Study
finds lack of research to support perio laser therapy
By Kathy Kincade, Editor in Chief
April 26,
2010 -- Soft-tissue lasers add no clinical value to the treatment of
periodontal disease beyond what can be achieved using scaling, planing, and conventional surgical procedures, according to
a literature review in the Journal
of the Canadian Dental Association (April 2010, Vol. 76:2, a30).
But other
research, and the evolving perception that periodontal disease is caused not by
oral bacteria but by inflammatory cells that overreact to the presence of the
bacteria, point to an issue that is not quite so black and white.
“One thing I know as a fact: Lasers are not
going away.”
— Samuel Low, D.D.S., M.S., president,
Periodontology
The
integration of dental lasers into daily practice is being advocated as a
"revenue booster" that offers patients a painless alternative to
surgical treatment of periodontal disease and a benefit over traditional
methods of therapy, according to Debora C. Matthews, D.D.S., M.Sc., chair of the department of dental clinical sciences
at
"Although
it may be true that dental lasers can increase revenue, statements relating to
the effects of lasers appear to be based primarily on manufacturers' claims of
laser efficacy rather than research data," she wrote.
In
particular, Dr. Matthews noted, soft-tissue lasers are being promoted as an
adjunct to, or substitute for, standard mechanical debridement of subgingival
root surfaces and periodontal pockets.
"The
use of lasers as an adjunct or alternative to conventional mechanical therapy
is based on the claim that subgingival curettage and eradication of pathogenic
bacteria will produce a sterile field, leading to elimination of periodontal
pockets," she wrote.
Dearth
of clinical research
But there
is little scientific evidence to support these claims, Dr. Matthews noted. In
fact, "there is a striking dearth of high-quality clinical research
examining the effect of laser use in nonsurgical
debridement to improve periodontal outcomes," she wrote.
Dr.
Matthews came to her conclusions after reviewing the most current clinical
evidence on the use of soft-tissue lasers in the nonsurgical
treatment of periodontal disease, including three systematic reviews. One of
the studies, commissioned for the American Academy of Periodontology
(AAP), located 278 articles on the use of lasers in periodontics
published before 2006 (Journal of Periodontology, April
2006, Vol. 77:4, pp. 545-564).
More
recently, two systematic reviews identified 19 randomized controlled clinical
trials, including 11 studies of the clinical effects of laser therapy compared
with mechanical debridement in patients with chronic periodontitis
(Journal of Periodontology, July 2009, Vol.
80:7, pp. 1041-1056; Journal
of Clinical Periodontology, September 2008,
Vol. 35:s8, pp. 29-44).
"None
of these trials found laser therapy -- alone or as an adjunct to SRP [scaling
and root planing] -- improved periodontal outcomes
compared with SRP alone," Dr. Matthews wrote. "There were no
statistically significant differences in microbial levels, attachment gain,
bleeding indices, or pocket depth reduction in 10 of the 11 studies."
Inflammatory
reaction
Dr.
Matthews is not alone in her findings. Samuel Low, D.D.S., M.S., president of
the AAP and a staunch supporter of the use of lasers for periodontal treatment,
said that, from an evidence-based standpoint, Dr. Matthews' conclusions are
correct. "I agree with the author that if you do SRP and you do it
competently, I doubt seriously that the addition of a laser is going to assist
in that process," he said.
And a
January 2010 study in Dental
Clinics of North America (Vol. 54:1, pp. 35-53) coauthored by Dr. Low
that examined the current peer-reviewed evidence on the use of lasers in
chronic periodontitis treatment also concluded there
is little evidence to support the purported benefits of lasers in treating
periodontal disease compared with traditional periodontal therapies. Because of
the lack of well-designed clinical trials, clinicians using lasers for the periodontitis treatment "should expect limited
clinical improvement in periodontal status," Dr. Low and his colleagues
wrote.
Where the
difference might be is the utilization of lasers in treating periodontal
disease from a surgical standpoint, Dr. Low noted. In fact, he believes that as
we gain a better understanding of the root causes of periodontitis,
this could open new doors for lasers in the treatment of this disease.
"The
AAP is moving more and more into the concept that it is inflammation that
causes the destruction in gum disease, not the bacteria itself," he said.
"It's like a bee sting: It is not the bee that kills you. It is your
reaction to the sting."
In patients
with periodontal disease, he noted, there is an inflammatory reaction -- an
overreaction by the cells to enzymes in the bacteria. "So with the laser,
if one removes some of the connective tissue that has these 'bad' inflammatory
memory cells in it, it is conceivable -- we don't have this based on science
yet -- that the posthealing response might be more
positive than just cleaning roots and removing bacteria," he said.
Toward
that end, a split-mouth, single-blind, randomized controlled clinical trial
published by the Journal of Periodontology
(April 16, 2010) concluded that a single application of a water-cooled Nd:YAG (neodymium-doped yttrium aluminum garnet) laser
"significantly improves clinical signs associated with periodontal
inflammation compared to treatment by SRP alone."
"There
probably are still some things we do not know because lasers in dentistry are a
very new frontier," Dr. Low said. "But one thing I know as a fact:
Lasers are not going away. In my practice, if you give a patient a choice
between a laser or a blade (for perio
therapy), they jump on the laser. If your patients are walking away from
surgery that is necessary to save their teeth, then you are doing them a
service by offering the laser."
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