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The Effect of Low-Level Laser Therapyas an Adjunct to Non-Surgical

Periodontal TreatmentGokce Aykol,* Ulku Baser,* Ilay Maden,* Zafer Kazak, Utku Onan,* Sevda Tanrikulu-Kucuk,Evin Ademoglu, Halim Issever, and Funda Yalcin*

Background:The aim of this study is to evaluate the effect of low-levellaser therapy (LLLT) as an adjunct to non-surgical periodontal therapy ofsmoking and non-smoking patients with moderate to advanced chronic peri-odontitis.

Methods: All 36 systemically healthy patients who were included in thestudy initially received non-surgical periodontal therapy. The LLLT group

(n=

18) received GaAlAs diode laser therapy as an adjunct to non-surgicalperiodontal therapy. A diode laser with a wavelength of 808 nm was usedfor the LLLT. Energy density of 4 J/cm2 was applied to the gingival surfaceafter periodontal treatment on the first, second, and seventh days. Eachof the LLLT and control groups was divided into two groups as smokingand non-smoking patients to investigate the effect of smoking on treat-ment. Gingival crevicular fluid samples were collected from all patientsand clinical parameters were recorded on baseline, the first, third, and sixthmonths after treatment. Matrix metalloproteinase-1, tissue inhibitor matrixmetalloproteinase-1, transforming growth factor-b1, and basic-fibroblastgrowth factor levels in the collected gingival crevicular fluid were mea-sured.

Results: The primary outcome variable in this study was change in gingi-val bleeding and inflammation. At all time points, the LLLT group showedsignificantly more improvement in sulcus bleeding index (SBI), clinical at-tachment level, and probing depth (PD) levels compared to the controlgroup (P

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or alternative to current mechanical treatment hada great run in the treatment of gingival inflammation.5,6

Among laser applications, low-level laser therapy(LLLT) is recommended for its pain-reducing, wound-healing promoter and anti-inflammatory effects.7

It is suggested that LLLT alters cellular behavior

by affecting the mitochondrial respiratory chain ormembrane calcium channels, and that it can facilitatecollagen synthesis, angiogenesis, and growth fac-tor release, which eventually accelerate wound heal-ing.8-12 The results of the studies investigating theeffects of LLLT on periodontitis are conflicting andfurther studies are needed. There are few in vivo stud-ies that evaluate LLLT as an adjunct to conventionalperiodontal treatment. Qadri et al.13 showed reducedperiodontal gingival inflammation with two differentlow-level lasers used as an adjunct to periodontaltreatment. On the other hand, Lai et al.14 reported that

low-power helium-neon laser as an adjunct to non-surgical periodontal treatment did not show any addi-tional clinical benefit.

Periodontal tissue healing constitutes a complexbiologic process regulated by interactions betweencells and growth factors triggering a series of cellu-lar events leading to new tissue formation.15 Duringwound healing inflammatory response and synthesisof specific extracellular matrix molecules by fibro-blasts, angiogenesis, reepithelialization, and remod-eling are regulated by growth factors includingtransforming growth factor-b1(TGF-b1) and basic-

fibroblast growth factor (b-FGF).3,16

In periodontitisthe degradation of extracellular matrix is thought tobe induced by an imbalance between matrix metallo-proteinases (MMPs) and their specific inhibitors (tis-sue inhibitor matrix metalloproteinase [TIMP]).17

On the other hand, although smoking is one of therisk factors that predispose to lower rates of successafter both surgical and non-surgical periodontal ther-apy,18,19 there are a limited number of studies thatevaluate the effect of LLLT on periodontal woundhealing in smokers.

The purpose of the study is to evaluate the effect ofLLLT as an adjunct to non-surgical periodontal treat-ment on clinical parameters; the effect of LLLT as anadjunct to non-surgical periodontal treatment onMMP-1, TIMP-1, TGF-b1, and b-FGF levels in gingivalcrevicular fluid (GCF); and the effect of LLLT as an ad-junct to non-surgical periodontal treatment on peri-odontal wound healing in smokers and non-smokerswith moderate to advanced chronic periodontitis.

MATERIALS AND METHODS

Subject Selection, Study Design, and ClinicalProcedures

Thirty six patients (22 men and 14 women) who were

classified as moderate to advanced chronic peri-

odontitis according to the 1999 American Academyof Periodontology workshop were included in thestudy.20 Patients were referred to the Department ofPeriodontology, Faculty of Dentistry, Istanbul Univer-sity, for periodontal treatment between May 2007 andMay 2009. The sex distribution was seven females

and 11 males, and there were nine smokers in eachgroup. The mean age was 42.22 7.53 years (agerange: 31 to 53 years) for the control group, and43.56 6.70 years (age range: 31 to 58 years) forthe LLLT group. Written informed consent was ob-tained from all subjects. The study protocol was ap-proved by the Ethics Commission of IstanbulUniversity for human subjects (2006/1471).

All patients were systemically healthy and not re-ceiving any medication at the time of study. The ex-clusion criteria were as follows: patients who hadany kind of periodontal treatment or used antibiotics

during the last 6 months, had an acute oral infection,orhad

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Laser treatment was performed by using a gallium-aluminum-arsenide (GaAlAs) diode laser.** Thephysical parameters of this unit used during the treat-ment were as follows: wavelength, 808 nm; averageoutput, 0.25 W; spot size, 0.28 cm2; and continuouswave output. Non-contact technique was applied for

10 seconds to the gingiva of incisors and premolarsand 20 seconds to the gingiva of molars. The applica-tion distance was 0.5 to 1 cm because this distancedifference did not affect the spot size with the hand-piece that was used. The energy density was 4 J/cm.2

Plaque index (PI),21 sulcus bleeding index (SBI),22

PD, and clinical attachment level (CAL) were recordedon sixsites per tooth (mesio-, mid-, anddisto-vestibular;mesio-, mid-, and disto-palatal) at baseline, 1, 3, and6 months after the treatment. All parameters weremeasured with a periodontal Williams probe cali-brated in millimeters. The cemento-enamel junction

was used as the reference point. All measurementswere done by a masked, calibrated examiner (GA).Three patients were included for intraexaminer re-producibility. The examiner measured the PD andSBI scores twice, 2 days apart in each patient. Themean difference was

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smokers PD and SBI levels compared to smokers towhom laser was not applied, between the baseline andall time points (P40 years.Unlike high-power lasers that are used to break down

tissue by their thermal effects, low-level lasers are

thought to work by the interaction of light with the celland tissue. This interaction might be affected bysome parameters, such as wavelength, power, energydensity, treatment duration, treatment intervention

time, method of application, structure, and conditionof tissue. The dose applied during laser application isone of the important treatment parameters to bene-fit from LLLT. However, a precisely determined dosehas not been proved for each indication. Biostimula-tion has been reported in the literature with dosesbetween 0.001 and 10 J/cm2 as a therapeutic win-dow.24 Even though applied dose is in the therapeu-tic window range, it might be too low or too highfor the desired effect. Mester et al.25 suggested in1971 that doses of 1 to 2 J/cm2 are necessary tosee an effect on wound healing. In our study we useda GaAlAs laser with a wavelength of 808 nm, outputpower of 0.25 W, and 4 J/cm2 energy density onthe first, second, and seventh days after the treat-ment. This dose has also been proved to enhanceepithelialization and wound healing by previous stud-ies after gingivectomy and gingivoplasty.26,27

The results of our study show that there is a statis-tically significant improvement in clinical parame-ters after non-surgical periodontal treatment ineach group. The beneficial effects of scaling and rootplaning combined with personal plaque control inthe treatment of periodontitis have been well doc-umented.2,4,28 These include reduction of clinical

inflammation, microbial shifts to a less pathogenic

Table 1.

Differences in Clinical Parameters

Parameter

(SD) Baseline 1 Month

Difference

(0 to 1 month)

P

Value 3 Months

Difference

(0 to 3 months) P Value 6 Months

Difference

(0 to 6 months)

P

Value

PIControl 1.79 0.66 0.70 0.67 1.09 0.81

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subgingival flora, PD reduction, and gain of clinicalattachment.In our study, the improvement in terms of mean dif-

ference of PD, CAL, and SBI scores is significantlymore in the LLLT group compared to the controlgroup. Even though the methodology of two studieswere not the same, Qadri et al.13 found in their studythat additional treatment with low-level lasers re-duced periodontal gingival inflammation and PD;the results of our study are parallel to this study,which reported only short-term effects of low-levellaser. Contrary to our findings, Lai et al.14 suggestedthat low-power laser did not result in any additionalclinical benefit. This might be a result of their appli-cation power density being low (2.83 mW/cm2) andhaving limited application sites. The use of differentkinds of lasers, doses, and duration preclude a com-parison of these two articles with our study.

LLLT after non-surgical periodontal treatment re-sulted in significantly more reduction of SBI scorecompared to the control group. This improvementcould be a result of an increase of the anti-inflamma-tory cytokine levels and an increase of microcircula-tion by the low-level laser irradiation.29

It is known that the efficacy of non-surgical peri-

odontal treatment is related to the initial PD, and

deeper pockets have more potential of PD reductionand CAL gain. Therefore, we allocated sites by initialPD to evaluate the adjunctive effect of low-level diodelaser separately for these sites. The difference of re-duction of PD in both moderate and deeper siteswas found to be statistically significant between thegroups. The LLLT groups reduction was significantlymore in the 6 months after treatment.

Smoking is one of the factors that affect the healingof periodontal tissues.30 We have also found addi-tional improvements in the smoking LLLT groupcompared to smokers who did not receive laser treat-ment. Significant reduction was found in SBI and PDafter 6 months and CAL after 3 months. This changemay be related to LLLT, because LLLT is reported tohave positive effects on microcirculation, collagen,and cytokine production, which are negatively ef-fected by smoking. We have also compared smokersand non-smokers who both received LLLT. Althoughsignificantly more reduction of SBI was detected innon-smokers, no statistically significant reductiondifference was found in PD and CAL among smokersand non-smokers in the LLLT group.

MMPs are key enzymes in normal and pathologictissue remodeling, such as wound healing and in-

flammation. MMP-1 is the major type of proteolytic

Table 2.

Differences in Biochemical Parameters

Parameter

(SD) Baseline 1 Month

Difference

(0 to

1 month) P Value

3 Months

Difference

(0 to

3 months) P Value

6 Months

Difference

(0 to

6 months) P Value

MMP-1 (ng/sample)

Control 1.02 0.58 0.58 0.30 0.49 0.57

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still unknown how b-FGF plays a role in periodontalwound healing.

Within its limits, our study shows that adjunction ofLLLT to scaling and root planing improves clinical re-sults, but the differences between the groups in clini-cal results do not reflect biochemical parameters. In

our study, the parameters that we evaluated to ob-serve wound healing with or without laser applicationshow compatible results with the clinical changes af-ter periodontal therapy.

We observed statistically significant differences onclinical parameter changes when we applied laser asan adjunct to non-surgical periodontal treatment.Even though there were statistical differences be-tween the groups, the clinical improvement observedwas rather minor. Only the laser-applied group insmokers showed statistically significant clinical im-provements. However, the differences between test

and control group in all evaluated parameters wereminimal at 6 months.

CONCLUSION

LLLT application as an adjunct to non-surgical treat-ment reduced gingival inflammation in patients whosmoke.

ACKNOWLEDGMENTS

The present work was supported by the researchfoundation of Istanbul University (Project No: T-969/06102006). The authors report no conflicts of interest

related to this study.

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Correspondence: Dr. Ulku Baser, Department of Periodon-tology, Faculty of Dentistry, Istanbul University, 34390Capa, Istanbul, Turkey. E-mail: baserulku@hotmail.com.

Submitted April 6, 2010; accepted for publication August29, 2010.

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