Role of Diode Lasers (800–980 Nm) as Adjuncts to Scaling and Root Planing in the Treatment of Chronic Periodontitis: A Systematic Review

Laser Therapy Versus Traditional Scaling and Root Planing: A Comparative Review

Scaling and root planing (SRP) removes bacterial plaque, calculus, and associated microorganisms from the surface of the tooth and the surrounding soft tissue. While complete eradication of pathogenic microbes is impossible, gross removal can lower the microbial load, which in turn reduces inflammation and contributes to positive clinical outcomes. Instrumentation in limited-access anatomic areas like furcation, grooves, deep pockets, concavities, and distal molar areas is technically demanding with traditional mechanical debridement. However, emerging advanced systems such as lasers with bactericidal and detoxification effects offer the benefit of reaching limited-access areas that traditional SRP cannot reach. A digitized search was done on PubMed, Embase, Medline, and Google Scholar using the keywords "lasers", "periodontal therapy", "scaling", and "root planing". Upon screening and reviewing, the shortlisted articles comprised narrative reviews, systematic reviews, randomized controlled trials, comparative studies, split-mouth studies, case series, and reports of non-surgical laser therapy and lasers as an adjunct to SRP. This review presents a comprehensive comparative evaluation of different laser modalities utilized in non-surgical periodontal treatment in contrast to standard SRP, rather than an exhaustive article review. It delves into the history and development of lasers, highlighting key advancements made in the realm of periodontics and dental care. This review includes an elucidation of the theory behind laser operation, along with an exploration of its intrinsic characteristics and breakdown of the various types of lasers that are currently available, and an examination of existing literature in both present and historical contexts regarding the comparison of various types of lasers with traditional periodontal treatment.

Anti-infective Efficacy of Mechanical Debridement with Adjunctive Modalities on Clinical and Cytokine Parameters in Treatment of Chronic Periodontitis: Randomized Controlled Clinical Trial

OBJECTIVES

 Periodontal debridement involves conventional scaling and root planing (SRP) along with variant forms of adjunctive therapies. In the present clinical trial, we investigated if the adjunctive use of HybenX gel or diode laser along with SRP could provide a favorable outcome for the treatment of chronic periodontitis.

MATERIALS AND METHODS

 The present study involved 60 subjects diagnosed with chronic periodontitis who were randomly assigned as test groups (laser or HybenX) or control group (SRP alone). The primary outcomes of the clinical trial were pocket probing depth (PPD) and clinical attachment level (CAL), which was evaluated at baseline and at third-month time interval. Additionally, secondary outcomes included estimation of reduction in inflammatory mediators interleukin 1β (IL-1β) and tumor necrosis factor α (TNF-α) in gingival crevicular fluid using enzyme-linked immunosorbent assay at baseline and third-month intervals.

STATISTICAL ANALYSIS

 Normality determination was checked using Shapiro-Wilk test. Since the data was not normally distributed, nonparametric tests were applied. The comparison of clinical parameters between the groups was analyzed with Kruskal-Wallis test. Wilcoxon sign rank test was used to compare the pairwise comparison of clinical parameters among the groups from baseline to third-month follow-up. The inflammatory mediators at various time points were compared using a One-way analysis of variance test, and the inflammatory mediators in each study group were compared using a paired t-test.

RESULTS

 Both the test groups demonstrated a decrease in PPD and CAL. However, the HybenX group exhibited statistically significant reduction at the end of the third-month study interval compared to the laser group and SRP alone. Further, the secondary outcome IL-1β and TNF-α analysis exhibited statistically significant reduction in all the groups posttherapy.

CONCLUSION

 The adjunctive application of HybenX gel yielded an advantage compared to laser and SRP for the treatment of chronic periodontitis.

CLINICAL RELEVANCE

 Adjunctive use of the oral tissue desiccant (HybenX gel) combined with SRP improved the periodontal pocket disinfection process and enhanced tissue healing devoid of adverse effects.

Diode laser as an adjunctive treatment for periodontitis: Arandomized controlled trial

OBJECTIVE

The aim of this randomized controlled trial was to assess clinical and patient reported outcomes of subgingival instrumentation (SI) with adjunctive use of diode laser (DL) versus SI alone in the treatment of periodontitis.

METHODS

Participants requiring non-surgical periodontal treatment were randomly allocated into two treatment groups: SI with DL or SI alone. Clinical parameters [full mouth bleeding and plaque scores (FMBS and FMPS), probing pocket depth and clinical attachment level] were recorded at baseline, three and 6 months post-treatment. Visual analogue scale was used to evaluate postoperative participants' perception of pain, swelling, bleeding, bruising and root sensitivity. The impact of periodontal treatment on quality of life was assessed using the General Oral Health Assessment Index (GOHAI) at 6 months.

RESULTS

A total of 22 participants with stage III/IV periodontitis completed the 6-month follow-up. SI with or without DL resulted in statistically significant reduction in FMBS, FMPS, PPDs, and percentage of PPDs of ≥5 mm at 3- and 6-month follow-up visits (p = 0.001 to <0.001). The participants in SI/DL group had a greater reduction in the percentage of deep PPDs (≥5 mm) compared to those receiving SI alone, but statistically significant differences between the two groups were not observed (16.40 ± 9.57 vs. 32.50 ± 38.76 at 3 months and 7.20 ± 6.86 vs. 19.50 ± 35.06 at 6 months). The difference in the mean total GOHAI scores was not statistically significant at 6 months with total GOHAI scores of 7.25 ± 2.45 and 5.40 ± 3.06 for SI and SI/DL groups, respectively.

CONCLUSION

Within the limitations of this study, the use of DL as an adjunct to SI in the treatment of stage III/IV periodontitis did not produce significant additional improvement in clinical parameters or patient reported outcomes in the 6-month observation period.

Clinical and microbiological efficacy of intra-pocket application of diode laser in grade C periodontitis: a randomized controlled clinical trial

BACKGROUND

Periodontitis is a microbially induced disease destroying structures anchoring teeth to jaw bones. Although metronidazole in combination with spiramycin is the effective conventional treatment of stage III grade C periodontitis, it has several systemic side effects. Laser therapy is widely used nowadays as an adjunct to scaling and root planing (SRP) to modulate inflammatory host response and eradicate microbes, due to bactericidal and detoxifying effects. Since microbiological analysis is one of the diagnostic methods identifying periodontal risk; our research aimed to investigate the efficacy of intra-pocket application of diode laser (980 nm) versus antibiotic therapy in enhancing clinical and microbiological parameters in stage III grade C periodontitis.

METHODS

A randomized controlled clinical trial was conducted on fifty patients with stage III grade C periodontitis, divided equally into two groups. We managed test group by SRP with intra-pocket application of diode laser (980 nm) and the control group by SRP with systemic antibiotic administration (spiramycin and metronidazole). Then, we measured periodontal pocket depth (PPD) and clinical attachment loss (CAL) for both groups, before treatment (baseline), four and twelve weeks after. Moreover, we collected gingival crevicular fluid from both groups at baseline, four and twelve weeks after treatment and analyzed by real-time polymerase chain reaction to detect the relative count of Aggregatibacter actinomycetemcomitans and Porhyromonas gingivalis.

RESULTS

Compared to baseline, all assessed clinical and microbiological parameters attested improvement at the end of the study period in each group individually with no significant difference between the two studied groups. Although, at twelve weeks, flare up of bacterial levels was detected with systemic antibiotic administration.

CONCLUSION

Laser therapy can be considered as an effective treatment modality in stage III grade C periodontitis, avoiding the systemic antibiotic side effects and solving the recurrence problems due to bacterial resistance by long term usage.

TRIAL REGISTRATION

NCT05222737 retrospectively on 03/02/2022, Clinicaltrial.gov.

Systemic inflammatory markers following adjunctive Nd:YAG (1064 nm) laser irradiation to step 2 of periodontal therapy: a 12-month, randomized, controlled trial

OBJECTIVES

The aim of this study was to investigate whether the use of adjunctive Nd:YAG (1064 nm) laser irradiation to full-mouth scaling and root planing (FM-SRP) may offer additional benefit in the systemic inflammatory status of the patient, as depicted in a variety of systemic biomarkers over FM-SRP alone, up to 12 months after treatment.

MATERIALS AND METHODS

A total of 60 otherwise healthy stage III/IV periodontal patients were equally distributed in 3 groups. The control group received FM-SRP. In laser A group, 1 week after FM-SRP, Nd:YAG laser irradiation was delivered in periodontal pockets with PD ≥ 4 mm using specific settings (3 W, 150 mJ, 20 Hz, 100 μs). In laser B group Nd:YAG laser irradiation was delivered twice, 1 week after FM-SRP and 1 week later with different settings compared to laser A (2 W, 200 mJ, 10 Hz, 100 μs).

RESULTS

A significant reduction (p = 0.038) of IL-1β serum levels at the 6-month time point was observed for laser A group. IL-6 was found statistically significantly increased (p = 0.011) in the control group at the 6-week time point, whereas no difference was reported for the laser-treated groups (laser A, laser B).

CONCLUSIONS

The adjunctive use of Nd:YAG laser irradiation, prevented from IL-6 increase after FM-SRP, 6 weeks after treatment. Similarly, Nd:YAG laser irradiation (3 W, 150 mJ, 20 Hz,100 μs) was associated with significantly lower IL-1β levels, 6 months post-operatively.

CLINICAL RELEVANCE

Additional Nd:YAG laser application to FM-SRP may provide a potential beneficial effect on systemic inflammation.

TRIAL REGISTRATION NUMBER

ISRCTN26692900.

REGISTRATION DATE

09/06/2022.

An Overview of the Systematic Evidence on the Adjunctive Use of Laser Therapy in Non-surgical Periodontal Treatment

This overview aimed to recapitulate the evidence related to laser application in non-surgical periodontal treatment along with conventional periodontal treatment for optimum clinical practice based on the available systematic reviews (SRs). An advanced literature search in the English language was conducted in the PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), ScienceDirect, and Scopus databases from January 2000 to October 2022. Two independent reviewers screened all the databases and extracted the data in duplicate. The risk of bias in the selected studies was assessed with the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) guideline for SRs. Cohen's kappa statistics were performed to assess the level of agreement for the assessment of the risk of bias. A total of 556 studies (PubMed = 115, Scopus = 66, ScienceDirect = 298, and MEDLINE = 77) were identified after the initial search using the keywords from different databases. After removing the duplicates and assessing the full manuscripts, a total of 24 studies were selected based on the inclusion criteria for the current overview. A total of three, four, 12, and five systematic reviews were classified as high, moderate, low, and critically low-quality SRs as per the AMSTAR 2 quality assessment tool. Cohen's Kappa statistics showed perfect (𝛋 =1.000) agreement between the two reviewers. Adjunctive laser therapy along with conventional non-surgical periodontal treatment might be effective in short-term treatment outcomes; however, evidence of long-term effects is still lacking.

Photobiomodulation for Managing "Dry Socket": A Randomised Controlled Trial

OBJECTIVE

There are no studies that have evaluated the effect of Alveogyl with and without adjunct photobiomodulation therapy (PBMT) in reducing self-rated post-operative pain (SPP) in patients with alveolar osteitis (AO; dry socket). The aim of the present randomised controlled trial was to assess the effectiveness of Alveogyl with and without PBMT for the management of SPP in patients with AO.

METHODS

Adult nonsmokers with diagnosed AO were included. Patients were randomly divided into 4 groups. In Group 1, patients underwent mechanical curettage (MC) with copious normal saline irrigation. In Group 2, patients underwent MC + Alveogyl dressings in extraction sites which were changed every 48 hours until cessation of pain. In Group 3, patients underwent MC + Alveogyl followed by PBMT using a 660-nm indium-gallium-aluminum-phosphide diode laser. In Group 4, patients were treated solely with PBMT. The visual analogue scale was used up to 3 postoperative days to assess SPP up to 3 days at 6- (T0) and 12-hour (T1) intervals. Statistical analyses were performed using the analysis of variance and Bonferroni post hoc adjustment tests. Correlation between SPP scores and age, sex, and eruption status of teeth was assessed using logistic regression models. P values <.01 were nominated as being statistically significant.

RESULTS

In all, 14, 13, 14, and 14 individuals with AO were included in groups 1, 2, 3 and 4, respectively. All patients had undergone extraction of mandibular third molars. At baseline and on day 1, there was no difference in SPP in all groups. On days 2 and 3, mean visual analogue scale (VAS) scores at T1 (P < .01) and T2 (P < .01) intervals were significantly high in Group 2 compared with Group 3. On days 2 and 3, mean VAS scores at T1 (P < .01) and T2 (P < .01) intervals were significantly high in Group 4 compared with Group 3. There was no difference in SPP in groups 3 and 4 on day 3 at T0 and T1 intervals.

CONCLUSIONS

PBMT following MC and Alveogyl dressing is more efficient in reducing SPP compared with MC with or without Alveogyl dressing in patients with AO.

High-frequency pulsed diode laser irradiation inhibits bone resorption in mice with ligature-induced periodontitis

AIM

The purpose of this study was to elucidate the suppressive effect of high-frequency pulsed diode laser irradiation on bone resorption and its biological effects for gene expression and microbiome composition on the gingival tissue in ligature-induced periodontitis in mice.

MATERIALS AND METHODS

Ligating ligature around the teeth and/or laser irradiation was performed on the gingival tissue in mice as follows: Co (no ligature and no laser irradiation), Li (ligation without laser irradiation), La (no ligature but with laser irradiation), and LiLa (ligation with laser irradiation). Bone resorption was evaluated using micro-computed tomography. RNA-seq analysis was performed on gingival tissues of all four groups at 3 days post ligation. The differences in microbial composition between Li and LiLa were evaluated based on the number of 16S rRNA gene sequences.

RESULTS

Bone resorption caused by ligation was significantly suppressed by laser irradiation. RNA-seq in Co and La gingival tissue revealed many differentially expressed genes, suggesting diode laser irradiation altered gene expression. Gene set enrichment analysis revealed mTORC1 signaling and E2F target gene sets were enriched in gingival tissues both in La and LiLa compared to that in Co and Li, respectively. The amount of extracted DNA from ligatures was reduced by laser irradiation, and bacterial network structure was altered between the Li and LiLa.

CONCLUSIONS

High-frequency pulsed diode laser irradiation showed biological effects and suppressed bone resorption in ligature-induced periodontitis. This article is protected by copyright. All rights reserved.

Comparison of the Treatment Efficacy of Endo−Perio Lesions Using a Standard Treatment Protocol and Extended by Using a Diode Laser (940 nm)

Marginal and periapical periodontal diseases cause massive destruction of tooth tissues and surrounding tissues, such as alveolar bone and maxillary sinus floor, visible on radiographs. Lesions involving the apical and marginal periodontium are endo−perio (EPL) lesions. This study aimed to compare the treatment efficacy of endo−perio lesions using a standard treatment protocol and a standard diode laser-assisted treatment protocol. The 12 patients were divided into the study (a) and control (b) group. Periodontal indices, tooth vitality and mobility, occlusal status, and radiographic diagnosis were evaluated. Standard EPL treatment was then performed—without (a) and with (b) the use of diode laser (940 nm). Again, after six months, the above-mentioned parameters were evaluated and compared. The treatment of endo−perio lesions is a significant challenge for modern dentistry. Diode lasers are increasingly used in addition to traditional treatment methods. The conventional use of a 940 nm diode laser with an average power of 0.8 W in pulsed mode allows for the depth of periodontal pockets to be reduced. In addition, the use of a diode laser has a significant effect on tooth mobility and reduces bone loss.

LASER in periodontal treatment: is it an effective treatment or science fiction?

There are several studies that evaluate the use of lasers in periodontal treatment in non-surgical or surgical therapy. However, while several studies showed clinically beneficial effects of some lasers in periodontal treatment, there are few clinical reports of additional advantages of lasers as adjunctive treatments in periodontology. The aim of this paper is to demonstrate and critically analyze the level of scientific evidence of effects of low-level lasers and high-power lasers in periodontology. A narrative review of the studies was carried out in each topic and type of laser or periodontal treatment. In nonsurgical periodontal therapy the results showed that there is an additional clinical benefit when using a diode laser (DL) associated with scaling and root planing (SRP) in patients with moderate to severe periodontitis. The Er:YAG laser seems to be the most suitable for nonsurgical periodontal therapy and promotes the same clinical effects as conventional therapy. In periodontal surgery vaporization of the gingival or mucosal tissue can be carried out with DL, CO2, Nd:YAG, Er:YAG and Er,Cr:YSGG lasers. Photobiomodulation (PBM), mediated by low-level lasers associated with non-surgical periodontal therapy, promotes additional benefits in the short term and accelerates the bone and gingival tissue repair process and also reduces postoperative symptoms of periodontal surgery. The effect of antimicrobial Photodynamic Therapy is relevant in the initial reevaluation periods. Studies have shown controversial results of the use of lasers in periodontics, and this fact may be due to the lack of standard parameters of irradiation in each clinical application.

Utilization of 810 nm Diode Laser Treatment in Periodontitis as an Alternative to Surgical Debridement Approach

The efficacy of surgical periodontal may be compromised by inadequate patients' self-performed plaque control or lack of supportive periodontal therapy. This clinical case report aimed to evaluate the effectiveness of 810 nm diode laser-assisted full-mouth sulcular debridement, as a potential treatment modality in the management of chronic periodontitis along with a 12-month follow-up evaluation. Each periodontal pocket was lased within 2 mm of deepest point, using a light contact of "hot tip" of the fiber with tissue [Average power-1W, emission mode-continuous wave, in "contact", beam diameter-400 µm, spot area at tissue-0.0013 cm² , fluence-124.9 J cm^-2 , power density-796 W cm^-2 , total energy-300 J, total treatment duration-300 s (5 min)]. The patient was followed up to 12 months and did not report any immediate or delayed complications such as any sign of photothermal damage, pain, tissue swelling and deformation, bleeding and infection. 810 nm diode laser-assisted sulcular debridement at low-power settings showed overall clinical and radiographic improvements and can be deemed as a potential alternative to surgical debridement approach, in persistent moderate periodontal pockets (4-6 mm).

Effect of tongue piercing on periodontal and peri-implant health: A cross-sectional case-control study in adults

OBJECTIVES

The authors hypothesize that periodontal and peri-implant inflammatory parameters are poorer in adult patients with tongue piercing compared with controls. The aim was to assess the influence of tongue piercing on periodontal and peri-implant health status in adults.

METHODS

Test and control groups comprised of individuals with and without tongue piercing, respectively. A questionnaire was used to collect information about gender, age, duration of tongue piercing and implants in function, jaw location of the implant, reasoning for wearing the tongue ornament, and oral hygiene and ornament cleaning habits. Full-mouth and peri-implant plaque index (PI), gingival index (GI), clinical attachment loss (CAL), probing depth (PD) and marginal/crestal bone loss (MBL and CBL, respectively) on mesial and distal surfaces of teeth/implants were recorded. The material (plastic or metal) from which, the bar and ball-ends of the ornament were fabricated was also recorded. A p < 0.01 was considered statistically significant.

RESULTS

Forty-eight and 49 individuals were included in the test and control groups, respectively. There was no difference in PI, GI, PD, CAL and MBL (mesial and distal) among individuals in the test and control groups. In the test group, peri-implant PI (p < 0.01), GI (p < 0.01), PD (p < 0.01) and mesial (p < 0.01) and distal (p < 0.01) CBL were significantly higher in the anterior mandible compared with implants in other jaw locations. In the control group, there was no difference in peri-implant PI, GI, PD and CBL around implants placed in both jaws.

CONCLUSION

Wearing tongue piercings could increase the risks of periodontal and peri-implant diseases particularly in the mandibular anterior segment.

Adjunctive laser or antimicrobial photodynamic therapy to non-surgical mechanical instrumentation in patients with untreated periodontitis: A systematic review and meta-analysis

AIM

To compare the adjunctive effects of lasers or antimicrobial photodynamic therapy (aPDT) to non-surgical mechanical instrumentation alone in untreated periodontitis patients.

MATERIALS AND METHODS

Two focused questions were addressed using the Population, Intervention, Comparison and Outcome criteria as follows: in patients with untreated periodontitis, (a) does laser application provide adjunctive effects on probing pocket depth (PPD) changes compared with non-surgical instrumentation alone? and (b) does application of aPDT provide adjunctive effects on PPD changes compared with non-surgical instrumentation alone? Both randomized controlled clinical trials (RCTs) and controlled clinical trials (CCTs) were included. Results of the meta-analysis are expressed as weighted mean differences (WMD) and reported according to the PRISMA guidelines.

RESULTS

Out of 1,202 records, 10 articles for adjunctive laser and 8 for adjunctive aPDT were included. With respect to PPD changes, 1 meta-analysis including 2 articles (total n = 42; split-mouth design) failed to identify a statistically significant difference (WMD = 0.35 mm; 95%CI: -0.04/0.73; p = .08) in favour of adjunctive aPDT (wavelength range 650-700 nm). In terms of adjunctive laser application, a high variability of clinical outcomes at 6 months was noted. Two articles included patient-reported outcomes and 10 reported on the presence/absence of harms/adverse effects.

CONCLUSIONS

Available evidence on adjunctive therapy with lasers and aPDT is limited by (a) the low number of controlled studies and (b) the heterogeneity of study designs. Patient-reported benefits remain to be demonstrated.

Comparative evaluation of improvement in periodontal and glycemic health status of type 2 diabetes mellitus patients after scaling and root planing with or without adjunctive use of diode laser

BACKGROUND

Periodontal treatment in diabetic patients reduces systemic inflammatory burden and hence should be closely coordinated with the patient's overall clinical diabetic management.

OBJECTIVE

To evaluate the effectiveness of diode laser (DL) (Biolase Epic^TM, 940 nm, Irvine, CA, USA) as an adjunct to scaling root and planing (SRP) on periodontal health and glycated hemoglobin (HbA1c) level of type 2 diabetes mellitus (T2DM) patients suffering from generalized chronic periodontitis (CP), currently, stage II or above/grade B or C periodontitis.

MATERIALS AND METHODOLOGY

After initial screening of 55 T2DM patients, a total of 44 T2DM-CP patients (between the age group of 30 and 65 years) were selected and randomly assigned into two groups. The groups were divided into control group (n=22), treated with scaling and root planing alone (SRP alone), and experimental group (n=22), treated with scaling and root planing along with laser therapy (SRP + DL). Laser irradiation was accomplished at perio pocket setting of 0.8 W (average) in a pulse interval of 1.0 ms and pulse length of 1.0 ms delivering 24 J of energy using a 300-μm fiber optic delivery system.

RESULTS

Thirty-seven out of 44 enrolled T2DM-CP patients completed the study. Both treatment modalities, i.e., SRP alone and SRP+DL resulted in mean significant (p < 0.001) improvement in periodontal health parameters (plaque index (PI), gingival index (GI), probing pocket depth (PPD) and clinical attachment loss (CAL)) and glycemic level (RBS, FBS, and HbA1c) in T2DM-CP patients after 6 months, and was higher in SRP+DL group in comparison to SRP alone. Among the periodontal health parameters, the mean PPD reduction and CAL gain were 51.78% and 48.26% in control as compared to 61.56% and 62.54% in experimental group respectively, whereas the mean significant reduction in HbA1c was 13.8% in SRP alone and 22.52% in SRP+DL group after 6 months (p < 0.05).

CONCLUSION

Periodontal treatment involving SRP+DL contributes to improved periodontal health parameters and HbA1c level in T2DM-CP patients.

Antibacterial effectiveness of scaling and root planing with and without photodynamic therapy against Campylobacter rectus counts in the oral biofilm of patients with periodontitis

BACKGROUND

It is hypothesized that scaling and root planning (SRP) with adjunct photodynamic therapy (PDT) is more effective in reducing Campylobacter rectus (C. rectus) from the oral biofilm (OB) among patients with periodontitis, than SRP alone. The objective was to compare the effectiveness of SRP with and without adjunct PDT in reducing OB C. rectus counts of patients with periodontitis.

METHODS

Chronic gastritis patients diagnosed with periodontitis were included. Therapeutically, the patients were divided into 2-groups. Patients in the test- and control-groups underwent SRP with and without adjunct PDT, respectively. In both groups, full-mouth plaque index (PI), bleeding on probing (BOP), probing depth (PD) and marginal bone loss (MBL) were measured and subgingival OB counts of C. rectus were measured at baseline and 12-weeks after treatment. Data normality was assessed and group-comparisons were done using the paired t-test and Man-Whitney U tests. A type-1 error rate of 5 % was used.

RESULTS

Thirty patients with periodontitis were included. All patients had Grade-B/Stage-II periodontitis. All participants were male with no significant difference in age. At baseline PI, BOP, PD and MBL were comparable in both groups. Counts of C. rectus in the subgingival OB samples were similar in both groups at baseline. At 12-weeks of follow-up, PI (P < 0.01), GI (P < 0.01) and PD (P < 0.01) were significantly higher in the control- compared with the test-group compared with baseline. The percentages of C. rectus -positive individuals were higher in the control- than the test-group at 12-weeks' (P < 0.01). At 12-weeks' follow-up the percentages of C. rectus -positive patients were comparable with their respective baseline percentages in the control-group.

CONCLUSION

Compared with SRP alone, adjuvant use of PDT is more efficient in eliminating C. rectus in the OB and reducing clinical parameters in patients with grade-B/Stage-II periodontitis.

Effect of adjunctive diode laser in the non-surgical periodontal treatment in patients with diabetes mellitus: a systematic review and meta-analysis

This study aimed to systematically review and analyze the present randomized clinical trials (RCTs) regarding the clinical efficacy of a diode laser (DL) adjuvant to scaling and root planning (SRP) in patients with chronic periodontitis (CP) who have diabetes mellitus (DM). Five databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trails, Web of Science, and Chinese BioMedical Literature Databases) were searched. A meta-analysis was implemented to evaluate periodontal parameters including probing depth (PD) and clinical attachment level (CAL) as primary outcomes. Hemoglobin A1c (HbA1c), plaque index (PI), and the gingival index (GI) were also observed as secondary outcomes. Independent scanning of 239 papers resulted in 9 RCTs. Moderate evidence demonstrated that the test groups showed significant benefits for PD reduction, CAL gain, and HbA1c reduction after 3 and 6 months. Significant differences in PI and GI reduction were not found except for GI reduction within 1 month. The collective evidence suggested that the DL with SRP had significant improvements in clinical results compared to SRP alone. Based on our results, the DL could be a recommended therapy for patients with CP who have DM.

In vivo investigation of diode laser application on red complex bacteria in non-surgical periodontal therapy: a split-mouth randomised control trial

Assessment of the efficacy of a single 810 nm diode laser application as an adjunctive treatment modality during the first intervention of non-surgical periodontal therapy (NPT). 25 patients diagnosed with chronic periodontitis underwent a split-mouth randomised control trial. The periodontal pockets of the test quadrants were treated with an 810 nm diode laser as an adjunct to NPT (Picasso GaAlAs; AMD Lasers). The laser was set at 1.0 W continuous wave, 400 µm tip, 796 W/cm² peak power density and a 32 J/cm² energy density. Therapeutic outcomes were evaluated based on the clinical parameters, which included probing pocket depth, recession, clinical attachment level, full mouth plaque score, full mouth bleeding on probing and tooth mobility. The baseline bacterial collection was completed from the periodontal pockets and then re-evaluated at 6 weeks. Clinical parameters demonstrated no statistical difference, with the exception of a statistically significant (P < 0.05) reduction in bleeding on probing for the test side. The test side resulted in a statistical increase of Capnocytophagaspecies and Treponemadenticola. The single application of the diode laser did not significantly improve the bacterial nor the clinical parameters in patients with chronic periodontitis.

Trial registration number: PACTR201909915338276.

Influence of root debridement with adjunct photodynamic therapy on periodontal parameters and gingival crevicular fluid cortisol levels among patients with and without type-2 diabetes mellitus

OBJECTIVE

The aim of the present study was to assess the influence of scaling and root planing (SRP) with adjunct antimicrobial photodynamic therapy (aPDT) on periodontal parameters and gingival crevicular fluid (GCF) cortisol levels in type-2 diabetic and non-diabetic patients with periodontitis.

METHODS

One hundred and twenty-eight patients with periodontitis (64 with and 64 without type-2 diabetes mellitus, respectively) were included. In the test- and control-groups, patients underwent SRP with and without aPDT, respectivey. In both groups, plaque and gingival indices (PI and GI), probing depth (PD), clinical attachment loss (CAL), marginal bone loss (MBL) and GCF volume and cortisol levels were assessed at baseline and three and six-months after SRP with or without aPDT. The aPDT was performed at baseline using methylene blue and photobiomodulation. The Kruskall-Wallis test was used to assess data normality; and group-comparisons were done. P-values, which were below 0.01 indicated statistical significance.

RESULTS

Sixty-four type-2 diabetic patients with and 64 non-diabetic patients with periodontitis were included. All individuals had Stage-III/Grade-C periodontitis. Among patients with type-2 diabetes mellitus (DM), there was no statistically significant difference in hemoblobin A1c, PI, GI, PD, CAL and MBL at baseline and at 3- and 6-months intervals. Amongst diabetic patietns, there was no difference in the GCF volume and cortisol levels in the test- and control-groups at all time intervals. In non-diabetic patients, there was a significqnt reductionin GCF volume and cortisol levels when SRP was done with aPDT than when SRP was carried out as the sole treatment strategy CONCLUSION: Among non-diabetic patients, SRP with aPDT helps reduce periodontal inflammation and GCF cortisol levels for up to 6-months; however poorly-controlled DM compromises the beneficial effects of this treatment strategy.

Periodontal Conditions and Whole Salivary IL-17A and -23 Levels among Young Adult Cannabis sativa (Marijuana)-Smokers, Heavy Cigarette-Smokers and Non-Smokers

In the United States, prevalence of marijuana-use has doubled in the past 2 decades. The aim was to compare the periodontal conditions and whole-salivary IL-17A and IL-23 levels among young adult marijuana-smokers, heavy cigarette-smokers and non-smokers. Self-reported marijuana-smokers, heavy-cigarette-smokers, non-smokers with periodontitis and periodontally-healthy non-smokers were included. Demographic data was recorded and full-mouth plaque index (PI), bleeding on probing (BoP), probing depth (PD) and clinical attachment loss (AL), marginal bone loss (MBL) and missing teeth were recorded. Levels of IL-17A and IL-23 levels were measured in the whole saliva. p < 0.01 was considered statistically significant. Fifteen-marijuana-smokers, 15 heavy-cigarette-smokers, 16 non-smokers-with-periodontitis and 15 periodontally-healthy-non-smokers) were included. The clinicoradiographic parameters were worse among marijuana-smokers (p < 0.01), cigarette-smokers (p < 0.01) and non-smokers-with-periodontitis (p < 0.01) than periodontally-healthy-non-smokers. Marijuana- and cigarette-smokers had Stage-IV/Grade C and non-smokers with periodontitis had Stage-III/Grade-C. Salivary IL-17A and IL-23 levels were higher in marijuana-smokers than cigarette-smokers (p < 0.01) and non-smokers-with-periodontitis (p < 0.01). Whole salivary IL-17A and IL-23 levels were higher among cigarette-smokers than non-smokers with periodontitis (p < 0.01) and periodontally-healthy-individuals (p < 0.01). Marijuana- and heavy cigarette-smokers have comparable clinicoradiographic periodontal statuses. This rejects hypothesis-1. However, whole salivary immunoinflammatory response may be moderately worse in marijuana-smokers compared with heavy cigarette-smokers and non-smoker with periodontitis thereby supporting hypothesis-2.

Nonsurgical periodontal therapy with/without 980 nm diode laser in patients after myocardial infarction: a randomized clinical trial

The purpose of this study was to evaluate the possible benefits (in terms of periodontal status improvement and periodontal bacteria count reduction) of using 980 nm diode laser in the treatment of periodontitis in patients after myocardial infarction. Thirty-six patients under 65 years of age (mean: 56.3 ± 7.9) with periodontitis, 6 weeks to 6 months after myocardial infarction, were recruited for the study. The control group (n = 18) received SRP (scaling, root planing and polishing) while the test group (n = 18) received SRP followed by laser therapy of the periodontal pockets with 980 nm diode laser, 1 W, continuous wave mode, 20 s per tooth side. Procedures were repeated twice at 5-7 day intervals. Microbiological and periodontal examination, including periodontal pocket depth (PPD), clinical attachment loss (CAL), bleeding on probing (BOP) and plaque control record (PCR), were performed before treatment, 2 weeks and 3 months after treatment. The study was registered on ClinicalTrials.gov with Identifier: NCT04145557, 29.10.2019 "retrospectively registered". Additional use of laser resulted in a significant reduction in pockets with PPD ≥ 7 mm (p = 0.0151). The diode laser reduced total bacteria count (p = 0.0154) and delayed recolonisation during a 3-month observation period. A significant increase in the number of Capnocytophaga gingivalis was observed in the control group (p = 0.048). Additional use of the diode laser after SRP had no significant effect on BOP, CAL and PCR. Within the limitations of our study, we can conclude that 980 nm diode laser can be a useful tool in the treatment of periodontitis in patients after myocardial infarction.

Clinical and Biochemical Evaluation of the Effect of Diode Laser Treatment Compared to the Non-surgical and Surgical Treatment of Periodontal Diseases

Background:

Periodontal therapy consists of eliminating the inflammation, treating periodontal pockets, motivating the patient for oral hygiene, and, if necessary, for surgical treatment. Recently, the application of a diode laser is widely being investigated for periodontal disease treatment.

Objective:

The analysis and evaluation of the clinical and biochemical impact of diode laser periodontal treatment, compared to either surgical or non-surgical, therapy, was the aim of this study.

Methods:

The study involved 80 patients older than 18 with at least 20 teeth. Evaluation of periodontal parameters was done conveniently on a single-rooted tooth (incisive, canine, premolar) on six surfaces, before the start of periodontal therapy, and after three, and six months. The laser used in the study was a diode laser with a wavelength of 980 nm. Digital X-rays were taken for bone level evaluation before and after the treatment. The presence of a bone destruction mediator (Matrix metalloproteinase-8 - MMP-8) was evaluated by the dipstick immunoassay test. Biochemical analysis and radiographic measurements were evaluated at the baseline and six months after the treatment. The statistical analysis included χ2-test and one-way ANOVA.

Results:

The results of this study showed that diode laser treatment was more effective in reducing periodontal clinical parameters, lowering MMP-8 levels and reducing the bone loss, compared to the group treated with scaling and root planning, or with a surgical approach.

Conclusion:

Diode laser may be considered as an effective alternative for periodontal treatment, with benefits in clinical and biochemical parameters.

Effect of Photobiomodulation on Secretion of IL-6 and IL-8 by Human Gingival Fibroblasts In Vitro

Objective: The aim of this study was to evaluate the effects of 940-nm diode laser irradiation on proinflammatory cytokine secretions [interleukin (IL)-6 and IL-8] by human gingival fibroblasts in vitro. Background: Photobiomodulation has been routinely used in many dental procedures; however, the exact biological action mechanism of photobiomodulation and its therapeutic benefits have not been established. Methods: Cells derived from systemically healthy individuals were treated with three different laser parameters-6 J for 20 sec [0.84 J/cm² (0.04 W/cm²)], 10 J for 20 sec [1.4 J/cm² (0.07 W/cm²)], and 14 J for 20 sec [1.97 J/cm² (0.09 W/cm²)]-in the presence and absence of 1 μg/mL lipopolysaccharide (LPS) stimulation. Laser irradiations were carried out by a 940-nm diode laser device in continuous pain therapy mode with a deep tissue handpiece. Changes in cell viability, cytokine secretions, and mitogen-activated protein kinase pathway expressions were investigated, and results were compared with negative (medium) and positive control (1 μg/mL LPS) groups. The data obtained were statistically analyzed by the Mann-Whitney U test for pairwise comparisons among groups at the 0.05 level of significance. Results: Laser therapy with 0.84-1.4 J/cm² amplified IL-6 and IL-8 secretions, whereas 1.97 J/cm² suppressed IL-6 and IL-8 release in LPS-stimulated cells. Cell viability did not show a variation with photobiomodulation. Conclusions: These results demonstrate that photobiomodulation can alter IL-6 and IL-8 release, with cytokine suppression potency at a relatively high dose, as demonstrated previously. However, in contrast, we found that a low level of stimulation (6 J) in the presence of inflammation (LPS stimulation) may further enhance IL-6 and IL-8 release. We also found that p38 and ERK1/2 pathways are activated by LPS as well as by photobiomodulation.

Acetylcysteine-decorated Prussian blue nanoparticles for strong photothermal sterilization and focal infection treatment

The major challenge in bacterial infection in clinical settings is the development of antimicrobial materials in the treatment of drug-resistant bacteria. Herein, we report a new strategy for efficient near-infrared radiation (NIR) photothermal sterilization and focal infection treatment by acetylcysteine-modified Prussian blue nanoparticles (AC-PB). Specifically, AC-PB is fabricated as a multifunctional therapeutic agent via a co-precipitation approach, where PB acts as an effective photothermal agent and AC could prevent the formation of bacteria cluster in biofilms and the bacterial adhesion on tissues to reduce the secretion of mucus and improve the efficacy. AC-PB shows strong synergistic photothermal sterilization ability in a concentration-dependent manner by using 980 nm NIR laser. 50 μg/mL of AC-PB can eliminate up to 74% of Gram-positive Staphylococcus aureus and up to 75% of Gram-negative Escherichia coli, while irradiation of 980 nm is minimally cytotoxic to mammalian cells. The NIR radiation can be efficiently converted into local heat by subcutaneous injection of AC-PB to kill bacteria effectively in vivo to treat a focal infection. The antibacterial mechanism suggests that AC can destroy bacteria-based biofilms, while the photothermal effect driven by NIR may break the lipids on cellular membrane. Thus, this work may provide a promising strategy for highly effective eradication of bacteria in clinics.

Effect of diode laser irradiation on the bond strength of polymerized non-simplified adhesive systems after 12 months of water storage

Objectives:

The aim of this in vitro study was to evaluate the bonding strength of non-simplified dentin bonding systems (DBS) to dentin irradiated with a diode laser (970 nm) immediately and after 12 months of water storage following either primer or bond application.

Material and methods:

The experimental design included three different factors: DBS type [Adper^TM Scotchbond Multipurpose (MP) and Clearfil™ SE Bond (CSE)], irradiation [without irradiation - control (C), irradiation after primer application (AP), and irradiation after bond application (AB)], and time [initial (I) and after 12 months of water storage (12 m)]. Sixty sound human third molars (n = 10) were obtained, and their flat occlusal dentin areas were prepared and standardized. Laser irradiation was performed in the contact mode perpendicular to the dental surface over an automatically selected scanning area at a pulse energy of 0.8 W, frequency of 10 Hz, and energy density of 66.67 J/cm². After 7 days of treatment, the specimens were cut, and half of them were subjected to microtensile testing (500 N/0.05 mm/min), whereas the remaining sticks were examined after 12 months of water storage. The obtained data were analyzed by three-way analysis of variance (ANOVA) followed by a Tukey test (p<0.05). The observed fracture modes were investigated using a portable digital microscope with a magnification of 40x.

Results:

Among the utilized DBS, MP generally exhibited higher bond strengths, but did not always differ from CSE under similar conditions. The irradiation factor was statistically significant only for the MP/AB groups. After 12 months of storage, all groups demonstrated a significant reduction in the bond strength, whereas the results of fracture analysis showed a predominance of the adhesive type.

Conclusions:

The laser treatment of non-simplified DBS was not able to stabilize their bonding characteristics after 12 months.

Anti-inflammatory effects of shikonin in human periodontal ligament cells

CONTEXT

Shikonin (SHI), an active component extracted from Radix Arnebiae, has been reported to possess anti-inflammatory properties in various cells. However, its effect on lipopolysaccharide (LPS)-stimulated human periodontal ligament cells (hPDLCs) is unknown.

OBJECTIVE

To investigate the effects of SHI on the expression of inflammatory related cytokines in LPS-stimulated hPDLCs.

MATERIALS AND METHODS

The effects of SHI (0.125, 0.25, 0.5, 1, and 2 μg/mL) on hPDLCs proliferation for 1, 3 and 7 days were measured using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. The expression of interleukin-1 (IL-1), IL-6, tumor necrosis factor-α (TNF-α), matrix metalloproteinase-2 (MMP-2), MMP-9 and cyclooxygenase-2 (COX-2) were detected in hPDLCs following SHI treatment (0.25 and 0.5 μg/mL) using Quantitative Reverse Transcriptase Polymerase Chain Reaction (qRT-PCR). The signaling pathways triggered by SHI in hPDLC were evaluated using western blotting.

RESULTS

LD50 of SHI is 1.7 μg/mL (day 1) and 1.1 μg/mL (day 3 and 7) in hPDLCs. No morphological changes were observed when hPDLCs were treated with LPS only (1 μg/mL) or LPS with SHI (0.25 and 0.5 μg/mL). Data from qRT-PCR suggests that SHI attenuates LPS-induced increases of IL-1, IL-6, TNF-α, MMP-2, MMP-9 and COX-2 in hPDLCs. Down-regulation of phosphorylated extracellular signal-regulated kinase (ERK) and nuclear factor-κB (NF-κB), and up-regulation of I-κB, were observed in LPS-stimulated hPDLCs after exposed to SHI at 0.25 or 0.5 μg/mL.

DISCUSSION AND CONCLUSIONS

SHI possesses anti-inflammatory effects in LPS-stimulated hPDLCs via phospho-ERK and NF-κB/I-κB signaling pathways; this suggests that SHI may hold potential as an anti-inflammatory agent against periodontitis.

Effects of diode laser application on inflammation and mpo in periodontal tissues in a rat model

Objective

In this study, we aimed to histologically and immunologically evaluate the effect of diode laser treatment when applied adjunctive to scaling and root planing (SRP) in an experimental periodontitis model.

Materials and methods

We used Wistar-Albino rats (n=60) with average weight of 230 g. Experimental periodontitis was induced by ligature at the right and left first mandibular molar teeth in all rats. After 11 days, the ligature was removed and rats were divided into two groups. The control group (n=30) received only SRP treatment, while the laser group (n=30) received a diode laser (GaAlAs, 810 nm, 1 W, 10 J, 20 s) treatment adjunctive to SRP. Ten rats in each group were sacrificed after 7, 15, and 30 days. Histopathological examination was performed in the left mandible of rats. Myeloperoxidase (MPO) was evaluated by western blot in the gingival specimens from the right mandible.

Results

MPO levels in the laser group were statistically significantly lower compared with the control group (p≤0.05). There was no statistically significance at any time between MPO levels in the control group (p>0.05). MPO levels in the laser group at the 7^th day were statistically significantly higher compared to the 15^th (p≤0.05) and the 30^th day (p≤0.05). Inflammatory cell infiltration decreased over time in both groups and was statistically significantly lower in the laser group than in the control group at all times (p≤0.01).

Conclusions

Within the limits of this study, we suggest that diode laser application is an adjunctive treatment because it reduced inflammation and MPO when applied in addition to SRP. On the other hand, more studies are needed for the assessment of the effects of diode laser application to periodontal tissues.

The Effects of Diode Laser Therapy as an Adjunct to Scaling and Root Planing in the Treatment of Aggressive Periodontitis: A 1-Year Randomized Controlled Clinical Trial

OBJECTIVE

The aim of this study was to investigate and compare the clinical, microbial, and inflammatory effects of a diode laser as an adjunct to scaling and root planing (SRP) versus SRP alone for the treatment of generalized aggressive periodontitis (GAgP).

METHODS

Using a split-mouth design, 31 patients with GAgP were enrolled in the study. The maxillary right and left quadrants were randomly assigned to SRP+diode laser or SRP alone. Patients were examined on a regular basis for clinical, microbiological, and inflammatory mediator changes over a 1-year period. Clinical attachment level (CAL) was the primary outcome variable chosen. In addition, subgingival biofilm samples and gingival crevicular fluid (GCF) inflammatory mediators were analyzed at each follow-up session.

RESULTS

Compared to baseline, both treatments demonstrated an improvement in periodontal parameters at 1 year. However, SRP+diode laser produced a significant improvement in probing depth (PD; 2.56 ± 0.44 vs. 3.36 ± 0.51 mm, p < 0.05) and CAL (3.47 ± 0.25 vs. 4.11 ± 0.26 mm, p < 0.05) values compared to SRP alone. Similarly, in the SRP+diode laser group, the bacteria of orange complex group were significantly reduced at 30 and 60 days compared to SRP alone. Moreover, SRP+diode laser determined a reduction in mean GCF level of interleukin (IL)-1β and IL-1β/IL-10 ratio at 15 and 30 days compared to SRP alone (p < 0.05).

CONCLUSIONS

At 1 year, SRP+diode laser yielded a significant reduction in some clinical parameters, while microbial and inflammatory mediator changes were not significantly reduced compared to SRP alone.

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair

Background

Reconstruction of the aortic major branches during thoracic endovascular aortic repair is complicated because of the complex anatomic configuration and variation of the aortic arch. In situ laser fenestration has shown great potential for the revascularization of aortic branches. This study aims to evaluate the feasibility, effectiveness, and safety of in situ laser fenestration on the three branches of the aortic arch during thoracic endovascular aortic repair.

Methods and Results

Before clinical application, the polytetrafluoroethylene and Dacron grafts were fenestrated by an 810‐nm laser system ex vivo, which did not damage the bare metal portion of the endografts and created a clean fenestration while maintaining the integrity of the endografts. In vivo, 6 anesthetized female swine survived after this operation, including stent‐graft implantation in the aortic arches, laser fenestration, and conduit implantation through the innominate arteries and the left carotid arteries. Based on the animal experiments, in situ laser fenestration during thoracic endovascular aortic repair was successively performed on 24 patients (aged 33–86 years) with aortic artery diseases (dissection type A: n=4, type B: n=7, aneurysm: n=2, mural thrombus: n=7). Fenestration of 3 aortic branches was performed in 2 (8.3%) patients. Both the left carotid artery and the left subclavian artery were fenestrated in 6 (25%) patients. Only left subclavian artery fenestration surgery was done in 16 (66.7%) patients. Among these patients, 1 fenestration was abandoned secondary to an acute takeoff of the innominate artery in a type III aortic arch. The average operative time was 137±15 minutes. The technical success rate was 95.8% (n=23). No fenestration‐related complications or neurological morbidity occurred after this operation. During a mean postoperative 10‐month follow‐up (range: 2–17 months), 1 patient died of severe pneumonia, and all the left subclavian artery and carotid artery stents were patent with no fenestration‐related endoleaks upon computed tomography angiography images.

Conclusions

In situ laser fenestration is a feasible, effective, rapid, repeatable, and safe option for the reconstruction of aortic arch during thoracic endovascular aortic repair, which might be available to revascularize the 3 branches. However, follow‐up periods should be extended to evaluate the robustness of this technique.

Three Hundred Patients Treated with Ultrapulsed 980 nm Diode Laser for Skin Disorders

The use of lasers in skin diseases is quite common. In contrast to other laser types, medical literature about 980 nm ultrapulsed diode laser is sparse in dermatology. Herein, we report the use of ultrapulsed diode 980 nm laser in 300 patients with vascular lesions, cysts and pseudocysts, infectious disease, and malignant tumors. This laser is a versatile tool with excellent safety and efficacy in the hands of the experienced user.

Effect of multiple-sweeping on ablation performance during ex vivo laser nephrectomy

BACKGROUND AND OBJECTIVE

Fiber-assisted laser surgery has been employed as a minimally invasive method in various medical fields. In spite of multiple sweeping on tissue during laser treatments, the rate of tissue removal gradually decreases and eventually leads to longer irradiation times as well as deeper thermal injury. The objective of the current study was to quantitatively investigate the effect of multiple fiber sweeps on ablation performance during ex vivo 532-nm laser nephrectomy.

MATERIALS AND METHODS

Porcine kidney tissue was used to evaluate variations in tissue ablation and coagulative necrosis after pre- and multiple-sweeping with a 532 nm wavelength at various fiber speeds (2, 4, and 6 mm/second). The distance between a fiber tip and tissue surface was initially set at 1.5 mm, and no further distance change was performed. Double-integrating spheres in conjunction with an adding-doubling method were employed to measure variations in optical properties of the tested tissue. The extent of ablation and coagulation was quantified to identify the role of multiple-sweeping at various fiber conditions.

RESULTS

Optical property measurements showed a 30% decrease in light absorption but a more than threefold increase in light scattering after irreversible thermal denaturation. Pre-sweeping yielded insignificant effects on tissue coagulation due to almost consistent coagulation depths with numbers of pre-sweeps. Ablation depths increased with more numbers of fiber sweeps and slower fiber speeds whereas coagulation depths thickened primarily with the slower speeds. Multiple-sweeping induced saturation in ablation volume with the increasing numbers of multiple-sweeps irrespective of the fiber speed.

CONCLUSION

A combination of coagulation barriers, spatial distribution of power, and temporal interplay of optical energy could attribute to continuously lessen the amount of the ablated tissue with the multiple sweeps. Optical power modulation with varying fiber conditions (speed and distance) will be examined to optimize surgical parameters and to sustain the equivalent ablation performance of the first sweep with the multiple sweeping for laser nephrectomy. Lasers Surg. Med. 48:616-623, 2016. © 2016 Wiley Periodicals, Inc.