Biological implant failures are primarily related to biofilm, which can lead to peri-mucositis and, further on, peri-implantitis. The 810-nm diode laser has an affinity for pigmented chromophores, so its use in the peri-implant sulcus has a significant bactericidal effect on the black-pigmented anaerobes such as Porphyromonas gingivalis. Therefore, it can be used to eliminate or reduce the bacterial count in the peri-implant sulcular fluid (PISF), thus increasing the life of the implants and reducing the chances of failure. The purpose of this study was to evaluate the efficacy of the 810-nm diode laser for the maintenance of dental implants and its use as a regular in-office tool for limiting the microbiological count in the PISF. Twenty patients undergoing implant treatment at the Department of Periodontology and Oral Implantology were randomly selected for the study. PISF samples were collected before and after the sulcus was lased with an 810-nm diode laser and sent for quantitative microbiological analysis using universal bacterial count, and the quantity of P gingivalis was evaluated using real-time polymerase chain reaction (PCR). The analysis revealed that after diode application, the median percentage drop in the microbial count was 76.67% and the median percentage drop in P gingivalis count was 99.28%. The use of an 810-nm diode laser resulted in the following outcomes: (1) drastic reduction in the total bacterial count around the implant and (2) significant reduction in the P gingivalis count, as evaluated by real-time PCR.

dental implants, peri-implant sulcular fluid, 810 nm diode laser, P gingivalis, polymerase chain reaction, microbiology

Taking into consideration the worldwide increase in the placement of dental implants, there is also a need for long-term maintenance of the implants. Although dental implants have been proven to be successful treatment modalities for partial or complete edentulism, biological failures have been frequently reported and are related to poor oral hygiene and loss of follow-up, which cause plaque accumulation, leading to destruction of the tissues/structures surrounding the implant. According to the American Academy of Periodontology, peri-mucositis is defined as an “inflammatory process around a dental implant without loss of supporting bone beyond biological bone remodeling.”1  Peri-mucositis eventually leads to peri-implantitis, which inadvertently may result in the loss of the dental implant. Peri-implantitis is defined as an “inflammatory reaction around osseointegrated dental implants, leading to progressive loss of supporting bone.” The frequency of peri-implantitis has been reported to be about 1% to 19%.2  Peri-implantitis results in the loss of surrounding bone beyond repair, causing failure and ultimately the unfortunate removal of the dental implant.

Predisposing factors of peri-implantitis are the lack of treatment of periodontal disease prior to placement of the dental implant; inability of the patient to maintain good oral hygiene; systemic factors that set in after the treatment has been completed, such as diabetes and use of smoked tobacco; genetic traits; and extruded cement during prosthesis placement, which causes irritation to the underlying tissues.3  Plaque and calculus around the dental implant lead to bacterial accumulation, and the micro-organisms on the implant are considered to initiate peri-implantitis.4,5 

There are numerous methods used for the decontamination of the implant surface, such as mechanical debridement, which can be done by carbon, titanium, or plastic curettes, ultrasonic scalers, and air abrasion; chemotherapeutic agents, which can be used the disinfection, such as chlorhexidine digluconate; minocycline microspheres; and tetracycline fibers, which have bactericidal action. Along with these methods come the unavoidable disadvantages faced after the use of the above techniques, such as resistant strains of bacteria when antibiotic therapy is considered and damage to the implant surface when mechanical methods are used, which lead to a rough surface that in turn harbors more bacteria, therefore not serving its purpose.6–14 

Recently, dental lasers such as diode, Nd:YAG, and CO2 are being used to reduce the count of micro-organisms, which directly increases the life of the dental implant.15–18 

Pocket sterilization is a routine procedure performed in cases of periodontitis that has the same effect of reduction in the bacterial load around the teeth. Longitudinal studies have shown that implants that have lasted for a long time in the oral cavity have been colonized by a predominantly gram-positive, facultative flora, which is established shortly after implant placement. Repeated microbiological sampling in patients with clinically stable implants showed no significant change in the composition of this flora over a duration of 5 years. In patients with a compromised periodontium around the implants, however, a significantly different flora was found: gram-negative anaerobic bacteria, particularly fusobacteria, spirochetes, and black-pigmenting organisms such as Prevotella intermedia were often present in large amounts.19 

The most commonly used lasers in dentistry, specifically in periodontology and oral implantology, are the diode laser, CO2 laser, Nd:YAG laser, and Er:YAG laser. These lasers are basically used in procedures such as subgingival debridement and curettage, flap surgery as an adjunct to mechanical debridement, osseous recontouring, and maintenance of implants, with the aim of preventing peri-implantitis. Nd:YAG lasers can be used in both noncontact and contact mode. Er:YAG lasers are suitable for the decontamination of implant surfaces without adverse effects to the surrounding bone. CO2 lasers are safe for use on titanium and hydroxyapatite implants.20,21 

Photodynamic therapy (PDT) uses low power diode laser in a combination with photosensitizing compounds.22  PDT has gained importance in dentistry in recent years. The main objective of PDT is the application of photosensitive dyes into the pockets and their activation with light, which kills the periodontal pathogens.23 

A study conducted by Romeo et al24  in 2016 demonstrated the effectiveness of antimicrobial PDT to treat peri-implantitis. Photodynamic therapy was used as an adjunct to conventional periodontal therapy, and after 24 weeks of the study, better values were observed in terms of bleeding on probing, probing pocket depth, and plaque index.24 

Socransky et al25  in 1998 used the checkerboard DNA-DNA hybridization and identified the species Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia. These bacteria have the highest affinity for the periodontium and are almost always present during periodontal disease and breakdown.25  The 810-nm diode laser has a strong affinity for P gingivalis. Therefore, in this study, the usage of a diode laser as a regular in-office tool for the maintenance of dental implants using total bacterial count and P gingivalis count using real-time polymerase chain reaction (PCR) has been studied.26 

Clinical procedure

The study was conducted in a dental institution in Pune, India, in patients who were being treated for missing teeth and who sought replacement with dental implants. Twenty implant sites, irrespective of their location in the oral cavity, were included in the study from among 9 patients at different stages of osseointegration who had bleeding on probing measured dichotomously. The samples were collected from patients who were recalled for follow-up mainly at 3, 6, 9, and 12 months after implant loading. Each sample was taken at only 1 stage of each implant. Ethical clearance was obtained from the local ethical committee, and written and verbal informed consent were obtained from the patients who agreed to take part in the study.

Peri-implant sulcular fluid samples were obtained from the patients and sent for total microbial count analysis and for total quantity of P gingivalis before and after the peri-implant sulcus was sterilized with the 810-nm diode laser.

Total microbial count analysis

The implant and its surrounding tissues were dried with a gauze so that saliva did not interfere with the study. Sterile paper points of 2% tapered diameter were passively inserted in the sulcus without causing undue trauma to the tissues (Figure 1). Figure 2 shows the intraoral periapical radiograph of the implants. The paper points were held in the sulcus for 10 to 20 seconds and immediately placed in a sterile Luria broth solution, which was contained in Eppendorf tubes and sealed. The area was anesthetized with 2% lignocaine with a dilution of 1:1 00 000 adrenaline. The sulcus was then sterilized with the 810-nm diode laser at 3 intervals for 20 seconds each (Figure 3). The settings of the laser were 1.5W and CW. The flexible fiber tip of the 810-nm diode laser had a diameter of 200 μm so as to not cause injury while insertion into the sulcus. Care was taken to ensure that both the patient and the operator were wearing safety goggles throughout the procedure when the laser was in use to prevent inadvertent damage to the eyes.

Figures 1–5.
Figure 1. Sample collection using 2% taper sterile paper points. Figure 2. Intraoral periapical radiograph of 32 and 42 implants. Figure 3. An 810-nm diode laser used at 3 intervals for 20 seconds each with settings at 1.5 W, continuous wave. Fiber tip of 200-μm diameter. Figure 4. Colonies of implant 42 before (250 CFU/mL) and after (60 CFU/mL) the use of an 810-nm diode laser. Figure 5. Colonies of implant 32 before (300 CFU/mL) and after (60 CFU/mL) the use of an 810-nm diode laser.
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Figure 1. Sample collection using 2% taper sterile paper points. Figure 2. Intraoral periapical radiograph of 32 and 42 implants. Figure 3. An 810-nm diode laser used at 3 intervals for 20 seconds each with settings at 1.5 W, continuous wave. Fiber tip of 200-μm diameter. Figure 4. Colonies of implant 42 before (250 CFU/mL) and after (60 CFU/mL) the use of an 810-nm diode laser. Figure 5. Colonies of implant 32 before (300 CFU/mL) and after (60 CFU/mL) the use of an 810-nm diode laser.

Figures 1–5.
Figure 1. Sample collection using 2% taper sterile paper points. Figure 2. Intraoral periapical radiograph of 32 and 42 implants. Figure 3. An 810-nm diode laser used at 3 intervals for 20 seconds each with settings at 1.5 W, continuous wave. Fiber tip of 200-μm diameter. Figure 4. Colonies of implant 42 before (250 CFU/mL) and after (60 CFU/mL) the use of an 810-nm diode laser. Figure 5. Colonies of implant 32 before (300 CFU/mL) and after (60 CFU/mL) the use of an 810-nm diode laser.
View largeDownload slide

Figure 1. Sample collection using 2% taper sterile paper points. Figure 2. Intraoral periapical radiograph of 32 and 42 implants. Figure 3. An 810-nm diode laser used at 3 intervals for 20 seconds each with settings at 1.5 W, continuous wave. Fiber tip of 200-μm diameter. Figure 4. Colonies of implant 42 before (250 CFU/mL) and after (60 CFU/mL) the use of an 810-nm diode laser. Figure 5. Colonies of implant 32 before (300 CFU/mL) and after (60 CFU/mL) the use of an 810-nm diode laser.

Close modal

These samples were then sent for microbiological analysis in the institution for a total colony count estimation in which the Luria broth was diluted to 1/10 and streaked on Luria agar plates. The agar plates were incubated for 24 hours, after which colonies of total bacteria started appearing on the plates and were counted visually (Figures 4 and 5).

Total quantity of P gingivalis bacteria

The same procedure to obtain the samples was performed as mentioned for the total bacterial count, but the sample was collected in Eppendorf tubes containing TE buffer. Real-time PCR (Figure 6) was used for the DNA identification of P gingivalis.

Figures 6–10.
Figure 6. Quantitative polymerase chain reaction equipment. Figure 7. Micropipettes in use for transferring the samples. Figure 8. Vortexing procedure. Figure 9. Vortexing procedure. Preparation of reaction mix. Figure 10. Polymerase chain reaction tube strip.
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Figure 6. Quantitative polymerase chain reaction equipment. Figure 7. Micropipettes in use for transferring the samples. Figure 8. Vortexing procedure. Figure 9. Vortexing procedure. Preparation of reaction mix. Figure 10. Polymerase chain reaction tube strip.

Figures 6–10.
Figure 6. Quantitative polymerase chain reaction equipment. Figure 7. Micropipettes in use for transferring the samples. Figure 8. Vortexing procedure. Figure 9. Vortexing procedure. Preparation of reaction mix. Figure 10. Polymerase chain reaction tube strip.
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Figure 6. Quantitative polymerase chain reaction equipment. Figure 7. Micropipettes in use for transferring the samples. Figure 8. Vortexing procedure. Figure 9. Vortexing procedure. Preparation of reaction mix. Figure 10. Polymerase chain reaction tube strip.

Close modal

The laboratory steps for real-time PCR used in the estimation of P gingivalis were as follows:

  1. TE buffer was made as follows: 1 M tris buffer: 0.5 mL; 0.5 M EDTA: 100 μL; distilled water: made to 50 mL.

  2. The transferred sample was centrifuged at 5000 rpm for 5 minutes.

  3. The supernatant fluid was discarded, and 500 μL of fresh TE buffer was added and centrifuged for 3–4 minutes. The above procedure was repeated 3–4 times with fresh TE buffer. The supernatant was discarded, and 50 μL of lysis buffer I was added, which was vortexed and kept for 5 minutes (Figures 7 and 8).

  4. Fifty microliters of lysis buffer II and 10 μL of proteinase-K (100 μg/mL) was added and vortexed vigorously. It was kept in a water bath at 60°C for 2 hours and then in a boiling water bath for 10 minutes. The DNA was then stored at −20°C.

Constituents of lysis buffer I comprised 1M Tris buffer (500 μL), Triton X-100 (500 μL), 0.5M EDTA (100 μL), and distilled water made to 50 mL. Constituents of lysis buffer II comprised Tris HCl (50 mM at 8.0 pH), KCl (50 mM), MgCl2 (2.5 mM), Tween 20 (0.45%), and Nodient P-40 (0.45%; Figure 9)

PCR procedure for P gingivalis

The following set of PCR primers was used, which are specific to the 16SrRNA gene of P gingivalis: forward primer: AGG CAG CTT GCC ATA CTG CG; reverse primer: ACT GTT AGC AAC TAC CGA TGT.

Real-time quantitative PCR (qPCR) amplification and detection were performed with the Realplex master cycler (Eppendorf) using a 96-well format. To limit contamination, reactions were set up in a Laminar air flow, and the reactions were run and analyzed at another laboratory where DNA manipulation was not performed. PCR reactions were performed in a total volume of 20 μL containing 2 μL of template DNA, 10 μL of Quantitect SYBR green PCR master mix (Qiagen, JJ Biotech, India), and 8 pm/μL of each of the P gingivalis–specific primers. (Qiagen Quantitect SYBR green PCR master mix was used, which contains 2.5 mM MgCl2. In addition, the master mix contains Taq polymerase enzyme, dNTP mix, and SYBR green dye.)

The stepwise preparation of the master mix was conducted as follows:

  1. PCR master mix was vortexed and briefly centrifuged after thawing.

  2. A thin-walled PCR tube (Figure 10) was placed on ice, and the following components were added for each 50-μL reaction: Quantitect SYBR green master mix: 10 μL; P gingivalis (forward primer): 0.3 μL (8 pmole); P gingivalis (reverse primer): 0.3 μL (8 pmole); template DNA: 2 μL (<1 μg/reaction); water: added to create a final volume of 20 μL.

  3. The samples were gently vortexed and spun down.

  4. The tubes were placed in a real-time thermal cycler (Eppendorf).

The qPCR reaction conditions were 95°C for 3 minutes, followed by 35 cycles of 95°C for 30 seconds, 60°C for 30 seconds, and 72°C for 30 seconds. Deionized water served as a negative control.

A fluorescence graph was obtained showing the amplification plot: fluorescence vs cycle numbers (Figure 11). The cycle number at which amplification was initiated is called the cycle threshold (Ct value). Standard curve was plotted using Ct values of standard DNA samples (known quantity). Unknown samples were run in real-time PCR to obtain Ct values for each sample, and then these Ct values were plotted on the standard curve to obtain the corresponding quantity.

Figures 11–13.
Figure 11. Fluorescence vs cycle numbers graph for Porphyromonas gingivalis. Figure 12. Total microbial count before and after 810-nm diode laser (graph). Figure 13.Porphyromonas gingivalis count before and after 810-nm diode laser (graph).
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Figure 11. Fluorescence vs cycle numbers graph for Porphyromonas gingivalis. Figure 12. Total microbial count before and after 810-nm diode laser (graph). Figure 13.Porphyromonas gingivalis count before and after 810-nm diode laser (graph).

Figures 11–13.
Figure 11. Fluorescence vs cycle numbers graph for Porphyromonas gingivalis. Figure 12. Total microbial count before and after 810-nm diode laser (graph). Figure 13.Porphyromonas gingivalis count before and after 810-nm diode laser (graph).
View largeDownload slide

Figure 11. Fluorescence vs cycle numbers graph for Porphyromonas gingivalis. Figure 12. Total microbial count before and after 810-nm diode laser (graph). Figure 13.Porphyromonas gingivalis count before and after 810-nm diode laser (graph).

Close modal

The P gingivalis count measured by real-time PCR for implant 32 was 4.89 × 106 DNA copies/μL before diode application and 3.20 × 103 DNA copies/μL after diode application; for implant 42, it was 4.66 × 108 DNA copies/μL before diode application and 3.43 × 107 DNA copies/μL after diode application.

An independent statistician performed the following tests for this study. The data for the continuous variables were presented as median and interquartile range (IQR). The pairwise statistical comparison of the median of the continuous variables was done using Wilcoxon's signed-rank test (nonparametric test for paired comparisons). All results are shown in tabular as well as graphical format to enable visualization of the statistically significant differences more clearly.

In the entire study, P values less than .05 were considered to be statistically significant. All hypotheses were formulated using 2-tailed alternatives against each null hypothesis (hypothesis of no difference). The entire data were statistically analyzed using the Statistical Package for Social Sciences (SPSS version 21.0, IBM Corporation, Armonk, NY) for Microsoft Windows.

In the present study, there was a drastic reduction in the total bacterial count and total P gingivalis count, following which 4 of 20 samples did not have a significant reduction in total bacterial count.

Total microbial count

The distribution of median (IQR) microbial count (CFU) before and after diode application was 300.0 (250–300) per mL and 60.0 (35–70) per mL, respectively. The distribution of the median microbial count after diode application was significantly lower compared with the median microbial count before diode application (P < .001). The median percentage drop in microbial count after diode application was 76.67% (Figure 12; Table 1).

Table 1

Total microbial count before and after 810-nm diode laser (chart)†

Total microbial count before and after 810-nm diode laser (chart)†
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Total microbial count before and after 810-nm diode laser (chart)†
View Large

P gingivalis count

The distribution of the median (IQR) bacterial count (P gingivalis DNA copies) before and after diode application was 6.32 × 106 (5.67 × 105–3.40 × 108) per μL and 4.49 × 103 (3.30 × 103–3.50 ×106) per μL. The distribution of the median bacterial count after diode application was significantly lower compared with the median bacterial count before diode application (P < .001). The median percentage drop in the bacterial count after diode application was 99.28% (Figure 13; Table 2).

Table 2

Porphyromonas gingivalis count before and after 810-nm diode laser (chart)†

Porphyromonas gingivalis count before and after 810-nm diode laser (chart)†
View large
Porphyromonas gingivalis count before and after 810-nm diode laser (chart)†
View Large

The results of this study showed a drastic reduction in the total microbial and P gingivalis count following the use of an 810-nm diode laser on peri-implant sulcus. With a rise in biologic failures related to implants, regular follow-up with good implant maintenance is required. There are different methods for implant maintenance, as mentioned, but they have several unavoidable disadvantages. The use of an 810-nm diode laser could have the disadvantage of overheating and then inadvertent damage to the implant surface. This was completely avoided by using the laser 3 times at an interval of 20 seconds to prevent overheating, while focusing on the sulcus lining in contact mode only. The 810-nm diode laser was set at 1.5W and CW in accordance with the settings for pocket sterilization. Irradiation with a diode laser also has a bio stimulating effect on osteoblasts in vitro, which might be used in the osseointegration and reosseointegration of ailing dental implants.27 

An 810-nm diode laser has an affinity for pigmented chromophores, so its use in the peri-implant sulcus showed a significant bactericidal effect on the putative pathogen P gingivalis, which is a gram-negative, non–spore- forming, anaerobic, rod-shaped bacteria that produces porphyrin pigments (dark brown/black pigments) and is one of the principal etiological agents in adult periodontitis that is also linked with peri-implant destruction. This can be attributed to the photothermal and ablative property of the laser. Local effects of the laser overcome the disadvantages caused by disinfection with chemotherapeutic agents such as chlorhexidine digluconate and tetracycline fibers, mechanical debridement, and so forth. There was no significant correlation observed between the different stages of osseointegration and the quantity of bacteria or P gingivalis.

There have been numerous studies conducted on the disinfection of the peri-implant sulcular area. A study conducted by Haas et al28  stated that radiation with a 905-nm diode laser along with toluidine blue could result in the reduction of Aggregatibacter actinomycetemcomitans, P gingivalis, and P intermedia bacteria. The study proved that that combined dye/laser treatment resulted in the complete destruction of periodontal pathogens.28  Another study by Kreisler et al29  indicated that erbium doped with a yttrium, aluminum, garnet (Er:YAG) laser (0.6–1.2 W or 60–120 mJ/110 pps) could kill more than 99% of bacteria with no damage to the titanium dental implant. Dörtbudak et al30  continued the study done by Hass et al28  in 1997 and found that using a low-power laser with diode (690 nm) for 60 seconds, after placing toluidine blue on the implant surface, could decrease the amount of bacteria up to 92%. Gonçalves et al31  conducted an in vitro study in which a 980-nm diode laser and 1064-nm Nd:YAG laser were used for implant disinfection. The Nd:YAG laser was able to promote a total reduction of bacteria on all implants irradiated. The results with the diode laser showed complete bacteria reduction on the implants irradiated with 3W. Irradiation with 2.5W and 3W achieved 100% bacteria reduction on P gingivalis–contaminated implants. The wavelengths used in this study provided bacterial reduction without causing any undue damage to the implant surfaces. The 980-nm diode and the 1064-nm Nd:YAG lasers were effective for the decontamination of P gingivalis and Enterococcus faecalis.31  Kotoku et al32  determined the effect of 405-nm diode laser irradiation on P gingivalis in vitro. They stated that the growth of P gingivalis was effectively inhibited by 405-nm diode laser irradiation, and the growth of >97% of bacteria was inhibited by irradiation at an energy density of >4.0 J/cm.2  The mechanism of the bactericidal effect was found to be photochemical rather than photothermal.32 

The two main outcomes of the study after 810-nm diode laser was used around the implant were as follows: 1) drastic reduction in the total bacterial count and 2) significant reduction in the P gingivalis count as evaluated by real-time PCR.

These 2 outcomes show that an 810-nm diode laser can be used as a regular tool for maintaining the implant without any harmful effects or damage to the implant or surrounding tissues.

As this study was conducted at a single point in time, samples were collected only once for each patient. A larger sample size, longer duration of follow-up and, sample collection at different stages of osseointegration would definitely aid in guiding the practitioner as to how frequently the 810-nm diode laser should be used to control the growth of P gingivalis and therefore prevent peri-implantitis. Other issues such as cost and availability of the equipment have to be considered prior to using lasers regularly in the practice. There is no absolute contraindication for the use of lasers.

Abbreviations

Abbreviations
CW:

continuous wave

EDTA:

ethylene diamine tetra-acetic acid

Er:YAG:

erbium-doped yttrium aluminium garnet

IQR:

interquartile range

Nd:YAG:

neodymium-doped yttrium aluminium garnet

PCR:

polymerase chain reaction

PDT:

photodynamic therapy

qPCR:

quantitative polymerase chain reaction

The authors would like to thank Dr Mehmood G. Sayyed, MSc, PhD, statistician/associate professor, Department of Statistics, Abeda Inamdar Senior College, Pune, India, for his help with the statistical analysis of the study. We would also like to thank Dr Kishore Bhat (MD, microbiology) and the team of the Central Research Laboratory of Maratha Mandal's Nathajirao G. Haglekar Institute of Dental Sciences and Research Centre, Belagavi, for their kind help with the microbiological aspects of the study. Without their sincere efforts, the completion of the study would have not been possible. We also thank Dr Shaila Bootwala (principal, Abeda Inamdar Senior College of Arts, Science and Commerce), Dr Devipriya Majumder (head of the Department of Microbiology), Dr Madhavi Rane (assistant professor, Department of Microbiology), and Ms Alia S. Dholkawala (MSc, microbiology postgraduate student) for their constant help with the microbiological aspects of the study.

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