|Year : 2021 | Volume
| Issue : 3 | Page : 227-233
Comparative evaluation of laser biostimulation as an adjunct to NSPT and ITS effects on AST levels in the management of chronic periodontitis: A randomized controlled trial
Stuti Gupta, Shivjot Chhina, Ejya Sharma, Shradha Sinha, Abhishek Mathur, Radhika Gupta
Department of Periodontology, Sharda School of Dental Sciences, Greater Noida, Uttar Pradesh, India
|Date of Submission||18-Jun-2020|
|Date of Decision||08-Mar-2021|
|Date of Acceptance||18-Mar-2021|
|Date of Web Publication||18-Jun-2021|
Dr. Stuti Gupta
Department of Periodontology, Sharda School of Dental Sciences, D 1601, Ace Platinum, Zeta-1, Greater Noida Uttar Pradesh.
Source of Support: None, Conflict of Interest: None
Aim: Clinical evaluation of aspartate aminotransferase (AST) in gingival crevicular fluid (GCF) with and without laser biostimulation as an adjunctive to non-surgical periodontal therapy (NSPT). Materials and Methods: This is a split-mouth randomized trial. Ten patients (20 sites) were diagnosed with chronic periodontitis as per the American Academy of Periodontology (AAP) classification (1999), and radiographic evidence of horizontal bone loss was provided. Scaling and root planning (SRP) was performed in both the test groups. One of the test groups was treated with low-level laser therapy (LLLT) along with SRP and another with only SRP. GCF collection was done at baseline, during the third and sixth months by using microcapillary tubes for the estimation of AST. Quantification of AST was done by a Semi-automated Clinical Chemistry Analyzer. The data were subjected to statistical analysis by an independent t-test, Kruskal–Wallis test, Mann–Whitney U test, Wilcoxon signed-rank test, and post hoc pairwise comparison. Results: The results revealed a statistically significant reduction in pocket probing depth (PPD) (P < 0.001) and relative attachment gain (P < 0.001) at the test sites when compared from baseline till six months. Similarly, there was a statistically significant reduction in AST levels in GCF at the sites treated with laser biostimulation along with NSPT (P < 0.001). Conclusion: Laser biostimulation along with NSPT has shown propitious results as per clinical and biochemical marker analysis and evaluation.
Keywords: Aspartate Aminotransferase, Gingival Crevicular Fluid, Low Level Laser Therapy, Scaling and Root Planning
|How to cite this article:|
Gupta S, Chhina S, Sharma E, Sinha S, Mathur A, Gupta R. Comparative evaluation of laser biostimulation as an adjunct to NSPT and ITS effects on AST levels in the management of chronic periodontitis: A randomized controlled trial. J Int Oral Health 2021;13:227-33
|How to cite this URL:|
Gupta S, Chhina S, Sharma E, Sinha S, Mathur A, Gupta R. Comparative evaluation of laser biostimulation as an adjunct to NSPT and ITS effects on AST levels in the management of chronic periodontitis: A randomized controlled trial. J Int Oral Health [serial online] 2021 [cited 2022 Aug 18];13:227-33. Available from: https://www.jioh.org/text.asp?2021/13/3/227/318445
| Introduction|| |
The term “periodontitis” can imply the destruction of connective tissue, loss of periodontal attachment, and alveolar bone resorption as a result of the interplay between the pathogenic microflora and the immune and inflammatory responses of the host. The immune system is triggered so as to protect the host against local microbial attacks and their damaging products from spreading into the gingival tissues.
GCF is treated as a diagnostic and prognostic marker for a noninvasive analysis of periodontitis, taking into account the indicators and markers of connective tissue and bone destruction; thus, it could be a useful prognostic marker in determining the severity of gingival disease. The composition of this fluid resembles that of serum and the rate of its flow has been illustrated to vary as a function of gingival inflammation. The potential diagnostic importance of gingival fluid was recognized more than 60 years ago by Brill and coworkers.,
Bacterial enzymes, microbial breakdown products, connective tissue degeneration products, host-mediated enzymes, inflammatory mediators, and extracellular matrix proteins, either together or individually, can be encountered in higher levels in gingival crevicular fluid during the active phase of periodontitis.
Laser therapy has been proposed as an adjunctive treatment to conventional periodontal therapy. Although systemic reviews have indicated that NSPT, using hand instruments and ultrasonic scalers, is the mainstay of all the periodontal therapies,, complete removal of the bacteria biofilm and their endotoxins in deeper areas of the pockets and furcation sites is often difficult to achieve with these conventional techniques., The bactericidal and detoxifying effects of the diode laser during NSPT have been documented.,, LLLT is capable of ablating and vaporizing residual organic debris, along with the microbial biofilm and calculus, and it can disinfect and remove the pocket’s sulcular lining. As an adjunct to SRP, laser energy aimed at reducing or eliminating bacteria, which may be useful in reducing PPD and bleeding on probing.,
The enzyme AST has been classically used as a diagnostic adjunct in human cardiac and hepatic tissue necrosis. After tissue damage; AST is found to be released from injured and dead cells in extracellular fluid and has been considered as a reliable biomarker for assaying. Elevated levels of AST are identified at sites undergoing gingival inflammation, attachment loss, and disease progression. Chambers et al. were the first to evaluate the changes in the AST level in GCF during the development of experimental periodontitis in beagle dogs. Keeping this tenet in mind, the present study was conducted with an aim of finding the efficacy of SRP with and without the adjunctive use of soft tissue diode lasers by analyzing the levels of changes of AST in GCF in patients with generalized chronic periodontitis. The null hypothesis was that there is no difference in treatment outcomes and AST levels between sites treated by SRP with laser and with SRP alone.
| Materials and Methods|| |
Setting and design
Ten systemically healthy patients with chronic periodontitis from the outpatient department of periodontology at ITS Dental College, Greater Noida were recruited as subjects for six months. A randomized controlled trial with split-mouth design was conducted. Sample size was determined using the help of a statistician after the submission of details of the study. Ten patients with bilateral periodontal pockets were recruited in the study. Randomization was done using a random number table generated through a computer.
Inclusion criteria were: patients presenting with chronic periodontitis as per AAP classification 1999, clinical probing depth ≥5 mm and ≤7 mm, and clinical attachment loss ≥4 mm in at least two adjacent sites per tooth. Eligibility criteria were the same as inclusion criteria, and the patients agreed to provide written consent for their participation. Exclusion criteria were: patients with systemic conditions and other diseases known to affect periodontal status, pregnant and lactating women, on hormonal contraceptives, periodontal pockets >8 mm, patients with adverse habits such as alcohol consumption, tobacco habits, patients who had received any surgical or NSPT in the past six months, and patients who had received any antimicrobial therapy in the past six months.
- Group 1: (10 sites): Full-mouth SRP with no laser irradiation
- Group 2: (10 sites): Full-mouth SRP with diode laser irradiation
Study grouping and allocation
Using a split-mouth design, 20 patients with bilateral periodontal pocket sites were randomly assigned to either Test group 1 or Test group 2. A brief study outline has been given for reference [Figure 1].
- Test Site 1: (10 sites): SRP
- Test Site 2: (10 sites): SRP with diode laser irradiation
No drop of patients was recorded during the study. A full-mouth periodontal examination was conducted for all the subjects. The following clinical parameters were recorded at: baseline, six weeks, three months, and six months after treatment:
- Pocket Probing Depth (PPD)
- Relative Attachment level (RAL)
- Gingival index (Loe and Silness 1963)
- Plaque index (Silness and Loe 1964)
Clinician 1 allocated the patients to both groups; clinician 2 recorded all the measurements from baseline to six months; and clinician 3 was responsible for all the treatments. Both the patients and clinicians 2 and 3 were blinded.
Zolar Photon Plus Soft Tissue Diode Laser: Wavelength: 980nm, weight <2 kg, dimensions: 205 × 130 × 50 mm, output power: 0.1–10 W. Manual settings: power, timer, mode more than 20 preset procedures, 3 levels of aiming beam intensity.
Microcapillary tubes of 1 µL calibrations, total capacity of 10 µL. (Manufactured by Sigma-Aldrich, Subsidiary of Merck KGa St. Louis, Missouri, USA.) Eppendorf tubes.
Phosphate-buffered Saline (1×). AST test kit: Manufactured by: TRANSASIA BIO-MEDICALS LTD in technical collaboration with ERBA Diagnostics Manheim GmbH, Germany.
Semi-automated clinical chemistry analyzer: Microlab 300; Manufactured by Merck, Germany.
Ultrasonic scaler: Woodpecker UDS-J Peizoelectric Ultrasonic scaler.
Clinical procedure (baseline visit)
- Test site 1: Subgingival SRP was done with the help of an ultrasonic scaler.
- Test site 2: Subgingival SRP was done with the help of an ultrasonic scaler followed by laser irradiation.
Procedure for laser irradiation: 980nm at a power output of 2.5 W in pulsed mode was used with the tip inserted into the pocket [Figure 2]. The optic fiber of 400 µm was moved from the coronal to the apical side of the pocket in parallel paths. Each site was radiated for 30s twice with a 60-s interval. GCF collection was done using calibrated microcapillary tubes [Figure 3].
| Results|| |
Age and gender
[Table 1] reveals the age and gender distribution of the total sample size. Seven males and three females were included in the study with a mean age of 38.43 ± 10.53 and 37.33 ± 11.68 years, respectively.
[Table 2] reveals that there was a reduction in the mean gingival index scores from baseline to three months and the reduction continued up to the six-month study period, which was found to be statistically significant (P < 0.0001).
[Table 3] shows that there was a reduction in the mean gingival index scores from baseline to three months and the reduction continued up to the six-month study period, which was found to be statistically significant (P < 0.0001).
Pocket probing depth at test sites 1 and 2
[Table 4] and [Figure 4]: The intragroup analysis of PPD at test sites 1 and 2 showed a statistically significant reduction from baseline to six months (P < 0.0001), but intergroup comparison did not reveal any statistically significant reduction in mean PPD.
|Table 4: Mean pocket probing depth from baseline to six months at Test sites 1 and 2|
Click here to view
Relative attachment level at test sites 1 and 2
[Table 5] and [Figure 5]: Results revealed that there was a statistically significant gain in mean relative attachment levels from baseline to six months in both groups 1 and 2 (P < 0.001) but no significant gain was revealed when intergroup comparisons were made between both the test groups.
|Table 5: Mean relative attachment level from baseline to six months at Test sites 1 and 2|
Click here to view
Aspartate aminotransferase levels in groups 1 and 2
[Table 6] and [Figure 6]: The intergroup comparison between groups 1 and 2 showed a greater reduction of AST levels in group 2 as compared with test group 1 from baseline to three months to six months with values as P < 0.005, P < 0.025, and P < 0.009, respectively.
|Table 6: Mean aspartate aminotransferase levels from baseline to six months in Test groups 1 and 2|
Click here to view
|Figure 6: Comparison of AST levels at baseline, three months and six months|
Click here to view
| Discussion|| |
The present study used a split-mouth design. The split-mouth design allows paired comparisons to be made. Thus, it has the additional advantage over two groups of unmatched subjects where subject variation could otherwise play a dominant role. Diode laser is used within a wavelength that lies within 800 to 980nm. Since the 980-nm diode laser does not interact with the hard dental tissues, it is an excellent soft-tissue laser instrument.
Traditionally, NSPT consists of SRP that aims at improving clinical parameters. It has been observed that SRP leads to a clinical improvement associated with a reduction or elimination of certain periodontal pathogens.
Apart from the treatment of active disease, literature also suggests that SRP is an essential part of the maintenance therapy for consolidating the clinical, microbiological, as well as biochemical improvements achieved as a result of initial therapy.,
It is well corroborated in the literature that laser therapies may serve as an auxillary treatment to conventional mechanical therapy in periodontal disease and may lead to resolution of inflammation. Renowned researchers have studied the effect of lasers on the resolution of periodontal diseases. The versatility of lasers and its salient properties, such as antimicrobial effects and biostimulation, has spurred many such investigations. GCF has been advocated as an important medium in the analysis and diagnosis of periodontitis, taking into account the indicators and markers of connective tissue and bone destruction; therefore, it has often been used as a useful illustrator in impelling the severity of periodontal diseases.
Diode laser is used within a wavelength that lies between 800 and 980nm. Since the 980-nm diode laser does not interact with the hard dental tissues, it is an excellent soft-tissue laser instrument.
Persson et al. had examined 25 patients treated for periodontitis who were seen for three-month maintenance visits during a two-year period. Eight sites were observed in each patient. The authors suggested that AST levels of 800 IU and greater in GCF were associated with clinical attachment loss. Oringer et al, revealed that AST levels were consequently reduced at 12 months’ post-treatment with STP in patients with chronic periodontitis. Koss et al identified the presence of enzymatic biomarkers of periodontal tissue destruction that distinguish clinical states of gingival–periodontal disease and concluded that enzymes such as Neutrophil elastase, AST, Alaninephosphatase, Matrix metalloproteinases, Cytokines, and Arylsulfatases have an important role in furtherance of the periodontal disease and can be used as diagnostic markers. Chaubey et al. (2014) aimed at estimating the changes in AST levels at selected sites after treatment and correlated the AST levels with clinical periodontal parameters. In the Periodontitis Group, correlation between PPD and AST at baseline was statistically significant (P < 0.05) and correlation between CAL and AST was statistically significant (P < 0.01) after treatment.
In the present study, AST levels showed a statistically significant reduction in both test groups 1 and 2. However, in Test group 2, LLLT along with NSPT showed greater reduction as compared with Test group 1, which included only NSPT (P < 0.005 at baseline, 0.025 at three months, and 0.009 at six months).
Although GCF analysis provides the status of inflammation without an impelling histopathological evaluation, it is still rife with controversy. First, GCF quantity outflow along with inflammation could also be affected by the extent of sulcular epithelium ulceration. There is a huge variation in the methods of collection, storage, and analysis of GCF along with elusion protocols, altering the values based on this variation. Also, the timing of fluid sample collection could alter results. Another important consideration is dry or buffer-based storage of samples. Though the recommended temperature of sample storage is -80° centigrade, whether all samples collected for various studies strictly adhere to this protocol is questionable.
Active disease status monitoring requires reliable diagnostic methods such as GCF components evaluation to assess the stages and severity of periodontal diseases. The evaluation of AST in GCF is one such biomarker that has been extensively studied to predict destructive periodontal disease activity and its abetment post-treatment. Laser biostimulation as an adjunct to SRP aims at reducing or eliminating bacterial load, which may be useful in reducing PPD and bleeding on probing.,
| Conclusion|| |
Laser biostimulation as an adjunct to NSPT would prove to reduce periodontal disease activity, thereby promoting an improvement in clinical values and lowering of the destructive biomarker AST by GCF analysis. Within the limitations of this study, it could be concluded that laser biostimulation does stand a chance and has better outcomes in periodontal therapy when conducted in conjunction with NSPT as compared with NSPT alone. Further research protocols, including larger sample size and longitudinal studies, are warranted to further authenticate the results of the present study.
My grateful thanks and deepest appreciation to my mentor Prof. Dr. Shivjot Chhina for guiding me through this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
SG and SC: Data collection; SS, ES, AM, and RG: data analysis, acquisition, and interpretation; SC and SG: Article preparation. Finally all authors had given consent for publication.
Ethical policy and institutional review board statement
Prior informed consent and ethical protocols as outlined by the Helsinki’s guidelines was taken from each patient after explaining the procedure in the patient’s language along with the potential risks and benefits involved. (Letter No. [IEC/PERIO/1/15] Trial ID: UMIN000031087.)
Patient declaration of consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/ have given his/ her/ their consent for his/ her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Data availability statement
Data are available on reasonable request with the corresponding author’s mail.
| References|| |
Lamster IB. Evaluation of components of gingival crevicular fluid as diagnostic tests. Ann Periodontol 1997;2:123-37.
Brill N, Björn H. Passage of tissue fluid into human gingival pockets. Acta Odontol Scand 1959;17:11-21.
Brill N. Influence of capillary permeability on flow of tissue fluid into gingival pockets. Acta Odontol Scand 1959;17:23-33.
Kaur S, Siddharth M, Gupta R, Gupta S. The effect of low-level diode (Gaalas) laser therapy as an adjunct to non surgical periodontal treatment in subjects with chronic periodontitis – a clinical study. Eur J Mol Clin Med2021;8:958-62.
Doğanay Yıldız E, Arslan H, Köseoğlu S, Arabacı T, Yıldız DA, Savran L. The effect of photobiomodulation on total amount of substance P in gingival crevicular fluid: Placebo-controlled randomized clinical trial. Lasers Med Sci 2019;34:517-23.
Ren C, McGrath C, Jin L, Zhang C, Yang Y. The effectiveness of low-level laser therapy as an adjunct to non-surgical periodontal treatment: A meta-analysis. J Periodontal Res 2017;52:8-20.
Gandhi KK, Pavaskar R, Cappetta EG, Drew HJ. Effectiveness of adjunctive use of low-level laser therapy and photodynamic therapy after scaling and root planning in patients with chronic periodontitis. Int J Periodont Restorative Dent 2019;39:837-43.
Kocher T, Fanghänel J, Schwahn C, Rühling A. A new ultrasonic device in maintenance therapy: Perception of pain and clinical efficacy. J Clin Periodontol 2005;32:425-9.
Pamuk F, Lütfioğlu M, Aydoğdu A, Koyuncuoglu CZ, Cifcibasi E, Badur OS. The effect of low-level laser therapy as an adjunct to non-surgical periodontal treatment on gingival crevicular fluid levels of transforming growth factor-beta 1, tissue plasminogen activator and plasminogen activator inhibitor 1 in smoking and non-smoking chronic periodontitis patients: A split-mouth, randomized control study. J Periodontal Res 2017;52:872-82.
Moritz A, Gutknecht N, Doertbudak O, Goharkhay K, Schoop U, Schauer P, et al
. Bacterial reduction in periodontal pockets through irradiation with a diode laser: A pilot study. J Clin Laser Med Surg 1997;15:33-7.
Harris DM, Yessik M. Therapeutic ratio quantifies laser antisepsis: Ablation of porphyromonas gingivalis with dental lasers. Lasers Surg Med 2004;35:206-13.
Al-Hamoudi N, Alsahhaf A, Al Deeb M, Alrabiah M, Vohra F, Abduljabbar T. Effect of scaling and root planing on the expression of anti-inflammatory cytokines (IL-4, IL-9, IL-10, and IL-13) in the gingival crevicular fluid of electronic cigarette users and non-smokers with moderate chronic periodontitis. J Periodontal Implant Sci 2020;50:74-82.
Kurgan Ş, Önder C, Balcı N, Fentoğlu Ö, Eser F, Balseven M, et al
. Gingival crevicular fluid tissue/blood vessel-type plasminogen activator and plasminogen activator inhibitor-2 levels in patients with rheumatoid arthritis: Effects of nonsurgical periodontal therapy. J Periodontal Res 2017;52:574-81.
Persson GR, Page RC. Effect of sampling time and repetition on gingival crevicular fluid and aspartate aminotransferase activity. J Periodontal Res 1990;25:236-42.
Imrey PB, Crawford JM, Cohen RL, Alves ME, McSwiggin TA, Chambers DA. A cross-sectional analysis of aspartate aminotransferase in human gingival crevicular fluid. J Periodontal Res 1991;26:75-84.
Chambers DA, Crawford JM, Mukherjee S, Cohen RL. Aspartate aminotransferase increases in crevicular fluid during experimental periodontitis in beagle dogs. J Periodontol 1984;55:526-30.
Siddique S, Panchmal GS, Pullishery F. Aspartate aminotransferase as a biomarker in periodontal disease: A comparative in vitro study. Saudi J Oral Sci 2016;3:18-24.
Ismaili B, Bokonjic D. Short-term low-level laser therapy attenuates inflammation and production of interleukin-1, but elevates the level of matrix metalloproteinase 9 in chronic periodontitis. J Int Dent Med Res 2014;7:7-13.
Oringer R, Howel T, Nevins M, Reasner D, Davis G. Relationship between crevicular aspartate amino transferase levels and periodontal disease progression. J Periodontal 2001;72:17-24.
Koss M, Castro C, Salum K, Lopez M. Enzymatic profile of gingival crevicular fluid in association with periodontal status. Labmedicine 2009;40:277-80.
Arora V, Chaubey K, Gupta S, Jafri Z, Narula IS. Effect of Non-surgical therapy on GCF Aspartate aminotransferase levels in chronic periodontitis patients. Indian J Dent Sci 2010;2:40-5.
Agarwal A, Gupta S, Tanwar D, Choudhary AA. Breadth of view for lasers in oral surgery. GJRA 2019;8:1-3.
Sharma E, Gupta S, Sinha S, Tanwar D. Comparative analysis of low level laser therapy and iontophoresis in management of dentinal hypersensitivity: A randomized clinical trial. Indian J App Res 2019;9:1-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]