Manuscript has been accepted for publication JDH , June 2014 D IODE - - PowerPoint PPT Presentation

Manuscript has been accepted for publication JDH, June 2014

DIODE LASER AS AN ADJUNCT TO SRP: THE CONTROVERSY

 AAP 2011 Statement of Efficacy regarding

diode: Minimal evidence to support

 Slot et al, 2014 Recommendation for

adjunctive use of diode: “Moderate” for changes in PPD, and CAL; Significant for BS

WHY DO PRACTITIONERS CONTINUE USING DIODES?

 12 of 14 studies showed

12 of 14 studies showed > > 1 clinical benefit 1 clinical benefit

 Borrajo et al., 2004

Borrajo et al., 2004

 Caruso et al., 2008

Caruso et al., 2008

 Lin et al., 2011

Lin et al., 2011

 Dukic et al., 2013

Dukic et al., 2013

 Zingale et al., 2012

Zingale et al., 2012

 Qadri et al., 2005

Qadri et al., 2005



.

WHY DO PRACTITIONERS CONTINUE USING DIODES?

 Assaf et al., 2007

Assaf et al., 2007

 Kamma et al, 2009

Kamma et al, 2009

 Moritz et al., 1997

Moritz et al., 1997

 Kr

Kreisler et al., 2005 eisler et al., 2005

 Saglam et al, 2014 15j/cm

Saglam et al, 2014 15j/cm2 @ 20s @ 20s

 PD, CAL impr

PD, CAL improved. GCF levels TIMP-1

• ved. GCF levels TIMP-1



 Űstun et al, 2014 760

stun et al, 2014 760 0 C @ 20s C @ 20s

 CAL impr

CAL improved. IL-1

• ved. IL-1β 

WHY

HY D

DO P PRACTITIONERS

RACTITIONERS C

CONTINUE

ONTINUE U

USING

SING D

DIODES

IODES?

?

 2 studies showed no sig. dif

2 studies showed no sig. diff. clinical out

• f. clinical out

come measur come measures es

 Contr

Control showed gr

• l showed greater clinical

eater clinical impr improvement

• vement

 Euzebio Alves, De Micheli et al 2012

Euzebio Alves, De Micheli et al 2012

 808nm 1193.7W/cm

808nm 1193.7W/cm2 @ 20s @ 20s

 De Micheli et al, 2011 808nm 1193.7W/

De Micheli et al, 2011 808nm 1193.7W/ cm cm2 1.5W @ 20s 1.5W @ 20s

WHY

HY S

SUCH

UCH V

VARIANCE

ARIANCE IN IN C

CLINICAL

LINICAL O

OUTCOME

UTCOME

MEASURES

EASURES?

 Weaknesses in study design:

eaknesses in study design:

 Small sample size

Small sample size

 Blinding

Blinding

 Inter/intra examiner calibration

Inter/intra examiner calibration

 Insufficient detail to be r

Insufficient detail to be repeatable epeatable

 Split-mouth/quadrant split-mouth

Split-mouth/quadrant split-mouth design design

WHY SUCH VARIANCE IN CLINICAL OUTCOME MEASURES?

 Heterogeneity of methodology

 Laser parameters

 Power Density: 350mW/cm2 to 2830

W/cm2

 Exposure time: 3s to 90s  Frequency of Laser TX: 1-6 times  Study Length : 6wks- 6m

WHY

HY S

SUCH

UCH V

VARIANCE

ARIANCE IN IN C

CLINICAL

LINICAL O

OUTCOME

UTCOME

MEASURES

EASURES?

 Assessment Parameters:

 Clinical:  Plaque Index to Clinical Crown

Length

 Microbiota  TC to Pg  Biochemical  TIMP-1 to IL-1β

WHY SUCH VARIANCE IN CLINICAL OUTCOME MEASURES?

 Periodontitis

 Chronic

Generalized, Severe

 Aggressive

WHY SUCH VARIANCE IN CLINICAL OUTCOME MEASURES?

 Response of Target Tissue  “Healthy” Subjects

 Smoking  Poor nutritional status  Undiagnosed Diabetes & Metabolic

Syndrome

BACTERIAL HOST INTERACTIONS

• Dr. Mark Ryder

Kornman, 2008

WHY SUCH VARIANCE IN CLINICAL OUTCOME MEASURES?

 Tissue response dependant on Tissue Health??  Human fibroblasts cultured in serum-starved

medium:

 Enhanced procollagen production when

exposed to LLLT Yamamoto 1996

 300 Diabetic Patients: Histological specimens

 Less inflammation, greater healing with LLLT  Obradovic 2012

WHY

HY S

SUCH

UCH V

VARIANCE

ARIANCE IN IN C

CLINICAL

LINICAL O

OUTCOME

UTCOME

MEASURES

EASURES?

 Unknown: Same positive effects in

compromised patients with power density used in adjunctive laser TX?

 Unknown: “Sham Laser” yields

unintended intervention and positive effects to control in studies like De Micheli’s 2011 & 2012?

DIODE

IODE L

LASER

ASER + RDT

+ RDT ≥ RDT A RDT ALONE

LONE? Exploring the Contr Exploring the Controversy

• versy

What we know:

 810nm DL (96J/cm2) Ablates Pg in vitro

 Harris, Yessik 2004

 980nm DL (94.3J/cm2) +SRP TBL, Pg Td 6m

post TX in patients with Aggressive Periodontitis vs SRP or LAS

 Kamma et al 2009

DIODE

IODE L

LASER

ASER + RDT

+ RDT ≥ RDT A RDT ALONE

LONE?

 819nm DL @1PW @ 15s/tooth reduces immediate

bacteremia associated with Ultrasonic scaling

 Assif et al, 2007

 805nm DL @2.5 PW@ 1s/PD 3X reduces bacterial

counts 100% vs 58%

 Moritz et al., 1998

 Study missing significance factor p

DIODE

IODE L

LASER

ASER + RDT

+ RDT ≥ RDT A RDT ALONE

LONE?

 Studies showing no significant reduction

in bacteria:

 635DL@10mW@90s/papilla

+830DL@70mW@ 25s/tooth 6X

 Qadri et al, 2005

 980DL @ 2.5PW @ 60s/pocket

 Caruso et al., 2008

 808DL @1.5W @20s/tooth

 De Micheli et al, 2011  Euzebio Alves, De Micheli et al, 2013

CURRENT

URRENT P

PARADIGMS

ARADIGMS O

OF P PERIODONT

ERIODONTAL AL

BIOFILM

IOFILM B

BEHA

EHAVIOR VIOR

 Consortium of

Consortium of Perio Perio Pathogens Pathogens associated with disease pr associated with disease progr

• gression

ession

 Porphyr

Porphyromonas

• monas gingivalis

gingivalis (Pg) (Pg)

 Tanner

annerella ella forsythia ( forsythia (Tf Tf)

 Treponema

eponema Denticola Denticola (Td) (Td)

•  Holt 2005

Holt 2005

CURRENT PARADIGMS OF PERIODONTAL BIOFILM BEHAVIOR

 Pg

Pg Keystone Pathogen Keystone Pathogen

 Small numbers dramatically alter the

Small numbers dramatically alter the composition of oral composition of oral micr microbiota

• biota



•  Dir

Directs genetic r ects genetic response of other esponse of other micr microbes and the host

• bes and the host

 Honda 2011,

Honda 2011, Hajishengallis Hajishengallis et al, et al, 2011 2011

BIOFILM BEHAVIOR: DISEASE TRANSMISSION

 Ther

There ar e are several potential sour e several potential sources for the ces for the re-infection of gingival cr e-infection of gingival crevice after evice after tr treatment: eatment:



Vertical or horizontal transmission. ertical or horizontal transmission.



Neighboring supra- and Neighboring supra- and subgingival subgingival biofilms biofilms still colonized by the species still colonized by the species in question in question Teles

eles 2006 2006

DISEASE TRANSMISSION: PROBLEM WITH SPLIT MOUTH STUDIES

 Pathogens in

Pathogens in biofilm biofilm may be may be released fr eleased from the

• m the biofilm

biofilm at one at one site, enabling them to colonize in site, enabling them to colonize in

• ther sites
• ther sites.

.

Socransky Socransky & & Haf Haffajee fajee, 2002 , 2002

DISEASE TRANSMISSION: PROBLEM WITH SPLIT MOUTH STUDIES

 The dental pr

The dental professional could also play a

• fessional could also play a

role in the r

• le in the re-colonization of oral species.

e-colonization of oral species.

 Periodontal pr

Periodontal probe could act as a carrier

• be could act as a carrier
• f periodontal pathogens to pr
• f periodontal pathogens to previously

eviously uninfected sites uninfected sites

 Christersson

Christersson 1985 1985

PERIODONTAL PROBES POTENTIALLY TRANSMIT BACTERIA

BACTERIAL TRANSMISSION VIA “SHAM LASER” ON CONTROL SUBJECTS: PROBLEM WITH SPLIT MOUTH STUDIES

NON SPLIT MOUTH STUDIES

 Moritz, 1998: Only non-split mouth to test

Moritz, 1998: Only non-split mouth to test

• bacteria. TC & tested bacteria r
• bacteria. TC & tested bacteria reduced DL

educed DL

 Borrajo

Borrajo, 2004: Significantly , 2004: Significantly  BOP DL BOP DL

 Saglam

Saglam, 2014: PD & CAL significantly , 2014: PD & CAL significantly impr

• improved. Sig. Dif
• ved. Sig. Diff in GCF levels of

f in GCF levels of TIMP-1 DL ( TIMP-1 DL (MMPs MMPs & IL & IL’s levels mixed) s levels mixed)

IMPOR

MPORTANCE ANCE OF OF L

LASER

ASER T

TECHNIQUE

ECHNIQUE

 Thr

Threshold for eshold for pulpal pulpal damage in vitr damage in vitro:

• :

 0.5 W for

0.5 W for ≥ 10S 10S ⎢ ⎢ root

• ot

 Anterior & maxillary pr

Anterior & maxillary premolars emolars

 Thicker dentin

Thicker dentin  gr greater eater pr protection

• tection

 Kreisler 2002

IMPOR

MPORTANCE ANCE OF OF L

LASER

ASER T

TECHNIQUE

ECHNIQUE

 Root Damage:  Very little negative effect at 0.5-1W @10s even if

 root with thin film of blood

 More blood, longer exposure time, and greater

angle of exposure  greater root damage.

 Recommendations: Parallel to

tooth, limit watts to 0.5, and 10s per pocket

 Kreisler 2002

IMPOR

MPORTANCE ANCE OF OF L

LASER

ASER T

TECHNIQUE

ECHNIQUE

 Sanz-Moliner

Sanz-Moliner University at Buf University at Buffalo, falo, NY 2012: NY 2012:

 Split-mouth Pilot Study:

Split-mouth Pilot Study:

 Intervention: SRP

Intervention: SRP , MWF + 810DL @ , MWF + 810DL @ 1W(A) + 810DL @ 0.1W 1W(A) + 810DL @ 0.1W

 Contr

Control: SRP

• l: SRP

, MWF + sham laser , MWF + sham laser

IMPOR

MPORTANCE ANCE OF OF L

LASER

ASER T

TECHNIQUE

ECHNIQUE

 Results:

Results:

 T

Test sites: est sites:

 Consumed significantly less

Consumed significantly less pain med pain med

 Reported significantly less pain

Reported significantly less pain

 Significantly r

Significantly reduced tissue educed tissue edema edema

 @ 1Wk Post Op.

@ 1Wk Post Op.

GOALS

OALS OF OF PERIODONT PERIODONTAL AL T

THERAPY

HERAPY

Chronic Periodontal Disease Healing BIOFILM Improve Host Response

GOALS

OALS OF OF PERIODONT PERIODONTAL AL T

THERAPY

HERAPY

Acute Disease Healing Lipoxins Improve Host Response

THANK YOU!

Capstone Mentors:

Dorothy J Rowe, RDH, MS, PhD Donald J. Coluzzi, DDS Douglas Gilio DDS

UCSF circa 1900 Celebrating 150 years! 118th Annual Scientific Session May 30-31, 2014