efficacy of scaling and root planing with and …

EFFICACY OF SCALING AND ROOT PLANING WITH AND

WITHOUT ADJUNCTIVE USE OF DIODE LASER OR

TETRACYCLINE FIBERS IN PATIENTS WITH GENERALISED

CHRONIC PERIODONTITIS - A COMPARATIVE STUDY

A Dissertation submitted

in partial fulfil lment of the requirements

for the degree of

MASTER OF DENTAL SURGERY

Branch II

DEPARTMENT OF PERIODONTOLOGY

THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY

CHENNAI- 600032

2014–2017

ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL

MELMARUVATHUR – 603319.

DEPARTMENT OF PERIODONTICS

CERTIFICATE

This is to certify that DR S.ANITHA DEVI, Post graduate

student (2014-2017) in the Department of Periodontics, Adhiparasakthi

Dental College and Hospital, Melmaruvathur – 603319, has done this

dissertation titled “EFFICACY OF SCALING AND ROOT PLANING

WITH AND WITHOUT ADJUNCTIVE USE OF DIODE LASER OR

TETRACYCLINE FIBERS IN PATIENTS WITH GENERALISED

CHRONIC PERIODONTITIS - A COMPARATIVE STUDY" under our

direct guidance and supervision in partial fulfil lment of the regulations

laid down by The Tamilnadu Dr. M.G.R Medical University, Chennai –

600032 for MDS; (Branch II) Department of Periodontics Degree

Examination.

Co-Guide Guide

Dr. VIDYA SEKHAR., MDS Dr. T. RAMAKRISHNAN., MDS

Reader Professor and HOD

Principal

Dr. S. THILLAINAYAGAM., MDS

APDCH

ACKNOWLEDGEMENT

I thank ALMIGHTY for answering my prayers and making me

what I am today.

I thank our Correspondent Dr. T. Ramesh , MD., for his vital

encouragement and support.

I am thankful to Dr. Thillainayagam M.D.S . , our beloved

principal, Adhiparasakthi Dental College and Hospital, Melmaruvathur

for providing me with the opportunity to util ize the facili ties of the

college.

I avail this opportunity to express my gratitude and reverence to

my beloved teacher Dr. T. Ramakrishnan. MDS . , Professor and Head,

Department of Periodontics, Adhiparasakthi Dental College and

Hospital, Melmaruvathur. His pursuit for perfection and immens e

support were a source of constant inspiration to me and without which

such an endeavour would never have materialized.

It is my duty to express my thanks to my Co -Guide Dr. Vidya

sekhar MDS . , Reader for her valuable suggestions and encouragement

throughout the completion of my Main dissertation. I am thankful and

express my gratitude to my teachers Dr. Mani Sundar MDS., Reader,

Dr. Ebenezer J MDS., Senior lecturer, Dr. Siva Ranjani P MDS.,

Senior lecturer.

I am thankful and I express my grati tude to my previous teachers

Dr. Sasireka MDS., professor and HOD, Dr. Bobby Kurian MDS.,

Reader, Dr Venkata Srikanth MDS., Reader.

I also wish to thank my post graduate colleague, Dr. Renganath

and I warmly acknowledge my juniors Dr. Shobana and Dr. Irudaya

Nirmala and also for my Sub Juniors.

I thank Mr. Pandiyan (statistician) for giving significance to my

study.

I thank Mr. Maveeran , Librarian and all the library staff,

Adhiparasakthi Dental College and Hospital, Melmaruvathur, for

favours rendered.

I extend my thanks to Mr. Babu, and all other staff at Netway

for their dedication and marvellous job in shaping this dissertation to

its finest form.

I owe my grati tude to my Parents who stood beside me during my

hard t ime and sacrificed so much to make me what I am today.

Dr. S.ANITHA DEVI

Post Graduate Student

DECLARATION

I hereby declare that no part of the dissertation will be utilized

for gaining financial assistance or any promotion without obtaining

prior permission of the Principal, Adhiparasakthi Dental College and

Hospital, Melmaruvathur – 603319. In addition, I declare that no part

of this work will be published either in print or in electronic media

without the guides who has been actively involved in dissertation. The

author has the right to reserve for publish work solely with the

permission of the Principal, Adhiparasakthi Dental College and

Hospital, Melmaruvathur – 603319

Co-Guide Guide & Head of department S ignature o f candidate

Dr Vidya Sekhar . , MDS Dr T . Ramakr ishnan. , MDS

Reader Professor and HOD

TITLE OF THE DISSERTATION “Efficacy of scaling and root

planing with and without

adjunctive use of diode laser or

tetracycline fibers in patients with

generalised chronic periodontitis "

- A comparative study

PLACE OF THE STUDY Adhiparasakthi Dental College

and Hospital , Melmaruvathur –

603319

DURATION OF THE COURSE 3 years

NAME OF THE GUIDE Dr. T. Ramakrishnan., MDS.

NAME OF CO-GUIDE Dr. Vidya Sekhar. , MDS.

ABSTRACT

BACKGROUND:

Periodontitis is a chronic inflammatory disease caused by bacterial infection of

the supporting tissues around the teeth. The removal of bacterial deposits and all the

factors that favour its accumulation is the primary treatment goal of phase I therapy.

However bacteria invading the periodontal connective tissue cannot be eliminated by

SRP alone. To disinfect the entire periodontal pocket and to achieve maximum

gingival healing, laser therapy or local drug delivery devices may be used. This study

compares the treatment outcome of diode laser therapy or tetracycline fibres as

adjuncts to SRP in generalised chronic periodontitis patients.

AIM:

To compare the changes in the sites treated with scaling and root planing alone

with sites treated with scaling and root planing along with adjunct use of diode laser

or scaling and root planing along with usage of tetracycline fibers as local drug

delivery agents in patients with generalised chronic periodontitis.

MATERIALS AND METHODS:

90 sites were divided into 3 groups with 30 sites in each group.

Group I- Sites treated with scaling and root planing alone

Group II- Sites treated with scaling and root planing along with use of diode laser (1.5

w,970nm,30sec,continuous wave).

Group III- Sites treated with scaling and root planing along with placement of

tetracycline fibers (periodontal plus AB)

Clinical index and clinical parameters such as Gingival index(GI), Periodontal pocket

depth (PPD), Clinical attachment level (CAL) were evaluated and compared within

and between the groups at baseline and at 3 rd month.

RESULTS:

When baseline GI scores and post operative GI scores were compared within

the group change was found to be statistically significant and between the groups the

change was not statistically significant. When baseline probing depth and baseline

CAL was compared between post operative probing depth and post operative CAL

within the group and between the groups the reduction in pocket depth and gain in

clinical attachment level was found to be statistically significant.

CONCLUSION:

Based on the findings of the present study, treatment with diode laser or

tetracycline Fibers as an adjunct to SRP may improve periodontal status compared to

SRP alone.

CONTENTS

S.NO TITLE PAGE NO

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 4

3 GENERAL REVIEW 5

4 REVIEW OF LITERATURE 14

5 MATERIALS AND METHODS 42

6 RESULTS 50

7 DISCUSSION 60

8 CONCLUSION 64

9 REFERENCES 65

10 ANNEXURE i

LIST OF FIGURE

FIGURE NO TITLE PAGE NO

Figure 1 Armamentarium 47

Figure 2 Pre operative probing depth 48

Figure 3 Sites treated with diode laser 48

Figure 4 Post operative probing depth 48

Figure 5 Pre operative probing depth 49

Figure 6 Placement of tetracycline fibers 49

Figure 7 Post operative probing depth 49

LIST OF TABLES

TABLE NO TITLE PAGE NO

Table 1 Comparison of pre operative and post

operative mean ± S.D values of Gingival

index score within the group and

between the three groups.

51


operative mean ± S.D values of probing

depth within the group and bet ween the

three groups.

54


operative mean ± S.D values of CAL

within the group and between the three

groups.

57

LIST OF CHARTS

S.NO TITLE PAGE NO

Chart 1 Comparison of mean Pre op and

Post op Gingival index scores

between the three groups

53


Post op PPD between the three

groups.

56


Post op CAL between the three

groups.

59


Post op Value of GI, PPD, CAL,

within the three groups

59

LIST OF ABBREVATIONS

Aa: Aggregatibacter Actinomycetemcomitans.

Ar : Argon.

Arf : Argon Fluoride.

BOP: Bleeding On Probing.

CG: Control Group.

CHX: Chlorhexidine Chip.

CP: Chronic Periodontitis.

CO2 : Carbon Dioxide.

ELISA: Enzyme-Linked Immunosorbent Assay.

Er: YAG : Erbium Doped: Yttrium-Aluminium- Garnet.

FDA : Food And Drug Administration.

GCF: Gingival Crevicular Fluid.

GI: Gingival Index.

GR: Gingival Recession.

GTR: Guided Tissue Regeneration.

GaAlAs : Gallium Aluminium Arsenide.

GaAs : Gall ium Arsenide.

HPLC: High Performance Liquid Chromatography.

He Ne: Helium Neon.

InGaAsP : Indium Gallium Arsenide Phosphorus.

InGaAs : Indium Gallium Arsenide.

KTP : Potassium Titanyl Phosphate.

LASER: Light Amplification by Stimulated Emission Of Radiation.

LG: Laser Group.

LLLT: Low-Level Laser Therapy.

LPS: Lipopolysacchrides.

M+A: Metronidazole Plus Amoxicillin.

MGI: Modified Gingival Index.

Nd:YAG :Neodymium-Doped: Yttrium-Garnet.

PPD: Periodontal Pocket Depth.

PBS: Papillary Bleeding Score.

PCR: Polymerase Chain Reaction.

PDL: Periodontal Ligament.

Pg: Porphyromonas gingivalis.

Pi: Prevotella intermedia.

PI : Plaque Index.

RAL: Relative Attachment Level.

SRP: Scaling And Root Planing.

TF: Tetracycline Fibers.

Xecl: Xenon Chloride.

Introduction

1

INTRODUCTION

Periodontal disease is a chronic inflammatory process

characterized by bacterial etiology. It results in progressive, site

specific destruction of the supporting tissues of the tooth, resulting in

a typical pathological lesion.1 The main aim of pocket therapy is to

eliminate the microbial causative factors of periodontal disease.

It is a well established fact that periodontal diseases are caused

by bacteria. Over t ime, this supra gingival plaque becomes more

complex, leading to a succession of bacteria that are more pathogenic.

Bacteria grow in an apical direction and become sub gingival, and

eventually, as bone is destroyed, a periodontal pocket is formed. In

periodontal pockets the bacteria form a highly structured and comp lex

biofilm. As this process continues, the bacterial biofilm extends so far

subgingivally that the patient cannot reach it during his regular oral

hygiene regime. Bacteria within the biofi lm are well protected from the

host’s immunologic mechanisms as wel l as from antibiotics used for

treatment.2

It is therefore logical to treat periodontal pockets by mechanical

removal of local factors and also by disruption of the sub gingival

plaque biofilm itself.

Introduction

2

Phase I therapy is the first in the sequence of pe riodontal

therapy. The objective of phase I therapy is to alter or eliminate the

microbial etiology and factors contributing to the disease. Certain

bacteria invading the periodontal connective tissue cannot be

eliminated by scaling and root planing alone. Therefore adjunctive use

of lasers or tetracycline fibers with SRP may be a choice of therapy in

patients with Generalised chronic Periodontitis .

Apart from conventional treatment modalities, numerous

adjunctive therapeutic strategies have evolved to m anage periodontal

diseases. The use of lasers or local drug delivery agents are some of

the adjunctive therapeutic agents presently available.2

Laser is an acronym for Light Amplification by Stimulated

Emission of Radiation2

In 2015, Antonio crispino evaluated the effect of a 940-nm

diode laser as an adjunct to SRP in patients affected by periodontitis.

He concluded that the laser diode can be routinely associated with

mechanical non-surgical therapy (SRP) in the treatment of periodontal

pockets of pat ients with moderate-to-severe chronic periodontitis.1

Goodson and his coworkers introduced the use of tetracycline as

a local drug delivery agent for the treatment of periodontal diseases.

Local drug delivery agents are available in several forms such as gels,

Introduction

3

strips, fibers, chips, ointments etc. Different antimi crobial agents such

as doxycycline, metronidazole, minocycline and chlorhexidine also

were used as local drug delivery agents in the various forms. Goodson

developed a local drug delivery system consist ing of an ethylene/ vinyl

acetate copolymer fiber(diameter 0.5mm) containing tetracycline

12.7mg per 9 inches. When it was packed into periodontal pockets, it

was well tolerated by the tissues as well provided better periodontal

health.2

This study was conducted to evaluate and compare the changes in

clinical index and clinical parameter of SRP treated sites alone with

sites treated by SRP along with the adjunctive use of diode laser or

tetracycline fibers( Periodontal Plus AB®).

Aims and Objectives

4

AIMS AND OBJECTIVES

AIMS:

To compare the effect of scaling and root planing with or without

the use of diode laser or tetracycline fibers in the treatment of

Generalised chronic periodontitis.

OBJECTIVE:

1) To compare effect of scaling and root planing alone with scaling

and root planing along with adjunctive use of diode laser

2) To compare the effect of scaling and root planing alone with

SRP plus tetracycline fibers.

3) To compare SRP +diode laser with SRP+ tetracycline fibers.

General Review

5

GENERAL REVIEW

Periodontal diseases are pathological conditions affecting the

supporting structures of the teeth. Various types of periodontal

diseases are chronic periodontitis, aggressive periodontitis ,

periodontitis as a manifestation of systemic disease and necrotizing

ulcerative periodontitis. The inflammatory periodontal diseases are

widely accepted as being caused by bacteria associated with dental

plaque. Other factors associated with the causation of disease include

interaction among the bacteria in the biofilm, the oral environmen t, and

the response of the host’s defense mechanisms to the bacterial assault.

Since the early 1970’s, the quest to identify bacterial specifici ty in

periodontal disease became the prominent area of investigation. This

lead Loesche (1976) to put forth the specific plaque hypothesis. He

suggested that specific bacteria cause specific forms of periodontal

diseases. Increasing knowledge of pathogenic bacteria in the causation

of periodontal disease has led to newer treatment strategies. These

newer strategies aim primarily at suppression or elimination of specific

periodontal diseases. Non-surgical therapy followed by surgical

therapy if necessary is the mainstay in the treatment of periodontal

disease. Scaling is the removal of biofilm and calculus from supra

gingival and sub gingival tooth surfaces . Root-planing is a procedure

by which residual embedded calculus and altered cementum is removed

to produce a smooth, hard, clean root surface.

General Review

6

These procedures are directed towards reducing bacterial load

and altering microbial composition in the periodontal pocket.3

SRP may

be carried out over several visits or i t may be comp leted in two

appointments within 24 hour period. They may involve the use of both

hand instruments and ultrasonics, or a combination of the se devices.

Root planing removes the cementum which becomes necrotic by

penetration of LPS endotoxins. A thorough SRP shifts the composition

of sub gingival micro biota from gram negative anaerobes to a gram

positive facultative bacteria. A profound reduc tion in Aa, Pg, Pi has

been observed. Thus the major goal of SRP is the removal of supra

gingival and sub gingival bacterial biofilm to obtain optimal gingival

health.

Nonsurgical periodontal procedures are challenging for the

clinician due to complex root anatomy and difficulty of access in deep

pockets. Thus they require a high degree of skil l. They can also be

challenging for patients, requiring extended chair -side time and

repeated visits , and range from uncomfortable to very painful on the

pain scale.

However, mechanical therapy itself may not always reduce or

eliminate the anaerobic infection with in the gingival tissues and areas

inaccessible to periodontal instrumentation . Moreover, recolonization

of disease associated bacteria may occur from bacteria lodged in

dentinal tubules causing diseased state. To overcome this, usage of

General Review

7

Lasers or addition of antimicrobials (systemic and local drug delivery)

would enhance the treatment protocol and serve as adjuncts to SRP.

LASERS:

Lasers is an acronym for light amplification by stimulated

emission of radiation.2 Natural oscil lations of atoms or molecules

between energy levels generate coherent electromagnetic radiation in

the ultraviolet, visible, or infrared regions of the spectrum. LASER is a

device that produces high intensity waves of a single wavelength.

LASER light can be collimated and thus focused into a small spot.

Initially introduced as an alternative to the traditional halogen curing

light, lasers are now the instrument of choice for various esthetic

dental treatments. Lasers are indicated for a wide variety of procedures

due to their many advantages.

Presently various laser systems have been used in dentistry.

Among them Carbon dioxide (CO 2), Neodymium-doped: Yttrium-

Garnet (Nd:YAG), Semiconductor diode lasers are used for soft tissue

treatment. Erbium doped: Yttrium -Aluminium- Garnet (Er:YAG) laser

is a hard tissue laser used for calculus removal from the subgingival

regions and decontamination of the diseased root surface.4

Laser Effects on Tissue

When the light energy from a laser falls on the t issue, the radiant

energy is absorbed by the tissues resulting in the following.

General Review

8

1. Photochemical interaction: e.g Bio -stimulation. Laser light

has a positive stimulatory effect on biochemical and

molecular processes required for healing and repair.

2. Photo thermal interaction: e.g Photo ablation. Removal of

soft tissue can be accomplished by vaporization of tissue

fluids and coagulation of tissue proteins. Hemostasis is

also achieved in the process.

3. Photo mechanical interaction: e.g Photo -disruption or

photo-disassociation.

4. Photo electrical interaction: e.g Photo -plasmolysis. Tissue

is removed through the formation of electrically charged

ions and particles that exist in a semi -gaseous high energy

state.5

Mechanism of action of lasers:

The physical principle of laser was developed from Einstein’s

theories in the early 1900s, and the first device was introduced in 1960

by Maiman. Since then, lasers have a wide application in medicine and

surgery. Laser light is a man-made. Lasers are heat producing devices

converting electromagnetic energy into thermal energy.

Laser light has three characteristic features:

1. Monochromatic: All waves produced by the laser have the same

frequency and energy.

General Review

9

2. Coherent: All waves are in the same phase, related to each other in

speed and time.

3. Collimated: All the emitted waves are nearly parallel and the beam

divergence is very low. Lasers emit photons with specific

wavelength exerting a strong effect on the target tissue. The

photon emitted depends on the state of the electron’s energy when

the photon is released.4

USES OF DIODE LASER :

Caries and calculus detection, intraoral soft tissue surgery,

sulcular debridement, treatment of dentin hypersensitivity and gingival

depigmentation.

Characteristics of lasers and its periodontal applications6

Lasers Wavelength Colour application

Excimer

Lasers

1. Argon fluoride (ArF)

2. Xenon Chloride (XeCl)

193nm

308nm

Ultraviolet

Ultraviolet

Hard tissue ablation,

dental calculus

removal

Gas

Lasers

1. Argon (Ar)

2. Helium Neon (HeNe)

3. CarbonDioxide (CO2)

488nm,514nm

637nm

10,600n

Blue

Blue-Green

Red Infrared

Intraoral soft tissue

surgery, sulcular

debridement,

analgesia, Treatment

of dentin

hypersensitivity,

analgesia Intraoral and

implant soft tissue

surgery, gingival

depigmentation

General Review

10

Diode

Lasers

1. Indium Gallium Arsenide

Phosphorus (InGaAsP)

2. Gallium Aluminium

Arsenide (GaAlAs)

3. Gallium Arsenide ( GaAs)

4. Indium Gallium Arsenide

(InGaAs)

488nm

655nm

670-830nm

840nm

Red

Red-

Infrared

Infrared

Infrared

Caries and calculus

detection Intraoral soft

tissue surgery, sulcular

debridement,

treatment of dentin

hypersensitivity,

gingival

depigmentation

Solid

State

Lasers

Frequency doubled

Alexandride

1. Potassium Titanyl Phosphate

(KTP)

2. Neodymium: YAG

(Nd:YAG)

3. Holmium:YAG (Ho:YAG)

4. Erbium,ChromiumYSGG

(Er,Cr:YSGG)

6. Erbium:YSGG

(Er:YSGG)

7. Erbium: YAG

(Er:YAG)

337nm

532nm

1,064nm

2,100nm

2,780nm

2,790nm

2,940nm

Ultraviolet

Green

Infrared

Infrared

Infrared

Infrared

Infrared

Selective ablation of

dental plaque and

calculus. In intraoral

soft tissue surgery,

sulcular debridement,

analgesia, treatment of

dentin hypersentivity,

gingival

depigmentation. In

intraoral general and

implant soft tissue

surgery, sulcular

debridement, scaling

of root surfaces,

osseous surgery,

treatment of dentin

hypersensitivity

analgesia, aphthous

ulcer treatment

LOCAL DRUG DELIVERY

Dr. Max Goodson in 1979 developed local delivery of

therapeutic agents into a viable concept. This mode of dr ug delivery

avoids most of the problems associated with systemic therapy. It

General Review

11

concentrates the drug in the target si te avoiding systemic

complications. For local delivery in the subgingival areas, various

antimicrobials have been tried e.g. tetracycline, c hlorhexidine and

metronidazole.

The use of locally delivered antimicrobials is a relatively new

addition in the management of periodontitis. The commonly used drug

delivery systems are: -

a) Metronidazole gel

b) Minocycline gel

c) Tetracycline fiber

d) Chlorhexidine chip

e) Doxycycline polymer.7

Tetracyclines have been used extensively in the treatment of

periodontal disease since many years. Tetracyclines are semi synthetic

chemotherapeutic agents which are bacteriostatic in action and hence

are effective against rapidly multiplying bacteria.

Tetracycline have been incorporated into a variety of delivery

systems(non resorbable or bio resorbable)for insertion into periodontal

pockets.8

Tetracycline fibers are the first available local drug. It had

ethylene/vinyl acetate copolymer fiber with diameter of 0.5 mm,

General Review

12

containing tetracycline12.7mg per 9 .1 inches. Actisite tetracycline

fibres, approved by the United States Food and Drug Administration

(FDA) and by the European Union's regulatory agencies, are non -

resorbable and safe. It is an inert copolymer loaded with 25% w/w

tetracycline HCI .It maintains constant concentrations more than 1000

µg/mL for a period of 10 days. Follow up showed reduction in t he 2

sub gingival micro biota. Periodontal Plus AB, a commercially

available bio resorbable tetracycline fibres developed with base of

collagen film, offers the advantage of no second appointment for

removal as it degrades within 7 days .

Doxycycline :

Atridox is a FDA approved 10% doxycycline in a gel system

using a syringe. GCF levels reached its peak to 1,500 -2,000 in 2 hours

following treatment with Atridox. These levels remained above 1000

µg/mL through 18 hours, and then levels gradually declined.

Metronidazole :

Elyzol is a topical medication containing an oil -based

metronidazole 25% dental gel, applied in viscous consistency to the

pocket. Yeal Shifrovitch et al 2009 in a study enabled the

understanding of metronidazole release kinetics from bioabsorbable

polymeric films and demonstrated good biocompatibility and the ability

to inhibit Bacteroides fragilis growth; therefore, they may be useful in

the treatment of periodontal diseases.

General Review

13

Chlorhexidine

Periochip is a small biodegradable chip con taining 2.5 mg of

chlorhexidine gluconate. Chlorhexidine gluconate is incorporated in a

hydrolysed gelatin matrix, cross -linked with glutaraldehyde . It also

contains glycerine and water.

Various agents available in market9

Agent Product available Dosage form

Tetracycline 1. Actisite (25%w/v tetracycline Hcl)

2. Periodontal plus AB(2mg of

Tetracycline in 25mg of collagen)

Non resorbable fiber

Doxycycline Atridox (10% Doxycycline) Bio degradable mix in syringe.

Minocycline Dentomycin gel (2% Minocycline) Biodegradable gel Arestin (2%

Minocycline) Biodegradable mix in

syringe Periocline (2.1%w/v

Minocycline) Ointment

Metronidazole Elyzol (25% Metronidazole) Biodegradable gel

Chlorhexidine 1. Periochip (2.5mg Chlorhexidine)

2. Periocol CG (2.5mg Chlorhexidine)

3. Chlosite (1.5% Chlorhexidine)

Biodegradable chip

Biodegradable chip

Review Of Literature

14

REVIEW OF LITERATURE

Ciando SG et al. (1992)1 0

evaluated the concentration and location of

tetracycline hydrochloride in tissue adjacent to periodontal pockets

treated with a tetracycline impregnated fiber. A secondary objective

was to determine if the pre surgical placement of fibers had any

adverse effects on healing following periodontal surgery. The study

population consisted of 10 patients with minimum 2 pockets of ≥ 5 mm

in depth and exhibiting bleeding on probing in both maxillary

quadrants. After an init ial scaling and root planing, 2 non -adjacent

pockets were selected, placebo or tetracycline fibers were randomly

used. Fibers were removed at the time of surgery; i .e., day 8, and

periodontal surgery was performed utilizing a flap incision that

allowed biopsy of inter dental papil la from each of the 2 test sites in

each quadrant. One biopsy was analyzed for tetracycline concentrations

by high performance liquid chromatography (HPLC). Light and

ultraviolet fluorescence microscopy are used to determine the location

of residual tetracycline and the intensity of inflammatory cell in

second biopsy and concluded presurgical use of si te-specific,

controlled delivery of tetracycline does not interfere with post -surgical

healing

Radvar M et al . (1996)1 1

evaluated the efficacy of three local drug

delivery as adjuncts to scaling and root planing in treatment of sites

with persistent periodontal lesions . 54 patients with 4 pockets ≥ 5 mm

https://www.ncbi.nlm.nih.gov/pubmed/?term=Radvar%20M%5BAuthor%5D&cauthor=true&cauthor_uid=8884642


15

and bleeding on probing were randomized in 4 treatment groups

including: SRP with application of 25% tetracycline fiber (S + Tet) in

13 patients, SRP with application of 2% minocycline gel (S + Min)

in14 patients , SRP with 25% metronidazole gel (S + Met) in14 patients

and SRP alone in 13 patients . Clinical measurements were taken at

baseline and after 6 weeks . All treatments were applied using the

protocols and resulted in significant improvement in probing depth,

attachment level, modified gingival index (MGI) scores and bleeding

on probing. The improvements in clinical parameters were imporved in

all three adjunctive treatment groups than SRP alone and concluded

that a treatment regimen of scaling and root planing plus tetracycline

fiber substitute gave the greatest advantage in the treatment of

persistent periodontal lesions atleast during the 6-week period

following treatment

Moritz A et al . (1998)1 2

examined the long-term effect of diode laser

therapy on periodontal pockets regarding to i ts bactericidal abilities

and the improvement of periodontal condition with Fifty patients , were

at random divided into laser-group and control group and

microbiologic samples were collected. After that periodic appointments

for 6 months were given. After evaluating periodontal indices

(bleeding on probing, Quigley-Hein) including pocket depths and oral

hygiene instructions with scaling therapy of all patients, the deepest

pockets of each quadrant of the laser-group’s were microbiologically

examined. Afterwards, all teeth were treated using diode laser. The


16

same treatment was given to control-group but instead of laser therapy

were rinsed with H2O2 and concluded diode laser reveals a bactericidal

effect addition to scaling. The diode laser therapy, in combination with

scaling, supports healing of the periodontal pockets through

eliminating bacteria.

Kreisler M et al . (2001)1 3

evaluated the effects of laser treatment of

root surface specimens on the attachment of periodontal ligament

(PDL) cells in vitro which methodology include that root specimens

were arranged from periodontally diseased teeth. PDL cell s were

obtained from human 3rd molar ligaments. Cells were cultured under

simple, standardized, and reproducible conditions. 150 root specimens

were treated with phase I therapy followed by air-powder abrasive

treatment; 75 were then lased and 75 were controls. The irradiation

time was 20 seconds at 1 W and it placed in culture dishes, covered

with a solution of PDL cells, and incubated for 3 days . Using

phosphate buffer the specimens were washed to remove cells not

attached to the surface, methylene blue was used to stained the

adherent cells . Cells were counted using a reflected light microscope

and the cell density per mm2 was calculated and concluded that the

application of the diode laser at the parameters used did not have a

positive effect on the new attachment of PDL cells on the tooth

specimens. It remnants to be investigated whether the difference

detected is really clinically relevant.


17

Grisi DC et al . (2002)1 4

evaluated the effectiveness of a controlled -

released chlorhexidine chip (CHX) as adjunctive therapy to SRP in the

treatment of chronic periodontitis. 20 patients with at least four sites

with probing depth ≥ 5 mm and bleeding on probing were selected.

This randomized single-blind study was carried out . The control group

were treated with SRP alone, while the test group were treated with

SRP plus CHX chip with clinical parameters Plaque Index (PI),

Gingival Recession (GR), Papillary Bleeding Score (PBS), Probing

Depth (PD) and Relative Attachment Level (RAL), Bleeding on

Probing (BOP), and the microbiological parameter BANA test were

recorded at baseline and after 3, 6 and 9 months and concluded that the

both groups presented significant improvements in a ll parameters

analyzed over the study period .

Miyazaki A et al . (2003)1 5

compared the effectiveness of laser

(Nd:YAG and CO2 )treatment to that of ultrasonic scaling, by

examining clinical parameters, subgingival microflora, and interleukin -

1 beta (IL-1β) in gingival crevicular fluid (GCF) with Eighteen

patients, each of whom had 2 or more sites with probing depth

measuring >5 mm, were included this clinical trial. The 41 sites were

randomly treatment with either Nd:YAG laser alone (n = 14, 100 mj, 20

pps, 2.0 W, 120 seconds), ultrasonic scaling alone (n = 14, maximum

power, 120 seconds) , CO2 laser alone (n = 13, 2.0 W, 120 seconds) . At

baseline and at 1, 4, and 12 weeks, clinical measurements (gingival

index, GI; plaque index, PI; bleeding on probing, BOP probing depth,


18

PD; clinical at tachment level, CAL) were performed and subgingival

plaque and GCF sampled. A quantitative analysis of P. gingivalis was

carried out using polymerase chain reaction (PCR) procedures. The

amounts of IL-1β were estimated by an enzyme -linked immunosorbent

assay (ELISA) and concluded that Nd:YAG laser and ultrasonic

scaling treatments showed signifi cant improvements in clinical

parameters and bacterial load compared to the baseline, but no

significant difference was observed between the 3 groups.

Walsh LJ (2003)1 6

reviewed the range of lasers now available for use

in dentistry. This paper summarizes key current app lications for lasers

in clinics. A diagnostic application of low power lasers is the detection

of caries, using fluorescence elicited from hydr oxyapati te or from

bacterial products. Laser fluorescence is an method for detecting and

quantifying incipient occlusal and cervical car ious lesions.

Photoactivated dye techniques can be used to disinfect root canals,

cavity preparations , periodontal pockets and peri-implanti tis. Powerful

lasers can be used for photodynamic therapy in the treatment of oral

mucosal malignancies . Tooth whitening can be done also by laser -

driven photochemical reactions . In combination with fluoride, laser

irradiation can improve the resistance of tooth structure to

demineralization, and this application is advantage for susceptible sites

in high caries ri sk patients. Laser technology for caries removal, cavity

preparation and soft tissue surgery is at a high state of refinement,

having several decades of improvement up to the current time. Used in


19

conjunction with or as a replacement for traditional method s, it is

expected that specific laser technologies will become an essential

component of contemporary dental practice over the next decade.

Borrajo JL et al. (2004)1 7

did a study to evaluate clinical efficacy of

InGaAsP diode laser as adjunct to traditional SRP as an adjuvant to

non-surgical periodontal treatment. Thirty patients suffering from

moderate periodontal disease have been considered and were randomly

selected to undergo either SRP combined with InGaAsP laser (980 nm

and 2 W ). Clinical parameters like papil la bleeding (PBI), bleeding on

probing (BOP), and clinical at tachment level (CAL) were registered at

the beginning and end of treatment and found that SRP in combination

with laser produce more clinical improvement over conventional

treatment.

Ambrosini P et al. (2005)1 8

evaluated scaling and root planing with

Nd:YAP laser in thirty subjects 20–60 years with periodontal pockets

at least 5 mm deep in each quadrant received phase I periodontal

theraphy. The study had a split -mouth design. The control site (SRP)

treated with SRP, and the test site was treated by both SRP plus

Nd:Yap (yttrium aluminum perovskite doped with neodym) laser.

Clinical conditions were evaluated at day 0 and 90 using the PI, GI,

bleeding on probing, PPD, and clinical attachment level. Microbial

sampling was also performed on days 0 and 90, and the presence of

A. actinomycetemcomitans , P. gingivalis , Prevotella intermedia , T.


20

forsythensis , and T. denticola was analysed by polymerase chain

reaction in laboratory. Post -operative pain or discomfort was measured

by the patient using a linear visual scale. Pearson's chi -squared test

was used to compare bacterial load and concluded that SRP was

effective in reducing levels of plaque, inflammation, and bleeding upon

probing. No additional advantage was ach ieved by using the Nd:YAP

laser.

Chanthaboury R et al . (2005)1 9

reviewed various studies of laser used

in periodontal debridment and concluded bacterial invasion cannot be

eradicated by mechanical debridement alone and concluded that more

vivo studies need to focus on laser.

Cobb C M et al. (2006)2 0

reviewed laser in periodontics and concluded

there is a vast need to develop an evidence-based approach to the use

of lasers for the treatment of CP and the current evidence says that the

use of Nd:YAG wavelength for the treatment of CP may be equivalent

to SRP with respect to reduction in probing depth and subgingival

bacteria population.

Divya P.V et al. (2006)2 1

reported that topical administration

mouthwash, dentifrice or gels can be used effectively in controlling

supra gingival plaque. Irrigation systems can deliver agents into deep

pockets but clinically not effective in stopping the progression of

periodontal attachment loss and concluded Local drug delivery appears


21

to be as effective as SRP with regards to reducing s igns of

inflammatory disease - redness, bleeding on probing, probing depth and

loss of cl inical attachment.

Lopez N J S et al . (2006)2 2

determined the effect of metronidazole

plus amoxicillin (M+A) as the sole therapy, on the subgingival

microbiota of chronic periodontitis with twenty-two patients with

untreated CP were randomly assigned to a group that received M+A for

7 days, or to a group receiving scaling and root planing (SRP) and two

placebos with Clinical measurements and concluded that Changes in

clinical and microbiological parameters were parallel after receiving

systemically administered M+A as the sole therapy or after receiving

SRP only.

Lee D et al . (2007)2 3

reviewed the application of laser in periodontics

and concluded that to have a successful periodontal treatment in long

term and patients need to be motivated and concluded that not so much

focus on techolongy.

Shahabouei M et al. (2007)2 4

compared the clinical and microbial

results of non surgical periodontal therapy alone with Nd: YAP laser in

6 patients with 48 periodontal pockets and concluded that application

together with conventional methods provide better cl inical and

microbial outcomes.


22

Cheng W H R et al . (2008)2 5

followed the periodontal healing response

changes over a 12-month period after non-surgical conventional

periodontal therapy with the adjunctive use of chlorhexidine and

periodic recalls in adults with down syndrome who presented init ially

with CP studied 21 subjects with down syndrome (14 males and seven

females; 25.3 – 5.5 years of age) CP was treated by non-surgical

conventional periodontal therapy(followed by monthly recalls)and the

adjunctive use of chlorhexidine gel for brushing, chlorhexidine

mouthwash twice daily. Clinical data were recorded and concluded

satisfactory healing responses were achieved after non-surgical

conventional periodontal therapy with the adjunctive use of

chlorhexidine and monthly recalls in adults with down syndrome with

chronic periodontitis and mild-to-moderate learning disabilities

Karlsson M R et al . (2008)2 6

did a study to systematically review the

evidence on the effectiveness of laser therapy as an adjunct to non -

surgical periodontal treatment in adults with chronic periodontitis. A

study was conducted with randomized controlled trials comparing the

outcomes of periodontitis with laser as an adjunct to SRP in the

treatment of CP. The electronic databases, Pubmed and cochrance

central register of controlled trials, were used as data sources.

screening, quality assessment and data abstraction, were conducted

independently by three reviewers. The primary outcome measured

evaluated were change in clinical attachment level, probing depth, and

bleeding on probing. it was found that no consistent evidence supports


23

the efficacy of laser treatment as an adju nct to non surgical periodontal

treatment in adults with chronic periodontitis

Lopes BMV et al . (2008)2 7

compared Er:YAG laser irradiation with or

without conventional scaling and root planing (SRP) to SRP only for

the treatment of periodontal pockets affected with chronic periodontit is

with Twenty-one subjects with pockets from 5 to 9 mm in non -adjacent

sites were studied. In a split -mouth design, each site was randomly

allocated to a treatment group: SRP and laser, laser only, SRP only , or

no treatment . The plaque index (PI), gingival index (GI), bleeding on

probing (BOP), and interleukin (IL) -1β levels in crevicular fluid were

evaluated at baseline, 12t h

and 30t h

day postoperatively, whereas

probing depth (PD), gingival recession (GR), and clinical attachmen t

level (CAL) were evaluated at baseline and 30 days after treatment and

concluded that Er:YAG laser irradiation may be used as an adjunctive

aid for the treatment of periodontal pockets, although a significant

CAL gain was observed with SRP alone and not with laser treatment.

Schwara F et al. (2008)2 8

conducted a systemic review of li terature to

evaluated the clinical effect of laser application compared with

conventional debridement in non surgical periodontal therapy in patient

with CP. And it was concluded that Er:YAG laser has characteristics

most suitable for the non surgical treatment of chronic periodontitis

and research conducted so far has indicated that its safety and effect


24

might be expected to be within the range for conventional mechanical

debridement.

Bains K V et al . (2009)2 9

laser in dentistry viz CO2, Ho:YAG,

Nd:YAG, Er:YAG, Nd:YAP, Cr:YSGG, GaAs (diode) and argon.

Er:YAG laser possesses the best property for subgingival calculus

removal without any thermal change in the root surface, soft tissue

surgical procedures, root surface alterations, degranulation and implant

surface decontamination along with proposed application in osseous

surgery. Epithelial exclusion using CO2 laser has retarded its

downward growth. Recent devices are Waterlase® and PeriowaveTM

systems, that have further enhanced the laser techonology for the

clinical applications; however, the cost of the laser device is still an

obstacle for its routine application and concluded that lasers have been

suggested as an adjunctive or alternative to conventional techniques for

various periodontal procedures.

Panwar M C L et al . (2009)3 0

reported SRP is the basic treatment for

periodontal disease. conventional treatment is limited by biochemical

considerations and physical impediments. Antimicrobial agents can be

used as an adjunct to overcome limitations of conventional therapy. In

Group A scaling and root planing was alone carried out whereas in

Group B tetracycline fibers were used along with scaling and root

planing. Result : using TF as an adjunct to scaling and root planing was

found to be more effective in reducing inflammation. The number of


25

sites with bleeding on probing were 12 in Group A and 4 in Group B

after 30 days. The mean decrease in probing depth was more in Group

B than Group A after 30 and 90 days. The decrease in probing depth

was statistically significant with both conventional therapy as well as

with tetracycline fibers. Concluded that local drug delivery with

tetracycline f iber is an effective non surgical method to improve

periodontal status.

Slot E D et al . (2009)3 1

evaluated, in a systematic manner and after a

comprehensive search of the li terature, the (additional) therapeutic

effects of using and concluded that there is no evidence to support the

Nd:YAG laser over traditional manner of periodontal therapy.

Srivastava R et al . (2009)3 2

study was undertaken to evaluate

clinically, the newly released sustained drugs, PerioCol (Chlorhexidine

- CHX- chip) with Periodontal Plus ABTM (Tetracycline fibers) with

Patients were allocated in 3 experimental treatment gro ups, Group A-

SRP + CHX Chip, Group B- SRP + TF, and Group C- SRP alone

(control group). Forty-five sites in 14 patients (9 females and 5 males)

with chronic periodontitis were evaluated clinically for probing depth

(PD) (5-8mm probing depth) and relative attachment level (RAL) and

concluded that the Combination of SRP + CHX chip (Group A) resulted

in added benefits compared to the other two treatment groups.


26

Soares F B P et al . (2009)3 3

evaluated the influence of scaling and root

planing (SRP), with and without the use of tetracycline -loaded bovine

absorbent membrane, in the reduction of periodontal pockets , probing

pocket depth (PPD), bleeding on probing (BOP) and plaque index (PI)

reduction. 24 patients were selected totalizing 144 random teeth

divided in 2 groups, n=72 teeth, control (SRP) and experimental (SRP

with tetracycline-loaded absorbent membrane). PPD, BOP and PI were

evaluated preoperatively and 28 days after the treatment. At the end of

the treatment the PPD values always lower than the baseline values.

There was a reduction of the PI in both methods , but it was more

evident on the experimental group. Concluded that the use of

tetracycline-loaded absorbent membrane result in a better prognosis

compared to scaling and root pl aning after only 28 days of evaluation.

Fallah A et al . (2010)3 4

studied the effect of 980 diode laser +scaling

and root planing versus SRP alone in the treatment of chronic

periodontitis with 21 healthy patients with moderate periodontitis with

a probing depth atleast of 5mm were included in the study and

concluded that there is siginificant improvement in the clinical

parameters.

Matthews D C et al . (2010)3 5

presented the most current clinical

evidence on the use of soft t issue lasers in the peri odontal disease and

concluded that there is no improvement in the clinical value.


27

Ayko G et al . (2011)3 6

evaluated the effect of low-level laser therapy

as an adjunct to non-surgical periodontal therapy among smoking and

non-smoking patients with moderate to advanced CP with 36

systemically healthy patients who were included in the study are

initially treated with phase I therapy. The LLLT group (n = 18) receive

(GaAlAs) laser therapy as an adjunct to non -surgical therapy. A diode

laser with a wavelength of 808 nm was used for the LLLT. After

periodontal treatment on the first, second, and seventh days the

Gingival surface was treated by energy density of 4 J/cm2. Each of the

LLLT and control groups were divided into 2 groups are smoking and

non-smoking patients to investigate the effect of smoking during

treatment. Gingival crevicular fluid samples were collected from all

patients and clinical parameters were recorded according to the

protocol (baseline, the fi rst, third, and sixth months ) after treatment.

Tissue inhibitor matrix metalloproteinase -1, Matrix metalloproteinase-

1,transforming growth factor -β1, and basic-fibroblast growth factor

levels in the collected gingival crevicular fluid were measured and

concluded that LLLT as an adjunctive therapy to non -surgical

periodontal treatment improves periodontal healing.

Birang R et al . (2011)3 7

investigated the effects of SRP assisted by the

two treatment modality, of diode laser or Chlorhexidine Gel

applications in comparison with SRP alone with 80 patients with

moderate to severe CP, each with at least three pockets 4–7 mm, were

selected for this study. Totally 66 pockets were selected and randomly


28

treated by either SRP alone, or SRP + diode laser (laser group),or by

SRP + chlorhexidine gel -xanthan based (gel group) and concluded that

treatment with diode laser or chlorhexidine gel as an adjunct to SRP

may improve periodontal and microbiological status, compared to SRP

alone. Diode laser showed better bacterici dal effects in long term.

Gill JS et al . (2011)3 8

compared the clinical efficacy of tetracycline

fibers and a xanthan based chlorhexidine gel in the treatment of

chronic periodontitis with 30 patients in age group of 30 -50 years

suffering from generalized chronic periodontitis were selected with

each subject two experimental sites were chosen that had probing depth

of 5 mm and were located in symmetric quadrants and sites were

randomized at split mouth level with one receiving tetracycline fibers

and other chlorxidine gel and concluded that the long term studies with

more samples are needed for further evaluate and compare the efficacy

of both materials.

Kalsi R et al . (2011)3 9

analysis the effect of local drug delivery in

chronic periodontitis and concluded that the local drug delivery

combined with SRP appears to p rovide additional benefits in PPD

reduction compared with SRP alone.

Lagdive S S et al . (2011)4 0

describes about the effectiveness of diode

laser for various periodontal surgeries and concluded that the patient’s

gingival health is improved in a minimally invasive gentle manner.


29

Lin J et al . (2011)4 1

examined non surgical treatment of periodontal

disease comparing with diode laser to subgingival curettage with

conventional hand instruments with 18 patients of moderate periodontal

degradation who are treated without local anesthesia and split into two

group and concluded that diode laser sub gingival curettage resulted

statistical improvement in clinical parameters compared to hand

instruments

Prasad SSV et al. (2011)4 2

reviewed about lasers in periodontics and

resulted as use of laser energy in period ontal therapy is indicated and

scientific li terature should be followed for future developments.

Sachdev S et al . (2011)4 3

compared the clinical efficacy of

tetracycline impregnated fibrillar collagen in conjunction with SRP,

SRP alone in the treatment of CP. The study was conducted in a split

mouth manner. 35 patients having at least two non adjacent sites in

different quadrants with periodontal pockets 5mm and with bleeding

on probing at init ial visit were treated with both scaling and root

planing plus tetracycline fibers or with either scaling and root planing

alone. Baseline and follow up measurements included plaque index,

gingival index, probing pocket depth and clinical attachment level.

Both treatment modalit ies were effective in improving clinical

parameters over 3 months recall. The combined antimicrobial and

mechanical debridement therapy has shown better results as compared

to SRP alone. Application of tetracycline in modified collagen matrix


30

following SRP shows better treatment of chronic adult periodontitis

and improving periodontal parameters for 3 months duration.

Bhardwaj A et al . (2012)4 4

reviewed various approaches of local drug

delivery systems for the administration of drugs to the periodontal

pocket and effectiveness of these systems in the periodontal therapy

and concluded that as a monotherapy, local drug delivery systems

incorporating a assortment of drugs can improve periodontal health.

Local drug delivery was effective as SRP with regards to reducing

signs of periodontal inflammatory. Local delivery may be an adjunct to

conventional therapy. The recent advances in periodontal local drug

delivery systems are - free mucoadhesive, biodegradable nanoparticles

technology has an immense opportunity for the designing of new,

low-dose and valuable treatment method by the use of controlled

device. These devices are more convenient, easy-to-use and more

effective than the regular drugs and medicines which act systemically.

Dodwad et al . (2012)4 5

reviewed about the local drug delivery in

periodontics: a strategic intervention and concluded that adjunctive use

of local drug delivery may provide a defined but limited beneficial

response. However the magnitude of change anticipated by combined

therapy must be interpreted in light of the severity of the defects being

treated. Therefore the clinician will need to make decisions based on

the desired outcomes of the therapy.


31

Jain R et al. (2012)4 6

evaluated the long term efficacy of a locally

delivered 2% minocycline gel as an adjunct to scaling and root planing

in managing chronic periodontitis by twenty two pairs of sites with

similar probing depths were randomly allocated to test and control

groups. All sites are treated with SRP plus minocycline gel in

the test sites.PPD, relative attachment levels, plaque index, and

microbiological parameters were evaluated for both the groups over a

9-month period and concluded that investigation did not show any

significant advantage of using 2% minocycline gel over SRP.

Kruger R et al . (2012)4 7

assessed the clinical and microbiological

outcomes of Er:YAG laser in comparsion with sonic debridement in the

treatment of periodontal pockets with 78 patients in supportive

periodontal therapy with two residual pockets were included ,clinical

parameters and microbiological analysis was performed employing a

DNA diagnostic test kit and concluded that both sonic and laser

treatment procedure during supportive periodontal care both clinical

microbiological outcomes can be similar .

Krohn dale I et al . (2012)4 8

compared the clinical and microbiologic al

effects using Er:YAG lasers with conventional debridement with

fifteen patients all smokers having at least four teeth with residual

probing depth more than 5mm were recruited and concluded that fail to

support that an ER:YAG laser may be superior to mechanical

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jain%20R%5BAuthor%5D&cauthor=true&cauthor_uid=23055582


32

debridement in the treatment of smokers with recurring chronic

inflammation.

Sgolastra F et al . (2012)4 9

meta-analysis is to evaluate scientific

evidence and effectiveness of SRP+DL compared to SRP alone in CP

patients and concluded that future long- term well-made parallel

randomized clinical trials are required to evaluate the effectiveness of

the adjunctive use of diode laser, as well as the appropriate dosimetry

and laser settings.

Venkatesh A et al . (2012)5 0

discussed the various anti microbials used

in treating periodontal which are delivered as local drug delivery

agents and concluded that the local drug delivery system is effective

for treating the single rooted teeth than multirooted teeth.

Balagopa S et al. (2013)5 1

reviewed about Chlorhexidine: the Gold

Standard Antiplaque Agent and concluded that Chlorhexidin e is one

chemical plaque, which has various clinical applications in denti stry

especially in periodontics. Chlorhexidine in its various formulations

has come to stay and it is appropriate to call i t the gold standard

chemical plaque control agent.

Dhariwal G et al . (2013)5 2

evaluated the efficacy of tetracycline fibre

used along with SRP for the treatment of CP and to compare with SRP

alone. Total of 20 patients with pocket depth ≥ 5 mm were selected for


33

the study. Patients were divided randomly into test group and Control

group. In the control group, periodontal pockets were treated SRP

alone. In the test group periodontal pocket were treated with scaling

and root planing followed by placement of tetracycline fibres. Clinical

parameters, Gingival Index, Plaque Index (Turesky, Gilmore and

Glickman modification of Quigley-Hein Plaque Index) and aspartate

transaminase levels in GCF were recorded at baseline, 15t h

and 30t h

days. Sulcus bleeding index, pocket probing depth and clinical

attachment level were recorded at baseline and 30 days and concluded

that Application of tetracycline in modified collagen matrix following

SRP might be beneficial in treatment of CP and improving periodontal

parameters.

Dukic W et al . (2013)5 3

evaluated the effect of a 980-nm diode laser as

an adjunct to SRP in 35 patients with CP were chosen for the split -

mouth clinical study. SRP was per - formed using a sonic device and

hand instruments. Quadrants were equally divided . Teeth were treated

with SRP in two quadrants (control groups CG), and the diode laser

was used adjunctively with SRP in cont ra lateral quadrants (laser

groups LG). Diode laser therapy was applied to pocket on days 1, 3,

and 7 after SRP. Baseline data, including approximal bleeding on

probing (BOP), plaque index (PI), probing depth (PD), and clinical

attachment level (CAL), were recorded before the treatment and 6 and

18 weeks after treatment. Changes in PD and CAL were analyzed

separately for initial ly moderate (4 to 6 mm) and deep (7 to 10 mm)


34

pockets and concluded that compared to SRP alone, multiple adjunctive

applications of a 980-nm diode laser with SRP showed PD

improvements only in moderate periodontal pockets (4 to 6 mm) .

Kaplish V et al . (2013)5 4

approaches the main delivery systems for the

administration of drugs to the periodontal pocket, the advancement of

these systems effectiveness in the periodontal therapy and concluded

that local drug delivery system is used effectively in controll ing tiss ue

associated bacteria, i t eradicates the pathogens for several weeks, local

drug delivery system is effectual for treating single rooted teeth than

multi rooted teeth and mode of treatment for shallow periodontal

pockets and recurrent periodontal disease.

Kotwal B et al . (2013)3 revisited the non surgical periodontal therapy

and concluded that non surgical periodontal therapy remains corner

stone of periodontal treatment, clinical trial are still needed to

objectively evaluate adjunctive periodontal therapy frequent

reevaluation and careful monitoring allows the p ractioner the

opportunity to intervene early in the diseased state.

Shah C et al . (2013)5 5

evaluated the effect of gingival curettage with

diode laser to gingival curettage with hand instrument s with 34

chronic periodontitis subjects, of male and Female were selected with

5 mm periodontal pockets (up to 7mm), indicated for curettage

procedures were chosen from each subject. In all patients contra lateral


35

sides were randomly divided into 2 groups. The patients had undergone

SRP before curettage procedure. On the experimen tal site curettage was

treated using diode laser (980 nm) and on control group treated with

curettage using gracey curettes . Clinical datas were collected at

baseline, 1s t

week, 6t h

week and at 3rd

month after therapy and

concluded that After 3 months of evaluation, the diode laser has shown

little additional benefits in curettage procedure done with laser when

compared to curettage procedure with hand instruments.

Uttamani J et al . (2013)5 6

reviewed most current clinical evidence the

use of soft tissue laser in order to aid the cl inicians non surgical

treatment of patients with periodontal disease.

Ashtapure V et al . (2014)5 7

reviewed the concepts of local drug

delivery in periodontics and emphasize on various drug systems

available to date and rationales of using those antibacterial drugs

systems through local delivery into the periodontal pockets.

Kotwal V et al . (2014)5 8

studied about the Clinical Evaluation of

Tetracycline Gel as a Local Drug Delivery System in Association With

SRP in Patients with CP - An in Vivo with A double blind study was

designed to test the effectiveness of the gel using clinical parameters

like gingival index, Plaque index, PPD and Sulcus bleeding index.

These indices were recorded at baseline,15t h

, 30t h

,60t h

and 90t h

day in

40 sites, > 4mm pockets in 11 patients . 20 received tetracycline gel and


36

rest 20 received placebo gel following SRP were compared and

concluded that cost-effective tetracycline gel could be an capable local

drug delivery system when used in adjunct to scaling and root planning

Plessas A et al . (2014)5 9

discussed the evidence behind the current

clinical practice for the administration of the CP patients including

oral hygiene methods, different periodontal therapeutic modalities

currently available are discussed and concluded that the nonsurgical

periodontal treatment remains the gold standard for managing the

periodontal patients. It can result in reduction of inflammation, PPD

and clinical attachment gain. There is no certain amount of initial PPD

where nonsurgical periodontal therapy is no longer effective. However,

it needs to be emphasized that the root instrumentati on is only

indicated for sites with probing depth 4mm and above as instrumenting

shallow sites will potentially develop loss of attachment.

Rajesh H et al . (2014)6 0

reviewed the various local drug delivery

devices used to treat periodontal disease and concluded that devices is

that it reduces the number of patient’s visit and ensures compliance.

Suchetha A et al . (2014)6 1

compared the efficacy of tetracycline

fibres, Povidone iodine when locally delivered to the moderately deep

periodontal pocket with 30 subjects were selected for the study and

divided into two groups; Group I treated with Tetracycline fibers

(Periodontal AB Plus), Group II treated with Povidone iodine local


37

drug delivery. The Gingival Index (GI), Probing Pocket Depth (PPD)

and Clinical Attachment Level (CAL) were measured at baseline and at

3 months and concluded that tetracycline fibers were more efficacious

in improving the periodontal health statu s when compared to Povidone

Iodine.

Crispino A et al . (2015)1 evaluated the effect of a 940nm diode laser

as an adjunct to SRP in patients affected by periodontitis of sixty eight

adult patients with moderate to severe periodontitis were sequentially

enrolled and undergone to periodontal examination and concluded that

the better clinical outcomes diode laser can be routinely associated

with SRP in the treatment of periodontal pockets of patients with

moderate to severe periodontitis.

Garg S et al . (2015)6 2

reviewed the current status of controlled local

delivery their usefulness, as well as the advancement of these systems

in the treatment of periodontitis and concluded that additional

randomized, controlled studies are needed to help delineate the types

of lesions, periodontal diseases, or specific situations where local

delivery systems would be most beneficial .

Kataria S et al . (2015)6 3

evaluate the efficacy of tetracycline fiber

(used as local drug delivery) along with scaling and root planing for

the treatment of CP, and compare the results with those ensuing after

scaling and root planing a lone by 50 patients were selected for the


38

study the treatment sites were divided into two groups using split

mouth technique. In each patient, periodontal pockets were treated with

SRP alone (control site), or treated by SRP with placement of

tetracycline fiber (test site), with the aim of evaluating A .

actinomycetemcomitans in CP and concluded that compared with SRP

alone, tetracycline fiber therapy along with SRP improves clinical

parameters and significantly reduces bacterial colony count in

treatment of chronic periodontitis.

Mehta W P et al . (2015)6 4

s tudied about the neem extract when

incorporated in LLD system used as adjunct to SRP in 15 patients

having CP (7 males and 8 females) with an average age of 25-55 yrs

and the clinical parameters such as Plaque index, Gingival index,

probing pocket depth were determined and microbiological study was

done to assess the subgingival flora of P. gingivalis, P . intermedia,

Fusobacterium nucleatum, A.actinomycetemcomitans. All clinical

parameters were evaluated at baseline, first month and third months.

Full mouth scaling and root planing was performed. 3 groups were

made Group A- SRP, Group B- SRP plus tetracycline fibers, Group C-

scaling and root planing along with placement of neem fibers. The

three selected sites were randomly assigned to one of the groups. The

test sites in group B & C received intra pocket placement of

tetracycline & neem fiber respectively and con cluded that Neem

extracts exhibited good antibacterial property, and was foun d to be


39

marginally better but not statistically significant than commercially

available tetracycline fibres.

Nidhi G et al . (2015)6 5

evaluated the clinical outcome following non

surgical periodontal therapy alone compared to tetracycline fiber

therapy used adjunctively with SRP in the treatment of CP patients and

concluded that Locally delivered tetracycline therapy has a specific

purpose, to control localized infection, whereas s caling is utilized to

remove calculus and other deposits.

Singla D et al . (2015)6 6

proposed as an adjunctive method for

nonsurgical periodontal therapy. The objective of this case report was

to investigate the effects of diode laser on the microbiological and

clinical parameters following SRP with moderate to severe CP, each

with probing pocket depth of 5 to 6 mm was selected. Preoperative and

1 week postoperative anaerobic microbiological samples were taken

from subgingival areas. Clinical parameters incl uding probing pocket

depth, clinical attachment loss and bleeding on probing were recorded

at 0, 1 and 3 months and concluded that Diode laser can be suggested

as an adjunctive method for treatment of moderate periodontal pockets

non- surgically.

Sweatha C et al . (2015)6 7

evaluated the efficacy of the adjunctive use

of minocycline plus SRP as compared with SRP alone in the treatment

of the CP and to compare the effects of local drug delivery of

minocycline microspheres as an adjunct SRP, SRP alone with total


40

number of 72 sites from 18 patients were selected for the study with

pocket depth ≥5 mm and had been diagnosed as CP , were selected for

the study. The selected groups were randomly divided into control

group (group I) test group (group II). Only SRP were done at the

baseline visit for the control sites as well as for test si tes with

application of Arestin™ (1 mg) and redelivery of Arestin™ (1 mg) was

done on 30th day. Clinical parameters such as plaque index, gingival

index, and gingival bleeding index were recorded at baseline, 30, 90

days and day 180 in the selected sites of both the groups. Probing

pocket depth and Clinical attachment level also was recorded at

baseline, day 90, and day 180 for both the groups and study confirm

that Arestin (1mg Minocycline microspheres) delivered in

biodegradable system, are a safe and efficient adjunct to SRP, and

produced significant clinical benefits when compared to SRP alone.

Smiley J C et al . (2015)6 8

Conducted a systematic review and meta -

analysis on nonsurgical treatment of patients with CP by means of SRP

with or without adjuncts and concluded that with a moderate level of

certainty, it found about 0.5mm improvement in CAL with SRP.

Combinations of SRP with adjuncts resulted in CAL improvements

between 0.2 and 0.6 mm over SRP alone. The panel judged the

following adjunctive therapies as beneficial: systemic sub

antimicrobial-dose doxycycline, chlorhexidine chips, systemic

antimicrobials, and photodynamic therapy with a diode laser. There


41

was a low level of certainty in the profit of the other incorporated

adjunctive therapies .

Jose A K et al . (2016)6 9

evaluated the effects of diode laser and

chlorhexidine chip as adjuncts to scaling and root planing in the

management of chronic periodontitis . The objective is to estimate the

outcome of chlorhexidine chip and diode laser as adjuncts to scaling

and root planing on clinical parameters like Plaque Index, Gingival

Index, probing pocket depth and clinical attachment level with Fifteen

chronic periodontitis patients having a probing pocket depth of 5mm-

7mm on atleast one interproximal site in each quadrant wer e included

in the study. After initial treatment, four sites in each patient were

randomly subjected to scaling and root planing (control), chlorhexidine

chip application (CHX chip group), diode laser (810 nm)

decontamination (Diode laser group) or combina tion of both (Diode

laser and chip group). PI, GI, PPD and CAL were assessed at baseline ,

first and third month and concluded that Chlorhexidine local delivery

alone or in combination with diode laser decontamination is effectual

in reducing probing pocket depth and improving clinical at tachment

levels when used as adjuncts to SRP in non-surgical periodontal

therapy of patients with CP.

Materials And Method

42

MATERIALS AND METHOD

The study was carried out in the Department of Periodontology,

Adhiparasakthi Dental College and Hospital , Melmarvathur. Ethical

clearance (2014-MD-BrII-BOB-04) was obtained from the IRB of the

institution. 18 Patients having pocket depth of 4 -6 mm atleast in two

teeth in each quadrant were selected after getting their informed

consent.

Selection of the subject:

Inclusion criteria

1. Systemically healthy patients.

2. Patient who have not had antibiotics during the past 3 months.

3. Selected teeth must have probing pocket depth of 4-6 mm.

Exclusion criteria

1. Smokers.

2. Patient who had not undergone any periodontal treatment during

the past 12months.

3. Pregnant and lactating patients.

4. Teeth indicated for extraction.

STUDY PROTOCOL:

90 sites in 18 patients were selected on the basis of inclusion and

exclusion criteria. In each patient three quadrants were selected


43

randomly and the treatment protocol for the selected site in each

quadrant was also decided randomly by lottery method. Th e sites were

divided into group I,II, and III, according to the treatment to be given.

Group I: SRP

Group II: SRP + diode laser

Group III: SRP + Tetracycline fibers.

A Stent was prepared to maintain the same angulation of the

probe to measure the clinical parameters. Clinical index and clinical

parameters to be measured are as follows.

Gingival index2:

The Gingival index was proposed in 1963 as method for

assessing the severity and quantity of gingival inflammation in

individual patients or among subject in large group. Only gingival

tissue are assessed with the GI. According to this method each of the

four areas of the tooth(facial, mesial, distal, lingual) are evaluated.

Scores and criteria for gingival index(GI)

0 Normal gingiva

1 Mild inflammation: slight change in color and sl ight edema; no

bleeding on probing

2 Moderate inflammation: redness. edema, and glazing, bleeding on

probing

3 Severe inflammation, marked redness and edema, ulceration;

tendency to spontaneous bleeding


44

PROBING DEPTH2:

One of the most important clinical parameters to be measured

and recorded when doing periodontal evaluation is probing depth. The

Probing depth is the distance to which a periodontal probe penetrates

into the pocket. The depth of penetration of a probe in a pocket

depends on such factors as size of the probe, force of its introduction,

direction of penetration, resistance of the tissue and convexity of the

crown.2

CLINICAL ATTACHMENT LEVEL2

As periodontal disease progresses, clinical attachment loss occur

through the destruction of the periodontal ligament and its adjacent

alveolar bone, subsequently leading to gingival recession and increased

probing depth. Therefore, the degree of CAL reflects the severity of

periodontal disease. CAL, which measures the distance between the

cemento-enamel junction and base of the pocket using a periodontal

probe is a criterion for the assessment of the severity of periodontal

disease.

The subjects were made aware of the procedure to be carried out

and the purpose of the study; and all the pertaining questions raised by

the patients were answered to the satisfaction of the patients to ensure

the cooperation. Written informed consent was obtained from the

subjects. Motivation of the subjects through detailed disc ussions was

done.


45

On the first visit the proforma was duly filled with all the

baseline clinical index and clinical parameters (GI, PPD, CAL). Supra

gingival scaling was performed and routine blood investigations were

carried out. The group I si tes were treated with SRP, gr oup II sites

were treated with SRP and adjunctive use of diode laser, group III sites

treated with SRP plus tetracycline fibers.

The si tes to be treated were infiltrated with 2% solutions of

lignocaine hydrochloride with 1:200000 adrenaline. In group I patients

sub gingival scaling and root planing are accomplished with either

universal or area specific gracey curettes. In group II patients, after

SRP, selected si tes were treated by diode laser. The diode was set 1.5

w, 970nm, 30 sec, continous wave and the tip was inserted into the

pocket. After insert ing the tip of the laser fiber into the base of the

pocket it was moved for a few seconds within the pocket and then

slowly withdrawn from the site. In group III Patients, after SRP,

tetracycline fibers were placed into the periodontal pockets

surrounding the teeth and the subjects were asked to refrain from tooth

brushing for the next one week in that particular si te.

Subjects were asked to use chlorhexidine mouthwash (0.2%)

twice daily for two weeks.

After completion of phase I therapy and the adjunct use of laser

and tetracycline fibers, the patients were reviewed every month to

check their compliance. On completion of 3rd month the clinical index

and clinical parameters were measured and evaluated again.


46

Basic Armamentarium:

1. Mouth mirror

2. UNC 15 probe

3. Tweezers

4. Explorer

5. Cotton pliers

6. Gauze

7. Surgical gloves

8. Mouth Masks, Head Cap

9. Lignocaine 2% with adrenaline 1:2,00,000

10.2ml syringe

11.Universal curettes-2R/2L & 4R/4L

12.Gracey curettes- #1-14

13.Diode laser kit

14.Periodontal plus AB


47

Figure :1

Armamentarium


48

Figure:2 Figure:3

Pre operative probing depth Sites treated with diode laser

Figure :4

Post operative probing depth


49

Figure :5 Figure:6

Pre operative probing depth Placement of tetracycline fibers

Figure:7

Post operative probing depth

Results

50

RESULTS

This randomized case control study was done to evaluate the

efficacy of 3 different treatment protocols namely Group -1 SRP,

Group-2 SRP + diode laser, Group-3 SRP with tetracycline fibers in

patients with Generalised Chronic Periodontitis .

A total of 18 patients were included in the study. 90 sites which

fulfilled the inclusion criteria was selected from these 18 patients.

Each group was allotted 30 sites and above said treatment protocol was

carried out. The clinical index and all the clini cal parameters were

measured at baseline and 3 rd month.

Students paired t test was used to compare the preoperative and

post operative values of GI, PPD and CAL within group I, group II,

group III respectively.

ANOVA was done to compare the GI, PPD and CAL values

between the 3 groups.

Results

51

Table 1:Comparison of pre operative and post operative mean ± S.D

values of Gingival index score within the group and between the

three groups.

Gingival index Group 1 Group 2 Group 3 P value

Pre operative 2.8±0.41 2.5±0.50 2.2±0.40 Group : I VS II

I VS III

II VS III

P-value: >0.827

Post operative 0.9±0.35 0.6±0.46 0.7±0.39 Group : I VS II

I VS III

II VS III

P-value: >0.792

Mean change 1.9 1.9 1.5

P- value 0.0000 0.0000 0.0000

Inter group : The preoperative mean gingival index score for group I

was 2.8 and postoperative mean gingival index score was 0.9. On

comparing the preoperative and postoperative gingival index score the

change was found to be statistically significant. (P -0.000).

The preoperative mean gingival index score for group II was 2.5

and postoperative mean gingival index score was 0.6. On comparing

the preoperative and postoperative gingival index score the change was

found to be statistically significant. (P -0.000).

Results

52

The preoperative mean gingival index score for group III was

2.2 and postoperative mean gingival index score was 0.7. On

comparing the preoperative and postoperative gingival index score the

change was found to be statistically significant. (P -0.000).

Intra group : The preoperative gingival index score for group I, II, III

was 2.8, 2.5, 2.2 respectively. On comparing the preoperative mean

gingival index scores between the groups the difference was not

statistically significant. (p - 0.827)

The post operative gingival index score for group I was 0.9, that

of group II and of group III was 0.6 and 0.7 respectively. On

comparing the post operative gingival index scores between group I

and group II; group I and group III; group II and group III the

difference was not statistically significant.(p -0.792)

Results

53

Chart 1: Comparison of mean Pre op and Post op Gingival index

scores between the three groups

preop

postop0

0.5

1

1.5

2

2.5

3

group Igroup II

group III

preop

postop

Results

54

Table 2: Comparison of pre operative and post operative

mean ± S.D values of probing depth within the group and


Probing depth Group 1 Group 2 Group 3 P- value

Preoperative

4.7mm

±0.44

4.86mm

±0.57

4.83mm

±0.74

Group : I VS II

I VS III

II VS III

P- Value: >0.672

Post operative

3.0mm

±0.37

2.6mm ±0.5

2.9mm

±0.60

Group : I VS II

I VS III

II VS III

P- Value: >0.008

Mean change 1.7mm 2.26mm 1.73mm

P- value 0.0000 0.0000 0.0000

Inter group : The mean preoperative probing depth for group I was

4.7mm and mean postoperative probing depth was 3.0mm. On

comparing the mean preoperative and mean postoperative probing

depth the reduction was found to be statistically significant. (P -0.000).

Results

55

The mean preoperative probing depth for group II was 4.86mm

and mean postoperative probing depth was 2.6mm. On comparing the

mean preoperative and mean postoperative probing depth the reduction

was found to be statistically significant. (P -0.000).

The mean preoperative probing depth for group III was 4.83mm

and mean postoperative probing depth was 2.9mm. On comparing the

mean preoperative and mean postoperative probing depth the reduction

was found to be statistically significant. (P -0.000).

Intra group : The mean preoperative probing depth for group I, II, III

was 4.7mm, 4.86mm, 4.83mm respectively. Comparison of the mean

preoperative probing depth between the groups I, II and III the

difference was not statistically significant.

The mean change in the probing depth for group I was 1.7mm,

that of group II was 2.26mm and of group III was 1.73mm. On

comparing the mean post operative probing depth between group I and

group II; group I-group III and group II and group III the difference

was stat istically significant.(0.008)

Results

56

Chart 2: Comparison of mean Pre op and Post op PPD


preop

postop0

1

2

3

4

5

group Igroup II

group III

preop

postop

Results

57

Table 3: Comparison of pre operative and post operative mean ±

S.D values of CAL within the group and between the three groups.

CAL Group 1 Group 2 Group 3 P- value

Preoperative 5.13mm ±0.57 5.16mm ±0.64 5.26mm ±0.58 Group : I VS II

I VS III

II VS III

P - Value: >0.672

Post operative 3.26mm ±0.58 2.80mm ±0.66 3.2mm ±0.67 Group : I VS II

I VS III

II VS III

P-Value: >0.010

Mean change 1.87mm 2.36mm 2.06mm

p-value 0.0000 0.0000 0.0000

Inter Group : The mean preoperative CAL for group I was 5.13mm and

mean postoperative CAL was 3.26mm. On comparing the mean

preoperative and mean postoperative CAL the gain was found to be

statistically significant. (P-0.000).

The mean preoperative CAL for group II was 5.16mm and mean

postoperative CAL was 2.8mm. On comparing the mean Preoperative

and mean postoperative CAL the gain was found to be statistically

significant. (P-0.000).

Results

58

The mean Preoperative CAL for group III was 5.26mm and mean

postoperative CAL was 3.2mm. On comparing the mean preoperative

and mean postoperative CAL the gain was found to be statistically

significant. (P-0.000).

Intra Group : The mean preoperative CAL for group I,II, III was

5.13mm,5.16mm,5.26mm respectively. Comparing the mean

preoperative CAL between the groups I, II and III the differences was

not statistically significant. (P-0.672)

The mean change in the CAL for group I was 1.87mm, that of

group II was 2.36mm and of group III was 2.06 mm. On comparing the

mean post operative change in the CAL between group I and group II;

group I-group III and group II and group III the difference was

statistically significant. (P-0.01.)

Results

59

Chart 3: Comparison of mean Pre op and Post op CAL


Chart 4 : Comparison of mean Pre op and Post op Value of

GI , PD, CAL, within the three groups

preop

postop0

1

2

3

4

5

6

group Igroup II

group III

preop

postop

group I

group III0

1

2

3

4

5

6

preop GI

postop GI

preop PD

postop PD

preop CAL

postop CAL

group I

group II

group III

Discussion

60

DISCUSSION

The primary goal of periodontal therapy is the removal of supra

and sub gingival bacterial deposits by mechanical debridement

consisting of scaling and root planing (SRP) using manual or power-

driven instruments. The complete removal of bacterial and their toxins

from periodontal pockets is not always achieved with conventional

mechanical treatment. The use of lasers and local drug delivery as an

adjunctive therapy for periodonta l disease may improve tissue healing

by bactericidal and detoxification effects2. This study was conducted to

evaluate and compare the changes in clinical index and clinical

parameter of SRP treated sites with sites treated by SRP along with the

adjunctive use of diode laser or tetracycline fibers (Periodontal Plus

AB®.).

The therapeutic clinical outcomes was assessed and compared

based on the clinical index and clinical parameters such as GI, PPD and

CAL.

The preoperative mean pocket depth and mean post operative

pocket depth of group I was found to be 4.7mm+3.0mm respectively.

The mean change in pocket depth for group I was 1.7mm. The mean pre

operative CAL and mean post operative CAL of group I was found to

be 5.13mm and 3.26mm. The mean gain in clinical attachment level

was found to be 1.87mm.

Discussion

61

The reduction in pocket depth and gain in CAL in group I sites

was observed where only scaling and root planing was carried out.

After scaling and root planing the inflammatory changes in the

periodontal pocket wall subside rendering the pocket inactive.

Reduction in pocket depth occurs by shrinkage of tissues along with

the formation of long junctional epithelium2.

In group II sites the mean preoperative pocket depth and mean

post operative pocket depth were found to be 4.86mm and 2.6mm

respectively. The reduction in pocket depth was 2.26mm. The mean and

post operative CAL was found to be 5.16mm +2.80mm. The mean gain

in CAL was found to be 2.36mm.

In group II si tes, treated with SRP + adjunct use of diode laser,

the mean pocket reduction of 2.26mm and mean gain in clinical

attachment of 2.36mm was observed. This reduction in pocket depth

and gain in CAL for group II sites was found to be more compared to

group I sites. This may be due to adjunctive use of l asers in these sites

after SRP.

Laser light at 800-980nm is highly absorbed in hemoglobin and

is indicated for treatment of soft tissue. Secondary effects of laser

treated sites include increased microcirculation, stimulation of immune

response and bactericidal effect. Laser therapy plays an important role

Discussion

62

in wound healing through haemostasis and coagulation which

eventually results in better periodontal health.

The reduction in pocket depth and gain in CAL in group II si tes

in this study is accordance with the study conducted by Neill and

Mellonig in 19972 6

.

In Group III sites, the mean preoperative pocket depth and mean

post operative pocket depth was 4.83mm and 2.9mm respectively. The

Mean reduction in pocket depth was 1.73mm. The mean Pre operative

CAL and mean Post operative CAL was found to be 5.26mm and 3.2mm

respectively. The mean gain in CAL was found to be 2.06mm.

In group III sites after scaling and root planing tetracycline

fibers as local drug was placed into the periodontal pocket. Reduc tion

in pocket depth and gain in clinical attachment may be because of

antimicrobial actions of tetracycline fibers placed in the sites. Along

with antimicrobial action it inhibits collagenase production, inhibits

bone resorption and has anti inflammatory action as well as the abil ity

to promote the attachment of fibroblast to root surfaces.

The reduction in pocket depth and gain CAL in group III sites

was accordance with the study conducted by Goodson (1979), Lindhe

(1979) and Pavia (2003). But not according to the results of the study

conducted by Thomas et al (1998)7.

Discussion

63

On comparing the reduction in GI score, reduction in pocket

depth and gain in clinical attachment level in all the three groups the

reduction in GI Scores, pocket depth was numerical ly more in group II

and gain in CAL was better in group II. Laser therapy in group II sites

and tetracycline fibers in group III sites definitely have an impact on

the microflora because of their bactericidal effect.

All the clinical parameters significantly improved in all the three

groups. Thus considering the limitation of this study, it can be

concluded that diode laser as an adjunct to SRP or Tetracycline fibers

(local drug delivery) as an adjunct to SRP can improve the periodontal

health in sites as compared to SRP alone.

Conclusion

64

CONCLUSION

Based on the findings of the present study, treatment with diode

laser or tetracycline fibers as an adjunct to SRP showed better

reduction in pocket depth and more gain in CAL compared to SRP

alone. Within the l imitation of this study it can be suggested that

treatment with diode laser or tetracycline fibers as an adjunct to SRP

may improve periodontal status compared to SRP alone.

Further study with large sample size and postoperative follow up

for a longer duration is necessary to confirm the results obtained in

this study.

References

65

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Annexure

i

ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL

Department of Periodontics

Patient Evaluation form

Efficacy of scaling and root planing with and without adjunctive use of diode laser or

tetracycline fibers in patients with generalised chronic periodontitis - A comparative study

OP.No: Date:

Name: Age: Gender: Address:

Occupation:

Chief complaint:

History of presenting illness:

Annexure

ii

Past medical history:

Past dental history:

Personal history:

Intra-Oral examination:

Indices:

GINGIVAL BLEEDING INDEX

17 16 15 14 13 12 11 21 22 23 24 25 26 27

47 46 45 44 43 42 41 31 32 33 34 35 36 37

Annexure

iii

PROBING DEPTH:

CAL:

palatal palatal palatal

17 16 15 14 13 12 11 21 22 23 24 25 26 27

Buccal labial buccal

lingual lingual lingual

47 46 45 44 43 42 41 31 32 33 34 35 36 37


17 16 15 14 13 12 11 21 22 23 24 25 26 27

47 46 45 44 43 42 41 31 32 33 34 35 36 37

Annexure

iv

DIAGNOSIS

TREATMENT PLAN:

TREATMENT DONE:

Annexure

v

Revaluation at 3rd month

Indices:

GINGIVAL BLEEDING INDEX

17 16 15 14 13 12 11 21 22 23 24 25 26 27

47 46 45 44 43 42 41 31 32 33 34 35 36 37

PROBING DEPTH:

CAL:

palatal palatal palatal

17 16 15 14 13 12 11 21 22 23 24 25 26 27


17 16 15 14 13 12 11 21 22 23 24 25 26 27

47 46 45 44 43 42 41 31 32 33 34 35 36 37

Annexure

vi

Lingual lingual

47 46 45 44 43 42 41 31 32 33 34 35 36 37

Buccal labial

Staff sign:

Annexure

vii

PARTICIPANT INFORMED CONSENT FORM (PICF)

(English)

Protocol / Study number :______________________

Participant identification number for this trial: _______________________

Title of

project:_________________________________________________________________

___________________________________________________________________________

__

Name of Principal Investigator:

_________________________Tel.No(s).__________________

The contents of the information sheet dated that was provided have been read carefully by me

/ explained in detail to me, in a language that I comprehend, and I have fully understood the

contents. I confirm that I have had the opportunity to ask questions.

The nature and purpose of the study and its potential risks / benefits and expected duration of

the study, and other relevant details of the study have been explained to me in detail. I

understand that my participation is voluntary and that I am free to withdraw at any time,

without giving any reason, without my medical care or legal right being affected.

Annexure

viii

I understand that the information collected about me from my participation in this research

and sections of any of my medical notes may be looked at by responsible individuals from

APDCH. I give permission for these individuals to have access to my records.

I agree to take part in the above study.

--------------------------------------------- Date:

(Signatures / Left Thumb Impression) Place:

Name of the Participant: ____________________________________

Son / Daughter / Spouse of:__________________________________

Complete postal address: _____________________________________

This is to certify that the above consent has been obtained in my presence.

------------------------------

Signatures of the Principal Investigator Date:

Place:

Annexure

ix

ப ொது வொய்ந ொய் சிகிச்சைக்கொன ஓப்புதல் டிவம்

துறற : _________________________________________

தேதி:

த ோயோளியின் பெயர் :

வயது / ெோலினம் :

புறத ோயோளி எண் :

அறுறவ சிகிச்றை மருத்துவ நிபுணரின் பெயர் :

சிகிச்றையின்பெயர் :____________________________________

அளிக்கப்ெடும் மயக்க மருந்தின் வறக :

எனது ேற்தெோறேய வோய் லம் குறித்தும், அேற்கு உரிய சிகிச்றைமுறறகறளயும், மோற்று

சிகிச்றை முறறகறளயும் மற்றும் சிகிச்றைதமற்பகோள்ளோவிடில் ஏற்ெடும் பின்விறளவுகறளயும்

ெல்மருத்துவர்முழுறமயோக என்னிடம் கூறினோர். அேற்கோன எனது ைந்தேகங்கறளயும்

ெல்மருத்துவரிடம் தகட்டு பேளிவுெடுத்திபகோண்தடன். தமலும் சிகிச்றைமுறற, என்

சிகிச்றையின் தெோது தேறவப்ெடும் மயக்க மருந்துகள் மற்றும்பிற மருந்துகள் பைலுத்ே

ைம்மதிக்கின்தறன். ோன் மனப்பூர்வமோக எனதுசிகிச்றைமுறற மற்றும் அேனோல் வரும்

பின்விறளவுகறளயும் ஏற்றுக்பகோள்கிதறன் மற்றும் மருத்துவர் கூறும் அறிவுறரகறளயும்

கறடபிடிப்தென்.

த ோயோளியின் உேவியோளர் / பெற்தறோரின் றகபயோப்ெம் த ோயோளியின் றகபயோப்ெம்

அறுறவசிகிச்றை நிபுணரின் றகபயோப்ெம் மருத்துவரின் றகபயோப்ெம்

INSTITUTIONAL ETHICS COMMITTEE AND REVIEW

BOARD

ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL Melmaruvathur, Tamilnadu-603019

MEMBER SECRETARY

Dr.S.Meenakshi, PhD

CHAIR PERSON

Prof.Dr.K.Rajkumar, BSc,MDS,

PhD MEMBERS

Prof.Dr.A.Momon Singh,MD

Prof.Dr.H.Murali, MDS

Dr.Muthuraj, MSc, MPhil, PhD

Prof.Dr.T.Ramakrishnan, MDS

Prof.Dr.T.Vetriselvan, MPharm,

PhD

Prof.Dr.A.Vasanthakumari, MDS

Prof.Dr.N.Venkatesan, MDS

Prof.Dr.K.Vijayalakshmi, MDS

Shri.Balaji, BA, BL

Shri.E.P.Elumalai

This ethical committee has undergone the research protocol

submitted by Dr S.ANITHA DEVI, Post Graduate Student,

Department of PERIODONTICS under the title "EFFICACY OF

SCALING AND ROOT PLANING WITH AND WITHOUT

ADJUNCTIVE USE OF DIODE LASER OR TETRACYCLINE

FIBERS IN PATIENTS WITH GENERALISED CHRONIC

PERIODONTITIS - A COMPARATIVE STUDY" “Reference No:

2014-MD-BrII-BOB-04 , under the guidance of

Dr. T. RAMAKRISHNAN., MDS for consideration of approval to

proceed with the study.

This committee has discussed about the material being

involved with the study, the qualification of the investigator, the

present norms and recommendation from the Clinical Research

scientific body and comes to a conclusion that this research

protocol fulfils the specific requirements and the committee

authorizes the proposal.

Date:

Member secretary

efficacy of scaling and root planing with and …

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