December 2, 2016
by Michelle Cortes, BSc, RDH
A 42-year-old male client presented with generalized chronic moderate to severe marginal gingivitis and generalized chronic moderate to advanced periodontitis. He reported that non-surgical periodontal therapy, by means of scaling and root planing, had failed to prevent increased clinical attachment loss and he was referred to a periodontist for pocket reduction surgery. After consultation, the treatment plan presented by the periodontist was rejected due to concerns regarding discomfort, recovery time and finances. I was introduced to this client after his own research led him to specifically seek out laser assisted periodontal therapy (LAPT) with a soft tissue diode laser.
The client presented to be in excellent health. No contraindications to treatment, systemic medical conditions, or history of smoking was reported. He had no known allergies and was not taking any medications.
The client reported he has a family history of periodontitis, including both his parents and siblings. He recalled having been diagnosed with ongoing periodontal disease for several years, leading to the suspicion of rapidly progressive juvenile periodontitis.
A full mouth series of radiographs revealed adequate bone levels, with no visible pathologies (Fig. 1).
Full Mouth Series
Soft Tissue Examination
A comprehensive periodontal and dentition exam revealed several areas of clinical attachment loss, 129 bleeding on probing sites, no furcations and mobility 1 on teeth 3.7, 4.4, 4.5, 4.6, and 4.7. Gingiva was stippled and spongy, reddish pink with inflamed papilla and rolled margins. Probing depths were recorded (Table 1).
The client reported brushing twice daily, flossing infrequently and presented with abundant plaque specifically on the interproximal and marginal 1/3 areas, and heavy supragingival and subgingival calculus deposits.
The use of diode lasers in the treatment of moderate to severe periodontal disease has been shown to improve and help sustain periodontal health (Goldstep 2010). The assessment findings gave me the confidence that scaling and root planing (SRP) along with laser assisted periodontal therapy (LAPT), modifications to the current oral homecare practice and maintenance therapy every three months would result in achieving an improved periodontal condition, while addressing the client’s concerns relating to minimal discomfort, recovery time, and financial commitment.
Treatment Plan Outline
A. Initial Therapy
1. Oral homecare instruction
2. Quadrant SRP with local anesthetic block
3. LAPT immediately following SRP
1. Six-week visual reevaluation
2. Three-month periodontal reevaluation
C. Maintenance therapies
A. Initial Therapy (four appointments)
1. Oral Home Care Instruction
The client was resistant to adapting a new homecare routine, citing that in his previous experiences he felt “lectured” to by his hygienist. Understanding the client’s concern, we worked together to create an oral homecare routine that emphasized plaque removal interproximally and at the gingival margin along with incorporating a daily antimicrobial mouthrinse. The client committed to brushing twice daily with a soft bristle toothbrush using Modified Stillman technique, flossing daily and rinsing with Listerine Zero Total Care daily.
2. Quadrant Scaling and Root Planing (SRP) with
One hour of SRP for each quadrant was performed using a HuFriedy Piezo ultrasonic and hand instrumentation with Gracey curettes. Profuse bleeding was observed with SRP. Debridement was completed in four appointments that were scheduled two weeks apart to aid with the client’s post-procedural comfort.
3. Laser Assisted Periodontal Therapy (LAPT)
Immediately following SRP, LAPT of the debrided quadrant was performed using a Sirona SIROLaser soft tissue diode laser with laser protective eyewear for the client and operator. A 320um optical fibre was selected using a continuous wave set at 1.3W with a non-initiated tip. The laser fibre tip was inserted into the sulcus 1mm above the base of the pocket using a sweeping motion for approximately 15 seconds per site, with care taken to keep the tip free from debris to avoid initiation (Pirnat, 2007). The client reported no discomfort throughout the procedure.
Mild post-procedural discomfort, in particular at the anesthetic injection site and in the areas that initially probed 6mm or greater, fully resolved by the following appointment two weeks later. Client’s homecare was reviewed at each appointment and initially demonstrated improvement; however, there were signs of regression at the last quadrant appointment after the client reported personal stress from a death in his family.
1. Six-week visual reevaluation (Fig. 2)
Probing after SRP and LAPT was intentionally avoided during the first three months to prevent damaging reattachment (Goldstep 2010). Tissues were observed to be pink and firm, papilla more pointed, generally flat margins with localized rolling at the mandibular anterior. Oral homecare improved and plaque accumulation was visibly reduced.
Six-week visual reevaluation
2. Three-month Periodontal Reevaluation
Periodontal probing demonstrated significant improvement in disease status with reduction in pocketing and bleeding. Oral homecare instruction was reviewed and client reported cessation of bleeding with brushing and flossing. SRP of the full dentition with ultrasonic and manual scalers with observed moderate bleeding was completed using four carpules of Oraqix for desensitization. LAPT of the full dentition was implemented again with the settings and technique used previously due to generalized chronic moderate papillary gingivitis and chronic moderate to severe periodontitis localized to teeth 1.7, 1.6, 2.6, 2.7.
Three-month Maintenance Therapies
Hygiene therapy intervals were maintained every three months (delayed once by the client due to a shoulder injury) with periodontal probing at each visit. Patient continued to demonstrate improvement in disease status despite inconsistent homecare due to motivation and injury. SRP of the full dentition continued to result in moderate bleeding. Two carpules of Oraqix were necessary to achieve desensitization six months after the initial therapy and no desensitization was required at subsequent visits. LAPT of the full dentition immediately following SRP with the settings and technique used previously at each appointment was implemented despite improving health due to the severity of initial condition, previous dental history and declining homecare.
Improvement three months after initial SRP and LAPT (Figs. 3, 4) was expected due to the removal of significant accumulated deposits and homecare improvements. However, cessation in bleeding with homecare, in addition to a 41.1% decrease in bleeding on probing, a 74.2% decrease in pockets 6mm and greater, and a 30.4% decrease in 4-5mm pockets was beyond my expectations.
The results of the subsequent maintenance therapies proved also to have unexpectedly positive results. In particular, a reduction in pocketing of 12mm to 5mm in 10 months (measured at 17MB and 16DB), an 88.4% overall decrease in bleeding, a 96.8% decrease in pockets 6mm and greater, and a 57.6% decrease in pockets 4-5mm, despite irregular homecare and delayed treatment.
Introducing laser assisted periodontal therapy in treating moderate to advanced periodontal disease for this client yielded an improved periodontal condition beyond expectations, without the need for surgical intervention, and with minimal discomfort.
The individual of the case study is referred to as a client rather than a patient in following with the generally accepted vocabulary supported by the College of Dental Hygienists of Ontario and the Regulated Health Professions Act. OH
Oral Health welcomes this original article.
1. Pirnat. (2007). Versatility of an 810 nm diode laser in dentistry: an overview. Journal of Laser and Health Academy, No. 4.
2. Goldstep. (2010). Diode Lasers for the Treatment of Periodontal Disease: The Story so Far. Dentaltown.com 54-58.
About the Author
Michelle Cortes has been practicing dental hygiene at Expressions Dental Care in Richmond Hill, Ontario since 2006 and has been providing laser assisted periodontal therapy since 2010. She is a registrant of the College of Dental Hygienists of Ontario and member of the Canadian Dental Hygienists Association. She holds soft tissue diode laser certifications with the Academy of Laser Dentistry, the Sirona Dental Academy and the International Center for Laser Education.