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ORIGINAL ARTICLE
Year : 2018  |  Volume : 22  |  Issue : 2  |  Page : 158-163  

Evaluation of diode laser and stannous fluoride in the treatment of root sensitivity after access flap surgery: Randomized controlled clinical trial


Department of Periodontology, MGV KBH Dental College and Hospital, Nashik, Maharashtra, India

Date of Submission02-Jan-2018
Date of Acceptance15-Mar-2018
Date of Web Publication23-Apr-2018

Correspondence Address:
Dr. Chetan Purushottam Raut
Ward No: 05, Karla Road, Swagat Colony, Near Tuljai Daily Needs, Wardha - 422 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_2_18

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   Abstract 


Background: Postsurgical root sensitivity has always been an enigma to the periodontists. There is a plethora of evidence suggesting the presence of root sensitivity following periodontal flap surgical procedures. Thus, the aim of the present study was to compare and evaluate the effect of low-power diode lasers with and without topical application of stannous fluoride (SnF2) gel in the treatment of root sensitivity and also evaluate whether laser creates any placebo effect in the control group or not. Materials and Methods: Thirty patients participated in this study and 99 teeth were included. Root sensitivity was assessed for all groups with a Verbal Rating Scale (VRS). For each patient, the teeth were randomized into three groups. In the test Group I, sensitive teeth were treated with SnF2and diode laser. In the test Group II, sensitive teeth were irradiated with laser only. In the control group, no treatment was performed. Results: The mean ± standard deviation (SD) score for VRS and Visual Analog Scale at baseline was not statistically significant (P > 0.05) between the three groups. After 15 min, statistical significant difference was seen in test Group I and test Group II, although no difference was found in the control group. At 15th day and 30th day, the mean ± SD scores were statistically significant (P < 0.05). Conclusion: Within the limitations of the study, it can be concluded that diode lasers alone and in combination with 0.4% SnF2was effective in the treatment of root sensitivity after access flap surgery.

Keywords: Dentin hypersensitivity, diode laser, root sensitivity, stannous fluoride


How to cite this article:
Raut CP, Sethi KS, Kohale B, Mamajiwala A, Warang A. Evaluation of diode laser and stannous fluoride in the treatment of root sensitivity after access flap surgery: Randomized controlled clinical trial. J Indian Soc Periodontol 2018;22:158-63

How to cite this URL:
Raut CP, Sethi KS, Kohale B, Mamajiwala A, Warang A. Evaluation of diode laser and stannous fluoride in the treatment of root sensitivity after access flap surgery: Randomized controlled clinical trial. J Indian Soc Periodontol [serial online] 2018 [cited 2018 May 21];22:158-63. Available from: http://www.jisponline.com/text.asp?2018/22/2/158/230830




   Introduction Top


Periodontal therapy for the management of chronic periodontitis requires nonsurgical or surgical intervention to establish healthy periodontal conditions. However, active periodontal therapy may lead to undesirable sequelae such as gingival recession or exposure of dentinal tubules, which leads to the development of dentin hypersensitivity (DH). Pain arising due to the exposed root surface is a most common complaint of the patients after undergoing periodontal therapy.[1],[2] Although root sensitivity is most common complaint, there is limited clinical research devoted to their treatment.

According to Addy et al.[3] and Canadian Consensus Document (2003),[4] DH is defined as pain derived from exposed dentin in response to chemical, thermal, tactile, or osmotic stimuli which cannot be explained as arising from any other dental defect or pathology. Since DH after periodontal therapy occurring due to denudation of root surfaces is a different condition, the term “root sensitivity” is more commonly used.[5] Although many studies or systematic reviews have been published indicating high prevalence of root sensitivity, but very few are aimed at intervening the problem.[5],[6] Lin and Gillam in a systematic review reported that the prevalence of root sensitivity following periodontal therapy was 36.8% after 1st week, 33.4% after 2nd week, and 29.6% after 4th week of the periodontal surgical procedures.[7] In spite of larger prevalence rates, there is a scarcity of clinical trials aimed at treating them. It can be said that although being most common postoperative finding, it is the most neglected and taken for granted aspect in clinical research.

Multiple treatment modalities have been used for the treatment of root sensitivity, which have shown variable results. The most commonly used are topical desensitizing agents, but these are not predictable. Over the last decade, these procedures have been supported by a laser-assisted treatment, often combined with topical agents.

Diode lasers can be used either by direct or indirect method in the treatment of DH. Direct method involves only laser irradiation over the area affected and indirect method involves the application of certain chemical agents followed by laser irradiation of the affected area.

For the indirect method, commonly used chemical agents are those containing the fluoride ions such as sodium fluoride and stannous fluoride (SnF2). The indirect method is based on the idea of combining the advantages of laser and fluoride therapy, thereby achieving as durable results as possible. Fluoride application along with laser helps in the occlusion of the melted dentin due to thermal effects of laser.

High-power lasers are known to act by, melting that occurs as a result of heat transmission. This interaction results in fusion and resolidification of dentin, with the consequent effect of sealing and reducing the diameter of the dentinal tubules. Thus, the use of combination therapy seems justified where lasers cause melting of dentinal tubules and fluoride agent helping in the formation of calcific barrier.[8]

Low-power lasers do not emit heat and stimulate the normality of cell functions. They act by changing the electrical potential of the cell membrane, activating the Na +/K + ATPase pumps, leading to increased adenosine triphosphate (ATP) synthesis, and bringing about analgesic, potential anti-inflammatory and biomodulation benefits to the cells.[9],[10] There is a possibility that low-power lasers may obliterate the dentinal tubules by the effect of photobiomodulation on dental pulp, due to an increase in cellular metabolic activity of the odontoblasts, so that they intensify the production of tertiary dentin.[11],[12]

In addition, it is not known that whether the combination of low-power lasers and fluoride is as effective as the combination of high-power lasers and fluoride therapy.

Thus, this randomized placebo-controlled clinical trial was designed to compare and evaluate the effect of low-power diode lasers with and without topical application of SnF2 gel in the treatment of DH after conventional access periodontal flap surgery.


   Materials and Methods Top


A total of 30 patients (14 males, 16 females age range 30–55 years) diagnosed with chronic periodontitis and indicated for conventional access flap surgery after phase I therapy, complaining of DH after surgery on the 7th postoperative day were selected for the study from the Outpatient Department of Periodontology [Figure 1]. Ethical clearance was obtained from the institutional ethical committee and written informed consent was signed by the patients.
Figure 1: Consort flowchart

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Sample size calculation

A minimum clinically significant difference in Visual Analog Scale (VAS) and Verbal Rating Scale (VRS) scores of 0.6 was determined from a previous study on DH.[13] The power analysis was done based on this minimum clinically significant difference, using α at level 0.05, at 80% power, and a σ of 1.12. According to these data, the number of teeth required to be involved to conduct this study was calculated as 30. Teeth were selected as unit for analysis.

Inclusion criteria for the study were (i) patients with moderate-to-severe chronic periodontitis indicated for conventional access flap surgery, (ii) postoperative hypersensitivity following flap surgery on the 7th postoperative day, (iii) teeth with dentinal hypersensitivity score of 2 or more on VRS, and (iv) patients free of any systemic disease.

Exclusion criteria were (i) absence of preoperative hypersensitivity, (ii) presence of carious lesions on the selected or neighboring teeth, (iii) abutment teeth for fixed or removable prostheses, (iv) teeth with wasting diseases, (v) patients using any form of desensitizing toothpaste, (vi) smokers, and (vii) patients on nonsteroidal anti-inflammatory drugs or antibiotics in the past 3 months.

Commercially available desensitizing paste (Colgate, GelKam®) and laser system (AlGaInAs) was used in the present study. The key ingredient of the desensitizing paste is 0.4% SnF2 and other ingredients are glycerin, hydroxyethylcellulose, and flavoring agents.

Laser parameter applied in the present study were diode laser with 940 nm wavelength with output power 0.8 W in a defocused mode for 80 s over a spot area of 2 cm with a resultant energy of 1.6 W/cm2.

Study design

This was a randomized placebo-controlled clinical trial where sensitive teeth in patients were randomized using lottery method. Not more than 6 teeth were selected in each patient. Teeth were divided equally into three groups as follows:

  1. Control group: Laser without activation – 33 teeth
  2. Test Group I: Laser plus SnF2 application – 33 teeth
  3. Test Group II: Only laser irradiation – 33 teeth.


Parameters evaluated

Root sensitivity was assessed in patients using two parameters, which were VRS and VAS at following intervals.

  1. Baseline
  2. After 15 min
  3. After 15 days
  4. After 30 days.


Verbal Rating Scale

This is a subjective pain rating scale where scores range from 0 to 3. Jet of cold air is applied over the affected area, the patient's response is evaluated, and following scores are given to particular response [Table 1].[14]
Table 1: Scoring system using Verbal Rating Scale

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Visual Analog Scale

It is a line of 10 cm in length, the extremes of which represent the limits of pain a patient might experience. Patients were asked to place a mark on the 10-cm line that indicated the intensity of their current level of sensitivity.[15]

Treatment procedure

This was a randomized placebo-controlled clinical study. On the 7th postoperative day of conventional access flap surgery after suture removal, only three teeth in anterior sextant with root sensitivity was included. Every adjacent tooth was excluded to avoid any carry over effects of the therapy provided. A jet of cold air was applied over the cervical area on the buccal surface of teeth approximately at a distance of 1 cm. After the application of air, stimulus patient's response was assessed using VRS and teeth with score of more than 2 were included.[16] After the selection and randomization process, the selected sites in patients were divided into three groups', namely, control group, test Group I, and test Group II, respectively.

In control group, selected teeth were properly isolated and dried. No application of 0.4% SnF2 was done. Laser irradiation without activating was done over the cervical area of the assessed tooth. Laser irradiation without activation was done purposely to use laser as a placebo and evaluate its placebo effect.

In test Group I, selected teeth were properly isolated and dried. After isolation, 0.4% SnF2 gel was applied with cotton pellet on the cervical area of the tooth surface and was left on tooth surface for 60 s. After the application of 0.4% SnF2 gel, laser irradiation was performed. The irradiation was done on the cervical area of the affected tooth at an approximate distance 1 cm in a sweeping motion. Only single application of laser was done and parameters (VRS and VAS) were evaluated after 15 min, at 15 days, and 30 days.

In test Group II, the area of selected teeth was properly isolated and dried. After isolation, hypersensitive teeth were irradiated using laser (940 nm diode laser, 0.8 W, and noncontact continuous mode).

Statistical analysis

Since the normality for the distribution of the pain scale scores in the various study subgroups was not met, the Kruskal–Wallis and Wilcoxon signed-rank tests were used to study the differences in pain score distributions for the three intergroups and two intragroups, respectively. Post hoc comparisons were done using Dunn–Bonferroni test. Statistical Package for the Social Sciences Inc., Version 20.1 (Chicago, USA) was used for statistical analysis. Statistical significance was set at P < 0.05.[17],[18]


   Results Top


All the patients completed the follow-up sessions and no patients were lost during follow-up. Mean VRS and VAS scores for air stimulus for all three groups at baseline, after 15 min, 15 days, and 1 month are shown in [Table 2] and [Table 3]. There was no significant difference in baseline scores in both groups for air stimulus. Intragroup comparison of changes in mean scores for VRS and VAS showed that the test group resulted in significant improvements from baseline to 15 min, 15 min to 15 days, and 15 days to 30 days. In Control group, results were not significant from baseline to 15 min, whereas they were significant from 15 min to 15 days and 15–30 days, respectively [Table 2] and [Table 3].
Table 2: Intragroup comparison of Verbal Rating Scale scores among the three groups

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Table 3: Intragroup comparison of Visual Analog Scale scores among the three groups

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Intergroup comparison showed that there was a significant reduction in mean scores of VRS and VAS between three groups at baseline, after 15 min, at 15 days, and 30 days, respectively [Table 4] and [Table 5].
Table 4: Intergroup comparison of Verbal Rating Scale scores among the three groups

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Table 5: Intergroup comparison of Visual Analog Scale scores among the three groups

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   Discussion Top


Postoperative root sensitivity is a common clinical condition and complaint of the patients after periodontal therapy. The results of the systematic review report that root sensitivity is most prevalent during the 1st postoperative week.[7] Thus, the availability of treatment that reduces or eliminates DH within a period of 24–48 h would be ideal. Thus, this study was conducted with the aim to treat root sensitivity occurring after periodontal surgery.

Lasers have been used to treat DH, but in recent year, low-level diode laser has been evaluated and has shown immediate efficacy. Although many different lasers have been evaluated, diode lasers have emerged as more popular form because of their ease in availability and subsequent low cost for treatment. Diode lasers can be used mainly in two forms, which are direct and indirect method, respectively. The direct method involves only the use of lasers and indirect method involves application of certain chemical agents and then irradiating the area with the lasers.[19]

Hypothesis behind the use of fluoride agent in indirect method is that it forms calcium fluoride crystals which are deposited on the open dentinal tubules giving the added advantage of blocking the tubules.[20] Sodium fluoride is the most commonly used fluoride agent. Results from the previous study have demonstrated significant improvement after using combination of lasers and NaF, but there are some limitations. NaF is known to cause soluble crystals of calcium fluoride that are susceptible to mechanical action or by the action of saliva. Thus, SnF2 has been evaluated as an alternative agent. SnF2 also acts by the same mechanism but forms insoluble precipitates of calcium fluoride that are resistant to abrasion. Another added advantage of using SnF2 is that one-time application of SnF2 is known to form calcium fluoride crystals within seconds.[21]

In the present study, the mean VRS and VAS scores at baseline were not significant which suggest that there was no difference between the three groups and all the pain scores were of the same level. The results of the present study suggest that in both test Group I and test Group II, there was immediate reduction in pain scores after 15 min suggesting the immediate efficacy of lasers. These results are in accordance with previous studies done by Kumar and Mehta [22] and Doshi et al.,[23] wherein they found that lasers had an immediate reduction of root sensitivity. With respect to control group, no reduction in pain scores were noted even though lasers were used as a placebo. This suggests that lasers are effective in immediate reduction of root sensitivity and thus makes them more acceptable form of treatment as there are currently no available topical agents that provide immediate reduction in root sensitivity. In addition, it can be said that in the present study no placebo effect was noted in control group where lasers irradiation was provided without activating the lasers. However, literature suggests that there is some controversy regarding the effect of placebo in DH. Some studies concluded that there is no effect of placebo, whereas some reported that there is possible placebo effect.[22],[23],[24],[25]

In the present study, after 15 days and after 30 days, significant results were obtained in all the three groups suggesting that there is a gradual reduction in the root sensitivity after periodontal therapy. The results of the present study are in accordance with the previous reports where gradual reduction in root sensitivity is found over 1 month after periodontal therapy.[26],[27],[28] However, the mean reduction of VRS and VAS scores were better in both test group suggesting improved outcomes are obtained after the therapy. These results are comparable to the previous trial conducted by Sicilia et al.[29] where they found that root sensitivity was significantly reduced in all three groups after 1 month.[29]

The results of the present study suggest that reduction in root sensitivity obtained by lasers and combination of laser with fluoride remains stable for 30 days. These findings are comparable to the previous study done by Yilmaz et al.[30] where they found that GaAlAs laser and NaF varnish treatments resulted in a significant reduction in the VAS scores immediately compared to the baseline and placebo treatments and remained stable for longer period of 6 months.

In the present study, on comparing two test groups after 15 min, at 15 days, and 30 days, it was found that there was no difference between them suggesting that in the present study there was no added advantage obtained after SnF2 application. These results are in accordance to a previous study done by Raichur et al.[31] where they compared the effect of diode laser alone with diode laser and SnF2 combination and with potassium nitrate paste. They found that mean reduction was more pronounced in only diode laser group as compared to other two groups. This might have occurred due to inability of SnF2 to form a calcific barrier, which has been shown inin vitro studies. It can be said that 0.4% SnF2 might just not be sufficient enough to form calcific barrier and further studies using higher concentration should be conducted. Another reason can be the methodological difficulty in assessment of pain score where a minor difference of 0.6 is contemplated as statistically significant. However, this is just a possibility and further histological study should be conducted to infer a strong conclusion.

In the present study, both test groups showed improvement in pain scores in comparison to control group although results were not significant after 15 and 30 days. However, there are many contradictory studies regarding the efficacy of lasers in the treatment of root sensitivity this is because of no general consensus regarding the use of laser parameters and their frequency of application.[32],[33],[34] Thus, to strengthen the evidence regarding the efficacy of lasers and to draw the attention of researchers toward the most neglected aspect, that is, root sensitivity which might negatively influence the patients' compliance and hamper the postsurgical results, this study was conducted.

Limitations of the study

  1. Limited sample size
  2. Short duration of the study
  3. This was a clinical study, but no scanning electron microscopy (SEM) analysis was done. Thus, further studies should be conducted using SEM analysis.



   Conclusion Top


Within the limitations of the study, it can be concluded that diode lasers alone and in combination with 0.4% SnF2 was effective in the treatment of root sensitivity after conventional access flap surgery and lasers did not have any placebo effect in the control group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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