Demographic data show that populations around the world are ageing. With the exception of 18 countries, the median age of all other national populations has been rising steadily [1], so the trend does not seem not seem to be just limited to the developed world. Recent research also suggests that the current rate of population ageing is in fact actually accelerating [2].

From a dental healthcare perspective, an increasingly older society presents a number of gerodontology-related challenges, as well as new opportunities for growth in the profession. Dental practitioners working with ageing populations are well advised to examine newer and more effective strategies for helping their older patients maintain a high standard of oral healthcare.

Oral healthcare concerns
One of the most widespread ailments afflicting older people is periodontal disease, which contributes to the loss of one out of every five teeth in adults in developed countries, and up to 40% of all dental extractions [3]. Periodontal disease is the most common form of gum disease, affecting not just the elderly, but up to 80% of the general population to some degree.

In addition to the significant effects on quality of life resulting from masticatory complications, poor oral health is known to be a major cause of cardiovascular disease and myocardial infarction. It is also associated with other systemic health issues, such as respiratory disease, stroke, osteoporosis and diabetes. It can lead to a major decline in quality of life among the elderly.

Compared with previous generations, older adults today are, in addition, more informed about the latest dental technologies and treatment options. As a consequence, they are more likely to demand a minimally invasive treatment plan aimed at preserving their original teeth for as long as possible.

Trends in periodontal treatment
The treatment of periodontal disease has traditionally been flap surgery, which involves folding a patient’s gum away from the tooth, carefully slicing through the anaesthetised gum with a scalpel, removing diseased tissue and suturing the wound. This is a highly invasive procedure that involves significant bleeding and post-operative discomfort. While surgical techniques have improved considerably in recent years, they are still considered to be traumatic and unpleasant for the patient.

Since the 1990s, a number of minimally invasive techniques have been developed for performing laser-based periodontal treatments. Compared with conventional methods, laser technology offers a number of distinct advantages for both the patient and practitioner, including greater comfort, speed and ease of procedures. There is also little or no need for suturing, and fewer if any post-operative complications.

Some of the newest and most promising laser-based periodontal treatments today combine the power of the two most effective “tools” used in laser surgery, the 1064 nm Nd:YAG and 2940 nm Er:YAG laser wavelengths. The Nd:YAG wavelength is used to penetrate soft tissue to create deeper thermal effects without damaging surface tissue, while the Er:YAG wavelength ablates a thin layer of either hard or soft tissue, thus removing diseased cells with each passage of the light beam [4, 5].

In one well-known approach [Figure 1], known as Wavelength-optimised Periodontal Therapy (WPT), laser energy is focused directly into the tooth pocket in a series of steps designed to eliminate bacteria, remove debris and reinforce the root structure [6]. In the first step, the diseased epithelial lining of the periodontal pocket is gently removed with a focused beam of 1064 nm Nd:YAG laser light, which also coagulates the tissue to prevent bleeding, thus enabling a visually clean surgical area. Due to its higher penetration, the Nd:YAG laser also allows for focused and deeper disinfection with greater precision in hard-to-reach areas.

In the second step, the 2940 nm Er:YAG laser wavelength is used to gently remove subgingival calculus from the root surface. The Er:YAG laser also has a strong anti-bacterial effect that facilitates bone healing and regeneration [7, 8]. Finally, in the third step, the Nd:Yag laser is again used to seal the pocket with a stable fibrin clot, resulting in faster healing and reattachment of soft tissues to the root surface.

Lasers: the future of periodontal care
Taken as a whole, the steps of the WPT procedure represent a new paradigm in the field of periodontics, allowing general practitioners to offer state-of-the-art, minimally invasive treatment capabilities for early-to-moderate, site-specific stages of periodontal disease, and allowing periodontists to focus on more complex and advanced cases, with patients in each category benefiting from less pain and fewer post-operative complications.

To perform laser periodontal treatments such as WPT effectively, both the Er:YAG and Nd:YAG laser wavelengths are needed. From a practical standpoint, the optimal choice for most dental practitioners would be to invest in a dual wavelength system that offers both lasers in a single package, such as the Lightwalker and AT Fidelis systems from Fotona. This eliminates the need for two separate systems with different controls and interfaces, and provides the convenience of being able to easily adjust and switch between the two laser sources during treatment procedures, saving valuable time and reducing the risk of error.
 
Lasers accelerate healing
Laser light has long been known to trigger a number of salutary effects on biological tissue. Certain parameters of laser light have been shown to stimulate the body’s own natural healing response, in part by helping to prevent tissue reinfection. This is an especially important consideration in gerodontology, since elderly patients tend to have weaker, partially compromised immune systems.

Studies have shown that laser treatments can help to stimulate the growth of new periodontal tissues and dental root surface coating (cementum), as well as the formation of new connective tissue (collagen) on roots, helping to minimise the risk of tooth loss [9]. The common theme in numerous areas of research seems to be that under suitable conditions, lasers can be invaluable tools for promoting faster tissue repair and wound healing.

Even in patients exhibiting advanced stages of periodontal disease, with pocket depths greater than 8 mm and extensive bone loss, recent studies have demonstrated that damage to the tooth structure and surrounding tissue can be significantly reduced. In many cases, bone can even be regenerated. Research has also shown that with laser treatments, reattachment of soft tissue to the tooth is faster and more likely to succeed [10].

Of course, as any medical practitioner knows, prevention is much better than cure, and this is certainly the case with oral healthcare. From the standpoint of gerodontology, one of the most important services that a general practitioner can offer is to proactively treat symptoms of periodontal disease at the earliest stage possible. This is not only a high-value service that can significantly improve the health and quality of life of older patients, but a source of revenue.

Summary
To meet the needs and expectations of a growing population of elderly patients, dental healthcare professionals will need to use new tools and pursue further education to meet the future demand for minimally invasive treatment options. This will require an initial investment in technology and training, but the benefits to patients and practitioners are clear. With new services to offer, such as laser-based periodontal therapy, both the general practitioner and the periodontist will find opportunities to expand their business, either by offering a wider range of patient options or by focusing on more advanced and specialised treatments.

References
1. http://en.wikipedia.org/wiki/Population_ageing
2. Luty W, Sanderson W, Scherbov S. The Coming Acceleration of Global Population Aging Jan 2008; 716-719.
3. Niessen LC, Weyant RJ. Causes of tooth loss in a veteran population. J Public Health Dent 1989; 49(1):19-23.
4. Gaspirc B & Skaleric U. Clinical Evaluation of Periodontal Surgical Treatment with an Er:YAG Laser: 5 Year Results. J Periodontal 2007; 1864 – 1869.
5. Gaspirc B & Skaleric U. Morphology, chemical structure and diffusion processes of root surface after Er:YAG and Nd:YAG laser irradiation. J Clinical Periodontology 2001; 28: 508–516.
6. Minimally Invasive Treatment of Periodontitis. World Dental Reporter. Sep  2010; 20-21.
7. Aleksic V et al. Low-level Er:YAG laser irradiation enhances osteoblast proliferation through activation of MAPK/ERK. Lasers in Medical Science 2010; 25(4):559-69.
8. Mizutani K et al. Periodontal tissue healing following flap surgery using an Er:YAG laser in dogs. Lasers in Surgery and Medicine 2006; 38: 314–324.
9. Raymond AY et al. Histologic evaluation of an Nd:YAG Laser-Assisted New Attachment Procedure in humans. Int’l. J. Periodontics and Restorative Dentistry 2007; 27 (6): 577-587.
10. Noguchi et al. Combined effects of Nd:YAG laser irradiation with local antibiotic application into periodontal pockets. J Intl Acad Periodontol 2005; 7(1):8-15.

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Ljubljana, Slovenia