|Year : 2018 | Volume
| Issue : 2 | Page : 64-69
Deploying diode laser in periodontics: An evidence-based review
Nidhi Kirit Shah, Jasuma J Rai, Deepak H Dave, Jaimini K Patel
Department of Periodontology and Implantology, KM Shah Dental College and Hospital, Vadodara, Gujarat, India
|Date of Web Publication||8-May-2018|
Nidhi Kirit Shah
Department of Periodontology, KM Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Vadodara - 391 760, Gujarat
Source of Support: None, Conflict of Interest: None
Lasers have completely changed the concept of dental treatment since three and half decades of 20th century. After the invention of ruby laser by Maiman in 1960, laser has become the most magnetizing technology in dentistry. Diode Lasers have been used in initial periodontal therapy, surgery, and also in implant treatment. In many countries Laser has become a part of the dental armamentarium. The included articles were searched from PubMed, Trip Database, Google scholar and Cocharane database. The purpose of this review article is to critically analyze the effectiveness of diode laser on soft and hard tissue in the field of Periodontics.
Keywords: Diode laser, periodontal surgery, periodontitis, periodontology, scaling and root planning
|How to cite this article:|
Shah NK, Rai JJ, Dave DH, Patel JK. Deploying diode laser in periodontics: An evidence-based review. Adv Hum Biol 2018;8:64-9
| Introduction|| |
One very exciting technology making great inroads into lot of areas of dentistry today is the LASER technology. Based on Albert Einstein's theory of spontaneous and stimulated emission of radiation, Maiman developed the first laser prototype in 1960. Maiman's device used a crystal medium of ruby that emitted a coherent radiant light from the crystal when stimulated by energy. Thus, the ruby laser was created. The application of a laser to dental tissue was reported by Stern and Sognnaes  and Goldman et al. in 1964, describing the effects of ruby laser on enamel and dentin with a disappointing result. The laser is an acronym for the light amplification by stimulated emission of radiation.
The laser beam is essentially a beam of a light comprising excited photons. Laser is a device that converts electrical or chemical energy into light energy. In contrast to ordinary light that is emitted spontaneously by excited atoms or molecules, the light emitted by the laser occurs when an atom or molecule retains excess energy until it is stimulated to emit it. The radiation emitted by lasers including both visible and invisible light is more generally termed as electromagnetic radiation. Albert Einstein first proposed the concept of stimulated emission of light in 1917. He described three processes:
- Spontaneous emission
- Stimulated emission.
| Laser Effects on Tissue|| |
The light energy from a laser can have four different interactions with the target tissue, and these interactions will depend on the optical properties of that tissue. The first three interactions are used in periodontics. When radiant energy is absorbed by tissue, four basic types of interactions or responses may occur.
Biostimulation, which describes the stimulatory effects of laser light on biochemical and molecular processes that normally occur in tissues such as healing and repair.
Photo thermal interactions include
Photoablation or the removal of tissue by vaporisation and superheating of tissue fluids, coagulation and haemostasis.
Photomechanical interaction include
Photo-disruption or photo-disassociation, which is the breaking apart of structures by laser light.
Photoelectrical interactions include
Photo plasmolysis which describes how tissue is removed through the formation of electrically charged ions and particles that exist in a semi-gasseous high energy state.
Lasers have tended to be big, clunky, hard to use, expensive machines that were largely ignored. Affordable, effective, user-friendly diode lasers (DLs) have only arrived on the scene since the early 1990s. The DL, in a very short time, has proven itself to be the ideal soft-tissue handpiece. The DL is a solid-state semiconductor laser that generally uses a combination of Gallium (Ga), Arsenide (Ar) and other elements such as Aluminium (Al) and Indium (In) to change electrical energy into light energy. The wavelength ranges from about 800 to 980 nm. It is emitted in continuous-wave and gated-pulsed modes and is usually operated in a contact method using a flexible fibre optic delivery system.
Laser light at 800–980 nm is poorly absorbed in water but highly absorbed in haemoglobin (Hb) and other pigments [Figure 1]. Since the DL basically does not interact with dental hard tissues but is an excellent as soft-tissue surgical laser, indicated for cutting and coagulating gingiva and oral mucosa, and for soft-tissue curettage or sulcular debridement.
The articles reviewed were from PubMed, Trip Database, Google scholar and Cocharane database; relevant studies were identified from January 1987 to July 2017. The MeSH terms used were 'lasers, semiconductor' (MeSH Terms) OR ('lasers' [All Fields] AND 'semiconductor' [All Fields]) OR 'semiconductor lasers' (All Fields) OR ('diode' [All Fields] AND 'laser' [All Fields]) OR 'diode laser' [All Fields]) AND (periodontal [All Fields] AND ('therapy' [Subheading] OR 'therapy' [All Fields] OR 'treatment' [All Fields] OR 'therapeutics' [MeSH Terms] OR 'therapeutics' [All Fields]. Only randomised control trials (RCTs), clinical control trial, systematic review and meta-analysis were included as evidences in this review.In vitro studies, animal studies and case reports were excluded.
| Discussion|| |
Many of these lasers have been shown to provide periodontal treatment benefits [Table 1]. To achieve an element of clarity and simplicity on this very complex topic, the following discussion exclusively addresses the use of the DL for periodontal treatment [Table 2].
|Table 2: Studies with level of evidence on application of diode laser in periodontics|
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In scaling and root planning
The use of DL is one of the most promising new technical modalities for nonsurgical periodontal treatment and has an advantage of reaching sites that cannot be approached by conventional mechanical instrumentation. In a randomised, parallel, controlled clinical trial, Saglam et al. assessed the clinical and biochemical efficacy of DL as an adjunct to scaling and root planning (SRP) in the treatment of chronic periodontitis (CP). The 6-month follow-up results showed a significant reduction in plaque Index (PI), gingival index (GI), bleeding on probing, probing pocket depth (PPD) and clinical attachment level (CAL) in patients treated with SRP and DL therapy as compared with patients who received SRP alone.
A systematic review conducted by Qadri et al. concluded that treatment of CP patients with probing the depth of ≥5 mm was more effective in DL s and SRP plus DL (800–980 nm) group as compared to SRP group alone. In contrast, Nguyen et al. found that adjunctive use of the DL to SRP did not enhance clinical outcomes compared to SRP alone in the treatment of inflamed sites with ≥5 mm probing depth.
Gupta et al. evaluated the effectiveness of DL on PI, GI, PPD and CAL and microbial count in CP patients and compared the outcome with SRP alone. He stated that the DL at a higher, but clinically safe frequency (940 nm) at repeated intervals showed a better efficacy in ensuring a better periodontal heath as compared to SRP alone. Alzoman and Diab  in a RCT showed the reduction in the percentage of Porphyromonas gingivalis-positive sites in the SRP + DL group after laser irradiation. Koçak et al. evaluated effect of non-surgical periodontal therapy with/without DL on clinical parameters, the levels of interleukin-1β (IL-1β), IL-6, IL-8, intercellular adhesion molecule and vascular cell adhesion molecule in gingival crevicular fluid and metabolic control (HbA1c) in CP patients with diabetes mellitus type 2 (DM2). The SRP + DL group provided better result in relation to clinical and immunological parameters. SRP especially in combination with DL shows improvement of glycemic control for DM2 patients with CP.
Dentine hypersensitivity (DH) is a common painful clinical problem arising from exposed dentine which can be as a result of the gingival recession, periodontal treatment such as scaling, root planing and also improper tooth brushing, which cannot be attributed to any other dental pathology. Dilsiz et al. randomly divided into two groups: the test group, which received treatment with desensitiser toothpaste and GaAlAs (diode) laser, and the control group, treated with desensitiser toothpaste. The result showed a higher degree of desensitisation in teeth with gingival recession in the test group than did the control group. Yilmaz et al. concluded that GaAlAs laser irradiation was effective in the treatment of DH, and it is a more comfortable and faster procedure than traditional DH treatment.
In photodynamic therapy
The presence of bacterial biofilms is the major cause of gingivitis and periodontitis, their mechanical removal is not often enough. Therefore, laser therapy (LT) and photodynamic therapy (PDT) can be effective as adjunctive treatment. Birang et al. did a study to compare SRP alone with an adjunct to LT and PDT and found that adjunctive LT or PDT shows more improvement in term of CAL gain compared to SRP alone (3 months follow-up). Regarding PPD reduction, adjunctive LT was more efficient than adjunctive PDT or SRP alone (P< 0.05) A similar study done by Teymouri et al. concluded that laser and PDT reduces the inflammatory mediators (IL-1β and IL-17) and improves the clinical symptoms (PPD and CAL).
Among the various techniques for depigmentation, lasers offer a promising therapeutic option since it is simple, painless due to formation of protein coagulum and leaves blood less field by sealing small blood and lymphatic vessels as a result of the heat generation. Another hypothesis for painless procedure was that there may be an increase in pain threshold after LT resulting in neural blockade, specifically inhibition of A and C neural fibres. This inhibition may be mediated by altering the axonal flow or by inhibiting neural enzymes). In addition, data suggest an increase in endorphin production and opioid receptor binding through opioid containing leucocytes. In a RCT (2016), the authors found the clinical efficacy of gingival depigmentation procedure was effective with both scalpel and laser techniques. However, the laser treated sites showed reduced pain experienced by the patient and better operator comfort. Slight melanin repigmentation was observed in three subjects treated with scalpel depigmentation procedure at the end of 1 year.
Poor oral hygiene induced inflammatory hyperplasia and/or altered passive eruption can affect several key elements of the smile such as tooth proportionality, proper gingival architecture, and even gingival display on smiling. The excision created by a soft-tissue DL can be more precise, with sterilising the wound, maintaining a clearer and clean surgical field when compared with using a scalpel. This finding was refuted by Sobouti et al. in their study.
In crown lengthening
Periodontal tissues should be prepared properly before restorative treatment to ensure good form, function, and aesthetics of the masticatory apparatus, as well as patient comfort. To et al. compared the effectiveness of the DL gingivectomy as an adjunct to nonsurgical periodontal treatment in the management of periodontal health among patients receiving fixed orthodontic appliance therapy (FOAT) and concluded that both treatments can be effective in the management of gingival health problems among patients receiving FOAT but, the adjunctive use of lasers can produce an earlier and greater improvement in gingival health. Ize-Iyamu et al. conducted an RCT and reported that orthodontic patients treated with the DL required less infiltration anaesthesia, had reduced bleeding during and after surgery, rapid post-operative haemostasis, elimination of the need for sutures and an improved post-operative comfort and healing.
The laser is a less-invasive method for operculectomy compared with the conventional techniques because it produces little cell destruction and less bleeding due to its haemostatic properties and requires the patient a reduced number of sessions and less chairside time for the most applications. Sabra  conducted a clinical study comparing healing process of impacted mandibular molar after removal of the pericoronal flap with surgical knife and DL. Healing increased in surgical knife group as 48%, 64%, 72% and 84% and in DL group as 60%, 72%, 80% and 96% on the 1st, 3rd, 5th and 7th day, respectively. Laser method showed faster elimination of pericoronitis symptoms and enhanced the healing process of soft tissues. Sripathi Rao et al. concluded that The use of DL in excision of operculum has several advantages over surgical knife such as enhanced haemostasis, less post-operative pain and a better post-operative healing.
An aberrant frenum encroaches the gingival health when it is attached too closely to the gingival margin, either due to interference in the plaque control or due to a muscle pull. DLs are used to treat such conditions to overcome the disadvantage of conventional therapy which includes post-surgical pain and discomfort, which is further aggravated when sutures come in contact with food. A clinical study of 25 patients, reported the lack of swelling, bleeding, pain or scar tissue formation with good wound healing and overall satisfaction after 4 weeks of follow up in the clinical application of laser-assisted frenectomy. Patel et al. in a RCT reported the degree of post-operative pain and healing experienced by patients during frenectomy procedure with surgical scalpel and DL. Results showed that patients treated with the DL had less post-operative pain and required fewer analgesics as compared to patients treated with the conventional scalpel technique. Wound healing at the 7th day and after 1 month for both the groups showed statistical significant difference with better outcome in laser group. Gandhi and Gandhi  compared the results of scalpel, electrocautery and DL in the treatment of frenectomy indicated that patients treated with the DL had less post-operative pain and required fewer analgesics. Wound healing at 7th day and after 1 month for all the groups showed statistical significant difference with better outcome in DL group.
In open flap surgery
Lasers have several potential benefits such as antibacterial effect and stimulation of wound healing. In addition, haemostasis and delaying epithelial migration may facilitate the outcome of flap surgery. In a clinical and microbiological study, DL was used as an adjunct to open flap debridement. The bactericidal effect of the DL was clearly evident by greater reduction of colony forming unit of obligate anaerobes in the test group than in the control group. In an another randomised trial, Lobo and Pol  concluded that, the DL can be safely and effectively used as an adjunct to the treatment of CP with the advantage of decreased gingival inflammation. Aena et al., in a randomised clinical trial reported that the use of an 810 nm DL provided additional benefits to Modified Widman Flap surgery in terms of clinical parameters such as papillary, bleeding Index and gain in CAL at 6 and 9 months.
Peri implantitis is an inflammatory disease that affects both hard and soft tissue and contributes to a progressive bone loss beyond the biologic remodeling around a functioning implant. Papadopoulos et al. (2015) stated that surgical treatment of peri-implantitis by access flaps leads to improvement of all clinical parameters studied while the additional use of DL does not seem to have an extra beneficiary effect. Arısan V et al. in a clinical trial concluded that adjunct use of DL did not yield any additional positive influence on the peri-implant healing compared with conventional scaling alone.
Low-level laser therapy
Low-level LT (LLLT) is a light source treatment that generates light of a single wavelength. The output powers range from 50 to 500 mW with wavelengths in the red and near infrared of the electromagnetic spectrum (630–980 nm) with pulsed or continuous-wave emission. The low-level lasers do not cause temperature elevation within the tissue, but rather produce their effects from photo biostimulation effect within the tissues. Laser enhanced biostimulation has been reported to induce intracellular metabolic changes, resulting in faster cell division, proliferation rate, migration of fibroblasts and rapid matrix production.
Low level lasers do not cut or ablate the tissue. LLLT devices include the gallium arsenide, gallium aluminium arsenide infrared semiconductor (gallium-aluminium-arsenide), and helium-neon lasers. The application of LLLT has become popular in a variety of clinical applications in periodontics including promotion of wound healing and reduction of pain and bone regeneration following non-surgical , and surgical procedures (Amorim et al., 2006).
| Conclusion|| |
The vivid use of DL in periodontology has led to a different approach to the treatment aspect for periodontal disease ranging from prophylaxis to treating advanced periodontal disease. There has been enough evidence on scaling and root planing. PDT, crown lengthening, open flap debridement, frenectomy and periimplantits. However, there is still a need for more data for the procedure such as gingivectomy and operculactomy. In general, the assessment and use of the DL could explore further benefits of the intervention in periodontal disease; which may pave the way for future research in this subject.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stern RH, Sognnaes RF. Laser beam effect on dental hard tissues. J Dent Res 1964;43:873.
Goldman L, Hornby P, Meyer R, Goldman B. Impact of the laser on dental caries. Nature 1964;203:417.
Pujara N, Zala H. Lasers: A double edged sword. Int J Sci Res 2013;6:2453-6.
Ramesh A, Bhandary R, Thomas B, Dsouza SR. Laser – A ray of hope in periodontics – A review article. Nitte Univ J Heath Sci 2014;4:138-42.
Sagar K, Kaur A, Patel P, Kumar V, Narang S, Ranga P. Diode laser as an established tool in periodontics – A review. Am J Oral Med Radiogr 2015;2:54-60.
Gupta S, Sawhney A, Jain G, Dhar S, Gupta B, Singh R, et al
. An evaluation of diode laser as an adjunct to scaling and root planning in the nonsurgical treatment of chronic periodontitis: A clinico-microbiological study. Dent Med Res 2016;4:44-9. [Full text]
Saglam M, Kantarci A, Dundar N, Hakki SS. Clinical and biochemical effects of diode laser as an adjunct to nonsurgical treatment of chronic periodontitis: A randomized, controlled clinical trial. Lasers Med Sci 2014;29:37-46.
Qadri T, Javed F, Johannsen G, Gustafsson A. Role of diode lasers (800-980 nm) as adjuncts to scaling and root planing in the treatment of chronic periodontitis: A systematic review. Photomed Laser Surg 2015;33:568-75.
Nguyen NT, Byarlay MR, Reinhardt RA, Marx DB, Meinberg TA, Kaldahl WB, et al.
Adjunctive non-surgical therapy of inflamed periodontal pockets during maintenance therapy using diode laser: A Randomized clinical trial. J Periodontol 2015;86:1133-40.
Alzoman HA, Diab HM. Effect of gallium aluminium arsenide diode laser therapy on Porphyromonas gingivalis
in chronic periodontitis: A randomized controlled trial. Int J Dent Hyg 2016;14:261-6.
Koçak E, Saǧlam M, Kayış SA, Dündar N, Kebapçılar L, Loos BG, et al.
Nonsurgical periodontal therapy with/without diode laser modulates metabolic control of type 2 diabetics with periodontitis: A randomized clinical trial. Lasers Med Sci 2016;31:343-53.
Dilsiz A, Aydın T, Emrem G. Effects of the combined desensitizing dentifrice and diode laser therapy in the treatment of desensitization of teeth with gingival recession. Photomed Laser Surg 2010;28 Suppl 2:S69-74.
Yilmaz HG, Kurtulmus-Yilmaz S, Cengiz E, Bayindir H, Aykac Y. Clinical evaluation of Er, Cr: YSGG and GaAlAs laser therapy for treating dentine hypersensitivity: A randomized controlled clinical trial. J Dent 2011;39:249-54.
Birang R, Shahaboui M, Kiani S, Shadmehr E, Naghsh N. Effect of nonsurgical periodontal treatment combined with diode laser or photodynamic therapy on chronic periodontitis: A Randomized controlled split-mouth clinical trial. J Lasers Med Sci 2015;6:112-9.
Teymouri F, Farhad SZ, Golestaneh H. The effect of photodynamic therapy and diode laser as adjunctive periodontal therapy on the inflammatory mediators levels in gingival crevicular fluid and clinical periodontal status. J Dent (Shiraz) 2016;17:226-32.
Pirnat S. Versatility of an 810 nm Diode laser in dentistry: An overview. LAHA 2007;4:1-9.
Suragimath G, Lohana MH, Varma S. A split mouth randomized clinical comparative study to evaluate the efficacy of gingival depigmentation procedure using conventional scalpel technique or diode laser. J Lasers Med Sci 2016;7:227-32.
Sobouti F, Rakhshan V, Chiniforush N, Khatami M. Effects of laser-assisted cosmetic smile lift gingivectomy on postoperative bleeding and pain in fixed orthodontic patients: A controlled clinical trial. Prog Orthod 2014;15:66.
To TN, Rabie AB, Wong RW, McGrath CP. The adjunct effectiveness of diode laser gingivectomy in maintaining periodontal health during orthodontic treatment: A randomized controlled clinical trial. Angle Orthod 2012;83:43-7.
Ize-Iyamu IN, Saheeb BD, Edetanlen BE. Comparing the 810nm diode laser with conventional surgery in orthodontic soft tissue procedures. Ghana Med J 2013;47:107-11.
Khan MA, Agrawal A, Saimbi CS, Chandra D, Kumar V. Diode laser: A novel approach for the treatment of pericoronitis. J Dent Lasers 2017;11:19-21. [Full text]
Sabra SM. Laser-aided for pericoronal bacterial load reduction and operculectomy healing of impacted mandibular molar. World Appl Sci J 2014;29:1-8.
Sripathi Rao BH, Rai BG, Sinha SS. Comparison of healing process of operculectomy with laser and surgical knife: A clinical study. Int J Curr Res 2016;8:25368-73.
Aldelaimi TN, Mahmood AS. Laser-assisted frenectomy using 980nm diode laser. J Dent Oral Disord Ther 2014;2:1.
Patel RM, Varma S, Suragimath G, Abbayya K, Zope SA, Kale V. Comparison of labial frenectomy procedure with conventional surgical technique and diode laser. J Dent Lasers 2015;9:94-9. [Full text]
Gandhi D, Gandhi P. Comparison of healing period after frenectomy using scalpel, electrocautery & diode laser. BJMMR 2017;21:1-9.
Gokhale SR, Padhye AM, Byakod G, Jain SA, Padbidri V, Shivaswamy S, et al.
Acomparative 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. Photomed Laser Surg 2012;30:598-603.
Lobo TM, Pol DG. Evaluation of the use of a 940 nm diode laser as an adjunct in flap surgery for treatment of chronic periodontitis. J Indian Soc Periodontol 2015;19:43-8.
] [Full text]
Aena PJ, Parul A, Siddharth P, Pravesh G, Vikas D, Vandita A, et al.
The clinical efficacy of laser assisted modified widman flap: A randomized split mouth clinical trial. Indian J Dent Res 2015;26:384-9.
] [Full text]
Rosen P, Clem D, Cochran D, Froum S, McAllister B, Renvert S, et al
. Peri-implant mucositis and peri-implantitis: A current understanding of their diagnoses and clinical implications. J Periodontol 2013;84:436-43.
Papadopoulos CA, Vouros I, Menexes G, Konstantinidis A. The utilization of a diode laser in the surgical treatment of peri-implantitis. A randomized clinical trial. Cin Oral Investig. 2015;19:1851-60.
Arısan V, Karabuda ZC, Arıcı SV, Topçuoǧlu N, ülekçi G. A randomized clinical trial of an adjunct diode laser application for the nonsurgical treatment of peri-implantitis. Photomed Laser Surg. 2015;33:547-54.
Suresh S, Merugu S, Mithradas N, Sivasankari. Low-level laser therapy: A biostimulation therapy in periodontics. SRM J Res Dent Sci 2015;6:53-6. [Full text]
Sudhakar U, Satyanarayana, Thilagar S, Suresh S. Clinical efficacy of low-level laser therapy as an adjunct to nonsurgical treatment of chronic periodontitis. J Dent Lasers 2015;9:31-7. [Full text]
Ren C, McGrath C, Jin L, Zhang C, Yang Y. The effectiveness of low-level laser therapy as an adjunct to non-surgical periodontal treatment: A meta-analysis. J Periodontal Res 2017;52:8-20.
Amorim JC, de Sousa GR, de Barros Silveira L, Prates RA, Pinotti M, Ribeiro MS, et al.
Clinical study of the gingiva healing after gingivectomy and low-level laser therapy. Photomed Laser Surg 2006;24:588-94.
[Table 1], [Table 2]