EFIKASNOST LASERA MALE SNAGE U TERAPIJI PARODONTOPATIJE LOW POWER LASER EFFICACY IN THE THERAPY OF PERIODONTITIS

Uvod. Parodontopatija je inflamatorno oboljenje potpornog aparata zuba. Spada u najrasprostranjenija oboljenja od kojih ljudi boluju i predstavlja ogroman problem kojem se pridaje sve veći značaj. Savremena terapija parodontopatije obuhvata klasične metode lečenja, hirurške metode i najnoviju lasersku tehnologiju. Terapija laserima male snage je potpuno bezbolna, neinvazivna i bez štetnih efekata. Cilj rada je bio ispitati efikasnost terapije laserima male snage kao dodatak bazičnoj terapiji parodontopatije. Materijal i metod. Ispitivanje je sprovedeno na 50 ispitanika sa parodontopatijom i kliničkim simptomom inflamacije gingive. Pri prvoj poseti određeni su indeksi: plak indeks (PI), gingivalni indeks (GI), parodontalni indeks po Ramfjordu (PDI), uklonjene meke i čvrste naslage, obrađeni parodontalni džepovi. Zatim je na desnoj strani vilica (grupa A) primenjena terapija GaAlAs laserom (Mils 94, 670 nm, 5 mW, 14 min). Terapija laserom je izostavljena na levoj strani vilice svakog ispitanika (grupa B), radi upoređivanja efekata terapije sa i bez lasera. Nakon prve, treće i pete terapije određeni su GI i PI, a nakon mesec dana GI, PI i PDI. Rezultati. Poređenjem srednjih vrednosti indeksa u odnosu na vrednost pre terapije uočeno je značajno smanjenje izraženije na lasiranoj strani. Poređenjem grupa utvrđena je manja vrednost kod lasirane u odnosu na nelasiranu stranu. Zaključak. Laseri male snage pokazali su se efikasnim u eliminaciji inflamacije gingive i unapređenju parodontalnog zdravlja, te se preporučuju kao dodatak bazičnoj terapiji parodontopatije.


Introduction
Periodontitis is an inflammatory disease of periodontal tissues caused by the specific oral bacterial biofilm [1][2][3] .Pathological changes are destructive and lead to the progression of the disease and anatomical and functional disintegration of the periodontium.This leads to loosening and subsequently a loss of one or more teeth.Epidemiological studies suggest that periodontitis is one of the most widespread diseases 4,5 .Because of these medical-social and economic moments, it represents a huge problem with increasing attention.
Of great practical importance in determining the prognosis and treatment plan is to estimate the degree of periodontal disease activity.Clinical experience shows that the most common type is exudativeproliferative gingival inflammation with a degenerative-atrophic processes that spread into the deeper parts of the periodontal tissues. 6It is believed that the intensity of gingival inflammation and attachment level are good indicators of disease activity and progression.However, the use of clinical parameters such as gingival index (GI), which determines the degree and location of gingival inflammation, and periodontal index (Periodontal Disease Index -PDI) which shows the degree of periodontal destruction and the loss of gingival attachment as an indicator of severity of periodontitis, are recommended 4 .After the diagnosis and assessment of disease severity are defined, an individual treatment plan for the each individual patient is made.Periodontal therapy begins by removing the plaque from teeth and pathological altered tissues from periodontal pockets 4 .
The tendency to constantly improve the quality of dental periodontal therapy is closely associated with new therapeutic developments.][9][10][11][12][13][14] Low power laser therapy (LLLT) has biostimulative effect, improves wound healing, reduces pain and swelling, and there are almost no contraindications for its use.Particularly important is the fact that the use of LLLT is completely painless, noninvasive and without harmful effect [15][16][17]
Zatim je na desnoj strani vilica (vrednosti predstavljene kao grupa A) primenjena terapija GaAlAs diodnim laserom The most commonly recommended treatment dose is 1 to 10 J/cm 2 per treatment.It should be insisted on the coordinated stand points, which would allow far more widespread and easier application of LLLT. 7,12e aim of the study The aim of the study was to investigate the efficacy of low power laser therapy as an adjunct to the basic periodontitis treatment.

Patients and Methods
The study was conducted at the Department of Oral Medicine and Periodontology, Dental Clinic, Faculty of Medicine in Niš.After establishing the aim of the study, the methodology was designed and then approved by the Faculty of Medicine Ethics Committee (No. 01-2800-7).The main criteria for selection of patients were determined before accessing the investigation.The necessary medical history was taken and dental examination was performed at the Dental Clinic.Selected patients had periodontitis with clinical symptoms of gingival inflammation.The study did not include the patients younger than 18 years of age, pregnant women, patients with blood diseases, acute and chronic infections, autoimmune diseases, patients on immunosuppressive therapy or phototherapy, photosensitivity and subjects that were, for whatever reason, on the antibiotic or corticosteroid therapy in the last three months.
Of the 50 patients, 24 were males and 26 females, aged 22 to 83 years (average age 44.6 years).The level of oral hygiene, gingival and periodontal measurements were made by using appropriate indices -plaque index (PI) 4 , gingival index (GI) 4 and periodontal Ramfjord index (PDI) 4 .
During the first visit, dental plaque was removed using a paste (Vantal, Galenika) and the rotating brush, and tartar was rewomed by the ultrasound Woodpecker (UDS-J) and manual instruments.In addition, periodontal pockets were treated using periodontal curettes and 3% hydrogen peroxide rinse.
Laser therapy was left out on the left side of the jaws of each patient (values are presented as group B), in order to compare the effect of treatment with and without laser.During the next four days at each visit, dental plaque was removed and the laser therapy was applied according to the same established protocol.After the first, third and fifth treatment during the control visit the next day, GI and PI were measured.Patients were educated how to maintain proper oral hygiene and one month after the therapy GI, PI and PDI were measured once again.
The parameters are presented as mean values (X) and standard deviations (SD).The coefficient of variation was determined as a measure of homogeneity of the samples with respect to the studied parameters.The statistically significant differences in the mean values between the two groups (A and B) were tested by the Student's t-test for independent samples.The calculations were performed by SPSS, version 15.0 and the results presented in tables using MS Office Excel program.

Results
Comparing the mean values of PI in relation to the value before the therapy, the statistically significant reduction of investigated indices was observed on the lased (A) and non-lased (B) sides of the jaws in all treatment periods (p <0,001).
Comparing the mean values between groups A and B, a statistically significant lower value of Pl was noticed on the lased (A) compared to non-lased (B) side after the first treatment (p <0,001).The PI values were slightly higher a month after compared to the values the fifth day of therapy , which means that the plaque reformed again (Table 1).
Mean GI values on the lased (A) and non-lased (B) jaw sides during the therapy are shown in Table 2.There was a statistically significant decrease in mean values of the GI index (p < 0,001), on the both jaw sides after each treatment period compared to the value before treatment.The t-test indicates a significant reduction in mean values on the lased side in each investigated time period.Comparing the mean values between groups A and B, a statistically significant lower GI value on the lased (A) compared to non-lased (B) side was noticed after the first treatment (p <0,001).
GI remains the same on the lased (A) side even one month after treatment.
Table 3 shows PDI values before and one month after therapy.The statistically significantly lower values of investigated index was noticed a month after therapy in both groups (A and B), p < 0,001.One month after therapy, lower PDI mean values were noticed on the lased (A) side, close to the level of statistical significance of 0,05 (p = 0,0655) (Table 3).

Discussion
A mass occurrence and frequent periodontitis relapses makes this disease a real social problem that highlights the growing importance of prophylaxis and therapy.Therefore, there is a need to seek new, more efficient means and methods of treatment. 1,4t is believed that in the pathogenesis of most if not all types of periodontitis bacteria play one of the most important etiological roles. 3,8Dental calculus, oral biofilm and periodontal pockets are generally considered the most important sites of bacterial accumulation.In this way, the therapeutic methods are directed towards the bacterial mechanical elimination.In periodontitis treatment, current concepts include the removal of soft plaque (oral biofilm and food debris) and calculus, and granulation tissue curettage in order to eliminate bacterial deposits and endotoxins.Traditionally, conventional mechanical treatment of root surface with the help of scalers, curettes, sickles and other instruments is used. 18In this investigation, in accordance with these concepts, we applied the same confirmed therapeutic procedures.
Istraživači ističu da dodatna terapija laserom male snage nakon primene bazične parodontološke terapije redukuje gingivalnu inflamaciju. 20,23Uočeno je da dodatno zračenje laserom male snage daje bolje terapeutske rezultate nego samostalno uklanjanje kamenca i konkremenata uz kiretažu parodontalnih džepova. 20Istraživači su istakli da je efekat LLLT bio najveći na nivou smanjenja gingivalnog indeksa i smanjenja dubine sondiranja. 24,25Sličan nalaz je uočen i u ovom istraživanju, gde je nakon bazične terapije i primenjene laseroterapije laserom male snage došlo do znatnog smanjenja stepena inflamacije koji je dokumentovan merenjem gingivalnog indeksa.Pošto je kod svih ispitanika desna strana vilice podvrgnuta laserskom zračenju, a leva služila kao kontrola, praćene su vrednosti indeksa u toku terapije.I kod lasirane i nelasirane strane nakon svih perioda terapije u odnosu na vrednost pre terapije došlo je do statistički značajnih smanjenja srednjih vrednosti GI (p<0,001).Vrednosti t-testa pri poređenju nakon prve, treće i pete terapije In recent years, there has beeu a growing interest in researching new therapeutic approaches that would be able to improve and simplify the mechanical debridement of root, which would also have antibacterial properties in order to reduce the number of bacteria associated with periodontitis. 19esearchers are testing the application of laser irradiation with different output power and wavelengths including Neodymium: YAG (Nd: YAG), Helium-Neon (HeNe), Gallium arsenide (GaAs), Galliun-Aluminum-Arsenid (GaAlAs) and argon laser.It was noticed that, if the laser irradiation is applied into the periodontal pockets, there is a reduction in the number of bacteria on the root surface. 18Low power laser therapy (LLLT) has become very popular in a variety of clinical applications 20 .It is assumed that LLLT reduces pain, accelerates wound healing and has a positive effect on inflammatory processes.Due to the lack of adequate research, it is not always possible to determine the optimum laser types and dose parameters. 202][23] In this study, the used doses are close to therapeutic doses of Mester.Laser was applied with output power of 5 mW and the exposure time of 6,5 minutes for each investigated area.
The researchers state that additional low power laser therapy after the application of basic periodontal therapy reduces gingival inflammation. 20,23It was noticed that additional low power laser irradiation yields better therapeutic results than only tartar removal and periodontal pockets curettage. 20he researchers noticed that the LLLT induces the highest reduction of gingival index and probing depth. 24,25A similar finding was observed in this study, where after the basic treatment and applied low power laser therapy, there was a significant inflammation reduction, which was measured by the gingival index.Indices were evaluated in all the patients during laser therapy.The right side of the jaws was subjected to laser irradiation, and the left one was the control side.Comparing the values before therapy with the values during the investigation period, on both sides of the jaws a statistically significant decrease of GI was noticed (p <0,001).When comparing the first, third and fifth day after therapy, a significant GI reduction was noticed on the lased side of the jaws.ukazuju na značajnije smanjenje srednjih vrednosti na lasiranoj strani vilice u ispitanika.
GI value on the lased side remained the same even one month after the therapy, which indicates a long-lasting LLLT effect.It is supposed that some of the LLLT effects are due to an increased microcirculation of the treated area.Schaffer et al. 26 monitored gingival microcirculation in systemically healthy volunteers with experimentally induced gingivitis and have not observed these LLLT effects.Contrary, the other authors have shown that LLLT has a positive effects on the microcirculation of the moderately inflamed gingiva, but not in a healthy and very inflamed gingival tissue. 27t is well known that gingival inflammation and active periodontitis increase the secretion of gingival fluid. 20Studies have shown a beneficial effect of LLLT on gingival inflammation through the reduction of gingival fluid. 20,26,27n this study PDI index values were measured before and one month after the last laser therapy.There was a statistically significant lower value of the PDI one month after the laser therapy compared to values at baseline (p < 0,001) with lower values on the lased side (p = 0,0655).These values indicate a beneficial effect of LLLT which supplements conventional periodontal therapy and enables faster healing of periodontal tissues, which is noticed through the reduction of PDI.
It is believed that LLLT reduces the accumulation of oral biofilm. 20It is not clear whether this occurs due to the decrease of inflammation or independent LLLT.It is evident that on the lased and non-lased jaw sides after all the treatment periods there was a statistically significant decrease in Pl compareding to the value before treatment.T-test showed a more pronounced decrease on the lased side ( p<0,001).After the first investigated period, a statistically significant lower Pl value on the lased jaw side compared to the non-lased side was noticed (p<0,001).It should be noticed that the PI value, a month after laser therapy, was slightly higher than the value after the fifth therapy, suggesting that the oral biofilm was reformed again.It is essential always to motivate patients to maintain oral hygiene at the high level, which is crucial for periodontal health maintenance.

Conclusion
Based on the applied methodology and obtained results, a significant decrease in periodontitis activity and improvement of periodontal health was observed when low power laser therapy was combined with the basic periodontal therapy, compared to the basic periodontal therapy alone.
Low-power lasers are effective in the elimination of gingival inflammation and improvement of periodontal health.They can be recommended as an adjunct to the basic periodontal therapy.