A 42-year-old male client presented with generalized chronic moderate to severe marginal gingivitis and generalized chronic moderate to advanced periodontitis. He reported that non-surgical periodontal treatment, through scaling and root planing, failed to prevent increased clinical attachment loss and was referred to a periodontist for pocket reduction surgery. After consultation, the treatment plan presented by the periodontist was rejected due to concerns about discomfort, recovery time, and finances. I was introduced to this client after his own research led him to specifically seek laser-assisted periodontal therapy (LAPT) with a soft tissue diode laser.
Assessment
Medical history
The client presented as being in good health. No contraindications to treatment, systemic medical conditions or smoking history were reported. He had no known allergies and was taking no medications.
Dental History
The client reported having a family history of periodontitis, including his parents and siblings. He recalled that he had been diagnosed with ongoing periodontal disease for several years, which led to the suspicion of rapidly progressive juvenile periodontitis.
Radiographic Evaluation
A series of oral radiographs revealed adequate bone levels, with no visible pathology (Fig. 1).
Fig. 1
Full Mouth series
Soft tissue examination
A comprehensive periodontal and dental examination revealed several areas of clinical attachment loss, 129 bleeding at probing sites, no swelling, and 1 mobility in teeth 3.7, 4.4, 4.5, 4.6, and 4.7. The gingiva was ridged and spongy, reddish pink with an inflamed papilla and rolled margins. Probing depths were recorded (Table 1).
Oral hygiene
The client reported brushing twice daily, flossing infrequently, and had abundant plaque especially in the mesial and marginal 1/3 areas and heavy supragingival and subgingival calculus deposits.
The use of diode lasers in the treatment of moderate to severe periodontal disease has been shown to improve and help maintain periodontal health (Goldstep 2010). The assessment findings gave me confidence that scaling and root planing (SRP) along with laser assisted periodontal therapy (LAPT), modifications to current oral home care practice and maintenance treatment every three months would have as resulting in an improved periodontal condition. client concerns about minimal discomfort, recovery time and financial commitment.
Treatment Plan Outline
A. Initial Treatment
1. Oral care instructions at home
2. Quadrant SRP with local anesthetic block
3. LAPT immediately after SRP
B. Reassessment
1. Six-week visual reassessment
2. Quarterly periodontal reassessment
C. Maintenance treatments
Clinical Technique
A. Initial treatment (four appointments)
1. Oral home care instruction
The client was experiencing resistance to adapting a new home care routine, reporting that in previous experiences he had felt “taught” by his hygienist. Understanding the client’s concern, we worked together to create an oral home care routine that emphasized plaque removal at the proximal and gingival margins along with incorporating a daily antimicrobial mouthwash. The client committed to brushing twice daily with a soft-bristled toothbrush using the Modified Stillman technique, flossing daily, and rinsing with Listerine Zero Total Care daily.
2. Quadrant Scaling and Root Planing (SRP) with
Anesthetic Block
One hour of SRP was performed for each quadrant using HuFriedy Piezo ultrasound and hand instruments with Gracey curettes. Heavy bleeding was observed with SRP. The cleaning was completed in four appointments scheduled two weeks apart to aid in the client’s post-procedure comfort.
3. Laser Assisted Periodontal Therapy (LAPT)
Immediately after SRP, LAPT of the dehydrated quadrant was performed using a Sirona SIROLaser soft tissue diode laser with laser protective goggles for the client and operator. A 320um optical fiber was selected using a continuous wave set at 1.3W with an unprimed edge. The tip of the laser fiber was inserted into the groove 1 mm above the base of the pocket using a sweeping motion for approximately 15 seconds per location, taking care to keep the tip free of debris to prevent initiation (Pirnat, 2007). The client reported no discomfort throughout the procedure.
Mild postoperative discomfort, particularly at the site of anesthetic injection and in areas initially probed 6 mm or more, resolved completely by the next appointment two weeks later. The client’s home care was reviewed at each appointment and initially showed improvement. However, there were signs of regression at the last quadrant appointment after the client reported personal stress from a death in the family.
B. Reassessment
1. Six-week visual reassessment (Fig. 2)
Detection after SRP and LAPT was deliberately avoided during the first three months to avoid damaging reconnection (Goldstep 2010). Tissues were noted to be pink and firm, papillae more pointed, generally flat borders with localized anterior mandibular rolling. Oral care at home improved and plaque build-up was visibly reduced.
Fig. 2
Six-week visual reassessment 
2. Quarterly Periodontal Reassessment
Periodontal probing showed a significant improvement in the disease state with a reduction in pocketing and bleeding. Home oral care instructions were reviewed and the client reported stopping the bleeding with brushing and flossing. SRP of complete dentition with ultrasonic and manual scaling with observed moderate bleeding was completed using four sheets of Oraqix for desensitization. LAPT of the complete dentition was re-applied with the previously used settings and technique due to generalized chronic moderate papillary gingivitis and chronic moderate to severe periodontitis localized to teeth 1.7, 1.6, 2.6, 2.7.
Quarterly Maintenance Treatments
Hygiene treatment intervals were maintained every three months (delayed once by the client due to a shoulder injury) with periodontal probing at each visit. The patient continued to show improvement in disease status despite inconsistent home care due to motivation and injury. SRP of complete dentition continued to result in moderate bleeding. Two ampoules of Oraqix were necessary to achieve desensitization six months after initial treatment, and no desensitization was required at subsequent visits. LAPT of the complete dentition immediately after SRP with the settings and technique previously used at each appointment was performed despite improving health due to the severity of the initial condition, previous dental history, and declining home care.
Improvement three months after initial SRP and LAPT (Fig. 3, 4) expected due to the removal of significant accumulated deposits and home care improvements. However, stopping bleeding with home care, in addition to a 41.1% reduction in bleeding on detection, a 74.2% reduction in pockets 6 mm and larger, and a 30.4% reduction in pockets 4 -5 mm, it was beyond my expectations.
The results of subsequent maintenance treatments also proved to be unexpectedly positive. Specifically, pocket reduction from 12mm to 5mm at 10 months (measured at 17MB and 16DB), 88.4% overall bleeding reduction, 96.8% reduction in pockets 6mm and larger, and 4- 5 mm by 57.6%. , despite irregular home care and delayed treatment.
Fig. 3
Fig. 4
conclusion
The introduction of laser-assisted periodontal therapy to treat moderate to advanced periodontal disease for this client resulted in improved periodontal status beyond expectations, without the need for surgery and with minimal discomfort.
Denial of responsibility
The case study individual is referred to as a client rather than a patient following the generally accepted vocabulary supported by the College of Dental Hygienists of Ontario and the Regulated Health Professions Act. OH
Oral Health welcomes this original article.
bibliographical references
1. Pirnat. (2007). Versatility of an 810 nm diode laser in dentistry: an overview. Journal of Laser and Health Academy, No. 4.
2. Goldstep. (2010). Diode lasers for the treatment of periodontal disease: The story so far. Dentaltown.com 54-58.
For Author
Michelle Cortes has been practicing dental hygiene at Expressions Dental Care in Richmond Hill, Ontario since 2006 and providing laser periodontal treatment since 2010. She is registered with the College of Dental Hygienists of Ontario and a member of the Canadian Dental Hygienists Association. He holds soft tissue diode laser certifications with the Academy of Laser Dentistry, the Sirona Academy of Dentistry, and the International Laser Training Center.
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