Enhancing Outcomes Of Non-Surgical Periodontal Therapy With Laser Technology
Article written by Beata Knysak for dentists, dental hygienists and therapists.
Periodontal disease is a major public health concern due to its high
prevalence. According to the data severe periodontitis is the sixth-most
prevalent condition in the world . In the United Kingdom, 62% of
adults under 40 years of age are affected by moderate periodontal
disease  and throughout the Covid-19 pandemic we have seen an immense
increase in the number of patients with periodontal tissue breakdown
and tooth loss.
While there is an increase in life expectancy and a significant
decrease in tooth loss, periodontal disease puts a burden on the
national healthcare systems across the globe.
Although bacteria arising from plaque is the main aetiological factor of periodontal disease, the host’s immune inflammatory response is accountable for the majority of the destructive changes seen in periodontal tissues. Even in healthy periodontium, host immune cells are continuously present, supporting the balance between microbial plaque and the host . Any interactions between the host and oral microbiota will either support the homeostasis or results in dysbiosis within the community of pathogenic microorganisms .
Periodontal health-associated commensals are vital in protecting this equilibrium by for example inhibiting the growth of periopathogenic microorganisms. However, quantitative and qualitative changes within subgingival plaque biofilm may lead to disturbed homeostasis, which subsequently leads to the onset of the periodontal disease with various degrees of periodontal tissue breakdown.
This is not a continuous process but alternates between a period of inactivity and aggravation and it can be affected by local and systemic factors [3&4]:
Microbial plaque-biofilm burden
Patient’s age, ethnicity, genetic predisposition and patient’s immune response
If not treated, periodontal disease leads to connective tissue destruction and alveolar bone resorption that eventually results in tooth loss . It negatively affects patient’s chewing function and aesthetics, it is a source of social inequality, and significantly impairs their quality of life.
The main objectives of non-surgical periodontal therapy (NSPT) are to provide the least invasive treatment that gives the patient the best and most predictable outcomes through the promotion of periodontal tissue regeneration and restoration of tooth function. After successful treatment, periodontal ligament (PDL) cells (fibroblasts) migrate and attach to the microorganism free root surface. They proliferate, differentiate and synthesise extracellular matrix proteins to form collagen fibres. It is crucial to obtain newly formed PDL to prevent apical migration of junctional epithelium and to allow regeneration of PDL, cementum and alveolar bone; therefore, the application of laser irradiation has been proposed to allow for the compatibility of root surfaces with regenerative processes.
An increasing number of studies have demonstrated the benefits of adjunctive laser therapy in conventional NSPT due to its reported ability to significantly reduce pathogens, promote healing and to suppress the inflammatory cytokine cascade through to surgical ablation of diseased tissues . As a result of its deeper penetration, diode laser has not only had bactericidal effects but also bio-stimulatory effects on periodontal ligament stem cells, osteoblasts and fibroblasts . The Erbium Chromium: Yttrium Scandium Gallium Garnet (Er,Cr:YSGG) laser, however, allows selective subgingival biofilm and calculus ablation without causing any thermal side effects (carbonisation) or morphologic changes to the root surface to allow the attachment of these cells . Also, when compared with conventional hand instrumentation, Er,Cr:YSGG laser therapy was not only found to promote PDL fibroblast cell migration and attachment, but it also increased the number of cells that differentiate in periodontal regeneration [11,12,13].
Although in the treatment of periodontal disease, surgical interventions (with the use of osseous graft material, barrier membranes or application of a biologically active material) deem to have more predictable outcomes than conventional NSPT, they may however, possess multiple shortfalls including high cost, painful healing and post-operative complications. Also, with regard to the application of local or systemic antibiotic there are multiple side-effects including antibiotic resistance, gastrointestinal complications or drug interactions.
There is an on-going discussion regarding the efficacy of laser therapy in the context of evidence-based practice. Whilst lasers remain a hugely controversial treatment modality, they have had a significant impact on the practice of modern dentistry, especially in periodontology, in a relatively short period of time without causing any adverse effects. For many years, diode and Er,Cr:YSGG laser therapies have been demonstrated as minimally invasive that bring more predictable outcomes .
Also, due to the individual wavelength of each laser and their distinctive soft and hard tissue interaction, making comparisons between lasers should be avoided.
Knowledge of standard parameters of irradiation for each clinical application, basic principles of photonic therapies by the dental care professional (GDP) as well as patient compliance and proper selection of adjunctive antimicrobial agents for sustained plaque control are important elements in achieving long-term successful results.
N.J. Kassebaum, E. Bernabe, M. Dahiya, B. Bhandari, C.J. Murray, W. Marcenes, Global burden of severe periodontitis in 1990-2010: a systematic review and meta-regression, J. Dent. Res. 93 (11) (2014) 1045–1053.;
Institut der Deutschen Zahnarzte (IDZ), ¨ Vierte Deutsche Mundgesundheitsstudie (DMS IV), Kassenzahnarztliche Bun- ¨ desvereinigung , Bundeszahnarztekammer, 2006.
Lalla E., Papapanou P.N. Diabetes mellitus and periodontitis: A tale of two common interrelated diseases. Nat. Rev. Endocrinol. 2011;7:738–748. doi: 10.1038/nrendo.2011.106.
Könönen, Eija et al. “Periodontitis: A Multifaceted Disease of Tooth-Supporting Tissues.” Journal of clinical medicine vol. 8,8 1135. 31 Jul. 2019, doi:10.3390/jcm8081135
Darveau R.P. Periodontitis: A polymicrobial disruption of host homeostasis. Nat. Rev. Microbiol. 2010;8:481–490. doi: 10.1038/nrmicro2337.
Sanz M., Beighton D., Curtis M.A., Cury J.A., Dige I., Dommisch H., Ellwood R., Giacaman R.A., Herrera D., Herzberg M.C., et al. Role of microbial biofilms in the maintenance of oral health and in the development of dental caries and periodontal diseases. Consensus report of group 1 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal disease. J. Clin. Periodontol. 2017;44(Suppl. 18):5–11.
Cronshaw, Mark & Parker, Steven & Ackroyd, Sonia & Lynch, Edward. (2019). Photobiomodulation therapy and periodontitis: a discussion paper.
N. Gutknecht, C. Van Betteray, S. Ozturan, L. Vanweersch, R. Franzen, "Laser Supported Reduction of Specific Microorganisms in the Periodontal Pocket with the Aid of an Er,Cr:YSGG Laser: A Pilot Study", The Scientific World Journal, vol. 2015, Article ID 450258, 7 pages, 2015. https://doi.org/10.1155/2015/450258
Schwarz, F., Aoki, A., Becker, J., & Sculean, A. (2008). Laser application in nonsurgical periodontal therapy: a systematic review. Journal of Clinical Periodontology, 35(s8), 29-44.
Hakki, S. S., Berk, G., Dundar, N., Saglam, M., & Berk, N. (2010). Effects of root planing procedures with hand instrument or erbium, chromium: yttrium– scandium–gallium–garnet laser irradiation on the root surfaces: a comparative scanning electron microscopy study. Lasers in Medical Science, 25(3), 345-353.
Hakki, S., Korkusuz, P., Berk, G., Dundar, N., Saglam, M., Bozkurt, B. and Purali, N. (2010). Comparison of Er,Cr:YSGG Laser and Hand Instrumentation on the Attachment of Periodontal Ligament Fibroblasts to Periodontally Diseased Root Surfaces: An In Vitro Study. Journal of Periodontology, 81(8), pp.1216-1225.
Oliveira, G., Sampaio, J. and Marcantonio, R. (2010). Effects of Er,Cr:YSGG Laser Irradiation on Root Surfaces for Adhesion of Blood Components and Morphology. Photomedicine and Laser Surgery, 28(6), pp.751-756.
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