The treatment of chronic periodontitis by non-surgical periodontal therapy in association with diode laser compared to conventional non-surgical therapy

Randomized controlled clinical trial


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Submission Date: 2020-02-18
Review Date: 2020-03-03
Pubblication Date: 2020-03-17
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Abstract

Abstract:

Mechanical surface treatment and removal of the above and subgingival biofilm (Tartar ablation; SRP) are considered the most suitable tools for the treatment of periodontal inflammatory diseases, with the aim of destroying bacterial bioflim, reducing bacteria, and slowing down recolonization by pathogenic microorganisms.
Often, however, the only S&RP are not enough, as there are patients who are experiencing relapses.
Recently, laser therapy has been suggested as a potential tool to improve the outcome of periodontal non-surgical treatment.
The objective of the following study was to evaluate the clinical healing of periodontal pockets treated with mechanical therapy, scaling and root planing, and diode laser application, compared to that obtained with non-surgical mechanical therapy alone.
The study was designed as a randomized controlled clinical trial. Patients in the control group (13 patients) underwent conventional non-surgical therapy only, while patients in the test group (17 patients) were associated with conventional non-surgical treatment, a laser irradiation session.
At baseline and after 6 months, the parameters of probing depth (PD), bleeding on probing (BOP), gingival recession (REC) were assessed
The main variable of this study was the PD (probing depth)
FMPS and FMBS at follow-up improved in both groups. The FMPS baseline test group 32.59 ± 6.74 - follow up 12.00 ± 3.16.
The baseline of the control group showed 33.00 ± 9.55, the follow up 13.15 ± 4.85 The FMBS baseline test group found 24.29 ± 5.01 while at follow 9.65 ± 2.69. The baseline control group 30.31 ± 7.74, Follow up 11.08 ± 2.33. There is a statistical significance. (P.VALUE 0.0001)
There were no significant differences between the groups in terms of PD, CAL and BOP at baseline and at follow-up.
PD Test group 4,89±1,58 3,95±0,85 0,0001 Control group 5,02±1,57 4,01±0,86
CAL (mm)Test group 0,89±2,29 0,77±1,91 Control group 0,28±1,38 0,24±1,14
REC Test group 0,19±0,49 0,19±0,51 Control group 0,06±0,29 0,57±029
BOP Test group 51,2% 23,5% Control group 54,0% 20,9%
The results showed differences in both baseline and follow-up for REC.
Test group 0,19±0,49 0,19±0,51-Control group0,06±0,29 0,57±029
In intra-group analyzes, there are differences between baseline and follow-up for all values, except for REC in the control group.
The diode laser can be used as an appropriate device for periodontal treatments, but it can offer additional and significant benefits if used according to appropriate protocols and parameters, and especially if associated with non-surgical, manual and ultrasound periodontal instrumentation, always site-specific , as it is a tool that does not replace traditional methods.

Introdution

Periodontal disease is a chronic inflammatory process, characterized by a bacterial etiology and by a cyclic evolution that determines a progressive and specific destruction of the supporting tissues of the tooth. 1 The use of the diode laser in non-surgical therapy does not replace treatment conventional, but can be associated and contribute to the success of therapy2-3. The term “laser” is an acronym: light amplification by stimulated emission of radiation, which indicates an amplified light radiation. 4 Periodontitis is an inflammatory response to the accumulation of bacterial biofilm with consequent destruction of the surrounding tissues. Non-surgical therapy is carried out to remove the bacterial biofilm from the root surface and stop the inflammatory process thus decreasing the bacterial load. 5-6

It is now known that non-surgical etiological therapy, through the control and removal of the bacterial biofilm and the tartar above and below the gingival, is at the basis of the prevention of periodontal disease and the maintenance of periodontal patients. 7-8

The etiology of this pathology is not attributable to a single bacterial species, but on the contrary it is the interaction between several specific pathogenic species, which contributes to the destruction of periodontal tissues.

In particular, subgingival species such as Aggregatibacteractinomycetemcomitans (Aa), Porphyromonasgengivalis (Pg) Prevotella intermedia (Pi) Tannerellaforsythensis (Tf) and Treponema denticola (Td) are considered to be the pathogenic species responsible for the disease .9

Over time, it was then observed that the results obtained with the ablation techniques with manual instruments and with sonic and ultrasonic instruments, proved to be superimposable. 10

Starting from these bases, the interest of the scientific community has slowly shifted more and more on the modifications that these treatments cause on the subgingival microflora, highlighting an effective reduction of the bacterial load, following the periodontal scaling therapies, once again confirming the efficacy of such therapies for the treatment of periodontal disease. 11

Finally, in recent years, the use of laser light in addition to conventional methods is spreading, but information about the results obtained is scarce.

The effective bactericidal power of this light radiation has been amply demonstrated in the bibliography, both through in vitro and in vivo studies..12

Some studies, including the one conducted by Derdilopoulou and coll. 13 in which an Er: YAG laser is used, and the most recent systematic review concerning the matter, agree in stating that the use of the laser to reduce the charge bacterial periodontal pathogen, does not appear to guarantee any additional effect, compared to normal periodontal scaling procedures.

Articles that focus their attention on the microbiological effects of the diode laser, compared to clinical evaluations are scarce, but even here many agree in reiterating that there are no substantial differences.14

Non-surgical periodontal therapy aims at the cleansing and / or detoxification of the coronal and radicular surfaces15in order to promote the existence of a subgingival microflora that is compatible with the periodontal health16 and above all the maintenance of the balance conditions achieved17

Evidence-based dental literature agrees that non-surgical periodontal instrumentation is associated with a greater attack gain than surgery 18-19.

Over time (5-6 years), all periodontal parameters are improved in case of non-surgical treatment.20

Non-surgical periodontal instrumentation can be performed according to multiple and different protocols 21-22-23-24.

There is no ideal protocol for the initial preparation, therefore the operator will evaluate the patient’s clinical conditions and psychological aspect and then decide on the most appropriate and personalized treatment modalities for individual needs.

The effectiveness of non-surgical periodontal treatment is linked both to the technique and manual skill of the operator but also to the selection of suitable instruments. 25

Laser assisted periodontal therapy

An emerging technology also in the field of non-surgical periodontology is represented by the laser with a wavelength between 808 and 980 nanometers, in the infrared spectrum, with a gallium arsenide source, more commonly called diode.

Used according to the protocols of international scientific literature, it has a bactericidal and detoxifying effect on the root surface, as it inactivates bacterial toxins26, causes haemostasis, does not produce smearlayer, however randomized controlled studies that demonstrate its efficacy and cost-evaluation are lacking. benefit is still unfavorable if its use is limited to non-surgical periodontology, intended as a causal preparation. 27

Laser therapy has an anesthetizing effect28, because it reverses the Sodium and Potassium pump at the cell membrane level for about 30 minutes, therefore this protects the patient’s comfort. Interacting with endogenous chromophores such as melanin and hemoglobin, it causes the vaporization of the granulation tissue, which comes out of the pocket in the form of clots, associated with reduced bleeding thanks to the hemostasis effect.

The reduction of the inflamed tissue thus obtained facilitates the operator in subsequent instrumentation maneuvers, which remain necessary.

The use of the laser must be preceded and followed by abundant washing with chlorhexidine digluconate, for preoperative disinfection and to facilitate the elimination of clots, whips and residual deposits in the pocket.

Different powers are used to activate a photothermal interaction that acts on the different biological tissues. 29

The passage of the electric current causes an induced heating of the laser beam which generates pressure pulses, both in the air close to the irradiated surface and in the fabric itself, with consequent photomechanical reaction. It also triggers a photochemical reaction with endogenous chromophores such as melanin and hemoglobin. 30

Background of the study

The treatment of choice for periodontitis must be the simplest and least traumatic one capable of stopping the disease by controlling its activity phases.

The first therapeutic approach is based on mechanical procedures31, the so-called scaling & root planing (S&RP) 32 which allow the removal of this biofilm and promote tissue repair. 33

In non-responsive patients additional therapeutic strategies are associated with treatment with S&RP which improve the results. Traditionally, the choice of additional therapy necessarily fell on the use of antibiotics given systemically or topically or on the use of antiseptics such as chlorhexidine.

In both the first and the second case, the rationale for this association lies in the fact that while mechanical therapy removes the sessile forms of the bacteria that make up the biofilm, antibiotics or antiseptics destroy the planktonic forms including those released by the biofilm by mechanical therapy. and prevents them from giving rise to a recurrence of the biofilm. Several controlled clinical trials have demonstrated the effectiveness of the association between scaling and root planing and antibiotic therapy34-35-36-37

For some years, a new therapeutic strategy associated with the treatment of periodontitis, laser therapy, has become available. 38

This method uses the use of a high intensity light source consisting of Laser (DIODE)

Rationale of the study

Mechanical surface treatment and removal of the above and subgingival biofilm (Tartar ablation; SRP) are considered the most suitable tools for the treatment of periodontal inflammatory diseases, with the aim of destroying bacterial bioflim, reducing bacteria, and slowing down recolonization by pathogenic microorganisms.

Often, however, the only S&RP are not enough, as there are patients who are experiencing relapses.

Recently, laser therapy has been suggested as a potential tool to improve the outcome of periodontal non-surgical treatment41

Objective of the study

The objective of the following study was to evaluate the clinical healing of periodontal pockets treated with mechanical therapy, scaling and root planing, and diode laser application, compared to that obtained with only non-surgical mechanical therapy.

Fig. 1 – Manual non-surgical instrumentation
Fig. 2 – Photo ablative laser therapy

Clinical cases

CASE 1: CONTROL GROUP
Disto-lingual dental element 46, female, non-smoking smoke
BASELINE
FOLLOW-UP
CASE 2: CONTROL GROUP
Dental element 34 mesio-buccal, male, non-smoking smoke
BASELINE
FOLLOW-UP
CASE 1: TEST GROUP
Dental element 23 mesio-buccal, female, non-smoking smoke
BASELINE
Laser therapy
FOLLOW-UP
CASE 2: TEST GROUP
Disto-buccal dental element 15, Male, Smoker smoke <10 / day
BASELINE
Laser therapy
FOLLOW-UP

Materials and methods

The study was designed as a randomized controlled clinical trial. The purpose of this study was to compare the clinical results of conventional non-surgical mechanical therapy with those obtained in patients treated with S&RP and with the addition of LASER therapy, to verify the hypothesis that the addition of laser therapy may be able to improve non-surgical periodontal therapy.

The main variable of this study is the PD (probing depth)

The secondary variables are FMPS (Full MouthPlaque Score); FMBS (Full Mouth Bleeding Score); BOP (Bleeding on Probing) CAL (Clinical Attack Level); REC (recession); MOBILITY’

Subject Population

From the pool of patients belonging to the Department of Reproductive and Odontostomatological Sciences of the University of Naples Federico II, 30 patients were selected based on specific criteria of inclusion criteria: both genders; age over 18; patients with periodontitis; 10 cigarettes / day; presence of at least 1 periodontal pocket greater than 6 mm per dial

Exclusion criteria: presence of systemic diseases; pregnancy and breastfeeding; antibiotic use in the past 6 months;

Experimental Procedures

In the control group, the following were used:

  • Scaler: ultrasonic scaler (EMS)
  • curettes: Gracey curette (7-8, 11-12, 13-14) standard model

Periodontal probe: 15mm North Carolina probe

In the test group, in addition to mechanical and manual instrumentation, the diode laser with a wavelength of 980 nm was associated in CW mode for 30 seconds in the pocket.

The optical fiber (300µm) was used with apico-coronal and mesio-distal movements

During the first visit, after an accurate anamnesis about the inclusion and exclusion criteria, the patient was informed about the clinical procedure to which he would have been subjected; subsequently we proceeded with the periodontal charting of the patient through the PD evaluation (depth of pocket), plaque, BOP (bleeding on probing) REC (recession), mobility.

  • The periodontal file was completed with the data obtained.
  • The collected data revealed a picture of the patient’s periodontal condition before proceeding with the treatment.
  • We therefore proceeded with regard to the patients of the control group (13 patients), with non-surgical therapy divided into five sessions: one dedicated to the ablation of tartar with the aid of an ultrasonic scaler and the other four intended for root planing carried out by dials, using the Gracey curettes, standard model (7-8,11-12,13-14).
  • The test group patients (17 patients) underwent conventional non-surgical treatment associated with a laser irradiation session.
  • Naturally, in order to obtain an effective and efficient collaboration on the part of the patient, a detailed motivation has been added regarding the maintenance of home oral hygiene, through which the appropriate brushing techniques, the use of dental floss have been illustrated. and the bottle brush.
  • Each patient received a toothbrush and toothpaste.
  • Finally, a six-month follow-up was carried out, with the aim of re-evaluating the data collected during the initial charting, to verify the effectiveness of the traditional non-surgical treatment, and of the non-surgical treatment associated with laser therapy.
Statistical analyses

The variables considered are expressed in millimeters for PD, REC, CAL and in percentages for FMBS, FMPS and BOP.

Baseline and follow up values ​​were compared by paired tests.

The tests used are those of Wilcoxon and T-TEST

A p-value <0.05 was considered statistically significant.

Results

TAB.1GRUPPO TEST (N° 17)GRUPPO CONTROLLO (N°13)p-VALUE
ETÀ49,76±6,5751,85±6,650,345
SESSO6F/11M9F/4M0,065
FUMO9N/8S10N/3S0,177
Tab. 1– Demographic data

DEMOGRAPHIC DATA: TABLE 1

for this experimental study we initially considered 40 patients, evaluating the exclusion and inclusion criteria we chose 30 patients for the randomized controlled clinical study. In the test group (GT) we studied 17 patients as clinical cases, in the control group (GC) 13 patients. An initial baseline visit and a six-month follow-up took place. According to statistics, the average age of the patients is around 49-51 years, in the GT male and non-smokers prevail; in the GC female and smokers prevail. (Fig.3)

TAB.2BASELINEFOLLOW-UPP-VALUE
FMPS
Test group32,59±6,7412,00±3,160,0001S
Control group33,00±9,5513,15±4,850,001 S
P-value0,7690,528 
FMBS
Test group24,29±5,019,65±2,690,001 S
Control group30,31±7,7411,08±2,330,0001 S
P-value0,029S0,083 
Tab. 2 – Clinical variations relating to fmps and fmbs Register with baseline and after 6 months of follow-up

CLINICAL VARIATIONS RELATING TO FMBS AND FMPS: TABLE 2

From the statistics carried out the FMPS and FMBS to follow-up improved in both groups. There is a statistical significance.

TAB.3BaselineFollow-upp-Value
PD (mm)
Test group4,89±1,583,95±0,850,0001S
Control group5,02±1,574,01±0,860,0001 S
p-value0,0750,129 
CAL (mm)
Test group0,89±2,290,77±1,910,0001 S
Control group0,28±1,380,24±1,140,0001 S
p-value0,0001 S0,0001 S 
REC
Test group0,19±0,490,19±0,510,999
Control group0,06±0,290,57±0290,096
p-value0,0001 S0,0001 S 
BOP
Test group51,2%23,5%0,0001 S
Control group54,0%20,9%0,0001 S
p-value0,2370,212 
Tab. 3 – Clinical variations relating to variables register with baseline and after 6 months of follow-up

CLINICAL VARIATIONS RELATING TO THE VARIABLES: TABLE 3

From the statistics carried out it is clear that there are no significant differences between the groups in terms of PD, CAL and BOP at the baseline and at follow-up. There are differences in both baseline and follow-up for REC.

In intra-group analyzes, there are differences between baseline and follow-up for all values, except for REC in the control group.

Fig. 3 demographic data

Discussion

The purpose of periodontal treatment is biological restoration and reattachment of periodontal tissues to the root surface. Thus, in the first phase of periodontal treatments, mechanical debridement and planning of the root surface are performed by manual and ultrasonic instruments. These tools make the tooth surface less susceptible to bacterial adhesion and predisposing them to a new periodontal clinical attack.

In the current study, the clinical parameters of PD, CAL, REC and BOP were measured before and 6 months after treatment. Patients who met the selected inclusion criteria were selected for the trial.

The results indicate an improvement in these indices both in the laser group and in the control group, except for the REC in the latter.

Although the improvements have been more evident, the difference is not statistically significant. The laser can be considered an adjunctive therapy to other conventional methods of treatment.

Conclusions

The analysis of the results obtained leads to conclusions consistent with what is already present in the literature.

The diode laser can be used as an appropriate device for periodontal treatments, but it can offer additional and significant benefits if used according to appropriate protocols and parameters, and especially if associated with non-surgical, manual and ultrasound periodontal instrumentation, always site-specific , as it is a tool that does not replace traditional methods.

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