A Comparative Evaluation of the Efficacy of Diode Laser asan Adjunct to Mechanical Debridement Versus Conventional

Mechanical Debridement in Periodontal Flap Surgery:A Clinical and Microbiological Study

Sneha R. Gokhale, M.D.S.,1 Ashvini M. Padhye, M.D.S.,1 Girish Byakod, M.D.S.,1

Sanjay A. Jain, M.D.S.,1 Vikram Padbidri, M.D.,2 and Sumanth Shivaswamy, M.D.S.1

Abstract

Background and objectives: Research has shown that mechanical methods of periodontal therapy alone may failto eliminate the tissue-invasive pathogenic flora; therefore, considerable attention has been given to adjunctiveantimicrobial measures. The purpose of this study is to evaluate the efficacy of diode laser as an adjunct tomechanical debridement in periodontal flap surgery, on the basis of clinical parameters and microbiologicalanalysis. Materials and methods: A total of 30 patients with generalized chronic periodontitis with probingdepth > 5 mm after phase I therapy were included in the study. Diode laser was used as an adjunct to open flapdebridement (test) as compared with conventional flap surgery (control) in a split-mouth study design. Clinicalparameters (plaque and gingival index, probing depth and relative clinical attachment level) and subgingivalplaque samples of test and control groups were analyzed at baseline and 3 months post-therapy. Visual ana-logue scale (VAS) was used to determine patient discomfort intraoperatively and after 1 week. Results: Thedifference between the clinical parameters in the test and control groups did not reach a statistical significance.However, there was a statistically significant reduction in colony forming units (CFU) of obligate anaerobes inthe test group as compared with the control group. The diode laser was well tolerated by the patients, asdetermined by the VAS. Conclusions: The bactericidal effect of the diode laser was clearly evident by greaterreduction of CFU of obligate anaerobes in the test group than in the control group.

Introduction

Periodontitis is the result of complex interrelation-ships between infectious agents such as bacteria and host

factors.1,2 It is universally accepted that periodontal disease isthe result of mixed bacterial infections that require the par-ticipation of a very limited number of the members of theanaerobic microbiota inhabiting the subgingival region, andresults in the destruction of the supporting structures of theteeth.3,4

Most conventional methods used to treat the disease in-volve disruption of the biofilm by mechanical removal ofsubgingival plaque and, sometimes, the adjuvant use of an-timicrobial agents and mechanical surgical debridement ofpocket and root surfaces damaged as a result of periodontaldisease. An alternative (ecological) approach would be to

alter the environment of the pocket to prevent the growth ofthe putative pathogens, as suggested by Marsh (ecologicalplaque hypothesis).5

The nonsurgical therapy leads to resolution of inflamma-tion, reduction in bacterial load, and reduction in probingpocket depth. However, the complete removal of bacterialtoxins from the root surfaces6 in the deep periodontalpockets is not always achieved with nonsurgical therapy.7

Instrumentation is not possible in inaccessible areas suchas furcation, grooves, and concavities.8 Also, according toSchenk et al.,9 sonic and ultrasonic instrumentation does notlead to killing of periopathogens. These instruments help toreduce the bacterial load by mechanical removal of plaqueand calculus.

Thus, surgical therapy performed in cases with persistentinflammation, deeper pockets, class II and III furcation

1Department of Periodontology and Implantology, M.A.Rangoonwala College of Dental Sciences and Research Centre, Maharashtra,India.

2Department of Microbiology, Jehangir Hospital, Maharashtra, India.

Photomedicine and Laser SurgeryVolume 30, Number 10, 2012ª Mary Ann Liebert, Inc.Pp. 598–603DOI: 10.1089/pho.2012.3252

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defects, and intrabony defects provides better accessibility toroot surfaces as well as osseous defects. However, perio-pathogens persist in the mixed-species plaque biofilm ontooth surfaces, adhere to and enter the epithelial cells, andare tissue invasive in nature.10 These are sources for re-colonization and reinfection. The limitations of the conven-tional therapy have probed us to implement the use ofadjunctive antimicrobial measures.

Laser-assisted periodontal therapy has attracted attentionrecently as a potential alternative or adjunct to conventionalmechanical debridement.11 Carbon dioxide (CO2) laser,neodymium doped:yttrium-aluminum-garnet (Nd:YAG) laser,and diode and erbium-doped:yttrium-aluminium-garnet(Er:YAG) laser have been used in the therapy of periodontalpocket for hard tissue as well as soft tissue management.12 Apart of the laser energy scatters and penetrates during irra-diation into periodontal pockets. The attenuated laser at alow energy level might then stimulate the cells of sur-rounding tissue resulting in reduction of the inflammatoryconditions (Shimizu et al.),13 in cell proliferation (Quadriet al.),14 and in increased flow of lymph (Shimotoyodomeet al.),15 improving the periodontal tissue attachment andpossibly reducing postoperative pain.

Diode laser has a wave length of 810 nm or 910–980 nm,which does not interact with dental hard tissues. Therefore,the laser is an excellent soft tissue surgical laser, indicated forcutting and coagulating gingiva and oral mucosa, and forsoft tissue curettage or sulcular debridement. It also has abactericidal effect.16 The purpose of this study was to eval-uate the adjunctive effects of the diode laser in open flapdebridement as compared with the conventional mechanicaldebridement as assessed by clinical and microbiologicalparameters.

Materials and Methods

Thirty patients were selected from the outpatient depart-ment of the Department of Periodontology and Oral Im-plantology of M.A. Rangoonwala College of Dental Sciencesand Research Centre, Pune, India. The study was approvedby the Local Ethical Committee (Protocol number MARDC/2008/P2). The study was explained to all the patients and aninformed consent was taken from all the patients. Patients30–50 years of age diagnosed with chronic periodontitis withprobing pocket depths ‡ 5 mm after phase I therapy wereincluded in the study. Smokers, pregnant women and lac-tating mothers, diabetic patients, and patients with a historyof administration of antibiotics 3 months prior to their firstvisit were excluded from the study.

Patients with persistent probing pocket depth ‡ 5 mmunderwent access flap surgery 4 weeks after phase I therapy.As this was a split-mouth study, patients with bilateralperiodontal pockets in the anterior sextant of either maxillaor mandible were selected for the study. Patients with bonyarchitecture where regenerative or resective surgeries wereneeded were not included in this study. Hence, only single-rooted teeth with horizontal bone loss were included in thisstudy.

Measurements (clinical parameters)

Plaque index (PI)17 (Silness and Loe) and gingival index18

(GI) (Loe and Silness) were calculated at the baseline.

Stents were prepared to standardize the probe angulationand the reference point. The same stent was used for thefollow-up measurements after 3 months.

The site with deepest probing pocket depth from the testand control groups was used for measuring all the parame-ters. Probing depth (PD) and relative clinical attachmentlevel (CAL) were measured with the help of UNC 15 probeand acrylic stent.

Microbial sampling

Microbiological analysis for the colony forming units(CFU) of obligate anaerobes was performed in 10 randomlyselected patients. Subgingival plaque samples were collectedfrom the deepest pocket in the test and control site with thehelp of paper points at baseline and at 3 months. The plaquesamples were transported in Robertson’s cooked meat mediato the microbiology laboratory within 1 h of collection.Samples were labeled and processed immediately. CFU ofobligate anaerobes were calculated by:

y · 10�d · 1=v

where d = dilution plated, v = volume plated, and y = colonycount on the plates (between 30 and 300)

Surgical protocol

The surgical sites were randomly allocated to test and thecontrol groups. Conventional access flap surgery with me-chanical debridement was performed on the control side.The test site included use of diode laser as an adjunct tomechanical debridement. Both the procedures were per-formed during the same sitting. Diode laser (Sunny Laser�)with a wavelength of 980 nm and a power setting of 2.5 Wwas used in continuous, contact mode with the help of aflexible fiberoptic delivery system (laser dose, 50 J/cm2). Thefiber was used in a ‘‘brush stroke’’ motion on the undersur-face of the flap to remove the pocket lining.

Postoperative care

Patients were given routine postoperative instructions.Antibiotics were not prescribed, as they would alter the floraand modify the effect of diode laser.

Visual analogue scale (VAS)

The intensity of pain experienced by the patient during thetreatment and 1 week postoperatively was analyzed with thehelp of a VAS.19 This scale had a marking from 0 to 10,with 0 = no pain, 1–3 = slight pain, 4–6 = moderate pain, and7–10 = severe pain. Patients were told to rate the intensity ofpain on a scale of 0 to 10.

Patients were kept on a maintenance protocol. At 3 monthfollow-up, clinical and microbiological parameters were an-alyzed for test and control sites.

Statistical analysis

The absolute change in each periodontal index at 3 monthfollow-up with respect to baseline was calculated using theformula: (postoperative index – preoperative Index).

DIODE LASER ASSISTED PERIODONTAL FLAP SURGERY 599

The statistical significance of several periodontal indicesstudied between two study groups was tested using theMann–Whitney U test. In each study group, the intragroupanalysis of baseline and 3 month follow-up indices was tes-ted using Wilcoxon’s signed-rank test, the statistical analysistool for paired data.

A p value < 0.05 was considered statistically significant.The entire data were analyzed using Statistical Package forSocial Sciences (SPSS version 11.5) for MS Windows.

Results

The study included 30 patients with generalized chronicperiodontitis within a range of 30–50 years of age, with amean age of 41.4 years.

Intragroup comparison

The changes in the clinical and microbiological parametersfrom baseline to 3 months within control and test group aredescribed.

The mean and standard deviation values for PI, GI, PD,and relative CAL at the baseline and at 3 months after sur-gery of control and test groups are shown in Table 1.

The values of PI in the control group were 0.55 – 0.46 at thebaseline and 0.30 – 0.44 at 3 months. The values of PI in thetest group were 0.54 – 0.45 at the baseline and 0.29 – 0.43 at 3months. This difference was also not found to be statisticallysignificant ( p value 0.077 and 0.052).

At 3 months, the GI and PD showed statistically signifi-cant decrease in both the groups and there was statisticallysignificant gain in CAL in both the groups.

The GI decreased from 1.07 – 0.77 to 0.56 – 0.62 in thecontrol group and from 1.09 – 0.75 to 0.30 – 0.47 in the testgroup after 3 months. The difference was statistically sig-nificant for both the groups ( p value 0.001).

There was reduction in PD from 5.80 – 1.19 mm to3.00 – 0.95 mm in the control group at 3 months. The PDdecreased from 6.03 – 1.22 to 2.97 – 0.72 mm at 3 months inthe test group. The difference was statistically significantwith a p value of 0.001 in both the groups.

The mean relative CAL was 11.5 – 1.97 and 11.07 – 1.57 mmin the control and test group, respectively, at the baseline.At 3 months, the mean relative CAL was 9.80 – 1.77 and9.70 – 1.62 mm in the control and test group, respectively,thus showing statistically significant gain in CAL comparedto baseline in both groups ( p value 0.001).

Table 2 shows the mean values of VAS of the test and thecontrol groups recorded intraoperatively and after 1 week.

The mean intraoperative value of VAS was 1.93 – 0.91 and1.80 – 0.85 at 1 week in the control group. The mean in-traoperative value of VAS was 1.90 – 0.96 and 1.83 – 1.23 at 1week in the test group. The difference was not found to bestatistically significant ( p value 0.417 and 0.713).

Table 3 shows mean values of CFU at baseline and3 months for the test and control groups.

The mean CFU of obligate anaerobes in the control groupdecreased from 4.09 · 104 – 2.72 · 104 to 7.07 · 103 – 14.9 · 103

CFU/mL, which was statistically significant ( p value 0.005).The mean CFU of obligate anaerobes in the test group de-creased from 3.47 · 104 – 3.00 · 104 to 3.01 · 103 – 9.5 · 103

CFU/mL, which was also statistically significant ( p value0.007).

Intergroup comparison

The comparison of mean values of PI, GI, PD, and relativeCAL in the control and the test groups are demonstrated inTable 4.

The difference between PI, GI, and PD reduction and gainin CAL between the control and test groups at 3 months wasnot statistically significant.

Table 5 shows comparison of VAS values in the controland test groups.

The difference between VAS between the control and testgroups was also not statistically significant intraoperatively( p value 0.903) and at 1 week ( p value 0.596).

Table 1. Intragroup Comparison of Periodontal

Parameters Studied

Groups andparameters

Day 0(n = 30)

Day 90(n = 30) p Value Significance

Test groupPlaque index 0.54 (0.45) 0.29 (0.43) 0.052 Not sigGingival index 1.09 (0.75) 0.30 (0.47) 0.001 SigProbing depth 6.03 (1.22) 2.97 (0.72) 0.001 SigClinical

attachmentlevel

11.07 (1.57) 9.70 (1.62) 0.001 Sig

Control groupPlaque index 0.55 (0.46) 0.30 (0.44) 0.077 Not sigGingival index 1.07 (0.77) 0.56 (0.62) 0.001 SigProbing depth 5.80 (1.19) 3.00 (0.95) 0.001 SigClinical

attachmentlevel

11.5 (1.97) 9.80 (1.77) 0.001 Sig

Table 2. Intragroup Comparison

of Visual Analogue Scale (VAS)

Groups andparameters

Intraop(n = 30)

1 weekpostop

(n = 30) p Value Significance

Test groupVAS 1.90 (0.96) 1.83 (1.23) 0.713 Not sig

Controlgroup

VAS 1.93 (0.91) 1.80 (0.85) 0.417 Not sig

Table 3. Intragroup Comparison of Colony

Forming Units (CFU)

Groups andparameters

Day 0(n = 10)

Day 90(n = 10) p Value Significance

Test groupCFU (per mL) 3.47 · 104

(3.00 · 104)3.01 · 103

(9.5 · 103)0.007 Sig

Control groupCFU (per mL) 4.09 · 104

(2.72 · 104)7.07 · 103

(4.9 · 103)0.005 Sig

600 GOKHALE ET AL.

Table 6 demonstrates the comparisons in the mean valuesof CFU in the control and test groups. The mean values ofCFU at baseline between the two groups were not signifi-cantly different ( p value 0.481). However, the mean value ofCFU at 3 months in the test group was significantly lowerthan in the control group ( p value 0.043).

Therefore, the results of the study show that there was noclinical relevance when the clinical parameters were com-pared in the control and test groups. However, there was astatistically significant reduction in CFUs of obligate anaer-obes in the test group as compared with control group.

Discussion

Successful periodontal therapy depends on anti-infectiveprocedures aimed at eliminating or suppressing pathogenic

organisms found in dental plaque associated with the toothsurface and within other niches in the oral cavity.20 Non-surgical mechanical therapy alone may not effectively elim-inate the periodontal disease completely, particularly in deeppockets.21 Hence, surgical therapy is performed, which pro-vides improved visualization of the root surface and defects.

Soft tissue lasers such as diode and Nd:YAG have thepotential for curettage of pocket wall and disinfection ofperiodontal pockets.12,22 Er:YAG laser can be used for bothsoft and hard tissue debridement. A search of literature re-views revealed very few reports of the use of CO2 and Er:-YAG lasers during surgical pocket therapy. However, thereare no reports of the use of diode laser as an adjunct tomechanical debridement in access flap surgery, although it isthe most commonly used laser. The adjunctive effects of di-ode laser in open flap debridement have been evaluated inthis study based on clinical and microbiological parameters.

In the present study, PI was used to monitor the oralhygiene status of the patients. The results demonstrate thatthere was no statistically significant difference in the PI atbaseline and at 3 months in the control and the test group.The PI score was consistently <1, suggesting maintenance offair oral hygiene by the patients throughout the study.

On the other hand, GI decreased significantly from base-line to 3 months in the control and the test groups. Thissuggests the effectiveness of access flap surgery in reducingthe signs of inflammation caused by effective removal ofcalculus and infected granulation tissue.23

A VAS was used to determine the pain perception by thepatient during the procedure and 1 week postoperatively.There was no statistically significant difference in the read-ings of VAS in both the groups, indicating that the level ofpatient comfort was similar in both groups. The use of diodelaser as an adjunct to mechanical debridement neither led topostoperative complications nor to delayed healing. Thisindicates that diode laser did not seem to have any detri-mental effect when employed in conjunction with peri-odontal surgery. According to Chow et al.,24 laser inducesinhibitory effects on the peripheral nerves by slowing theconduction velocity (CV) and/or reducing the amplitude ofcompound action potentials.

Centty et al.25 used CO2 laser (8 W and 20 Hz) on the outerand inner aspects of the mucoperiosteal flap. CO2 laser wasfound to increase the effectiveness of periodontal therapythrough epithelial exclusion technique. Gaspirc et al.26 re-ported the long-term clinical outcome comparing the Er:YAGlaser-assisted periodontal flap surgery with conventional

Table 4. Intergroup Comparison of Periodontal

Parameters Studied

Parameters

Testgroup

(n = 30)

Controlgroup

(n = 30) p Value Significance

Plaque indexDay 0 0.54 (0.45) 0.55 (0.46) 0.892 Not sigDay 90 0.29 (0.43) 0.30 (0.44) 0.929 Not sigChange

(Day 0 –Day 90)

0.25 (0.62) 0.25 (0.64) 0.944 Not sig

Gingival indexDay 0 1.09 (0.75) 1.07 (0.77) 0.938 Not sigDay 90 0.30 (0.47) 0.56 (0.62) 0.105 Not sigChange

(Day 0 –Day 90)

0.79 (0.64) 0.51 (0.63) 0.110 Not sig

Probing depthDay 0 6.03 (1.22) 5.80 (1.19) 0.291 Not sigDay 90 2.97 (0.72) 3.00 (0.95) 0.931 Not sigChange

(Day 0 –Day 90)

3.07 (1.41) 2.80 (1.03) 0.778 Not sig

Rel. clin.att. levelDay 0 11.07 (1.57) 11.5 (1.97) 0.716 Not sigDay 90 9.70 (1.62) 9.80 (1.77) 0.815 Not sigChange

(Day 0 –Day 90)

1.37 (1.29) 1.70 (1.53) 0.292 Not sig

Table 5. Intergroup Comparison of Visual

Analogue Scale (VAS)

Parameters

Testgroup

(n = 30)

Controlgroup

(n = 30) p Value Significance

VASIntraoperative 1.90 (0.96) 1.93 (0.91) 0.903 Not sig1 week

postoperatve1.83 (1.23) 1.80 (0.85) 0.596 Not sig

Change(1 week –intraoperative)

0.07 (0.87) 0.13 (0.82) 0.900 Not sig

Table 6. Intergroup Comparison of Colony

Forming Units (CFU)

Parameters

Testgroup

(n = 10)

Controlgroup

(n = 10) p Value Significance

CFU (per mL)Day 0 3.47 · 104

(3.0 · 104)4.09 · 104

(2.7 · 104)0.481 Not sig

Day 90 3.01 · 103

(9.5 · 103)7.07 · 103

(14.9 · 103)0.043 Sig

Change (Day90 –Day 0)

3.17 · 104

(2.7 · 104)3.38 · 104

(1.9 · 104)0.853 Not sig

DIODE LASER ASSISTED PERIODONTAL FLAP SURGERY 601

treatment using the modified Widman flap procedure. In thisinvestigation, the reduction of pocket depth and the gain ofclinical attachment level were significantly greater in the la-ser group at 6–36 months after surgery.

Every laser has a different property and different tissueinteractions, which depend upon the wavelength, power,waveform, tissue optical properties and tissue thermalproperties.

Diode laser is an excellent soft tissue laser and is availablein smaller cost-effective units. The radiation of diode lasershows greater absorption and less penetration than doesNd:YAG laser, especially in blood-rich tissue. Therefore,collateral damage with diode laser is less than with Nd:YAGor CO2 laser.27 The wavelength of diode laser is absorbed bythe hemoglobin, which leads to tissue coagulation and for-mation of charred layer. Diode leads to thermocoagulation ofthe blood vessels, which is responsible for its hemostatic ef-fect.27 Thus, diode laser is an excellent soft tissue laser be-cause of its tissue coagulating and hemostatic properties.

The laser mode of antisepsis has several potential advan-tages over traditional biochemical antibiotics. A therapeuticdose can be delivered to a greater depth locally and leaves noresidual concentration.28 Laser radiation affects equally ex-tracellular and intracellular pigmented pathogens and canaccess other privileged sites such as calculus and dentinaltubules. Laser antisepsis has no known systemic side effects,resistances, or negative interactions with other modes oftherapy.28 Laser energy has the potential to breach the pro-tective mechanisms of biofilms.29

In the present study, there was a statistically significantreduction in the number of CFUs of anaerobes in the laser-treated group as compared with the control group. Thewavelength of the diode laser was absorbed by protoheminand protoporphyrin IX pigments of the pigmented anaerobicperiopathogens.30 This led to vaporization of water andcaused lysis of the cell wall of the bacteria, leading to celldeath. It was effective against the tissue invasive perio-pathogens caused by absorption of laser energy up to2 – 1 mm in the deeper tissues.30

Since the mid-1990s, herpes viruses have emerged as pu-tative pathogens in various types of periodontal disease.31,32

Laser irradiation may also kill the herpes viruses in the tis-sues because of deeper penetration of laser energy. However,further studies are required to substantiate this hypothesis.

The disadvantages of the diode laser are ineffectiveness ofcalculus removal from the root surface and possibility ofthermal damage to the bone in the presence of blood and athigh power settings. However, thermal damage can beavoided with appropriate power settings and by using thelaser intermittently, which would allow the tissues to cool.Castro et al.33 evaluated effects of diode laser on root surfaceafter using it as an adjunct to pocket therapy in a histologicalstudy. They did not observe any changes in the root surfacecaused by thermal damage.

It has been hypothesized that the charred layer that formson the undersurface of the flap prevents the epithelial migra-tion and promotes new attachment. Crespi et al.34 providedhistological evidence of formation of new cementum, peri-odontal ligament, and bone when CO2 laser was used for de-bridement in class III furcation defects in dogs. Mizutani et al.35

used Er:YAG laser for debridement during access flap surgeryand noted that laser promoted more new bone formation.

The bactericidal effect of diode laser is evident from thereduction in the CFU of obligate anaerobes. The possible roleof diode laser in killing viruses and promoting formation ofnew attachment can also be contemplated.

Conclusions

Diode laser was well tolerated by the patients and itdemonstrated a significant bactericidal effect. Therefore, la-sers can form an integral part of periodontal therapy in thefuture.

However, further longitudinal studies are required toevaluate the long-term effects of diode laser on clinical aswell as microbiological parameters. The bactericidal effect ofdiode laser on specific microorganisms and viruses and timetaken for microbial recolonization needs to be determined byfurther studies. Further animal studies are required to pro-vide an insight into the healing and a possible role for diodelaser in the formation of new attachment.

Author Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Sneha R. Gokhale

Department of Periodontology and ImplantologyM.A.Rangoonwala College of Dental Sciences

and Research CentrePUNE-411001

MaharashtraIndia

E-mail: gokhalesneha@yahoo.com

DIODE LASER ASSISTED PERIODONTAL FLAP SURGERY 603

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1. Mehmet Saglam, Alpdogan Kantarci, Niyazi Dundar, Sema S. Hakki. 2012. Clinical and biochemical effects of diode laser asan adjunct to nonsurgical treatment of chronic periodontitis: a randomized, controlled clinical trial. Lasers in Medical Science .[CrossRef]