels.

CONCLUSION

Laser technology is a recent addition to the tools utilized in managing periodontal   disease. It appears that the various wavelengths are effective as an antibacterial modality but possibly not from a photodynamic effect. In removing calculus and endotoxin from root surfaces, the erbium laser may be effective due to its affinity for hydroxyl apatite. Most laser wavelengths will remove sulcular epithelium and de-granulate wound areas.  However, systematic reviews of non-surgical periodontal protocols do not suggest the use of lasers in decreasing pocket depth and increasing attachment levels with exception of possibly the erbium laser due to the affinity for root surfaces. A valid comparison  with clinical studies involving the laser versus conventional  therapy  is challenging due to: 1) different  laser wavelengths, 2) wide variations in laser  parameters,  3) differences  in well  controlled  experimental protocols   with  valid/reliable   metrics and   4)  inconsistencies in severity of the diagnosis and  respective treatment protocols.

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