Having just read Drs. Douglas Dederich and Ronald Bushick’s February JADA article, "Lasers in Dentistry: Separating Science From Hype," I am compelled to write this letter in support of the article in general and, more specifically, the section concerning laser curettage.
Although clinical experience, technical ability and intuition are indispensable in the practice of dentistry, these attributes are no longer sufficient as the sole skills necessary to provide the best possible result from periodontal therapy. The ultimate applicability and strength of recommendation for a specific treatment modality must be based on the weight of evidence.
Randomized controlled clinical trials carry more weight than even a large series of case observations, because of the greater potential for bias when observations are made under uncontrolled conditions. The dental literature is replete with clinical observations that have evolved from private-practice settings. However, such studies rarely present concurrent controls and, therefore, the effectiveness of treatment is likely to be overstated.
The number of longitudinal, randomized clinical trials evaluating various periodontal treatments is considerable. Current recommendations for periodontal treatment and the appropriate modalities of therapy are based on such studies. Simply put, evidence-based treatment uses the accumulated evidence derived from published studies that have been subjected to the peer-review process. Thus, it is necessary to understand that the order of decreasing relevance for experimental and/or clinical study designs is randomized, blinded, controlled, longitudinal clinical trials; cohort or longitudinal studies; case-controlled studies; noncontrolled case studies; descriptive studies; in vivo animal studies; and in vitro laboratory studies.
To date, there has been no randomized blind controlled longitudinal clinical trial comparing laser subgingival curettage or laser-assisted new attachment procedure, or LANAP (Millennium Dental Technologies, Cerritos, Calif.), to the traditional periodontal therapies of scaling and root planing and/or Widman flap surgery.
I conducted a computerized dental literature review of 21 different journals, focusing on periodontal applications of dental lasers. This review yielded a total of 230 (100 percent) articles concerning lasers and periodontics, published from 1990 to 2004. These articles break down as follows: randomized blinded controlled longitudinal clinical trials, no articles (0.0 percent); cohort or longitudinal studies, nine articles (3.9 percent); case-controlled studies, 10 articles (4.3 percent); and noncontrolled case studies, 16 articles (7.0 percent), for a total of 35 articles (14.2 percent).
Collectively, these studies involved three different laser wavelengths (Nd:YAG, Er:YAG and diode), and nearly as many different study designs as there are studies. The diversity in study designs makes meaningful comparisons impossible. The collected studies indicate reductions in subgingival microbial populations and probing depth, and modest gains in clinical attachment levels.1–12 However, in most of the studies in which scaling and root planing or subgingival curettage were compared to laser therapy, the results were either not significant or marginally so.3,5,7–11
Until a multicenter, randomized, blinded, controlled, longitudinal clinical trial involving a significant number of patients is executed and published in a peer-reviewed journal, manufacturers are guilty of a quasi-promotion of uncontrolled human research when they market dental lasers as a legitimate modality for the treatment of inflammatory periodontal disease.
At present, we simply do not have sufficient data to warrant the application of this instrumentation over traditional therapy. Hopefully, well-designed clinical trials will be applied to the question in the immediate future. If so, the profession can then base the choice of therapy on reasonable and reliable data.
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