The Combined Use of Nd:YAG Laser and Enamel Matrix Proteins in the Treatment of Periodontal Infrabony Defects

Root surface biomodification in periodontal therapy: Biological rationale and clinical applications

Regenerative periodontal therapy aims to form new cementum, periodontal ligament, and alveolar bone, all sealed by gingival tissue. The root surface acts as the wound margin during this regeneration process. Root surface biomodification (root conditioning/root decontamination), therefore, seems instrumental in promoting surface decontamination and enhancing tissue attachment by removing the smear layer, exposing collagen fibrils, and facilitating blood clot formation and stabilization. This review attempted to provide an all-encompassing, evidence-based assessment of the role of root surface biomodification in regenerative periodontal therapy, particularly in intrabony defects, furcation defects, and root coverage procedures. The reviewed evidence suggested that root conditioning agents, whether used independently or in conjunction with bone graft materials, biological agents, membranes, or connective tissue grafts, do not offer any clinical advantage regarding clinical attachment gain. Thus, integrating chemical methods with the mechanical root instrumentation process does not necessarily contribute to superior clinical outcomes.

Nd:YAG laser therapy on postoperative pain, swelling, and trismus after mandibular third molar surgery: a randomized double-blinded clinical study

This study aims to evaluate the effect of Nd:YAG laser therapy (NdLT) on postoperative pain, swelling, and trismus after mandibular third molar (M3) surgery. Three hundred patients were randomly divided into the Nd group (n = 100), medication group (n = 100), and Nd+medication (Nd+m) group (n = 100). The WHARFE classification system was used to assess surgical difficulty. After surgery, the Nd group was irradiated by the Nd:YAG laser in very long-pulsed mode (VLP, pulse duration 1 ms, 20 Hz, 4 W, R21-C3) in 6 regions of the extraction socket with a total energy of 300 J. For the medication group, dexamethasone 0.75 mg and loxoprofen 60 mg were prescribed immediately and every 12 h thereafter for 3 days. The Nd+m group received both treatments mentioned above. Pain assessment was performed at 6, 24, 48, and 72 h postoperatively using the visual analog scale (VAS). Swelling was evaluated by changes in the distance from (1) the tragus to the labial commissure, (2) the tragus to the pogonion, and (3) the mandibular angle to the lateral canthus preoperatively and 72 h postoperatively. Trismus was assessed by the change in maximum mouth opening. Groups Nd and Nd+m had lower VAS scores at 6 h, 24 h, and 48 h (F = 13.80, p = 0.00), but the difference between the two groups was not significant (F = 1.34, p = 0.11). However, no significant difference was observed at 72 h (p = 0.10). There was no significant difference in swelling or trismus among the three groups (p > 0.05). NdLT is an effective approach to improve complications after M3 surgery.

Efficacy of biologics for the treatment of periodontal infrabony defects: An American Academy of Periodontology best evidence systematic review and network meta-analysis

BACKGROUND

A large variety of biomaterials, biologics and membranes have been utilized in the past 40 years for the regenerative treatment of periodontal infrabony defects. Biologic agents have progressively gained popularity among clinicians and are routinely used for periodontal regeneration. In alignment with the goals of the American Academy of Periodontology (AAP) Best Evidence Consensus (BEC) on the use of biologic mediators in contemporary clinical practice, the aim of this sytematic review was to evaluate the effect of biologic agents, specifically autogenous blood-dervied products (ABPs), enamel matrix derivative (EMD) and recombinant human platelet-derived growth factor-BB (rhPDGF-BB), on the regenerative outcomes of infrabony defects.

METHODS

A detailed systematic search was conducted to identify eligible randomized control trials (RCTs) reporting the outcomes of periodontal regenerative therapy using biologics for the treatment of infrabony defects. A frequentist mixed-modeling approach to network meta-analysis (NMA), characterized by the assessment of three individual components for the treatment of an infrabony defect (the bone graft material [BG], the biologic agent, the application of a barrier membrane) was performed to evaluate and compare the relative efficacy of the different components, on the outcomes of different therapeutic modalities of periodontal regeneration.

RESULTS

A total of 153 eligible RCTs were included, with 150 studies contributing to the NMA. The quantitative analysis showed that the addition of biologic agents to bone graft significantly improves the clinical and radiographic outcomes, as compared to BG and flap procedures alone. Barrier membranes enhanced the regenerative outcomes of BG but did not provide further benefits in combination with biologics. The type of BG (autogenous, allogeneic, xenogeneic or alloplastic) and the biologic agent (EMD, platelet-rich fibrin [PRF], platelet-rich plasma [PRP] or rhPDGF-BB) played a significant role on the final outcomes of infrabony defects. Allogeneic and xenogeneic BGs exhibited statistically significantly superior clinical gain than synthetic and autogenous BGs (p < 0.05 in all the comparisons), while rhPDGF-BB and PRF demonstrated significantly higher stability of the gingival margin (p < 0.01) and radiographic bone fill/gain (p < 0.05), together with greater, although not statistically significant, clinical attachment level gain and pocket depth reduction, than EMD and PRP. Overall, rhPDGF-BB exhibited the largest effect size for most parameters, including clinical attachment level gain, pocket depth reduction, less gingival recession and radiographic linear bone gain. Considering the relatively high number of trials presenting an unclear or high risk of bias, the strength of recommendation supporting the use of PRP was judged weak, while the recommendation for EMD, PRF and rhPDGF-BB was deemed in favor.

CONCLUSIONS

Biologics enhance the outcomes of periodontal regenerative therapy. Combination therapies involving BGs + biologics or BGs + barrier membrane demonstrated to be superior to monotherapies. The choice of the type of BG and biologic agent seems to have significant impact on the clinical and radiographic outcomes of infrabony defects.

Rare earth smart nanomaterials for bone tissue engineering and implantology: Advances, challenges, and prospects

Bone grafts or prosthetic implant designing for clinical application is challenging due to the complexity of integrated physiological processes. The revolutionary advances of nanotechnology in the biomaterial field expedite and endorse the current unresolved complexity in functional bone graft and implant design. Rare earth (RE) materials are emerging biomaterials in tissue engineering due to their unique biocompatibility, fluorescence upconversion, antimicrobial, antioxidants, and anti-inflammatory properties. Researchers have developed various RE smart nano-biomaterials for bone tissue engineering and implantology applications in the past two decades. Furthermore, researchers have explored the molecular mechanisms of RE material-mediated tissue regeneration. Recent advances in biomedical applications of micro or nano-scale RE materials have provided a foundation for developing novel, cost-effective bone tissue engineering strategies. This review attempted to provide an overview of RE nanomaterials' technological innovations in bone tissue engineering and implantology and summarized the osteogenic, angiogenic, immunomodulatory, antioxidant, in vivo bone tissue imaging, and antimicrobial properties of various RE nanomaterials, as well as the molecular mechanisms involved in these biological events. Further, we extend to discuss the challenges and prospects of RE smart nano-biomaterials in the field of bone tissue engineering and implantology.

Decontamination and Biomodification of Periodontally Affected Root Surface for Successful Regeneration: Is There Room for Improvement?

Periodontitis is a multifactorial inflammatory condition associated with an oral microbiome dysbiosis that results in gingival inflammation and clinical attachment loss. Periodontal therapies are based on scaling and root planing to disturb the bacterial biofilm mechanically and remove calculus and contaminated cementum. Research does not support the use of root modifiers for decontamination and biomodification of periodontally affected root surfaces. Standardized clinical trials in large populations, assessing biological and patient-reported outcome measures, are necessary to evaluate candidate biomaterials for decontamination and biomodification of periodontally affected root surfaces.

Photobiomodulation in Periodontology and Implant Dentistry: Part 1

(Part 2 of this article can be located at www.liebertpub.com/doi/10.1089/photob.2019.4731.) Objective: Finding evidence-based treatment strategies for low-level light therapy (LLLT) and the correct incorporation of these treatment methods in the clinical practice of periodontics. Background: Photobiomodulation has been shown to have biostimulatory, anti-inflammatory and analgesic effects that can be beneficial in periodontal and dental implant treatment procedures. Methods: In this review we have addressed some clinical questions regarding the potential clinical application of low-level light irradiation and its photobiomodulatory effects in periodontology and implantology. The literature was searched for in vivo (animal or clinical) articles written in English in four electronic databases of PubMed, Scopus, Google Scholar, and Cochrane Library until April 2019. Only studies with low irradiation doses without any thermal effects used only for their photobiomodulatory purposes were included. Results: We were able to find relevant studies for all of our questions, and positive effects for the application of light therapy were reported in most of the studies. However, there is still great deal of heterogeneity in terms of study designs and most importantly in light irradiation devices and the parameters used. Owing to this issue it was not possible to reach specific evidence-based irradiation protocols for the questions addressed in this review. Conclusions: Based on our search results, an obvious positive effect of LLLT on stimulation of healing of periodontal soft and hard tissues and reduction of inflammation can be seen. Future well-designed randomized control studies with the same irradiation settings and systematic reviews evaluating the studies found on the questions mentioned are necessary to reach evidence-based recommendations.

Periodontal and peri-implant wound healing following laser therapy

Laser irradiation has numerous favorable characteristics, such as ablation or vaporization, hemostasis, biostimulation (photobiomodulation) and microbial inhibition and destruction, which induce various beneficial therapeutic effects and biological responses. Therefore, the use of lasers is considered effective and suitable for treating a variety of inflammatory and infectious oral conditions. The CO2 , neodymium-doped yttrium-aluminium-garnet (Nd:YAG) and diode lasers have mainly been used for periodontal soft-tissue management. With development of the erbium-doped yttrium-aluminium-garnet (Er:YAG) and erbium, chromium-doped yttrium-scandium-gallium-garnet (Er,Cr:YSGG) lasers, which can be applied not only on soft tissues but also on dental hard tissues, the application of lasers dramatically expanded from periodontal soft-tissue management to hard-tissue treatment. Currently, various periodontal tissues (such as gingiva, tooth roots and bone tissue), as well as titanium implant surfaces, can be treated with lasers, and a variety of dental laser systems are being employed for the management of periodontal and peri-implant diseases. In periodontics, mechanical therapy has conventionally been the mainstream of treatment; however, complete bacterial eradication and/or optimal wound healing may not be necessarily achieved with conventional mechanical therapy alone. Consequently, in addition to chemotherapy consisting of antibiotics and anti-inflammatory agents, phototherapy using lasers and light-emitting diodes has been gradually integrated with mechanical therapy to enhance subsequent wound healing by achieving thorough debridement, decontamination and tissue stimulation. With increasing evidence of benefits, therapies with low- and high-level lasers play an important role in wound healing/tissue regeneration in the treatment of periodontal and peri-implant diseases. This article discusses the outcomes of laser therapy in soft-tissue management, periodontal nonsurgical and surgical treatment, osseous surgery and peri-implant treatment, focusing on postoperative wound healing of periodontal and peri-implant tissues, based on scientific evidence from currently available basic and clinical studies, as well as on case reports.

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.

Trauma from instrumentation after non-surgical periodontal treatment with ultrasonic scalers and Nd:YAG laser

OBJECTIVE

Periodontal therapies aimed at altering the progression of periodontal diseases must include meticulous mechanical debridement during both the non-surgical and the surgical phases of periodontal treatment. The aim of this study was to evaluate and compare the immediate effect of trauma from instrumentation on clinical attachment level after non-surgical periodontal treatment with ultrasonic scalers and a Nd:YAG laser.

MATERIALS AND METHODS

Twenty-four patients with untreated chronic periodontitis, presenting probing depths of 4-6 mm on anterior teeth, upper and lower, were entered into the study. The selected teeth were probed with a pressure-controlled probe, guided by stents. Each quadrant was randomly allocated in a split-mouth design either to treatment with Nd:YAG laser using an energy of 1W, 100mj, 1064nm (test group) or to periodontal treatment using ultrasonic scalers (control group). Clinical parameters, including plaque index (PI), bleeding on probing (BOP), probing pocket depth (PPD) and probing attachment level (PAL) were acquired prior to and immediately after treatment.

RESULTS

Statistical analysis demonstrated no differences between groups at baseline for all parameters (p > 0.05). Immediately after treatment, the control group showed a greater PAL loss than the test group (p < 0.05). For the control group, there were statistically significant differences between PAL immediately before and after treatment (p < 0.05), but not test group (p > 0.05).

CONCLUSIONS

Within the limits of the present study, it may be concluded that non-surgical periodontal treatment with ultrasonic scalers causes a mean immediate attachment loss of 0.68 mm and that a Nd:YAG laser seems to reduce significantly the trauma the instrumentation produced.

KTP laser therapy as an adjunctive to scaling and root planing in treatment of chronic periodontitis

OBJECTIVE

The main goal of periodontal treatment is to control infection and, thereby, curb disease progression. Recent studies have suggested that the use of a laser as an adjunct to scaling and root planing (SRP) might improve the effectiveness of conventional periodontal treatment. The aim of this study was to evaluate and compare the clinical effects of potassium-titanyl-phosphate (KTP) laser therapy in the treatment of chronic periodontitis in combination with traditional SRP.

MATERIALS AND METHODS

Twenty-four patients with untreated chronic periodontitis were treated using a split-mouth study design in which each side was randomly treated by SRP alone (control group) or KTP laser (0.8W, time on 50 ms, time off 50 ms, 30 s, 532 nm) followed by SRP (test group). In the distribution of the teeth (total = 124 teeth) in the patients, 106 (86%) were molars and 18 (14%) were premolars. The selected teeth were probed with a pressure-controlled probe, guided by stents. Clinical periodontal parameters including plaque index (PI), bleeding on probing (BOP), probing pocket depth (PPD) and probing attachment level (PAL) were recorded at baseline and at 2 and 12 months following therapy.

RESULTS

Statistical analysis demonstrated no differences between groups at baseline for all parameters (p > 0.05). BOP and PPD reductions and PAL gains were statistically significant both between baseline and 2 months and between baseline and 12 months in both groups (p < 0.05). The test group showed a greater reduction in PPD compared to the control group (p < 0.05). In addition, the test group showed a greater probing attachment gain compared to the control group (p < 0.05).

CONCLUSIONS

In patients with chronic periodontitis, clinical outcomes of conventional periodontal treatment can be improved by using an adjunctive KTP laser.

Significance of scaling and root planing with and without adjunctive use of a water-cooled pulsed Nd:YAG laser for the treatment of periodontal inflammation

The aim was to assess the significance of scaling and root planing (SRP) with adjunctive use of a water-cooled pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for the treatment of periodontal inflammation. Thirty-nine patients were equally divided into three groups. In group 1, the upper jaw was treated with Nd:YAG laser application; whereas in groups 2 and 3, the upper jaw was treated with SRP alone and Nd:YAG laser application immediately after SRP, respectively. In each group, probing pocket depth (PPD), plaque index (PI), and gingival index (GI) were measured and gingival crevicular fluid (GCF) volume was determined after using at 1 week and after 3 months. Three-month follow-up results showed that PPD, PI, GI, and GCF volume were significantly reduced in group 3 compared to groups 1 and 2. In short term, SRP with a single application of a water-cooled pulsed Nd:YAG laser reduced PI, GI, PPD, and GCF volume more significantly compared to when Nd:YAG laser and SRP are used alone to treat periodontal inflammation.