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

Manuscript has been accepted for publication JDH , June 2014

D IODE L ASER AS AN A DJUNCT TO SRP: � T HE C ONTROVERSY  AAP 2011 Statement of Efficacy regarding diode: Minimal evidence to support �  Slot et al, 2014 Recommendation for adjunctive use of diode: “Moderate” for changes in PPD, and CAL; Significant for BS �

W HY D O P RACTITIONERS C ONTINUE U SING D IODES ?  12 of 14 studies showed 12 of 14 studies showed > > 1 clinical benefit 1 clinical benefit �  Borrajo et al., 2004 Borrajo et al., 2004 �  Caruso et al., 2008 Caruso et al., 2008 �  Lin et al., 2011 Lin et al., 2011 �  Dukic et al., 2013 Dukic et al., 2013 �  Zingale et al., 2012 Zingale et al., 2012 �  Qadri et al., 2005 Qadri et al., 2005 � . � 

W HY D O P RACTITIONERS C ONTINUE U SING D IODES ? �  Assaf et al., 2007 Assaf et al., 2007 �  Kamma et al, 2009 Kamma et al, 2009 �  Moritz et al., 1997 Moritz et al., 1997 �  Kr Kreisler et al., 2005 eisler et al., 2005 �  Saglam et al, 2014 15j/cm Saglam et al, 2014 15j/cm 2 @ 20s @ 20s �  PD, CAL impr PD, CAL improved. GCF levels TIMP-1 oved. GCF levels TIMP-1 � �  Ű stun et al, 2014 760 stun et al, 2014 760 0 C @ 20s C @ 20s �  CAL impr CAL improved. IL-1 oved. IL-1 β  �

W HY HY D D O P P RACTITIONERS RACTITIONERS C C ONTINUE ONTINUE U U SING SING D D IODES IODES ? ? �  2 studies showed no sig. dif 2 studies showed no sig. diff. clinical out f. clinical out come measur come measures es �  Contr Control showed gr ol showed greater clinical eater clinical impr improvement ovement �  Euzebio Alves, De Micheli et al 2012 Euzebio Alves, De Micheli et al 2012 �  808nm 1193.7W/cm 808nm 1193.7W/cm 2 @ 20s @ 20s �  De Micheli et al, 2011 808nm 1193.7W/ De Micheli et al, 2011 808nm 1193.7W/ cm cm 2 1.5W @ 20s 1.5W @ 20s �

W HY HY S S UCH UCH V V ARIANCE ARIANCE IN IN C C LINICAL LINICAL O O UTCOME UTCOME M EASURES EASURES ? �  Weaknesses in study design: eaknesses in study design: �  Small sample size Small sample size �  Blinding Blinding �  Inter/intra examiner calibration Inter/intra examiner calibration �  Insufficient detail to be r Insufficient detail to be repeatable epeatable �  Split-mouth/quadrant split-mouth Split-mouth/quadrant split-mouth design design �

W HY S UCH V ARIANCE IN C LINICAL O UTCOME M EASURES ? �  Heterogeneity of methodology �  Laser parameters �  Power Density: 350mW/cm 2 to 2830 W/cm 2 �  Exposure time: 3s to 90s �  Frequency of Laser TX: 1-6 times �  Study Length : 6wks- 6m �

W HY HY S S UCH UCH V V ARIANCE ARIANCE IN IN C C LINICAL LINICAL O O UTCOME UTCOME M EASURES EASURES ? �  Assessment Parameters: �  Clinical: �  Plaque Index to Clinical Crown Length �  Microbiota �  TC to Pg �  Biochemical �  TIMP-1 to IL-1 β �

W HY S UCH V ARIANCE IN C LINICAL O UTCOME M EASURES ? �  Periodontitis �  Chronic � � � Generalized, Severe �  Aggressive �

W HY S UCH V ARIANCE IN C LINICAL O UTCOME M EASURES ? �  Response of Target Tissue �  “Healthy” Subjects �  Smoking �  Poor nutritional status �  Undiagnosed Diabetes & Metabolic Syndrome �

B ACTERIAL H OST I NTERACTIONS Kornman, 2008 � Dr. Mark Ryder �

W HY S UCH V ARIANCE IN C LINICAL O UTCOME M EASURES ? �  Tissue response dependant on Tissue Health?? �  Human fibroblasts cultured in serum-starved medium: �  Enhanced procollagen production when exposed to LLLT Yamamoto 1996 �  300 Diabetic Patients: Histological specimens �  Less inflammation, greater healing with LLLT �  Obradovic 2012 �

W HY HY S S UCH UCH V V ARIANCE ARIANCE IN IN C C LINICAL LINICAL O O UTCOME UTCOME M EASURES EASURES ? �  Unknown: Same positive effects in compromised patients with power density used in adjunctive laser TX? �  Unknown: “Sham Laser” yields unintended intervention and positive effects to control in studies like De Micheli’s 2011 & 2012? �

D IODE IODE L L ASER ASER + RDT + RDT ≥ RDT A RDT A LONE LONE ? � Exploring the Contr Exploring the Controversy oversy � What we know: �  810nm DL (96J/cm 2 ) Ablates Pg in vitro �  Harris, Yessik 2004 �  980nm DL (94.3J/cm 2 ) +SRP TBL, Pg Td 6m post TX in patients with Aggressive Periodontitis vs SRP or LAS �  Kamma et al 2009 �

D IODE IODE L L ASER ASER + RDT + RDT ≥ RDT A RDT A LONE LONE ? �  819nm DL @1PW @ 15s/tooth reduces immediate bacteremia associated with Ultrasonic scaling �  Assif et al, 2007 �  805nm DL @2.5 PW@ 1s/PD 3X reduces bacterial counts 100% vs 58% �  Moritz et al., 1998 �  Study missing significance factor p �

D IODE IODE L L ASER ASER + RDT + RDT ≥ RDT A RDT A LONE LONE ? �  Studies showing no significant reduction in bacteria: �  635DL@10mW@90s/papilla +830DL@70mW@ 25s/tooth 6X �  Qadri et al, 2005 �  980DL @ 2.5PW @ 60s/pocket �  Caruso et al., 2008 �  808DL @1.5W @20s/tooth �  De Micheli et al, 2011 �  Euzebio Alves, De Micheli et al, 2013 �

C URRENT URRENT P P ARADIGMS ARADIGMS O O F P P ERIODONT AL ERIODONTAL B IOFILM IOFILM B B EHA EHAVIOR VIOR �  Consortium of Consortium of Perio Perio Pathogens Pathogens associated with disease progr associated with disease pr ogression ession �  Porphyr Porphyromonas omonas gingivalis gingivalis (Pg) (Pg) �  Tanner annerella ella forsythia ( forsythia (Tf Tf) �  Treponema eponema Denticola Denticola (Td) (Td) ��  Holt 2005 Holt 2005 �

C URRENT P ARADIGMS O F P ERIODONTAL B IOFILM B EHAVIOR �  Pg Pg Keystone Pathogen Keystone Pathogen �  Small numbers dramatically alter the Small numbers dramatically alter the composition of oral composition of oral micr microbiota obiota � ��   Dir Directs genetic r ects genetic response of other esponse of other micr microbes and the host obes and the host �  Honda 2011, Honda 2011, Hajishengallis Hajishengallis et al, et al, 2011 2011 �

B IOFILM B EHAVIOR : D ISEASE T RANSMISSION �  Ther There ar e are several potential sour e several potential sources for the ces for the re-infection of gingival cr e-infection of gingival crevice after evice after tr treatment: eatment: �  � Vertical or horizontal transmission. ertical or horizontal transmission. �  � Neighboring supra- and Neighboring supra- and subgingival subgingival � biofilms biofilms still colonized by the species still colonized by the species � in question in question Teles eles 2006 2006 �

D ISEASE T RANSMISSION : P ROBLEM WITH S PLIT M OUTH S TUDIES �  Pathogens in Pathogens in biofilm biofilm may be may be released fr eleased from the om the biofilm biofilm at one at one site, enabling them to colonize in site, enabling them to colonize in other sites other sites . . � Socransky Socransky & & Haf Haffajee fajee, 2002 , 2002 �

D ISEASE T RANSMISSION : P ROBLEM WITH S PLIT M OUTH S TUDIES �  The dental pr The dental professional could also play a ofessional could also play a role in the r ole in the re-colonization of oral species. e-colonization of oral species. �  Periodontal pr Periodontal probe could act as a carrier obe could act as a carrier of periodontal pathogens to pr of periodontal pathogens to previously eviously uninfected sites uninfected sites �  Christersson Christersson 1985 1985 �

P ERIODONTAL P ROBES P OTENTIALLY T RANSMIT B ACTERIA �

B ACTERIAL T RANSMISSION VIA “S HAM L ASER ” ON C ONTROL S UBJECTS : P ROBLEM WITH S PLIT M OUTH STUDIES �

N ON S PLIT M OUTH S TUDIES �  Moritz, 1998: Only non-split mouth to test Moritz, 1998: Only non-split mouth to test bacteria. TC & tested bacteria r bacteria. TC & tested bacteria reduced DL educed DL �  Borrajo Borrajo, 2004: Significantly , 2004: Significantly  BOP DL BOP DL �  Saglam Saglam, 2014: PD & CAL significantly , 2014: PD & CAL significantly impr improved. Sig. Dif oved. Sig. Diff in GCF levels of f in GCF levels of TIMP-1 DL ( TIMP-1 DL (MMPs MMPs & IL & IL’s levels mixed) s levels mixed) �

I MPOR ANCE OF OF L L ASER ASER T T ECHNIQUE MPORTANCE ECHNIQUE �  Thr Threshold for eshold for pulpal pulpal damage in vitr damage in vitro: o: �  0.5 W for 0.5 W for ≥ 10S 10S ⎢ ⎢ root oot �  Anterior & maxillary pr Anterior & maxillary premolars emolars �  Thicker dentin Thicker dentin  gr greater eater pr protection otection �  Kreisler 2002 �

I MPOR ANCE OF OF L L ASER ASER T T ECHNIQUE MPORTANCE ECHNIQUE �  Root Damage: �  Very little negative effect at 0.5-1W @10s even if  root with thin film of blood �  More blood, longer exposure time, and greater angle of exposure  greater root damage. �  Recommendations: Parallel to tooth, limit watts to 0.5, and 10s per pocket �  Kreisler 2002 �