Patient-reported outcomes of laser-assisted pain control following non-surgical and surgical periodontal therapy: A systematic review and meta-analysis

Current status of Er:YAG laser in periodontal surgery

Lasers have numerous advantageous tissue interactions such as ablation or vaporization, hemostasis, bacterial killing, as well as biological effects, which induce various beneficial therapeutic effects and biological responses in the tissues. Thus, lasers are considered an effective and suitable device for treating a variety of inflammatory and infectious conditions of periodontal disease. Among various laser systems, the Er:YAG laser, which can be effectively and safely used in both soft and hard tissues with minimal thermal side effects, has been attracting much attention in periodontal therapy. This laser can effectively and precisely debride the diseased root surface including calculus removal, ablate diseased connective tissues within the bone defects, and stimulate the irradiated surrounding periodontal tissues during surgery, resulting in favorable wound healing as well as regeneration of periodontal tissues. The safe and effective performance of Er:YAG laser-assisted periodontal surgery has been reported with comparable and occasionally superior clinical outcomes compared to conventional surgery. This article explains the characteristics of the Er:YAG laser and introduces its applications in periodontal surgery including conventional flap surgery, regenerative surgery, and flapless surgery, based on scientific evidence from currently available basic and clinical studies as well as cases reports.

Laser light: Illuminating the path to enhanced periodontal care

The utilisation of laser technology in the realm of periodontal care represents a significant advancement in clinical practice. This article delves into the historical context of laser therapy in medicine, from its inception in 1960 to its evolution into low-level laser therapy (LLLT). LLLT, often referred to as photobiomodulation (PBM), has garnered attention due to its potential to enhance periodontal treatment outcomes. The article thoroughly examines the mechanisms of action of photobiomodulation therapy PBM(T), covering its impact on cellular and tissue levels. The authors explore the evidence-based recommendations for the use of PBM(T) in periodontal care, shedding light on its potential to improve periodontal conditions, especially when applied as an adjunct to conventional treatments. They investigate the role of PBM(T) in individuals and its possible contribution to periodontal health. Additionally, the article delves into its application in periodontal regenerative procedures and its ability to expedite soft tissue wound healing and the effects of PBM(T) in reducing periodontal inflammation and mitigating post-periodontal surgery discomfort. In conclusion, the article calls for enhanced clinical research to streamline laser procedures, develop antimicrobial photodynamic therapy, and conduct well-designed randomised controlled trials (RCTs). It also emphasises the importance of understanding the impact of laser therapy on therapeutic and biological goals, the potential to reduce invasive procedures, and the necessity of adequate research funding.

Histologic Evaluation of Effect of Three Wavelengths of Diode Laser on Human Gingival Margins

Introduction: Available evidence suggests that the response of the intervened tissue is directly linked to the effects generated by the cutting instrument used. To determine the histological findings in gingival tissue margins excised through gingivectomies performed using 450 nm, 940 nm, and 980 nm diode lasers. The present study aimed to determine the histological findings in gingival tissue margins excised through gingivectomies performed using 450 nm, 940 nm, and 980 nm diode lasers. Methods: Gingival tissue samples were collected from 30 patients who had undergone gingivectomy procedures. Each study group comprised 10 patients who willingly provided their samples after providing informed consent. The visualization of histological findings was facilitated through Hematoxylin-Eosin staining. Additionally, variables related to pain and hemostasis were assessed during the intraoperative period. Results: The incision quality was categorized as irregular across all three wavelengths. Histological examination of the epithelial tissue revealed the absence of carbonization and the preservation of cell morphology in over 50% of the resection margin in samples obtained with the 450 nm and 940 nm wavelengths. In the connective tissue, observations included carbonization, collagen coagulation, and basophilia, with the 980 nm wavelength demonstrating the highest percentage of samples displaying collagen coagulation in more than 50% of the resection margin. Conversely, the 450 nm wavelength exhibited the highest degree of preservation of the fibroblast structure. Conclusion: Based on a comprehensive analysis of the study results, it can be inferred that the 450nm and 940nm wavelength lasers tend to produce less thermal damage and better cell preservation when compared to the 980nm wavelength.

Application of Different Wavelengths of LED Lights in Antimicrobial Photodynamic Therapy for the Treatment of Periodontal Disease

Therapeutic light has been increasingly used in clinical dentistry for surgical ablation, disinfection, bio-stimulation, reduction in inflammation, and promotion of wound healing. Photodynamic therapy (PDT), a type of phototherapy, has been used to selectively destroy tumor cells. Antimicrobial PDT (a-PDT) is used to inactivate causative bacteria in infectious oral diseases, such as periodontitis. Several studies have reported that this minimally invasive technique has favorable therapeutic outcomes with a low probability of adverse effects. PDT is based on the photochemical reaction between light, a photosensitizer, and oxygen, which affects its efficacy. Low-power lasers have been predominantly used in phototherapy for periodontal treatments, while light-emitting diodes (LEDs) have received considerable attention as a novel light source in recent years. LEDs can emit broad wavelengths of light, from infrared to ultraviolet, and the lower directivity of LED light appears to be suitable for plaque control over large and complex surfaces. In addition, LED devices are small, lightweight, and less expensive than lasers. Although limited evidence exists on LED-based a-PDT for periodontitis, a-PDT using red or blue LED light could be effective in attenuating bacteria associated with periodontal diseases. LEDs have the potential to provide a new direction for light therapy in periodontics.

Er:YAG laser-assisted comprehensive periodontal pocket therapy for residual periodontal pocket treatment: A randomized controlled clinical trial

BACKGROUND

This study evaluated the effectiveness of a novel pocket therapy (Er:YAG laser-assisted comprehensive periodontal pocket therapy [Er-LCPT]) for residual pocket treatment, compared with conventional mechanical treatment alone, in a randomized controlled clinical trial.

METHODS

Two sites in 18 patients having residual periodontal pockets of ≥5 mm depth, extant following initial active therapy, or during supportive therapy, were randomized into two groups in a split mouth design: the control group received scaling and root planing (SRP) by curette, and the test group received Er-LCPT using curette and laser. With Er-LCPT, after root debridement, inflamed connective tissue on the inner gingival surface and on the bone surface/within extant bone defects was thoroughly debrided. Furthermore, removal of proximate oral epithelium and coagulation of the blood clot in the pocket entrance were performed with laser. Clinical parameters were evaluated, before and after treatment, through 12 months.

RESULTS

Both groups showed significant improvements in clinical parameters. With Er-LCPT, pocket debridement was thoroughly and safely performed, without any adverse side effects and complications, and favorable healing was observed in most of the cases. At 12 months, Er-LCPT demonstrated significantly higher probing pocket depth reduction (2.78 mm vs. 1.89 mm on average; p = 0.012, Wilcoxon signed-rank test), clinical attachment gain (1.67 mm vs. 1.06 mm; p = 0.004) as primary outcomes, and reduced BOP value (0.89 vs. 0.56; p = 0.031), compared with SRP alone.

CONCLUSION

The results of this study indicate that Er-LCPT is more effective for residual pocket treatment, compared with SRP alone.

Effect of photobiomodulation adjunct to periodontal therapy on individuals with type 2 diabetes mellitus regarding periodontal clinical parameters: a systematic review and meta-analysis

The purpose of this study is to evaluate the scientific evidence on the impact of photobiomodulation adjunct to non-surgical periodontal treatment on individuals with type 2 diabetes mellitus (T2DM). The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed. A protocol was registered in the International Prospective Registry of Systematic Reviews (PROSPERO #CRD42022310756). The research was carried out in seven databases, with no restrictions regarding the year of publication. Our work included studies that compared periodontal clinical parameters among individuals undergoing non-surgical periodontal therapy associated with photobiomodulation and a control group of individuals undergoing non-surgical periodontal treatment. Study selection, data extraction, and risk of bias assessment (RoB 2.0) were performed by two review authors. Meta-analysis was performed. Mean difference (MD) and a 95% confidence interval (CI) were provided. Three hundred forty-one studies were identified, of which eight studies were included. The meta-analysis demonstrated that photobiomodulation adjunctive to periodontal therapy in individuals with diabetes resulted in a greater reduction in probing depth and greater attachment gain in comparison to periodontal treatment alone (p < 0.05). The included studies exhibited a low risk of bias. Photobiomodulation adjunct to periodontal therapy contributes to the improvement of periodontal clinical parameters in individuals with T2DM.

Next-Generation Examination, Diagnosis, and Personalized Medicine in Periodontal Disease

Periodontal disease, a major cause of tooth loss, is an infectious disease caused by bacteria with the additional aspect of being a noncommunicable disease closely related to lifestyle. Tissue destruction based on chronic inflammation is influenced by host and environmental factors. The treatment of periodontal disease varies according to the condition of each individual patient. Although guidelines provide standardized treatment, optimization is difficult because of the wide range of treatment options and variations in the ideas and skills of the treating practitioner. The new medical concepts of “precision medicine” and “personalized medicine” can provide more predictive treatment than conventional methods by stratifying patients in detail and prescribing treatment methods accordingly. This requires a new diagnostic system that integrates information on individual patient backgrounds (biomarkers, genetics, environment, and lifestyle) with conventional medical examination information. Currently, various biomarkers and other new examination indices are being investigated, and studies on periodontal disease-related genes and the complexity of oral bacteria are underway. This review discusses the possibilities and future challenges of precision periodontics and describes the new generation of laboratory methods and advanced periodontal disease treatment approaches as the basis for this new field.

Comparison of clinical outcomes of non-surgical adjunctive use of the 980-nm diode laser to conventional periodontal flap procedure-a randomised controlled split-mouth clinical trial

Lasers have been found to be effective as an adjunctive in periodontal therapy. The objective of the study was to compare the outcomes of non-surgical adjunctive use of 980-nm diode laser to that of conventional flap surgery in terms of clinical outcome measures and radiographic osseous defect depths. This study was designed as a double-blinded split-mouth randomised controlled clinical trial. A total of fifteen patients (30 quadrants) with generalised periodontitis stage III grade B were randomly assigned test group (diode laser) and control group (conventional flap surgery). Both test and control groups had 15 quadrants each. At 3 months, the probing pocket depth (PPD) was 3.46 ± 0.19 mm (test) and 4.20 ± 0.20 mm (control), with a statistically significant difference between the groups (p = 0.01). Similarly, at 6 months re-evaluation, PPD was 1.46 ± 0.12 mm (test) and 2.33 ± 0.13 mm (control) with a highly significant statistical difference (p = 0.001). Plaque index showed a difference between both test and control groups at baseline, 3 months and 6 months (p = 0.001) while gingival index, modified sulcular bleeding index and radiographic osseous defect depth showed a difference at 3 months and 6 months (p = 0.001). Within the study's limitations, 980-nm diode laser can result in significant improvements in the clinical and radiographic parameters and is very well tolerated by the subjects.

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.

Novel flapless esthetic procedure for the elimination of extended gingival metal tattoos adjacent to prosthetic teeth: Er:YAG laser micro-keyhole surgery

PURPOSE

This article describes a novel, minimally invasive procedure called Er:YAG laser micro-keyhole surgery (EL-MIKS) that removes metal or amalgam tattoos in the gingiva adjacent to prosthetic teeth without gingival deformity and recession. We aimed to evaluate the clinical efficacy of EL-MIKS for removing metal tattoos and present its long-term treatment outcomes.

METHODS

The EL-MIKS procedure consists of several steps that are all performed under a microscope. First, a micro-keyhole (1-2 mm diameter) was prepared using an Er:YAG laser in the center of the metal pigmentation. The connective tissue was evaporated in the deep layer, where metal debris was deposited. Second, within the accessible range, the irradiation angle was changed in various directions to ablate the metal pieces and discolored connective tissue without enlarging the keyhole. Finally, after blood filled the space created by the tissue evaporation, the surface of the blood clot at the entrance of the micro-keyhole was thermally coagulated with defocus laser irradiation. Pigmentation that could not be successfully removed from a single micro-keyhole was treated by forming new micro-keyholes at a distance of 3 mm or more from each previously created hole. Depigmentation over an extended area was completed over a few sessions every 4 weeks without gingival recession after surgery.

CONCLUSIONS

EL-MIKS, a novel depigmentation technique, was able to successfully remove an extended area of metal tattoos in the gingiva using a simpler, easier, and less invasive procedure than conventional periodontal plastic surgery. Esthetic restoration was successfully achieved without postoperative alteration of the gingival contour.

Effects of Antioxidant in Adjunct with Periodontal Therapy in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis

This review investigated whether the adjunctive use of antioxidants with periodontal therapy improves periodontal parameters in patients with type 2 diabetes. A systematic and extensive literature search for randomized controlled trials (RCTs) conducted before April 2021 was performed on the PubMed, Cochrane Library, and Web of Science databases. The risk of bias was assessed using the Cochrane risk-of-bias tool. A meta-analysis was performed to quantitatively evaluate the clinical outcomes following periodontal therapy. After independent screening of 137 initial records, nine records from eight RCTs were included. The risk-of-bias assessment revealed that all RCTs had methodological weaknesses regarding selective bias, although other risk factors for bias were not evident. This meta-analysis of two RCTs showed that periodontal pocket depths were significantly reduced in the groups treated with combined non-surgical periodontal therapy and melatonin than in those treated with non-surgical periodontal therapy alone. The present systematic review and meta-analysis suggest that the adjunctive use of melatonin, resveratrol, omega-3 fatty acids with cranberry juice, propolis, and aloe vera gel with periodontal therapy significantly improves periodontal disease parameters in patients with type 2 diabetes, and melatonin application combined with non-surgical periodontal therapy might significantly reduce periodontal pocket depth. However, there are still limited studies of melatonin in combination with non-surgical periodontal therapy in Type 2 diabetic patients, and more well-designed RCTs are required to be further investigated.

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.

A novel minimally-invasive approach for metal tattoo removal with Er:YAG laser

OBJECTIVE

Few effective and established treatment methods can remove gingival metal or amalgam tattoos. With this case series, we aimed to demonstrate the use of a novel minimally invasive technique to remove metal tattoos using an erbium-doped yttrium aluminum garnet (Er:YAG) laser.

MATERIALS AND METHODS

We retrospectively collected clinical data from 18 patients who had undergone Er:YAG laser treatment to remove metal tattoos. Minimal gingival ablation using an Er:YAG laser directed towards the pigmented area was performed, which exposed metal debris within the connective tissue that was carefully removed. A dental microscope was employed to identify the metal debris, for accurate irradiation, and to minimize wounding by reducing invasion. Postoperative gingival color and morphology, and visual analog scale as a patient-reported outcome assessing postoperative pain were evaluated.

RESULTS

All patients' metal tattoos were removed completely and safely during short procedures. Considerable esthetic improvements and favorable wound healing were achieved with almost no postoperative pain or complications.

CONCLUSION

The findings from this case series suggest that this novel minimally invasive therapy for metal tattoo removal that involved the Er:YAG laser is effective and safe, is associated with successful outcomes, and contributes greatly to patients' esthetic satisfaction.

CLINICAL SIGNIFICANCE

Metal tattoo removal using an Er:YAG laser safely and successfully improved gingival esthetics. This novel technique is much simpler and less invasive than conventional periodontal plastic surgery, and it may be more reliable regarding esthetic gingival improvements as it is associated with favorable wound healing, and it could offer significant benefits to patients by alleviating physical and mental stresses via reduced chair time and postoperative pain.