Laser Applications in Periodontal Therapy
technological advance in both medicine and dentistry has been the use of
lasers. This position paper is a reflection
of the use of lasers in periodontal therapy with specific emphasis on efficacy
and treatment outcomes. As with any new
technology or technique, it is important to compare treatment outcomes against those
of existing traditional methods. An
extensive search of the current literature by the AADC Positions Committee was
conducted with emphasis on high level research involving randomized controlled
trials and systematic literature reviews where available. The Committee also
broadened the scope of the literature search by including current relevant
studies and opinions of respected organizations such as the American Association
of Periodontists (AAP), American Dental Association (ADA), and the Food and
Drug Administration (FDA).
Background and Summary of Evidence
are found in the literature describing techniques designed to regenerate new
periodontal attachment for patients with periodontal disease: Excisional New
Attachment Procedure (ENAP) and Laser Assisted New Attachment Procedure (LANAP). It is purported that these procedures, either
on their own or in conjunction with scaling and root planing (SRP), more
effectively reduce loss of clinical attachment level (CAL) and/or create
clinically significant new tissue attachment. When compared with traditional SRP or curettage, more complete removal
of diseased epithelium and more effective reduction of bacterial load in the gingival
sulcus have been proposed as the mechanisms by which laser therapy has been
advocated to be more effective. An article by Goldstep states the following:
More recent studies have shown that
instrumentation of the soft periodontal tissues with a diode laser leads to
complete epithelium removal while instrumentation with conventional curettes
leaves significant epithelial remnants.
There is very compelling evidence in the
dental literature that the addition of diode laser treatment to SRP planing (the gold standard in non surgical
periodontal treatment) will produce significant improved results.
There is significant proof that the addition
of Laser Assisted Periodontal Therapy to conventional scaling and root planing
by Goldstep is characteristic of a position paper and includes a bibliography
of supporting articles and studies. It is also noted in Dr. Goldstep’s
credentials that she is a consultant to a number of dental companies. However,
it is not specified whether her consulting duties exclude or include any laser
manufacturers in order to establish a lack of bias or confirm any potential
conflicts of interest.
An article by
Moritz et al. describes the bactericidal effects of the diode laser used in
conjunction with SRP which more effectively reduces inflammation when compared
with SRP and rinsing with H2O2. This study divided patients into two groups: a study group consisting of 37 patients who
underwent laser treatment in conjunction with SRP and a control group consisting
of 13 patients who received SRP and follow-up rinsing with H2O2. Results demonstrated that patients who were
treated with the laser along with SRP had significantly lower bacterial counts
after 6 months.
Moritz et al. study may indeed demonstrate the bactericidal effects of laser
treatment, it does not demonstrate long term effectiveness of therapy. Further, the Committee considers the study to
be questionable. Specifically, the study
demonstrates the following design deficiencies:
published study indicates patients were randomly subdivided, but does not
identify the randomization method.
of the study participants were not considered in the final evaluation because
of inadequate hygiene. There were none
removed from the control group for inadequate hygiene. It is possible that removal of participants
from the study group could weaken the evidence in favor of laser therapy thereby
creating a bias and skewing the results.
study group received laser therapy at appointment 2, followed by another laser
treatment at appointment 4 (less than 2 months after the first laser treatment)
and once again at appointment 5 (2 months after the second laser
treatment). A microscopic examination
was performed 2 months after the third laser therapy session. The effectiveness of bacterial reduction
after 2 months following 3 laser treatments completed within the previous 6
months does not, represent a significant finding of long term success.
is apparent from the published study that the examiner (one examiner for all
exams for both groups) was not blinded which could introduce a bias
particularly when pocket depth probings are subjective.
article published by Yukna et al. reported histological treatment outcomes
demonstrating that delivery of LANAP using a Nd:YAG laser reduced probing
depths and increased clinical attachment gains in teeth affected by moderate to
severe periodontal disease when compared to the outcomes of teeth treated with conventional
SRP alone. The authors found that the teeth treated with adjunctive laser
therapy showed new cementum growth and new connective tissue attachment. In
contrast, the control group teeth (treated by conventional SRP alone) showed reattachment
by long junctional epithelium only without evidence of regeneration of cementum
or new connective tissue attachment. However, while the outcomes of this
study may appear to support the clinical value of adjunctive laser therapy in
managing periodontal disease, it is important to note that the study was of
short duration (3 months), not double blinded, and the sample size was limited
to the treatment of 6 subject teeth (treated with LANAP) and 6 control teeth
(treated with SRP alone). In addition, the study was funded and supported by a
laser manufacturer which may raise questions about potential bias.
researched the counterbalance of literature and found a more extensive compilation
of studies where the results demonstrate no significant benefit associated with
the use of lasers in the treatment of periodontal disease. An article by Cobb concludes
...there is limited
evidence suggesting that lasers used in an adjunctive capacity to scaling and
root planing may provide some additional benefit. Establishment of a sound evidence base for
laser usage in treatment of chronic periodontitis will require randomized,
blinded, controlled, longitudinal, clinical trials.
systematic review by Karlsson, Lofgren, and Jansson rises to a higher level of evidence
No consistent evidence supports the efficacy
of laser treatment as an adjunct to non-surgical periodontal treatment in adults
with chronic periodontitis. More randomized controlled clinical trials are
controlled trial published by Ambrosini et al. demonstrated no additional
advantage of laser application delivered in conjunction with SRP over SRP
alone. While the study may be considered
dated since it was published in 2005 and was limited to a sample size of 30,
the overall study design is considered strong because it removed most
confounding influences by using the same patient as both control and study
group. In this study, patients were treated with SRP alone on one side of the
mouth and SRP with adjunctive laser treatment on the other side.
studies comparing SRP alone and SRP with adjunctive laser treatment confirmed
the results of the Ambrosini et al. study. Tomasi, Schander, and Dahlen found a statistically significant
difference in probing depth reduction and clinical attachment level gain using
the Er:YAG laser over ultrasonic scaling alone one month following
treatment. However, after 4 months,
there was no statistically significant difference in either pocket depth (PD)
or CAL.The study also found no significant
differences in microbiologic composition at baseline, 2 days post intervention,
and 30 days post intervention. They did
observe less treatment discomfort with the laser treatment over the ultrasonic
scaler. The authors concluded that the
result of the trial failed to demonstrate any apparent advantage using the
Er:YAG laser for subgingival debridement.
Lopes et al. published
a study that resulted in similar conclusions to those found in previous
studies. This study included 21 subjects with pocket depths ranging from 5 to 9
mm and used a split-mouth design that randomly allocated sites to SRP and laser,
laser only, SRP only and no treatment. While bleeding on probing and probing depths improved in each of the
treatment groups over the no treatment group, the CAL gain was significant for
the SRP only group without similar CAL gains observed in the other treatment
The AAP also published
a statement regarding the use of dental lasers for ENAP in 1999 and concluded,
in part, the following:
The Academy is not aware of any published
data that indicates that the ENAP laser procedure is any more effective…than
traditional scaling and planing.
There are no published data that demonstrate
that either curettage or ENAP are effective in periodontal regeneration. To the contrary, there is peer reviewed
evidence, both in vivo and in vitro, that use of lasers for ENAP procedures
and/or gingival curettage may place patients at risk for damage to root
surfaces and subjacent alveolar bone that, in turn, could render these tissues
incompatible to normal cell attachment and healing.
Committee is not aware of any changes or updates to the statement from the AAP.
Additionally, Dederich and Bushick from the ADA Council on Scientific Affairs
and Division of Science published an article discussing the different types of
lasers currently used in dentistry, safety, efficacy and effectiveness, and
clinical applications. Their conclusions include the following:
…many lasers now sold in the United States
have a 510(k) clearance for marketing through the U.S. Food and Drug
Administration, or FDA, but how many dentists understand what this clearance
signifies? This clearance enables companies to expedite the process of entry to
the marketplace for products the FDA considers similar to devices already on
the market. Often, this 510(k) clearance is misconstrued as FDA approval, which
requires multiple-site testing to demonstrate safety and efficacy. To obtain
510(k) clearance, manufacturers must demonstrate only results equivalent to
those of an existing, approved technology. From
the scientific perspective, however, such an abbreviated process has
A critical review of the best available
evidence, however, strongly indicates that there is no added benefit to the
patient when this procedure (laser curettage) is performed after traditional
mechanical scaling and root planing.
Proponents of laser curettage point to the
ability of these lasers to kill microorganisms.
Although the data indicates that this effect is possible albeit
inconsistent, it has not been correlated with an improvement in periodontal
With no demonstrable benefit and with a
significant risk of collateral damage to the periodontium, laser curettage
appears to be neither scientifically nor ethically justified.
the article by Dederich and Bushick, the ADA Council on Scientific Affairs published
a statement in April 2009 on lasers in dentistry. The statement further addressed
the safety and efficacy of lasers and clinical applications including treatment
of periodontal disease. The conclusions drawn in the ADA statement remain largely unchanged from
those previously cited by Dederich and Bushnick. Some of the highlights of the ADA’s statement include
All dental lasers currently available on the U.S. market
have been issued 510(k) clearances by the FDA. 510(k) submissions are reviewed
and processed by the Center for Devices and Radiological Health (CDRH) in the
Given the many factors that are appropriate
to evaluate when using lasers in biological systems, the Council feels that the
510(k) process alone is not inherently sufficient to scientifically demonstrate
safety, efficacy, or effectiveness for marketed dental laser applications in
all cases. Properly designed preclinical and clinical studies are often needed
to demonstrate safety, efficacy and clinical effectiveness for specific
products and uses.
encourages dental practitioners to cautiously consider claims of safety and
efficacy that are purely based on the product having been cleared for market by
the FDA through the 510(k) process. It is appropriate and prudent for the
practitioner to request detailed information from the manufacturer about the
scientific evidence that forms the basis for the marketed use.
There is little convincing clinical evidence that
adjunctive laser curettage produces a result superior to adjunctive mechanical
or chemical curettage, or even scaling and root planing alone. Current evidence
suggests that therapies intended to arrest and control periodontitis depend
primarily on effective root debridement.
clinical data from properly designed clinical trials with adequate sample sizes
are still required before it can be known to what extent LANAP is safe and
effective across the spectrum of patients with chronic periodontitis. The
Council therefore cautions clinicians to weigh the available evidence for LANAP
when considering the options available for treatment of the periodontal
Lasers, as a
group, have inconsistently demonstrated the ability to reduce microorganisms
within a periodontal pocket. It appears from the literature that mechanical
root debridement remains a priority to attain improvements in clinical
attachment levels. However, limited new data suggest that clinical outcomes may
be enhanced by the adjunctive use (following root debridement) of a
bactericidal irrigant activated by a cold laser.
the current scientific literature related to the use of lasers in the treatment
of chronic periodontal disease, the AADC Positions Committee has concluded that
the best available evidence-based studies do not support the adjunctive value
of lasers for improving clinical outcomes when used alone or in conjunction
with conventional surgical and non-surgical periodontal therapy. The Positions
Committee acknowledges that more extensive research should continue in order to
best assess the role of adjunctive laser therapy in the treatment of
periodontal disease and ascertain any contributions to improving long term
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AADC Positions Committee
Pesillo (Principal Author)
Dr. Stephanie Lepsky
Dr. Cary Sun
Dr. Fred Tye