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Clinical Advances in Periodontics; Copyright 2013

DOI: 10.1902/cap.2013.120061

Use of the Carbon Dioxide Laser as an Adjunct to Scaling and Root Planing for Clinical New Attachment: A Case Series Jeffrey D. Pope, DDS, MS* Jeffrey A. Rossmann, DDS, MS* David G. Kerns, DMD, MS* M. Miles Beach, DMD, MS* Daisha J. Cipher, PhD† *Department of Periodontics, Texas A&M Health Science Center, Baylor College of Dentistry, Dallas, TX. †

Department of Biostatistics and Research, University of Texas Arlington, Arlington, TX.

Introduction: Severe, chronic periodontitis is typically treated either with scaling and root planing or surgical therapy in an effort to gain clinical attachment. The advantage of non-surgical therapy is decreased morbidity to the patient; however the site typically heals by formation of a long junctional epithelium. The advantage of surgical therapy is access for debridement and the use of bone or bone substitutes in combination with a barrier membrane for epithelial exclusion. Surgical therapy is more invasive and patient acceptance of treatment is typically more challenging than a non-surgical approach. The use of lasers in dentistry appears to be rapidly increasing as evidenced by the influx of new lasers into the dental market as well as numerous anecdotal reports of beneficial results with their use. Case Series: This report presents a novel approach to the treatment of severe, chronic periodontitis utilizing the carbon dioxide (CO 2 ) laser in combination with scaling and root planing. This study presents the findings of 17 patients that were compared in a split-mouth design and followed for 3 months. To the authors’ knowledge, this is the first reported case series utilizing the CO 2 laser for de-epithelialization in combination with scaling and root planing for the treatment of chronic periodontitis. Conclusion: Sites treated with the CO 2 laser tended to show a greater decrease in probing depths, greater amounts of recession, and greater gains in clinical attachment levels, however the results were not statistically significantly better than scaling and root planing alone. KEY WORDS: Case reports; periodontitis; lasers; dental scaling; regeneration. BACKGROUND The primary goal of scaling and root planing or surgical therapy for the treatment of periodontal disease is the formation of new clinical attachment. Scaling and root planing is not expected to influence new bone formation to any great degree but hopefully would lead to healing with a connective tissue attachment rather than a long junctional epithelium.1 Predominant human histologic evidence demonstrates healing by a long junctional epithelium with no or minimal connective tissue attachment.2 Often clinicians treat intrabony defects with guided tissue regeneration (GTR) where the operator reflects fullthickness mucoperiosteal flaps, debrides the defect, grafts with bone or a bone substitute, and covers the graft with a barrier membrane.3 The concept of GTR is to selectively allow cells from the bone, connective tissue, and periodontal ligament to repopulate the root surface before epithelial cells contact the healing site. The laser has been used extensively in the dental field since its inception and was first applied in vivo to human teeth in 1965.4 Rossmann et al. showed the carbon dioxide (CO 2 ) laser will effectively remove gingival epithelium without causing damage to the underlying connective tissue.5,6,7,8 A controlled clinical trial by Centty et al. evaluated patients with contra-lateral defects in a split-mouth design.9 The results of this study also verified the CO 2

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Clinical Advances in Periodontics; Copyright 2013

DOI: 10.1902/cap.2013.120061

laser can de-epithelialize completely the inner and outer aspect of a mucoperiosteal flap while leaving the underlying connective tissue undisturbed. In an attempt to utilize the concepts of GTR in a non-surgical protocol, this case series presents a novel approach to periodontal treatment with the adjunctive use of the CO 2 laser. This series is a prospective, split-mouth design that evaluates the clinical outcome of using the CO 2 laser de-epithelialization technique to block epithelial downgrowth in conjunction with scaling and root planing (test sites) versus scaling and root planing alone (control sites) for the treatment of severe, chronic periodontitis. CLINICAL PRESENTATION AND CASE MANAGEMENT This case series consisted of seventeen patients (9 male and 8 female) ages 34-71 (mean 54 years) and was conducted from February 2011 to April 2012. Study subjects were required to have a minimum of two contralaterally similar periodontal probing depths (PD) ≥ 5mm with clinical attachment loss (CA LOSS) ≥ 4mm on two or more posterior teeth (Figure 1). Recession (REC), bleeding on probing (BOP), furcation involvement (FUR), and mobility (MOB) were also recorded. There were 92 posterior teeth with 252 qualifying sites that were included in the study. A custom acrylic stent was used for reproducible measurements and one UNC 15 probe was used for all examinations. At the initial evaluation, oral hygiene instructions were given and reinforced at every patient visit. Approval for research was granted by the Institutional Review Board at Texas A&M Health Science Center, Baylor College of Dentistry. All subjects signed a written informed consent document prior to treatment. Patients were subjected to scaling and root planing (S&RP) under local anesthesia. All scaling and root planing was performed by the author (J.P.). Soft tissue curettage was inadvertently performed during the scaling procedure. No direct attempt was made to remove the sulcular epithelium by directing the instruments toward the soft tissue wall. Immediately following S&RP, the patient’s left or right side was randomly assigned to the test or control group using a random allocation table. The control side did not receive any additional treatment. The test side was treated using a CO 2 laser set at 8 watts pulsed mode using a 0.8mm spot size to deliver an energy density of approximately 150-250mJ/cm2. This power setting has been histologically shown to effectively remove epithelium without damaging the underlying connective tissue.5,6,7,8 The buccal and lingual gingival epithelium was completely removed around the test teeth to a level approximately 5mm apical to the gingival margin (Figure 2). Care was taken to avoid using the CO 2 laser on hard tissue or mucosa; the laser tip was not introduced into the periodontal pocket. Patients were given 0.12% chlorhexidine gluconate at the initial visit with instructions to use the mouth rinse twice daily for the first 4 weeks following scaling and root planing. The patients returned at 10, 20, and 30 days post-scaling for additional laser de-epithelialization (at a similar or reduced setting) to the test side in an effort to block epithelial downgrowth on the root surface, using a previously published protocol (Figure 3).10 This was performed under local anesthesia as needed for patient comfort. Patients were instructed to take 400mg of ibuprofen every four to six hours as needed for discomfort. Patients were evaluated 3 months post-scaling (Figure 4). Clinical measurements were taken at baseline by the primary examiner (J.P.) and one additional periodontist (J.R. or D.K.). Final measurements were taken by a blinded examiner (M.B.). STATISTICAL ANALYSIS The unit of analysis for this study was the patient, with teeth nested within patients. Mean ± standard deviations were calculated for the continuous clinical measurements and n (%) for binary measurements (see Table 1). Linear mixed models were constructed to compare the two procedures on changes over time in probing depths, recession, clinical attachment levels, and bleeding on probing. The fixed-effects portion of each model was “Procedure” (CO 2 laser in combination with scaling and root planning versus scaling and root planning alone), and the random effects portion of each model was the patient, with teeth nested within each patient. “Time” was specified as the repeated effect, with 2 levels (Baseline and 3-months post-op) with a first-order autoregressive covariance structure. Subsequently, data collected from maxillary molars, maxillary premolars, mandibular molars, and mandibular premolars were analyzed separately. First, linear mixed models were computed within each of the four categories to compare the two procedures on changes over time in probing depths, recession, clinical attachment levels, and bleeding on probing. Main effects for “Procedure” and “Time” were tested (exactly as described above). Second, linear mixed models were computed between each of the four categories to compare each category with one another. Main effects for “Time” and “Category” were tested.

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Clinical Advances in Periodontics; Copyright 2013

DOI: 10.1902/cap.2013.120061

CLINICAL OUTCOMES Analyses of Whole Sample The linear mixed model for probing depths indicated that there was no significant effect for procedure, F(1,15.7) = 1.04, p = 0.32. However, all sites significantly improved over time, F(1,20.5) = 53.3, p < 0.0001. Probing depths averaged 6.1 ± 1.5 mm at baseline and improved to 4.1 ± 1.4 mm at 3 months for the test sites. For the control sites, probing depths averaged 6.0 ± 1.2 mm at baseline and improved to 4.5 ± 1.7 mm at 3 months. In summary, all sites exhibited improvement regardless of the procedure received (Table 1). The linear mixed model for recession indicated that there was no significant effect for procedure, F(1,226.5) = 0.45, p = 0.50. Recession levels averaged 0.2 ± 1.3 mm at baseline and 1.0 ± 1.2 mm at 3 months for the test sites. For the control sites, recession levels averaged 0.1 ± 1.3 mm at baseline and 0.8 ± 1.5 mm at 3 months. All patients showed increased amounts of recession regardless of the procedure received (Table 1). The linear mixed model for clinical attachment levels indicated that there was no significant effect for procedure, F(1,22) = 0.07, p = 0.80. However, all sites significantly improved over time, F(1,11.3) = 32.7, p < 0.0001. Clinical attachment levels averaged 6.3 ± 1.8 mm at baseline and improved to 5.0 ± 2.0 mm at 3 months for the test sites. For the control sites, clinical attachment levels averaged 6.1 ± 2.0 mm at baseline and improved to 5.3 ± 2.6 mm at 3 months. Therefore, all patients showed improved clinical attachment levels regardless of the procedure received (Table 1). The linear mixed model for bleeding on probing indicated that there was no significant effect for procedure, F(1,15.1) = 0.51, p = 0.49. However, all patients significantly improved over time, F(1,25.7) = 34.1, p < 0.0001. Bleeding on probing at baseline was 94.9% and improved to 52.5% at 3 months for the test sites. For the control sites, bleeding on probing was 94.4% at baseline and improved to 56.8% at 3 months. Therefore, all patients showed a reduction in bleeding on probing regardless of the procedure received (Table 1). Overall, sites treated with the CO 2 laser had a slightly greater reduction in probing depths, greater amounts of recession, and slightly greater clinical attachment level gains than sites treated by scaling and root planing alone. Analyses of Data Within and Between Maxillary Molars, Maxillary Premolars, Mandibular Molars, and Mandibular Premolars As shown in Table 2, linear mixed models computed within each of the four categories to compare the two procedures on changes over time revealed that probing depths significantly decreased over time within each category. With the exception of maxillary premolars, clinical attachment levels significantly decreased over time. Recession did not significantly differ within any of the four subcategories over time (p > 0.10). Bleeding on probing significantly decreased over time within each category. Finally, none of the outcomes significantly differed by procedure within any of the categories (p > 0.15). As shown in Table 2, linear mixed models computed between each of the four categories to compare each category with one another revealed three significant differences. Mandibular premolar probing depths and recession were significantly lower at follow-up than the maxillary premolars (p = 0.038 and p = 0.03, respectively). Mandibular molar bleeding on probing values were significantly lower than maxillary molars at follow-up (p = 0.03). No other significant comparisons emerged. No site-specific data analysis was performed for furcation involvement, mobility, vertical defects or mucogingival defects. All data was analyzed as mean data plus/minus standard deviation for comparative analysis. The authors did not note any observational differences between groups for how the test and control sites responded to these parameters. DISCUSSION In this case series, a novel approach was utilized in an attempt to apply the concepts of GTR in a non-surgical manner for the treatment of severe, chronic periodontitis. Within the confines of this study, the adjunctive use of CO 2 laser de-epithelialization was not clinically nor statistically significantly better than scaling and root planing alone for the treatment of severe, chronic periodontitis in selected posterior teeth.

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Clinical Advances in Periodontics; Copyright 2013

DOI: 10.1902/cap.2013.120061

It is possible that plaque control was a factor in the outcome of this study. A plaque index was never recorded at any time period. By having the patients return every 2-3 weeks for plaque control and prophylaxis, the outcome of this study may have been different. Many recent reports of laser use in the literature involve inserting the laser tip into the sulcus so that the laser irradiates the sulcular epithelium and root surface.1 In this report, the CO 2 laser was only used on the outer gingival epithelium and only posterior teeth were studied. This could be another reason the results of this case series are not in agreement with other authors that report positive gains from laser therapy inside the sulcus. Additionally, a study by Crespi et al. used the CO 2 laser in a defocused mode for root conditioning and de-epithelialization of the inner wall of the gingival flap and found a significant improvement in CAL over a 15 year follow-up when compared to Modified Widman flap surgery.11 The non-surgical results from this case series are in agreement with other non-surgical studies. Kaldahl et al. reported a 1.23mm reduction in probing depth (0.96mm gain in clinical attachment) for sites with initial probing depths from 5.0-6.0mm at 3 months.12 The authors also saw a probing depth reduction of 2.18mm (1.66mm gain in clinical attachment) in sites ≥ 7.0mm. Cobb reported that in pockets which initially measured 4-6 mm, the mean reduction in probing depth was 1.29mm with a net gain in clinical attachment levels of 0.55mm.13 Periodontal pockets ≥ 7.0mm showed a mean reduction in probing depth of 2.16mm and a gain in attachment level of 1.19mm. In this study, when the authors combined the test and control sites, there was a 1.8mm reduction in probing (1.0mm clinical attachment gain) for all sites with probing depths ≥ 5.0mm at 3 months. Further research is needed to evaluate the efficacy of CO 2 laser therapy in combination with non-surgical therapy. For future studies, the authors recommend establishing the patient’s plaque control and possibly irradiating the sulcus and/or root surface using a defocused mode. A larger sample size would confirm any trends noted with the adjunctive use of a CO 2 laser in combination with scaling and root planing. SUMMARY Why are these cases new information? • To the authors’ knowledge, this is the first reported case series utilizing the CO 2 laser for deepithelialization in combination with scaling and root planing for the treatment of chronic periodontitis. What are the keys to successful management of these cases? • Good compliance, frequent periodontal recall visits, and adequate plaque control is crucial to the success of any type of periodontal therapy. Definitive root debridement for the removal of biofilm and subgingival calculus is essential for obtaining new attachment. What are the primary limitations to success in these cases? • Compliance with recall visits and adequate plaque control are important in the maintenance of clinical attachment levels. Access to deeper pocket depths and furcation involvement are critical elements for non-surgical therapy in molar areas. Multiple treatment visits during the first month of therapy are required. ACKNOWLEDGMENTS The authors would like to thank the following people for their contributions to the preparation and completion of this case series: Dr. Terry Rees*, Dr. Emet Schneiderman^, Ms. Jan Steele*, Ms. Carla Thomas*, Ms. Karen Fuentes*, and Ms. Angela Lee-Noles*. *Department of Periodontics, Baylor College of Dentistry, Texas A&M Health Science Center ^Department of Biomedical Sciences, Baylor College of Dentistry, Texas A&M Health Science Center The authors report no conflicts of interest related to this case series.

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Clinical Advances in Periodontics; Copyright 2013

DOI: 10.1902/cap.2013.120061

REFERENCES 1.

Yukna RA, Carr RL, Evans GH. Histologic evaluation of an Nd:YAG Laser-Assisted New Attachment Procedure in humans. Int Journal Periodontics Restorative Dent 2007;27:577-587.

2.

Cobb CM. Non-surgical pocket therapy: mechanical. Ann Periodontol 1996;1:443-490.

3.

Gottlow, J, Nyman S, Lindhe J, et al. New attachment formation in the human periodontium by guided tissue regeneration. J ClinPeriodontol 1986; 13:604-16.

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Goldman L, Gray JA, Goldman J, Goldman B, Meyer R. Effect of laser impacts on teeth. JAMA 1965; 70:601606.

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Rossmann J, Gottlieb S, Koudelka B, McQuade M. Effects of carbon dioxide laser irradiation on gingiva. J Periodontol 1987; 58:423-425.

6.

Rossmann J, McQuade M, Turunen M. Retardation of epithelial migration in monkeys using a carbon dioxide laser. J Periodontol 1992; 63:902-907.

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Rossmann J, Cobb, C. Lasers in periodontal therapy. Periodontology 2000 1995; 9:150-164.

8.

Rossmann J. Lasers in Periodontics: Academy Report. J Periodontol 2002; 73:1231-1239.

9.

Centty I, Blank L, Levy B, et al. Carbon dioxide laser for de-epithelialization of periodontal flaps. J Periodontol 1997; 68: 763.

10. Israel M, Rossmann J, Froum S. Use of the carbon dioxide laser in retarding epithelial migration: A pilot histological human study utilizing case reports. J Periodontol 1995; 66:197-204. 11. Crespi R, Cappare P, Gherlone E, Romanos G. Comparison of modified Widman and coronally advanced flap surgery combined with CO 2 laser root irradiation in periodontal therapy: A 15-year follow-up. Int J Periodontics Restorative Dent 2011; 31:641-651. 12. Kaldahl W, Kalkwarf K, Patil K, Dyer J, Bates R. Evaluation of four modalities of periodontal therapy. JPeriodontol 1988;59:783-793. 13. Cobb C M: Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planning. J ClinPeriodontol2002; 29 (Suppl 2): 6-16. Please send correspondence to: Jeffrey A. Rossmann, DDS, MS Department of Periodontics Texas A&M Health Science Center Baylor College of Dentistry 3302 Gaston Avenue Dallas, Texas 75246 JRossmann@bcd.tamhsc.edu Submitted May 16, 2012; accepted for publication March 26, 2013.

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Clinical Advances in Periodontics; Copyright 2013

DOI: 10.1902/cap.2013.120061

Figure 1. Test sites at baseline. Figure 2. CO2 laser de-epithelialization of the test sites at baseline. Figure 3. Test sites 10 days post-laser de-epithelialization. Figure 4. Test sites at 3 months.

Table 1 Clinlcal Outcomes for Analysis of Whole Sample Baseline PD REC CA LOSS Test Sites 6.1 0.2 6.3 Control Sites 6.0 0.1 6.1 Whole 6.1 0.2 6.2 Sample Baseline to 3 Months PD REC CA LOSS Test Sites -2.0 0.8 -1.3 Control Sites -1.5 0.7 -0.8 Whole -1.8 0.7 -1.0 Sample p = 0.32 p = 0.50 p = 0.80

BOP

3 Months PD

REC

95% 94% 95%

4.1 4.5 4.3

1.0 0.8 0.9

CA LOSS 5.0 5.3 5.2

BOP 53% 57% 55%

BOP -42% -37% -40% p = 0.49

Negative numbers indicate a reduced probing depth, gain in clinical attachment, and reduction in the total number of bleeding sites. Positive numbers indicate a gain in recession. The unit of measure for all numbers is mm, except BOP which is a percentage of sites involved.

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Clinical Advances in Periodontics; Copyright 2013

DOI: 10.1902/cap.2013.120061

TABLE 2 Clinical Analysis of Patient Data According to Site Baseline Tooth Type PD Test Maxillary Molars

Control Total Test

Maxillary Premolars

Control Total Test

Mandibular Molars

Control Total Test

Mandibular Premolars

Control Total Test

Total

Control Total

Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation Mean Std. Deviation

6.20 1.13 6.38 1.43 6.29 1.29 5.56 0.51 5.53 0.70 5.54 0.62 6.46 2.46 5.77 0.92 6.16 1.95 6.00 1.15 6.09 1.14 6.05 1.12 6.11 1.50 6.00 1.20 6.05 1.35

REC 0.44 1.18 0.54 1.48 0.49 1.33 0.04 1.21 -0.28 0.85 -0.15 1.01 0.04 1.53 -0.09 1.02 -0.02 1.32 -0.20 1.03 -0.36 1.29 -0.29 1.15 0.20 1.27 0.11 1.28 0.16 1.27

The unit of measure for all numbers is mm.

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CA LOSS 6.64 1.75 6.91 2.52 6.77 2.16 5.60 1.41 5.25 1.05 5.39 1.21 6.50 2.06 5.68 1.39 6.14 1.83 5.80 1.48 5.73 1.10 5.76 1.26 6.31 1.78 6.11 2.02 6.21 1.91

3 Months PD

REC

4.58 1.52 5.32 1.86 4.95 1.73 4.00 1.41 3.75 1.05 3.85 1.21 3.54 1.04 4.18 1.22 3.82 1.16 3.10 0.57 3.45 0.93 3.29 0.78 4.08 1.42 4.50 1.66 4.30 1.56

0.98 1.37 1.05 1.89 1.02 1.65 0.92 1.41 0.42 1.18 0.62 1.29 0.82 0.77 0.55 0.51 0.70 0.68 1.30 0.67 1.00 0.77 1.14 0.73 0.96 1.21 0.78 1.47 0.86 1.35

CA LOSS 5.56 2.32 6.38 3.23 5.97 2.83 4.92 1.82 4.17 1.61 4.48 1.73 4.36 1.28 4.73 1.55 4.52 1.40 4.40 1.07 4.45 1.37 4.43 1.21 5.04 1.98 5.28 2.64 5.16 2.34


Clinical Advances in Periodontics; Copyright 2013

DOI: 10.1902/cap.2013.120061

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CO2 Laser Treatment for Perio Defects