Er:YAG laser versus scaling and root planing as alternative or adjuvant for chronic periodontitis treatment: a systematic review

Multivariate analysis of oral mucosal ulcers during orthodontic treatment

BACKGROUND

Orthodontic treatment can easily cause local soft tissue reactions in the oral cavity of patients under mechanical stress, leading to oral mucosal ulcers and affecting their quality of life. At present, only limited literature has explored the factors leading to oral ulcers in orthodontic treatment, and these research results are still controversial.

AIM

To investigate the current status and related factors of oral mucosal ulcers during orthodontic treatment, aiming to provide a valuable reference for preventing this disease in clinical practice.

METHODS

A total of 587 patients who underwent orthodontic treatment at the Peking University School of Stomatology and Hospital of Stomatology between 2020 and 2022 were selected and allocated to an observation or control group according to the incidence of oral mucosal ulcers during orthodontic therapy. A questionnaire survey was constructed to collect patient data, including basic information, lifestyle and eating habits, treatment details, mental factors, and trace element levels, and a comparative analysis of this data was performed between the two groups.

RESULTS

A logistic regression model with oral ulcers as the dependent variable was established. The regression results showed that age (≥ 60 years: odds ratio [OR]: 6.820; 95% confidence interval [CI]: 2.226–20.893), smoking history (smoking: OR: 4.434; 95%CI: 2.527–7.782), toothbrush hardness (hard: OR: 2.804; 95%CI: 1.746–4.505), dietary temperature (hot diet: OR: 1.399; 95%CI: 1.220–1.722), treatment course (> 1 year: OR: 3.830; 95%CI: 2.203–6.659), and tooth brushing frequency (> 1 time per day: OR: 0.228; 95%CI: 0.138–0.377) were independent factors for oral mucosal ulcers (P < 0.05). Furthermore, Zn level (OR: 0.945; 95%CI: 0.927–0.964) was a protective factor against oral ulcers, while the SAS (OR: 1.284; 95%CI: 1.197–1.378) and SDS (OR: 1.322; 95%CI: 1.231–1.419) scores were risk factors.

CONCLUSION

Age ≥ 60 years, smoking history, hard toothbrush, hot diet, treatment course for > 1 year, tooth brushing frequency of ≤ 1 time per day, and mental anxiety are independent risk factors for oral mucosal ulcers. Therefore, these factors should receive clinical attention and be incorporated into the development and optimization of preventive strategies for reducing oral ulcer incidence.

Combined application of Er:YAG laser and low-level laser in non-surgical treatment of periodontitis

BACKGROUND

To compare the efficacy of combined treatment of Er:YAG laser (ERL) and low-level laser therapy (LLLT) with single laser applications, and scaling and root planing (SRP) for non-surgical periodontal treatment.

METHODS

In a randomized controlled trial, 25 non-smoking Stage II or Stage III periodontitis patients were recruited. The four intraoral quadrants were randomly assigned to four different treatments: (1) combined application with ERL plus SRP plus LLLT; (2) ERL plus SRP; (3) SRP plus LLLT; and (4) SRP. We assessed periodontal indexes, including probing depth (PD), clinical attachment level (CAL), bleeding index (BI), and plaque index (PLI), along with three cytokines (IL-1β, TNF-α, IL-10) from gingival crevicular fluid and red complex pathogens from subgingival dental plaque at baseline, 3 months, and 6 months.

RESULTS

For initial moderate pockets (4 mm ≤ PD ≤ 6 mm), quadrants treated with ERL+SRP+LLLT, ERL+SRP, and SRP+LLLT exhibited greater PD improvement compared to the control (SRP) quadrants at the 3-month follow-up (1.25 ± 1.06, 1.23 ± 1.12, 1.00 ± 1.21 vs. 0.98 ± 1.21 mm) and the 6-month follow-up (1.35 ± 1.06, 1.23 ± 1.17, 1.35 ± 0.98 vs. 0.98 ± 1.23 mm) (p = 0.002). Quadrants treated with ERL+SRP+LLLT and SRP+LLLT showed more CAL gain means than the control quadrants at the 3-month follow-up (0.96 ± 1.42, 0.61 ± 1.39 vs. 0.55 ± 1.57 mm) and the 6-month follow-up (0.84 ± 1.54, 0.89 ± 1.49 vs. 0.48 ± 1.68 mm) (p = 0.008). For initial deep pockets (PD ≥ 7 mm), the ERL+SRP+LLLT quadrants had more PD improvement and CAL gain compared to the control quadrants at follow-up. There were no significant differences in BI, PLI, inflammatory cytokines, and periodontal pathogens among the four groups.

CONCLUSION

The combined application of ERL and LLLT demonstrated potential efficacy in reducing PD, particularly for deep pockets.

PLAIN LANGUAGE SUMMARY

To compare the therapy effect of combined use of Er:YAG laser (ERL) and low level laser therapy (LLLT) with single laser applications, and traditional periodontal treatment (SRP). A total of 25 non smoking patients with periodontitis were involved, and their mouths were divided into four sections, each receiving a different treatment: ERL+SRP+LLLT, ERL+SRP, SRP+LLLT, and SRP. Clinical indexes and laboratory indicators were assessed at baseline, 3 months, and 6 months. After six months, for initial moderate pockets, combined laser group and single laser group showed better improvements than traditional group in reducing the depth of periodontal pockets and increasing attachment levels. But for initial deep pockets, only combined laser group showed better improvement than traditional group. There were no significant differences in bleeding, plaque, inflammation, or harmful bacterial levels among the groups. These findings suggest that the integration of Er:YAG laser and low level laser therapy into standard periodontal treatment may enhance the treatment's benefits in reducing pocket depth, especially for severe conditions.

Far-ultraviolet irradiation at 222 nm destroys and sterilizes the biofilms formed by periodontitis pathogens

BACKGROUND

Periodontal disease is the leading cause of tooth loss, and an association between periodontal disease and non-oral systemic diseases has been shown. Formation of biofilm by periodontal pathogens such as Fusobacterium nucleatum, Porphyromonas gingivalis, and Streptococcus mutans and their resistance to antimicrobial agents are at the root of persistent and chronic bacterial infections.

METHODS

The bactericidal effect of far-ultraviolet (F-UV) light irradiation at 222 nm on periodontal bacteria was assessed qualitatively and quantitatively. The effect of biofilm disruption by F-UV light on periodontal bacteria was examined by crystal violet staining, and the morphologic changes of the biofilm after F-UV irradiation were explored by confocal laser microscopy and scanning electron microscopy. We developed a thin fiber-type 222 nm F-UV irradiator and studied its safety and effect of reducing bacteria in rodent models.

RESULTS

F-UV light at 222 nm had a bactericidal effect on F. nucleatum, P. gingivalis, and S. mutans. Irradiation with F-UV light reduced the biofilm formed by the bacteria and sterilized them from within. Confocal laser microscopy showed a clear reduction in biofilm thickness, and scanning electron microscopy confirmed disintegration of the biofilm architecture. F-UV irradiation was less damaging to DNA and less cytotoxic than deep-ultraviolet light, and it reduced bacterial counts on the tooth surface.

CONCLUSION

F-UV irradiation has the potential to destroy biofilm and act as a bactericide against pathogenic bacteria in the biofilm.

Effects of low-level Er:YAG laser irradiation on proliferation and gene expression in primary gingival fibroblasts isolated from mouse maxilla

We investigated the effects of low-level Er:YAG laser irradiation on proliferation and alternations in early gene expression of gingival fibroblasts. Mice primary gingival fibroblasts were irradiated with an Er:YAG laser (1.8, 3.9, and 5.8 J/cm2 ). Irradiation at 3.9 J/cm2 promoted cell proliferation without significant changes in lactate dehydrogenase or Hspa1a expression. Three hours after irradiation at 3.9 J/cm2 , the Fn1 expression level was significantly increased. RNA-seq identified 15 differentially expressed genes between irradiated and non-irradiated cells, some of which belonged to immediate early genes (IEGs). Kyoto Encyclopedia of Genes and Genomes pathway analysis indicated MAPK pathway enhancement, and gene set enrichment analysis showed enrichment in the TGF-β signaling gene set. Enhanced proliferation via laser irradiation disappeared upon inhibition of Dusp4, Dusp5, and Tgfr1 expression. Low-level Er:YAG laser irradiation, especially at 3.9 J/cm2 without a major temperature elevation, enhanced fibroblast proliferation, via TGF-β and the MAPK signaling pathway following IEG expression.

Photoinactivation and Photoablation of Porphyromonas gingivalis

Several types of phototherapy target human pathogens and Porphyromonas gingivitis (Pg) in particular. The various approaches can be organized into five different treatment modes sorted by different power densities, interaction times, effective wavelengths and mechanisms of action. Mode 1: antimicrobial ultraviolet (aUV); mode 2: antimicrobial blue light (aBL); mode 3: antimicrobial selective photothermolysis (aSP); mode 4: antimicrobial vaporization; mode 5: antimicrobial photodynamic therapy (aPDT). This report reviews the literature to identify for each mode (a) the putative molecular mechanism of action; (b) the effective wavelength range and penetration depth; (c) selectivity; (d) in vitro outcomes; and (e) clinical trial/study outcomes as these elements apply to Porphyromonas gingivalis (Pg). The characteristics of each mode influence how each is translated into the clinic.

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.

Status of North American Graduate Programs in Periodontics Providing Laser Education and Clinical Training: A Cross-Sectional Survey

The aim of this cross-sectional study was to evaluate the status of laser use and training in the U.S. and Canadian graduate periodontology programs. A survey questionnaire was sent electronically to 55 periodontology program directors in North America. The questions focused on laser implementation, types of lasers used, for which procedures lasers were used, and level of education/clinical training provided to residents. Data were analyzed using descriptive statistics and Fisher’s exact test. Twenty-two directors responded (40%). Most programs (86%) used lasers and 89% used a diode laser. Laser treatment was the most used for periimplantitis (84%). Fifteen programs (79%) provided didactic and clinical training, with 47% programs giving 4–12 h of didactic training. In 53% of programs, residents completed 4 to10 procedures. Only 29% of programs had residents who had received a certification in lasers, with most (80%) programs requiring between 1–9 cases for certification. Of the participants not providing laser training, the major barrier was indicated as being “expense”, with 68.7% reporting plans to implement laser education. Conclusions: Most graduate periodontics programs were providing laser training and treatment. There was great variability regarding the training methods, specifically in number of dedicated laser courses, time allocated for laser training, and prerequisites for laser certification.

Erbium lasers in non-surgical periodontal therapy: an umbrella review and evidence gap map analysis

The literature on the efficacy of erbium lasers for nonsurgical periodontal therapy is inconsistent. The objective of the umbrella review was to collate the information available in the systematic reviews to provide a comprehensive synthesis of clinical and patient reported outcomes following the use of erbium lasers for non-surgical periodontal therapy. An electronic database search was carried out, and systematic reviews/meta-analyses which assessed the efficacy of erbium lasers as monotherapy or as an adjunct to scaling and root planing were included. The methodological quality and reporting quality of the included studies were assessed. 15 Systematic reviews/meta-analyses were obtained after title, abstract, and full text search. The meta-analyses data revealed a clinical attachment level gain, reduction in probing pocket depth at 1 and 3-month follow-up, and no additional benefit at ≥ 6-month follow-up in the erbium laser group. The evidence gap map revealed lack of clinical outcome data at > 6-month follow-up and dearth in studies assessing patient reported outcome measures and adverse events. Erbium lasers may provide short-term clinical benefits, and further studies with standardized laser parameters evaluating long-term follow-up, patient-reported outcome measures, and adverse events are needed.

An In Vitro study to compare dental laser with other treatment modalities on biofilm ablation from implant and tooth surfaces

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Methodology:

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Adjunctive Er:YAG laser in non-surgical periodontal therapy of patients with inadequately controlled type 2 diabetes mellitus: A split-mouth randomized controlled study

BACKGROUND AND OBJECTIVE

Limited studies are available comparing the outcomes of non-surgical periodontal therapy (NSPT) with or without adjunctive Er:YAG laser (ERL) in patients with type 2 diabetes mellitus (T2DM). This study evaluated the effects of ERL adjunctive NSPT on single-rooted teeth of inadequately controlled T2DM patients with periodontitis.

METHODS

Twenty-two inadequately controlled T2DM participants with periodontitis were recruited. Adopting a double-blinded split-mouth design and under block randomization, we investigated the effects of ERL in calculus removal then degranulation mode, or a sham treatment, adjunct NSPT, which included two visits of full-mouth root surface debridement delivered within 4-10 days, to test or control single-rooted teeth (Wuxi Stomatology Hospital, trial 2017-016). We followed periodontal parameters (plaque %, bleeding on probing [BOP] %, probing pocket depth [PPD], probing attachment level [PAL]) and selected systemic parameters (fasting plasma glucose [FPG], glycosylated hemoglobin [HbA1c%], high sensitivity C-reactive protein) at baseline, one, three, and six months after periodontal treatment.

RESULTS

The study was completed as planned. Periodontal parameters, FPG and HbA1c% of the 22 participants appeared significantly improved at six months (p < 0.001). The 44 ERL treated, compared to 44 sham treated single-rooted teeth exhibited significant improvement in BOP, mean PPD, and mean PAL at various postoperative follow-up time points (effect size ≥0.44; p < 0.001). No adverse event was reported.

CONCLUSION

Periodontal treatment outcomes in the T2DM patients with inadequate glycemic control were better in the single-rooted teeth received ERL adjunct NSPT. Further studies are warranted to confirm the observations reported in this short-term clinical study.

Erbium-doped: yttrium-aluminum-garnet (Er:YAG) versus scaling and root planing for the treatment of periodontal disease: A single-blinded split-mouth randomized clinical trial

BACKGROUND

This randomized, controlled clinical trial aimed to compare the differences in periodontal clinical outcomes, duration of the procedure, and patient's experience between conventional scaling and root planing and erbium-doped: yttrium-aluminum-garnet (Er:YAG) in the treatment of generalized moderate to severe chronic periodontitis or generalized Stages II or III, and Grade B periodontitis based on the Centers for Disease Control (CDC), American Academy of Periodontology (AAP), and European Federation of Periodontology (EFP) definitions.

METHODS

Thirty subjects were initially recruited. In a split-mouth fashion, right and left sides were randomly allocated into two treatment arms: conventional scaling and root planing (C-SRP) versus laser-assisted scaling and root planing (L-SRP). A blinded examiner recorded clinical measurements at baseline and 3 months. Duration of the procedure was also recorded for each visit, and the patient's experience was assessed with a questionnaire at baseline, 1, and 3 months.

RESULTS

The final sample consisted of 26 subjects. Both treatments resulted in overall improvement, but no significant differences were found between modalities for clinical attachment gain or probing depth reduction. The duration of the procedure was approximately half for L-SRP, and postoperative sensitivity was greater in C-SRP.

CONCLUSIONS

The low-energy protocol with Er:YAG (50 mJ) used for the non-surgical treatment of moderate-severe chronic or Stage II-III, Grade B periodontitis performed in this study population was a treatment modality that yielded similar clinical improvements when compared to conventional scaling and root planing.

The Use of Lasers in Dental Materials: A Review

Lasers have been well integrated in clinical dentistry for the last two decades, providing clinical alternatives in the management of both soft and hard tissues with an expanding use in the field of dental materials. One of their main advantages is that they can deliver very low to very high concentrated power at an exact point on any substrate by all possible means. The aim of this review is to thoroughly analyze the use of lasers in the processing of dental materials and to enlighten the new trends in laser technology focused on dental material management. New approaches for the elaboration of dental materials that require high energy levels and delicate processing, such as metals, ceramics, and resins are provided, while time consuming laboratory procedures, such as cutting restorative materials, welding, and sintering are facilitated. In addition, surface characteristics of titanium alloys and high strength ceramics can be altered. Finally, the potential of lasers to increase the adhesion of zirconia ceramics to different substrates has been tested for all laser devices, including a new ultrafast generation of lasers.

Impact of Adjunctive Diode Laser Application to Non-Surgical Periodontal Therapy on Clinical, Microbiological and Immunological Outcomes in Management of Chronic Periodontitis: A Systematic Review of Human Randomized Controlled Clinical Trials

Background

Due to the limitations of scaling and root planing (SRP) in chronic periodontitis (CP) management, research has been focused on utilising additional therapies to enhance conventional treatment methods. The present systematic review is aimed to appraise the accessible scientific evidence of in vivo human studies to establish the effectiveness of adjunctive diode (λ 808- λ 980nm) laser treatment to SRP in CP.

Methodology

This systematic review was conducted following the PRISMA statement guidelines. The review protocol is registered in PROSPERO (CRD 42021227695). The search strategies were based on structured electronic and manual (with appropriate keywords) and were conducted to collect the applicable published data on RCTs studies (in vivo human), spanning over ten years between August 2010 and August 2020. The articles were selected to address the following research focus question: “Does diode laser (λ 808- λ 980nm) therapy have superior effects as an adjunct to SPR, compared to SRP alone, in terms of clinical or microbiological or immunological profiles in the management of CP?”

Results

Fifteen articles met the eligibility criteria and are included in this review. A wide range of discrepancies and inconsistencies were shown in the outcomes of the laser and SPR treatment modality, compared to SRP alone. The data on standardised study protocol, optimal laser parameters and outcome measurements were inconclusive, and a high risk of bias in the majority of the studies observed, which are crucial in establishing a homogenous and reproducible protocol.

Conclusion

In light of the confined evidence-based data and critical evaluation of this systematic review, the efficacy of adjunctive diode laser treatment ranging between 808 and 980nm to SRP remains debatable. The observational quality of the present systematic review was emphasised after scrutinising the available data, and an attempt to propose a laser protocol for future RCTs consideration was a great challenge due to an absence of clear and standardised recommendations in delivering a reliable laser protocol which can be replicable by future investigators. RCTs with robust methodology are warranted.

Short-term results of the combined application of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and erbium-doped yttrium aluminum garnet (Er:YAG) laser in the treatment of periodontal disease: a randomized controlled trial

Objectives

Nd:YAG and Er:YAG lasers have been previously used as an adjunct in periodontal therapy. The aim of this single-blinded randomized controlled clinical trial was to evaluate the efficacy of a combined application of Nd:YAG and Er:YAG laser irradiation in periodontal treatment.

Materials and methods

Twenty-two patients with at least one site of ≥ 6 mm periodontal probing depth (PPD) after mechanical debridement with curettes and sonic instruments at periodontal reevaluation were included in the study. Patients were randomly allocated at a 1:1 ratio to either a combined Nd:YAG/Er:YAG laser therapy (test group) or a “turned off” laser therapy (control group). The Nd:YAG laser was used for periodontal pocket deepithelialization and to stabilize the resulting blood clot. The Er:YAG laser was primarily used for root surface modification. PPD (mm), clinical attachment level (CAL, mm), and bleeding on probing (BOP, +/−) at the site of laser treatment were evaluated at baseline and 2 months after treatment.

Results

The mean improvements from baseline to 2-month follow-up for PPD were significantly better in the laser group (2.05 ± 0.82 mm) compared to the control group (0.64 ± 0.90 mm; p = 0.001). Likewise, the gain in CAL was significantly better in the laser group (1.50 ± 1.10 mm) than in the control group (0.55 ± 1.01mm; p = 0.046).

Conclusions

The combined application of Nd:YAG and Er:YAG laser irradiation as an adjunct to conventional non-surgical therapy showed a significant beneficial effect on periodontal treatment results.

Clinical relevance

Combined Nd:YAG and Er:YAG laser irradiation could be a useful procedure additionally to conventional non-surgical periodontal therapy to improve periodontal treatment results.

Clinical trial registration

ISRCTN registry #ISRCTN32132076

Efficacy of laser monotherapy or non-surgical mechanical instrumentation in the management of untreated periodontitis patients. A systematic review and meta-analysis

OBJECTIVE

To evaluate and compare the effects of laser monotherapy with non-surgical mechanical instrumentation alone in untreated periodontitis patients.

MATERIALS AND METHODS

A focused question was formulated based on the Population, Intervention, Comparison, Outcome, and Study design criteria (PICOS): in patients with untreated periodontitis, does laser mono-therapy provide adjunctive effects on pocket probing depth (PPD) changes compared with non-surgical instrumentation alone? Both randomized controlled clinical trials (RCTs) and controlled clinical trials (CCTs) were included. The results of the meta-analyses are expressed as weighted mean differences (WMD) and reported according to the PRISMA guidelines.

RESULTS

The search yielded 1268 records, out of which 8 articles could be included. With respect to PPD changes, a meta-analysis including 5 articles (n = 148) failed to identify statistically significant differences in favor of laser monotherapy for PPD change (WMD = 0.14 mm; 95% CI: - 0.04/0.32; z = 1.51; p = 0.132) nor for clinical attachment level (CAL) (WMD = 0.04 mm; 95% CI: - 0.35/0.42; z = 0.19; p = 0.850). Data on cost-effectiveness are lacking. One study reported patient-related outcome measures (PROMS).

CONCLUSIONS

In untreated periodontitis patients, laser monotherapy does not yield superior clinical benefits compared with non-surgical mechanical instrumentation alone.

CLINICAL RELEVANCE

In untreated periodontitis patients, mechanical instrumentation with hand and/or ultrasonic instruments remains the standard of care.

Effects of Er:YAG laser pre-treatment on dentin structure and bonding strength of primary teeth: an in vitro study

Background

To investigate the effects of Er:YAG laser pre-treatment on the dentin structure and shear bond strength of primary teeth.

Methods

Dentin specimens were prepared using freshly extracted intact primary molars and divided randomly into four groups based on the surface treatment applied. The control and etchant groups received no treatment and conventional acid etching treatment, respectively, while the energy and frequency groups received laser surface treatment with variable energy (50–300 mJ) and frequency (5–30 Hz) parameters. The morphology was observed using scanning electron microscopy. The surface-treated dentin slices were bonded to resin tablets, followed by thermocycle treatment. The shear strength was determined using a universal testing machine and de-bonded surfaces were observed using a stereomicroscope.

Results

SEM observation showed that the surface morphology of the dentin slices changed after etching as well as after Er:YAG laser pre-treatment with different energy and frequency values. The dentin tubules opened within a specific energy (50–200 mJ) and frequency (5–20 Hz) range. Beyond this range, the intertubular dentin showed cracks and structural disintegration. Shear strength tests showed no significant changes after acid etching. The shear strength increased significantly (P < 0.05) after Er:YAG laser pre-treatment compared with that of the control group. The shear strength increased within the same energy (50–200 mJ) and frequency (5–20 Hz) range as the tubule opening, but not significantly (P > 0.05). The most common mode of interface failure was adhesive (interface) failure, followed by mixed and resin cohesive failure.

Conclusions

Pre-treatment using Er:YAG laser opens the dentinal tubules without the formation of a smear layer and improves the bonding strength between the primary teeth dentin and the resin composites.

Transurethral resection in women with symptomatic keratinizing squamous metaplasia of urinary bladder: A retrospective study of 92 cases

Objectives

To investigate the efficacy of transurethral resection (TUR) on relieving urinary symptoms in patients with keratinizing squamous metaplasia (KSM) of the urinary bladder.

Methods

Data were analyzed from a retrospective study of patients receiving transurethral bipolar plasma resection (bi‐TUR) treatment for symptomatic KSM. Urinary symptoms were assessed by the International Prostate Symptom Score (IPSS) and a numeric rating scale pain score. Efficacy was assessed using the IPSS to determine changes from baseline in lower urinary tract symptoms (LUTS). Self‐reported quality of life (QoL) was assessed by the last question of the IPSS questionnaire.

Results

A total of 92 female patients were included in the analysis. The median age was 42 years. LUTS, pain, and hematuria were the most common symptoms that affected patients. The median follow‐up duration was 51 months. There were significant improvements in LUTS from baseline IPSS after TUR (P < .001). The percentage of the patients with moderate to severe LUTS went down from 52.2% to 18.5%. The median Numeric Rating Scale (NRS)‐11 pain score reduced from 3 at baseline to 0 at the last visit. Twenty‐one out of 40 patients reported that the pain symptoms disappeared completely. No patients reported hematuria symptoms at the final follow‐up. Improvement of self‐reported QoL was significant (P < .001). A total of 57.6% of patients reported an improvement, 26.1% of patients reported no improvement, and 16.3% reported deterioration.

Conclusions

Bi‐TUR therapy significantly relieved urinary symptoms in women with KSM. Improvement of QoL was acceptable with a success rate of 57.6%. Considering the very low complication rate, our study supported bi‐TUR as an alternative treatment for patients who are resistant to medical therapy.

Photonic Therapy in Periodontal Diseases an Overview with Appraisal of the Literature and Reasoned Treatment Recommendations

Recent reviews and meta-analyses of the literature over the past quarter-century have failed to provide enough evidence to prove or disprove the actual utility of photonic therapy in periodontitis, alone or adjunctive to conventional approaches. This apparent paradox has been explained by the many physical, molecular, biological, anatomical, and technical variables of photonic treatments, which can differ in light-emitting devices (laser or LED), wavelengths, irradiation power and modes, clinical objectives, follow-up times, disease grading, and assessment methods. This multi-faceted, controversial scenario has led practitioners to underestimate the actual potential of photonic therapy in periodontal diseases. In this critical appraisal of the literature, we have briefly summarized the main photonic therapies and instruments used in Periodontology, highlighting their main characteristics and limitations. Then, we have tried to identify and discuss the key methodological issues which can have an impact on the outcome of photonic therapies. Our main goal was to identify the best parameters, settings, and methodologies to perform effective periodontal photonic treatments and to extrapolate some recommendations for clinical use. Should these recommendations find a consensus among periodontologists and be adopted in future clinical studies, they will hopefully contribute to dissipate the present confusion and uncertainty on this complex matter.

SMARTp: A SMART design for nonsurgical treatments of chronic periodontitis with spatially referenced and nonrandomly missing skewed outcomes

This paper proposes dynamic treatment regimes (DTRs) as effective individualized treatment strategies for managing chronic periodontitis. The proposed DTRs are studied via SMARTp-a two-stage sequential multiple assignment randomized trial (SMART) design. For this design, we propose a statistical analysis plan and a novel cluster-level sample size calculation method that factors in typical features of periodontal responses such as non-Gaussianity, spatial clustering, and nonrandom missingness. Here, each patient is viewed as a cluster, and a tooth within a patient's mouth is viewed as an individual unit inside the cluster, with the tooth-level covariance structure described by a conditionally autoregressive structure. To accommodate possible skewness and tail behavior, the tooth-level clinical attachment level (CAL) response is assumed to be skew-t, with the nonrandomly missing structure captured via a shared parameter model corresponding to the missingness indicator. The proposed method considers mean comparison for the regimes with or without sharing an initial treatment, where the expected values and corresponding variances or covariance for the sample means of a pair of DTRs are derived by the inverse probability weighting and method of moments. Simulation studies are conducted to investigate the finite-sample performance of the proposed sample size formulas under a variety of outcome-generating scenarios. An R package SMARTp implementing our sample size formula is available at the Comprehensive R Archive Network for free download.

Clinical Effectiveness of Er: YAG Lasers Adjunct to Scaling and Root Planing in Non-Surgical Treatment of Chronic Periodontitis: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND Er: YAG lasers (ERLs) show suitable characteristics for scaling and root planing, but previous studies have drawn conflicting conclusions. This meta-analysis aimed to systematically appraise the available evidence concerning the effectiveness of ERLs as an adjunct to scaling and root planing (SRP) for non-surgical periodontal treatment. MATERIAL AND METHODS Randomized controlled trials (RCTs) comparing ERLs+SRP with SRP alone for the treatment of chronic periodontitis were searched in 9 electronic biomedical databases up to January 2018. The weighted mean differences (WMDs) and 95% confidence intervals (CIs) were counted for probing depth (PD) reduction, clinical attachment level (CAL) gain, and visual analog scale (VAS) score. Heterogeneity was evaluated with the I² statistic for interstudy comparisons and the χ²-based Q statistic for intra-study comparisons. Sensitivity analysis was conducted by switching to a random or fixed effect model based on the heterogeneity. Publication bias was measured by Begg's test. RESULTS Ten related RCTs met the inclusion criteria. There were statistically significant differences in the assessed clinical parameters at the three-month follow-up: PD reduction (WMD=0.32, 95%CI range from 0.14 to 0.51, p<0.001; p=0.003, I²=69.7%); CAL gain (WMD=0.31, 95%CI range from 0.22 to 0.40, p<0.001; p=0.209, I²=28.8%); and VAS scores (WMD=-1.38, 95%CI range from -2.45 to -0.31, p<0.001; p=0.182, I²=44%). There were no significant differences at the six- and twelve-month follow-ups. Sensitivity analysis revealed that the results were consistent. No evidence of publication bias was detected. CONCLUSIONS This systematic analysis demonstrated that ERLs+SRP provides additional short-term effectiveness and that patients experience less pain compared to SRP. There were no significant differences at the medium-term and long-term follow-ups. Long-term well-designed RCTs are required.

Comparison of clinical parameters, microbiological effects and calprotectin counts in gingival crevicular fluid between Er: YAG laser and conventional periodontal therapies: A split-mouth, single-blinded, randomized controlled trial

BACKGROUND

The erbium-doped yttrium, aluminum, and garnet (Er:YAG) laser is thought to be the most promising laser for periodontal treatment; however, its application is still under consideration. The aim of this study was to compare Er:YAG laser monotherapy with conventional scaling and root planing (SRP) for chronic periodontitis using clinical parameters, the detection rate of periodontal pathogens, and the calprotectin level in gingival crevicular fluid.

METHODS

Twenty-seven participants with moderate-to-advanced chronic periodontitis were included. In a split-mouth design, the 2 half-mouths of each participant were randomly assigned to Er:YAG laser or SRP (combination of ultrasonic and manual instruments) treatment. Clinical parameters were recorded at baseline, 6 weeks, and 3 and 6 months after treatment. At the same time points, gingival crevicular fluid was collected to analyze the detection rate of 6 periodontal pathogens by polymerase chain reaction and the levels of calprotectin by enzyme-linked immunosorbent assay.

RESULTS

Both treatment groups showed significant reductions in probing depth (PD), bleeding index (BI), and clinical attachment level (CAL) from baseline to 6 months. For sites with 4 mm ≤ PD ≤ 6 mm at baseline, SRP resulted in a greater reduction in PD and CAL than Er:YAG laser treatment, and the difference remained at 6 months post-treatment (P = .01 and P < .01, respectively). For sites with PD ≥7 mm at baseline, the clinical parameters showed similar results between the 2 groups. SRP resulted in a lower detection rate of Porphyromonas gingivalis at 6 months post-treatment. The levels of calprotectin were significantly decreased from baseline to 6 months in both groups, without a significant difference between the groups.

CONCLUSION

For mild pockets, conventional SRP may still be the preferred choice. For deep pockets, Er:YAG laser treatment could be an effective alternative. Studies are needed to explore more advanced instruments and new application methods for the Er:YAG laser for periodontal treatment in deep pockets.

Combined application of Er:YAG and Nd:YAG lasers in treatment of chronic periodontitis. A split-mouth, single-blind, randomized controlled trial

BACKGROUND

The aim of the present study was to compare the effectiveness of combined Er:YAG and Nd:YAG laser therapy to that of scaling and root planing with hand instruments in non-surgical treatment of chronic periodontitis.

MATERIAL AND METHODS

Twenty-five systemically healthy patients with chronic periodontitis were selected for this study. The quadrants were randomly allocated in a split-mouth design to either combined Er:YAG (160 mJ/pulse, 10 Hz) and Nd:YAG laser (100 mJ/pulse, 20 Hz) therapy (test group) or scaling and root planing alone (control group). At baseline, 1 month and 3 months after treatment, plaque index, gingival index, probing depth, clinical attachment level and bleeding on probing (%), were recorded and gingival crevicular fluid and subgingival plaque samples were taken. The gingival crevicular fluid levels of interleukin-1β and tumor necrosis factor-α were analyzed by enzyme-linked immunosorbent assay. Quantitative analysis of red complex bacteria was performed using quantitative real-time polymerase chain reaction.

RESULTS

The clinical parameters had significantly improved for both groups after treatment. There were statistically significant differences in probing depth and clinical attachment level between the test and control groups only for deep pockets (≥7 mm) (P<.05). No significant differences between the two groups were observed for the biochemical and microbiological parameters at any time points (P>.05).

CONCLUSIONS

The present study suggests that a combined course of Er:YAG and Nd:YAG laser therapy may be beneficial particularly in inaccessible areas such as deep pockets on a short-term basis. Further, well-designed studies are required to assess the effectiveness of the combination of these lasers.

In Vitro-Activity of Er:YAG Laser in Comparison with other Treatment Modalities on Biofilm Ablation from Implant and Tooth Surfaces

BACKGROUND AND AIM

Bacterial biofilms play a major role in the etiology of periodontal and peri-implant diseases. The aim of the study was to evaluate the removal of bacterial biofilms and attachment of epithelial cells (EC), gingival fibroblasts (GF) and osteoblast-like cells (OC) to dentin and titanium surfaces after Er:YAG laser (Er:YAG) in comparison with other treatment methods.

MATERIAL AND METHODS

Multi-species bacterial biofilms were grown on standardized dentin and titanium specimens with a sand-blasted and acid etched (SLA) surface for 3.5 d. Thereafter, the specimens were placed into artificially-created pockets. The following methods for biofilm removal were used: 1) Gracey (dentin) or titanium curettes (CUR), 2) Er:YAG, 3) photodynamic therapy (PDT) and 4) CUR with adjunctive PDT (CUR/PDT). Colony forming units (CFUs) of the remaining biofilms and attachment of EC, GF and OC were determined. Statistical analysis was performed by means of ANOVA with post-hoc LSD.

RESULTS

All treatment methods decreased statistically significantly (p<0.001) total CFUs in biofilms compared with untreated dentin and titanium surfaces respectively. On dentin, Er:YAG was equally efficient as CUR and PDT but inferior to CUR/PDT (p = 0.005). On titanium, surfaces, the use of Er:YAG resulted in statistically significantly superior biofilm removal compared to the 3 other treatments (each p<0.001). Counts of attached EC, GF and OC were the lowest on untreated contaminated dentin and titanium surfaces each. After CUR/PDT higher EC counts were found on dentin (p = 0.006). On titanium, all decontamination methods statistically significantly increased (p<0.001) the counts of attached EC without differences between groups. Statistically significantly higher counts of GF (p = 0.024) and OC (p<0.001) were observed after Er:YAG decontamination compared with untreated surfaces.

CONCLUSION

Ablation of subgingival biofilms and in particular decontamination of titanium implant surfaces with an Er:YAG laser seem to be a promising approach and warrants further investigations.

Commentary: Is There Clinical Benefit From Using a Diode or Neodymium:Yttrium-Aluminum-Garnet Laser in the Treatment of Periodontitis?

Despite a quarter of a century of laser research, there is a persistent debate regarding the efficacy of dental lasers in the treatment of periodontitis or periodontal maintenance therapy. There are many claims and much hyperbole surrounding the use of lasers, either as a monotherapy or adjunctive to scaling and root planing, to treat periodontitis. There is little evidence that using a diode or neodymium:yttrium-aluminum-garnet laser adds clinical value over and above conventional non-surgical or surgical periodontal treatment. There is a significant need for better designed human clinical trials. Data from such trials should be analyzed according to initial probing depth and characteristics of the treated sites, such as non-molar, molar flat surfaces, and molar furcations, and evaluated for long-term post-treatment results.

Microbiological effects and recolonization patterns after adjunctive subgingival debridement with Er:YAG laser

OBJECTIVES

The objective of this study was to assess the microbiological effects and recolonization patterns after non-surgical periodontal treatment protocol based on the adjunctive use of erbium-doped yttrium aluminium garnet (Er:YAG) laser.

MATERIAL AND METHODS

Patients diagnosed with chronic periodontitis were randomly assigned to two different treatment protocols: test, full-mouth subgingival ultrasonic instrumentation followed by Er-YAG laser application 1 week later to sites with initial probing pocket depth ≥4.5 mm; and control, full-mouth ultrasonic subgingival instrumentation within 1 week. Clinical (at sampled sites) and microbiological (culture-based) parameters were recorded at baseline and 3 and 12 months. Microbiological variables included total counts, frequency of detection, proportions and counts of target species.

RESULTS

Results from 19 test and 21 control patients were compared. Minor changes were observed for total colony-forming units, with no differences between groups. For the frequency of detection, a limited and similar impact in both groups was observed for the most prevalent (over 80 %) periodontal pathogens (Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum). For proportions, reductions in P. gingivalis occurred at 3 months, both in the test and control groups (from 16.3 to 10 % and 16 to 14.8 %, respectively), although these differences were not statistically significant. At 12 months, the test group showed a statistically significant greater reduction in probing depth for the sampled sites.

CONCLUSIONS

The adjunctive use of Er:YAG laser when compared with conventional ultrasonic debridement did not provide a microbiological added benefit.

CLINICAL RELEVANCE

Even though some clinical benefits with the adjunctive laser application were identified when comparing both treatment protocols, there were no differences in microbiological outcomes or in the bacterial recolonization patterns.