Received: 4 April 2023 | Revised: 12 July 2023 | Accepted: 15 July 2023

DOI: 10.1002/cre2.769

ORIGINAL ARTICLE

Efficacy of two diode lasers in the removal of calculus from the

root surface: An in vitro study

Domenico Marcattili | Leonardo Mancini | Francesco Tarallo |

Fabio Casalena | Carla Pietropaoli | Enrico Marchetti

Department of Life, Health & Environmental

Sciences, University of L'Aquila, L'Aquila, Italy Abstract
Introduction: Scaling and root planning (SRP) is still the gold standard of nonsurgical
Correspondence
Enrico Marchetti, Department of Life, Health periodontal therapy, and it has been accompanied by several supportive therapies in
& Environmental Sciences, University of recent years. One of the most studied methods is the diode laser, thanks to its
L'Aquila, P.le S. Tommasi 1, 67100
L'Aquila Italy. thermal and bactericidal properties. Our trial intended to verify whether it could
Email: enrico.marchetti@univaq.it influence the chemical bond between calculus and the root surface.
Objectives: The aim of the study was to assess the efficacy of the diode laser prior
the mechanical removal of calculus in an in vitro application. The reduction in time
and the number of strokes required to clean the untreated root surfaces were
evaluated as primary outcomes. The pressure was considered as a secondary
outcome.
Methods: A total of 75 extracted human teeth with subgingival calculus were
assigned equally among three treatment groups (n = 25) according to the size of the
occupied areas, which were classified by evaluating the pixel numbers. The groups
were assigned to either no pretreatment application (A), Laser Diode Fox III (Sweden
& Martina) (B) or Wiser Laser Evolution (Doctor Smile) (C). The weight for
instrumentation was calibrated for an After Five curette (Hu‐Friedy, Chicago). A new
set of tools was used for each group, and the curettes were sharpened after each use
with the Sidekick sharpener (Hu‐Friedy, Chicago).
Results: A Kruskal–Wallis test was used to assess the significance for each
considered parameter. The results were statistically significant for each parameter
for the two groups where the laser was used compared to the control group.
Conclusions: Despite the limitations of an in vitro study, data showed that the diode
laser had an overall positive effect on root debridement, facilitating SRP in terms of
stroke count, time, and pressure.

KEYWORDS
debridement, dental calculus, diode laser, root planing, scaling

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.

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758 | MARCATTILI ET AL.

1 | INTRODUCTION allows the adhesion of calcified deposits to the root surface, through a
photochemical effect, thus facilitating their removal with conventional
Periodontitis is a chronic inflammatory disease associated with a instruments (Ben Hatit et al., 1996; Chantaboury & Trinakis, 2005;
biofilm of dysbiotic bacteria that results in the progressive destruc- Cobb, 1996; Midda, 1992). The purpose of this study was to evaluate
tion of the tooth‐supporting apparatus. It is characterized by the loss whether using the DL in the pretreatment SRP facilitates the removal
of periodontal support tissue, manifested through gingival bleeding, of tartar deposits through the weakening of the bond between
clinical attachment loss (CAL), the presence of periodontal pockets, calculus and the root surface.
and the loss of alveolar bone, which is assessed radiographically
(Papapanou et al., 2018). It is one of the main reasons for adult tooth
loss (Jenkins et al., 1988) and needs adequate treatment. 2 | M A T E R I A L S AN D M E T H O D S
Treating periodontal disease is a very complex challenge. Initially,
it is essential to remove the biofilm from the root and subgingival SRP was performed using manual instruments on the dental surfaces
surface (Van der Weijden & Timmerman, 2002). The main approach with the presence of calculus after undergoing three different
of nonsurgical periodontal therapy is scaling and root planning (SRP), pretreatment procedures. The aim of the study was to evaluate the
which is used to remove tartar and subgingival biofilm. Subgingival number of strokes and the time required to remove the calculus from
calculus is one of the factors that contribute to the cyclical nature of the root surface, to evaluate the possible positive effect of the laser
periodontal disease (Moskow, 1970). The removal of tartar repre- used before the nonsurgical periodontal therapy.
sents one of the greatest challenges in nonsurgical periodontal
therapy, especially when it is found in harder areas to reach, such as
the bottom of the periodontal pocket or the furcation of multi‐rooted 2.1 | Sample preparation and distribution
teeth. Sherman et al. (1990a) analyzed the effectiveness of SRP by
evaluating residual calculus and found the presence of calculus Human teeth extracted for periodontal reasons were stored in a
residues on 75% of teeth examined under a stereomicroscope, Allen saline solution (NaCl 0.90% w/v) and later assigned to one of the
and Kerr (1965) showed that the presence of calculus, even if sterile, three treatments. The collection of human teeth and their use for
caused a toxic effect on surrounding tissues, highlighting that the study purposes was approved by the Internal Review Board of the
calculus must be completely removed to eliminate its inflammatory University of Study of L'Aquila (No.: 02/2019). All teeth showed
effect. tartar under the enamel‐cement junction, occupying variable areas in
The role of calculus as an inflammatory factor is still under terms of size, and position along the root. All 75 teeth satisfied the
discussion. Sherman et al. showed that gingival changes after SRP, main inclusion criteria: intact and caries‐free root surfaces displayed
such as probing depth, bleeding, and periodontal attachment, are not plain root areas affected by calculus. Single and multirooted teeth
affected by the presence of residual calculus, (Sherman et al., 1990b), were equally included.
although the formation of a new epithelial attachment has been Each sample was positioned horizontally in a block of resin
observed in areas where residual calculus are present (Listgarten & (Palapress) to provide fixation during debridement and standardized
Ellegaard, 1973). positioning for photographic analysis. The samples were bi‐digitally
In the last decade, several lasers have been used as a support in fixed with the exposed calculus surface on the top to allow direct
the treatment of periodontitis; among the most used is the diode access for the treating agents and curettes. All samples were
laser (DL) (809–980 nm), with the Nd:YAG being capable of both consecutively numbered from 1 to 75.
decontaminating and remodeling the tissues (Cobb et al., 2010). All sites of interest were photographed (7200D; Nikon) under a
Moreover, the laser increases hemostasis through coagulation and stereomicroscope (Leica). The areas covered with calculus were
occlusion of arterioles, venules, and capillaries, induced by heat, manually determined and measured by calculating the number of
(Cobb et al., 2010), allowing a visible and clean operating field. The pixels (Preibisch et al., 2009). To account for the equal distribution of
heat given off by the laser also has a bactericidal effect on the target areas affected by calculus among the three treatment groups, the
site (Cobb et al., 2010). assignment of the total number of teeth (n = 75) to each group was
Considering the microbial components, laser irradiation, with its stratified by the pixel count (Figure 1).
bactericidal effect, could represent a valid aid to “nonsurgical
periodontal therapy” (SRP) (Moritz et al., 1998). As already mentioned,
all lasers have a thermal effect, and the non‐spore‐producing bacteria, 2.2 | Calculus pretreatment in SRP
including the anaerobic bacteria responsible for periodontal disease,
are deactivated at a temperature of around 50°C (Cobb, 2006; The samples of Group B were pretreated with Fox III DL (Sweden &
McDavid et al., 2001). In addition, coagulation of the inflammatory Martina) with a fiber of 300 µm, a power of 2.5 W, 10 ms pulse
tissue of the periodontal pocket and hemostasis are also obtained at length, and a 10 ms pulse pause for 30 s (Figures 2a and 3a). The
60°C. A further effect to be considered in nonsurgical periodontal samples of Group C were pretreated with Wiser Laser Evolution
therapy is the possibility of the DL weakening the chemical bond that (Doctor Smile) with a frequency of 2.5 W ‐ average 0.7 W, pulse
 20574347, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cre2.769 by Cochrane Mexico, Wiley Online Library on [06/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MARCATTILI ET AL. | 759

F I G U R E 1 Labeling the area of interest (yellow line) and its

extension upon a plane portion of the root.

FIGURE 4 (a) Strokes on the balance. (b) Detail of strokes on the

tooth.

coronal, parallel to the axis of the tooth. A weight of 800–1000 g was

applied during scaling, and the instrument was sharpened after each
use (Sidekick, Hu Friedy, Chicago) (Busslinger et al., 2001).
The first investigator (MB) selected and preconditioned the
specimens. The second, blinded, investigator (CP) carried out all
treatments, recorded the time required for treatment (in seconds), as
well as the number of strokes, monitored the weight applied during
treatment, and proved the thoroughness of the debridement by the
tactile detection of remnant calculus on the surfaces (Figure 4a,b).
Each sample was treated until the area of interest showed no
F I G U R E 2 (a) Laser diode Fox III (Sweden & Martina). (b) Wiser residual calculus by visual and tactile inspection (CP‐15 Probe, Hu‐
laser evolution (Doctor Smile). Friedy, Chicago). After root debridement, the surfaces were photo-
graphed under microscopic magnification to record the results.

2.3 | Statistical analysis

Data were recorded in a spreadsheet and analyzed by a non‐

parametric approach because of the non‐normal distribution checked
using Kolmogorov–Smirnov's test. Specifically, the overall p‐trend for
each outcome of interest (i.e., pressure, time and numbers of strokes)
was explored by the Kruskal–Wallis test (Figure 5), while pairwise
comparisons were evaluated by the Mann–Whitney's test with
Bonferroni's correction. Medians and interquartile ranges (IQR) were
derived and presented in the results (Table 1). Data were analyzed as
recorded, and no missing data were present. The level of statistical
significance was set at p > .05. Post hoc power was estimated at 77%

F I G U R E 3 (a) Laser diode Fox III (Sweden & Martina) tip to detect a large effect size (d = 0.8) at the difference of a parameter
activated. (b) Wiser laser evolution (Doctor Smile) tip activated. between two groups.

length of 30 ms, and pulse pause 70 ms for 30 s (Figures 2b and 3b). 3 | RESULTS
Both DLs were used according to the manufacturer's indications.
No additional treatment to SRP was applied in the control group The average tartar present on each tooth, expressed in pixels, was
(group A). Each group was supplied with a new curette (After Five, 1,637,705 ± 1,617,704 pixels in Group A (control group),
Hu‐Friedy, Chicago); working strokes were performed from apical to 1,536,570 ± 1,392,091 pixels in Group B (Laser Diode Fox, Sweden
 20574347, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cre2.769 by Cochrane Mexico, Wiley Online Library on [06/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
760 | MARCATTILI ET AL.

F I G U R E 5 Plots with the results analyzed by the Kruskal–Wallis test. In each group (pressure, time, and strokes), statistically significant
results between the test groups (b and c) and the control group (a) were recorded.

TABLE 1 Median and interquartile range (IQR) of the time, strokes, and pressure of the three groups.

Group N Median IQR p‐Value (KW) p‐Value (MW)

Time (s) A 25 175 98–282 .011 A versus B; p = .054 A versus C;

p = .017 B versus C; p = 1.000
B 25 75 57–126

C 25 81 44–128

Pressure (gr) A 25 920 575–920 .005 A versus B; p = .030 A versus C;

p = .010 B versus C; p = .810
B 25 700 550–800

C 25 650 500–750

Strokes (N) A 25 30 25–35 .002 A versus B; p = .057 A versus C;

p = .002 B versus C; p = .381
B 25 24 15–33

C 25 16 8–26

Note: Kruskall–Wallis (KW) test was used for differences at distributions between the three groups. Mann–Whitney (MW) test was adjusted with
Bonferroni for the pairwise comparisons.

& Martina), and 1,420,084 ± 1,014,378 pixels in Group C (Wiser Laser There were statistically significant differences among the three
Evolution, Doctor Smile). groups (p = .011), but not between Group B (Laser Diode Fox,
The average tartar expressed as a percentage of the total tooth Sweden & Martina) and Group C (Wiser Laser Evolution, Doctor
surface was 17.53 ± 0.13% in Group A (control group), 16.92 ± 0.12% Smile) (p = 1.000). There were statistically strong differences between
in Group B (Laser Diode Fox, Sweden & Martina), and 17.40 ± 0.13% Group A (control group) and Group B (Laser Diode Fox, Sweden &
in Group C (Wiser Laser Evolution, Doctor Smile). Martina) (p = .054) and significant between Group A (control group)
There were no statistically significant differences in the and Group C (Wiser Laser Evolution, Doctor Smile) (p = .017)
homogeneity of the three groups, both as a function of the average (Table 1).
tartar present on each tooth and of the average tartar expressed as a
percentage of the total surface of the tooth.
3.2 | Pressure

3.1 | Time The pressure, expressed in bar, for each group was as follows
(median, IQR): Group A (control group) 920 (575–920) bar, Group B
The time, expressed in seconds, for each group was as follows (Laser Diode Fox, Sweden & Martina) 700 (550–800) bar, and Group
(median, IQR): Group A (control group) 175 (98–282) s, Group B C (Wiser Laser Evolution, Doctor Smile) 650 (500–750) bar.
(Group, Laser Diode Fox, Sweden & Martina) 75 (57–126) s, and There were statistically significant differences among the three
Group C (Group, Wiser Laser Evolution, Doctor Smile) 81 groups (p = .005), except between Group B (Laser Diode Fox, Sweden
(44–128) s. & Martina) and Group C (Wiser Laser Evolution, Doctor Smile)
 20574347, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cre2.769 by Cochrane Mexico, Wiley Online Library on [06/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MARCATTILI ET AL. | 761

(p = .810). There were statistically significant differences between DL. Statistically significant variations were determined among all
Group A (control group) and Group B (Laser Diode Fox, Sweden & three groups in terms of time, pressure, and the number of strokes
Martina) (p = .030), and between Group A (control group) and Group required to achieve the elimination of calculus. The distribution of the
C (Wiser Laser Evolution, Doctor Smile) (p = .010) (Table 1). expanse of the tooth surface covered by calculus was made uniform
by the stratified distribution within the three treatment groups. The
specific reason why these results were obtained is still unclear but
3.3 | Strokes count appears to be due to a weakening of the chemical bond between the
hematic tartar and the root surface. In fact, other studies
The number of strokes was 30 (25–35) (median, IQR) in Group A (Chantaboury & Trinakis, 2005; Cobb, 1996; Midda, 1992) agree
(control group), 24 (15–33) in Group B (Laser Diode Fox, Sweden & that the use of the laser may alter the chemical bond between tartar
Martina), and 16 (8–26) in Group C (Wiser Laser Evolution, Doctor and root surface through the application of an energy source. A
Smile). plausible explanation could be that the tissue absorbs an amount of
There were statistically significant differences among the three radiation per volume and transforms it into an amount of energy,
groups (p = .002), but not between Group B (Laser Diode Fox, depending on the exposure time used. This speculation can also be
Sweden & Martina) and Group C (Wiser Laser Evolution, Doctor supported by the fact that both lasers used were pulsed light.
Smile) (p = .381). There were statistically strong differences between According to numerous studies, a pulsed‐light‐laser can emit power
Group A (control group) and Group B (Laser Diode Fox, Sweden & peaks significantly greater than their average power. Therefore,
Martina) (p = .057), and between Group A (control group) and Group pulsed lasers offer very efficient spot‐welding capability, which
C (Wiser Laser Evolution, Doctor Smile) (p = .002) (Table 1). proves to be an advantage, especially where greater penetration
In the following figure, p‐values should be updated: through the tissues is required (Assuncao & Williams, 2013).
Moreover, the results of our study are also supported by Roncati
et al., in which the DL was used to pretreat the root surface to
4 | DISC US SION facilitate its subsequent removal with mechanical instrumentation
(Roncati & Gariffo, 2014). To the best of our knowledge, other
Root surface debridement is considered the fundamental and necessary studies in the literature that have used the DL to precondition the
practice to decontaminate the root surface, eliminate the bacterial root surface, obtaining results contrasting with those demonstrated
component and promote healing with subsequent clinical attachment in our study, have not been reported. Instead, contrasting results
improvement (Arcuri et al., 2020; Sanz et al., 2012). However, numerous were reported by Becker et al., where the preconditioning of calculus
studies in the literature have proposed alternative methods to achieve present on the root surface with an alkaline solution based on
the identical goal (Katsikanis et al., 2020; Sumra et al., 2019). Despite hypochlorite and amino acids did not show statistically significant
numerous efforts and several of both chemical and mechanical results in terms of instrumentation time and number of strokes
technologies, SRP still proved to be the gold standard (Katsikanis performed by curettes (Becker et al., 2018). The authors asserted
et al., 2020; Sanz et al., 2012). In fact, the efforts proposed do not seem that the solution did not chemically alter the surface of the tartar, in
to gain higher clinical results in treating periodontitis for a lengthy term. fact, not increasing the effectiveness of the SRP. It is plausible that
Reasonably, these techniques have been considered useful as a the conflicting results obtained in their study are due to an
coadjutant in support to SRP. The laser is sort of a strategy. insufficient exposure of root calculus to the chemical agent making
Several advantages of the laser include extreme compactness, its use ineffective.
affordability, ease of operation, simple setup, and versatility. DL is Furthermore, the following limitations ought to be considered:
particularly useful in periodontal treatment because its wavelengths the low sample size which may also jeopardize the results, the in vitro
are highly absorbed in the melanin and hemoglobin found in the soft model, which may simplify the clinical reality (no interference of
tissue. When patients are affected by periodontitis, biofilm commu- blood) and the bidimensional analysis of the extension of calculus on
nities tend to increase. Healthy pink tissue becomes red in color the root surface while it should be taken into account in its three‐
(because it has more pigment) and is associated with increased dimensionality for a more reliable reading. This could have led to a
bleeding due to inflammation (Verma et al., 2012). For this reason, we nonhomogeneous distribution within the three groups under consid-
chose to compare the effectiveness of two DLs despite the fact that, eration since only the width of the tartar and not the thickness has
since this is an in vitro study, there are no inflamed soft tissues in been considered.
which the laser performs the aforementioned functions.
Therefore, the main objective of this in vitro study was to
ascertain whether the use of the DL could facilitate SRP treatment by 5 | CONCLUSION
decreasing the patient's chair time and the number of applications of
both manual and mechanical instruments. The results of this trial The results of the study showed that the use of the diode laser before
suggest that there may be a development in accomplishing whole SRP is associated with a statistically significant reduction of time,
root debridement of calculus through SRP preceded by the usage of a pressure, and strokes when compared to the control group. These
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762 | MARCATTILI ET AL.

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