Adjunctive Diode Laser Therapy and Probiotic Lactobacillus Therapy in the Treatment of Periodontitis and Peri-Implant Disease

Summary

This article describes two protocols: 1) adjunctive diode laser therapy for treating periodontitis and 2) probiotic Lactobacillus therapy for treating peri-implant disease, with emphasis on the laser usage mode (inside or outside pocket), laser application regimen (single or multiple sessions), and a probiotic protocol of professional and home administration.

Abstract

Periodontal and peri-implant diseases are plaque-induced infections with a high prevalence, seriously impairing people's quality of life. The diode laser has long been recommended as adjunctive therapy in treating periodontitis. However, the optimal combination of usage mode (inside or outside periodontal pocket) and application regimen (single or multiple sessions of appointment) has not been described in detail. Meanwhile, probiotic Lactobacillus is regarded as a potential adjuvant in the management of the peri-implant disease. Nonetheless, a detailed protocol for an effective probiotic application is lacking. This article aims to summarize two clinical protocols. For periodontitis, the optimal collaboration of laser usage mode and application regimen was identified. Regarding peri-implant mucositis, a combined therapy containing professional topical use and home administration of probiotic Lactobacillus was established. This updated laser protocol clarifies the relationship between the treatment mode (inside or outside the periodontal pocket) and the number of laser appointments, further refining the existing diode laser therapy. For inside pocket irradiation, a single session of laser treatment is suggested whereas, for outside pocket irradiation, multiple sessions of laser treatment provide better effects. The improved probiotic Lactobacillus therapy resulted in the disappearance of swelling of the peri-implant mucosa, a reduced bleeding on probing (BOP), and an obvious reduction and good control of plaque and pigmentation; however, probing pocket depth (PPD) had limited improvement. The current protocol should be regarded as preliminary and could be further enhanced.

Introduction

Periodontal disease is a chronic multifactorial infection resulting in progressive destruction of periodontium¹. Its severe form, periodontitis, affects up to 50% population worldwide² and is regarded as a major cause of tooth loss in adults³. Replacement of missing teeth with dental implants has been extensively favored over traditional options⁴. The implants show prominent functional and aesthetic performances with a long-term survival rate of 96.1% after 10 years^5,6. The implants, however, can suffer from peri-implant disease leading to mucosal inflammation (peri-implant mucositis) or surrounding bone loss (peri-implantitis)⁷, which may cause the implant failure⁸. Therefore, it is of utmost necessity to manage the periodontal and peri-implant diseases effectively, in order to preserve natural teeth or improve the survival rate of dental implants.

Periodontal and peri-implant diseases share similar etiology⁹, i.e., both are initiated by exposure to dental plaque, consisting mainly of anaerobic and microaerophilic bacteria¹⁰. Mechanical debridement is considered a reliable modality to achieve efficient disruption of pathogenic deposits on root or implant surfaces¹¹. Nevertheless, it has restricted accessibility using instruments when there is complex tooth anatomy (i.e., root furcation and groove), leading to insufficient decontamination¹². Under this context, the application of lasers and probiotics has emerged to supplement mechanical debridement^13,14.

A variety of lasers have been proposed for periodontal treatment, such as Nd:YAG; CO₂; Er:YAG; Er,Cr:YSGG; and diode laser¹⁵. Among these, the diode laser is the most popular choice for clinical treatment due to its portability and low cost¹⁶. The diode laser has been recommended as an ideal adjunct in destroying biofilms, eliminating inflammation, and facilitating wound healing due to its photobiomodulation and photothermal effects^12,13. The diversity of laser usages, nonetheless, leads to significant clinical heterogeneity among current studies. Thus, in our recent publication, we evaluated 30 clinical trials and summarized the optimal combination of laser usage mode and application regimen¹². However, few studies report the detailed procedure of the combination protocol. On the other hand, probiotic Lactobacillus has been drawing increasing attention as a potential adjuvant in treating peri-implant disease, due to its antimicrobial and anti-inflammatory performances^17,18. The clinical benefits, however, have not reached an agreeable consensus. One critical account referred to the variety of probiotic administration protocols¹⁷.

Based on the current evidence, this article describes two modified clinical protocols: the existing protocol for the use of adjunctive diode laser in treating periodontitis is improved based on two laser usage modes (inside or outside pocket) and two application regimens (single or multiple sessions of appointment)¹². For the adjunctive probiotic Lactobacillus therapy in treating peri-implant disease, a combination of professional local use and home administration of probiotic is described¹⁷.

Protocol

This study was approved by the Institutional Review Board of the College of Stomatology, Xi'an Jiaotong University (xjkqll[2022]NO.034). Informed consent was available from the patients involved in this study.

1. Adjunctive diode laser therapy in the non-surgical treatment of periodontitis

1. Eligibility criteria
   1. Use the following inclusion criteria: age ≥ 18 years; probing pocket depth (PPD) ≥ 5 mm; detectable clinical attachment loss (CAL) and radiographic bone loss (RBL).
   2. Use the following exclusion criteria: patients with systematic diseases or under medication that may affect the inflammation and healing process; patients who had received periodontal treatment within 6 months; smokers or alcoholics; pregnant or lactating patients; periodontal-endodontic combined lesions; class III tooth mobility.
2. Clinical examination
   1. Measure full-mouth PPD, bleeding on probing (BOP) at six sites per tooth (i.e., mesiobuccal, buccal, distobuccal, distolingual, lingual, and mesiolingual), and mobility of each tooth, excluding third molars. Measure CAL for teeth with PPD ≥ 5 mm. Detect the cementoenamel junction by probing to calculate the CAL.
   2. Record the baseline parameters on a periodontal chart (Supplementary File 1).
3. Disinfection and anesthesia
   1. Gargle with 3% hydrogen peroxide for 1 min, followed by pure water. Disinfect the operating area with 1% iodophor. Administer a local injection of primacaine adrenaline for anesthesia.
4. Mechanical debridement by scaling and root planing (SRP)
   NOTE: SRP is necessary for treating periodontitis including ultrasonic or manual cleaning. Dental scaling removes the plaque and calculus from the surface of the tooth above and below the gumline. Root planing usually follows dental scaling and attempts to smooth out the rough surface of the root and helps the gums to reattach to the teeth.
   1. Firstly, use an ultrasonic device to perform SRP for teeth with PPD > 3 mm. Secondly, use hand-held instruments (Gracey curettes 5/6, 7/8, 11/12, and 13/14) to perform SRP for teeth with PPD > 3 mm (Figure 1). Thirdly, use an ultrasonic device to perform SRP for these teeth a second time.
      NOTE: The diode laser alone is not effective in eliminating calculus, so a thorough SRP cannot be omitted. If the patient has a large number of affected teeth, only one quadrant can be treated at each appointment. The ultrasonic and manual SRP can be performed within 1-4 appointments.
   2. Rinse the periodontal pockets with 3% hydrogen peroxide and gargle with pure water.
   3. Apply polishing paste to the teeth surface, polish the full-mouth teeth surfaces using a low-speed handpiece with a rubber cap, and then gargle with pure water.
5. Adjunctive diode laser therapy
   NOTE: Choose teeth with PPD ≥ 5 mm for laser treatment. Choose one of the following two usage modes (i.e., steps 1.5.1 or 1.5.2).
   1. Inside pocket laser irradiation (only one session of laser appointment per tooth is suggested) (Figure 2A).
      1. Ensure that both the operator and patient wear protective goggles to protect the eyes from laser damage.
      2. Prepare the diode laser device (wavelength = 980 nm, output power = 1 W, power density = 1414.7 W/cm², continuous wave, 300 µm fiber optic delivery system).
         NOTE: Improperly increasing the power may cause thermal damage; please consult the laser manufacturer and follow the manufacturer's instructions before use.
      3. Calibrate the length of the fiber tip exposed to 1 mm less than the measured PPD (Figure 2B).
         NOTE: To prevent bleeding due to the insertion of the fiber tip too deep into the periodontal pocket, it is generally recommended that the exposed fiber tip length is 1 mm less than the measured periodontal pocket depth.
      4. Gently insert the fiber tip into the periodontal pocket 1 mm less than the measured PPD, and slowly sweep the tip both in mesial-distal and apical-coronal directions for 30 s per tooth (Figure 2B,C).
         NOTE: During this process, inserting the fiber too deeply into the periodontal pocket can irritate periodontal bleeding and thus prevent the laser from acting. Remove the granulation attached to the fiber tip using a cotton ball containing 75% alcohol to avoid jeopardizing the laser effectiveness.
   2. Outside pocket laser irradiation (a total of 3-5 sessions of laser appointments per tooth is suggested) (Figure 3A).
      1. Ensure that both the operator and patient wear protective goggles to protect the eyes from laser damage.
      2. Prepare the diode laser device (wavelength = 980 nm, output power = 0.4 W, power density = 566.2 W/cm², continuous wave, 300 µm fiber optic delivery system).
      3. Irradiate the gingival surface of the pocket for approximately 15 s per pocket, with the laser fiber tip 5 mm (2-10 mm) away from the gingival surface and directed at an angle of 90° (Figure 3B,C).
      4. Repeat the same outside pocket laser treatment after 1, 3, 5, and 7 days.
6. Give oral hygiene instruction (OHI) to each patient, including Bass brushing technique, interdental floss, and brush¹⁹.
7. Clinical examination
   1. Measure the PPD, CAL, and BOP for each tooth 4-6 weeks, 3 months, and 6 months after periodontal treatment. Record the postoperative parameters on a new periodontal chart (Supplementary File 1).
   2. Compare the baseline and postoperative parameters.

2. Adjunctive probiotic therapy in the nonsurgical treatment of peri-implant mucositis (Figure 4A)

1. Eligibility criteria
   1. Use the following inclusion criteria: age ≥ 18 years; at least one implant with erythema, swelling, suppuration, or BOP in the peri-implant mucosa; radiographic bone loss (RBL) < 2 mm.
   2. Use the following exclusion criteria: peri-implantitis (RBL ≥ 2 mm); implants with mobility; patients with systematic diseases or under medication that may affect the inflammation and healing process; patients who had received periodontal treatment within 6 months; smokers or alcoholics; pregnant or lactating patients.
2. Clinical examination
   1. Measure the clinical parameters PPD, BOP at six sites per implant (i.e., mesiobuccal, buccal, distobuccal, distolingual, lingual, and mesiolingual), and plaque index (PI) at four sites per implant (i.e., mesial, buccal, distal, and lingual).
   2. Record the baseline parameters on a periodontal chart (Supplementary File 1).
3. For disinfection, gargle with 3% hydrogen peroxide for 1 min, followed by pure water.
4. Mechanical debridement by supragingival scaling
   1. Use a titanium ultrasound tip to perform supragingival scaling for the mucositis implants, adjusting the mode to medium power (Figure 4B). Rinse the pockets with 3% hydrogen peroxide, and then gargle with pure water.
      NOTE: Supragingival scaling removes the plaque and calculus from the surface of the implant denture above the gumline.
5. Professional administration of probiotic
   1. Grind the probiotic tablet into powder using a sterilized mortar (Figure 4C).
      NOTE: If there are lumpy particles in the powder, they can easily clog the syringe.
   2. Make a solution of probiotic powder and sterile saline in a 1:3 ratio (Figure 4D). Deliver the probiotic solution into the peri-implant sulcus using a 5 mL syringe with a blunted and soft tip (Figure 4E).
6. Home administration of probiotics
   1. Instruct the patients to dissolve one tablet for approximately 10 min in the oral cavity every 12 h, twice a day for 1 month (Figure 4A).
7. Give OHI to each patient, including Bass brushing technique, interdental floss, and brush¹⁹.
8. Clinical examination
   1. Measure the PPD, PI, and BOP for each implant 4-6 weeks, 3 months, and 6 months after treatment. Record the postoperative parameters on a new periodontal chart (Supplementary File 1).
   2. Compare the baseline and postoperative parameters.

Results

Periodontal pockets with PPD ≥ 5 mm require laser irradiation after SRP, as it is difficult to obtain complete debridement by SRP alone (Figure 1A,B). After SRP, if the periodontal pockets bleed profusely and clot on the tooth surface, the operator needs to stop the bleeding and remove the clot by rinsing and gargling several times. This is because a large amount of blood will prevent the laser from working (Figure 1C,D).

Discussion

Although diode laser has been widely utilized in periodontal therapy, the clinical effectiveness remains controversial among current clinical trials^15,20. As demonstrated, the laser usage mode and application regimen have significant impacts on the efficacy of periodontal laser therapy¹². Most researchers, however, ignore the potential role, eliciting results that are hard to explain. Under different usage modes, excessive or insufficient ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
1% iodophor	ADF, China	21031051	100 mL
3% hydrogen peroxide	Hebei Jianning, China	210910	500 mL
75% alcohol	Shandong Anjie, China	2021100227	500 mL
Diode laser (FOX 980)	A.R.C, Germany	PS01013	300-μm fiber tip
Gracey curettes	Hu-Friedy, USA	5/6, 7/8, 11/12, 13/14
Low-speed handpiece	NSK, Japan	0BB81855
Periodontal probe	Shanghai Kangqiao Dental Instruments Factory, China	44759.00
Periodontal ultrasonic device (PT3)	Guilin zhuomuniao Medical Instrument, China	P2090028PT3
Polishing paste	Datsing, China	21010701
Primacaine adrenaline	Produits Dentaires Pierre Rolland, France	S-52	1.7 mL
Probiotic	Biogaia, Sweden	Prodentis	30 probiotic tablets (24 g)
Titanium ultrasound tip (P59)	Guilin Zhuomuniao Medical Instrument, China	200805