Erbium:YAG laser compared Erbium:YAG laser compared to scaling and root planing to scaling and root planing

in periodontal treatmentin periodontal treatment

A controlled, prospective clinical studyA controlled, prospective clinical study

Frank Schwarz*¹, Anton Sculean², Thomas Georg² and Elmar Reich²

¹ Department of Oral and Maxillofacial Surgery Ludwig Maximilians University Munich, Germany

² Department of Periodontology and Conservative Dentistry, University of Saarland Homburg, Germany

Background:Background:

The Er:YAG laser is expected to be useful in The Er:YAG laser is expected to be useful in

medical and dental applications because its medical and dental applications because its

emission wavelenght (2.94 µm) is highly emission wavelenght (2.94 µm) is highly

absorbed by waterabsorbed by water

Background:Background:

Er:YAG lasers have shown their capacity in Er:YAG lasers have shown their capacity in

removing plaque and calculus present on removing plaque and calculus present on

periodontally diseased root surfaces periodontally diseased root surfaces in vitroin vitro

and and in vivoin vivo (Aoki et al. 1994, Folwaczny et (Aoki et al. 1994, Folwaczny et

al. 2000, Schwarz et al. 2001)al. 2000, Schwarz et al. 2001)

Background:Background:StudyStudy TimeTime GroupGroup PPD (0)PPD (0) PPD (1)PPD (1) CAL (0)CAL (0) CAL (1)CAL (1)

Watanabe et al.Watanabe et al.

J Clin Laser Med Surg 1996J Clin Laser Med Surg 1996

4 Weeks4 Weeks LaserLaser 5.6 ± 2.05.6 ± 2.0 2.6 2.6 ± 0.9± 0.9 -- --

Jepsen at al.Jepsen at al.

J Dent Res (Abstr) 2000J Dent Res (Abstr) 2000

3 Months3 Months LaserLaserSRPSRP

3.9 3.9 ± 0.8± 0.83.9 ± 0.83.9 ± 0.8

2.9 2.9 0.60.6

2.9 2.9 0.60.6

Gain:Gain:Gain:Gain:

0.3 0.3 0.20.2

0.4 0.4 0.30.3

Schwarz et al.Schwarz et al.

Parodontologie 2000Parodontologie 20006 Months6 Months LaserLaser 4.7 4.7 ± 0.7± 0.7 3.1 ± 0.63.1 ± 0.6 6.1 ± 1.16.1 ± 1.1 4.6 ± 1.04.6 ± 1.0

Schwarz et al.Schwarz et al.

J Periodontol 2001J Periodontol 20016 Months6 Months LaserLaser

SRPSRP4.9 4.9 ± 0.7± 0.75.0 ± 0.65.0 ± 0.6

2.9 2.9 ± 0.6± 0.63.4 ± 0.73.4 ± 0.7

6.3 6.3 ± 1.1± 1.16.5 ± 1.06.5 ± 1.0

4.4 4.4 ± 1.0± 1.05.5 ± 1.05.5 ± 1.0

Schwarz et al.Schwarz et al.

J Clin Periodontol (in press)J Clin Periodontol (in press)12 Months12 Months Laser + SRPLaser + SRP

LaserLaser5.2 ± 0.85.2 ± 0.85.0 ± 0.75.0 ± 0.7

3.2 ± 0.83.2 ± 0.83.3 ± 0.73.3 ± 0.7

6.9 ± 1.06.9 ± 1.06.6 ± 1.16.6 ± 1.1

5.3 ± 1.05.3 ± 1.05.0 ± 0.75.0 ± 0.7

Objectives:Objectives:

The aim of the present study was to assess The aim of the present study was to assess

the clinical effectiveness of an Er:YAG laser the clinical effectiveness of an Er:YAG laser

when compared to well established when compared to well established

procedures such as scaling and root planingprocedures such as scaling and root planing

Material and Methods:Material and Methods:

20 patients (age: 28 to 79 years) 20 patients (age: 28 to 79 years) advanced periodontal diseaseadvanced periodontal diseasea total of 34 maxillary and 21 mandibular a total of 34 maxillary and 21 mandibular pairs of contralateral single- and multi- pairs of contralateral single- and multi- rooted teethrooted teethgood oral hygienegood oral hygieneno systemic diseasesno systemic diseasestreatment according to a split-mouth designtreatment according to a split-mouth design

Material and Methods:Material and Methods:

For 4 weeks before treatment all patients For 4 weeks before treatment all patients were enrolled in a hygiene program and were enrolled in a hygiene program and received oral hygiene instructions at 2 to 4 received oral hygiene instructions at 2 to 4 appointments as well as professional tooth appointments as well as professional tooth cleaning according to individual needscleaning according to individual needs

A supragingival professional tooth cleaning A supragingival professional tooth cleaning was performed at baseline as well as 3, 6 and was performed at baseline as well as 3, 6 and 12 months after treatment12 months after treatment

Treatment of test group:Treatment of test group:

KEY IIKEY II®® (KaVo, Biberach, Germany) (KaVo, Biberach, Germany)handpiece 2056handpiece 2056fiber tips of 0.5 x 1.65 and 0.5 x 1.1fiber tips of 0.5 x 1.65 and 0.5 x 1.1energy level 160 mJ/pulse at 10 ppsenergy level 160 mJ/pulse at 10 ppswater irrigationwater irrigationtreatment from coronal to apical in parallel treatment from coronal to apical in parallel pathspathsinclination of the fiber tip of 15-20inclination of the fiber tip of 15-20° to root ° to root surface (Folwaczny et al. 2001)surface (Folwaczny et al. 2001)treatment under local anesthesiatreatment under local anesthesia

CLINICAL PICTURECLINICAL PICTURE

HANDPIECE 2056HANDPIECE 2056

Background:Background:

Treatment of control group:Treatment of control group:

scaling and root planing (SRP)scaling and root planing (SRP)

Gracey curettes (Hu-Friedy, Chicago, USA) Gracey curettes (Hu-Friedy, Chicago, USA)

no. 1/2, 3/4, 7/8, 11/12, 13/14no. 1/2, 3/4, 7/8, 11/12, 13/14

treatment under local anesthesiatreatment under local anesthesia

Treatment time:Treatment time:

Single rooted teethSingle rooted teeth Multi rooted teethMulti rooted teeth

LaserLaser 5 minutes5 minutes 10 minutes10 minutes

SRPSRP 9 minutes9 minutes 15 minutes15 minutes

Clinical measurements:Clinical measurements:

plaque index (PI) (Silness & Löe 1964)plaque index (PI) (Silness & Löe 1964)

gingival index (GI) (Löe & Silness 1963)gingival index (GI) (Löe & Silness 1963)

bleeding on probing (BOP)bleeding on probing (BOP)

probing pocket depth (PPD)probing pocket depth (PPD)

gingival recessions (GR)gingival recessions (GR)

clinical attachment level (CAL)clinical attachment level (CAL)

Microbiological evaluation:Microbiological evaluation:

subgingival plaque samplessubgingival plaque samples

analysed using darkfield microscopy for the analysed using darkfield microscopy for the

presence of:presence of:

– coccicocci

– non motile rodsnon motile rods

– motile rodsmotile rods

– SpirochetesSpirochetes

((Listgarten & Helldén 1978Listgarten & Helldén 1978))

Assessments:Assessments:

recordings of clinical indices were assessed recordings of clinical indices were assessed

before treatment, 3, 6 and 12 months after before treatment, 3, 6 and 12 months after

treatment treatment

one calibrated and blinded examinerone calibrated and blinded examiner

statistical analysis by paired statistical analysis by paired tt-test -test (n.s. = non significant; * (n.s. = non significant; * pp0.05; ** 0.05; ** pp0.01; *** 0.01; *** pp0.001)0.001)

IndexIndex Baseline Baseline (± SD)(± SD)

3 Months 3 Months (± SD)(± SD)

PP 6 Months 6 Months (± SD)(± SD)

PP 12 Months 12 Months (± SD)(± SD)

PP

PIPI LaserLaser SRPSRP PP Value Value

1.0 1.0 0.6 0.61.0 1.0 0.6 0.6

n.s.n.s.

0.7 0.7 0.4 0.40.5 0.5 0.5 0.5

n.s.n.s.

****

0.7 0.7 0.4 0.40.7 0.7 0.5 0.5

n.s.n.s.

****

0.6 0.6 0.4 0.40.7 0.7 0.5 0.5

n.s.n.s.

****

GIGI LaserLaser SRPSRP PP Value Value

1.9 1.9 0.6 0.61.9 1.9 0.6 0.6

n.s.n.s.

0.5 0.5 0.6 0.60.7 0.7 0.8 0.8

n.s.n.s.

************

0.3 0.3 0.6 0.60.4 0.4 0.8 0.8

n.s.n.s.

************

0.4 0.4 0.3 0.30.5 0.5 0.7 0.7

n.s.n.s.

************

BOPBOP LaserLaser SRPSRP PP Value Value

56 %56 %52 %52 %n.s.n.s.

17 %17 %22 %22 %

**

************

13 %13 %23 %23 %

**

************

14 %14 %26 %26 %

****

************

Results (PI/ GI/ BOP):Results (PI/ GI/ BOP):

Results (PPD/ GR/ CAL):Results (PPD/ GR/ CAL):IndexIndex Baseline Baseline

(± SD)(± SD)3 Months 3 Months

(± SD)(± SD)PP 6 Months6 Months

(± SD)(± SD)PP 12 Months 12 Months

(± SD)(± SD)PP

PPDPPD LaserLaser SRPSRP PP Value Value

4.9 ± 0.74.9 ± 0.75.0 ± 0.65.0 ± 0.6

n.s.n.s.

3.5 ± 0.63.5 ± 0.63.8 ± 0.73.8 ± 0.7

**

************

2.9 ± 0.62.9 ± 0.63.4 ± 0.73.4 ± 0.7

******

************

3.0 ± 0.83.0 ± 0.83.5 ± 1.33.5 ± 1.3

******

************

GRGR LaserLaser SRPSRP PP Value Value

1.4 ± 0.81.4 ± 0.81.5 ± 0.81.5 ± 0.8

n.s.n.s.

1.5 ± 0.71.5 ± 0.71.9 ± 0.81.9 ± 0.8

****

n.s.n.s.******

1.5 ± 0.71.5 ± 0.72.0 ± 0.82.0 ± 0.8

******

n.s.n.s.******

1.5 ± 0.71.5 ± 0.72.1 ± 0.72.1 ± 0.7

******

n.s.n.s.******

CALCAL LaserLaser SRPSRP PP Value Value

6.3 ± 1.16.3 ± 1.16.5 ± 1.06.5 ± 1.0

n.s.n.s.

5.1 ± 1.05.1 ± 1.05.6 ± 1.15.6 ± 1.1

****

************

4.4 ± 1.04.4 ± 1.05.5 ± 1.05.5 ± 1.0

******

************

4.5 ± 1.34.5 ± 1.35.6 ± 1.45.6 ± 1.4

******

************

Distribution of bacteria (Laser):Distribution of bacteria (Laser):

0%

5%

10%

15%

20%

25%

30%

35%

40%

cocci non-motile rods motile rods spirochetes

Laser Baseline

Laser 3 Months

Laser 6 Months

Laser 12 Months

Distribution of bacteria (SRP):Distribution of bacteria (SRP):

0%

5%

10%

15%

20%

25%

30%

35%

40%

cocci non-motile rods motile rods spirochetes

SRP Baseline

SRP 3 Months

SRP 6 Months

SRP 12 Months

Conclusion:Conclusion:

The results of the present study indicate The results of the present study indicate

that non-surgical periodontal treatment that non-surgical periodontal treatment

with an Er:YAG laser is an alternative to with an Er:YAG laser is an alternative to

scaling and root planing with hand scaling and root planing with hand

instrumentsinstruments