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Lasers in Dental Science

, Volume 2, Issue 1, pp 1–12 | Cite as

Antibacterial effect of using the Er:YAG laser or Er,Cr:YSGG laser compared to conventional instrumentation method—a literature review

  • Muftah Agoob Alfergany
  • Riman Nasher
  • Norbert Gutknecht
Review Article
  • 568 Downloads

Abstract

Background data

Although many studies have evaluated the effectiveness of the Er:YAG laser or Er,Cr:YSGG laser as an adjunct to initial periodontal therapy, there was no literature review after 2007 on the antibacterial effect of erbium lasers and conventional periodontal instruments.

Purpose

The aim of this review was to evaluate the effectiveness of using Er:YAG laser or Er,Cr:YSGG laser on the reduction of bacteria causing the periodontal disease in comparison to that with the hand, sonic, or ultrasonic scaling devices.

Material and methods

This is a review based on the literature search in PubMed and Google Scholar. The search is limited to publications in the period between January 2007 and April 2017, in the English language.

Results

Fourteen publications were found to be appropriate to the inclusion criteria of this review and screened according to the research question: is there a difference in the effect on the bacteria causing the periodontal disease by using Er:YAG laser or Er,Cr:YSGG laser in comparison to that with the hand, sonic, and ultrasonic scaling devices?

Conclusion

The beneficial effects of the erbium lasers as an adjunct to SRP have been established. By using the erbium lasers as an adjunctive therapy to the SRP, the users can have better antibacterial effects than conventional methods.

Keywords

Er:YAG laser Er,Cr:YSGG laser Nonsurgical periodontal therapy Root surface debridement Periodontitis therapy Ultrasonic periodontal instrumentation 

Introduction

The formation of dental plaque biofilms includes a series of steps that begins with the initial colonization of the pellicle and ends with the complex formation of a mature biofilm. Dental plaque biofilms can appear on a variety of tooth surfaces including fissures, smooth surfaces, and gingival crevices [1]. This thin, initial biofilm has been almost always present on the tooth surface as it forms immediately after cleaning [2]. An initial few layers (1–20) of the biofilm consist mostly gram-positive cocci bacteria, followed by some gram-positive rods and filaments, and a very small amount of gram-negative cocci. The gram-positive cocci species involved in this conditioning layer include, but are not limited to, Streptococcus mutans, Streptococcus mitis, Streptococcus sanguis, Streptococcus oralis, Rothia dentocariosa, and Staphylococcus epidermidis. The gram-negative rod and filament species include Actinomyces viscosus, Actinomyces Israelis, Actinomyces gerencseriae, and the Corynebacterium species. Veillonella parvula and the Neisseria species make up some of the few gram-negative cocci, which are aerobes or facultative aerobes and are able to adhere to the non-exfoliating hard tooth surfaces [3]. It was found in previous study that there is insufficient evidence to suggest that any specific wavelength of laser is superior to the traditional modalities of therapy. Current evidence does suggest that use of the Nd:YAG or Er:YAG wavelengths for treatment of chronic periodontitis may be equivalent to SRP with respect to reduction in PD and subgingival bacterial populations [4]. The aim of this review was to evaluate the effectiveness of using Er:YAG laser or Er,Cr:YSGG laser on the reduction of bacteria causing the periodontal disease in comparison to that with the hand, sonic, or ultrasonic scaling devices.

Materials and methods

This is a review based on the literature search in PubMed and Google Scholar. The search is limited to publications in the period between January 2007 and April 2017, in the English language.

Inclusion criteria:
  • In vitro studies, in vivo studies, and human studies.

  • Er:YAG laser, Er,Cr:YSGG laser, hand, and ultrasonic periodontal instruments.

  • Patient with periodontitis.

  • Articles searched in PubMed and Google Scholar,

  • Only articles in the English language.

  • Articles were published between January 2007 and April 2017.

  • In following criteria.

  1. 1.

    Antibacterial effect of using of different periodontal instruments (disinfection, detoxification).

     
  • Periodontitis was defined by clinical attachment loss or alveolar bone loss of 1 mm or more and a pocket probing depth of 4 mm or more.

Exclusion criteria:
  • Animal studies, literature reviews.

  • Implantology (peri-implantitis).

  • Patients with systemic diseases or conditions that affect healing, smoking, and patients taking antibiotic therapy when there is a medical condition were excluded

  • Insufficient information on laser settings.

  • Calculus detection and periodontal tissue engineering

  • The following criteria are excluded from the review.

  1. 1.

    Pain during and after periodontal therapy.

     
  2. 2.

    Thermal side effects to adjacent tissue.

     
  3. 3.

    Healing period of periodontal disease after treatment

     
  4. 4.

    The gain of clinical attachment.

     
  • Studies on the treatment of periodontitis necrotizing periodontal diseases, abscesses of the periodontal tissue, periodontitis associated with endodontic lesions, or developmental or acquired deformities and condition.

  • Studies investigating surgical interventions (frenectomy, vestibuloplasties, excisional procedures, crown lengthening, incisions, and drainages; implant exposures during second-stage surgery are excluded.

  • Damaging occurs in the adjacent tissues such as bone by using the Er:YAG laser or Er,Cr:YSGG laser.

Research question

Is there a difference in the effect on the reduction of bacteria causing the periodontal disease in using Er:YAG laser or Er,Cr:YSGG laser in comparison to that with the hand, sonic, or ultrasonic scaling devices?

Results

The electronic databases have been systematically screened (Medline via PubMed and Google Scholar) for papers published between January 2007 and April 2017 with an additional research in Research Gate.

The search produced 2619 records (Fig. 1). By reading and analyzing the research title, all researches have been excluded that duplicated and related to other topics. All studies appearing to meet inclusion criteria would then be obtained and reviewed in full. A total of 193 articles were possible to be included. Initial screening of the titles and abstract resulted in the further consideration of 179 publications to be excluded, and these 179 were excluded on the basis of studies that presented data on probing depth, clinical attachment level, and bleeding on probing (57); animal studies (44); studies that presented data on effect of erbium lasers on the root surface (33); literature reviews (31); and studies that presented data on calculus removal activity of the erbium lasers or conventional instruments (14), whereas the remaining (14) publications have been obtained and analyzed in full text.
Fig. 1

Description of selection process of the included publications

Evaluation of the antibacterial effectiveness was based on collecting the results and conclusions from each reviewed study, reviewing, and presenting all available evidence and scoring according to explained criteria. This method patently is susceptible to the inaccuracy essential in the individual estimation of the reviewer. However, after taking great care to find all relevant studies, basically assess each study, combining the findings from individual studies in an unbiased manner (Tables 1 and 2). The data were recorded using the following indices:

Antibacterial effects index

3 = strong bactericidal effects, 2 = average bactericidal effects, 1 = weak bactericidal effects, and 0 = very weak bactericidal effect.
Table 1

Antibacterial effect of using the different periodontal instruments

N

Author/year

Type/time

Design/samples

Purpose

Instrument

Finding

Laser type/parameters

Conventional instrument

1

Derdilopoulou et al. 2007 [5]

-Split mouth designs

-72 patients

-G-1 Curettes (H-group),

-G-2 Er:YAG laser (L-group),

-G-3 sonic device (S-group)

-G-4 ultrasonic device (U-group)

microorganisms

-(Aa), (Pg)

-(Pi), (Tf), (Td)

To evaluate and compare the microbiological effects of hand instruments,

Er:YAG laser, sonic, and ultrasonic scalers in patients with chronic periodontitis

-RR 10 Hz

-W/water irrigation

-Fiber tips

-TD 0.5 × 1.65 and 0.5 × 1.1 mm

-TA15–20°

-Gracey Curettes

-Ultrasonic instrumentation piezo-electric device

-Three months post-operatively, the amounts of Pg, Pi, Tf, and Td were significantly reduced in all groups.

-Laser and sonic instrumentation failed to reduce Aa. Six months after therapy.

-Curettes, Er:YAG laser, sonic, and ultrasonic scalers resulted in a significant reduction of Aa, Pg, Pi, Tf, and Td 3 months after therapy.

2

Ioannou et al. 2009 [6]

-Randomized clinical and microbiological trial

33 patients with chronic periodontitis

-G-1 SRP with hand instruments

-G-2 SRP with ultrasonic debridement (UD)

microbiological samples for

-(Pg), (Aa)

-(Td), (Tf)

To compare the effectiveness of scaling and root planing (SRP) with the use of hand instruments to that of non- surgical treatment with the use of an ultrasonic device, using clinical and microbiological criteria

Not reported

-Gracey Curettes

-Ultra-sonic instrument Piezo-electric device

-Numerical decrease was observed for P. gingivalis, T. forsythia and T. denticola in both groups.

-At the 3-month examination, a numerical decrease was observed for all species, except for A. actinomycetemcomitans.

-Both treatment modalities provided comparable clinical results in the treatment of chronic periodontitis.

3

Lopes et al. 2010 [7]

Split-mouth design

-19 patients with pockets from 5 to 9 mm

-G-1) SRPL = SRP and laser

-G-2) L = laser

-G-3) SRP = SRP only

-G-4) C = no treatment

microbiological samples for

-(Aa), (Pg)

-(Pi), (Tf),

-(Pn)

To compared (Er:YAG laser) irradiation (100 mJ/pulse;

10 Hz; 12.9 J/cm2) with or without conventional scaling and root

planing (SRP) to SRP only for treatment of periodontal pockets

-Er:YAG laser

-E 100 mJ/pulse

-RR 10 Hz

-ED 12.9 J/cm2

-PD 250 to 500 μs

-TD 1.1 × 0.5 mm

-30° angle

-(Specific manual Curettes)

-SRPL and L presented a significant reduction in the percentage of sites with bacteria 6 and 12 months after therapy.

-After 1-month reduction in Pg, Pi, Pn, and Tf in the SRPL group; a reduction in Aa, Pg, and Pn in L; a reduction in Aa and Tf in SRP.

-3 months, a reduction in Pg, Pi, Pn, and Tf in the SRPL group; a reduction in Pg in L; and no significant reduction for SRP

-After 6 months, a reduction in Aa, Pg, Pn, and Tf in the SRPL group; a reduction in Aa in L; and no significant reduction0020for SRP.

-After 12 months, a reduction in Aa, Pg, Pi, Pn, and Tf in the SRPL group; a reduction in Aa and Pg in L

4

Domínguez et al. 2010 [8]

-Randomized, longitudinal clinical trial

-30 patients

with chronic periodontitis

-15 patients for each group

-G-1(SRP + ERL)

-G-2(SRP)bacterial samples for

-(Pg), (Pi)

-(Pm), (Fn)

-(Cr), (Ec)

-(Tf), (En)

-(Aa)

To compare the effects of fluorescence-controlled Er:YAG laser radiation after SRP with SRP alone on the treatment of chronic periodontitis

-Er:YAG laser

-E 160 mJ/pulse

-RR 10 Hz

-Water irrigation

-Specially designed periodontal handpiece (2261, KaVo)

-Chisel-shaped glass fiber tip

-TD 0.4 mm × 1.65 mm, 15–20° angle

-Ultra-sound sonic

-Gracey Curettes

-No significant differences were detected for clinical, microbiological variables and TAS of GCF between SRP and SRP + ERL groups.

-SRP + ERL allowed a decrease of the levels of pro-inflammatory cytokines and prevented a fast process of recolonization.

-With regard to the amount of Pg, the laser adjunctive treatment revealed a significantly higher reduction if compared with SRP alone 4 and 8 weeks after therapy.

5

Akiyama et al. 2011 [9]

In vitrostudy

-20 periodontally diseased teeth

-G-1 (8 teeth)

divided into 2 halves

RH = control

LH = Er:YAG laser

-G-2 (12 teeth)

divided into 2 halves

RH = US for SRP

LH = Er:YAG laser for SRP

To investigate the effect of Er:YAG laser irradiation on the morphology of periodontopathic bacteria and to compare the bacterial elimination effect of the laser and the ultrasonic scaler on the diseased root surfaces

-Er:YAG laser

-2940 nm

-Single pulse

-E 50 mJ,

-RR 10 Hz

-ED 14.2 J/cm2 on the tip

-ED 8.0 J/cm2

-Straight contact tip

-2 mm distance

-30° angle

-20 ml/min irrigation

-Ultra-sonic scaler

-The laser irradiation produced an ablation spot on the P. gingivalis.

-Er:YAG laser treatment could significantly reduce root surface contamination.

-Laser-treated root surface was significantly lower than that of the ultrasonically debrided root surface in the aerobic and anaerobic conditions.

-The decontamination effect of the Er:YAG laser on diseased root surfaces was superior to that of the ultrasonic scaler in vitro.

6

Ratka-Krüger et al. 2012 [10]

-Randomized controlled split mouth study

-78 patients

microbiological

evaluation

-(Aa), (Pg)

-(Tf), (Td)

-(Pi), (Pm)

-(Fn), (Cr)

-(En), (Ec,

-(Cs)

To assess clinical and microbiological outcomes of an Er:YAG laser in comparison with sonic debridement in the treatment of persistent periodontal pockets

-Er:YAG laser

-2061 handpiece

-E 120 mJ at the laser pane

-97 mJ at the

working tip

-ED 14.7 J/cm2

-RR 10 Hz

-15–20° angle

-W/water spray

-Sonic scaler

-Microbiological analysis failed to expose any significant difference based on treatment group or period.

-No difference in all bacterial species could be shown between the two treatment procedures both 13 and 26 months after treatment.

7

Malali et al. 2012 [11]

-Randomized, single blind,

prospective controlled clinical trial

-30 patient

with chronic periodontitis

3 groups

-G-1 = hand Curettes (group H) (n = 10)

-G-2 = ultrasonic scalers

(group U) (n = 10)

-G-3 = Er:YAG lasers (group L) (n = 10)

To compare the clinical parameters and crevicular cell population, par-

ticularly leukocyte counts, changes after initial periodontal therapy with different instruments by a chairside laboratory technique, in severe periodontitis patient

-Er:YAG laser

-160 mJ/pulse

-RR 10 Hz

-Water irrigation

-Chisel type fiber tips

-R14C Handpiece

-TD 1.5 × 0.5 mm

-15–20° angle

- Gracey

Curettes

-Magneto-strictive ultrasonic (Cavitron)

-Laboratory assessments revealed significant differences in all groups between baseline, day 7, and day 90.

-Hand Curettes were the most successful for maintaining the levels of microorganisms and leukocytes.

-Er:YAG lasers are promising in treating periodontitis.

-For better results, the speed of ultrasonic scalers, more efficient de-epithelization of Er:YAG lasers, and smooth root surface of hand instruments, should be combined, through using the three systems together.

8

Komatsu et al. 2012 [12]

-Case-control

Study

-20 chronic periodontitis Randomly treated for quadrant SRP

-G-1 (n = 10) conventional hand instrument

-G-2 (n = 10)

Er: YAG laser

-(Pi), (Pg)

-(Tf), (Td)

-(F.nucleatum(

-Streptococcus spp.

-lactobacillus

To evaluate whether

(Er:YAG laser) could be prophylactic methods against transient bacteremia during scaling and root planing. To confirm the efficacies of SRP with Er:YAG laser by clinical and microbiologic evaluations

-Er:YAG laser

-Tapered contact tip

-E 100 mJ

-5–7 ml/m water

Irrigation

-TL 3 mm

-TD 600 μm at basic and 400 μm at top

-15–30° angle

-Gracey Curettes

-Provide the novel important Findings that Er:YAG laser could be an adjunctive prophylactic method against transient bacteremia during SRP.

-Reduction of the subgingival bacterial counts between baseline and 1 month after SRP were also comparable between the two groups.

-The incidence of bacteremia during SRP was 0% in the Er:YAG laser group.

-The incidence of bacteremia during SRP was 80% in the hand instrument group

9

Yılmaz et al. 2013 [13]

-Randomized controlled

clinical trial

-30 patients with CP

3 groups

-G-1 = (n = 10)

(SRP) + Er:YAG laser

-G-2 = (n = 10)

SRP + topical gaseous ozone

-G-3 = (n = 10)

SRP alone

To evaluate the clinical and microbiological results of treatment with the Er:YAG laser and topical gaseous ozone application as adjuncts to initial periodontal therapy in (CP) patients.

-Er:YAG laser

-RR 20 Hz,

-50 mJ/pulse,

-IT 1 min/pocket,

-30°angle tips

-Water irrigation

Not reported

-There was a better resolution of infection in the SRP + Er:YAG laser group.

-Although statistically not significant, the fact that the obligate anaerobic change was mostly observed in the SRP+ Er:YAG laser group and a similar decrease was noted in the SRP + topical gaseous ozone group, shows that ozone has an antimicrobial effect equivalent to that of the Er:YAG laser.

10

Yaneva et al. 2014 [14]

-Split-mouth design

-30 patients with chronic periodontitis

-G-1 (test group) w/ Er:YAG laser

-G-2 (control) group w/ Gracey

Curettes

microbiological

evaluation

-(P.g.), (Td)

-(T.f.),(P.i.)

To evaluate the early microbiological and clinical effectiveness of the Er:YAG laser in the treatment of chronic periodontitis

-Er:YAG laser

-E 100 Mj

-RR 15 Hz

-Chisel tip

-15–20° angle

-5–6A/W spray

-Contact hard tissue mode

-For cleaning

-E 50 mJ

-RR 30 Hz

-Non-contact mode

-Gracey Curettes

-Significant reduction in the red complex was found one month after the therapy in both groups.

-Microbiological analysis revealed that the pathogens from the red complex decreased 3 times in the control and 6 times in the test group.

-Er:YAG laser has some advantages over the conventionalnonsurgicaltreatment of moderate chronic periodontal disease with hand instruments.

11

Yaneva et al. 2014 [15]

-A split-mouth design

-20 patients w/ moderate chronic periodontitis

-Control group

SRP w/ hand instruments

-Test group SRP w/ Er:YAG L

microbiologic sampling for

-(Aa), (Pg), (Tf)

-(Td), (Pi), (Pm)

-(Fn), (En), (Cg)

To evaluate the bactericidal effectiveness of using a fiberlessEr:YAG laser inthe first stage of therapy for moderate chronic periodontitis and to compare it with conventional treatment

-Er:YAG laser

-E 100 mJ

-RR 15 Hz

-P 1.5 W

-Chisel tip

-TL 17 mm

-10–15° angle

-E 50 mJ

-RR 30 Hz

-P 1.5 W

-Non-contact

-Sapphire tip

-TD 0.6 mm

-TL17 mm

-Gracey Curettes

-The total number of all microorganisms decreased significantly in both the control group and test group.

-1 month after treatment, all microorganisms decreased as compared to baseline and were more pronounced in the test group.

-The laser system has a higher bactericidal potential than the treatment with hand instruments.

-The Er:YAG laser seems to be a promising tool in antibacterial periodontal therapy.

-Er:YAG lasers possess bactericidal potential when used in the initial stage of therapy for moderate chronic periodontitis.

12

Gutknecht et al. 2015 [16]

-A Pilot clinical Study

-12 patients with chronic periodontitis

-For all teeth = scaling with a sonic scaler and Gracey Curettes

-Two quadrants = Er,Cr:YSGG laser

-microbiologic sampling for

-(Pi),(Tf)

-(Td), (Fn)

-(Pg), (Aa)

To evaluate the effectiveness of a radial firing tip of an Er,Cr:YSGG laser as an adjunct to a nonsurgical periodontal treatment

-Er,Cr:YSGG laser

-RR 30 Hz

-E 40 mJ

-11% air, 20% water

-PD 140 μs

-P 1.5 W

-Pp 285.71 W

-H-mode

-Bottom-up technique

-Radial firing tip (RFPT 5–14 tip)

-TD 580 μm and at tip 100 μm

-TL 14 mm

-Ultra-sonic devices

-Gracey Curettes

-Sonic scaler

-The total bacterial load was reduced significantly throughout the whole examination time.

-Antibacterial effect of the laser treatment was very effective and enduring.

-Slight higher reduction of pocket depth was found in the lased group after six months.

13

Sanz-Sánchez et al. 2016 [17]

-12-month Randomized clinical trial

40 patients w/CP

-Test group = SRP w/US and after (7 days, 4.5 mm PD) Er:YAG laser

-Control = SRP w/US

Microbiological samples

-(Aa), (Tf)

-(Pg), (Pi)

-(Pm), (Pn)

-(Cr), (Fn)

To assess the microbiological effects and recolonization patterns after nonsurgical periodontal treatment protocol based on the adjunctive use of Er:YAG laser.

-Er:YAG laser

-W/ feedback system

-E 160 mJ (136 mJ at the tip)

-RR 10 Hz

-Sapphire tip

-TD0.5 × 1.65

-15–20° angle

-Piezo-ceramic ultrasonic device

-The adjunctive use of Er:YAG laser when compared with conventional ultrasonic debridement did not provide a microbiological added benefit.

-There were no differences in microbiological outcomes or in bacterial recolonization.

-Minor changes were detected for the log-transformed total anaerobic counts, without demonstrating significant differences between groups.

-No significant differences were detected between groups at baseline.

14

Milne et al. 2016 [18]

-Split-mouth design

-21 patients

-Test group

-Control groups

microbiological samples

-(Pg)

-(Td)

-(Tf)

-(Aa)

To compare the effects of subgingival debridement using Er:YAG laser with conventional mechanical SRP on the relative subgingival levels of P. gingivalis, T.

forsythia, T. denticola, and A. actinomycetem-comitans

at 6 and 12 weeks post-treatment

-Same in (soo L. et al. 2012)

-Er:YAG laser

-RR 10 Hz

-E 160 mJ (114 to 136 mJ at the tip)

-Chisel tip

-TD (0.5 × 1.1 and 0.5 × 1.65)

-15–20° angle

-ED (18.8 J/cm2 and 14.5 J/cm2)

-P2061 handpiece

-W/ water irrigation

-Ultrasonic scaler (EMS Piezon)

-Gracey Curettes and furcation files

-All four species decreased over the study period.

-Tf and Pg were significantly reduced post-treatment for both ERL and SRP

-ERL treatment resulted in a reduction of Td.

-Following SRP treatment, Aa was significantly reduced at 12 weeks.

-No statistical significant difference was seen when treatments were compared at 6 and 12 weeks.

-A comparable reduction in the level of the four periodontal pathogens assayed was achieved with Er:YAG laser debridement and mechanical scaling and root planning

Table 2

Table showing how many studies found SRP alone, ERL alone or combination of SRP and ERL significantly better in reducing bacteria

Author/year

SRP alone

ERL alone

Combination of SRP and ERL

Derdilopoulou et al. 2007 [5]

?

Ioannou et al. 2009 [6]

?

?

Lopes et al. 2010 [7]

×

Domínguez et al. 2010 [8]

×

?

Akiyama et al. 2011 [9]

×

?

Ratka-Krüger et al. 2012 [10]

?

Malali et al. 2012 [11]

×

?

Komatsu et al. 2012 [12]

×

?

Yılmaz et al. 2013 [13]

×

?

Yaneva et al. 2014 [14]

×

?

Yaneva et al. 2014 [15]

×

?

Gutknecht et al. 2015 [16]

×

?

Sanz-Sánchez et al. 2016 [17]

×

?

×

Milne et al. 2016 [18]

×

?

(×) not significantly better in reducing bacteria, (✓) significantly better in reducing bacteria, (?) it was not discussed in the studySRP scaling and root planning, ER erbium lasers

Antibacterial effect of using the different periodontal instruments

Discussion

Antibacterial effect of Er,Cr:YSGG laser

The clinical and microbiological improvements may be a combination of a beneficial conditioning of the root surface, mechanical disorganization of the biofilm, and reduction in viable bacteria as well as inactivating bacterial toxins [19].

The newest investigations show promising results concerning the Er,Cr:YSGG laser. Gutknecht et al. (2015) performed a study to evaluate the capability of the Er,Cr:YSGG laser with a wavelength of 2780 nm and a 360° firing elastic tip to be the appropriate tool to reduce pathogen microorganisms in the oral cavity. Also, to eliminate the biofilm on the diseased root surfaces and the infected gingiva around the tooth in addition to a nonsurgical conservative periodontal treatment and proved that the Er,Cr:YSGG laser with a 360 firing tip is able to reduce pathogen microorganisms in the periodontal niche significantly (Fig. 2). Microbiological examinations showed a strong reduction of the whole bacterial amount in the pocket as well as the number of each periodontal pathogen. This result stayed true until 6 months after treatment [16].
Fig.2

Diagram showing the antibacterial effect (ABA) using different periodontal instruments. HI = hand instrument, US = ultrasonic scaler, No. of st = number of studies. 3 = strong bactericidal effects. 2 = average bactericidal effects. 1 = weak bactericidal effects. 0 = very weak bactericidal effects

Antibacterial effect of Er:YAG laser

The Er:YAG laser has a wavelength of 2.94 μm, and it may have bactericidal effects and potential to remove bacterial endotoxins and calculus from the root surface, due to its high-water absorption capacity. Therefore, it involves less thermal risk for mineralized surfaces [20, 21]. Lopes et al. (2010) determined that in non-surgical periodontal treatment, Er:YAG laser may be an alternative treatment for reduction and control of the proliferation of microorganisms in persistent periodontitis [7]. Domínguez et al. (2010) have also demonstrated that the use of the Er:YAG laser radiation as a coadjutant of scaling and root planing (SRP + ERL) allowed a decrease in the levels of pro-inflammatory cytokines and prevented a fast process of recolonization. This study also remarks that the adjunctive application of fluorescence-controlled Er:YAG laser radiation prevents a fast process of recolonization [8].

Conventional instruments used for mechanical root surface debridement. Although they have been proven to be effective therapeutic methods, they are laborious and technique-dependent, and the bacterial elimination is incomplete. Also, the access to conventional mechanical instruments to narrow spaces is limited [22]. Therefore, attempts have been made to find other novel therapeutic adjuncts or alternatives to supplement the conventional mechanical methods. Akiyama et al. (2011) found that the Er:YAG laser could ablate subgingival calculi and bacterial plaque effectively with the probe in light contact with the root surface and with no application of pressure to remove calculus. Also, Er:YAG laser treatment could significantly reduce root surface contamination. Laser-treated root surface was significantly lower than that of the ultrasonically debrided root surface in the aerobic and anaerobic conditions. Er:YAG laser irradiation caused thermal vaporization of periopathogenic bacteria and that under the equal efficiency of root debridement. The decontamination effect of the Er:YAG laser on diseased root surfaces was superior to that of the ultrasonic scaler. Regarding the bacterial elimination effect, both treatments generally achieved almost all biofilm removal from the treated surface. However, in both treatments, some islets of the biofilm or bacteria still remained at the non-contact sites in the treated areas [9].

Antibacterial effect of the conventional instruments

Hand instruments, sonic, and ultrasonic devices have been applied for subgingival mechanical debridement; however, both treatment procedures may not be predictable to allow a complete removal of all subgingival calculus and microorganisms from the root surface [22]. Ultrasonic scalers were first designed for gross supragingival scaling and removal of stains, but recently, by modification of the diameter and length of the tips, they have become a routine part of scaling and root planing (SRP) procedure [23, 24]. Ioannou et al. (2009) have been found that both treatment modalities (hand and ultrasonic) provided comparable clinical results and significant reduction of the pathogens in the treatment of chronic periodontitis [6].

Comparing the antibacterial effect of the different periodontal instruments

On the bactericidal effect of the Er:YAG laser, Ratka-Krüger et al. (2012) have done study that examined the antibacterial effect of an Er:YAG laser, and a sonic device during periodontal supportive care also found that the microbiological assessment did not reveal a change of the bacterial load over time. The two treatment groups failed to reveal significant changes for most bacterial species, and they have indicated that both sonic and laser treatment procedures during supportive periodontal care are suitable to achieve similar clinical and microbiological outcomes [10]. Malali et al. (2012) also concluded after comparing the effectiveness of Er:YAG laser with two formerly successful instruments, hand instruments, and ultrasonic scalers to determine the subgingival cell population changes in moderately deep and deep pockets, that, although Er:YAG lasers are clinically as efficient as hand instruments and ultrasonic scalers in treating periodontal disease, they do not seem to be notably superior to conventional systems. For better results, the speed of ultrasonic scalers, more efficient de-epithelization of Er:YAG lasers, and smooth root surface of hand instruments should be combined, through using the three systems together [11].

According to the current findings that shown that Er:YAG lasers possess bactericidal potential, their antibacterial effectiveness has been demonstrated in connection with caries lesions, root canals, and periodontal pockets [7, 25]. Yaneva et al. (2014) also talk about how to evaluate the bactericidal effectiveness of using a fiberless Er:YAG laser (in which the energy is generated in the handpiece and delivered directly to the working tip) in the first stage of therapy for moderate chronic periodontitis and compared it with conventional treatment. They found that the results of their study confirm the results of other studies that have shown that Er:YAG laser possesses antimicrobial effectiveness in clinical conditions, moreover concluded that SRP with the Er:YAG laser can be used as an alternative treatment in periodontitis because of its proven effectiveness of reduction of the periodontal pathogens [15]. On the contrary, Sanz-Sánchez et al. (2016) reported that their study investigation was in agreement with most published evidence, failing to demonstrate a statistically significant microbiological benefit when using the Er:YAG laser application and failed to demonstrate microbiological advantages when using Er:YAG laser application 1 week after a full-mouth ultrasonic debridement in patients with chronic periodontitis. In addition to that, there were no significant microbiological differences after 1 year also [17]. Milne et al. (2016) also found similar results, when they compared the effects of subgingival debridement using Er:YAG laser with conventional mechanical SRP on the relative subgingival levels of P. gingivalis, T. forsythia, T. denticola, and A. actinomycetemcomitans at 6 and 12 weeks post-treatment. They confirm this by stating that the Er:YAG laser compared with the ‘gold standard’ mechanical (SRP) was equally effective at reducing T. forsythia and P. gingivalis. Er:YAG laser treatment may be more effective than SRP at reducing the level of T. denticola and SRP more effective than Er:YAG laser treatment for reducing of A. actinomycetemcomitans. That means that there is a comparable reduction in the level of the four periodontal pathogens assayed that was achieved with Er:YAG laser debridement and mechanical scaling and root planning, and therefore, no significant difference was seen when treatments were compared at 6 and 12 weeks [18]. The improved decontamination effect of Er:YAG laser might be explained by Komatsu et al. (2012). They evaluated the efficacies of two methods (conventional SRP, SRP with Er:YAG laser) for clinical and microbiologic findings, and preventing the incidence of bacteremia during quadrant (SRP). It was demonstrated that SRP with Er:YAG laser could not only be an alternative treatment for improvement of clinical and microorganism situations but also a novel prophylactic method against transient bacteremia; they provided that the novel important findings that Er:YAG laser could be an adjunctive prophylactic method against transient bacteremia during SRP [12]. Furthermore, Yaneva et al. (2014) concluded that the microbiological analysis revealed that the pathogens from the red complex decreased 3 times in the control group (SRP) and 6 times in the test group (Er:YAG laser). Therefore, the Er:YAG laser demonstrates pronounced early effectiveness in chronic periodontitis treatment and would be an appropriate alternative to the conventional periodontal therapy; also, Er:YAG laser possesses a well-defined effectiveness in the treatment of moderate chronic periodontitis in the early healing period, which would be a prerequisite for long-term positive therapeutic outcomes [14].

Conclusion

Based on this systematic review results, the following can be concluded:
  1. 1.

    The beneficial effects of the erbium lasers as an adjunct to SRP have been established. By using the erbium lasers as an adjunctive therapy to the SRP, the users can have better antibacterial effects than conventional methods.

     
  2. 2.

    Erbium lasers, ultrasonic scaler, and hand instrument resulted in a significant reduction in the level of the periodontal microorganisms; the reduction in the level of the periodontal microorganisms treated with erbium lasers is comparable to that achieved with conventional instruments alone. The results of the present review indicate that nonsurgical periodontal treatment with erbium lasers as an adjunct to SRP may be an alternative treatment for reduction and manage the periodontal microorganisms.

     
  3. 3.

    It is important to adjust the erbium laser parameters according to the severity of the periodontal disease. The results of the present review indicate that, using the erbium laser as an adjunctive therapy to the SRP at low energy within power output range of 0.5 to 1.8 W (50 to 120 mJ and 10 to 15 Hz) with long pulse duration 200 to 400 μs, in non-contact mode 1.5 to 2 mm distance with tip angle to the root surface between 10° and 40° and 50 to 70% air/water irrigation for Er:YAG laser and at low energy within power output range of 1.25 to 1.5 W, with pulse duration 140 to 200 μs, radial firing tip in non-contact mode 1.5 to 2 mm distance with tip angle to the root surface between 10° and 40° and 30 to 50% air/water irrigation for Er,Cr:YSGG laser can be appropriate to reduce periodontal microorganisms.

     

Recommendation

The therapeutic use of erbium lasers of nonsurgical periodontal therapy shows a lot of good results and success. The practitioner should have a lot of knowledge and training in the field of laser and laser physics, such as laser settings and laser-tissue interaction to get the optimal treatment results.

References

  1. 1.
    Marsh P (2004) Dental plaque as a microbial biofilm. Caries Res 38(3):204–211.  https://doi.org/10.1159/000077756 CrossRefPubMedGoogle Scholar
  2. 2.
    Haps S, Slot D, Berchier C, Van der Weijden G (2008) The effect of cetylpyridinium chloride-containing mouth rinses as adjuncts to toothbrushing on plaque and parameters of gingival inflammation: a systematic review. Int J Dent Hyg 6(4):290–303.  https://doi.org/10.1111/j.1601-5037.2008.00344.x CrossRefPubMedGoogle Scholar
  3. 3.
    Sbordone L, Bortolaia C (2003) Oral microbial biofilms and plaque-related diseases: microbial communities and their role in the shift from oral health to disease. Clin Oral Investig 7(4):181–188.  https://doi.org/10.1007/s00784-003-0236-1 CrossRefPubMedGoogle Scholar
  4. 4.
    Cobb CM (2006) Lasers in periodontics: a review of the literature. J Periodontol 77(4):545–564.  https://doi.org/10.1902/jop.2006.050417 CrossRefPubMedGoogle Scholar
  5. 5.
    Derdilopoulou FV, Nonhoff J, Neumann K, Kielbassa AM (2007) Microbiological findings after periodontal therapy using curettes, Er: YAG laser, sonic, and ultrasonic scalers. J Clin Periodontol 34(7):588–598.  https://doi.org/10.1111/j.1600-051X.2007.01093.x CrossRefPubMedGoogle Scholar
  6. 6.
    Ioannou I, Dimitriadis N, Papadimitriou K, Sakellari D, Vouros I, Konstantinidis A (2009) Hand instrumentation versus ultrasonic debridement in the treatment of chronic periodontitis: a randomized clinical and microbiological trial. J Clin Periodontol 36(2):132–141.  https://doi.org/10.1111/j.1600-051X.2008.01347.x CrossRefPubMedGoogle Scholar
  7. 7.
    Lopes BM, Theodoro LH, Melo RF, Thompson GM, Marcantonio RA (2010) Clinical and microbiologic follow-up evaluations after non-surgical periodontal treatment with erbium:YAG laser and scaling and root planing. J Periodontol 81(5):682–691.  https://doi.org/10.1902/jop.2010.090300 CrossRefPubMedGoogle Scholar
  8. 8.
    Domínguez A, Gómez C, García-Kass AI, García-Nuñez JA (2010) IL-1β, TNF-α, total antioxidative status and microbiological findings in chronic periodontitis treated with fluorescence-controlled Er: YAG laser radiation. Lasers Surg Med 42(1):24–31.  https://doi.org/10.1002/lsm.20873 CrossRefPubMedGoogle Scholar
  9. 9.
    Akiyama F, Aoki A, Miura-Uchiyama M, Sasaki KM, Ichinose S, Umeda M, Ishikawa I, Izumi Y (2011) In vitro studies of the ablation mechanism of periodontopathic bacteria and decontamination effect on periodontally diseased root surfaces by erbium:yttrium-aluminum-garnet laser. Lasers Med Sci 26(2):193–204.  https://doi.org/10.1007/s10103-010-0763-3 CrossRefPubMedGoogle Scholar
  10. 10.
    Ratka-Krüger P, Mahl D, Deimling D, Mönting JS, Jachmann I, Al-Machot E, Sculean A, Berakdar M, Jervøe-Storm PM, Braun A (2012) Er: YAG laser treatment in supportive periodontal therapy. J Clin Periodontol 39(5):483–489.  https://doi.org/10.1111/j.1600-051X.2012.01857.x CrossRefPubMedGoogle Scholar
  11. 11.
    Malali E, Kadir T, Noyan U (2012) Er: YAG lasers versus ultrasonic and hand instruments in periodontal therapy: clinical parameters, intracrevicular micro-organism and leukocyte counts. Photomed Laser Surg 30(9):543–550.  https://doi.org/10.1089/pho.2011.3202 CrossRefPubMedGoogle Scholar
  12. 12.
    Komatsu Y, Morozumi T, Abe D, Okada M, Nakasone N, Okuda K, Yoshie H (2012) Effects of erbium-doped: yttrium aluminum garnet (Er: YAG) laser on bacteremia due to scaling and root planing. J Lasers Med Sci 3(4):175Google Scholar
  13. 13.
    Yılmaz S, Algan S, Gursoy H, Noyan U, Kuru BE, Kadir T (2013) Evaluation of the clinical and antimicrobial effects of the Er: YAG laser or topical gaseous ozone as adjuncts to initial periodontal therapy. Photomed Laser Surg 31(6):293–298.  https://doi.org/10.1089/pho.2012.3379 CrossRefPubMedGoogle Scholar
  14. 14.
    Yaneva B, Firkova E, Karaslavova E (2014) Early clinical effectiveness of Er: Yag laser in association with the red complex of bacteria in the initial treatment of moderate chronic periodontitis. Acta Med Bulg 41(1):37–44Google Scholar
  15. 15.
    Yaneva B, Firkova E, Karaslavova E, Romanos GE (2014) Bactericidal effects of using a fiber-less Er:YAG laser system for treatment of moderate chronic periodontitis: preliminary results. Quintessence Int (Berlin, Germany: 1985) 45(6):489–497.  https://doi.org/10.3290/j.qi.a31803
  16. 16.
    Gutknecht N, Van Betteray C, Ozturan S, Vanweersch L, Franzen R (2015) Laser supported reduction of specific microorganisms in the periodontal pocket with the aid of an Er,Cr:YSGG laser: apilot study. Sci World J 2015:1–7.  https://doi.org/10.1155/2015/450258 Google Scholar
  17. 17.
    Sanz-Sánchez I, Ortiz-Vigón A, Herrera D, Sanz M (2016) Microbiological effects and recolonization patterns after adjunctive subgingival debridement with Er: YAG laser. Clin Oral Investig 20(6):1253–1261.CrossRefPubMedGoogle Scholar
  18. 18.
    Milne TJ, Coates DE, Leichter JW, Soo L, Williams SM, Seymour GJ, Cullinan MP (2016) Periodontopathogen levels following the use of an Er:YAG laser in the treatment of chronic periodontitis. Aust Dent J 61(1):35–44.  https://doi.org/10.1111/adj.12306
  19. 19.
    Ishikawa I, Aoki A, Takasaki AA, Mizutani K, Sasaki KM, Izumi Y (2009) Application of lasers in periodontics: true innovation or myth? Periodontol 50(1):90–126.  https://doi.org/10.1111/j.1600-0757.2008.00283.x CrossRefGoogle Scholar
  20. 20.
    Folwaczny M, Mehl A, Haffner C, Benz C, Hickel R (2000) Root substance removal with Er: YAG laser radiation at different parameters using a new delivery system. J Periodontol 71(2):147–155.  https://doi.org/10.1902/jop.2000.71.2.147 CrossRefPubMedGoogle Scholar
  21. 21.
    Schwarz F, Aoki A, Becker J, Sculean A (2008) Laser application in non-surgical periodontal therapy: a systematic review. J Clin Periodontol 35(s8):29–44.  https://doi.org/10.1111/j.1600-051X.2008.01259.x CrossRefPubMedGoogle Scholar
  22. 22.
    Kepic TJ, O'Leary TJ, Kafrawy AH (1990) Total calculus removal: an attainable objective? J Periodontol 61(1):16–20.  https://doi.org/10.1902/jop.1990.61.1.16 CrossRefPubMedGoogle Scholar
  23. 23.
    Cohen R (2003) Position paper: periodontal maintenance. J Periodontol 74(9):1395–1401.  https://doi.org/10.1902/jop.2003.74.9.1395 CrossRefPubMedGoogle Scholar
  24. 24.
    Dragoo MR (1992) A clinical evaluation of hand and ultrasonic instruments on subgingival debridement. Port I. With unmodified and modified ultrasonic inserts. Int J Periodontics Restorative Dent 12(4):310–323PubMedGoogle Scholar
  25. 25.
    Ando Y, Aoki A, Watanabe H, Ishikawa I (1996) Bactericidal effect of erbium YAG laser on periodontopathic bacteria. Lasers Surg Med 19(2):190–200.  https://doi.org/10.1002/(sici)1096-9101(1996)19:2<190::aid-lsm11>3.0.co;2-b CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2017

Authors and Affiliations

  • Muftah Agoob Alfergany
    • 1
  • Riman Nasher
    • 1
  • Norbert Gutknecht
    • 1
  1. 1.Department of Conservative Dentistry, Periodontology and Preventive DentistryRWTH Aachen University HospitalAachenGermany

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