Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2013; 58: 4149
SCIENTIFIC ARTICLE
doi: 10.1111/adj.12021

Comparison of periodontal open ap debridement versus

closed debridement with Er,Cr:YSGG laser
M Gupta,* AK Lamba,* M Verma, F Faraz,* S Tandon,* K Chawla,* DK Koli
*Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India.
Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India.

ABSTRACT
Background: Traditional periodontal open flap debridement (OFD) results in reduced pocket depth (PD), clinical attach-
ment loss (CAL), gingival recession (GR) and postoperative pain and discomfort. The quest to overcome these shortcom-
ings has led to research into Er,Cr:YSGG laser assisted pocket therapy (ELAPT). This study was designed to compare
the clinical outcomes of ELAPT versus OFD.
Methods: Fifteen patients with a PD of 5 mm and 8 mm at two sites were selected. Test sites (Group 1) were treated
by ELAPT and the control (Group 2) by OFD. Clinical parameters were recorded at baseline, 3 and 6 months and
included Plaque Index (PI), Gingival Index (GI), modified Sulcular Bleeding Index (mSBI), PD, CAL and GR.
Results: Both treatments produced a reduction in PI, GI, mSBI and PD, an increase in GR, and a gain in CAL at 3 and
6 months. The mean gain of CAL in Group 1 at 3 and 6 months (1.60  0.78 and 1.80  0.63) was similar (p > 0.05)
to the value of Group 2 (1.93  0.88 and 2.00  0.54). GR increased significantly (p < 0.05) only in Group 2 at 3 and
6 months (1.80  0.56 and 1.87  0.64) compared to Group 1 (0.50  0.68 and 0.60  0.74).
Conclusions: ELAPT compared with OFD results in similar CAL gains with less GR and significant reductions in PD, GI
and mSBI, and may be considered as an alternative to surgical therapy.
Keywords: Er,Cr:YSGG laser, open flap debridement, periodontitis, non-surgical.
Abbreviations and acronyms: CAL = clinical attachment loss; ELAPT = Er,Cr:YSGG laser assisted pocket therapy; GI = Gingival
Index; GR = gingival recession; OFD = open flap debridement; PD = pocket depth; PI = Plaque Index.
(Accepted for publication 23 May 2012.)

Different lasers, e.g. the diode, Nd:YAG, CO2, Er:

INTRODUCTION
Periodontal therapy is directed at disease prevention,
slowing or arresting disease progression, regeneration
of lost periodontal tissues, and maintaining the
achieved therapeutic objectives.1,2 A variety of tech-
niques have been used for periodontal therapy, e.g.
scaling and root planing, subgingival curettage, gingi-
vectomy and full or split thickness flap procedures
with or without osseous recontouring.1,3,4 Tradi-
tional periodontal surgery results in reduced pocket
depth due to apical repositioning of the gingival mar-
gin, exposing the root surface to the oral cavity. It
results in possible attachment loss, gingival cratering
and gingival recession.5 The pain and discomfort
associated with periodontal surgery is also well
known.6 The quest to overcome these shortcomings
has led to research into laser assisted periodontal
therapy.
2013 Australian Dental Association
YAG and Er,Cr:YSGG have been proposed and are
expected to serve as an alternative or an adjunctive
treatment to conventional, mechanical periodontal
therapy.7,8 Laser periodontal therapy is predicated on
the concept of subgingival curettage and/or reattach-
ment and regeneration of the attachment apparatus
and is commonly referred to as non-surgical.7 It
allows for selective removal of sulcular or pocket epi-
thelium while preserving connective fibrous tissues.9 It
defines the tissue margins, preserves the integrity of
the mucosa and aids in maintaining the free gingival
crest.9 High patient comfort and acceptance has been
reported with laser periodontal therapy.9 With thin
and flexible fibres, laser device energy can be delivered
to sites in the periodontal pocket that conventional
mechanical instrumentation is unable to reach.10
Laser periodontal therapy eliminates pockets with
minimal recession or repositioning of the gingival
41
M Gupta et al.
margin.10 Other advantages include haemostasis, less
postoperative swelling, a reduction in bacterial popu-
lation at the surgical site, less need for suturing, faster
healing and less postoperative pain.11
Laser systems such as CO2, diode and Nd:YAG
have been used for oral soft tissue procedures such as
gingivectomies, frenectomies, etc.12 Due to an excel-
lent soft tissue ablation capacity, CO2 lasers have
been successfully used as an adjunctive tool to
de-epithelialize the mucoperiosteal flap during tradi-
tional flap surgery.13 Diode and Nd:YAG lasers have
been used mainly for laser-assisted subgingival curet-
tage and disinfection of the periodontal pocket with
various degrees of success.13 However with these
lasers, a profound thermal effect on target tissues
including gingival tissue, periodontal ligament, cemen-
tum and bone has been seen and their use for peri-
odontal application does not appear promising.14
The potential use of Er,Cr:YSGG laser as a tool for
the non-surgical debridement of pathological periodon-
tal pockets is related to its capacity to ablate soft tissue
with minimal thermal side effects.15 Because the Er,Cr:
YSGG laser has a wavelength close to the peak of
absorption coefficient of water, absorption of the
energy by water occurs rapidly, resulting in evapora-
tion of water, microexplosive ablation and reduced
heat accumulation.15 It also possesses bactericidal
effects because of the high coefficient of absorption of
the used light frequency by lipopolysaccharides.15 It
has also been shown to have a significant bactericidal
effect on both P. gingivalis and A. actinomycetemcomi-
tans, which are primary components of periodontal
infection.15 Er,Cr:YSGG laser irradiation can be safely
and effectively utilized in periodontal pocket therapy,
and has the potential to promote new attachment.15 It
has been claimed in the literature that the Er,Cr:YSGG
laser system provides a more comfortable patient expe-
rience with less trauma and postoperative complica-
tions, as well as a decreased healing time16 compared
to conventional flap surgery.
Therefore, the purpose of this study was to evaluate
and compare the clinical outcomes of Er,Cr:YSGG
laser-assisted periodontal pocket therapy versus open
flap debridement procedure.
MATERIALS AND METHODS
The study was designed as a single-blinded, split-
mouth, randomized and controlled trial of 6-month
duration. The study protocol was reviewed and
approved by the Ethics Committee of the Maulana
Azad Institute of Dental Sciences (Delhi University),
New Delhi. The study was conducted in accordance
with the Helsinki Declaration of 1975, as revised in
2000, and all participants signed informed consent
forms.
42
Fifteen patients between the age of 20 and 54 years
of either gender having a probing depth of 5 mm at
a minimum of two sites were selected from the
Periodontics Outpatient Department, Maulana Azad
Institute of Dental Sciences, New Delhi, India. The
subjects were selected randomly with no discrimina-
tion of gender, caste, religion or socio-economic sta-
tus. Inclusion criteria were residual presence of
probing depth of 5 mm and 8 mm at a minimum
of two sites and good level of oral hygiene (PI <1)
after initial therapy. Patients were excluded from par-
ticipation in the study if they presented with diabetes,
coronary heart disease, chronic obstructive pulmonary
disease, tobacco use, or the use of antibiotics in the
previous 6 months.
On one side, teeth were treated by Er,Cr:YSGG
laser (ELAPT; test group), whereas teeth of the con-
tralateral side were treated by open flap debridement
(OFD; control group). In the control group (OFD),
the area to undergo surgery was anaesthetized with
2% lignocaine hydrochloride solution with adrenaline
(1:80 000). Intracrevicular incisions were placed. The
granulation tissue was removed from the defects and
the roots were thoroughly scaled and planed. No root
surface conditioning was performed. The control sites
were then sutured with simple interrupted sutures.
(Fig. 1).
For Er,Cr:YSGG laser assisted periodontal pocket
therapy (ELAPT; test group) no local anaesthesia was
given.13,15 If required, the pocket to be treated was
lightly irrigated with 2% lignocaine hydrochloride
solution with adrenaline (1:80 000).15 The patient and
all operatory personnel were made to wear protective
laser eyewear. The following settings were used for
ELAPT: power 1W, water 10%, air 12% and
frequency 20 Hz. A 600 sapphire laser tip (9 mm
length) was used and inserted into the sulcus to the
base of the pocket. The laser tip was then withdrawn
1 mm from the base and activated. The tip was
moved apico-coronally (vertically) and mesio-distally
(horizontally) in sweeping motions in the pocket. The
tip was angled so that the energy was directed parallel
to the root and towards the inner epithelial lining of
the sulcus. The tip was kept constantly moving inside
the pocket. The objective was to remove the epithelial
lining of the pocket. Each pocket was lased for
60 seconds.
Following lasing of the pocket, any visible deposits
on the root surfaces were removed using hand and
ultrasonic instruments. The area was then irrigated
with sterile saline. The gingival tissue was compressed
against the root surface to close the pocket and to aid
in the formation and stabilization of fibrin clot. No
sutures or periodontal dressings were given (Fig. 2).
A second and third cycle of lasing was repeated
with similar settings every third day. This was
2013 Australian Dental Association
 Open ap debridement versus laser

(a) (b)

(c) (d)

Fig. 1 Open ap debridement. (a) pre-operative; (b) intra-operative; (c) postoperative 3 months; (d) postoperative 6 months.

(a) (b)

(c) (d)

Fig. 2 Laser assisted periodontal pocket therapy. (a) pre-operative; (b) intra-operative; (c) postoperative 3 months; (d) postoperative 6 months.

attempted with the consideration of delaying epithelial Data collection

downgrowth and promoting regeneration of periodon-
The baseline data were recorded before treatment and
tal tissues.
at 3 months and 6 months following treatment. The
Postoperatively no antibiotics or analgesics were
data collection was performed by the same blinded
prescribed. Patients were instructed to discontinue
and calibrated investigator.
toothbrushing for the day of the treatment, avoiding
Clinical measurements were taken at six points
trauma at the treated site. A 60-second rinse with
around each tooth: mesio-lingual, mesio-facial, facial,
10 ml of 0.2% chlorhexidine gluconate solution twice
disto-facial, disto-lingual and lingual.
daily for 1 week was prescribed.
2013 Australian Dental Association 43
M Gupta et al.

The following clinical parameters were measured: mean PD at baseline, 3 months and 6 months for both
Plaque Index (PI), Gingival Index (GI), Probing Depth the laser treatment group and the OFD group was found
(PD), Clinical Attachment Level (CAL), Gingival to be statistically significant (p < 0.05) (Table 2).
Recession (GR) and modified Sulcular Bleeding Index The mean PD reduction at 3 months was found to
(mSBI). PD was determined with a calibrated conven- be 2.66  0.88 among the laser treatment group and
tional periodontal probe. 3.60  0.70 among the OFD group. The mean PD
reduction at 6 months was found to be 2.46  0.62
among the laser treatment group and 3.80  0.80
Intra-examiner reliability
among the OFD group. The comparison of mean PD
Four patients, each with two contralateral teeth with reduction at 3 months and 6 months between the
PD >5 mm, were used to calibrate the examiner. The laser treatment and OFD was found to be statistically
examiner evaluated the patients at two appointments significant (p < 0.05) (Table 3).
that were separated by 5 days. Calibration was This implies that although the PD decreased signifi-
accepted if the data at baseline and 5 days later were cantly in both treatment groups compared to baseline,
similar at a >90% level. This procedure was repeated OFD was more effective in reduction of PD compared
periodically during the 6-month study period. to laser assisted pocket therapy at both 3 and 6 months
post-treatment intervals.
Statistical analysis
Clinical attachment level
A software package was used for the statistical analy-
sis [SPSS (Statistical Package for Social Sciences) The mean CAL at baseline was 7.93  1.16, at
Version 16]. The unpaired t-test was used for compar- 3 months 6.33  1.35 and at 6 months 6.13  1.19
ison of mean values between the LASER and OFD
groups, and ANOVA test was used for comparison of Table 2. Comparison of mean values of PD at
mean values within the LASER and OFD groups at baseline, 3 months and 6 months
the different intervals. The level of significance was Intervals Probing LASER (  r) OFD (  r)
taken at 5% (p < 0.05). The alpha error was set at depth (mm)
0.05. Data are presented as means SD. The power 1 Baseline 6.93  1.03 6.93  0.70
of the study, given 1 mm as a significant difference 2 3 months 4.87  1.25 3.33  0.62
between groups, was calculated to be 0.99. 3 6 months 4.47  0.92 3.13  0.74
p-value 0.000* 0.000*
Post hoc comparison 1 > 2, 3 1 > 2, 3
RESULTS *- S.
The comparison of mean values of each parameter Table 3. Comparison of mean change in PD, CAL,
between the LASER and OFD group at baseline was GR, GI, PI and mSBI
done and there were no statistically significant differ-
ences (p > 0.05) between the two treatment groups in Parameter LASER OFD p-value
any of the recorded parameters (Table 1). PD reduction 2.06  0.88 3.60  0.70 0.000*
at 3 months (mm)
PD reduction 2.46  0.62 3.80  0.80 0.000*
Probing depth at 6 months (mm)
CAL gain 1.60  0.78 1.93  0.88 0.122
The mean PD at baseline was 6.93  1.03, at 3 months at 3 months (mm)
4.87  1.25 and at 6 months 4.47  0.92 among the CAL gain 1.80  0.63 2.00  0.54 0.269
at 6 months (mm)
laser treatment group. The mean PD at baseline was GR increase 0.53  0.68 1.80  0.56 0.000*
6.93  0.70, at 3 months 3.33  0.62 and at 6 months at 3 months (mm)
3.13  0.74 among the OFD group. The comparison of GR increase 0.60  0.74 1.87  0.64 0.000*
at 6 months (mm)
GI score reduction 0.55  0.24 0.95  0.24 0.000*
Table 1. Comparison of mean values of PD, CAL, GR, at 3 months
GI, PI and mSBI at baseline GI score reduction 0.52  0.26 0.95  0.24 0.000*
at 6 months
LASER OFD p-value PI score reduction 0.17  0.18 0.20  0.27 0.726
at 3 months
PD (mm) 6.93  1.03 6.93  0.70 0.332 PI score reduction 0.08  0.20 0.17  0.21 0.388
CAL (mm) 7.93  1.16 8.13  0.83 0.708 at 6 months
GR (mm) 1.00  0.65 1.07  0.59 0.135 mSBI score reduction 0.52  0.31 0.78  0.30 0.022*
GI 1.50  0.28 1.65  0.31 0.178 at 3 months
PI 0.77  0.22 0.80  0.23 0.818 mSBI score reduction 0.53  0.28 0.85  0.28 0.005*
mSBI 1.22  0.31 1.27  0.35 0.681 at 6 months

44 2013 Australian Dental Association


among the laser treatment group. The mean CAL at
baseline was 8.13  0.83, at 3 months 6.20  0.94
and at 6 months 6.13  0.83 among the OFD group.
The comparison of mean CAL at baseline, 3 months
and 6 months for the laser treatment and OFD group
was found to be statistically significant (p < 0.05)
(Table 4).
The mean CAL gain at 3 months was found to be
1.60  0.78 among the laser treatment group and
1.93  0.88 among the OFD group. The mean CAL
gain at 6 months was found to be 1.80  0.63 among
the laser treatment group and 2.00  0.54 among the
OFD group. The comparison of mean CAL gain at
3 months and 6 months between the laser treatment
and OFD was found to be statistically not significant
(p > 0.05) (Table 3).
This implies that there was significant gain in CAL
in both treatment groups compared to baseline, and
laser assisted pocket therapy was equally effective in
producing CAL gain compared to OFD at both 3 and
6 month post-treatment intervals.
Gingival recession
The mean GR at baseline was 1.00  0.65, at
3 months 1.53  0.92 and at 6 months 1.60  0.99
among the laser treatment group. The mean GR at
baseline was 1.07  0.59, at 3 months 2.87  0.74
and at 6 months 2.93  0.80 among the OFD group.
The comparison of mean GR at baseline, 3 months
and 6 months for the laser treatment group was found
to be statistically not significant (p > 0.05) but for the
OFD group was found to be statistically significant
(p < 0.05) (Table 5).
Table 4. Comparison of mean values of CAL at
baseline, 3 months and 6 months
Intervals Clinical Attachment LASER (  r)
Level (mm)
1 Baseline 7.93  1.16
2 3 months 6.33  1.35
3 6 months 6.13  1.19
p-value 0.000*
Post hoc comparison 1 > 2, 3
Table 5. Comparison of mean values of GR at
baseline, 3 months and 6 months
Intervals Gingival LASER (  r)
recession (mm)
1 Baseline 1.00  0.65
2 3 months 1.53  0.92
3 6 months 1.60  0.99
p-value 0.063
Post-hoc comparison - 1 > 2, 3
2013 Australian Dental Association
Open ap debridement versus laser
The mean increase in GR at 3 months was found to
be 0.53  0.68 among the laser treatment group and
1.80  0.56 among the OFD group. The mean
increase in GR at 6 months was found to be
0.60  0.74 among the laser treatment group and
1.87  0.64 among the OFD group.
The comparison of mean increase in GR at
3 months and 6 months between the laser treatment
and OFD was found to be statistically significant
(p < 0.05) (Table 3). This implies that sites treated
with laser assisted pocket therapy show significantly
less GR when compared to sites treated with OFD.
Gingival Index
The mean reduction in GI score at 3 months was
found to be 0.55  0.24 among the laser treatment
group and 0.95  0.24 among the OFD group. The
mean reduction in GI score at 6 months was found to
be 0.52  0.26 among the laser treatment group and
0.95  0.24 among the OFD group. The comparison
of mean reduction in GI scores at 3 months and
6 months between the laser treatment group and the
OFD group was found to be statistically significant
(p < 0.05) (Table 3).
This implies that although the GI decreased signifi-
cantly in both treatment groups compared to baseline,
OFD was more effective in reduction of GI compared
to laser assisted pocket therapy at both 3 and
6 month post-treatment intervals.
Plaque Index
The comparison of mean reduction in PI score at
3 months and 6 months between the laser treatment
group and the OFD group was found to be statistically
not significant (p > 0.05) (Table 3). This implies that
the relatively low baseline values for PI in both treat-
OFD (  r) ment groups did not change significantly over the
6 months of the study and yielded no statistical differ-
8.13  0.83 ence between the groups.
6.20  0.94
6.13  0.83
0.000* Modied Sulcular Bleeding Index
1 > 2, 3
The mean reduction in mSBI score at 3 months was
found to be 0.52  0.31 among the laser treatment
group and 0.78  0.30 among the OFD group. The
mean reduction in mSBI score at 6 months was found
to be 0.53  0.28 among the laser treatment group
and 0.85  0.28 among the OFD group. The compar-
OFD (  r)
ison of mean reduction in mSBI score at 3 months
and 6 months between the laser treatment group and
1.07  0.59
2.87  0.74 the OFD group was found to be statistically signifi-
2.93  0.80 cant (p < 0.05) (Table 3).
0.000* This implies that although the mSBI decreased
significantly in both treatment groups compared to
45
M Gupta et al.
baseline, OFD was more effective in reduction of
mSBI compared to laser assisted pocket therapy at
both 3 and 6 month post-treatment intervals.
DISCUSSION
With the discovery of lasers and research into their
applicability for dental use, laser energy has emerged
as a newer modality of therapy in the field of
periodontics.13 Laser energy is capable of ablating
and vaporizing residual organic debris, including
microbial plaque and probably calculus, and it can
disinfect and remove the pockets sulcular lining.13
Adjunctive therapy with laser energy, aimed at reduc-
ing or eliminating bacteria may be useful in reducing
probing depth and bleeding on probing.7,8,13 Non-
surgical laser pocket therapy offers several advantages
over conventional surgical procedures such as minimal
bleeding, instant sterilization of the surgical site,
reduced bacteraemia, reduced mechanical trauma,
minimal postoperative swelling and scarring, and min-
imal postoperative pain.7,17,18 It can be associated
with cementum-mediated new connective tissue
attachment and apparent periodontal regeneration on
previously diseased root surfaces.8
The ideal properties of a laser that can be used suc-
cessfully for periodontal pocket therapy are that it
should be bactericidal, easy to deliver into the pocket
and safe enough to use in a periodontal pocket so that
it causes no harm to the root surface. Current literature
identifies erbium lasers (Er:YAG and Er,Cr:YSGG) as
the most appropriate device for non-surgical periodon-
tal treatment due to their high absorption in water and
lack of thermal penetration.8,19 Also, as the interaction
between the erbium laser wavelength and gingival
tissues is shallow in depth (0.10.3 mm), it results in
less wound contraction and a reduced inflammatory
response.19 Studies have shown that the erbium laser
can remove epithelium effectively without damaging
the underlying connective tissue. Furthermore, in an
animal study the erbium laser has been seen to induce
new cementum formation after pocket irradiation.20
According to Kaldahl et al.,5 Schwarz et al.21 and
Sculean et al.17 smokers have a less favourable
response to non-surgical and surgical periodontal ther-
apy. Therefore, smokers were excluded from the
study. Patients who had poorly controlled diabetes
were also excluded from the study as, according to
Derdilopoulou et al.22 and Gaspirc,1 diabetics have
increased microbial challenge and delayed wound
healing which could influence the outcome of the ther-
apy. The defect sites were selected in patients using
clinical criteria similar to studies of Miyazaki et al.23
and Tomasi et al.18
All patients were subjected to initial preparation
which consisted of full mouth scaling and root
46
planing as this allows for optimal tissue health and
plaque control, thereby enhancing treatment out-
comes. All measurements were taken with a manual
calibrated UNC-15 periodontal probe which had col-
our coding at 5, 10, 15 mm with markings 0 to 15,
each marking at 1 mm intervals, making it easier to
reproduce the measurement. Before treatment, a cus-
tomized acrylic stent was fabricated on the study cast
for each patient. The stent was grooved in an occlusal
apical direction. This was done to minimize change in
the direction of probing at subsequent recordings. All
these measurements were made from a fixed reference
point on the stent, in accordance with the study by
Miyazaki et al.23
For the test site, laser assisted pocket therapy was
performed without the application of local anaesthesia
as, according to Sjostrom and Friskopp,24 pain experi-
ence during laser therapy for periodontal procedures
is negligible and does not require the use of anaesthet-
ics and results in diminished bleeding. The settings
used for ELAPT were in accordance with the sug-
gested clinical specifications by BIOLASE Technol-
ogy. The calibration for the initial therapy with laser
tip was done at 1 mm less than the pocket probing
depth of the treatment site as this measurement allows
for the laser energy to penetrate the tissue and reduce
the bacterial load without the fibre touching the epi-
thelial attachment at the bottom of the pocket.15 After
completion of the laser assisted pocket therapy no
sutures or periodontal dressing were given. Postopera-
tively, no antibiotics and analgesics were prescribed.
A second and third cycle of lasing was done at every
third day in an attempt to delay epithelial down-
growth and promote periodontal tissue regeneration
as, according to Goldman et al.,25 during the healing
phase, migration of the epithelium begins from the
existing epithelium of attached gingiva and new epi-
thelium begins to cover the exposed gingival corium
within 2 to 3 days. Furthermore, formation and orga-
nization of connective tissue fibres takes place during
healing and these fibers, although somewhat immature
in arrangement and width, appear well organized in
about 1014 days.25 In light of this, lasing wasnt
done beyond three cycles to prevent any inadvertent
damage to the healing connective tissue fibres within
the pocket. Also, the sulcus heals from the bottom up
and hence during the second and third lasing, the tip
was placed 2 mm less than the pocket probing depth
of the treatment site to allow healing at the floor of
the pocket.26,27 The postoperative instructions and
recalls were in accordance with studies by Schwarz
et al.,7 Sculean et al.,17 Raffetto15 and Gaspirc.1 Rep-
robing treatment sites were not attempted before
3 months as tissue reattachment to the root surface
could be damaged with a probe, delaying the healing
process.26,27
2013 Australian Dental Association

For the control site, open flap debridement was per-
formed and the soft tissue flap was repositioned at the
original level and closed with simple interrupted
sutures using 30 silk to obtain primary soft tissue
closure. The control site was then covered with perio-
dontal dressing. According to Nasr et al.,28 periodon-
tal dressing prevents the impingement of foreign
materials into the control site and also minimizes flap
displacement which would jeopardize the success of
the treatment. Patients were given both verbal and
written instructions. Antibiotics were prescribed to all
patients after open flap debridement. According to
Kornman et al.,29 antibiotics provide clinical benefits
during the postoperative phase of periodontal surgery
as bacterial contamination adversely affects the clinical
outcome of treatment. Patients were given pain medica-
tion to avoid discomfort after the effect of anaesthesia
wore off. Patients were instructed to use 0.2% chlorh-
exidine gluconate mouthwash twice daily for 4 weeks.
According to Newman et al.30 and Addy,31 chlorhexi-
dine helps in reducing the bacterial load in the oral
cavity and prevents the accumulation of plaque.
At the baseline examination, there were no statisti-
cally significant differences between the two treatment
groups in any of the recorded parameters. Both treat-
ments produced a reduction in PI, GI, mSBI and PD,
an increase in GR, and a gain in CAL at 3 and
6 month post-treatment intervals.
In both treatment groups, the PD decreased signifi-
cantly compared to baseline (p < 0.05). However, the
mean PD reduction at 3 and 6 months was signifi-
cantly greater (p < 0.05) for the OFD sites than for
sites treated with laser assisted pocket therapy. As a
primary outcome variable, significant gain in CAL
was recorded compared to baseline in both the treat-
ment groups (p < 0.05). The mean gain of CAL in the
laser treatment group at 3 and 6 months was similar
to the value of the control group (p > 0.05). Gingival
recession increased significantly only in the OFD
group compared to baseline (p < 0.05). The mean GR
at 3 and 6 months was significantly lower (p < 0.05)
for the laser treatment sites.
GI decreased significantly in both groups post-treat-
ment at 3 and 6 months (p < 0.05). However, OFD
was significantly effective (p < 0.05) in reduction of
GI as compared to laser assisted pocket therapy at
both 3 and 6 months post-treatment intervals. Also,
the mSBI scores for both treatment groups reduced
significantly after treatment (p < 0.05), although the
OFD group exhibited a significantly lower mSBI score
at 3 and 6 months postoperatively compared to the
laser treatment group (p < 0.05).
The results obtained in the present study with OFD
in terms of reduction in PD and gain in CALs confirm
those reported by Lindhe et al.,32 Pihlstrom et al.,33
Isidor and Karring,34 and Sculean et al.17 For the laser
2013 Australian Dental Association
Open ap debridement versus laser
assisted pocket therapy, the reduction in PD and gain
in CAL values are consistent with those of Watanabe
et al.,35 Schwarz et al.,7,21 Sculean et al.,17 Tomasi
et al.,18 and Gaspirc and Skaleric.1 The changes seen
with laser therapy may be attributed to the fact that
due to the lasers ablating action, the epithelium lining
the soft tissue wall of the pocket and the adjacent
inflammatory cell infiltrate may have been removed.
In addition, the low dose radiation that scatters into
the surrounding tissues may possess a beneficial effect
on the healing process.8,35 Also, erbium laser therapy
might have resulted in improved proliferation of fibro-
blasts and their adhesion to root surfaces leading to
CAL gain.7 Results from similar studies with Er:YAG
have also indicated that due to the minimally invasive
nature of laser treatment, trauma to hard and soft tis-
sues is minimal, causing less GR.7,21 There is less col-
lagen remodelling, faster healing and minimal scar
tissue with laser assisted pocket therapy which might
explain why less GR takes place.
Erbium lasers have antimicrobial effects and detoxi-
fication properties. They have a high bactericidal
potential against periodontopathic bacteria.36,37 The
lack of microbial data in the study does not allow us
to correlate the levels of microbiota in baseline pock-
ets and in residual pockets after the surgery with clini-
cal parameters at different time periods in study.
However, a clinical indicator of inflammation, bleed-
ing on probing (mSBI and GI scores) roughly reflects
the level of periodontal pathogens in the pocket.38,39
So it can be hypothesized that the reduction in GI and
mSBI scores might be due to a bactericidal and detox-
ification effect of the laser.
The results of the present study showed significant
differences between the OFD and laser assisted pocket
therapy treated sites with regard to reduction in PD,
mean increase in GR, improvement in GI and mSBI
scores. However, both sites demonstrated similar
improvements in terms of gain in CAL. The greater
pocket depth reduction in the case of OFD may also
be attributed to the higher amount of GR seen post-
operatively and it can be assumed that although sig-
nificant difference was found in terms of PD
reduction in favour of OFD but the change was at the
cost of recession. It was also observed that laser
assisted pocket therapy was far less invasive and less
time consuming than OFD, and required almost no
use of analgesia increasing patient compliance. This
treatment modality had no postoperative complica-
tions or impaired clinical healing, indicating that this
type of laser treatment may not have any detrimental
effect when employed for pocket therapy.
Within the constraints of this study, it can be con-
cluded that the use of an Er,Cr:YSGG laser in the
non-surgical treatment of periodontal pockets can
result in similar CAL gains to that of OFD with much
47
M Gupta et al.
less recession and can also result in statistically signifi-
cant reductions in PD, GI and mSBI. It may be con-
sidered as an alternative to the surgical therapy for
pockets ranging from 5 to 8 mm, especially in the
anterior zone of the oral cavity where aesthetics play
a key role. In addition, laser assisted pocket therapy
seems to possess additional benefits in terms of having
no need of analgesia, less mechanical trauma, instant
sterilization of the treated site, less postoperative com-
plications (swelling and pain), no need of antibiotics
as well as analgesics postoperatively, a minimally
invasive procedure with greater patient compliance
and less time consuming with minimal bleeding. How-
ever, OFD showed significantly better results com-
pared to laser assisted pocket therapy in terms of PD
reduction, GI score and mSBI score improvements.
Also, true periodontal regeneration can only be evalu-
ated histologically and it is recommended that further
longitudinal clinical trials be conducted to analyse the
maximum potential of lasers in non-surgical as well
as surgical periodontal therapy.
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