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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 121-125

Clinical study evaluating the effectiveness and efficiency of Metrohex Plus Gel and diode laser therapy along with standard mechanical debridement for managing chronic periodontitis

Department of Periodontology and Oral Implantology, K. D. Dental College and Hospital, Mathura, Uttar Pradesh, India

Date of Submission04-Oct-2021
Date of Decision08-Mar-2022
Date of Acceptance21-Mar-2022
Date of Web Publication01-Jul-2022

Correspondence Address:
Gaurav Singh
House No. 652 VPO. Kaurali, Ballabgarh, Faridabad - 121 101, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jorr.jorr_69_21

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Aim: A study was carried out to determine how effective diode lasers and Metrohex Plus Gel are at managing chronic periodontitis when compared to standard periodontal therapy.
Materials and Methods: A total of 90 sites having periodontal probing depth (PPD*) ≥5 mm were included with patients aged around 35–60 years. Each group contains 30 sites as follows: Group I – laser-assisted new attachment procedure*, Group II – Metrohex Plus Gel, Group III – scaling root planing (SRP)* alone.
Results: Based on the average gingival index* value at baseline, 1 and 3 months, the values were 1.9 ± 0.67, 0.99 ± 0.26, and 0.89 ± 0.19, respectively. The mean plaque index* score decreased to 1.12 ± 0.31 at 1 month and 0.80 ± 0.31 at 3 months from 2.30 ± 0.58 at baseline. A PPD* reduction of 0.85 ± 0.03 mm was observed at 3 months for sites treated with laser, which was significantly higher than the reductions for sites treated with Metrohex plus (metronidazole 10 mg + chlorhexidine gluconate 0.25% w/w and hyaluronic acid) and SRP* alone. PPD* reductions were not significantly different between Groups I and II. Group II showed a 0.35 ± 0.11 mm improvement in clinical attachment levels compared to Group III.
Conclusion: As opposed to simple SRP, diode laser therapy and Metrohex Plus Gel improve all clinical parameters in patients with periodontitis.

Keywords: Chronic periodontitis, laser-assisted new attachment procedure, local drug delivery, scaling root planing

How to cite this article:
Singh G, Chauhan SS, Sinha A, Sharma S. Clinical study evaluating the effectiveness and efficiency of Metrohex Plus Gel and diode laser therapy along with standard mechanical debridement for managing chronic periodontitis. J Oral Res Rev 2022;14:121-5

How to cite this URL:
Singh G, Chauhan SS, Sinha A, Sharma S. Clinical study evaluating the effectiveness and efficiency of Metrohex Plus Gel and diode laser therapy along with standard mechanical debridement for managing chronic periodontitis. J Oral Res Rev [serial online] 2022 [cited 2022 Dec 3];14:121-5. Available from: https://www.jorr.org/text.asp?2022/14/2/121/349714

  Introduction Top

Periodontitis is the most common oral disease worldwide.[1] The interaction of pathogenic plaque microflora, immune responses, and environmental factors contribute to the development of tooth decay.[2] The term “gold standard” for periodontal treatment is complete mechanical debridement.[3] Majority of the periodontal patients can be managed by nonsurgical periodontal treatment. Hence, various adjuncts to scaling and root planing have been introduced into periodontal practice over the years.[4] A number of antibiotics, both commercially available and indigenously prepared, have been employed as adjuncts to mechanical instrumentation in the management of periodontal diseases. Different antibiotics such as tetracyclines, nitroimidazoles, fluoroquinolones, and macrolides have been used as local drug delivery (LDD) agents in various studies with promising clinical and microbiological results.[5],[6] Lasers were introduced into periodontal practice at the turn of this century. The suggested applications of lasers in periodontal treatment are manifold. They are used for intraoral soft-tissue procedures such as frenectomy, gingivectomy, gingivoplasty, de-epithelization of reflected flaps, removal of granulation tissue, second stage of dental implants, lesion ablation, coagulation of free gingival graft donor sites, and gingival depigmentation.[7] The nonsurgical laser-assisted periodontal therapy includes preprocedural disinfection, subgingival curettage, sulcular debridement, and decontamination.[8]

Various adjunctive techniques can improve the treatment outcome of chronic periodontitis.[9] As compared to conventional soft-tissue surgery, lasers achieved good hemostasis, sterilization, and reduced postoperative pain.[10] One such procedure is a laser-assisted new attachment procedure that enables both of these goals with better patient acceptance and minimal postoperative complications. The aim of our study was to determine whether diode lasers are better at treating chronic periodontitis than LDD system or conventional mechanical debridement method.

  Materials and Methods Top

The study was conducted in Department of Periodontology and Oral Implantology, KD Dental College and Hospital, Mathura.

As determined by the following inclusion and exclusion criteria, 90 sites with patients 35–60 years of age were divided into three groups using split-mouth design.

Inclusion criteria

  1. Basic health (no hypertension, stroke, poorly controlled diabetes, etc.)
  2. Periodontal pockets (probing depth >5 mm) without adjacent teeth that bleed or suppurate when probed.

Exclusion criteria

  1. Tooth involving the furcation
  2. A periodontal disease that is aggressive
  3. Systemic antimicrobial therapy 2 months before entering the study
  4. Hypersensitivity to metronidazole, chlorhexidine, or hyaluronic acid
  5. Previous periodontal surgery
  6. Smoking
  7. A periodontal visit was completed within 3 months of the baseline examination.

This study was approved by Ethical Committee organized at KD Dental College and Hospital, Mathura, Uttar Pradesh.

Statistical analysis

In this study, Wilcoxon signed-rank test, Mann–Whitney U test, and t-test are used.

Study design

Our study design used a split-mouth approach with different quadrants selected for each patient. All the patients were evaluated using three types of delivery methods:

  • Scaling root planing (SRP)* alone,
  • Metrohex plus, and
  • diode laser.

Before the procedure, each quadrant was randomly assigned (by the toss of a coin).

As followed- GROUP I- with diode laser, GROUP II- local drug delivery, GROUP III- SRP alone [Figure 1].
Figure 1: (a) 940 nm portable diode laser unit with a fiber-optic delivery system (b) Metrohex Plus Gel

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Analyzing clinical parameters

A single examiner conducted clinical periodontal examinations on all patients. We used a University of North Carolina 15” periodontal probe to measure clinical probing measurements. The two-dimensional probe angulation was standardized with custom-made acrylic stents and indelible markers used to identify its position and direction. A month and 3 months later, the recordings were repeated. A reference point for measuring attachment level was the cementoenamel junction. We measured plaque index (PI*),[11] gingival index (GI*),[12] PPD,* and clinical attachment levels (CAL)* at baseline, 1 month, and 3 months after treatment. To find the index value per tooth, the mesiobuccal, facial, distobuccal, and lingual values were averaged.

Group I: Laser-assisted new attachment procedure

To deliver energy to the site, we used a 940 nm diode laser unit (with a maximum power output of 10 W) together with a disposable fiber-optic tip measuring 30 μin diameter and measuring 7 mm long. An initial 4 W laser with a fiber-optic tip was advanced circumferentially around the teeth in a coronal–apical pass to probe for pocket epithelium in a coronal–apical pass without directing it toward the bone or teeth [Figure 2]a and [Figure 2]b. In relation to the affected tooth, horizontal strokes were used on the inner lining of both the facial and palatal pockets to deliver a dose of 10–12 J/mm of probing depth. Next, 0.03% chlorhexidine solution was made from a four-fold dilution of a 0.12% chlorhexidine gluconate mouthwash and used for irrigation and cooling. A second laser pass in an apical–coronal direction followed. The pulse has a peak power of 308 W per pulse, with an average power of 4.0 W and a pulse duration of 650 μs. To induce hemostasis and soft tissue adhesion at the tooth-gingival flap interface, about 4–5 J per mm of probing depth are delivered. The patients were not sutured following surgery and instructed and trained on the maintenance of periodontal health on a daily basis.
Figure 2: (a and b) Intraoperative photograph – application of the diode laser on the inner lining of the periodontal pocket lining. Intraoperative photograph (c) baseline, (d) after 3 months: Measuring probing pocket depth

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Group II: Controlled-release drugs: metronidazole-containing gel 10 mg, chlorhexidine gluconate 0.25%, and hyaluronic acid

As expected, investigators performed scale and root planing to achieve an even, clean, and hard surface at baseline. With a syringe, the following gel (1 ml) was administered directly into the pocket: (metronidazole gel and 0.25% chlorhexidine gluconate and hyaluronic acid gel) [Figure 3].
Figure 3: (a) Intraoperative photograph of the placement of Metrohex Plus Gel. Intraoperative photograph (b) baseline (c) after 3 months: Measuring probing pocket depth

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Group III: Scaling root planing alone

SRP done with Piezo Electric Scaler Followed by post operative instructions.

  Results Top

Statistical analyses were performed on a computer using SPSS 21 for Windows (Headquarter In Chicago, Incorporated in Delaware). We calculated the means and standard deviations of the PI [Table 1], GI [Table 2], probing pocket depth [Table 3], and CAL [Table 4] for each group and at a number of time intervals. The P value was ≤0.05 considered significant.
Table 1: Comparison of mean values of plaque index scores at baseline, 1 month, and 3 months

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Table 2: Comparison of mean values of gingival index scores at baseline, 1 month, and 3 months

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Table 3: Intergroup comparison of mean values of pocket depth at baseline, 1 month, and 3 months

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Table 4: Intergroup comparison of mean values of clinical attachment level at baseline, 1 month and 3 months

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Gingival and plaque index

At the beginning of each treatment period, the PI was 2.30 ± 0.58. It was 1.12 ± 0.31 at 30 days and 0.80 ± 0.31 at 3 months. [Table 1] shows that PI scores decreased significantly at each interval. As for GI values, the baseline values were 1.99 ± 0.67, while the mean values at 1 month and 3 months were 0.99 ± 0.26 and 0.78 ± 0.19, respectively. During each period, PI scores decreased significantly [Table 2].

Probing pocket depth

All three Groups in this study experienced significant decreases in pocket depth over time [Table 3]. A statistically significant difference was observed between Group I [Figure 2]C and [Figure 2]d and Group III [Figure 4] at the end of the study; Group II shows a statistically insignificant difference between Group I and Group III. The mean depth of the pockets decreased by 0.35 × 0.12 significantly between Groups I and II. The figure shows the mean PPD* reduction over time. (A, B).
Figure 4: Intraoperative photograph of scaling root planing (a) baseline, (b) after 3 months: Measuring probing pocket depth

Click here to view

Clinical attachment levels*

All sites showed a relative gain when comparing their baselines with CAL. When compared to baseline, improvements in all three groups were statistically significant [Table 4]. The statistically significant difference in attachment level between Group I and Group III at the end of the study were 0.55 × 0.35 mm. The results of Group II at 3 months were statistically nonsignificant when compared to Group III because it improved CAL by 0.35 × 0.11 mm over Group III. In comparison of Group I and Group II over 3 months, there was no statistically significant difference in CAL gain between the two groups. Below is a comparison of mean clinical attachment gains over different time frames.

  Discussion Top

Periodontitis can be prevented with SRP combined with plaque control by a patient. There is strong evidence to back this up. In such situations, adjunctive treatment may be required. Previous studies indicate that the treatment of pockets by scaling and root planing, followed by routine maintenance therapy every 3 months results in the maintenance of attachment levels and the reduction of probing depths.[12],[13] Diode lasers have wavelengths of 800–980 nm, which are well absorbed by pigmented tissues and can be used as a tool for treating darkened, inflamed tissues and bacteria. Diode lasers have been proven to have an antibacterial effect in several studies.[14],[15]

However, some systematic reviews have shown no benefit to the use of lasers in conjunction with nonsurgical treatment of chronic periodontitis. Lasers in dentistry are generally advantageous. The American Academy of Periodontology had also stated these things.[16],[17]

Although oral prophylaxis was provided at baseline, it was repeated after 2 weeks to standardize and compare with gold-standard procedures of nonsurgical therapy.

At 3 months, there was no statistically significant difference in PI and GI between the groups. Compared to the control group (SRP), more reduction was observed in the test groups. These new interventions might explain this.

Taking frequent systemic antibiotics over an extended period may be associated with potential risks, such as resistance development, noncompliance, and superimposed infections. Therefore, local delivery of antimicrobials can provide a useful solution to these problems. A LDD system enables higher concentrations and minimal dosage at the target site, as well as increased patient acceptance, resulting in fewer applications.[18] Recently, there has been a craze for using newer technology, and lasers are no exception. The laser-assisted new attachment procedure (LANAP) protocol was created in 1989 by Gregg and McCarthy,[19] and it was approved by the FDA in 2004. Researches concluded that LANAP resulted in regeneration of human periodontium in various studies.[20],[21],[22],[23]

In addition to the numerous advantages of laser-assisted surgery for periodontal pockets, there are fewer complications such as postoperative recession and sensitivity, better psychological experience, greater patient acceptance, and more predictability. An alternative to the ND: YAG laser used in the initial protocol, a diode laser, was used to avoid root surface damage as well as to provide a deeper penetration depth. Diabetic patients with borderline glycated hemoglobin levels make conventional surgery somewhat unpredictable both with regard to its outcomes during operations and afterward.

In addition, laser treatments have some disadvantages, such as that they cannot remove hard deposits, that they can damage hard tissues, and that they require a large investment. Moreover, the laser procedure takes more time, and the laser equipment has to be handled carefully to avoid damage to the eye.

  Conclusion Top

Dentistry now uses lasers as adjuncts to traditional periodontal treatments. LANAP facilitates true regeneration by stimulating regeneration of the attached apparatus. Treatment with LANAP emphasizes both bactericidal and detoxifying effects, as well as reducing the underlying causes of the disease. Implementing these principles successfully should result in long-term improvement. Treatment compliance and outcomes are more likely to be improved. Research and close observation are necessary for periodontal regeneration.


I would like to express my gratitude to my advisor, my Guide Dr. Shailendra S. Chauhan (Professor and Head of department), Dr. Aditya Sinha (reader), Dr.Satendra Sharma (Reader), Dr. Sakaham Kulshrestha (Post Graduate Student) for their guidance and support throughout this study.

Ethical clearance

This is not a part of thesis work it's is a independent clinical study this is not my thesis this is just an external work.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kinane DF, Lindhe J, Trombelli L. Clinical Periodontology and Implant Dentistry. UK: Blackwell publishing; 2008. p. 420-6.  Back to cited text no. 1
Tatakis DN, Kumar PS. Etiology and pathogenesis of periodontal diseases. Dent Clin North Am 2005;49:491-516, v.  Back to cited text no. 2
Cobb CM. Non-surgical pocket therapy: Mechanical. Ann Periodontol 1996;1:443-90.  Back to cited text no. 3
Newman MG, Takei HH, Klokkevold PR, Carranza FA. Clinical Periodontology. 10th ed. St. Louis Missouri: Saunders Elsevier; 2006.  Back to cited text no. 4
Divya PV, Nandakumar K. Local drug delivery protocol in periodontics. Trendsiomater Artif Organs 2006;19:74-80.  Back to cited text no. 5
Matesanz-Pérez P, García-Gargallo M, Figuero E, Bascones-Martínez A, Sanz M, Herrera D. A systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared with subgingival debridement alone, in the treatment of chronic periodontitis. J Clin Periodontol 2013;40:227-41.  Back to cited text no. 6
Keshava A, Girish S. Lasers a boon or myth in periodontal treatment. Indian Journals 2013;4:1-6.  Back to cited text no. 7
Schwarz F, Aoki A, Becker J, Sculean A. Laser application in non-surgical periodontal therapy: A systematic review. J Clin Periodontol 2008;35:29-44.  Back to cited text no. 8
Hanes PJ, Purvis JP. Local anti-infective therapy. A systematic review. Ann Periodontol 2003;8:79-98.  Back to cited text no. 9
Wigdor HA, Walsh JT Jr., Featherstone JD, Visuri SR, Fried D, Waldvogel JL. Lasers in dentistry. Lasers Surg Med 1995;16:103-33.  Back to cited text no. 10
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.  Back to cited text no. 11
Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical periodontal therapy. I. Moderately advanced periodontitis. J Clin Periodontol 1981;8:57-72.  Back to cited text no. 12
Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal therapy. II. Severely advanced periodontitis. J Clin Periodontol 1984;11:63-76.  Back to cited text no. 13
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 14
Cobb CM, McCawley TK, Killoy WJ. A preliminary study on the effects of the Nd: YAG laser on root surfaces and subgingival microflora in vivo. J Periodontol 1992;63:701-7.  Back to cited text no. 15
Moritz A, Gutknecht N, Doertbudak O, Goharkhay K, Schoop U, Schauer P, et al. Bacterial reduction in periodontal pockets through irradiation with a diode laser: A pilot study. J Clin Laser Med Surg 1997;15:33-7.  Back to cited text no. 16
Moritz A, Schoop U, Goharkhay K, Schauer P, Doertbudak O, Wernisch J, et al. Treatment of periodontal pockets with a diode laser. Lasers Surg Med 1998;22:302-11.  Back to cited text no. 17
Research, Science and Therapy Committee of the American Academy of Periodontology. Lasers in periodontics. J Periodontol 2002;73:1231-9.  Back to cited text no. 18
American Academy of Periodontology statement on the efficacy of lasers in the non-surgical treatment of inflammatory periodontal disease. J Periodontol 2011;82:513-4.  Back to cited text no. 19
Slots J; Research, Science and Therapy Committee. Systemic antibiotics in periodontics. J Periodontol 2004;75:1553-65.  Back to cited text no. 20
Gregg RH, McCarthy DK. Laser ENAP for periodontal bone regeneration. Dent Today 1998;17:88-91.  Back to cited text no. 21
Yukna RA, Carr RL, Evans GH. Histologic evaluation of an Nd: YAG laser-assisted new attachment procedure in humans. Int J Periodontics Restorative Dent 2007;27:577-87.  Back to cited text no. 22
Kimmel D. Laser-assisted new attachment procedure (LANAP). Int Mag Laser Dent 2011;3.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]


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