The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 13, 2019

Root Surface Bio-modification with Erbium Lasers- A Myth or a Reality??



Vamsi Lavu, Subramoniam Sundaram, Ram Sabarish , Suresh Ranga Rao*
Department of Periodontics, Faculty of Dental Sciences, Sri Ramachandra University, Porur, Tamil Nadu, Chennai, India

Abstract

The objective of this literature review was to critically review the evidence available in the literature regarding the expediency of erbium family of lasers for root bio modification as a part of periodontal therapy. The literature search was performed on the Pubmed using MeSH words such as "lasers/therapeutic use, scaling, dental calculus, tooth root/anatomy and histology, ultrasonic therapy". The studies were screened and were grouped as follows: those evaluating a) efficacy for calculus removal with the Erbium family of laser b) root surface changes following Er YAG and Er Cr YSGG application c) comparative studies of the Er YAG, Er Cr YSGG lasers versus conventional methods of root surface modification d) Bio compatibility of root surface following Erbium laser treatment e) Studies on the combined efficacy of laser root modification with conventional methods towards root surface bio-modification f) Studies on effectiveness of root surface bio-modification prior to root coverage procedures. In conclusion, the erbium family has a proven anti-bacterial action, predictable calculus removal, minimal root substance removal, and appears to favor cell attachment. The Erbium family of lasers appears to be a useful adjunct for the management of periodontal disease.

Keywords: Cementum, dental calculus, Er-YAG lasers, non-surgical therapy, periodontitis, root bio-modification.


Article Information


Identifiers and Pagination:

Year: 2015
Volume: 9
First Page: 79
Last Page: 86
Publisher Id: TODENTJ-9-79
DOI: 10.2174/1874210601509010079

Article History:

Received Date: 18/11/2014
Revision Received Date: 3/12/2014
Acceptance Date: 10/12/2014
Electronic publication date: 10 /2/2015
Collection year: 2015

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open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Department of Periodontics, Faculty of Dental Sciences, Sri Ramachandra University, No.1 Ramachandra Nagar, Porur, Chennai – 600116, Tamil Nadu, India; Tel: +91-44-2476-8027, Extn: 8256; E-mail: chennaidentist@gmail.com




INTRODUCTION

One of the most challenging aspects of periodontal therapy is the development of a predictable approach for root surface modification. Root surface modification gains importance due to the fact that the biofilm contributes to root surface changes which impair regeneration attempts. In order to achieve an understanding of why regeneration attempts succeed or fail, knowledge of root surface changes in periodontal disease and its clinical implication becomes essential.

A BRIEF OVERVIEW OF ROOT SURFACE CHANGES IN PERIODONTAL DISEASE

The etiology of periodontitis is bacteria which attach to the root surface and thrive in a biofilm environment. These bacteria later become partially mineralized to form calculus. A portion of the bacteria remains unattached, float freely in the gingival crevicular area and are commonly responsible for tissue invasion of the periodontium, resulting in a variety of host bacterial interactions which manifest clinically as periodontal disease [1Offenbacher S, Barros SP, Singer RE, Moss K, Williams RC, Beck JD. Periodontal disease at the biofilm-gingival interface. J Periodontol 2007; 78: 1911,-25.].

The root surface undergoes a series of changes in its physical, chemical nature and also becomes cytotoxic due to the release of bacterial toxins that get attached to the root cementum. Broadly, the changes include a loss of fiber attachment from the cementum area (physical) [2Armitage GC, Christie TM. Structural changes in exposed cementum. II.; Electron microscopic observations. J Periodontol Res 1973; 8: 356-65.], demineralization of the root surface forming craters/ root caries (chemical changes) [3Sottosanti JS. A possible relationship between occlusion, root resorption and the progression of periodontal disease. J West Soc Periodontol 1977; 25: 69.] and lipopolysaccharide attachment to cementum surface (necrotic / altered cementum)[4Aleo JJ, De Renzis FA, Farber PA, Varboncoeur AP. The presence and biologic activity of cementum- bound endotoxin. J Periodontol 1974; 45: 672-5.].

Rationale for Root Bio-modification

The factors influencing successful periodontal therapeutic outcomes (regeneration) include [5Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976; 47: 256-60.]

  1. Clot stability.
  2. Cell migration towards the root surface.
  3. Cell attachment.
  4. Cell proliferation and differentiation.

The root surface properties play an important role in all the above mentioned events as established by Polson and Caton [6Polson AM, Caton J. Factors influencing periodontal repair and regeneration. J Periodontol 1982; 53: 617-25.]who postulated that ideal root surface should be free of contaminants and superficial layer of hypermineralized cementum. Therefore preparation of a root surface which is favorable for the above mentioned events constitutes the rationale behind root bio-modification.

Root Modification/Bio-modification

Root bio-modification refers to procedures which are done to de-toxify, de-contaminate and de- mineralize the root surface, thereby removing the smear layer and exposing the collagenous matrix of dentin and cementum [7Hanes PJ, Polson AM, Ladenheim S. Cell and fiber attachment to demineralized dentin from normal root surfaces. J Periodontol 1985; 56: 752-65.]. The oldest and the most conventional methods include scaling and root planing which are primarily aimed at the gross removal of microbes from the root surface. The scaling and root planing had a limitation in that; it also resulted in removal of cementum and formation of smear layer [8Blomlöf JP, Blomlöf LB, Lindskog SF. Smear removal and collagen exposure after non-surgical root planing followed by etching with an EDTA gel preparation. J Periodontol 1996; 67: 841-5.]. This was followed by the advent of root conditioning agents,

Root conditioning agents aimed at the removal of the smear layer [9Garrett JS, Crigger M, Egelberg J. Effects of citric acid on diseased root surfaces. J Periodontol Res 1978; 13: 155-63.] produced during scaling and root planing to expose the dentinal tubules and dentinal collagen (to favor the joining of the Sharpey’s fibers with root collagen). This modality gave way to application of fibronectin and recombinant forms of growth factors such as PDGF, BMP, enamel matrix proteins [10Froum S, Lemler J, Horowitz R, Davidson B. The use of enamel matrix derivative in the treatment of periodontal osseous defect a clinical decision tree based on biologic principles of regeneration. Int J Restorative Dent 2001; 21: 437- 49.]. These factors provided the signals for the cell chemotaxis, attachment, proliferation and differentiation. The use of recombinant growth factors for root bio-modification is limited as they are expensive and cannot be used as a mono-therapy. In addition, a cocktail of growth factors which act in a sequential manner are needed to obtain a successful periodontal regeneration. Amongst, the above mentioned modalities of treatment only EMDOGAIN (enamel matrix proteins) have demonstrated new cementum formation [11Yukna RA, Mellonig JT. Histologic evaluation of periodontal healing in humans following regeneratice therapy with enamel matrix derivative a 10 case series. J Periodontol 2000; 71: 752-9.].

A significant step towards successful periodontal regeneration could be attained if the surface contaminants could be removed with minimum damage to underlying cementum. In this regard, the Erbium lasers represent a potential therapeutic tool. A summary of the various root bio-modification agents used are provided in Table 1.

Table 1.

Root conditioning agents used in periodontal therapy.




Table 2.

Summary of various studies performed comparing the efficacy of calculus removal using Erbium laser and conventional methods.




Table 3.

Studies summarizing the biological reaction of the cells to erbium treated root surfaces.




Table 4.

Erbium family of lasers vis a vis conventional methods of root modification.




LASERS AS A THERAPEUTIC MODALITY FOR ROOT SURFACE MODIFICATION

The effect of laser on any given tissue depends on the optical properties of the tissue on which it is incident. The root surface is composed of cementum primarily and in a few cases dentinal tubules exposed at the cemento-enamel junction. Water and hydroxyapatite serve as the chromophores (substance which can absorb the radiation of a particular wavelength). As a result only lasers which are absorbed in these chromophores demonstrate adequate therapeutic ability in root surface modification. These include the erbium family of lasers (Er YAG, Er YSGG), CO2 lasers, Holmium YAG (Yttrium Aluminum Garnet) laser. Among these, the erbium family has shown considerable promise for the purpose of root modification [22rizwan m. [No Authors Listed] American Academy of Periodontology Statement on the Efficacy of Lasers in the Non-Surgical Treatment of Inflammatory Periodontal Disease. J Periodontol 2011; 82: 513-14.].

The Erbium family which includes the erbium YAG (Yttrium Aluminium Garnet) and Erbium chromium YSGG (Yttrium Scandium Gallium Garnet) are solid phase lasers wherein the Yttrium Garnet crystals are doped with Aluminium or Scandium and Gallium. The wavelength of the Erbium YAG is 2940 nm and Er: Cr YSGG 2780 nm respectively. The Erbium: YAG laser belongs to the near infra red spectrum and it has proven efficacy in ablation of dental hard tissue [23Paghdiwala A. Application of the erbium: YAG laser on hard dental tissues measurement of the temerature changes and depths of cut. Lasers in Medcine Surgery, and Dentistry Proc ICALEO 1988; 64: 192-201., 24Keller U, Hibst R. Ablative effect of an Er: YAG laser on enamel and dentin [Article in German]. Dtsch Zahnarztl Z 1989; 44: 600-2.].

The unique properties [25Schwarz F, Sculean A, Berakdar M, Szathmari L, Georg T, Becker J. In vivo and in vitro effects of an Er YAG laser, a GaAlAs diode laser, and scaling and root planing on periodontally diseased root surfaces a comparative histologic study. Lasers Surg Med 2003; 32: 359-66.] of the Erbium laser family include

  1. High absorption in water as compared to Carbon dioxide (CO2) / Neodymium Yttrium Aluminium Garnet (Nd:YAG) lasers.
  2. Good absorption in hydroxyapatite
  3. Minimal thermal damage to the soft / hard tissue on which it is incident.

The incident laser beam is absorbed by water which undergoes a rapid thermal expansion and induces microexplosions and removal of the hard tissue (enamel, dentin and bone). The erbium family of lasers is used with water (irrigant) and the amount of water flow influences the efficacy and depth of penetration of the laser in the tissue [24Keller U, Hibst R. Ablative effect of an Er: YAG laser on enamel and dentin [Article in German]. Dtsch Zahnarztl Z 1989; 44: 600-2.].

Methodology for Literature Review

The literature review was performed by conducting a search on PubMed/ Medline using a combination of the MeSH Words “Er: YAG lasers, YSGG Lasers, root scaling, dental calculus, tooth root, ultrasonic therapy”. The available literature was then compiled and the various studies were grouped under the following heads as follows:

Studies evaluating the:

  1. Efficacy of Erbium family of lasers for calculus removal.
  2. Root surface changes following Er YAG and Er Cr YSGG application.
  3. Comparative studies of the Er YAG, Er Cr YSGG lasers versus conventional methods of root surface modification.
  4. Biocompatibility of root surface following Erbium laser treatment.
  5. Combined efficacy of laser root modification and conventional methods towards root surface bio-modification.
  6. Effectiveness of root surface bio-modification prior to root coverage procedures.

CALCULUS REMOVAL FOLLOWING ERBIUM LASER APPLICATION

The Erbium family has been found to be an efficient tool for calculus removal from the root surface with minimal thermal damage to the cementum. This is evidenced in numerous studies which have been summarized in Table 2. In recent times, the removal of calculus has been made more predictable due to the development of a “fluorescence feedback system”. This system was developed based on the findings of a study by Folwaczny et al. [26Folwaczny M, Heym R, Mehl A, Hickel R. Subgingival calculus detection with fluorescence induced by 655 nm InGaAsP diode laser radiation. J Periodontol 2002; 73: 597-601.] who demonstrated a strong fluorescence in sub-gingival calculus when exposed to 655nm diode laser irradiation. This principle has been incorporated into an Er YAG laser unit which gets activated only if a certain threshold level for fluorescence of the root surface is exceeded. From the studies summarized in Table 2, it can be inferred that Erbium laser with fluorescent feedback provided a good alternative to conventional methods for calculus removal.

Root Surface Changes and Parameters Influencing the Root Bio-modification with Erbium Lasers

The Erbium family has a minimum penetration depth due to its high absorption in water. This entails a safe usage with minimum or no thermal damage to the root cementum and dentin. Studies have demonstrated variable changes in the root surface morphology depending on power setting and tip angulations used. Gaspric and Skaleric [38Gaspirc B, Skaleric U. Morphology, chemical structure and diffusion processes of root surface after Er: YAG and Nd: YAG laser irradiation. J Clin Periodontol 2001; 28: 508-16.] demonstrated that a variation of energy applied (60mJ, 80 mJ and 100 mJ) resulted in varying root surface morphology. At 60mJ, single craters were produced without deposits of melted mineral and exposed dentinal tubules. At 80mJ, numerous confluent craters were observed. At 100 mJ, larger ablation defects were observed. Er :YAG laser when used at different power settings ranging from 25 to 100 mJ/sec on the root surface in vitro produced a 15 micron layer of damaged tissue within the cementum, with an absence of Sharpey’s fibers [39Fujii T, Baehni PC, Kawai O, Kawakami T, Matsuda K, Kowashi Y. Scanning electron microscopic study of the effects of Er YAG laser on root cementum. J Periodontol 1998; 69: 1283-90.]. However, when used in vivo a smooth root surface was observed even at higher settings [30Eberhard J, Ehlers H, Falk W, Açil Y, Albers HK, Jepsen S. Efficacy of subgingival calculus removal with Er YAG laser compared to mechanical debridement an in situ study. J Clin Periodontol 2003; 30: 511-8.].

Angulations of the tip remain a significant factor influencing root surface roughness. Folwaczny et al. [40Folwaczny M, George G, Thiele L, Mehl A, Hickel R. Root surface roughness following Er: YAG laser irradiation at different radiation energies and working tip angulations. J Clin Periodontol 2002; 29: 598-603.] evaluated the influence of various tip angulations (15,30,45,60,90 degrees) on root substance removal and surface roughness. A control group consisting of root surface instrumented with curettes was used. The authors observed no statistically significant difference in the roughness values of the root surface treated with laser and curettes. Also the differences in root substance removal were not significant when different angulations were used. The erbium family of lasers appears to be relatively safe at low energy settings and produce minimal root structure damage.

Root Surface Bio-compatibility after Erbium Laser Therapy

Studies have evaluated biocompatibility of the laser treated root surface in terms of

  1. Elimination of endotoxin from the root surface.
  2. Removal of the smear layer.
  3. Reaction of cells to laser treated root surfaces (in vitro).

Endotoxin Elimination from the Root Surface

Endotoxin on the root surface contributes to the cytotoxic effects of the diseased root [4Aleo JJ, De Renzis FA, Farber PA, Varboncoeur AP. The presence and biologic activity of cementum- bound endotoxin. J Periodontol 1974; 45: 672-5.]. An in-vitro study on lipopolysaccharide removal from the root surface with Erbium laser revealed a 83.1% reduction of the lipopolysaccharide from the irradiated root surface [41Yamaguchi H, Kobayashi K, Osada R , et al. Effects of irradiation of an erbium: YAG laser on root surfaces. J Periodontol 1997; 68: 1151-5.] The endotoxin removal efficacy of erbium lasers has also been assessed by the chromogenic, quantitative Limulus – amoebocyte-lysate assay. The authors observed a reduction of LPS on root surface irradiated with erbium lasers and this reduction was proportional to the energy setting that is used [42Folwaczny M, Aggstaller H, Mehl A, Hickel R. Removal of bacterial endotoxin from root surface with Er YAG laser. Am J Dent 2003; 16: 3-5.]. Akiyama et al. [43Akiyama F, Aoki A, Miura-Uchiyama M , et al. 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 2011; 26: 193-204.] used SEM and transmission electron microscopy to determine the effect of Er:YAG laser on endotoxin . The authors found that Erbium laser ablates periodontopathic bacteria with thermal vaporization, and its bacterial elimination effect on the diseased root surfaces appears to be superior to that of the ultrasonic scaler. The observations of the above studies provide evidence for the effectiveness of the Erbium laser in managing the cytotoxic changes.

Smear Layer Removal

The formation of a smear layer consisting of dentinal debris and some bacteria occurs after scaling and root planing [8Blomlöf JP, Blomlöf LB, Lindskog SF. Smear removal and collagen exposure after non-surgical root planing followed by etching with an EDTA gel preparation. J Periodontol 1996; 67: 841-5.]. The removal of this smear layer assumes clinical importance due to the fact that the smear layer prevents attachment of connective tissue to the root surface. The hard tissue lasers such as the Erbium lasers have been proposed as an alternative to chemical conditioning of root surface for removal of smear layer. Recent studies [44Theodoro LH, Zezell DM, Garcia VG , et al. Comparative analysis of root surface smear layer removal by different etching modalities or erbium: yttrium-aluminum-garnet laser irradiation. A scanning electron microscopy study Lasers Med Sci 2010; 25: 485-91., 45Cekici A, Maden I, Yildiz S, San T, Isik G. Evaluation of blood cell attachment on Er YAG laser applied root surface using scanning electron microscopy. Int J Med Sci 2013; 10: 560-6.] compared the efficacy of smear layer removal by chemical root modification agents vs Erbium laser (Figs. (1, 2)). The authors have reported an equivalent and complete smear layer removal by erbium laser.

Fig. (1)

Scanning Electron Microscope picture of periodontally disease root surface treated with citric acid (25%, pH 1.5 for 10 seconds) demonstrating a complete removal of smear layer and patent dentinal tubules.



Fig. (2)

Scanning Electron Microscope picture of periodontally diseased root surface treated with Er YAG laser (15.92 J/cm2) demonstrating the removal of smear layer, roughened root surfaces and patent dentinal tubules.



Biological Reaction of the Cells to Erbium Treated Root Surfaces

This assumes great importance as it represents one of the most important factors influencing success in periodontal regeneration. The various studies performed to assess the biologic reaction of cells of the periodontium to erbium laser treated root surface are summarized in Table 3. It can be inferred from these studies (Table 3) that a stable blood clot is formed and periodontal ligament fibroblast attachment is more favored on the laser treated root surface.

Effectiveness of Combined Therapy in Root Modification

Erbium lasers have also been used in combination with conventional methods such as acid conditioning of the root [56Maruyama H, Aoki A, Sasaki KM , et al. The effect of chemical and/or mechanical conditioning on the Er: YAG laser-treated root cementum analysis of surface morphology and periodontal ligament fibroblast attachment. Lasers Surg Med 2008; 40: 211-2.] and recombinant human growth factors (PDGF BB) [57Belal MH, Watanabe H, Ichinose S, Ishikawa I. Effect of Er: YAG laser combined with rhPDGF-BB on attachment of cultured fibroblasts to periodontally involved root surfaces. J Periodontol 2007; 78: 1329-41.] on periodontally involved root surfaces with improved fibroblast adhesion and proliferation being reported.

Root Surface Bio-Modification Prior to Root Coverage Procedures

Root bio-modification has been performed as an adjunct to root coverage procedures for improving the outcomes. Conventional methods of root bio- modification prior to root coverage include the use of chemical modification agents such as citric acid, tetracycline [58Caffesse RG, De LaRosa M, Garza M, Munne-Travers A, Mondragon JC, Weltman R. Citric acid demineralization and sub-epithelial connective tissue grafts. J Periodontol 2000; 71: 568-72.,59Bittencourt S, Ribeiro Edel P, Sallum EA, Sallum AW, Nociti FH Jr, Casati MZ. Root surface bio-modification with EDTA for the treatment of gingival recession with a semi-lunar coronally repositioned flap. J Periodontol 1999; 70: 1695-701.]. One of the novel applications of the Er YAG laser has been its use for root bio-modification prior to root coverage procedures. A study by Dilsiz A et al. [60Dilsiz A, Aydin T, Yavuz MS. Root surface biomodification with an Er: YAG laser for the treatment of gingival recession with subepithelial connective tissue grafts. Photomed Laser Surg 2010; 28: 511-7.] revealed no significant improvement in the clinical outcomes following adjunctive use of erbium laser for root modification prior to root coverage. A recent systematic review [61Oliveira GH, Muncinelli EA. Efficacy of root surface bio-modification in root coverage a systematic review. J Can Dent Assoc 2012; 78: c122.] evaluating the effectiveness of adjunctive use of chemical agents and lasers for root bio-modification prior to recession coverage reported no additional benefit in terms of clinical parameter improvement. It can be inferred that erbium lasers do not appear to improve the outcomes of root coverage procedures when used as an adjunct.

A recent systematic review and meta analysis by Sgolatra et al. [62Sgolastra F, Petrucci A, Gatto R, Monaco A. Efficacy of Er YAG laser in the treatment of chronic periodontitis systematic review and meta-analysis. Lasers Med Sci 2012; 27: 661-73.] analyzed the efficacy of Erbium laser as compared to scaling and root planing in treatment of chronic periodontitis. The authors observed no statistically significant difference in any of the investigated clinical parameters and attributed this finding to the heterogeneity of the data collected in the five randomized controlled trials included in the meta analysis.

SUMMARY AND CONCLUSION

The existing literature serves to highlight the promising role of Erbium family of lasers in root bio-modification. The erbium family has a proven anti-bacterial action, predictable calculus removal, minimal root substance removal, and appears to favor cell attachment (when used in combination with acid conditioning or growth factors). A comparative summary of Erbium family of laser vs the conventional techniques for root bio-modification is given in Table 4. In conclusion, Erbium lasers are a useful tool in the periodontist’s armamentarium and can be used for root modification.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

The authors acknowledge the contribution of Ms Cynthia Milton, Lecturer in English, Sri Ramachandra University towards correction of the grammar and language of this manuscript.

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