Douglas Dederich BSEE, DDS, MSc, PhD, Cert. Perio.
This review did not show the Er:YAG laser to be superior to traditional scaling and root planing when assessing probing depth, gingival recession and attachment level.
This well-conducted review cautiously suggests that the Er:YAG laser was not superior to traditional therapy in the treatment of chronic periodontal disease.
What is the efficacy of the Er:YAG laser when used as an alternative treatment to scaling and root planing (SRP) in the treatment of patients with chronic periodontitis?
The authors conducted a comprehensive search of seven electronic databases from the earliest records until January 5, 2011. Further, 14 journals were manually searched from their earliest records until December 2010. Principle inclusion criteria were randomized controlled clinical trials, studies comparing Er:YAG laser with manual or ultrasonic SRP alone; studies involving human adult subjects (age>18 years), and patients with chronic periodontitis. Exclusion criteria were patients with systemic disease, those who consumed antibiotics or medications within the last 6 months that are known to affect periodontal tissue or treatment, or who underwent periodontal treatment within the last 6 months; treatment follow-up of
Five studies met the inclusion criteria, totaling 105 patients. Researchers evaluated 66 patients at 3 and 6 months; 19 patients at 1, 3, 6 and 12 months; and 20 patients at 1 and 2 years. The review authors judged three of the five studies to have a high risk of bias. The meta-analysis showed no significant difference between laser and mechanical SRP groups for any of the outcomes. A regression asymmetry test did not suggest a publication bias for the selected outcomes. Mean Difference (MD) at 12 months for Clinical Attachment Level was 0.09 [-1.51, 1.68], MD for Probing Depth at 12 months was -0.09 [-1.1, 0.92], and MD for Gingival Recession at 12 months was -0.20 [-0.72, 0.31].
While patients in both groups-- the laser and SRP-- showed a consistent improvement in the clinical outcomes, this review did not find evidence for the superior effectiveness of the Er:YAG laser when used alone compared to mechanical SRP alone. However, limitations of the evidence suggest that this conclusion be viewed with caution.
Source of Funding:
Importance and Context:
Mechanical root debridement has a long history of success and a solid foundation of clinical research to support it. Therefore, it is important to know whether there is any clinical benefit to the patient beyond that seen with mechanical SRP of using the laser to justify the additional cost of the technology and training.
Strengths and Weaknesses of the Systematic Review:
The authors used accepted and rigorous methods to identify studies to be included in the review. They clearly defined inclusion and exclusion criteria and did not apply any language restriction. The authors described and followed a process for contacting the corresponding author to obtain missing, unclear or unpublished data. They conducted an independent review of the studies and employed a method of resolving differences between reviewers. An acceptable agreement during the screening process between the two reviewers was calculated (kappa=0.61). The authors performed a quality assessment and subsequent risk of bias estimate for each study according to CONSORT guidelines and assessed heterogeneity They assessed and estimated publication bias as being low. Meta-analyses of the clinical attachment level gain, probing depth reduction, and changes in gingival recession were performed using weighted mean differences for continuous data with 95 percent confidence intervals, nested in a random effect model. Unfortunately, it was not clear how this study was funded or whether a conflict of interest existed amongst the authors.
Strengths and Weaknesses of the Evidence:
The number of studies included was small, containing only 105 patients in total. The confidence intervals reported in the selected studies for all of the outcome variables are typically quite wide, reducing the discriminatory ability of the meta-analysis. The review authors estimated that three of the five included studies had a high risk of bias. Further, they noted a significant degree of heterogeneity between the studies. A recently published RCT (N=28, split-mouth-design) found slightly better periodontal and patient-centered outcomes with mechanical debridement over Er:YAG laser after 6 and 12 weeks.(1) However, limitations in the available evidence suggest caution in the interpretation of these results. Well-designed RCTs are needed to give more clarity in this area.
Implications for Dental Practice:
Based on this systematic review, the evidence does not seem to support the superiority of the Er:YAG laser over mechanical SRP in the treatment of chronic periodontal disease. This systematic review does not address other questions of perhaps greater clinical import:does the Er:YAG laser add any benefit to the patient when used adjunctively after mechanical SRP? And does the Er:YAG laser provide a similar result as SRP while simultaneously being more comfortable for the patient?
1. Soo L, Leichter JW, Windel J et al. A comparison of Er:YAG laser and mechanical debridement for the non-surgical treatment of chronic periodontitis: a randomized, prospective clinical study. J Clin Periodontol 2012; 39:537-45
*Support for this Critical Summary was provided by a grant from the Canadian Institutes of Health Research*