LASER curettage as adjunct to SRP, compared to SRP alone, in patients with periodontitis and controlled type 2 diabetes mellitus: A comparative clinical study.

AIM: To compare the effect of scaling and root planning (SRP) alone, and laser curettage as an adjunct to SRP, on the clinical parameters of patients with periodontitis and controlled type 2 diabetes mellitus.
MATERIALS AND METHODS: Ten patients were divided into two equal groups in a split-mouth design - Group I: SRP alone, Group II: SRP + laser curettage. The following clinical parameters were recorded: (i) Gingival index (ii) plaque index (iii) sulcular bleeding index (iv) probing depth (PD) and (v) clinical attachment level (CAL). SRP was done in one quadrant using Gracey curettes and in another quadrant SRP plus laser curettage was done. Three weeks after the therapy, the clinical parameters were recorded and the results were analyzed and the percentage of improvement were evaluated.
RESULTS: The results of this study indicated that both SRP and SRP + laser curettage were efficient for reducing gingival inflammation and PD. Group II showed more reduction in PD and more gain in CAL than Group I. Mean reduction in PD was 20.22% in Group I and 26.76% in Group II. Mean CAL gain is 32.5% in Group II and 22.34% in Group I.
CONCLUSION: In both the groups, gingival inflammation was reduced. When laser curettage was used as adjunct to SRP more reduction in PD and CAL was seen.

RCT Entities:   Population Interventions Outcomes

Diabetes mellitus (DM) is a chronic metabolic disorder caused by inherited or acquired deficiency in production of insulin by the pancreas or by the ineffectiveness of the insulin produced.[1] Periodontitis is an inflammatory disease of the supporting tissues of the teeth. The most common causative factors are microbes or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with the pocket formation, recession or both.[2] Periodontitis is considered as the sixth complication of diabetes.[3] Periodontitis and diabetes have a two-way relationship. DM increases the risk of periodontitis, and severe periodontitis coexists with severe DM. Hence, it is mandatory for diabetic patients to receive adequate treatment for periodontitis.[4] The basic treatment modality for periodontitis is scaling and root planing. The conventional periodontal procedure includes scaling and root planning (SRP), which consists of debridement of contaminated root surfaces as well as the elimination of bacteria and their endotoxins from the cementum and from the adjacent periodontal tissues. Scaling, root planning and curettage procedure creates a long junctional epithelium with no connective tissue attachment.[5] When laser curettage is done in the pockets, the ablating action of the laser removes the epithelium lining the soft tissue walls of the pocket and the adjacent inflammatory cell infiltrates and the low dose radiation that scatters into the surrounding tissues possess the beneficial effects on the healing process. The laser causes a photochemical reaction in the cell known as photobiomodulation, which induces tissue repair and wound healing.[6] Laser curettage also promotes the synthesis of DNA and RNA, increases the production of proteins, modulates enzymatic activity, affects intracellular and extracellular pH, which accelerates cell metabolism. Studies have shown that laser curettage causes expression of multiple genes related to cellular proliferation and migration and induces production of cytokines and growth factors.[7] Several studies have shown that laser curettage as an adjunctive therapy to nonsurgical periodontal treatment improves periodontal healing.[8910]

This study compares the clinical parameters of DM patients with periodontitis after treatment with SRP alone, SRP with laser curettage.

Materials and Methods

Ten patients with the age groups ranging from 35 to 60 years, with moderate chronic periodontitis and controlled type 2 DM with probing depth (PD) >5 mm, having no ongoing general disease except for type 2 diabetes and not under any medication other than anti-diabetic therapy were selected for the study. Those who had taken an antibiotic during the last 4 weeks, had uncontrolled diabetes and had periodontal treatment in the last 3 months were excluded from the study. None of the patients had received laser treatment before. The following data were also collected: Type of DM and duration (years since diagnosis); fasting blood sugar; postprandial; random blood sugar; HbA1c, patient's age, and sex. An informed consent was obtained from the patient before the study was initiated. Baseline measurements of the gingival index (GI), plaque index (PI), sulcular bleeding index (SBI), PD and clinical attachment level (CAL) were recorded at baseline and 3 weeks after therapy. Two quadrants in each jaw were divided in a split-mouth design into two groups Group I: SRP alone [Figure 1] Group II: SRP + laser curettage (photon 3 W dental diode laser 810 nm) [Figure 2]. Both the groups underwent mechanical debridement with ultrasonic scaler, followed by root planing with Gracey curettes under local anesthesia. On the same day the laser therapy was performed in the Group II site [Figure 3].

Figure 1

Preoperative probing depth of Group I

Figure 2

Preoperative probing depth of Group II

Figure 3

Laser curettage in Group II

Laser curettage

The laser employed was hand-held battery operated photon 3 W dental diode laser 810 nm (Zolar). The power was set to 0.8 W and the continuous mode was used [Figure 4]. The tip of the laser was uninitiated and inserted into the depth of the pocket. Tip was slightly angulated against the root surface and then the laser was activated along with slow movement in apical direction until bottom of the pocket was reached. Three weeks after the last procedure, the clinical examination was done in the same way as at the baseline [Figures 5 and 6].

Figure 4

Eight hundred and ten nm diode laser

Figure 5

Postoperative probing depth of Group I

Figure 6

Postoperative probing depth of Group II

Results

At baseline, PI score was 2.08 and reduced to 1.67 3 weeks postoperative period in both SRP and SRP + laser curettage groups [Graph 1 and Table 1]. The GI score was reduced from 2.09 to 1.69 3 weeks after therapy in both the groups [Graph 2 and Table 2]. SBI was reduced from 3.2 at baseline to 1.83 weeks after therapy in both the groups [Graph 3 and Table 3].

Graph 1

Changes in plaque index of Group I and Group II after 21 days

Table 1

Changes in PI of group I and group II after 21 days

Graph 2

Changes in gingival index of Group I and Group II after 21 days

Table 2

Changes in GI of group I and group II after 21 days

Graph 3

Changes in sulcular bleeding index of Group I and Group II after 21 days

Table 3

Changes in SBI of group I and group II after 21 days

The mean PD at baseline was 3.3 in Group I and reduced to 2.63 weeks after therapy [Graph 4 and Table 4]. Mean PD in Group II at baseline was 3.7 and reduced to 2.67 3 weeks after therapy [Graph 5 and Table 5]. The comparison between treatment groups revealed a significantly greater mean PD reduction in Group II than in Group I (20.22% in Group I vs. 26.76% in Group II) [Graphs 6 and 7]. CAL in Group I at baseline was 3.01 and improved to 3.73 weeks after therapy [Graph 8 and Table 6]. CAL in Group II at baseline was 2.6 and was improved to 3.73 weeks after therapy [Graph 9 and Table 7] (32.5% in Group II and 22.34% in Group I) [Graphs 10 and 11].

Graph 4

Reduction in probing depth in Group I after 21 days

Table 4

Reduction in PD in group I after 21 days

Graph 5

Reduction in probing depth in Group II after 21 days

Table 5

Reduction in PD in group II after 21 days

Graph 6

Percentage of probing depth reduction in Group I after 21 days

Graph 7

Percentage of probing depth reduction in Group II after 21 days

Graph 8

Gain in clinical attachment level in Group I after 21 days

Table 6

Gain in CAL in group I after 21 days

Graph 9

Gain in clinical attachment level in Group II after 21 days

Table 7

Gain in CAL in group II after 21 days

Graph 10

Percentage of clinical attachment level gain in Group I after 21 days

Graph 11

Percentage of clinical attachment level gain in Group II after 21 days

Discussion

Diabetes mellitus and periodontitis are common chronic infections that affect the general population. DM is a group of metabolic disorders characterized by chronic hyperglycemia resulting from the defects in insulin secretion, insulin action or both.[11] Periodontal disease is a bacterial infection resulting in inflammation and destruction of tooth-supporting tissues.[2] Studies have proved that type 1 and type 2 diabetes increase the risk and severity of periodontitis, which is recognized as the sixth serious complication of diabetes.[1213]

Although several studies have been done to show the comparing the effect of laser therapy as an adjunct to SRP and SRP alone, no study has been done specifically in diabetic patients with periodontits. This study was done to evaluate the clinical parameters in diabetic patients with periodontitis when treated with SRP alone and SRP with laser therapy. In this study, PI, GI, SBI, PD and CAL was evaluated at baseline and 3 weeks after therapy.

Plaque Index score was 2.08 at baseline and reduced to 1.67 3 weeks postoperative period in both the groups. This correlates to a study by Baredkar et al. which showed a reduction in PI from baseline to the final assessment 6 months after SRP.[14]

In the study, GI score was reduced from 2.09 to 1.69 3 weeks after therapy in both the groups. This is in accordance to a study by Fallah et al., which showed a significant reduction in GI in both groups after 6 weeks.[15]

Sulcular bleeding index was reduced from a baseline score of 3.2 to 1.8 3 weeks after therapy in both the groups in the current study. Similar studies by Moritz et al. and Gutknecht et al. showed statistically significant improvement in bleeding on probing (BOP) following treatment compared to baseline.[1617] According to Lang et al. reduction in BOP scores is accompanied by decrease in periodontal inflammation.[18] As mentioned above, SRP and Laser curettage reduces gingival inflammation and as a result, reduction in BOP score was seen after the therapy.

The current study also showed significant reduction in PD and gain in CAL in both the groups and Group II showed more reduction in PD and more gain in CAL than Group I. The mean PD at baseline was 3.3 in Group I and reduced to 2.6 3 weeks after therapy. Mean PD in Group II at baseline was 3.7 and reduced to 2.67 3 weeks after therapy. The comparison between treatment groups revealed 20.22% PD reduction in Group I and 26.76% PD reduction in Group II, hence showing that Group II had 6.54% more significant reduction in PD than Group I. This is similar to study by Kelbauskiene et al. in which the use of laser in addition to SRP resulted in a statistically significant and consistently greater reduction in PD when compared to the results of SRP alone.[19] Increased PD in periodontitis patients is because the tip of the probe passes through the inflamed tissues to stop at the most coronal intact fibers. Following periodontal therapy PD measurements is decreased because of reduction in inflammation which results in decreased penetrability of the gingival tissues by the probe. Several studies have shown the reduction in inflammatory mediators following laser therapy.[202122]

The enhanced reduction of inflammation induced by laser therapy is also due to effective bacterial reduction property of laser. Moritz et al. demonstrated that diode laser light at 805 nm eliminated Aggregatibacter actinomycetumcomitans and Porphyromonas gingivalis in periodontal pockets.[17] Lin et al. demonstrated that subgingival treatment with the diode laser effectively inhibiting recolonization of A. actinomycetumcomitans for up to 28 days than in root planing.[23] Pick et al. showed that diode laser light not only eliminates bacteria but also inactivates bacterial toxins diffused within root cementum. A study by Moritz et al. showed that Gram-negative species showed immediate structural damage when exposed to the laser. Diode laser at 810 nm causes bacterial damage without injury to periodontal tissues.[21]

In this study, CAL in Group I at baseline was 3.01 and increased to 3.7 3 weeks after therapy. CAL in Group II at baseline was 2.6 and increased to 3.7 3 weeks after therapy. CAL gain was 32.5% in Group II and 22.34% in Group I. Hence, Group II showed 10.16% more CAL gain than Group I. This can be supported by study by Yukna et al. 2007, which showed a significant reduction in PD with increased CALs associated with laser therapy in patients with periodontitis.[24] The above result shows that laser treatment supports new connective tissue formation. Healing after SRP is by the proliferation of epithelium along the root surface resulting in the formation of a long junctional epithelium, and true periodontal regeneration is not obtained. However, laser application facilitates removal of epithelium from periodontal pockets and enables true periodontal regeneration. New cementum and connective tissue formation after laser therapy was demonstrated by Romeo et al.[25] Study by Tomasi et al. showed greater mean PD reduction and greater mean CAL gain in the laser treatment group than instrumentation groups.[6]

Numerous studies have found that diode laser exhibits anti-inflammatory action with an improved periodontal wound healing in systemically compromised patients, especially in DM. Ribeiro et al. reported that laser periodontal therapy following SRP reduces gingival inflammation and matrix metalloproteinase-8 expression and histological examination showed a reduction in inflammatory cells.[20] Findings by Safavi et al. suggested an inhibitory effect of laser periodontal therapy on interleukin-1 β and interferon γ production and explained the anti-inflammatory effects of laser.[21] According to Capon et al., the increased accelerated wound healing in laser is due to induction of heat shock proteins, which play a role in the expression of transforming growth factors and improvement in proliferation of fibroblasts and adhesion to the root surface.[22] Diode laser therapy benefits the periodontium directly by eliminating the pathogens and disinfecting the pockets and indirectly by reducing the hyper-inflammatory status of DM patients. Laser therapy also enhances the collagen formation and thus healing will be accelerated in DM patients. Thus, in this study Laser + SRP showed faster healing and improved PD reduction and gain in CAL in diabetic patients. However, only the clinical parameters were assessed in the current study and hence further biochemical, microbiological and histomorphometric analysis is required to confirm the action of adjunctive laser curettage in the nonsurgical periodontal therapy of diabetic patients.

Conclusion

This study indicates that laser curettage with SRP resulted in increased PD reduction and greater gain in CAL in diabetic patients with periodontitis. It can be concluded that laser therapy in adjunct with SRP offers additional benefits in periodontal therapy compared to SRP alone, especially in systemically compromised patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.