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.

Periodontal and peri‐implant wound healing following laser therapy

The aim of this randomized, parallel, controlled clinical trial was to examine the clinical and biochemical efficacy of diode laser as an adjunct to scaling and root planing (SRP). Thirty chronic periodontitis patients were randomly assigned into two groups to receive SRP alone (control) or SRP followed by diode laser (test). Plaque index, gingival index, bleeding on probing, probing depth, and clinical attachment level were measured at baseline and at 1, 3, and 6 months after treatment. The gingival crevicular fluid levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), matrix metalloproteinase-1 (MMP-1), matrix metalloproteinase-8 (MMP-8) and tissue inhibitor matrix metalloproteinase-1 (TIMP-1) were analyzed by enzyme-linked immunosorbent assay. Test group showed significantly a better outcome compared to the control group in full-mouth clinical parameters. MMP-1, MMP-8, and TIMP-1 showed significant differences between groups after treatment compared to baseline (p < 0.05). The total amount of IL-1β, IL-6, MMP-1, MMP-8, and TIMP-1 decreased (p < 0.05) and IL-8 increased after treatment in both test and control groups (p < 0.05). Diode laser provided significant improvements in clinical parameters and MMP-8 was significantly impacted by the adjunctive laser treatment at first month providing an insight to how lasers can enhance the outcomes of the nonsurgical periodontal therapy.

Clinical and biochemical effects of diode laser as an adjunct to nonsurgical treatment of chronic periodontitis: a randomized, controlled clinical trial

The dental literature contains 25 years of accumulated reports and clinical studies addressing the utility of lasers in the treatment of periodontitis, both as a monotherapy or as an adjunct to surgical and nonsurgical therapy. Yet, the evidence from the 118 human clinical studies cited in this narrative review remains conflicted and insufficient to suggest that integration of a laser in a periodontal treatment protocol will provide antimicrobial and healing outcomes superior to those achieved by traditional therapy. When viewed as a collective body of evidence, it becomes apparent that a majority of the studies are underpowered and exhibit significant heterogeneity in design. Furthermore, the collected studies report a varied choice of parameters, even within the same wavelength of laser. There is little uniformity between studies in the reporting of measured clinical parameters. Most studies reported 3- and/or 6-month post-treatment results; however, the range of time intervals includes studies reporting results from 1 week to up to 1–12 months or longer. Lastly, many studies were considered at risk for bias as a result of a lack of examiner masking and/or calibration. There is great need for well-designed, highly controlled multicenter clinical trials that are adequately powered in terms of subject enrollment, that use similar protocols in terms of laser parameters and that report measureable outcomes in a uniform manner. Without such studies, the questions surrounding the use of lasers in the treatment of periodontal disease will persist.

Lasers and the treatment of periodontitis: the essence and the noise

BACKGROUND The aim of this systematic review and meta-analyses was to assess the quality of evidence and efficacy of antimicrobial photodynamic therapy (aPDT) and laser irradiation (LI) as an adjunct to open flap debridement (OFD) in the treatment of chronic periodontitis. METHODS Electronic searches were conducted in databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Oral Health Group Trials Register databases) up to March 2019. Randomized clinical trials (RCTs) comparing clinical efficacy of either aPDT and/or LI, placebo, or no treatment were included. Primary outcomes included clinical attachment level (CAL), while secondary outcomes were reduction in probing depth (PD) and gingival recession (GR) depth. The weighted mean differences (WMD) of outcomes and 95% confidence intervals (CI) for each variable were calculated using random effect model. RESULTS Six RCTs were included. For aPDT studies, the overall mean difference for CAL gain (WMD = -0.61, 95% CI = -1.22 to -0.016, P = .044) and PD reduction (WMD = -1.79, 95% CI = -3.44 to -0.14, P = .034) was significant between aPDT and OFD groups at follow-up. No significant overall mean difference was observed for GR depth (WMD = 0.02, 95% CI = -0.75 to 0.79, P = .95). For LI studies, none of the clinical periodontal parameters including CAL gain (WMD = 0.23, 95% CI = -0.09 to 0.55, P = .159, Figure 3A), PD reduction (WMD = 0.31, 95% CI = -0.67 to 1.31, P = .52, Figure 3B) and GR depth (WMD = -0.34, 95% CI = -2.47 to 1.78, P = .74, Figure 3C) were found to be significant between LI and OFD groups at follow-up. CONCLUSION With the limited data available, only aPDT as an adjunct to OFD showed superior results for clinical periodontal parameters compared to OFD alone in the treatment of chronic periodontitis. Further RCTs are warranted in order to obtain robust conclusions with regard to laser therapy.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/phpp.12499

Clinical efficacy of photodynamic therapy and laser irradiation as an adjunct to open flap debridement in the treatment of chronic periodontitis: A systematic review and meta‐analysis

The aim of the present study was to evaluate the effects of photobiomodulation (PBM) on cytokine levels and angiogenesis during oral wound healing. Ulcers were made on the dorsum of the tongue in 48 Wistar rats. Irradiation with an indium-gallium-aluminum-phosphide (InGaAlP) laser (660 nm; output power, 40 mW; spot size, 0.04 cm(2)) was performed once a day on two points of the ulcer for 14 days. Two different energy densities were used: 4 J/cm(2) (energy per point 0.16 J, total energy 0.32 J) and 20 J/cm(2) (energy per point 0.8 J, total energy 1.6 J). Tissue levels of interleukin (IL)-1β and tumor necrosis factor (TNF)-α were investigated by enzyme-linked immunosorbent assay (ELISA). Image analysis of CD31-immunostained sections was used to investigate microvessel density (MVD). PBM increased the tissue levels of IL-1β at the early stage of oral wound healing (p < 0.01) and increased the tissue levels of TNF-α during all stages of oral wound healing (p < 0.05). PBM at a dose of 4 J/cm(2) produced more significant results regarding cytokine modulation and was associated with higher MVD at day 5. Collectively, these findings indicate that cytokine modulation and increased angiogenesis are among the basic mechanisms whereby PBM improves oral wound repair.

Photobiomodulation regulates cytokine release and new blood vessel formation during oral wound healing in rats.

Background and objectives: Research has shown that mechanical methods of periodontal therapy alone may fail to eliminate the tissue-invasive pathogenic flora; therefore, considerable attention has been given to adjunctive antimicrobial measures. The purpose of this study is to evaluate the efficacy of diode laser as an adjunct to mechanical debridement in periodontal flap surgery, on the basis of clinical parameters and microbiological analysis. Materials and methods: A total of 30 patients with generalized chronic periodontitis with probing depth >5 mm after phase I therapy were included in the study. Diode laser was used as an adjunct to open flap debridement (test) as compared with conventional flap surgery (control) in a split-mouth study design. Clinical parameters (plaque and gingival index, probing depth and relative clinical attachment level) and subgingival plaque samples of test and control groups were analyzed at baseline and 3 months post-therapy. Visual analogue scale (VAS) was used ...

A comparative evaluation of the efficacy of diode laser as an adjunct to mechanical debridement versus conventional mechanical debridement in periodontal flap surgery: a clinical and microbiological study.

Background: In the contemporary dental practice, alleviation of pain is the most important factor to ameliorate patient's condition and to gain one's confidence towards the skills of the operator. Such confidence aids to the ultimate success of the treatment procedures. Aims and Objectives: This study compares the pain response of a group of 10 subjects to the Wand ® with the response to traditional syringe injections and also compares the extent of the area anesthetized. Materials and Methods: 10 subjects were selected for the study and 20 injections were given contralaterally to them, 10 with Wand ® , and rest with the traditional aspirating syringe. Each subject received 2 injections on the palate, Left side with Wand ® (test) and Right side with Traditional syringe (control). All injections were given by the same investigator without the use of topical anesthetic spray/gel. Pain perception levels were recorded with a visual analogue scale. Also the extent of area anesthetized with a single palatal injection was assessed by probing. Results: The results showed injections with the syringe were more painful than injections with the Wand ® in 2 of 10 subjects. Also the extent of the area anesthetized by both the techniques was similar except in 2 patients. Conclusion: The Wand ® results in less painful injections; however, mean ratings of pain for both the groups, were mostly below the annoying level of pain. Also, the areas covered by the anesthetic effect of both the injections were comparatively similar.

A clinical comparison of pain perception and extent of area anesthetized by Wand(®) and a traditional syringe.

Objective: This randomized controlled double-blinded split mouth study sought to compare the levels of dentinal hypersensitivity (DH) and pain after 660 nm laser irradiation in test and control sites following periodontal flap surgery. Background data: Dentinal hypersensitivity and pain are the two main causes of discomfort after periodontal flap surgery. The analgesic and desensitising property of low-level lasers can be used to reduce postoperative complications following periodontal flap surgery. Materials and methods: Thirty patients were enrolled in this study. Periodontal flap surgery was performed on 60 sites. The test site was randomly determined for laser irradiation, and was irradiated by a sweeping motion of 660 nm laser (25 mW, 4.5 J) for 3 min for 3 consecutive days. The control site served as a placebo. Although the laser was used in a similar motion in the control sites, it was not activated postoperatively. A visual analogue scale (VAS) and verbal rating scale (VRS) for pain and D...

Effect of low-level laser therapy in reducing dentinal hypersensitivity and pain following periodontal flap surgery.

Background: Chlorhexidine (CHX) is considered as a gold standard of antimicrobial rinses. Various herbal oral rinses are available in the market. However, little is known of its effectiveness. Aim: The aim of this study was to evaluate the clinical changes after the usage of herbal oral rinse and 0.12% CHX. Subjects and Methods: In a randomized clinical trial, 76 patients with dental plaque-induced gingivitis were assigned to Group I (Herbal Oral Rinse - Hiora ; ) and 76 patients with dental plaque-induced gingivitis to Group II (0.12% Chlorhexidine-Peridex ; ). Gingival index and Plaque index scores were recorded at baseline and 21 days after scaling. Results: Intragroup comparison in both groups showed that plaque index and gingival index scores were statistically significant after 21 days as compared to baseline. Intergroup comparison showed that plaque index scores and gingival index scores were statistically significant in Group II as compared to Group I. Conclusion: When herbal oral rinse was compared to 0.12% CHX, 0.12% CHX mouth rinse effectively reduced the clinical symptoms of plaque-induced gingivitis.

The comparative effects of 0.12% chlorhexidine and herbal oral rinse on dental plaque-induced gingivitis: A randomized clinical trial.

Real-time dynamic navigation shows various advantages over static guides in the placement of dental implants. The goal of this article is to highlight a safe and alternative approach for transcrestal sinus augmentation and immediate implantation by dynamic navigation. It elaborates and defines numerous advantages of the trace and place workflow over the fiducial technique in dynamic navigation. The usage of osseodensifying burs were shown to have higher bone-implant contact, stability, and insertion torque. Their application allows drill-tip calibration that can thus be used for dynamic navigation allowing a real-time surgical evaluation for the implant placement. This article describes a novel technique for transcrestal sinus augmentation during implant placement with osseodensifying burs using dynamic navigation.

Sanjay Jain

Papers

A comparative evaluation of the efficacy of diode laser as an adjunct to mechanical debridement versus conventional mechanical debridement in periodontal flap surgery: a clinical and microbiological study.

A clinical comparison of pain perception and extent of area anesthetized by Wand(®) and a traditional syringe.

Effect of low-level laser therapy in reducing dentinal hypersensitivity and pain following periodontal flap surgery.

The comparative effects of 0.12% chlorhexidine and herbal oral rinse on dental plaque-induced gingivitis: A randomized clinical trial.

A dynamic surgical navigational approach for immediate implantation and transcrestal sinus augmentation.