First Phase Nonsurgical LaserPeriodontal Treatment:A Case StudyBy Nora Raffetto, RDH

Introduction

Figure 1. Probing pre-treatment for the assess-ment and diagnosis of periodontal disease.

Periodontal disease can have periods of intense activityand periods of dormancy. Today, it is widely accepted thatperiodontal disease triggers a host-inflammatory responsethat contributes to the changes in the metabolism oftheconnective tissue and supporting bone. '^^ It becomes in-creasingly important to manage this destructive disease byaddressing the microbes responsible while protecting the pa-tient's health.^ Thorough treatment of periodontitis must be

performed in a way thatminimizes the risk of sideeffects for the patient.

Soft tissue lasers area good choice for thereduction ofthe micro-bial population whileproviding coagulation ofthe treatment area. Thelaser energy is transmit-ted through the fluid inthe sulcus and is mostattracted to and reactivewith the inflamed tissueand pigmented bacteria.The laser is used ad-junctively in periodontaltherapy after the hardaccretions have beenremoved on the tooth androot surfaces.'^ The den-tal hygienist generally isthe provider of this initialnonsurgical treatment.

Case Presentation

The patient, a44-year-old Caucasianmale, presented withgeneralized bleeding andinflammation. His healthhistory indicated that hehad good general healthand was taking an over-the-counter multivitamin.He reported that it hadbeen two years since hislast periodontal evalua-tion and prophylaxis.

Figure 2. The probe chart pre-treatment Isused for the calibration of the laser fber duringtherapy.

The periodontal examination included a full-mouth X-ray,complete periodontal probing, hard tissue examination, oralcancer screening, and evaluation ofthe occlusion. The resultsof this exam showed generalized inflammation, supra- andsubgingival calculus, recession of 1 mm to 2 mm on #6 and#11 due to ocdusal trauma, and horizontal bone loss in themolar and premolar areas of 2 mm to 5 mm (figures 1 and2). No hard tissue lesions were found. The complete examled to a diagnosis of moderate generalized periodontisis.*

Short-Term Goals

1. Initiate good plaque control with an oral hygieneprogram tailored to the patient's needs.

2. Adjust the ocdusal interferences for more balancedcontacts on tooth #s 5 and #11,

3. Dbride all hard tissues followed by laser treatmentofthe soft tissues.

Long-Term Goals

Improve periodontal condition with a gain in clinicalattachment levels.

Help patient maintain a high level of oral hygiene,

Treatment Plan

The diagnosis of moderate generalized chronic perio-dontitis was discussed with the patient and the doctor, Thehygienist presented the treatment plan.

1. Complete debridement of the hard tissues usingultrasonics and hand scaling.

2. Perform laser bacterial reduction followed by lasercoagulation ofthe infected sites. The treatment laser is an 810-830 nm diode

laser (DioDent, Hoya ConBio, Fremont, Calif.). The fiber for this treatment is a 400-micron ber. Bacterial reduction settings are 500mW CW for

10-15 seconds per site. Coagulation settings are 700mW CW for 10 sec-

onds per site.'3. Conduct oral hygiene instruction tailored for the

patient's needs.

Treatment Sequence

The patient was treated in four one-hour appoint-ments with seven days between appointments. Treatment

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Figure 3. Prior to laser treatment the laser fberis easily calibrated using a probe to adjust thefber length.

Figure 4. The iaser fber after calibration ispiaced on the tissue at the top of the sulcus tostart treatment.

Started in the lower right quadrant, thearea with the deepest pocket depths(figures 3 and 4).

Anesthesia used for treatnnent was atopical anesthesia rinse of 1% dycloninehydrochloride. After ultrasonic and scalingwas completed, the laser was used withthe laser ber calibrated to the depth ofthe sulcus being treated minus 1 mm. Thetarget tissue was the inflamed epitheliallining of the pocket. The fiber was placedon the tissue at the top of the sulcusand moved both horizontally and verti-cally "painting" the tissue on the wall ofthe sulcus with laser energy down to thecalibrated depth. The fiber was inspectedoften during laser use and any accumu-lated debris was wiped off with dry gauzeto avoid any inefficiency (figure 5),

As the treatment sequence pro-gressed the previously treated sites wereretreated with the laser using only thebacterial reduction setting and time. Theber during re-treatment was calibratedto the pocket depth minus 2 mm to avoiddisturbing the healing that had started atthe bottom of the sulcus.

Treatment Assessment

The patient returned one month afterhis laser treatment was completed so thattissue healing could be checked and homecare skills evaluated. No probing wasdone at this appointment. The patientreported that he had no postoperativediscomfort. Home care evaluation showedthe patient was compliant with his recom-mended home care routine, and his tissueshowed improvement with no inflamma-tion present.

The author recommends that lightprobing start at three months posttreat-ment and a definitive six-point probingbe done at six months following lasertherapy (gure 6). The rational for theprobing schedule of laser-treated ar-eas is suggested because the tissue atthe bottom of the sulcus is healing. Thefibers are fragile as they reattach to theroot surface and could be damaged byintroducing a probe too early, delayinghealing.''^

Figure 5. Accumulated debris on the iaser beris wiped off with a dry gauze to ensure lasereffciency.

Figure 6. Six-point probing resumes at the6-month post-treatment appointment.

The author recommends that lightprobing start at three monthsposttreatment and a definitivesix-point probing be done at sixmonths foiiowing iaser therapy

Assessment of treatment and recarewas done at three, six, nine, and 12months following laser therapy (figure 7).The probing depths improved; a gain inclinical attachment levels was noted; noinflammation was present; the tissue tone

Figure 7. The 2-month post laser therapyprobe chart indicates pocket depths have beenreduced,

was good, showing increased stipplingand the patient remained committed tothe recommended home care.

Prognosis

The long-term prognosis for thispatient is good. Regular recare appoint-ments are necessary to dbride any cal-culus and blofilm accumulation, to evalu-ate the pocket depths including tissuetone and inflammation and to continue tomonitor patient home care skills.

Conclusion

Laser-assisted first phase periodontaltherapy often delivered by the dentalhygienist is a successful treatment op-tion that can effectively help the patientachieve and maintain optimum levels ofhealth.^'" Studies of laser soft-tissuetherapy and clinical observations of pa-tients treated with the soft-tissue lasersare showing good results. With educationand experience, the entire dental teamcan use the laser as a powerful tool in thetreatment of periodontal disease.

References

1. Zambn JJ. Periodontal diseases; microbial Fac-tors. Ann Periodontol 1996; 1:879-925.

2, Kornman KS, Page RC, Tonetti MS. The hostresponse to microbial challenge in periodontitis:

l a s e r s continued on page 14

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handles covered in plastic, instruments in disposablepaper and plastic sterilization pouches, disposable suc-tion tips, paper-covered instrument trays and ourselves,wrapped in a disposable gown.

It doesn't have to be this way. Instead of disposingof more than 680 million throwaway paper and plasticbarriers each year, we can make the switch to dothdental operatory products and earth-friendly surfacedisinfectants. Reusable cloth head rest covers and pa-tient bibs are more comfortable for patients and morecost-effective for the practice. Wiping down chairs andother surfaces with disinfectants is equally as effectivein preventing cross-contamination as using big rolls ofplastic that are thrown away in the trash. Wearing clothlab coats that can be washed and reused not only saveswaste but communicates a more upscale image.

The same is true for sterilization. The U.S. dental industryis responsible for the disposal of 1.7 billion instrument andsterilization pouches each year, just about all of which end upin landlls. Whether you are using cassettes or wraps, imple-menting a doth sterilization program is easy to do, and whencombined with cloth patient barriers, can save a practice morethan $2,000 a year, according to a study from the Eco-DentistryAssociation.5 Cloth sterilization wraps serve a dual function asa tray cover, eliminating yet another piece of paper. When dothwraps become worn after years of use in the dental office, theytoo can be reused by your local animal shelter.

Incorporating reusable stainless steel suction tips instead ofthe throwaway plastic HVE tips not only saves waste, it savesmoney$170 a year, (enough to pay for a very nice lunch forthe whole dental team) while diverting significant waste fromthe landfill. Buying prophy paste in bulk and using stainless steelreusable prophy cups is another money saver. Switching to reus-able "rinse and swish" cups after a professional teeth cleaning iseasier on the Earth and adds a spa feel to the practice.

It's Easy Being Green

Eco-friend!y, reusable alternatives are readily available, bothfor the dental office and in our everyday lives. All it takes is ashift in mindset, a move away from the notion of a disposablesociety that ignores the value of resources toward one whereeach resource is appropriately stewarded. Just like you don'thave to treat the whole U.S. population to make a difference inperiodontal disease, you don't have to tackle all of the world'senvironmental problems to make a difference. All we ask is thatyou do what you can do, and that you start today.

References

t . Demographic data on periodontal disease prevalence in the United States.Available at: http://www.nlm,nih.gov/medlineplus/gumdisease.html

2,The great garbage patch: stop trashing the ocean. Available at http;//www.greatgarbagepatch.org/

3. The basic problem with coffee cups. Available at http://sustainabilityjssexy.com/facts,html

4. Bottled water; bottles of trouble. Available at http://www,h2oconserve,org/?page_id=15&pd=bottle

5. Stewards of good health and a healthy planet: catch the green wave. Availableat http;//ecodentistry,org

Fred Pockrass, DDS, has been a restorative dentist for more than 25 years,and along with his wife Ina, co-created Transcendentist in 2003, thecountry's first eco-friendly dental office in Berkeley, Calif. He also serveson the editorial advisory board of Access and the advisory board of the

For More Informationhttp://www.greatgarbagepatch.orghttp://www.greenpeace.org/international/http://www.ecodentistry.org - green dental solutionshttp://www.h2oconserve.org/?pagejd=15&pd=bottlehttp://www.treehugger.comhttp://www.to-goware.com/http://www.greenhome.com/http://www.epa.gov/mercury/consumer.htmhttp://www.forharmony.net/documents/newsletter-summer-2008.pdfhttp://www.dimatecrisis.nethttp://www.nlm.nih.gov/medlineplus/gumdisease.html

Eco-Dentistry Association, a membership organization of which he is theco-creator.

Ina Pockrass, JD, is an attorney and eco-entrepreneur. She is CEO ofTranscendentist, Inc. and co-founder of and advisory board member of theEco-Dentistry Association.

Portions of this material were included in "The Case for Going Green," apresentation by Dr. Fred & Ina Pockrass, at University of the Pacific, SanFrancisco, Calif., May 22, 2009.

lasers cor)tinued from page 10

assembling the players. Periodontol 2000 1997; 14:33-53,3. Ishikawa I, Nakashima K, Koseki T. Induction of the immune response to

periodontopathic bacteria and its role in the pathogenesis of periodonti-tis. Periodontol 2000 1997; t 4 ; 7 9 - l l l ,

4. Meill ME, Mellonig IT. Clinical efficacy of the Nd:YAG laser for combina-tion periodontitis therapy. Pract Periodontics Aesthet Dent 1997 9:1-5.

5. Badoz JM, Gagneur A, Clinical comparison of the effectiveness of novelsonic instruments and curettes for periodontal debridement after 2months, J Gin Periodontol 2002; 29(7):66L

6. Armitage GC. Development of a classification system for periodontaldiseases and conditions, Ann Periodontol 1999; 4: 1-6.

7. Raffetto N, Lasers for initial periodontal therapy. Dent Clin North Am2004; 48(4):923-36,

8. Andreana S. The use of diode lasers in periodontal therapy: literaturereview and suggested technique. Dent Today 2005; 24( l l } :130, 132-5,

9. Coluzzi 0] , Lasers and soft tissue currettege: an update. Compend Con-tin Educ Dent 2002; 23(11A}:11O4-U,

10. Casper p]. Peaks and valleys: a three-year case study examining theuse of diode laser-assisted periodontal therapy, J Acad Laser Dent 2004;12(4):17-9.

11. 5mith ML. NdiYAG laser-assisted treatment of moderate chronic perio-dontitis, ] Dent Laser 2008; 16(l):23-9,

Nora Raffetto, RDH, is a 1971 graduate of Cabrillo College with anAAS degree in Dental Hygiene. She recently retired after 38 yearsworking in a general practice setting in Redwood City, Calif. She hasbeen using lasers sine e 1992 and attained her Nd:YAG AdvancedProficiency in 1994 and Diode Advanced Proficiency in 2001 fromthe Academy of Laser Dentistry. Raffetto has served on the AcademyBoard as the Auxiliary Representative and has been a memberof the Certification and Scientific Sessions committees. She haspublished several articles on lasers and contributed a chapter forthe October 2004 issue of Dental Clinics of North America. She hastrained dentists and hygienists in both Standard Prociency coursesand Laser Soft Tissue Management courses. Raffetto holds a DentalLaser Educator certificate from the University of California at SanFrancisco and is the 2001 recipient of the Leon Goldman Award forClinical Excellence. Raffetto has been a member of ADHA since 1970and is currently a member of the editorial advisory board of Access.Disclosure: Nora Raffetto has no financial affiliations with any lasercompany. She has taught laser courses for laser companies andreceived an honorarium.

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