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Australian Dental Journal

The official journal of the Australian Dental Association


Australian Dental Journal 2013; 58: 4149
SCIENTIFIC ARTICLE
doi: 10.1111/adj.12021

Comparison of periodontal open ap debridement versus


closed debridement with Er,Cr:YSGG laser
M Gupta,* AK Lamba,* M Verma, F Faraz,* S Tandon,* K Chawla,* DK Koli
*Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India.
Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India.

ABSTRACT
Background: Traditional periodontal open flap debridement (OFD) results in reduced pocket depth (PD), clinical attach-
ment loss (CAL), gingival recession (GR) and postoperative pain and discomfort. The quest to overcome these shortcom-
ings has led to research into Er,Cr:YSGG laser assisted pocket therapy (ELAPT). This study was designed to compare
the clinical outcomes of ELAPT versus OFD.
Methods: Fifteen patients with a PD of 5 mm and 8 mm at two sites were selected. Test sites (Group 1) were treated
by ELAPT and the control (Group 2) by OFD. Clinical parameters were recorded at baseline, 3 and 6 months and
included Plaque Index (PI), Gingival Index (GI), modified Sulcular Bleeding Index (mSBI), PD, CAL and GR.
Results: Both treatments produced a reduction in PI, GI, mSBI and PD, an increase in GR, and a gain in CAL at 3 and
6 months. The mean gain of CAL in Group 1 at 3 and 6 months (1.60  0.78 and 1.80  0.63) was similar (p > 0.05)
to the value of Group 2 (1.93  0.88 and 2.00  0.54). GR increased significantly (p < 0.05) only in Group 2 at 3 and
6 months (1.80  0.56 and 1.87  0.64) compared to Group 1 (0.50  0.68 and 0.60  0.74).
Conclusions: ELAPT compared with OFD results in similar CAL gains with less GR and significant reductions in PD, GI
and mSBI, and may be considered as an alternative to surgical therapy.
Keywords: Er,Cr:YSGG laser, open flap debridement, periodontitis, non-surgical.
Abbreviations and acronyms: CAL = clinical attachment loss; ELAPT = Er,Cr:YSGG laser assisted pocket therapy; GI = Gingival
Index; GR = gingival recession; OFD = open flap debridement; PD = pocket depth; PI = Plaque Index.
(Accepted for publication 23 May 2012.)

Different lasers, e.g. the diode, Nd:YAG, CO2, Er:


INTRODUCTION
YAG and Er,Cr:YSGG have been proposed and are
Periodontal therapy is directed at disease prevention, expected to serve as an alternative or an adjunctive
slowing or arresting disease progression, regeneration treatment to conventional, mechanical periodontal
of lost periodontal tissues, and maintaining the therapy.7,8 Laser periodontal therapy is predicated on
achieved therapeutic objectives.1,2 A variety of tech- the concept of subgingival curettage and/or reattach-
niques have been used for periodontal therapy, e.g. ment and regeneration of the attachment apparatus
scaling and root planing, subgingival curettage, gingi- and is commonly referred to as non-surgical.7 It
vectomy and full or split thickness flap procedures allows for selective removal of sulcular or pocket epi-
with or without osseous recontouring.1,3,4 Tradi- thelium while preserving connective fibrous tissues.9 It
tional periodontal surgery results in reduced pocket defines the tissue margins, preserves the integrity of
depth due to apical repositioning of the gingival mar- the mucosa and aids in maintaining the free gingival
gin, exposing the root surface to the oral cavity. It crest.9 High patient comfort and acceptance has been
results in possible attachment loss, gingival cratering reported with laser periodontal therapy.9 With thin
and gingival recession.5 The pain and discomfort and flexible fibres, laser device energy can be delivered
associated with periodontal surgery is also well to sites in the periodontal pocket that conventional
known.6 The quest to overcome these shortcomings mechanical instrumentation is unable to reach.10
has led to research into laser assisted periodontal Laser periodontal therapy eliminates pockets with
therapy. minimal recession or repositioning of the gingival
2013 Australian Dental Association 41
M Gupta et al.

margin.10 Other advantages include haemostasis, less Fifteen patients between the age of 20 and 54 years
postoperative swelling, a reduction in bacterial popu- of either gender having a probing depth of 5 mm at
lation at the surgical site, less need for suturing, faster a minimum of two sites were selected from the
healing and less postoperative pain.11 Periodontics Outpatient Department, Maulana Azad
Laser systems such as CO2, diode and Nd:YAG Institute of Dental Sciences, New Delhi, India. The
have been used for oral soft tissue procedures such as subjects were selected randomly with no discrimina-
gingivectomies, frenectomies, etc.12 Due to an excel- tion of gender, caste, religion or socio-economic sta-
lent soft tissue ablation capacity, CO2 lasers have tus. Inclusion criteria were residual presence of
been successfully used as an adjunctive tool to probing depth of 5 mm and 8 mm at a minimum
de-epithelialize the mucoperiosteal flap during tradi- of two sites and good level of oral hygiene (PI <1)
tional flap surgery.13 Diode and Nd:YAG lasers have after initial therapy. Patients were excluded from par-
been used mainly for laser-assisted subgingival curet- ticipation in the study if they presented with diabetes,
tage and disinfection of the periodontal pocket with coronary heart disease, chronic obstructive pulmonary
various degrees of success.13 However with these disease, tobacco use, or the use of antibiotics in the
lasers, a profound thermal effect on target tissues previous 6 months.
including gingival tissue, periodontal ligament, cemen- On one side, teeth were treated by Er,Cr:YSGG
tum and bone has been seen and their use for peri- laser (ELAPT; test group), whereas teeth of the con-
odontal application does not appear promising.14 tralateral side were treated by open flap debridement
The potential use of Er,Cr:YSGG laser as a tool for (OFD; control group). In the control group (OFD),
the non-surgical debridement of pathological periodon- the area to undergo surgery was anaesthetized with
tal pockets is related to its capacity to ablate soft tissue 2% lignocaine hydrochloride solution with adrenaline
with minimal thermal side effects.15 Because the Er,Cr: (1:80 000). Intracrevicular incisions were placed. The
YSGG laser has a wavelength close to the peak of granulation tissue was removed from the defects and
absorption coefficient of water, absorption of the the roots were thoroughly scaled and planed. No root
energy by water occurs rapidly, resulting in evapora- surface conditioning was performed. The control sites
tion of water, microexplosive ablation and reduced were then sutured with simple interrupted sutures.
heat accumulation.15 It also possesses bactericidal (Fig. 1).
effects because of the high coefficient of absorption of For Er,Cr:YSGG laser assisted periodontal pocket
the used light frequency by lipopolysaccharides.15 It therapy (ELAPT; test group) no local anaesthesia was
has also been shown to have a significant bactericidal given.13,15 If required, the pocket to be treated was
effect on both P. gingivalis and A. actinomycetemcomi- lightly irrigated with 2% lignocaine hydrochloride
tans, which are primary components of periodontal solution with adrenaline (1:80 000).15 The patient and
infection.15 Er,Cr:YSGG laser irradiation can be safely all operatory personnel were made to wear protective
and effectively utilized in periodontal pocket therapy, laser eyewear. The following settings were used for
and has the potential to promote new attachment.15 It ELAPT: power 1W, water 10%, air 12% and
has been claimed in the literature that the Er,Cr:YSGG frequency 20 Hz. A 600 sapphire laser tip (9 mm
laser system provides a more comfortable patient expe- length) was used and inserted into the sulcus to the
rience with less trauma and postoperative complica- base of the pocket. The laser tip was then withdrawn
tions, as well as a decreased healing time16 compared 1 mm from the base and activated. The tip was
to conventional flap surgery. moved apico-coronally (vertically) and mesio-distally
Therefore, the purpose of this study was to evaluate (horizontally) in sweeping motions in the pocket. The
and compare the clinical outcomes of Er,Cr:YSGG tip was angled so that the energy was directed parallel
laser-assisted periodontal pocket therapy versus open to the root and towards the inner epithelial lining of
flap debridement procedure. the sulcus. The tip was kept constantly moving inside
the pocket. The objective was to remove the epithelial
lining of the pocket. Each pocket was lased for
MATERIALS AND METHODS
60 seconds.
The study was designed as a single-blinded, split- Following lasing of the pocket, any visible deposits
mouth, randomized and controlled trial of 6-month on the root surfaces were removed using hand and
duration. The study protocol was reviewed and ultrasonic instruments. The area was then irrigated
approved by the Ethics Committee of the Maulana with sterile saline. The gingival tissue was compressed
Azad Institute of Dental Sciences (Delhi University), against the root surface to close the pocket and to aid
New Delhi. The study was conducted in accordance in the formation and stabilization of fibrin clot. No
with the Helsinki Declaration of 1975, as revised in sutures or periodontal dressings were given (Fig. 2).
2000, and all participants signed informed consent A second and third cycle of lasing was repeated
forms. with similar settings every third day. This was
42 2013 Australian Dental Association
Open ap debridement versus laser

(a) (b)

(c) (d)

Fig. 1 Open ap debridement. (a) pre-operative; (b) intra-operative; (c) postoperative 3 months; (d) postoperative 6 months.

(a) (b)

(c) (d)

Fig. 2 Laser assisted periodontal pocket therapy. (a) pre-operative; (b) intra-operative; (c) postoperative 3 months; (d) postoperative 6 months.

attempted with the consideration of delaying epithelial Data collection


downgrowth and promoting regeneration of periodon-
The baseline data were recorded before treatment and
tal tissues.
at 3 months and 6 months following treatment. The
Postoperatively no antibiotics or analgesics were
data collection was performed by the same blinded
prescribed. Patients were instructed to discontinue
and calibrated investigator.
toothbrushing for the day of the treatment, avoiding
Clinical measurements were taken at six points
trauma at the treated site. A 60-second rinse with
around each tooth: mesio-lingual, mesio-facial, facial,
10 ml of 0.2% chlorhexidine gluconate solution twice
disto-facial, disto-lingual and lingual.
daily for 1 week was prescribed.
2013 Australian Dental Association 43
M Gupta et al.

The following clinical parameters were measured: mean PD at baseline, 3 months and 6 months for both
Plaque Index (PI), Gingival Index (GI), Probing Depth the laser treatment group and the OFD group was found
(PD), Clinical Attachment Level (CAL), Gingival to be statistically significant (p < 0.05) (Table 2).
Recession (GR) and modified Sulcular Bleeding Index The mean PD reduction at 3 months was found to
(mSBI). PD was determined with a calibrated conven- be 2.66  0.88 among the laser treatment group and
tional periodontal probe. 3.60  0.70 among the OFD group. The mean PD
reduction at 6 months was found to be 2.46  0.62
among the laser treatment group and 3.80  0.80
Intra-examiner reliability
among the OFD group. The comparison of mean PD
Four patients, each with two contralateral teeth with reduction at 3 months and 6 months between the
PD >5 mm, were used to calibrate the examiner. The laser treatment and OFD was found to be statistically
examiner evaluated the patients at two appointments significant (p < 0.05) (Table 3).
that were separated by 5 days. Calibration was This implies that although the PD decreased signifi-
accepted if the data at baseline and 5 days later were cantly in both treatment groups compared to baseline,
similar at a >90% level. This procedure was repeated OFD was more effective in reduction of PD compared
periodically during the 6-month study period. to laser assisted pocket therapy at both 3 and 6 months
post-treatment intervals.
Statistical analysis
Clinical attachment level
A software package was used for the statistical analy-
sis [SPSS (Statistical Package for Social Sciences) The mean CAL at baseline was 7.93  1.16, at
Version 16]. The unpaired t-test was used for compar- 3 months 6.33  1.35 and at 6 months 6.13  1.19
ison of mean values between the LASER and OFD
groups, and ANOVA test was used for comparison of Table 2. Comparison of mean values of PD at
mean values within the LASER and OFD groups at baseline, 3 months and 6 months
the different intervals. The level of significance was Intervals Probing LASER (  r) OFD (  r)
taken at 5% (p < 0.05). The alpha error was set at depth (mm)
0.05. Data are presented as means SD. The power 1 Baseline 6.93  1.03 6.93  0.70
of the study, given 1 mm as a significant difference 2 3 months 4.87  1.25 3.33  0.62
between groups, was calculated to be 0.99. 3 6 months 4.47  0.92 3.13  0.74
p-value 0.000* 0.000*
Post hoc comparison 1 > 2, 3 1 > 2, 3
RESULTS *- S.
The comparison of mean values of each parameter Table 3. Comparison of mean change in PD, CAL,
between the LASER and OFD group at baseline was GR, GI, PI and mSBI
done and there were no statistically significant differ-
ences (p > 0.05) between the two treatment groups in Parameter LASER OFD p-value
any of the recorded parameters (Table 1). PD reduction 2.06  0.88 3.60  0.70 0.000*
at 3 months (mm)
PD reduction 2.46  0.62 3.80  0.80 0.000*
Probing depth at 6 months (mm)
CAL gain 1.60  0.78 1.93  0.88 0.122
The mean PD at baseline was 6.93  1.03, at 3 months at 3 months (mm)
4.87  1.25 and at 6 months 4.47  0.92 among the CAL gain 1.80  0.63 2.00  0.54 0.269
at 6 months (mm)
laser treatment group. The mean PD at baseline was GR increase 0.53  0.68 1.80  0.56 0.000*
6.93  0.70, at 3 months 3.33  0.62 and at 6 months at 3 months (mm)
3.13  0.74 among the OFD group. The comparison of GR increase 0.60  0.74 1.87  0.64 0.000*
at 6 months (mm)
GI score reduction 0.55  0.24 0.95  0.24 0.000*
Table 1. Comparison of mean values of PD, CAL, GR, at 3 months
GI, PI and mSBI at baseline GI score reduction 0.52  0.26 0.95  0.24 0.000*
at 6 months
LASER OFD p-value PI score reduction 0.17  0.18 0.20  0.27 0.726
at 3 months
PD (mm) 6.93  1.03 6.93  0.70 0.332 PI score reduction 0.08  0.20 0.17  0.21 0.388
CAL (mm) 7.93  1.16 8.13  0.83 0.708 at 6 months
GR (mm) 1.00  0.65 1.07  0.59 0.135 mSBI score reduction 0.52  0.31 0.78  0.30 0.022*
GI 1.50  0.28 1.65  0.31 0.178 at 3 months
PI 0.77  0.22 0.80  0.23 0.818 mSBI score reduction 0.53  0.28 0.85  0.28 0.005*
mSBI 1.22  0.31 1.27  0.35 0.681 at 6 months

44 2013 Australian Dental Association


Open ap debridement versus laser

among the laser treatment group. The mean CAL at The mean increase in GR at 3 months was found to
baseline was 8.13  0.83, at 3 months 6.20  0.94 be 0.53  0.68 among the laser treatment group and
and at 6 months 6.13  0.83 among the OFD group. 1.80  0.56 among the OFD group. The mean
The comparison of mean CAL at baseline, 3 months increase in GR at 6 months was found to be
and 6 months for the laser treatment and OFD group 0.60  0.74 among the laser treatment group and
was found to be statistically significant (p < 0.05) 1.87  0.64 among the OFD group.
(Table 4). The comparison of mean increase in GR at
The mean CAL gain at 3 months was found to be 3 months and 6 months between the laser treatment
1.60  0.78 among the laser treatment group and and OFD was found to be statistically significant
1.93  0.88 among the OFD group. The mean CAL (p < 0.05) (Table 3). This implies that sites treated
gain at 6 months was found to be 1.80  0.63 among with laser assisted pocket therapy show significantly
the laser treatment group and 2.00  0.54 among the less GR when compared to sites treated with OFD.
OFD group. The comparison of mean CAL gain at
3 months and 6 months between the laser treatment
Gingival Index
and OFD was found to be statistically not significant
(p > 0.05) (Table 3). The mean reduction in GI score at 3 months was
This implies that there was significant gain in CAL found to be 0.55  0.24 among the laser treatment
in both treatment groups compared to baseline, and group and 0.95  0.24 among the OFD group. The
laser assisted pocket therapy was equally effective in mean reduction in GI score at 6 months was found to
producing CAL gain compared to OFD at both 3 and be 0.52  0.26 among the laser treatment group and
6 month post-treatment intervals. 0.95  0.24 among the OFD group. The comparison
of mean reduction in GI scores at 3 months and
6 months between the laser treatment group and the
Gingival recession
OFD group was found to be statistically significant
The mean GR at baseline was 1.00  0.65, at (p < 0.05) (Table 3).
3 months 1.53  0.92 and at 6 months 1.60  0.99 This implies that although the GI decreased signifi-
among the laser treatment group. The mean GR at cantly in both treatment groups compared to baseline,
baseline was 1.07  0.59, at 3 months 2.87  0.74 OFD was more effective in reduction of GI compared
and at 6 months 2.93  0.80 among the OFD group. to laser assisted pocket therapy at both 3 and
The comparison of mean GR at baseline, 3 months 6 month post-treatment intervals.
and 6 months for the laser treatment group was found
to be statistically not significant (p > 0.05) but for the
Plaque Index
OFD group was found to be statistically significant
(p < 0.05) (Table 5). The comparison of mean reduction in PI score at
3 months and 6 months between the laser treatment
group and the OFD group was found to be statistically
Table 4. Comparison of mean values of CAL at not significant (p > 0.05) (Table 3). This implies that
baseline, 3 months and 6 months the relatively low baseline values for PI in both treat-
Intervals Clinical Attachment LASER (  r) OFD (  r) ment groups did not change significantly over the
Level (mm) 6 months of the study and yielded no statistical differ-
1 Baseline 7.93  1.16 8.13  0.83 ence between the groups.
2 3 months 6.33  1.35 6.20  0.94
3 6 months 6.13  1.19 6.13  0.83
p-value 0.000* 0.000* Modied Sulcular Bleeding Index
Post hoc comparison 1 > 2, 3 1 > 2, 3
The mean reduction in mSBI score at 3 months was
found to be 0.52  0.31 among the laser treatment
group and 0.78  0.30 among the OFD group. The
Table 5. Comparison of mean values of GR at mean reduction in mSBI score at 6 months was found
baseline, 3 months and 6 months to be 0.53  0.28 among the laser treatment group
and 0.85  0.28 among the OFD group. The compar-
Intervals Gingival LASER (  r) OFD (  r)
recession (mm) ison of mean reduction in mSBI score at 3 months
and 6 months between the laser treatment group and
1 Baseline 1.00  0.65 1.07  0.59
2 3 months 1.53  0.92 2.87  0.74 the OFD group was found to be statistically signifi-
3 6 months 1.60  0.99 2.93  0.80 cant (p < 0.05) (Table 3).
p-value 0.063 0.000* This implies that although the mSBI decreased
Post-hoc comparison - 1 > 2, 3
significantly in both treatment groups compared to
2013 Australian Dental Association 45
M Gupta et al.

baseline, OFD was more effective in reduction of planing as this allows for optimal tissue health and
mSBI compared to laser assisted pocket therapy at plaque control, thereby enhancing treatment out-
both 3 and 6 month post-treatment intervals. comes. All measurements were taken with a manual
calibrated UNC-15 periodontal probe which had col-
our coding at 5, 10, 15 mm with markings 0 to 15,
DISCUSSION
each marking at 1 mm intervals, making it easier to
With the discovery of lasers and research into their reproduce the measurement. Before treatment, a cus-
applicability for dental use, laser energy has emerged tomized acrylic stent was fabricated on the study cast
as a newer modality of therapy in the field of for each patient. The stent was grooved in an occlusal
periodontics.13 Laser energy is capable of ablating apical direction. This was done to minimize change in
and vaporizing residual organic debris, including the direction of probing at subsequent recordings. All
microbial plaque and probably calculus, and it can these measurements were made from a fixed reference
disinfect and remove the pockets sulcular lining.13 point on the stent, in accordance with the study by
Adjunctive therapy with laser energy, aimed at reduc- Miyazaki et al.23
ing or eliminating bacteria may be useful in reducing For the test site, laser assisted pocket therapy was
probing depth and bleeding on probing.7,8,13 Non- performed without the application of local anaesthesia
surgical laser pocket therapy offers several advantages as, according to Sjostrom and Friskopp,24 pain experi-
over conventional surgical procedures such as minimal ence during laser therapy for periodontal procedures
bleeding, instant sterilization of the surgical site, is negligible and does not require the use of anaesthet-
reduced bacteraemia, reduced mechanical trauma, ics and results in diminished bleeding. The settings
minimal postoperative swelling and scarring, and min- used for ELAPT were in accordance with the sug-
imal postoperative pain.7,17,18 It can be associated gested clinical specifications by BIOLASE Technol-
with cementum-mediated new connective tissue ogy. The calibration for the initial therapy with laser
attachment and apparent periodontal regeneration on tip was done at 1 mm less than the pocket probing
previously diseased root surfaces.8 depth of the treatment site as this measurement allows
The ideal properties of a laser that can be used suc- for the laser energy to penetrate the tissue and reduce
cessfully for periodontal pocket therapy are that it the bacterial load without the fibre touching the epi-
should be bactericidal, easy to deliver into the pocket thelial attachment at the bottom of the pocket.15 After
and safe enough to use in a periodontal pocket so that completion of the laser assisted pocket therapy no
it causes no harm to the root surface. Current literature sutures or periodontal dressing were given. Postopera-
identifies erbium lasers (Er:YAG and Er,Cr:YSGG) as tively, no antibiotics and analgesics were prescribed.
the most appropriate device for non-surgical periodon- A second and third cycle of lasing was done at every
tal treatment due to their high absorption in water and third day in an attempt to delay epithelial down-
lack of thermal penetration.8,19 Also, as the interaction growth and promote periodontal tissue regeneration
between the erbium laser wavelength and gingival as, according to Goldman et al.,25 during the healing
tissues is shallow in depth (0.10.3 mm), it results in phase, migration of the epithelium begins from the
less wound contraction and a reduced inflammatory existing epithelium of attached gingiva and new epi-
response.19 Studies have shown that the erbium laser thelium begins to cover the exposed gingival corium
can remove epithelium effectively without damaging within 2 to 3 days. Furthermore, formation and orga-
the underlying connective tissue. Furthermore, in an nization of connective tissue fibres takes place during
animal study the erbium laser has been seen to induce healing and these fibers, although somewhat immature
new cementum formation after pocket irradiation.20 in arrangement and width, appear well organized in
According to Kaldahl et al.,5 Schwarz et al.21 and about 1014 days.25 In light of this, lasing wasnt
Sculean et al.17 smokers have a less favourable done beyond three cycles to prevent any inadvertent
response to non-surgical and surgical periodontal ther- damage to the healing connective tissue fibres within
apy. Therefore, smokers were excluded from the the pocket. Also, the sulcus heals from the bottom up
study. Patients who had poorly controlled diabetes and hence during the second and third lasing, the tip
were also excluded from the study as, according to was placed 2 mm less than the pocket probing depth
Derdilopoulou et al.22 and Gaspirc,1 diabetics have of the treatment site to allow healing at the floor of
increased microbial challenge and delayed wound the pocket.26,27 The postoperative instructions and
healing which could influence the outcome of the ther- recalls were in accordance with studies by Schwarz
apy. The defect sites were selected in patients using et al.,7 Sculean et al.,17 Raffetto15 and Gaspirc.1 Rep-
clinical criteria similar to studies of Miyazaki et al.23 robing treatment sites were not attempted before
and Tomasi et al.18 3 months as tissue reattachment to the root surface
All patients were subjected to initial preparation could be damaged with a probe, delaying the healing
which consisted of full mouth scaling and root process.26,27
46 2013 Australian Dental Association
Open ap debridement versus laser

For the control site, open flap debridement was per- assisted pocket therapy, the reduction in PD and gain
formed and the soft tissue flap was repositioned at the in CAL values are consistent with those of Watanabe
original level and closed with simple interrupted et al.,35 Schwarz et al.,7,21 Sculean et al.,17 Tomasi
sutures using 30 silk to obtain primary soft tissue et al.,18 and Gaspirc and Skaleric.1 The changes seen
closure. The control site was then covered with perio- with laser therapy may be attributed to the fact that
dontal dressing. According to Nasr et al.,28 periodon- due to the lasers ablating action, the epithelium lining
tal dressing prevents the impingement of foreign the soft tissue wall of the pocket and the adjacent
materials into the control site and also minimizes flap inflammatory cell infiltrate may have been removed.
displacement which would jeopardize the success of In addition, the low dose radiation that scatters into
the treatment. Patients were given both verbal and the surrounding tissues may possess a beneficial effect
written instructions. Antibiotics were prescribed to all on the healing process.8,35 Also, erbium laser therapy
patients after open flap debridement. According to might have resulted in improved proliferation of fibro-
Kornman et al.,29 antibiotics provide clinical benefits blasts and their adhesion to root surfaces leading to
during the postoperative phase of periodontal surgery CAL gain.7 Results from similar studies with Er:YAG
as bacterial contamination adversely affects the clinical have also indicated that due to the minimally invasive
outcome of treatment. Patients were given pain medica- nature of laser treatment, trauma to hard and soft tis-
tion to avoid discomfort after the effect of anaesthesia sues is minimal, causing less GR.7,21 There is less col-
wore off. Patients were instructed to use 0.2% chlorh- lagen remodelling, faster healing and minimal scar
exidine gluconate mouthwash twice daily for 4 weeks. tissue with laser assisted pocket therapy which might
According to Newman et al.30 and Addy,31 chlorhexi- explain why less GR takes place.
dine helps in reducing the bacterial load in the oral Erbium lasers have antimicrobial effects and detoxi-
cavity and prevents the accumulation of plaque. fication properties. They have a high bactericidal
At the baseline examination, there were no statisti- potential against periodontopathic bacteria.36,37 The
cally significant differences between the two treatment lack of microbial data in the study does not allow us
groups in any of the recorded parameters. Both treat- to correlate the levels of microbiota in baseline pock-
ments produced a reduction in PI, GI, mSBI and PD, ets and in residual pockets after the surgery with clini-
an increase in GR, and a gain in CAL at 3 and cal parameters at different time periods in study.
6 month post-treatment intervals. However, a clinical indicator of inflammation, bleed-
In both treatment groups, the PD decreased signifi- ing on probing (mSBI and GI scores) roughly reflects
cantly compared to baseline (p < 0.05). However, the the level of periodontal pathogens in the pocket.38,39
mean PD reduction at 3 and 6 months was signifi- So it can be hypothesized that the reduction in GI and
cantly greater (p < 0.05) for the OFD sites than for mSBI scores might be due to a bactericidal and detox-
sites treated with laser assisted pocket therapy. As a ification effect of the laser.
primary outcome variable, significant gain in CAL The results of the present study showed significant
was recorded compared to baseline in both the treat- differences between the OFD and laser assisted pocket
ment groups (p < 0.05). The mean gain of CAL in the therapy treated sites with regard to reduction in PD,
laser treatment group at 3 and 6 months was similar mean increase in GR, improvement in GI and mSBI
to the value of the control group (p > 0.05). Gingival scores. However, both sites demonstrated similar
recession increased significantly only in the OFD improvements in terms of gain in CAL. The greater
group compared to baseline (p < 0.05). The mean GR pocket depth reduction in the case of OFD may also
at 3 and 6 months was significantly lower (p < 0.05) be attributed to the higher amount of GR seen post-
for the laser treatment sites. operatively and it can be assumed that although sig-
GI decreased significantly in both groups post-treat- nificant difference was found in terms of PD
ment at 3 and 6 months (p < 0.05). However, OFD reduction in favour of OFD but the change was at the
was significantly effective (p < 0.05) in reduction of cost of recession. It was also observed that laser
GI as compared to laser assisted pocket therapy at assisted pocket therapy was far less invasive and less
both 3 and 6 months post-treatment intervals. Also, time consuming than OFD, and required almost no
the mSBI scores for both treatment groups reduced use of analgesia increasing patient compliance. This
significantly after treatment (p < 0.05), although the treatment modality had no postoperative complica-
OFD group exhibited a significantly lower mSBI score tions or impaired clinical healing, indicating that this
at 3 and 6 months postoperatively compared to the type of laser treatment may not have any detrimental
laser treatment group (p < 0.05). effect when employed for pocket therapy.
The results obtained in the present study with OFD Within the constraints of this study, it can be con-
in terms of reduction in PD and gain in CALs confirm cluded that the use of an Er,Cr:YSGG laser in the
those reported by Lindhe et al.,32 Pihlstrom et al.,33 non-surgical treatment of periodontal pockets can
Isidor and Karring,34 and Sculean et al.17 For the laser result in similar CAL gains to that of OFD with much
2013 Australian Dental Association 47
M Gupta et al.

less recession and can also result in statistically signifi- 14. Dean DB. Concepts in laser periodontal therapy using the Er,
Cr:YSGG laser. The Academy of Dental Therapeutics and Sto-
cant reductions in PD, GI and mSBI. It may be con- matology.
sidered as an alternative to the surgical therapy for
15. Raffetto N. Lasers for initial periodontal therapy. Dent Clin
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