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Adjunctive laser or antimicrobial photodynamic therapy to nonsurgical mechanical instrumentation in patients with untreated

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stated inclusion criteria; 5, no data at 6-month 
follow-up; 6, other reasons (e.g. follow-up time unknown).
aNo author response to inquiry e-mail for data clarification. 
182  |     SALVI et AL.
the use of local anaesthesia was observed in two articles (Dilsiz et 
al., 2013; Kelbauskiene et al., 2011).
3.2.5 | Outcomes
The outcomes of the 10 articles evaluating adjunctive laser ther-
apy are summarized in Table 3. The data of the included RCTs 
provide an inconclusive picture regarding benefits of adjunctive 
laser application. Meta-analyses on the primary outcome meas-
ure could not be performed for lasers grouped with a wavelength 
range of 810–980 nm and a wavelength range of 2,780–2,940 nm 
due to (a) the low number of comparable studies, (b) the hetero-
geneity of study designs and/or (c) the lack of reporting of mean 
PPD changes between baseline and the 6-month follow-up in the 
original articles.
Table 6a summarizes the percentages of studies reporting on 
secondary outcomes. CAL change (i.e. 100%), Plaque Index change 
(i.e. 90%) and change in BoP (i.e. 90%) were reported with the high-
est frequency. Harms or adverse effects and change in subgingival 
biofilm composition were reported in four articles (i.e. 40%), while 
change in GCF biomarkers levels/volumes were reported in three 
articles (i.e. 30%). Residual PPD and PROMs were reported in one 
article (i.e. 10%).
3.3 | Adjunctive aPDT
3.3.1 | Description of included studies
The characteristics of the eight included articles (Al-Askar et al., 
2017; Berakdar, Callaway, Eddin, Ross, & Willershausen, 2012; 
Betsy, Prasanth, Baiju, Prasanthila, & Subhash, 2014; Bundidpun, 
Srisuwantha, & Laosrisin, 2018; Dilsiz et al., 2013; Malgikar et al., 
2016; Raut, Sethi, Kohale, Mamajiwala, & Warang, 2018; Theodoro 
et al., 2012) are summarized in Table 4.
3.3.2 | Study design
All studies were designed as RCTs. Five out of 8 studies applied a 
split-mouth design, that is test and control interventions were com-
pared within a patient (Berakdar et al., 2012; Bundidpun et al., 2018; 
Dilsiz et al., 2013; Malgikar et al., 2016; Theodoro et al., 2012). Three 
studies used two separate patient groups, that is non-surgical me-
chanical debridement without (control group) and with adjunctive 
aPDT treatment (test group) (Al-Askar et al., 2017; Betsy et al., 2014; 
Raut et al., 2018).
None of the included studies was funded by an industrial part-
ner. Examiner calibration was reported in six articles (Al-Askar et al., 
2017; Betsy et al., 2014; Dilsiz et al., 2013; Malgikar et al., 2016; Raut 
et al., 2018; Theodoro et al., 2012). A formal power calculation was 
described in five (Al-Askar et al., 2017; Betsy et al., 2014; Bundidpun 
et al., 2018; Raut et al., 2018; Theodoro et al., 2012) of the eight 
included articles.
All studies were conducted in a single university or specialist 
centre.
3.3.3 | Study samples
Samples sizes varied from 20 to 88 patients. The total number of pa-
tients observed was 331, that is 123 patients received test and con-
trol interventions in a split-mouth design, and 208 patients received 
either mechanical debridement without (104 patients as controls) or 
with adjunctive aPDT treatment (104 patients as test group). Mean 
age of included patients ranged from 41 to 59 years, and the propor-
tion of females varied from 0% to 65%.
In all studies, patients with systemic conditions, pregnant or 
lactating women and patients who had taken antibiotics in the past 
3–12 months were excluded. One study included exclusively pa-
tients with medically diagnosed prediabetes (Al-Askar et al., 2017). 
Smoking was an exclusion criterion in all studies.
Dental and periodontal characteristics of the patients included 
varied considerably between studies. While case definitions and re-
quirements in terms of PPD differed among studies, in all studies 
but 1 (Al-Askar et al., 2017) patients were diagnosed with chronic 
periodontitis according to the 1999 classification (Armitage, 1999). 
Nine articles specified a minimum of PPD ≥4–7 mm in at least 3–6 
teeth or sites. One article defined the presence of PPD >5 mm and 
CAL >4 mm without definition of a minimum number of teeth (Raut 
et al., 2018). Three articles (Berakdar et al., 2012; Dilsiz et al., 2013; 
Theodoro et al., 2012) called for the presence of BoP. Five arti-
cles defined the presence of at least 20 teeth (Betsy et al., 2014; 
Bundidpun et al., 2018; Dilsiz et al., 2013; Malgikar et al., 2016; 
Theodoro et al., 2012).
The number of tooth sites treated with adjunctive aPDT (test 
procedure) ranged from 33 to 839 sites. Four articles did not specify 
the exact number of teeth or sites treated per patient and/or treat-
ment arm (Al-Askar et al., 2017; Dilsiz et al., 2013; Malgikar et al., 
2016; Raut et al., 2018). In four articles, treated sites were speci-
fied in terms of PPD and the presence of BoP (Al-Askar et al., 2017; 
Berakdar et al., 2012; Betsy et al., 2014; Theodoro et al., 2012). One 
article reported exclusively single-rooted teeth in the analysis (Betsy 
et al., 2014).
3.3.4 | Intervention/comparison
A diode laser was used in the eight articles included. All articles but 
1 (Raut et al., 2018) stated the laser manufacturer which differed 
among studies. The most commonly used laser tips were fibre optic 
tips (Betsy et al., 2014; Bundidpun et al., 2018; Dilsiz et al., 2013; 
Malgikar et al., 2016; Theodoro et al., 2012). In the remaining three 
articles, the material of the laser tip was not reported. If reported, 
diameter of the laser tip ranged from 200 to 400 μm. The output 
     |  183SALVI et AL.
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