Upload
others
View
5
Download
0
Embed Size (px)
Citation preview
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
Table 2 Comparison of pre operative and post
operative mean ± S.D values of probing
depth within the group and bet ween the
three groups.
54
Table 3 Comparison of pre operative and post
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
Chart 2 Comparison of mean Pre op and
Post op PPD between the three
groups.
56
Chart 3 Comparison of mean Pre op and
Post op CAL between the three
groups.
59
Chart 4 Comparison of mean Pre op and
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
Review Of Literature
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
Review Of Literature
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.
Review Of Literature
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,
Review Of Literature
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
Review Of Literature
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.
Review Of Literature
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
Review Of Literature
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.
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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.
Review Of Literature
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.
Review Of Literature
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
Review Of Literature
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.
Review Of Literature
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
Review Of Literature
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.
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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)
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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
Review Of Literature
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
Materials And Method
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
Materials And Method
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.
Materials And Method
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.
Materials And Method
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
Materials And Method
47
Figure :1
Armamentarium
Materials And Method
48
Figure:2 Figure:3
Pre operative probing depth Sites treated with diode laser
Figure :4
Post operative probing depth
Materials And Method
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
between the three groups.
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
between the three groups.
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
between the three groups.
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
REFERENCES
1. Crispino A, Figliuzzi MM, Iovane C, DelGiudice T, Lomanno S,
Pacifico D, Fortunato L, Del Giudice R. Effectiveness of a diode
laser in addition to non-surgical periodontal therapy: study of
intervention. Annali di stomatologia. 2015 Jan;6(1):15.
2. Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's
clinical periodontology. Elsevier health sciences; 2011 Feb 14.
3. Kotwal D, Mahajan D, Kalvani D, Dewan D. Non -Surgical
Periodontal Therapy-Revisited. IOSR Journal of Dental and
Medical Sciences (IOSR-JDMS).;1(9):15-9.
4. Dang AB, Rallan NS. Role of lasers in periodontology: A
Review. Annals. 2013;1(01):8.
5. Ramesh A, Bhandary R, Thomas B, Dsouza SR. Laser -a ray of
hope in periodontics-a review article. Nitte University Journal of
Health Science. 2014 Sep 1;4(3):138.
6. Prasad SS, Reddy RN, Agarwal N. Lasers in Periodontics: A
Review. Indian Journal of Stomatology. 2011 Sep 1;2(3).
7. Panwar M, Gupta SH. Local drug delivery with tetracycl in e
fiber: An alternative to surgical periodontal therapy. Medical
Journal Armed Forces India. 2009 Jul 31;65(3):244 -6.
8. Sachdeva S, Agarwal V. Evaluation of commercially available
biodegradable tetracycline fiber therapy in chronic periodontitis.
Journal of Indian Society of Periodontology. 2011
Apr;15(2):130.
References
66
9. Ramesh A, Prakash P A & Thomas B. Local Drug Delivery in
periodontal diseases. A Review. Nitte University Journal of
Health Science 2016;6(1):74-9.
10.Ciando SG, Cobb CM, Leung M. Tissue concentration an d
localization of tetracycline following si te -specific tetracycline
fiber therapy. Journal of periodontology. 1992 Oct;63(10):
849-53.
11.Radvar M, Pourtaghi N, Kinane DF. Comparison of 3 Periodontal
Local Antibiotic Therapies in Persistent Periodontal Pockets*.
Journal of periodontology. 1996 Sep;67(9):860 -5.
12.Moritz A, Schoop U, Goharkhay K, Schauer P, Doertbudak O,
Wernisch J, Sperr W. Treatment of periodontal pockets with a
diode laser. Lasers in surgery and medicine. 1998 Jun;22(5):
302-11.
13.Kreisler M, Meyer C, Stender E, Daubländer M, Willershausen -
Zönnchen B, d 'Hoedt B. Effect of diode laser irradiation on the
attachment rate of periodontal ligament cells: an in vitro study.
Journal of periodontology. 2001 Oct 1;72(10):1312 -7.
14.Grisi DC, Salvador SL, Figueiredo LC, Souza SL, Novaes AB,
Grisi MF. Effect of a controlled ‐release chlorhexidine chip on
clinical and microbiological parameters of periodontal syndrome.
Journal of clinical periodontology. 2002 Oct 1;29(10):875 -81.
15.Miyazaki A, Yamaguchi T, Nishikata J, Okuda K, Suda S, Orima
K, Kobayashi T, Yamazaki K, Yoshikawa E, Yoshie H. Effects of
Nd: YAG and CO2 laser treatment and ultrasonic scaling on
References
67
periodontal pockets of chronic periodontitis patients. Journal of
periodontology. 2003 Feb 1;74(2):175-80.
16.Walsh LJ. The current status of laser applications in dentistry.
Australian dental journal. 2003 Sep 1;48(3):146 -55.
17.Borrajo JL, Varela LG, Castro GL, Rodriguez -Nunez I, Torreira
MG. Diode laser (980 nm) as adjunct to scaling and root planing.
Photomedicine and Laser Therapy. 2004 Dec 1;22(6):509 -12.
18.Ambrosini P, Miller N, Briançon S, Gallina S, Penaud J. Clinical
and microbiological evaluation of the effectiveness of the Nd:
Yap laser for the initial treatment of adult periodontit is. Journal
of clinical periodontology. 2005 Jun 1;32(6):670 -6.
19.Rachel Chanthaboury RD, Irinakis T. The use of lasers for
periodontal debridement: marketing tool or proven therapy?. J
Can Dent Assoc. 2005;71(9):653 -8.
20.Cobb CM. Lasers in periodontics: a review of the lit erature.
Journal of periodontology. 2006 Apr;77(4):545 -64.
21.Divya PV, Nandakumar K. Local Drug Delivery—Periocol In
Periodontics. Trends Biomater Artif Organs. 2006;19(2):74 -80.
22.López NJ, Socransky SS, Da Silva I, Japlit MR, Haffajee AD.
Effects of metronidazole plus amoxicillin as the only therapy on
the microbiological and clinical parameters of untreated chronic
periodontitis. Journal of clinical periodontology. 2006 Sep
1;33(9):648-60.
23.Lee DH. Application of lasers in periodontics: a new approach in
periodontal treatment. Dental Bulletin. 2007 Oct 12;12(10):23 -5.
References
68
24.Shahabouei M, Shirani AM, Navabakbar F, Montazeri PM,
Birang R, Mir M, Mogharehabed A. The clinical and microbial
evaluation of Nd: YAG laser in periodontal pocket healing. J
Oral Laser Appl. 2007 Sep 1;7:233-8.
25.Cheng RH, Leung WK, Corbet EF. Non-surgical periodontal
therapy with adjunctive chlorhexidine use in adults with down
syndrome: a prospective case series. Journal of periodontology.
2008 Feb;79(2):379-85.
26.Karlsson MR, Diogo Löfgren CI, Jan sson HM. The effect of laser
therapy as an adjunct to non-surgical periodontal treatment in
subjects with chronic periodontitis: a systematic review. Journal
of periodontology. 2008 Nov;79(11):2021-8.
27.Lopes BM, Marcantonio RA, Thompson GM, Neves LH,
Theodoro LH. Short -term clinical and immunologic effects of
scaling and root planing with Er: YAG laser in chronic
periodontitis. Journal of periodontology. 2008 Jul;79(7):1158 -67.
28.Schwarz F, Aoki A, Becker J, Sculean A. Laser application in
non‐surgical periodontal therapy: a systematic review. Journal of
clinical periodontology. 2008 Sep 1;35(s8):29 -44.
29.Bains VK, Gupta S, Bains R. Lasers in periodontics: An
overview. J Oral Health Community Dent. 2010;4:29 -34.
30.Panwar M, Gupta SH. Local drug delivery with tetracycl ine
fiber: An alternative to surgical periodontal therapy. Medical
Journal Armed Forces India. 2009 Jul 31;65(3):244 -6.
References
69
31.Slot DE, Kranendonk AA, Paraskevas S, Van der Weijden F. The
effect of a pulsed Nd: YAG laser in non -surgical periodontal
therapy. Journal of periodontology. 2009 Jul;80(7):1041 -56.
32.Srivastava R, Verma PK, Tandon P, Kumar RM, Gupta KK,
Srivastava A. Chlorhexidine chip and tetracycline fibers as
adjunct to scaling and root planing-A clinical study.
33.Soares PB, Menezes HH, Naves MD, Taga EM, Magalhães DD.
Effect of absorbent tetracycline -loaded membrane used in the
reduction of periodontal pockets: an in vivo study. Brazilian
dental journal. 2009;20(5):414 -8.
34.Fallah A. Effects of 980 diode laser treatment combined with
scaling and root planing on periodontal pockets in chronic
periodontitis patients. InBiOS 2010 Feb 11 (pp. 75490D -
75490D). International Society for Optics and Photonics.
35.Matthews DC. Seeing the Light -The Truth about Soft Tissue
Lasers and Nonsurgical Periodontal Therap y. Journal of the
Canadian Dental Association. 2010 Apr 1;76(2).
36.Aykol G, Baser U, Maden I, Kazak Z, Onan U, Tanrikulu -Kucuk
S, Ademoglu E, Issever H, Yalcin F. The effect of low -level
laser therapy as an adjunct to non -surgical periodontal treatment.
Journal of periodontology. 2011 Mar;82(3):481 -8.
37.Birang R, Yaghini J , Adibrad M, Kiany S, Mohammadi Z, Birang
E. The Effects of Diode Laser (980 nm Wavelength) and
Chlorhexidin Gel in the Treatment of Chronic Periodontitis.
Journal of Lasers in Medical Sciences. 2011 Oct 1;2(4):131.
References
70
38.Gill JS, Bharti V, Gupta H, Gill S. Non-surgical management of
chronic periodontitis with two local drug delivery agents -A
comparative study. Journal of Clinical and Experimental
Dentistry. 2011;3(5):424-9.
39.Kalsi R, Vandana KL, Prakash S. Effect of local drug delivery in
chronic periodontitis patients: A meta -analysis. Journal of Indian
Society of Periodontology. 2011 Oct 1;15(4):304.
40.Lagdive SS, Marawar PP, Mani AM. Semiconductor Diode Lasers
in Periodontics: An Innovative and Safe. Indian journal of basic
and applied medical research. 2011;1(1):66 -70.
41.Lin J, Bi L, Wang L, Song Y, Ma W, Jensen S, Cao D. Gingival
curettage study comparing a laser treatment to hand instruments.
Lasers in medical science. 2011 Jan 1;26(1):7 -11.
42.Prasad SS, Reddy RN, Agarwal N. Lasers in Periodontics: A
Review. Indian Journal of Stomatology. 2011 Sep 1;2(3).
43.Sachdeva S, Agarwal V. Evaluation of commercially available
biodegradable tetracycline fiber therapy in chronic periodontitis.
Journal of Indian Society of Periodontology. 2011
Apr;15(2):130.
44.Bhardwaj A, Bhardwaj V S. Local drug delivery in
periodontology. Recent Advances in Pharmaceutical Science
Research 2012;1(1)1-5.
45.Dodwad V, Vaish, Mahajan A, Chhokra M. Local drug delivery
in periodontics: a strategic intervention. International Journal of
Pharmacy and Pharmaceutical Sciences 2012;4(4)30 -34.
References
71
46.Jain R, Mohamed F, Hemalatha M. Minocycline containing local
drug delivery system in the management of chronic periodontitis:
A randomized controlled tria l. Journal of Indian Society of
Periodontology. 2012 Apr;16(2):179.
47.Ratka‐Krüger P, Mahl D, Deimling D, Mönting JS, Jachmann I,
Al‐Machot E, Sculean A, Berakdar M, Jervøe ‐Storm PM, Braun
A. Er: YAG laser treatment in supportive periodontal therapy.
Journal of clinical periodontology. 2012 May 1;39(5):483 -9.
48.Krohn‐Dale I, Bøe OE, Enersen M, Leknes KN. Er: YAG laser in
the treatment of periodontal sites with recurring chronic
inflammation: a 12‐month randomized, controlled clinical trial.
Journal of clinical periodontology. 2012 Aug 1;39(8):745 -52.
49.Sgolastra F, Severino M, Gatto R, Monaco A. Effectiveness of
diode laser as adjunct ive therapy to scaling root planing in the
treatment of chronic periodontitis: a meta -analysis. Lasers in
medical science. 2013 Sep 1;28(5):1393-402.
50.Venkatesh A, Ramamurthy J. Local drug delivery systems in the
treatment of periodontitis–An Overview. Int J Pharm Pharm Sci.
2012;4(1):30-7.
51.Balagopal S, Arjunkumar R. Chlorhexidine: the gold standard
antiplaque agent. J Pharm Sci Res. 2013;5(12):270-4.
52.Dhariwal G and Malho S. Tetracycline fibers plus scaling and
root planing Versus Scaling and root planing alone in chronic
periodontitis: effect on GCF aspartate transaminase level. J
Pharm Biomed Sci 2013 ; 32(32):1265 -70.
References
72
53.Dukić W, Bago I, Aurer A, Roguljić M. Clinical effectiveness of
diode laser therapy as an adjunct to non -surgical periodontal
treatment: a randomized clinical study. Journal of
periodontology. 2013 Aug;84(8):1111-7.
54.Kaplish V, Walia MK, Kumar HS. Local drug delivery sys tems in
the treatment of periodontitis: A review. Pharmacophore. 2013
Mar 1;4(2):39-49.
55.Shah C, Modi B, Budhiraja S, Desai K. A Short Term
Comparative Clinical Evaluation of Diode Laser and Hand
Instruments for Gingival Curettage. Advances In Human
Biology. 2013 Apr 30;3(1):37-42.
56.Uttamani J, Shaikh I, Kulkarni V. Use of Lasers in Nonsurgical
Periodontal Therapy. International Journal of Experimental
Dental Science. 2013 Jan 7;2(1):29 -32.
57.Ashaputre V, Limaye M. Local drug delivery in periodontics: A
tactical entereaty. Journal of research in pharmaceutical science
2014;2(1):06-11.
58.Kotwal V, Tiwari S, Jandial S. Clinical Evaluation of
Tetracycline Gel as a Local Drug Delivery System in Association
With Scaling and Root Planing in Patients with Chronic
Periodontitis-An in Vivo Study. National Journal of Medical and
Dental Research. 2014 Oct 1;3(1):44.
59.Plessas A. Nonsurgical periodontal treatment: review of the
evidence. Oral Health Dent Manag. 2014 Mar;13(1):71 -80.
References
73
60.Rajesh H, Boloor A V, Rao S A, Prathap S, H aziel JD. Local
drug delivery devices used for treating periodontitis - a
review.2014;3(6) 904-.09.
61.Suchetha A, Garg A, Lakshmi P, Sapna N, Mundinamane DB,
Apoorva SM. Povidone Iodine vs Tetracycline Fibers -To Analyse
the Therapeutic Effect. Journal of Ora l Health & Community
Dentistry. 2014 Jan 1;8(1).
62.Garg S. Local Drug Delivery Systems as an Adjunct to Cure
Periodontitis-The Novel Dental Applicant. Pharmaceutical
Methods. 2015 Jan 1;6(1):1.
63.Kataria S, Chandrashekar KT, Mishra R, Tripathi V, Galav A,
Sthapak U. Effect of tetracycline HCL (periodontal plus AB) on
Aggregatibacter actinomycetemcomitans levels in chronic
periodontitis. Arch Oral Dent Res. 2015;2(1):1 -8.
64.Mehta W P, Kudva P, Kudva P H. Comparative Evaluation Of
The Efficacy Of Neem And Tetracycl ine When Incorporated In A
Local Drug Delivery System When Used As An Adjunct To
Scaling And Root Planing A Clinico -Microbiological Study.
IOSR Journal of Dental and Medical Sciences 2015 ;14(4):47 -50.
65.Nidhi G, Amit G, Anirudh A, Sumit S, Shiv G. Journal of
Chemical and Pharmaceutical Research, 2015, 7(9):56 -59.
66.Singla D, Manjunath S, Singh A, Bhattacharya S H, Singh R,
Sarkar A. Laser-assisted Sulcular Debridement. Journal of Dental
Sciences and Oral Rehabili tat ion 2015;6(3):145 -147.
References
74
67.Sweatha C, Srikanth C, Babu R M A. Comparative study of the
effect of minocycline microspheres as an adjunct to scaling and
root planing versus scaling and root planing alone in the
treatment of chronic periodontitis. Int ernational journal of recent
scientific research 2015;6(4):3540-50 .
68.Smiley CJ, Tracy SL, Abt E, Michalowicz BS, John MT,
Gunsolley J, Cobb CM, Rossmann J, Harrel SK, Forrest JL,
Hujoel PP. Systematic review and meta -analysis on the
nonsurgical treatment of chronic periodontitis by means of
scaling and root planing with or without adjuncts. The Journal of
the American Dental Association. 2015 Jul 31;146(7):508 -24.
69.Jose KA, Ambooken M, Mathew JJ, Issac AV, Kunju AP,
Parameshwaran RA. Management of Chronic Periodontitis Using
Chlorhexidine Chip and Diode Laser-A Clinical Study. Journal of
clinical and diagnostic research: JCDR. 2016 Apr;10(4):ZC76.
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
Buccal labial buccal
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
Buccal labial buccal
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