Periodontal Regeneration Effects of LLLT

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Periodontal Regeneration Effect of Superpulsed
High-Intensity 910-nm Diode Cold Lasers and the
Clinical Applications as an Adjunct to
Conventional Periodontal Therapy
Fred Stalley, DDS1 (presenting) Robert
Gougaloff, DMD1 Nelson Marquina, DC, MSc, PhD2
Joseph Tregaskes, DDS, MS3 Anton Cherry, DC4
1Redondo Beach Dental Group, Redondo Beach,
California 2Virginia State University,
Petersburg, Virginia 3JNT Dental, Richmond,
Virginia 4USA Laser Biotech Inc., Richmond,
Virginia  
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Disclosure
Dr. Stalley and Dr. Gougaloff have no commercial
relationships relative to this presentation.
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Periodontal Regeneration Effects of Phototherapy

• As an adjunct to conventional periodontal therapy

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Periodontal Disease

• Over 50 of the U.S. population aged 30 years or
  older have gingivitis
• 26 of the population aged 20 years or older had
  destructive periodontitis
• In total, over 75 of the U.S. population has
  some form of periodontal disease

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Periodontal Diseases

• GINGIVITIS
• Non-destructive inflammation of gingival tissues
• PERIODONTITIS
• Destructive disease, which results in loss of
  attachment or bone

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Periodontal Disease Process

• Tissues respond to plaque by the process of
  inflammation
• Bacteria in plaque release biologically active
  substances, s.a. organic acids, endotoxins and
  chemotactic peptides
• Host tissue responds by leukocyte infiltration
  releasing cytokines, s.a. interleukin-1ß,
  interleukin-8, prostaglandins and TNF-a, as well
  proteolytic enzymes (collagenase) and
  metalloproteinases (MMP-8)
• These substances are responsible for the
  destruction of pathogenic bacteria, however, when
  produced in very high concentrations they also
  destroy periodontal tissues.

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Treatment of Periodontal Disease

• Mechanical derbridement
• Chemotherapeutics (Arrestin)
• LANAP procedure
• Soft tissue surgery
• Guided Tissue Regeneration procedures
• Application of growth factors

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It is the host immune response, which is directly
responsibel for the destructive process !!!

• The pathogenic bacteria alone are just the
  catalyst !!

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The Periodontal Disease Process
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Periodontal Healing

• Regeneration
• Restitutio ad integrum
• Fully rebuilds structure and function of lost
  periodontal tissues
• Re-establishment of bone, cementum and true
  periodontal ligament
• Cells must come from PDL (PDL fibroblasts)

• Repair
• A tissue is formed which does not allow for
  original morphological and functional restoration
• LJE (most common after periodontal therapy)
• CT attachment with radicular resorption
• Ankylosis with radicular resorption

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Regeneration or Repair ?

• Regeneration
• Application of Growth Factors (PDGF, FGF-1,
  TGF-ß)
• Application of Amelogenin-like factors (EMDs,
  s.a. Emdogain)
• Applications of Morphogens (BMPs)
• Phototherapy ?!?!

• Repair
• Scaling and Root Planing
• Open flap debridement
• LANAP procedure
• Osseous surgery (less LJE)
• Most GTR procedures

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The Periodontal Healing Process
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So what about the science behind Phototherapy ?

• Saygun et al., 2007 found that Phototherapy
  appears to have a dramatic effect on the release
  of IGF-1, FGF and HGF
• Safavi et al., 2007 found that Phototherapy
  reduces the production of IL-8 and IFN-?, but at
  the same time increases the production of PDGF
  and TGF-ß
• Amorim et al., 2006 showed that gingivectomy
  patients exhibited better ginigival healing
  biometrically after 28 days, one the quadrant
  treated with Phototherpay
• Pourzarandian et al., 2005 demonstrated that in
  vitro low level laser exposure of human gingival
  fibroblasts stimulates their proliferation
• Qadri et al., 2005 examined patients in a
  double blind study receiving conventional
  periodontal therapy and randomized unilateral
  Phototherapy and showed that there was a
  reduction in PD, plaque scores and gingival
  indices, as well as a reduction of MMP-8 levels
  in the GCF.
• Kreisler et al., 2003 showed that periodontal
  ligament fibroblasts have a considerably higher
  proliferation activity for up to 72 hours after
  after exposure to a low-level GaAlAs laser

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Molecular and cellular effects of Phototherapy

• Increased cell metabolism
• Increased collagen and fibronectin synthesis in
  fibroblasts thus faster deposition of
  extracellular matrix
• Increased release of growth factors s.a. PDGF,
  IGF-1, FGF-1, amelogens and morphogens
• Reduction in MMP-8, IL-1, IFN-? (cause
  inflammation)
• Increased rate of cell differentiation
  (mesynchemal cells ? fibroblasts ? epithelial
  cells)
• Stimulation of DNA and RNA synthesis in cell
  nuclei and thus faster mitotic cycle

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Phototherapy and Periodontal Therapy (Hypothesis)

• To be used as a adjunct-therapy
• Faster healing from conventional therapy
• Improved periodontal index scores (CAL,
  bone-level, etc)
• Perhaps stimulate Regeneration instead of
  Repair

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Proposed Research Project

• Phase I study with 20-30 patients
• Controlled, randomized, prospective double blind
  split-mouth design study
• Two patient populations
• PDs of 4-5mm on two sites bilaterally on initial
  exam
• PDs of 5-6mm on two sites bilaterally on initial
  exam
• Parameters assessed BOP, PI, CAL, Radiographic
  Bone Level (RBL)
• These parameters will be assessed on initial exam
  and 8 weeks after initial periodontal treatment
• Phototherapy sessions twice per week for a total
  of 6 weeks on randomly chosen Therapy side only
• Mock Phototherapy treatment on control side

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Patient Selection Criteria

• Patients between 40 and 60 years of age
• Subjects must have at least two sites on each of
  the contro-lateral sides demonstrating 4mm or
  higher PDs
• Subjects with PDs of 8mm or more will not be
  considered
• Subjects must be acceptable candidates for minor
  periodontal procedures (ASA Type I)
• Subjects who smoke will not be considered
• Subjects who have been or are currently on
  Bisphosphenate therapy will not be considered

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Materials

• Laser System
• Super-pulsed, dual frequency (665nm and 910nm)
  GaAs laser (Lumix 2 Dental from USA Laser
  Biotech, Inc.)
• Calibrated Periodontal Probes
• U. North Carolina No. 15 probes (Hu-Friedy,
  Chicago, Il)

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Methods

• Each subject will exhibit equal periodontally
  compromised conditions on both sides of either
  jaw
• Both sides will receive mechanical debridement
  (Scaling Rootplaning)
• One side (chosen at random ahead of time) will
  receive Phototherapy for 90 seconds per site
  with the following settings 100 modulation _at_ 30
  KHz pulse frequency 24.3 Joules per site
• The control side will receive mock laser
  treatment with the guide light operational but
  no laser action
• Neither the treating hygienists, nor the patients
  will know which side received the Phototherapy.
• Statistical analysis will be done via a
  One-Way-ANOVA for each of the parametric
  measurements, where the two severity groups will
  serve as the categorical independent variables
  and the laser treatment as the dependent variable.

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Future studies to consider

• Since this study only quantifies the parametric
  results of periodontal indices
• Future studies may include the investigation of
  the quality of the periodontal regeneration
• Histological examination as to what type of
  attachment is regenerated i.e. is it actually
  regeneration or just repair via LJE

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