Lasers, Hygiene, and Periodontal Disease

Periodontal Disease/Systemic Disease Links

The connection between periodontal disease and systemic disease is undeniable. Researchers such as Jeffery Ebersole, PhD, University of Texas San Antonio, in 1997 linked oral infection with the increased development of inflammatory factors like alpha 2-macroglobulins and C-reactive protein.1 Researchers at the University of North Carolina and the University of Buffalo New York in 1999 also found a connection between periodontal disease infection and systemic diseases.¹

The systemic link extends to the following:²

• Cardiovascular disease
• Stroke
• Diabetes
• Low birth weight and pre-term birth babies
• Pulmonary diseases
• Obesity
• Pancreatic cancer

Biofilms and Their Role in Disease

Biofilms, complex organized communities of pathogenic micro-organisms, play a large role in the development of periodontal disease and to the invasion into the vascular system, exposing other organ systems to the increased risk of disease.³

J.W. Costerton, PhD, MS, from the University of Southern California Center for Biofilms, has done extensive research on biofilms and their mechanism of action. Through his work we now know that the complex make up of the biofilm community includes pathogens from early developmental stages through to mature disease-causing stages. Their ability for self-preservation is remarkable, including nutritional needs, inter-pathogen communication, and trans-location. What is really surprising is his discovery that only 20 percent of the biofilm are pathogens, while 80 percent of the biofilm comprise the gelatinous matrix, a slime layer composed of self-secreted glycoproteins and polysaccharides.³

The question for dental hygienists now becomes, how we adjust our periodontal disease therapy modalities to rid the infected periodontal pocket of this gelatinous material causing disease not only locally in the pocket, but systemically once introduced into the vascular system. We do that through the use of the high technology instruments now available, such as ultrasonic scalers and lasers.

Why Lasers in Periodontal Therapy?

The current mode of dealing with disease-causing organisms within the human body is through the use of chemotherapeutics, delivered both systemically and locally. There are two problems we face with this modality. The first is that there will always be a certain percentage of the patient population that will have contra-indications for using certain chemotherapeutics. They may have systemic reactions to certain medications or they may be pregnant. The second is the fact that the overuse of medications for infection, specifically antibiotics, has resulted in what are being called “superbugs,” or pathogens that are resistant to current medications available for use.

Lasers currently used in dentistry for the treatment of periodontal disease exert their bacterial reduction effect through Photothermal means.⁴ Used well below the surgical parameters used for other laser therapies, dental lasers deliver light energy locally to the infected site to eradicate the bacteria by causing a rupture of the cell wall. Laser energy is delivered by light to which there are no contra-indications and to which the bacteria cannot develop a resistance to.

Laser devices have been available to the dental profession since the early 1990s, with the first devices being both expensive and bulky. Both of these factors, along with limited clinical studies, slowed the growth of lasers in dentistry. This is no longer the case. The evolution of lasers has made them user- and operatory-friendly, with some devices being slightly larger than a Palm Pilot, and very affordable. Couple this with the extensive clinical studies already done and currently being done on the incorporation of lasers into dental procedures and lasers become a device to be considered for every dental office.

Where to Incorporate Lasers

Periodontal disease is indicated by bleeding gingiva, increased pocket depths, recession, bone loss, furcation involvement, mobility and exudate, often resulting in the loss of the tooth. As the pocket depths increase, the accumulation of both hard and soft debris increases, creating the perfect site for the advancement of the periodontal disease process. To determine the necessary treatment, a full periodontal assessment is required and should include notation of all of the factors mentioned above.

Exhibited disease can be at any stage progression to incorporate adjunctive laser therapy. Sites that bleed at any probed depth are diseased and can benefit from the addition of the laser energy for bacterial control.

Incorporating the laser will:

• Reduce the bacterial count within the pocket;
• Coagulate only the diseased tissue for removal;
• Provide a biostimulatory effect for better healing; and
• Reduce the need for chemotherapeutics.

When to Incorporate Lasers

The laser should be used during the phase one, non-surgical therapy, much like ultrasonic instruments.⁵ It is during these appointments that the diseased pocket sites require thorough debridement of both the hard and soft debris. The effectiveness of the removal of the hard debris from the root surface easily can be measured easily by exploring the smoothness of the root surface. It is the effectiveness of the removal of the soft debris that can be more difficult and since we know that the soft debris is the biofilm, instrument modalities beyond the hand scaler must be considered.

The pocket space can be effectively “flushed” by the use of ultrasonic instrumentation but what of the tissue itself. Exposing the diseased tissue to laser energy will assist bacterial control by penetrating as many as 3 mm to 4 mm of tissue.⁴ As the appointment process moves along, previously treated sites should be revisited to control bacteria and allow for optimum healing.

Once the primary therapy appointments are finished, the patient is placed on a maintenance program. The laser can be easily incorporated into these appointments to assist in the bacterial control and to maintain periodontal health.⁵ It only takes a few seconds of laser exposure at each regressing site to achieve a bactericidal effect, thereby eliminating the need for additional chemotherapeutics. Since the oral cavity can never be pathogen free, the laser will always be an effective instrument choice for the periodontal maintenance patient.

REFERENCES

1. Ebersole JL, Machen RL, Steffen MJ, Willmann DE. Systemic acute-phase reactants, C reactive and haptoglobin in adult periodontitis. Clin Exp Immunol 1997; 107:347-52.
2. Fine JB, Yao S. The Influence of Periodontal Inflammation on Systemic Diseases and Medical Conditions. Access May-June 2007; 14-19.
3. Costerton JW. New Ammunition. Dimensions Dent Hyg May 2007; Vol. 5, No. 5: 14-16.
4. Dental Clinics of North America. Lasers in Clinical Dentistry Oct 2004; Vol. 48, No. 4.
5. Gutierrez T. Diode Laser for Bacterial Reduction and Coagulation: An Adjunctive Treatment for Periodontal Disease. Cont Oral Hyg Dec 2005; Vol. 5, No. 12: 20-21.