Lasers Med Sci (2011) 26:711
DOI 10.1007/s10103-009-0732-x
ORIGINAL ARTICLE
Gingival curettage study comparing a laser treatment
to hand instruments
Jiang Lin & Liangjia Bi & Li Wang & Yuqi Song &
Wei Ma & Steve Jensen & Densen Cao
Received: 19 January 2009 / Accepted: 25 August 2009 / Published online: 30 September 2009
# Springer-Verlag London Ltd 2009
Abstract The purpose of this clinical study was to examine
nonsurgical treatments of periodontal disease comparing a
diode laser to subgingival curettage with conventional hand
instruments. The study group comprised 18 patients with
moderate periodontal degradation who were treated without
local anesthesia. Each quadrant was randomly allocated in a
split-mouth design either to treatment with a 810-nm diode
laser using an energy of 2 W (test group) or to gingival
curettage using hand instruments (control group). Clinical
data, including plaque index (PI), gingival index (GI),
sulcus bleeding index (SBI), pocket depth (PD), clinical
attachment level (CAL) and visual analog scale (VAS)
score were acquired prior to and 4 weeks after treatment.
The treatment time for each tooth was also recorded. The
results demonstrated a statistically significant reduction of
the GI, SBI and PD and a significant gain in CAL in both
groups after 4 weeks. However, there were no significant
J. Lin
Department of Stomatology, the Fourth College,
Harbin Medical University,
Harbin, Heilongjiang Province, China
e-mail: Kelvinperio@163.com
L. Bi : Y. Song : W. Ma
Department of Stomatology, Fourth College,
Harbin Medical University,
Harbin, Habei Province, China
L. Wang
Department of Periodontology, College of Stomatology,
Harbin Medical University,
Harbin, Habei Province, China
S. Jensen (*) : D. Cao
CAO Group, Inc,
4628 West Skyhawk Drive,
West Jordan, UT 84084, USA
e-mail: steve.jensen@caogroup.com
differences between the test and control groups for the
above data. The score for the degree of treatment discomfort
was significantly lower and the average treatment time was
significantly less in the test group than in the control group.
Diode laser subgingival curettage resulted in statistically
significant improvements in PD, SBI, GI and CAL with less
discomfort and treatment time compared to treatment with
the hand instruments.
Keywords Gingival curettage . Diode laser .
Periodontal disease
Introduction
As early as 1992 the use of lasers in the treatment of
periodontal disease was reported [1, 2]. Current therapy for
periodontitis entails periodontal debridement, which
involves the removal or disruption of bacterial plaque,
its byproducts, and retained calculus deposits from the
coronal surfaces, root surfaces and the tissue walls of the
periodontal pocket [3]. Treatment with a combination of
hand-activated and ultrasonic instrumentation is the
treatment now widely preferred. However, conventional
hand instruments require more time, physical effort and
dexterity. In recent years, treatment modalities have been
devised utilizing the diode laser for bacterial reduction and
sulcular debridement in order to disinfect the involved
periodontal pocket [4, 5]. A study has also demonstrated
that root surfaces treated with a diode laser in vivo show
no damage to the cementum tissue and no signs of
thermal side effects in any of the teeth treated [6]. The
purpose of this study was to assess the clinical effective-
ness of a diode laser compared to conventional gingival
curettage with hand instruments in patients with chronic
periodontitis.
8 Lasers Med Sci (2011) 26:711

Materials and methods
Patient selection
The study group comprised 18 patients (10 men and
8 women) with a mean age of 40.33 years (range
2565 years) with mild to moderate chronic periodontitis.
They were all referred to the Department of Stomatology,
Fourth Affiliated College of Harbin Medical University, for
periodontal therapy. The local ethics committee approved
patient selection, management, and surgical protocols. All
participants signed informed consent forms. The criteria for
inclusion in the study were: (1) medical history revealing
good general health; (2) excluding third molars, each
subject had to have at least 20 natural teeth present in the
mouth (a pocket depth of at least three teeth in at least two
different quadrants was required as the patient was to be
his/her own control); (3) an average plaque level of 1
according to the Quigley and Hein plaque scoring method
as modified by Turesky; and (4) evidence of bleeding and
gingivitis. The criteria for exclusion were: (1) the presence
of systemic disease which could influence the outcome of
the therapy; (2) current pregnancy or any physical condition
that would limit instrument manipulation; (3) present
medications that would be likely to affect gingival health;
(4) presence of rampant dental caries; and (5) requirement
for premedication with antibiotics for dental examinations.
Study design
The study followed a single-blind, split-mouth, randomized
design. Each quadrant was randomly allocated either to
treatment with an 810-nm diode laser using an energy of
2 W (test group) or to gingival curettage using hand
instruments (control group). A total of 36 quadrants (18 in
the maxillary jaw, 18 in the mandibular jaw) were included.
A total of 206 teeth (78 single-rooted, 128 multirooted) and
1,236 sites were divided equally between the right and left
sides. The quadrants randomly designated for laser treat-
ment would receive the laser treatment (test group),
whereas teeth of the contralateral side would receive
treatment by hand curettage (control group). The same
experienced operator treated all patients. Patient oral
hygiene instructions were presented at baseline and at 1
and 4 weeks after treatment.
removing the inflamed epithelial lining of the sulcus was
performed using hand instruments (Gracey curettes;
Hu-Friedy, Shanghai, China). An Odyssey diode laser
(Ivoclar Vivadent, Schaan, Liechtenstein) was utilized for
the test group under the following conditions: 810 nm
wavelength, 2-W laser output in continuous mode, and
400 m fiber tip. The cladding of the fiber was stripped
and then cut to the approximate measured pocket depth,
which varied from patient to patient. By lightly contacting the
sulcular lining from coronal to apical at an angle of
approximately 20 to the long axis of the tooth, the fiber
was made to make slow measured passes around the
entire circumference of the tooth. Upon completion, the
entire periodontal quadrant was flooded with a 1.0%
chlorhexidine gluconate solution. The average treatment
time for both the control group and the diode laser test
group was recorded.
Clinical assessments
Clinical data, including plaque index (PI), gingival index
(GI), sulcus bleeding index (SBI), pocket depth (PD),
clinical attachment level (CAL) and visual analog scale
(VAS) score were collected before treatment (baseline) and
at follow-up examinations at 1 week and 4 weeks after
treatment by a qualified examiner (different from the
therapist). The treatment time for each tooth was also
recorded. The examiner was blind with respect to treatment
quadrant assignments and modalities. The variables
recorded were as follows:
PI Quigley and Hein Plaque Scoring Method
as modified by Turesky.
PD The distance in millimeters from the
gingival margin to the bottom of the pocket
was taken at six points around each tooth.
BI Mazza bleeding index.
GI Le and Silness gingival index.
CAL The distance in millimeters from
cementoenamel junction to the bottom of
the pocket.
Gingival The degree of discomfort experienced
sensitivity before and during treatment and during the
Table 1 Changes in plaque index

Treatment Baseline One week Four weeks p value

Treatments
Laser 2.360.97 1.300.73 1.900.80 *
The patients were treated without local anesthesia. Subjects Hand 2.691.02 1.500.71 1.980.90 *
first received a scaling treatment with an ultrasonic device p value * * NS
(XO Odontoson, XO CARE, Glostrup, Denmark; frequency
42 kHz, amplitude 1020m) to remove plaque and calculus NS not significant (p>0.05).
from all the teeth. In the control group gingival curettage for *p<0.001, mixed linear models.
Lasers Med Sci (2011) 26:711 9

Table 2 Changes in pocket depth (PD), clinical attachment level Table 4 Treatment times
(CAL), gingival index (GI), and bleeding index (BI)
Treatment Single-root Multi-root p value
Variable Treatment Baseline Four weeks p value
Hand 3.630.82 min 5.160.53 min *
PD (mm) Laser 4.420.45 2.880.60 * Laser 1.660.25 min 2.880.27 min *
Hand 4.400.46 2.910.66 * p value * *
p value NS NS
CAL (mm) Laser 1.1080.356 0.4570.305 * *p<0.01, mixed linear models.
Hand 1.2050.406 0.5030.308 *
p value NS NS were observed, except for PI for which a difference was
BI Laser 2.880.76 1.530.61 * found between the two groups. PI, GI and BI showed a
Hand 2.930.76 1.420.59 * significant improvement compared to baseline in both groups
p value NS 0.6636 NS 0.1601 (p<0.001). PD showed a significant decrease and CAL a
GI Laser 1.900.30 1.380.49 * significant gain in the two groups at 4 weeks (p<0.001).
Hand 1.920.27 1.260.44 * There was a significant difference in VAS score during
p value NS NS treatment (p<0.001) but no significant difference at 1 week
and 4 weeks between the two groups. No statistically
NS not significant (p>0.05).
significant difference in any of the parameters was found at
*p<0.001, mixed linear models. 4 weeks. Average treatment times were significantly less
(p<0.01) for single-rooted teeth than for multirooted teeth for
post-treatment phase (1 and 4 weeks both treatment modalities, and were significantly less
examination) was graded by the patient (p<0.01) for laser treatment than for hand treatment for both
using a 10-cm visual analog scale (VAS) types of tooth (Table 4).
with none and unbearable as verbal
endpoints.
Treatment The time spent by the therapist on each Discussion
time tooth with periodontitis in both groups.
Gingival curettage with either the diode laser or hand
instruments led to significant improvements in all
Statistical analysis investigated clinical parameters at 4 weeks following
treatment. After initial oral hygiene education, the PI in
A software package was used for the statistical analysis both groups had decreased greatly 1 week after the
(SAS version 9.1.2). The mixed linear models were used to treatment but had increased after 4 weeks. This suggests
compare the mean values of all investigated clinical the necessity for reinforcement of oral hygiene education
parameters between baseline and 4 weeks for each after a period time.
treatment group. The treatment groups were also compared The results of many laboratory and clinical trials have
at baseline and after 4 weeks using the mixed linear model. demonstrated that the laser is an alternative nonsurgical
treatment for periodontal diseases or an adjunct to traditional
scaling and root planing. For example, lasers can remove
Results calculus, etch roots, and create a biocompatible surface for
effective reattachment [7]. Furthermore, lasers can accelerate
All patients returned for all scheduled visits. No complications wound healing [8], and the diode laser has been reported to
such as abscesses or infections were observed throughout the help reduce inflammation in the periodontal pockets and
study. The mean clinical changes from baseline to 4 weeks are support healing of the periodontal pockets through the
shown in Tables 1, 2 and 3. At baseline, no statistically elimination of bacteria [9]. Several studies have demon-
significant differences in any of the investigated parameters strated that laser therapy is superior to scaling and root

Table 3 Changes in visual

analog scale score Treatment Baseline During treatment One week Four weeks p value

Hand 1.922.37 41.428.63 1.311.53 0.140.38 *

Laser 1.611.75 26.426.97 1.171.21 0.421.02 *
NS not significant (p>0.05).
p value NS * NS NS
*p<0.001, mixed linear models.
10
planing treatment alone [1013]. However, in this study
no differences were detected between the two evaluated
treatment modalities in terms of change in clinical
outcome variables at 4 weeks after treatment. These
finding are in accordance with data reported in the
literature on the use of lasers for nonsurgical treatment
of periodontal diseases [14], showing no statistically
significant difference in clinical outcomes compared to
mechanical instrumentation. However, in the test group
the patients perceived less treatment discomfort during
treatment and had an overall preference for the laser
modality. The degree of discomfort experienced after
treatment (1 week and 4 weeks) was lower than at
baseline, and there was no difference between the two
treatments. The results were similar to those reported by
Tomasi et al. [15]. The results show that the diode laser may
help patients overcome anxiety during subgingival curettage
treatment especially without the use of anesthetics and
improve gingival sensitivity.
The current concept for treatment of periodontitis is to
eliminate infection, because periodontal disease is generally
accepted as an infectious disease [16], and mechanical
therapy is considered the basic prerequisite for long-term
treatment success [17]. Conventional periodontal instru-
ments including the ultrasonic scaler and hand instruments
are used for removing calculus, planing root surfaces,
curetting gingival tissue, or removal of diseased tissue.
Ultrasonic instrumentation has been shown to be as
effective as hand instruments in subgingival calculus
removal [18, 19], but such instruments cannot remove the
inflamed epithelial lining of the pocket. Hand instruments
can do the job; however, they have many disadvantages.
such as the need for greater skill, more time, more effort by
the operator, and more discomfort for the patient.
In a related study the diode laser at low power was able
to remove the thin pocket epithelium in the same way
regardless of the level of surgical experience of the
practitioner [20]. Sites instrumented with the conventional
curettes demonstrated significant epithelial remnants in all
tissues. The authors therefore concluded that treatment with
the diode laser leads to complete epithelial removal from
the soft periodontal tissues in contrast to conventional
treatment methods with hand instruments (independent of
the clinician's experience). Gingival curettage utilizing a
laser for deepithelization of the periodontal pockets has also
been confirmed to be a safe clinical procedure and can be
recommended [21].
In our study, the mean PD of the laser group was
reduced from 4.42 mm to 2.88 mm, and the mean CAL
showed a gain from 1.108 mm to 0.457 mm. These results
were statistically and clinically significant compared to
baseline, demonstrating that the laser is an effective
treatment. Although there was no difference in the overall
Lasers Med Sci (2011) 26:711
clinical outcome between the two groups, the advantages of
the laser compared to hand instruments were significant and
included increased coagulation that yields better surgical
visualization, decreased pain, increased patient acceptance,
shorter operating time and less effort. However, the laser is
not preferred for the removal of calculus; even the effective
Er:YAG laser is not ideal for this purpose. It has been
reported that only 68.4% of the root of surface was
calculus-free in contrast to 94% after scaling and root
planing following tooth extraction [22]. So in this study all
subjects received ultrasonic scaling treatment to remove
plaque and calculus on the teeth including hard aggregations
on the root prior to gingival curettage.
In conclusion, the results of the present study indicate
that diode laser curettage followed by disinfection with
1% chlorhexidine gluconate is an effective alternative
nonsurgical treatment of periodontal disease especially
for those patients who have blood coagulation problems,
greater sensitivity to pain or resistance to local anesthetic
drugs.
Acknowledgements This study was funded by a grant from CAO
Group Inc.
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