Abstract
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In the past several decades, there has been extensive development of periodontal treatment. However, although considerable progress has been made in this area, we are still looking for therapy modalities that are safe, efficient, patient centered, and, last but not least, cost-effective. For more than 50 years, the dental community has looked at lasers and their expediency for the treatment of various dental conditions. The application of lasers has been recognized as an adjunctive or alternative approach in periodontal and peri-implant therapy. I am convinced that the time has come to make laser therapy a new gold standard—a necessary step in protocol of periodontal pocket treatment. The unique characteristics of laser technology, such as ablation, hemostasis, bactericidal and detoxification effect, as well as promotion of tissue regeneration and wound healing make it possible to treat soft and hard tissues in a manner that is beyond the scope of conventional techniques. 1
The established traditional gold standard in periodontal treatment is ultrasound and hand instrumentation. However, evidence has demonstrated that mechanical debridement alone, such as scaling and root planing (SRP), may not be sufficient to eradicate the periodontal pathogens; therefore, adjunctive use of systemic antibiotics is recommended for the treatment of aggressive or severe chronic periodontitis. Clinical improvements, particularly the reduction of deep pockets, from the adjunctive antibiotic therapy are meaningful in that it can reduce the need of surgical therapy after SRP. However, subgingival bacteria exist in biofilm, not as single cells, and as such are more difficult to eliminate with antibiotics. There is general agreement that antibiotics affect general health—they disrupt the healthy equilibrium in the intestinal tract, and thus can affect host defense mechanisms and the functioning of the immune system. It cannot be overstated that clinicians be cautious and selective in applying the adjunctive antibiotic therapy because of a multiplicity of possible side effects of systemic antibiotics, including allergic reactions, drug interactions, and bacterial resistance. World Health Organization has long been educating and warning of the growing problem of antibiotic resistance, caused by overprescribing, patients not finishing their treatment, overuse of antibiotics in livestock and fish farming, poor infection control in hospitals, lack of hygiene, and poor sanitation. Lack of new antibiotics is especially worrying—there has not been a new one in three decades, whereas there are new diseases and super bugs developing all the time.
Antibiotic resistance has become a serious public health issue in recent years with high economic and social costs. It prolongs the healing and thus the treatment, contributes to higher mortality, increases the economic costs of medical care as it requires more expensive drugs, and thus increases burden on the health system. Dentists can contribute to solving these problems by selective, rather than routine, use of antibiotics, and by developing treatment protocols that are minimally invasive, safe, and efficient, such as laser therapy. Gutknecht et al. 2 showed that laser treatment is a new effective way of treating periodontitis without antibiotics, and emphasized that even if it helps to avoid loading human systems with antimicrobials only in some cases, it is already a positive step.
Research shows how periodontal health influences general health. Periodontitis is associated with most chronic inflammatory diseases of ageing, including atherogenic cardiovascular disease, stroke, type 2 diabetes, rheumatoid arthritis, chronic kidney disease, obesity, and chronic obstructive pulmonary disease. 3 The costs of treatment of combined chronic inflammatory diseases, including periodontal diseases, are so high that we need to look for efficient ways to reduce them and ensure improvement of general health. Cost-based results suggest that laser periodontal therapy has the potential to be an effective, minimally invasive, and safe treatment modality. Laser technology contributes to greater patient safety without producing irreversible changes and results in less postoperative pain and fewer complications. In their editorial, Brugnera Junior and Bagnato point out an important advantage of phototherapy—a possibility of numerous applications with no side effects. 4
Photodynamic therapy—light-induced inactivation of toxic microorganisms—is a novel therapeutic approach that best exemplifies how safe and efficient laser technology is in the treatment of periodontal inflammation. Eradication of periopathogens using photodynamic therapy is defined as antimicrobial photodynamic therapy (aPDT), photodynamic antimicrobial chemotherapy, or photodynamic disinfection. Photoinactivation of bacteria is tightly restricted to the localization of the photosensitizer, ensuring the protection of distant cells from side effects. Since conventional treatment such as SRP does not completely eliminate periodontal pathogens, especially in deep periodontal pockets, aPDT makes an alternative therapeutic strategy. A systematic review and meta-analysis 5 reported clinically and statistically significant differences between aPDT adjunctive to SRP and conventional SRP alone in probing depth (PD) reduction. Photoactive disinfection helps ensure a lasting success of periodontal treatment as a supportive therapy for clinical attachment level gain, PD reduction, and is recommended for the maintenance treatment of residual pockets.
Systematic literature reviews describe the many positive effects of laser therapy. There are clinical reports of successful laser applications in periodontal and peri-implant diseases. High-power lasers have been especially useful for periodontal debridement, ablation, vaporization, hemostasis, and disinfection effects as well as biological effects, such as photobiomodulation. Two procedures merit special attention—laser-assisted new attachment procedure (LANAP) and laser-assisted comprehensive periodontal pocket therapy (Er-LCTP). Both constitute minimally invasive and effective approaches. Studies show that laser periodontal debridement is a novel prophylactic treatment to prevent or minimize transient bacteria with no or minimal root surface damage. LANAP, a minimally invasive technique of pocket therapy using Nd:YAG laser, helps achieve new connective tissue attachment and promotes regeneration of root surface. Er-LCTP, which uses erbium laser, has been reported effective in subgingival calculus removal in nonsurgical pocket therapy. Erbium lasers are capable of ablating subgingival calculus effectively without causing thermal damage on the root surface, any significant side effects, and complications. The Er:YAG laser is used both as an alternative and an adjunct to mechanical therapy for pocket treatment in clinical practice. In the application of an Er:YAG laser for surgical debridement, the Er:YAG laser not only facilitates the debridement procedure in flap surgery but also might be advantageous for tissue repair and regeneration. Looking at the reported positive effects of both therapies, it seems a natural step in the development of minimally invasive, efficient, and safe treatment to combine both high-power lasers in a single protocol.
Several decades after the introduction of lasers into treatment protocols, we have at our disposal enough evidence that laser technology constitutes a beneficial adjunct or alternative therapy. Considering all the established positive effects of using lasers in periodontal and peri-implant treatment, as well as promising preliminary results of currently conducted studies, I would suggest the dental community stick to the old postulate—“primum non nocere” and look at ways to apply treatment procedures that benefit the patient, ensure best results and efficacy. Laser technology offers such a possibility and thus should become a new gold standard in the treatment of periodontal and peri-implant diseases.