Lasers, EBDH, and snakes...oh, my!

by Lynne H. Slim RDH, BSDH, MSDH
[email protected]

Rays of sunlight poured through my windows on a hot summer's day. Even though it was early evening, temps in Atlanta were still way above normal. I hesitated taking my daily walk/jog with my walking buddy, Nellie, but when I grabbed her leash she knew it was time and hid under a living room chair. Nellie is a two-year-old, miniature, longhaired dachshund, and she's incredibly shy. I have to tug on her leash to get her cooperation while climbing our 600-foot driveway before she'll move faster than a turtle.

After walking, I let Nellie off the leash so she could wander around the creek in front of our house. When she didn't scratch at the front door to come in, I went to find her and noticed that she wasn't herself. Her neck was grossly distorted, and there was blood dripping from her neck onto the hardwood floor. After lifting her long snout, I saw a huge abscess about the size of a golf ball. Things went from bad to worse very quickly. Nellie went into shock and I had to rush her to an emergency animal clinic.

Standing in the emergency room operatory for what seemed like hours, my mind wandered and I began wondering what kind of protocol the emergency room veterianarian would follow, especially if it turned out that Nellie had been bitten by a brown recluse spider or, heaven forbid, a venomous snake. It just so happened I was about to write a column on evidence-based periodontal protocols, so I was curious about how the doctor would approach this particular emergency. After examining Nellie, she guessed it was a snakebite. The diagnosis was confirmed the following morning by our regular veterinarian.

Many medical procedures, including snakebites, follow evidence-based (EB) protocols. I even found an EB "national" snakebite management protocol from India, because so many people are bitten there and die. There are 65 snake species in India that can inflict a fatal bite.

Registered nurses and physicians are far ahead of hygienists and dentists in applying evidence-based decision making to clinical point of care. This is a theme that excites my passion when I am discussing periodontal therapy. When I spent time with wound care nurses at Emory University in Atlanta, Ga., last fall, I was struck by their dedication to and understanding of evidence-based medicine. In chronic wound care nursing, nurses use evidence-based wound care protocols in the form of written guidelines, and they are taught how to measure performance in order to improve quality. Let's take this one step further in dentistry and look at how we can apply this way of thinking to nonsurgical periodontal protocols.

Here's a hypothetical situation. Your current employer, Dr. Nora Tocsyn, purchases a PerioLase MVP-7 from Millenium Dental Technologies. A general dentist who no longer refers patients to a periodontist, she wants to perform the Millenium LANAP protocol on patients with chronic periodontitis in an attempt to regenerate bone. Consequently, she asks you to take a course sponsored by Millenium on your role and the LANAP protocol.

You look over the course description and one of the stated course objectives is to teach you to perform long-term maintenance with laser pocket disinfection. As someone who is learning to apply evidence-based dental hygiene (EBDH) chairside, you know how important it is to integrate information given to you by the Millenium-sponsored instructors with evidence-based information from original research.

The path to finding the appropriate references isn't always easy. In a nutshell, it's best to look at it as a cycle, because oral health research is dynamic rather than static. New research findings are constantly becoming available. You have to sift through the highest levels of evidence (if they exist and sometimes there isn't any) to find the best available evidence. You don't want the process to take up too much time either.

Take a look at Figure 1. You'll be able to visualize what constitutes higher quality evidence. Let's apply it to laser pocket disinfection. In this particular case, the PerioLase laser wavelength is an Nd:YAG. The question we're looking to answer is this: "What evidence is there to recommend (and even charge extra for) Nd:YAG laser pocket disinfection as an adjunct to periodontal maintenance or SRP?" First, recognize that there are different laser wavelengths and you are specifically sleuthing for studies that have tested the effect of the Nd:YAG as an adjunct. Single studies are often a low level of evidence unless it's a randomized controlled trial (RCT). Review Figure 1 again.

Here's your plan. You jump on your new MacBook after work as a professional sleuth. First you want to look for systematic reviews of the literature (highest form of evidence), so you google PubMed Home and type in the following key words: systematic review/periodontitis/laser therapy. Up pops a couple of good citations, one of which is a systematic review and the other a chapter from a narrative review. Here's a summary of what each review concluded:

1. To date, there is no consistent evidence supporting the efficacy of laser treatment as an adjunct to nonsurgical periodontal treatment in adults with chronic periodontitis. More randomized controlled clinical trials are needed.1
2. When Nd:YAG alone (without SRP) was used in nonsurgical periodontal therapy, it was shown to be less effective for root debridement than conventional mechanical therapy (SRP). However, the authors also mentioned that it might hold promise as an adjunctive therapy following conventional SRP in nonsurgical periodontal therapy.2
3. Published clinical trials indicate only a slightly greater benefit adjunctively with respect to gains in CAL, probing depth, BOP, and subgingival microbial loads.3

In the end, look at the most current and highest quality evidence, talk to clinical experts, look for clinical guidelines, and make a decision you can support. Let your conscience and professional integrity be your guides.

References

1. Karlsson MR, Diogo Löfgren Cl, Jansson, HM. The effect of laser therapy as an adjunct to nonsurgical periodontal treatment in subjects with chronic periodontitis: a systematic review. J Periodontol Nov. 2008; 79(11): 2021-2128.
2. Ishikawa I, et al. Application of lasers in periodontics: true innovation or myth? Periodontol 2000 Jun. 2009; 50(1): 90-126.
3. Cobb CM, Low SB, Coluzzi DJ. Lasers and the treatment of chronic periodontitis. Dent Clin N Am 2010; 54: 35-53.

Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.