The Official Journal of the Academy of Laser Dentistry ... · † Case Report: Removal of Porcelain...

• Clinical Technique: Periodontal Health System

• Scientific Review: Laser-Tissue Interaction I

• Position Paper: Laser Safety in Dentistry

• Case Report: Soft Tissue Management During Implant Restoration

• Case Report: Removal of Porcelain Veneers

The Official Journal of the Academy of Laser Dentistry 2009 • Vol. 17 No. 1The Official Journal of the Academy of Laser Dentistry 2009 • Vol. 17 No. 1

Feature Articles by 2008 Leon Goldman Clinical Excellence Award WinnersDr. Giovanni Olivi on page 6Dr. Frank Yung on page 13

Academy of Laser Dentistry3300 University Drive, Suite 704

Coral Springs, FL 33065

In This Issue CE Credits Available

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TAB LE O F C O NTENTSThe official journal of the

Academy of Laser Dentistry

Editor-in-ChiefDonald J. Coluzzi, DDSPortola Valley, CA [email protected]

Managing EditorGail S. Siminovsky, CAE, Executive DirectorCoral Springs, FL [email protected]

Consulting EditorJohn G. Sulewski, MA Huntington Woods, MI [email protected]

Associate EditorsCraig Gimbel, DDS, Denville, NJAlan J. Goldstein, DMD, New York, NYPeter Pang, DDS, Sonoma, CADonald E. Patthoff, DDS, Martinsburg, WVSteven P.A. Parker, BDS, LDS RCS, MFGDP,

Harrogate, United KingdomPeter Rechmann, Prof. Dr. med. dent.,

San Francisco, CADavid Roshkind, DMD, Gainesville, FLWayne Selting, DDS, Colorado Springs, COMichael D. Swick, DMD, Conneaut Lake, PA

PublisherMax G. MosesMember Media

1844 N. Larrabee • Chicago, IL 60614312-296-7864 • Fax: 312-896-9119

[email protected]

Design and LayoutDiva Design

2616 Missum Pointe • San Marcos, TX 78666512-665-0544 • Fax 609-678-0544

[email protected]

Editorial Office3300 University Drive, Suite 704

Coral Springs, FL 33065

954-346-3776 Fax 954-757-2598

[email protected]

The Academy of Laser Dentistry is a not-for-profitorganization qualifying under Section 501(c)(3) ofthe Internal Revenue Code. The Academy of LaserDentistry is an international professional member-ship association of dental practitioners and sup-porting organizations dedicated to improving thehealth and well-being of patients through theproper use of laser technology. The Academy isdedicated to the advancement of knowledge,research and education and to the exchange ofinformation relative to the art and science of theuse of lasers in dentistry. The Academy endorsesthe Curriculum Guidelines and Standards forDental Laser Education.

Journal of Laser Dentistry

ED ITO R’S V IEWDental Lasers – Award-Winning and Reward-Delivering ............................5Donald J. Coluzzi, DDS, Portola Valley, California

C OV ER FEATU R E # 1C LIN IC AL R EV IEW AN D C ASE R EPO RTA Dental Laser and a Microscope: The Perfect Match................................6Giovanni Olivi, DMD; Maria Daniela Genovese, MD, DMD, Rome, Italy

C OV ER FEATU R E # 2C LIN IC AL R EV IEW AN D C ASE R EPO RTThe Use of an Er:YAG Laser in Periodontal Surgery: Clinical Cases with Long-Term Follow-Up......................................................13Frank Yung, DDS, Toronto, Ontario, Canada

C LIN IC AL R EV IEW AN D C ASE R EPO RTA Periodontal Health System: Diagnosis, Treatment, and Retention ........21Arthur B. Levy, DMD, Chester, New Jersey

SC IENTIF IC R EV IEWLaser-Tissue Interaction I ....................................................................................27Michael D. Swick, DMD, Conneaut Lake, Pennsylvania

C ASE R EPO RTEr,Cr:YSGG Laser Use for Soft Tissue Management During the Restoration of an Implant: A Case Report ..............................34Shawn Adibi, DDS, Houston, Texas

C ASE R EPO RTThe Removal of Porcelain Veneers Using an Er:YAG Laser: A Report of Two Cases ..........................................37Alfred D. Wyatt, Jr., DMD, College Park, Georgia

PO SIT IO N PAP ERLaser Safety in Dentistry......................................................................................39Laser Safety Committee, Academy of Laser Dentistry: CarolineSweeney, MBA, MA, BSc, OTR (Committee Chair); Donald J. Coluzzi,DDS; Penny Parker, RDN; Steven P.A. Parker, BDS, LDS, MFGDP;John G. Sulewski, MA; Joel M. White, DDS, MS

SYMPO SIU M P RO C EED INGSProceedings of the ALD/FDA 2008 Joint Symposium on Lasers and Light-Based Technology Utilization in Dentistry....................50Donald J. Coluzzi, DDS, San Francisco, California

R ESEARC H AB STR AC TSThe Use of Erbium Lasers to Remove Porcelain Veneers ........................58

C O NTIN U ING ED U C ATIO NCE Program ............................................................................................................62CE Questions ..........................................................................................................63CE Registration Form & Answer Sheet ..........................................................64Answers to Previous CE Programs ..................................................................65

The Journal of Laser DentistryThe mission of the Journal of Laser Dentistry is to provide a professional journal that helps tofulfill the goal of information dissemination by the Academy of Laser Dentistry. The purpose ofthe Journal of Laser Dentistry is to present information about the use of lasers in dentistry.All articles are peer-reviewed. Issues include manuscripts on current indications for uses oflasers for dental applications, clinical case studies, reviews of topics relevant to laser dentistry,research articles, clinical studies, research abstracts detailing the scientific basis for the safetyand efficacy of the devices, and articles about future and experimental procedures. In addition,featured columnists offer clinical insights, and editorials describe personal viewpoints.

Journal of Laser Dentistry: Guidelines for AuthorsThe Academy of Laser Dentistry Welcomes Your Articles for Submission

The Journal of Laser Dentistry publish-es articles pertaining to the art, science,and practice of laser dentistry. Articlesmay be scientific and clinical in naturediscussing new techniques, research,and programs, or may be applications-oriented describing specific problemsand solutions. While lasers are our pre-ferred orientation, other high-technolo-gy articles, as well as insights into mar-keting, practice management, regula-tion, and other aspects of dentistry thatmay be of interest to the dental profes-sion, may be appropriate. All articlesare peer-reviewed prior to acceptance,modification, or rejection.

These guidelines are designed tohelp potential authors in writing andsubmitting manuscripts to the Journalof Laser Dentistry, the official publica-tion of the Academy of Laser Dentistry(ALD). Please follow these instructionscarefully to expedite review and process-ing of your submission. Manuscriptsthat do not adhere to these instructionswill not be accepted for consideration.The Academy of Laser Dentistry and theeditors and publisher of the Journal ofLaser Dentistry endorse the “UniformRequirements of Manuscripts Submittedto Biomedical Journals” (www.icmje.org).The Journal reserves the right to reviseor rescind these guidelines.

Authors are advised to read the morecomprehensive Guidelines for Authorsand required forms available by mail oronline at www.laserdentistry.org.

Manuscript EligibilitySubmitted manuscripts must be writtenclearly and concisely in AmericanEnglish and appropriate for a scholarlyjournal. Write in active voice and usedeclarative sentences. Manuscripts willbe considered for publication on the con-dition that they have been submittedexclusively to the Journal, and have notbeen published or submitted for publica-tion in any part or form in another publi-cation of any type, professional or lay, orin any language elsewhere, and with theunderstanding that they will not bereprinted without written consent fromboth the managing editor and the author.

PermissionsDirect quotations of 100 or more words,and illustrations, figures, tables, orother materials (or adaptations thereof)that have appeared in copyrightedmaterial or are in press must be accom-panied by written permission for theiruse in the Journal of Laser Dentistryfrom the copyright owner and originalauthor along with complete informationregarding source, including (as applica-ble) author(s), title of article, title of

journal or book, year, volume number,issue number, pages. Photographs ofidentifiable persons must be accompa-nied by valid signed releases indicatinginformed consent. When informed con-sent has been obtained from anypatient, identifiable or not, it should benoted in the manuscript. The appropri-ate Permission Letters must be submit-ted with the manuscript. Suggestedtemplate letters are available online.

CopyrightAll manuscript rights shall be trans-ferred to the Journal of Laser Dentistryupon submission. Upon submission ofthe manuscript, authors agree to sub-mit a completed Copyright TransferAgreement form, available online. If themanuscript is rejected for publication,all copyrights will be retained by theauthor(s).

CommercialismALD members are interested in learn-ing about new products and serviceofferings, however ALD stresses thatsubmitted manuscripts should be edu-cational in nature. The emphasis is onscientific research and sound clinicaland practical advice, rather than pro-motion of a specific product or service.

Disclosure of Commercial RelationshipsAccording to the Academy’s Conflict ofInterest and Disclosure policy, manu-script authors and their institutions areexpected to disclose any economic orfinancial support, as well as any per-sonal, commercial, technological, aca-demic, intellectual, professional, philo-sophical, political, or religious interestsor potential bias that may be perceivedas creating a conflict related to thematerial being published. Such condi-tions may include employment, consul-tancies, stock ownership or other equityinterests, honoraria, stipends, paidexpert testimony, patent ownership,patent licensing arrangements, royal-ties, or serving as an officer, director, orowner of a company whose products, orproducts of a competitor, are identified.Sources of support in the form of con-tracts, grants, equipment, drugs, mate-rial donations, clinical materials, specialdiscounts or gifts, or other forms of sup-port should be specified. The roles of thestudy or manuscript sponsor(s), if any,are to be described. Disclosure state-ments are printed at the end of the arti-cle following the author’s biography.This policy is intended to alert the audi-ence to any potential bias or conflict sothat readers may form their own judg-ments about the material being pre-sented. Disclosure forms are to be

signed by each author. Manuscripts willnot be reviewed without the Journalhaving this form on file.

The Academy of Laser Dentistry alsorequires that authors disclose whetherany product discussed in their manu-script is unlabeled for the use discussedor is investigational.

The Disclosure Statement form isavailable online and must be submittedwith the manuscript.

Manuscript TypesSubmissions to the Journal should belimited to one of the types indicatedbelow.• Scientific / Technology / Clinical

Review• Case Reports and Clinical Case

Studies• Scientific / Clinical Research• Randomized Clinical Trials• Advances in Dental Products• Trends• Practice Management• Guest Editorials and Essays• Letters to the Editor• Book Reviews

Manuscript Preparation and SubmissionFormatAll submitted manuscripts should bedouble-spaced, using 12 pt. font sizewith at least 6 mm between lines.Submit manuscripts in Microsoft Word(.doc), using either the Windows orMacintosh platform. Manuscripts mustbe submitted electronically in this for-mat. Hard copy-only submissions willnot be accepted.

Unacceptable FormatsThe following submission formats areunacceptable and will be returned:• Manuscripts submitted in desktop

publishing software• PowerPoint presentations• Any text files with embedded images• Images in lower than the minimum

prescribed resolution.

Manuscript ComponentsTitle PageThe title page of the manuscript shouldinclude a concise and informative titleof the article; the first name, middle ini-tial(s), and last name of each author,along with the academic degree(s), pro-fessional title(s), and the name andlocation (city, state, zip code) of currentinstitutional affiliation(s) and depart-ment(s). Authors who are private practi-tioners should identify their location(city, state, and country). Include allinformation in the title that will makeelectronic retrieval of the article sensi-tive and specific. Titles of case studies

should include the laser wavelength(s)and type(s) utilized for treatment (forexample, “810-nm GaAlAs diode”).

Identify the complete address, busi-ness and home telephone numbers, faxnumber, e-mail address, and Web siteaddress (if any) for all authors. Identifyone author as the corresponding author.Unless requested otherwise, the e-mailaddress is published in the Journal.

AbstractA self-standing summary of the text ofup to 250 words should precede theintroduction. It should provide an accu-rate summary of the most significantpoints and be representative of theentire article’s content. Provide the con-text or background for the article, basicprocedures, main findings and conclu-sions. Emphasize new or importantaspects. Do not use abbreviations (otherthan standard units of measurement) orreferences in the abstract.

Author(s) BiographyProvide a brief, current biographicalsketch of each author that includes pro-fessional education and professionalaffiliations. For authors who hold teach-ing positions, include the title, depart-ment, and school. For authors who arein federal service, include rank or titleand station.

ReferencesReferences are to be cited in the text bynumber in order of appearance, withthe number appearing either as asuperscript or in brackets. The refer-ence list should appear at the end of themanuscript with references in order offirst appearance in the text of the man-uscript. The reference list must betyped double-spaced on a separate pageand numbered in the same sequence asthe reference citations appear in thetext. Prior to submission, all referencesare to be properly prepared in the cor-rect format, checked for completeness,carefully verified against their originaldocuments, and checked for accuratecorrespondence between referencescited in the text and listed in theReferences section.• For journal citations, include sur-

names and all initials of all authors,complete title of article, name of jour-nal (abbreviated according to the U.S.National Library of Medicine(www.nlm.nih.gov/services/lpabbrev.html), year of publication,volume, issue number, and completeinclusive page numbers. If abstractsare cited, add the abstract numberafter the page number.

• For book citations, specify surnamesand initials of all authors, chapternumber and title (if applicable), edi-tors’ surnames and initials, booktitle, volume number (if applicable),

edition number (if applicable), cityand full name of publisher, year ofpublication, and inclusive page num-bers of citation.

• For government publications or bul-letins, identify the author(s) (if given);title; department, bureau, agency, oroffice; the publication series, report,or monograph number; location ofpublisher; publisher; year of publica-tion; and inclusive page numbers.

• For articles published online but notyet in print, cite with the paper’sDigital Object Identifier (DOI) addedto the end of the reference.

• For Web citations, list the authorsand titles if known, then the URLand date it was accessed.

• For presentations, list the authors,title of presentation, indication thatthe reference is a lecture, name ofconference or presentation venue,date, and location.

Illustration Captions and LegendsAll illustrations must be accompanied byindividual explanatory captions whichshould be typed double-spaced on a sepa-rate page with Arabic numerals corre-sponding to their respective illustration.

TablesTables must be typewritten double-spaced, including column heads, data,and footnotes, and submitted on sepa-rate pages. The tables are to be cited inthe text and numbered consecutively inArabic numerals in the order of theirappearance in the text. Provide a con-cise title for each table that highlightsthe key result.

IllustrationsIllustrations include photographs, radi-ographs, micrographs, charts, graphs,and maps. Each should be numbered andcited in the text in the order of appear-ance and be accompanied by explanatorycaptions. Do not embed figures withinthe manuscript text. Each figure andtable should be no larger than 8-1/2 x 11inches. Digital files must measure atleast 5 inches (127 mm) in width. Theimage must be submitted in the size it

will be printed, or larger. Illustrationsare to augment, not repeat, material inthe text. Graphs must not repeat datapresented in tables. Clinical photographsmust comply with ALD’s Guidelines forClinical Photography, available online.Authors are to certify in a cover letterthat digitized illustrations accuratelyrepresent the original data, condition, orimage and are not electronically edited.

Publisher and Copyright HolderThe Journal of Laser Dentistry is pub-lished by Max G. Moses, MemberMedia, 1844 N. Larrabee, Chicago, IL60614, Telephone: (312) 296-7864; Fax:(312) 896-9119. The Journal of LaserDentistry is copyrighted by TheAcademy of Laser Dentistry, 3300University Drive, Suite 704, CoralSprings, FL 33065, Telephone: (954)346-3776; Fax: (954) 757-2598.

Articles, Questions, IdeasQuestions about clinical cases, scientificresearch, or ideas for other articles maybe directed to Donald J. Coluzzi, Editor-in-Chief, by e-mail: [email protected].

Submission of Filesby E-mail:Send your completed files by e-mail(files up to 10 MB are acceptable). Iffiles are larger than 10 MB, they maybe compressed or sent as more than onefile, with appropriate labels. Filesshould be submitted to: Donald J.Coluzzi, Editor-in-Chief, by e-mail:[email protected].

By Federal Express or OtherInsured Courier:If using a courier, please send the file asa CD-ROM, include a hard copy of yourmanuscript and also send a verificationby e-mail to Gail Siminovsky ([email protected]).Gail SiminovskyAcademy of Laser Dentistry3300 University Drive, Suite 704Coral Springs, FL 33065Phone: (954) 346-3776.

Summary of Illustration Types and Specifications

IllustrationType

Definition and ExamplesPreferredFormat

RequiredResolution

Line Art andVector Graphics

Black and white graphic with noshading (e.g., graphs, charts, maps)

EPS or JPG 1200 DPI

Halftone Art

Photographs, drawings, or paint-ing with fine shading (e.g., radi-ographs, micrographs with scalebars, intraoral photographs)

TIFF orJPG

300 DPI (black &white) 600 DPI (color)

CombinationArt

Combination of halftone and lineart (e.g., halftones containingline drawing, extensive lettering,color diagrams)

EPS or JPG 1200 DPI

Editorial PolicyThe Journal of Laser Dentistry is devoted to providing the Academy and its members with comprehensive clinical, didactic andresearch information about the safe and effective uses of lasers in dentistry. All statements of opinions and/or fact are publishedunder the authority of the authors, including editorials and articles. The Academy is not responsible for the opinions expressedby the writers, editors or advertisers. The views are not to be accepted as the views of the Academy of Laser Dentistry unlesssuch statements have been expressly adopted by the organization. Information on any research, clinical procedures or productsmay be obtained from the author. Comments concerning content may be directed to the Academy’s main office by e-mail [email protected]

SubmissionsWe encourage prospective authors to follow JLD’s “Instructions to Authors” before submitting manuscripts. To obtain a copy,please go to our Web site www.laserdentistry.org/press.cfm. Please send manuscripts by e-mail to the Editor at [email protected].

Disclosure Policy of Contributing Authors’ Commercial RelationshipsAccording to the Academy’s Conflict of Interest and Disclosure policy, authors of manuscripts for JLD are expected to discloseany economic support, personal interests, or potential bias that may be perceived as creating a conflict related to the materialbeing published. Disclosure statements are printed at the end of the article following the author’s biography. This policy isintended to alert the audience to any potential bias or conflict so that readers may form their own judgments about the materialbeing presented.

Disclosure Statement for the Academy of Laser DentistryThe Academy of Laser Dentistry has no financial interest in any manufacturers or vendors of dental supplies.

Reprint Permission PolicyWritten permission must be obtained to duplicate and/or distribute any portion of the Journal of Laser Dentistry. Reprints maybe obtained directly from the Academy of Laser Dentistry provided that any appropriate fee is paid.

Copyright 2008 Academy of Laser Dentistry. All rights reserved unless other ownership is indicated. If any omission or infringementof copyright has occurred through oversight, upon notification amendment will be made in a future issue. No part of this publica-tion may be reproduced or transmitted in any form or by any means, individually or by any means, without permission from thecopyright holder.

The Journal of the Academy of Laser Dentistry ISSN# 1935-2557.

JLD is published quarterly and mailed nonprofit standard mail to all ALD members. Issues are also mailed to new memberprospects and dentists requesting information on lasers in dentistry.

Advertising Information and RatesDisplay rates are available at www.laserdentistry.org/press.cfm and/or supplied upon request. Insertion orders and materials shouldbe sent to Bill Spilman, Innovative Media Solutions, P.O. Box 399, Oneida, IL 61467, 877-878-3260, fax: 309-483-2371, [email protected]. For a copy of JLD Advertising Guidelines go to www.laserdentistry.org/press_advguide_policy.cfm.The cost for a classified ad in one issue is $50 for the first 25 words and $2.00 for each additional word beyond 25. ALD membersreceive a 20% discount. Payment must accompany ad copy and is payable to the Academy of Laser Dentistry in U.S. funds only.Classified advertising is not open to commercial enterprises. Companies are encouraged to contact Bill Spilman for information on dis-play advertising specifications and rates. The Academy reserves the right to edit or refuse ads.

Editor’s Note on Advertising: The Journal of Laser Dentistry currently accepts advertisements for different dental laser educational programs. Not all dental laser educationalcourses are recognized by the Academy of Laser Dentistry. ALD as an independent professional dental organization is concerned that coursesmeet the stringent guidelines following professional standards of education. Readers are advised to verify with ALD whether or not specificcourses are recognized by the Academy of Laser Dentistry in their use of the Curriculum Guidelines and Standards for Dental Laser Education.

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ED ITO R’S V IEW

This issue of the Journal contains abroad base of articles about dentallasers, describing clinical success aswell as basic understanding abouttheir interactions and safety. Threeof the authors are recipients of theAcademy of Laser Dentistry’shonors; the other writers describeprinciples of use that will help toachieve an optimum outcome.

Two highlights are descriptiveclinical articles from both of theLeon Goldman Clinical ExcellenceAward winners from 2008:• Dr. Giovanni Olivi, along with his

wife Daniela, has written aboutthe use of the dental operatingmicroscope for exact visualizationof a variety of laser procedures.The magnification gained by themicroscope not only increases thevisual acuity of the clinicianduring the procedure, but alsoclearly shows the benefit using alaser.

• Dr. Frank Yung offers a long-term clinical retrospective studyof his use of an Er:YAG laser inperiodontal surgery. Dr. Yungclosely followed 60 patients foran average of 2.4 years, andreports on the treatment andresults of four of them who exem-plify the overall results.Another highlight is from Dr.

Arthur Levy, who received theAcademy’s Distinguished ServiceAward in 2007. Dr. Levy provides

his clinical protocol for periodontaltherapy using a soft tissue laseradjunctively that has proved verysuccessful for over the course of 15years.

Additional features include:• Dr. Michael Swick presents the

first part of a two-part scientificdiscussion of laser-tissue interac-tion. His manuscript gives detailsabout fundamental actions ofhow laser radiation affects dentaltissues. The article is accompa-nied by a self-instructionprogram that is eligible forcontinuing education credit.

• Dr. Shawn Adibi presents asuccessful clinical procedureusing an Er,Cr:YSGG laser forsoft tissue preparation around animplant fixture for a finalrestoration.

• Dr. Alfred Wyatt describes histechnique of using an Er:YAGlaser to remove porcelain veneersthat need replacement.Also of significance is the

Academy Position Paper on LaserSafety, written by the Laser SafetyCommittee (chaired by CarolineSweeney) and adopted by the Boardof Directors.

Lastly, I describe the proceedingsof the joint meeting of the Academyand the U.S. Food and DrugAdministration that was held inDecember 2008. The Academy’steam of presenters joined with other

speakers involved in research anddevelopment to offer information tointerested parties as an opportunityto learn more about the present andfuture applications of lasers.

I hope you enjoy the information,and I hope to see you at ALD 2009Conference and Exhibition in LasVegas. As usual, I look forward toyour submission of a manuscript thatI can share with your colleagues.

AU THO R B IO GR AP HYDr. Donald Coluzzi, a 1970 grad-uate of the University of SouthernCalifornia School of Dentistry, is anassociate clinical professor in theDepartment of Preventive andRestorative Dental Sciences at theUniversity of California SanFrancisco School of Dentistry. Acharter member and past Presidentof the Academy of Laser Dentistry,he has used dental lasers sinceearly 1991. He has AdvancedProficiency in Nd:YAG and Er:YAGlaser wavelengths. He is the 1999recipient of the Leon GoldmanAward for Clinical Excellence andthe 2006 Distinguished ServiceAward from the Academy of LaserDentistry, a Fellow of the AmericanCollege of Dentists, and a Master ofthe Academy of Laser Dentistry. Dr.Coluzzi has presented about lasersworldwide, co-authored two books,and published several peer-reviewed articles.

Disclosure: Dr. Coluzzi is a pastlecturer for Hoya ConBio, a past andpresent presenter at American DentalAssociation, California DentalAssociation, Texas Dental Association,and other international organizations.He has no financial interest in anycompany. ■■

Coluzzi

Dental Lasers – Award-Winning and Reward-DeliveringDonald J. Coluzzi, DDS, Portola Valley, California

J Laser Dent 2009;17(1):5

SYNO P SIS

Donald J. Coluzzi, editor-in-chief, describes the contents of this issue,

illustrating the value and benefit of scientific, clinical, and safety-

related expertise.

A Dental Laser and a Microscope: The Perfect MatchGiovanni Olivi, DMD; Maria Daniela Genovese, MD, DMD, Rome, ItalyJ Laser Dent 2009;17(1):6-12

INTRO D U C TIO NThe use of the Dental OperatingMicroscope (DOM) was introducedin the 1970s.1-3 At the start of the1990s, it was used only in oper-ating rooms. However, by 2000, theDOM was no longer used only byprosthodontists4 or endodontists,5-7

but could be found in many privatepractices of general dentistry.

Nd:YAG and CO2 surgical laserswere available at the start of the1990s, erbium and diode laserswere introduced in the middle ofthe decade, and their usageincreased greatly by 2000.

The use of high technology oper-ative and diagnostic devices as wellas an awareness of minimally inva-sive dentistry (MID) is graduallychanging dental care. The conceptof MID includes early diagnosisand minimal tissue removal.8-9 Thecommon focus is tissue preserva-tion, preferably by preventingdisease from occurring and inter-cepting its progress; but also byremoving the pathology with aslittle tissue loss as possible. MID isbased on diagnostic proceduressuch as probing enamel fissures. In1992 Penning and colleagues10

reported that the probing offissures was not effective for detec-tion of incipient decay, due to theircomplex anatomy. In 1998, a laser

(DIAGNOdent, KaVo DentalGmbH, Biberach, Germany) wasintroduced for caries detection.11-13

The technology is based on themeasurement of the difference influorescence of healthy and decayedtissues. The device detects occlusalcaries at a level superior to whatcould be obtained with a bitewingX-ray, and has improved the sensi-tivity and specificity for diagnosisat the proximal aspect.14-15

The use of high magnification andcoaxial illumination along withdental lasers allows those who workwith microdentistry techniques todiagnose and treat decay at theearliest possible stage, and to mini-mize the removal of healthy hard andsoft tissues, with a more conservativeresult, as shown in Figures 1-4.

TH E O P ER ATINGMIC RO SC O P E IND ENTISTRYDentistry, like all branches ofsurgery, has always been consid-ered as a manifestation of the finemotor and tactile skills of the indi-vidual operator. Use of eitherloupes or the microscope withcoaxial illumination improves one’svisual acuity. Van As16 reportedthat, when magnification beyond 6Xis used, the effectiveness of tactileinspection decreases, and that

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C OV ER FEATU R E # 1

Olivi and Genovese

SYNO P SIS

A laser and magnification play a fundamental role in contemporary

dental practice, where a micro-invasive approach, precision, and

esthetics produce the desired clinical results. The purpose of this

article is to describe the advantages of the use of these high tech-

nology devices in dentistry.

Figure 2: DIAGNOdent detecting cariouslesion of the fissure

Figure 4: Composite resin restorationcompleted

Figure 1: Small carious lesion on distalfissure of a deciduous second upper molar

Figure 3: Minimally invasive cavity prepa-ration utilizing an Er:YAG laser

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many clinicians who use a higher-power microscope rely more onvisual inspection.

Miniaturized instruments areneeded in order to maintain thecorrect proportions between themagnified treatment area and theinstruments being used, so that theoperator has correct spatial orienta-

tion and ease of movement. In addi-tion, the instruments should notobstruct the operating field. Figures5 and 6 show examples of suchinstruments compared to conven-tional sizes; bur sizes compared tolaser tips are shown in Figure 7.

The clinician who begins oper-ating at high magnification willnotice that small movements appearextremely large, and the authorshave experienced unpleasant sensa-tions from headaches to nausea while

performing the treatment. Withtraining, these movements can becalibrated into smaller ones withreduced proportions, evolving intomotions as small as 10 to 20microns.16-17 The authors have foundthat an operator’s comfort willprogressively increase, thanks to theideal posture of the head, neck, shoul-ders, and back, as well as the armsand forearms which are maintainedin position by special operatingchairs with flexible armrests. Themicroscope can help to maintain acorrect head position independent ofthe quadrant being observed (Figure

Olivi and Genovese

Figure 5: Top, large mirror used forphotographs; middle, a standard mirror#5; bottom, a micromirror used duringendodontic surgery

Figure 6: Left, traditional ISO 010-012burs for cavity preparation and cariouslesion removal; right, microburs ISO 005-006-007 for minimally invasive therapy.Note the small working part and thelong, slender neck of these burs formicropreparation

Figure 7: Laser tips and conventional burcomparisons. On the left, note the lengthof different laser tips, from 21 mm and300-micron diameter on the top to 4 mmand 600-micron diameter on the bottom.On the right, from top to bottom, is an ISO006 bur, a curved (80-degree) 600-micronlaser tip, and ISO 012 burs adjacent to400- and 600-micron laser tips

Figure 8: The dental operating micro-scope allows the correct ergonomicposition of the operator’s head and neck

Figure 9: Visualization with loupes forcingthe operator’s head into an incorrectposition. This posture of the head andneck causes subsequent incorrectposture of the shoulders and back

Figure 10: Preoperative view of patientwho is congenitally missing the upperright lateral incisor

Figure 11: Tooth preparation for estheticrestoration of cuspid performed at 4.5Xmagnification through the dental oper-ating microscope. Note the preservationof the marginal gingiva

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8), while loupes sometimes force theoperator into incorrect posture, asshown in Figure 9.

Confidence in visual acuity willincrease until it surpasses confidencein tactile sensation, with an increasein technical prowess with better clin-ical results. Figures 10 to 13demonstrate an example of the excel-lent view that magnification canprovide in a restorative procedure.

TH E O P ER ATINGMIC RO SC O P E AN DLASER D ENTISTRYThe DOM provides the clinicianexcellent visualization of laser-

when viewed through the micro-scope.

The authors have found thatthey can more easily determineideal laser parameters. Since powercan be adjusted by focusing or defo-cusing the laser handpiece,magnification can verify the idealworking distance to the tissue.Moreover, the speed of movement ofthe beam is easily seen which couldincrease cutting efficiency andminimize collateral thermaldamage. As an example, the well-defined incision in Figure 15 wasaccomplished by using a DOM.

Two clinical procedures willillustrate the benefit of magnifica-tion. A soft tissue lesion shown inFigure 16 can be excised as shownin Figure 17. The procedure can becarefully performed with very little

Olivi and Genovese

tissue interaction. Both contactand noncontact procedures benefitfrom the improved visual controlwhich allows the correct aiming,focusing, and defocusing of thelaser beam. For example, Figure14 shows the proper placement ofthe optic fiber of a diode laser

Figure 14: View of beginning of softtissue surgery to treat the fibrous mucosacovering the lower second molar. An 810-nm diode laser is being used (X4)

Figure 15: Incision for operculectomycontinues. An 810-nm diode laser isbeing used with a 400-micron fiber, 1.8W CW, in contact mode. Note the vapor-ization zone, the thin layer of necrosis(black), the surrounding blanching area(white), and excellent hemostasis (X4)

Figure16: Papilloma-like lesion andanatomical contiguity with the salivaryorificies (X10)

Figure 17: Excisional biopsy performedwith an Er:YAG laser, 400-micron tip, 80mJ, 20 pps, in contact mode. Note theabsence of charring tissue, limitedbleeding, and a small blanching areaalong with some warming of thebordering tissue (X4). The incisionpreserved the adjacent salivary tissues

Figure 18: Complete healing after 21days (X2.5)

Figure 12: Three-year postoperative view(X6.25). There is no discoloration orleakage of the ceramic restoration, andthe soft tissue is healthy

Figure 13: Three-year postoperative viewat higher magnification (X10). Note thatthere is no discoloration or leakage, andthe soft tissue shows no recession orinflamation

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disturbance of the surroundinghealthy tissue, and healing isuneventful, as shown in Figure 18.Figure 19 shows the removal of acarious lesion with exposed pulpal

tissue. Precise aiming of the laserenergy produces coagulation, asshown in Figure 20, with minimalexposure of the beam to the adja-cent dentin.

HAR D T ISSU E TH ER APYTraditional mechnical tooth prepa-ration is performed with a bur incontact as an abrasive process. The

erbium laser instead uses aphotothermal interaction in noncon-tact mode, which varies from abouta 1 mm to a 15 mm focal spot fordifferent instruments. To ensureprecision placement of the laser

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Figure 19: Cavity preparation of firstupper molar with a small pulp exposure.The high magnification (X10) showedthat the size of the exposure is similar tothe size of the laser spot (600-microns),and that the bleeding is limited withoutsigns of inflamation

Figure 20: Pulpal coagulation with an810-nm diode laser, 400-micron fiber, 0.8W CW in defocused mode. The 10Xmagnification image shows superficialcoagulation of the pulp. After 5 years thetooth remained vital

Figure 21: Stable support of arms andforearms, mantained in position byspecial operating flexible armrests, helpsto increase the operator’s motor andtactile skills

Figure 22: Bimanual technique: Note theworking hand with the fingers rested onthe same maxillary area of work and theother hand helping to aim the laser for acorrect, precise laser irradiation. The highillumination of the working area and themagnification from the microscopeincrease the visual acuity

Figure 23: Cavity preparation of secondlower premolar. The precision of the irra-diation of the distal cavity is facilitated byresting the tip on the marginal ridge ofthe proximal tooth

Figure 24: An Er,Cr:YSGG laser performingan implant uncovering, using a 400-micron, 9-mm long tip. The 10Xmagnification provided the visual acuityto maintain the 1-mm noncontactdistance using a long tip

Figure 25: Er:YAG laser preparing a distalcavity on a central incisor, using a 600-micron, 30-degree curved tip (X6.5)

Figure 26: During a cavity preparation of acentral incisor with an Er:YAG laser using a600-micron, 30-degree curved tip, magni-fication facilitates aiming the laser beaminto the undercut of a distal cavity (X6.5)

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energy, the operator’s arms, elbows,and wrists should be in a stableposition as shown in Figure 21, andthe clinician’s fingers should rest onthe teeth of the corresponding archof the procedure (Figure 22). Also,the accurate aim of the beam canbe facilitated by resting the head ofthe laser handpiece or the lateralpart of the tip on the adjacentteeth, on the marginal ridge ofproximal teeth for a Class II prepa-ration, or on the edge of the cavityitself, as shown in Figure 23. Then,simple delicate movements of the

handpiece will provide a change ininclination during the laser irradia-tion. Every movement of the patientis aligned with the movement of theoperator’s hand so that the possi-bility of errant irradiation is easierto control, since small patientmotions could produce large visualchanges of the magnified operatingarea.

Some laser manufacturersprovide tips that are 9-14 mm long,which improve the angle of visionwithout obstruction (Figure 24).Other manufacturers have realizedthat providing an angular handpieceor tip would work better for minimalinterventions performed with themicroscope. With these angled tips,it is also possible to interact withcarious tissue in the undercut, or onthe axial distal walls of the proximal

cavities that are otherwise difficultto treat (Figure 25 and 26).

In the authors’ experience, afteran initial training period and alearning curve from 6 to 12 months,it is possible to perform a dentalprocedure with laser technologyand the operating microscope thatis minimally invasive, simple, andsafe. Again, two clinical cases illus-

Olivi and Genovese

Figure 32: An implant fixture uncoveringusing an erbium laser with water spray toreduce thermal damage (X10)

Figure 33: A healing screw was placedimmediately after the uncovering.Magnification aided in contouring thegingiva so that, after healing, propertissue contour will be present (X4)

Figure 29: After the root end obturation,the laser was used to decontaminate theroot end surface. Note the very cleanoperative area (X6.25)

Figure 30: Proximal decay of upper bicus-pids (X4)

Figure 31: Minimally invasive laser prepa-rations. Note the precision of the laserirradiation and preservation of thehealthy surrounding tooth structure. Asnoted in the text, both hands wereresting on the maxillary arch (X4)

Figure 27: Upper second premolar apexafter laser removal of granulomatosistissue and evaluation of the amount ofroot stucture to remove. Note how theprobe shows a working area less thanone square centimeter (X6.25)

Figure 28: Er:YAG laser cut of the rootapex. A 400-micron chisel tip was used(X10)

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trate this. Figures 27 to 29 demon-strate an apicoectomy procedure,and Figures 30 and 31 show theremoval of two carious lesions andthe finished preparation of the

teeth with well-defined margins.

SO FT T ISSU E TH ER APYAll laser wavelengths perform softtissue surgery; and, with the tech-niques described above, the DOMoffers the clinician the ability tomore precisely focus the energyonto the target tissue, whether incontact or in noncontact. Theauthors have found that it ispossible to avoid charring orburning, to achieve coagulationwhen needed, to perform vaporiza-tion and contouring of the softtissue, and to verify the exact posi-tion of the cementoenamel junction.

The last two clinical cases rein-force the benefits of magnificationduring laser treatments. The firstshows how the Er:YAG laser wasused to uncover an implant fixtureas well as contour the soft tissue(Figure 32) so that a healing cap

can be placed (Figure 33). Thesecond shows an aesthetic softtissue crown lengthening (Figures34 to 37). The enamel surface wasslightly ablated during the proce-dure but the follow-up photographshows remineralization (Figures37a and 37b). The DOM was asignificant aid in determining theenamel damage and its subsequentrepair.

During a frenectomy procedure,it is possible to check the vaporiza-tion that has occurred and theremoval of the collagen fibers fromthe periosteum; controlling theenergy and the focus avoids damagefrom overheating the periosteumtissue, permitting safe, predictable,and asymptomatic healing, as

Olivi and Genovese

Figure 34: Preoperative view of twocentral incisors with a diastema, a conicaltooth shape, and asymmetrical gingivalalignment (X4)

Figure 35: Immediate postoperative viewafter an erbium laser was used for toothpreparation and soft tissue crownlengthening. Composite resin was usedto accomplish the closure of thediastema (X4)

Figure 36: Magnification (X10) of thetissue shown in Figure 35. Note thelimited bleeding but the unwantedetching of the enamel, due to an incor-rect aiming of the erbium laser

Figures 37a and 37b: Very high magnifica-tion of the tissue shown in Figure 36 after14 days of topical fluoride gel application(X40). The enamel has remineralized andthe soft tissue has healed

Figure 38: Preoperative view of an insuffi-cient width of attached gingiva due toorthodontic problems. The treatmentplan is to revise the frenum’s insertion tolimit the frenum’s traction on themarginal gingiva

Figure 39: Immediate postoperative viewof the frenectomy performed with anEr,Cr:YSGG laser (X10). Magnification helpsthe complete and correct removal of allthe collagen fibers so that the new attach-ment occurs on the mucogingival line.Note the absence of charring in the tissues

Figure 40: Two-week postoperative viewof the healed frenum attachment (X10).Note the scarred area that maintains thefrenum in a lower position, without trac-tion on the marginal gingiva

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shown in Figures 38 to 40.

C O NC LU SIO NThe microscope combined with theuse of a dental laser can produceseveral benefits for patients andclinicians.

Patients can be treated withtherapies that preserve the mosttissue and with beneficial postoper-ative sequelae, according to aminimally invasive philosophy ofdentistry, thanks to the possibilityof early diagnosis and conservativetreatments.

Dental clinicians have the possi-bility of learning new operatingtechniques, and once the learningcurve is completed, they can usethe new technologies to improvetheir clinical results, expendingless energy, and achieving moreprofessional success.

The authors believe thattogether with the ongoing experi-mental research in new, improvedoperative protocols, it is also neces-sary to propose practical operatingtechniques to standardize dentalpractice, to improve both the thera-pies and the outcomes.

AU THO R B IO GR AP H IESDr. Giovanni Olivi practices inesthetic and restorative dentistryin Rome. He is an active member ofALD, a founding fellow and Boardmember of the InternationalAcademy of High Tech, and anactive member of the ItalianAcademy of Microscope Dentistry.He is a speaker in national andinternational laser conferences andcurrently he is a consultingprofessor for Masters in LaserDentistry at University courses inGenoa, Florence, and serves thesame role for the European Masterdegree in Oral Laser Applicationsat the University of Nice andUniversity of Parma. Dr. Olivi isthe recipient of the 2007 LeonGoldman Award, presented for clin-

ical excellence in laser dentistryfrom the Academy of LaserDentistry. Dr. Olivi may becontacted by e-mail [email protected].

Disclosure: Dr. Olivi is a boardmember of the International Academyfor High Tech for which he receives nocompensation.

Dr. Maria Daniela Genovese prac-tices in Rome and received her MDdegree in 1985, followed by her DMDin 1989. She also received advancedtraining in Pediatric Dentistry andOrthodontics during that time andachieved a master’s degree inGnathology and Posturology in 2001.She has been using dental laserssince 2000. Dr. Genovese is an activemember of IAHT (the InternationalAcademy of High Tech) and of SIOI(Italian Society of PediatricDentistry). She is a national andinternational speaker and hasauthored and co-authored severalarticles on these topics. Dr. Genovesemay be contacted by e-mail [email protected].

Disclosure: Dr. Genovese has no affi-lations to disclose.

B IB LIO GR AP HY1. Baumann RR. Was bietet das opera-

tionmikroskop dem zahnarzt?Quintessenz 1975;26(2):33-34.

2. Baumann R. Endodontie und opera-tionmikroskop. Quintessenz1975;26(10):55-58.

3. Apotheker H, Jako GJ. A microscopefor use in dentistry. J Microsurg1981;3(1):7-10

4. Martignoni M, Schönenberger A.Precision fixed prosthodontics:Clinical and laboratory aspects.Chicago: Quintessence PublishingCo., Inc., 1990:15-29.

5. Carr GB. Microscopes in endodon-tics. J Calif Dent Assoc1992;20(11):55-61

6. Pecora G, Andreana S. Use of dental

operating microscope in endodonticsurgery. Oral Surg Oral Med OralPathol 1993;75(6):751-758.

7. Ruddle CJ. Endodontic perforationrepair: Using the surgical operatingmicroscope. Dent Today1994;13(5):48, 50, 52-53.

8. Ericson D. What is minimally inva-sive dentistry? Oral Health PrevDent 2004;2 Suppl 1:287-292.

9. Ericson D. The concept of minimallyinvasive dentistry. Dent Update2007;34(1):9-10, 12-14, 17-18.

10. Penning C, van Amerongen JP, SeefRE, ten Cate JM. Validity of probingfor fissure caries diagnosis. CariesRes 1992;26(6):445-449.

11. Hibst R, Gall R. Development of adiode laser-based fluorescence cariesdetector. Caries Res 1998;32(4):294,Abstract 80.

12. Hibst R, Paulus R. A new approachon fluorescence spectroscopy forcaries detection. In: FeatherstoneJDB, Rechman P, Fried D, editors.Laser in dentistry V, January 24-25,1999, San Jose, Calif. Proc SPIE3593. Bellingham, Wash.: SPIE –The International Society forOptical Engineering, 1999:141-147.

13. Virajsilp V, Thearmontree A,Paiboonwarachat D, Aryatawong S.Comparison of proximal cariesdetection in primary teeth betweenlaser fluorescence and bitewingradiography. Pediatr Dent2005;27(6):493-499.

14. Lussi A, Hack A, Hug I,Heckenberger H, Megert B, Stich H.Detection of approximal caries witha new laser fluorescence device.Caries Res 2006;40(2):97-103.

15. Black, RB. Technic for nonmechan-ical preparation of cavities andprophylaxis. J Am Dent Assoc1945;32(15):955-965.

16. van As GA. Use of the dental oper-ating microscope in laser dentistry:Seeing the light. J Laser Dent2007;15(3):122-129.

17. Tibbetts LS, Shanelec D. Periodontalmicrosurgery. Dent Clin North Am1998;42(2):339-359. ■■

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The Use of an Er:YAG Laser in Periodontal Surgery: ClinicalCases with Long-Term Follow-UpFrank Yung, DDS, Toronto, Ontario, CanadaJ Laser Dent 2009;17(1):13-20

INTRO D U C TIO NWhile the regimen of scaling androot planing (SRP) remains anessential part of any management ofperiodontal diseases, there are clin-ical situations in which the surgicalexcision of infected tissues or modifi-cations of healthy structures isrequired after the initial mechanicaldebridement. Conventional surgicaltechniques, such as curettage,gingivectomy, full- or split-thicknessflap, and other procedures, havebeen proven to be effective intreating moderate-to-advanced peri-odontitis,1-2 but the need to improvepostoperative morbidity and controlover-treatment outcome haveprovided the impetus to explorefurther for better surgical tech-niques and treatment alternatives.The principle behind laser surgery isthe selective absorption of opticalenergy delivered by a specific laserwavelength to produce thermaleffects on the target tissues to beexcised or modified. The advantagesof utilizing a laser for surgery over“cold steel” or electrosurgery arewell documented in the literature,with some specific benefit differ-ences among wavelengths.3-5 Theoverall recovery experiences andsurgical results are so much more

pleasant and predictable than thoseof conventional surgery so that forsome surgical procedures, such as inthe fields of ophthalmology,6

otolaryngology,7 and dermatology,8

the use of lasers have replaced othermodalities in many instances.

During the 1960s and 1970s,different kinds of lasers withdifferent wavelengths wereinvented, and they were studiedsubsequently for possible dentalapplications. Laser instruments,including carbon dioxide (CO2),neodymium:yttrium, aluminum,garnet (Nd:YAG), argon, galliumarsenide (diode), anderbium:yttrium, aluminum, garnet(Er:YAG) were found to be effectivefor soft tissue surgery, includingperiodontics.9-10 The Er:YAG laser,which was developed in the early1970s,11 also offered hard tissueapplications.

The 2940-nm wavelength of theEr:YAG laser has absorption char-acteristics completely differentfrom Nd:YAG, argon, and diodelasers; it is very highly absorbed bywater and moderately so by dentalenamel.12-13 This specific and selec-tive laser energy absorption bywater causes rapid micro-explo-sions of the water molecules

SYNO P SIS

This article describes the treatment of 60 patients with periodontitis

using an Er:YAG laser with a long-term follow-up of an average of 2.4

years. It is an uncontrolled study of clinical cases whose goal was to

assess the effectiveness of the use of the laser. Representative exam-

ples of those cases will be shown.

AB STR AC TSince its U.S. Food and DrugAdministration (FDA) marketingclearance as a hard and soft tissuelaser, the Er:YAG laser wavelengthhas been used quite successfullyfor restorative procedures and, tosome extent, bone surgery.Although this laser was studied forsoft tissue management andsurgical periodontal treatment,concerns over inadvertent hardtissue collateral damage and poorcoagulation have hindered thislaser from being used as an all-tissue dental laser. The purpose ofthis uncontrolled clinical study wasto investigate these concernsthrough the use of this laser in peri-odontal surgical situations. Sixtypatients were treated with variousforms of periodontal surgery withan Er:YAG laser. Irradiation wasperformed at 30-120 mJ/pulse and10-30 Hz under constant water irri-gation in contact mode. Clinicalparameters, such as clinical attach-ment level, vitality test, andradiographs, were collected.Postoperative bleeding and toothvitality were evaluated immediatelyafter the surgery, and at 24 hours, 1and 4 weeks, 3 months, and up to4 years later. The Er:YAG laser effec-tively ablated periodontal tissues,including the alveolar bone andinfected granulation tissues. Patientdemand for local anesthetics waslow and, with one exception, therewas no medication prescribed forpostsurgical care. There were noreports of abnormal postoperativehemorrhage at the 24-hour and 1-week postsurgical assessmentappointments. The treated peri-odontal tissues demonstratedremarkable recovery and all thecontiguous teeth remained vital,functional, and asymptomaticduring the average mean follow-upperiod of 2.4 years. With carefultreatment planning and laser tiporientation, periodontal surgery canbe performed safely by Er:YAG laserwith no collateral damage.Although coagulation is not concur-rent with tissue ablation, naturalhemostasis was found to beadequate. Less-than-profoundcoagulation may be preferable forbetter wound healing.

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initiated by the selective energyabsorption within the target tissue,and provides the foundation for thewater-mediated, photo-thermal-mechanical ablation of the Er:YAGlaser.14 Whereas the optical energyis very strongly absorbed by thewater molecules within the superfi-cial layers of the target tissue, thepenetration depth of this laserbeam is limited to a few microme-ters close to the surface. Based onthis unique combination of strongsuperficial absorption and shallowpenetration, tissues with highwater content, such as dentin orgingival tissues, can be ablated orexcised precisely by these micro-explosions with almost nonexistentthermal damage to the underlyingtissues as long as there is properwater irrigation at the site.

An Er:YAG laser device wascleared for marketing by the U.S.FDA in 1997 for certain hard andsoft tissue procedures, such ascaries removal and cavity prepara-tion, as well as incision andexcision of intraoral soft tissues.Other Er:YAG laser instrumentswere then cleared for sulculardebridement in 1999, and in 2004for osseous surgery. Animal studieshave shown that this laser wave-length demonstrates suitability forvaporizing bone with minimalthermal damage and good postoper-ative healing.15-18

While the use of this laser wave-length for dental hard tissue isrelatively well-established in contem-porary dentistry, there is somedebate about its usefulness for softtissue or periodontal procedures.19-20

On the one hand, the Er:YAGlaser’s radiation has been found tobe strongly absorbed by many path-ogenic bacteria that are related toperiodontal infections,21-23 and it hasbeen shown to be effective inremoving root-bound calculuswithout damage to the cementumand dentin.24 Therefore, it has beenstudied for nonsurgical periodontaltherapy, and significant gains inclinical attachments have been

reported.19, 25-27 However, for peri-odontal surgery, there are twocommon concerns for the use of thislaser wavelength: (1) there is a lackof selective energy absorptionbetween the target tissues and thecontiguous nontarget tissues, suchas the root and bone surfaces, and(2) the shallow energy penetrationprovides coagulation that is not asprofound, and hemostasis is notconcurrent with tissue ablation asthe other soft tissue lasers, such asCO2, argon, diode, or Nd:YAG. Thepurpose of this study, therefore, wasto evaluate these concerns clinicallyand determine whether the Er:YAGlaser with full-time water irrigationwas suitable for periodontal surgeryin a safe and effective manner.

MATER IALS AN DMETHO D SIn this study, 60 patients (33 malesand 27 females with a mean age of49 years) were treated for variousperiodontal conditions, such asacute periodontitis, refractory peri-odontitis, gingival naevi,pre-prosthodontic and orthodonticperiodontal surgery. The patientswere selected based on thefollowing criteria: (1) no existingsystemic diseases such as diabetes28

or hemorrhagic disorder that couldaffect the treatment outcome, (2) nohistory of antibiotic therapy onemonth prior to the surgical proce-dures, and (3) teeth directly relatedto the surgical site should be vitaland their periodontal conditionswere, if possible stabilized withconventional scaling, root planing,and prophylaxis. Consent for peri-odontal and especially lasertreatment was obtained. Provisionsof the Helsinki Declaration of 1975,ethical principles in medicalresearch involving human subjects,as revised in 2000, were observedthroughout this study. Surgicalinterventions, such as surgicalcurettage, gingivectomy, gingivo-plasty, osteoectomy, andosteoplasty, were considered only incases of acute periodontitis or when

the periodontal inflammation failedto improve in three months afterconventional mechanical debride-ment.

Documentation, such as clinicalattachment levels, tooth vitalitytests, intraoral photographs, andpanoramic and periapical radi-ographs, were collected before thelaser treatment. The surgical siteswere locally infiltrated withXylocaine (lidocaine HCl, with1:100,000 epinephrine (DentsplyCanada Ltd., Woodbridge, Ontario,Canada), and no nerve block wasused. All of the laser surgical proce-dures were performed with Er:YAG(2940-nm) lasers (DELightTM andVersaWave®, HOYA ConBio,Fremont, Calif.), and strict lasersafety requirements in the operato-ries were observed.29-30 The surgicalsites were irradiated with multiplelaser pulses, with individual pulseenergies varying between 30 and120 mJ, pulse repetition ratesbetween 10 and 30 Hz, and pulseduration of approximately 250-300µs. The laser beam was deliveredthrough an optical fiber connectedto a round-exit contact tip 600 µmin diameter. The exit power at thecontact tip was monitored by apower meter (PowerMax 600TM,Molectron Detector, Inc., Portland,Ore.) before each procedure. Thiscontact tip was kept in near ordirect contact with the targettissues, with variations of spotdiameters between 0.6 and 1 mm.Power densities of 162 to 12 W/cm2,based on the 600-µm contact tipand power output measured by thepower meter, were applied; higherdensity was used for tissue ablationand lower setting for bacterialreduction and tissue coagulation.The surgical site was irrigatedthroughout the laser procedureswith filtered water emitted fromthe contact tip itself and from anexternal air-and-water syringe. Atthe completion of the surgicalprocedure, hemostatic cottonpellets (Racellet #3, Pascal Co.,Inc., Bellevue, Wash.) and/or 4-O

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silk sutures were used as neces-sary. The patients were instructedto follow the postsurgical careprotocol, and no prescriptions foranalgesics or antibiotics wereprescribed. No special mouthrinsewas given, and regular home careexcept at the surgical site wassuggested. All of the patients werecontacted the next day for postop-erative assessment. Regular homemaintenance resumed after thesurgical sites were re-examined,and the sutures were removed atthe one-week recall appointments.All of the clinical observations,along with the patients’ assess-ments, were collected one week, onemonth, three months, and up tofour years later. It is important tonote that this study made noattempt to gather statistics thatwould be analyzed for probabilitysignificance; rather it attempted toshow that the use of the laser wasbeneficial in the treatment of thepatients’ periodontal disease.

R ESU LTSA total of 67 vital teeth were directlytreated with a combination of 104individual surgical procedures forthis group of patients. The mostcommon procedures were surgical

curettage (n = 52), followed bygingivectomy (n = 47). The mostcommon surgical site was the poste-rior maxilla (n = 29), followed by theposterior mandible (n = 24). Themost common indication for laserperiodontal surgery (24 out of 60procedures) was moderate-to-severeacute periodontitis. The averageamount of local anesthetic used was0.5 ml; only local infiltration wasused and no nerve block wasrequired. Despite the extensivenature of some of these procedures,there were only two cases in whichconventional full periosteal flapswere raised; sutures were requiredfor these two cases, as well as for fiveother surgical sites. The blood clot-ting process was enhanced throughthe use of the hemostatic cottonpellets in 16 sites. There was noreport of air emphysema at any ofthe surgical sites. After the lasertreatments, one of the patients wasprescribed a course of antibiotics as aprecaution due to the severity of theinitial infection, and because thesurgical site was very close to themaxillary sinus; otherwise nomedication was prescribed for theother patients. They were contacted

the next day and no bleeding orswelling was reported. One of thepatients took an over-the-counteranalgesic, and another complained ofsoreness but did not require anymedication; mild soreness to nodiscomfort were reported by the restof the group. One patient didcomplain of sensitivity to tempera-ture which required one week for thesymptoms to be resolved. Follow-upperiods ranged from 6 to 54 months,with an average mean follow-upperiod of 2.4 years. The probingdepths were normal, and there weresigns of clinical attachment improve-ments. All of the treated teethremained vital and functional duringthe follow-up period.

C LIN IC AL C ASESPatient #1The patient was a 63-year-oldfemale recovering from breastcancer treatment. Although hermedical history was not ideal, shewas selected because her lastchemotherapy treatment had beenmore than three months prior, andher periodontal health was excel-lent. For this patient to have a morebalanced gingival appearance,crown lengthening was required(Figure 1). After the surgical area

Figure 1: An intraoral view of patient #1with a transitional acrylic bridge (teeth#8 to 10) before laser crown lengthening

Figure 2: The initial outline of the newgingival level for tooth #8 was preparedwith the Er:YAG laser

Figure 3: The attached gingiva wasexcised and the underlying alveolar crestmodified

Figure 4: Laser gingivoplasty orfestooning of the new gingival margincompleted

Figure 5: Two-week postoperative view,before the final insertion and after theabutments were etched with the sameEr:YAG laser

Figure 6: Four-month recall with healthygingival margin

was anesthetized and the new para-bolic level was initially designedwith superficial lasing (Figure 2),the excess gingival tissues wereremoved with the Er:YAG laser. Toachieve normal biological width atthe new gingival level, the under-lying dental alveolar bone wasreduced (Figure 3). Laser gingivo-plasty, or festooning, was used tobevel the surface geometry of thenew attached gingiva (Figure 4),and the final impression was takenafter the abutment was prepared.

The subsequent healing wasuneventful, mild sensitivity wasreported, but she did not requireany medication. The gingivalmargin was stable and healthyenough for the final insertion in 2weeks (Figure 5). The surgicalresults remained stable, and thecentral incisor was asymptomatic 6months later (Figure 6).

Because gingiva and bone arecomposed of varying densities offibrous connective tissues, extracel-lular components, and high watercontent (approximately 70% forgingiva and 10 to 20% for bone),through selective laser energyabsorption and by keeping thecontact tip either angled away from

the root and bone surfaces for theselective gingivectomy or along theedges of the alveolar bone formarginal osteoectomy, both the softand hard tissues were ablated andmodified with the same laser. Withproper water irrigation, there was nosurface carbonization, smoke forma-tion, or tissue shrinkage. Thetreatment outcome of this procedurewas relatively predictable, and hemo-stasis was stable enough that thefinal impression was taken at theend of the surgical procedure. Therewas a safety concern when this hardtissue laser was employed in suchclose proximity to the root surfaceand the alveolar bone. As demon-strated, if the intention and thedirection of the energy applicationare carefully planned ahead, thislaser may be used safely for selectiveablations, even in such a confinedsurgical site. In spite of the initialconcern over her possible weakenedimmune response and healingcapacity for which conventionaltreatment had been refused, as notedbefore, the wound healing wasuneventful and took place withoutthe assistance of medication.

Patient #2For this patient, surgical peri-odontal treatment was also refusedbecause the prognosis for hisinfected premolar was deemedhopeless. For this 66-year-old malepatient, who was taking antihyper-tensive medication, it wasrecommended that his upper rightsecond premolar be extractedbecause of acute periodontitis andsevere bone loss (Figures 7 and 8).

The patient’s blood pressure wasstable and under control, and therest of his dentition was functionaland normal. After the buccal andlingual areas were anesthetized, abuccal mucoperiosteal flap wasraised. The infected granulationtissues were removed around theroot surfaces and on the raised flap

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Figure 7: An intraoral photograph ofpatient #2 showing buccal swelling anddeep mesial pocket at tooth #4

Figure 8: A pretreatment periapical radio-graph illustrating severe bone loss

Figure 9: A periosteal flap was raised, andthe underlying granulation tissues on theroots, the adjacent alveolar bone, and theflap itself were ablated with the laser

Figure 10: One-week recall with no signof complications

Figure 11: One-month recall on the samesite with good periodontal recovery

Figure 12: Six-month recall with newbuccal attached gingiva and reducedmesial pocket

Figure 13: A periapical radiograph withsigns of bone regeneration 6 months later

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(Figure 9). Granulation tissuesusually carry much higher watercontent than healthy fibroustissues such as the attachedgingiva, a fact that can be exploitedquite well by the strong water-

affinity of erbium lasers.With water irrigation, the exposed

bone surfaces were lightly irradiatedin noncontact mode with the lowestpower density setting. Once stablehemostasis was accomplished, thesurgical wound was closed with a 4-O silk suture. Despite the initialinfection and gingival swelling, noantibiotics or analgesic medicationswere prescribed. There was no reportof any swelling or pain, and, mostimportantly, there was no bleeding atthe day-after reassessment. Thesurgical area was monitored furtherfor 1 week (Figure 10), 1 month(Figure 11), and 6 months (Figure12). Clinically, the premolar was

asymptomatic and functional in 2months, and there were radiographicsigns of bone regeneration in 6months (Figure 13).

Patient #3This patient was only 26 years oldwhen the extraction of her peri-odontally weakened right lateralincisor (Figure 14) was recom-mended (Figure 15).

Although her overall periodontalcondition improved after sessions ofconventional debridement (Figure16), this extensive periodontalpocket (Figure 17) became anurgent concern when orthodontictreatment was considered.

Figure 14: Patient #3, a 26-year-oldhealthy female patient with generalizedchronic periodontitis

Figure 15: Apical radiograph of the upperright lateral incisor

Figure 16: Seven months later, afterconventional nonsurgical debridementand prophylaxis

Figure 17: Seven-month postoperativeprobing of the lingual pocket of the rightlateral incisor still demonstrates signifi-cant depth

Figure 18: Exposure of the lingual pocketfollowed by laser removal of granulationtissue and bacterial reduction

Figure 19: Surgical closure with sutures

Figure 20: One-week postoperative view

Figure 21: Thirty-month postoperativeprobing, showing reattachment

Figure 22: Thirty-month postoperativeradiograph

The surgical approach was verysimilar to the one taken for patient#5 in terms of controlled access,granulation tissue removal, rootsurface irradiation (Figure 18) andsuturing (Figure 19). The recoveryof her surgical site was uneventful1 week later (Figure 20) andremained asymptomatic throughouther ensuing orthodontic treatment.

Two-and-a-half years later, boththe periodontal probing (Figure 21)and radiograph (Figure 22) showquite satisfactory clinical reattach-ment (Figure 21) and boneremodeling around the initially“hopeless’ incisor.

Patient #4This patient was a healthy 58-year-old male who presented with aninfected periodontal pocket (Figure23). After it was probed and cali-brated (Figure 24), the inflamedgranulation tissues were selectivelyseparated from the remaininghealthy attached gingiva and withinthe periodontal pocket (Figure 25).

Although infection was initially

present, no medication wasprescribed and the patient reportedno need for any; the surgical siterecovered without any incident(Figure 26). Clinical attachmentwas eventually reestablished in 1month (Figure 27) and remainedstable 2 years later (Figure 28).

D ISC U SSIO NThere were 23 similar clinicalscenarios in the study. The patientstypically presented with varyingdegrees of symptoms andcontributing factors, which wouldnormally require invasive conven-tional open-flap surgery andprescriptions for antibiotics andanalgesics, followed by a longperiod of convalescence. With theflexibility of the Er:YAG lasercontact tip, the surgical sites werecarefully and precisely designed,the subsequent instrumentationswere less invasive, and laserenergy transfer was finelycontrolled. As a result, the healingexperiences of these patients weremuch more pleasant, and thesurgical outcomes were morecontrolled.

Although there were signs ofclinical reattachments for all of thetreated areas consistent with

Gaspirc and Skaleric38 in their five-year, 25-patient study, there was noattempt to compare the quantita-tive assessment of the clinicalattachment levels, since the goldstandard for surgical reassessmentof the actual bone level is notappropriate for clinical studies ofthis nature. Then, again, if themain objective of periodontalsurgery is the establishment of anew connective tissue attachmentto a root surface previously exposedto periodontal disease, the collec-tive clinical and radiographicobservations are quite supportive ofthe effectiveness of this new treat-ment modality.

With the ablation of both hard26

(alveolar bone) and soft tissue32

(granulation and gingival tissue)precisely controlled, periodontaltissue reshaping or recontouringcan be planned and performed effi-ciently with the Er:YAG laser. Thebactericidal21-23 and possible bio-stimulation33 effects of thisradiation with no carbonization orintense coagulation allow fasterwound healing without any majorpostoperative swelling, pain, orbleeding. By allowing the various

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Figure 23: Initial view of periodontalabscess on the facial aspect of tooth #30of patient #4

Figure 24: Periodontal probe being usedto ascertain extensions of the pocket

Figure 25: Immediate postoperative viewafter laser ablation of granulation tissue

Figure 26: One-week postoperative view

Figure 27: One-month postoperative view

Figure 28: Two-year postoperative probing

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growth factors involved in woundhealing to work soon after thesurgery, the less-than-profoundhemostasis from the Er:YAG laseras compared with other intensecoagulation, can be beneficial and,in many situations, preferable.While these laser surgical benefitscan be helpful in certain aspects ofperiodontal surgery, it is importantto note that the use of lasersshould be considered as an additionto our present armamentarium, notas a replacement for the well-estab-lished surgical principles andtechniques that have been devel-oped since the first gingivectomywas reported.1 Because of the non-touch to light-touch requirements,the use of lasers is technique-sensi-tive, and due to the proximity ofthe irradiation to dental and bonetissues, proper training and under-standing of basic laser physics isrequired. Appropriate laser param-eters, such as power density, pulseduration, exposure time, and waterirrigation, should be carefullyconsidered. Although the lasertreatments in this study have beensuccessfully carried out, one cannotignore an enormous contributingfactor to success: the patient’scompliance with respect to his orher daily bacterial plaque control.

It is normal to expect a bettertreatment outcome, or at leastbetter control of it, when we incor-porate any new technology into ouroperatory. The object of this studywas to document tissue responsesto Er:YAG laser radiation use insurgical periodontal procedures. Inparticular, we wanted to evaluatewhether it was safe and effective tooperate the laser in close proximityto root and bone surfaces with lessprofound coagulation. In thepresent study, there were noreports of any postoperative hemor-rhagic complications or side effectsamong the 60 patients, and thedental hard tissues thatsurrounded the target sitesremained vital, functional, andasymptomatic.

The average amount of anes-thetics that were reported and theway the anesthetics were usedseem to suggest that the demandfor anesthetics was reduced. Thismay be related to the moreconfined and superficial surgicalsites, which, in turn, reduced thepossibility of bacteremia and thedemand for antibiotics and anal-gesics. This was of benefit to someof the patients in this study whohad significant medical history.

C O NC LU SIO NThis is an uncontrolled clinicalstudy that has evolved from aprivate practice setting; however,the potential benefits of using anEr:YAG laser for periodontalsurgery are quite evident. Based onthe clinical observations collected, itis both safe and effective to use thislaser wavelength in the mannerdescribed for periodontal surgery.Further investigation, ideally in theform of a randomized, controlledclinical study, will be required tovalidate these clinical results.

AU THO R B IO GR AP HYDr. Frank Yung graduated withhonors from the Faculty ofDentistry, University of Toronto,Ontario, Canada in 1980. From theAcademy of Laser Dentistry heachieved his Advanced Proficiencyin the use of diode (980 nm) andEr:YAG (2940 nm) lasers in 2003and 2004, respectively, and receivedhis Educator certificate in 2005and the Leon Goldman Award forclinical excellence in 2007. He isalso a Fellow of the AmericanSociety for Laser Medicine andSurgery. Dr. Yung may be contactedby e-mail [email protected].

Disclosure: Dr. Yung lectures for theInstitute for Laser Dentistry andreceives honoraria as compensation.

R EFER ENC ES1. Stern IB, Everett FG, Robicsek K. S.

Robicsek – A pioneer in the surgicaltreatment of periodontal disease. JPeriodontol 1965;36(1):265-268.

2. Goldman HM. The development ofphysiologic gingival contours bygingivoplasty. Oral Surg Oral MedOral Pathol 1950;3(7):879-888.

3. Kardos TB, Ferguson MM.Comparison of cryosurgery and thecarbon dioxide laser in mucosalhealing. Int J Oral Maxillofac Surg1991;20(2):108-111.

4. Kaminer R, Liebow C, MargaroneIII JE, Zambon JJ. Bacteremiafollowing laser and conventionalsurgery in hamsters. J OralMaxillofac Surg 1990;48(1):45-48.

5. Pick RM, Colvard MD. Currentstatus of lasers in soft tissue dentalsurgery. J Periodontol1993;64(7):589-602.

6. Krauss JM, Puliafito CA. Lasers inophthalmology. Lasers Sur Med1995;17(2):102-159.

7. Werner JA, Gottschlich S. Recentadvances. Otorhinolaryngology. BMJ1997;315(7104):354-357.

8. Alster TS, Lupton JR. Lasers indermatology. An overview of typesand indications. Am J ClinDermatol 2001;2(5):291-303.

9. Israel M. Use of the CO2 laser insoft tissue and periodontal surgery.Pract Periodontics Aesthet Dent1994;6(6):57-64.

10. Romanos GE. Clinical applicationsof the Nd:YAG laser in oral softtissue surgery and periodontology. JClin Laser Med Surg1994;12(2):103-108.

11. Zharikov EV, Zhekov VI, KulevskiiLA, Murina TM, Osiko VV,Prokhorov AM, Savel’ev AD,Smirnov VV, Starikov BP,Timoshechkin MI. Stimulated emis-sion from Er3+ ions in yttriumaluminum garnet crystal at λ =2.94 µ. Sov J Quantum Electron1975;4(8):1039-1040.

12. Hale GM, Querry MR. Opticalconstants of water in the 200-nm to200-µm wavelength region. Appl Opt1973;12(3):555.

13. Featherstone JDB, Fried D.Fundamental interactions of laserswith dental hard tissues. Med LaserAppl 2001;16(3):181-194.

14. Hibst R, Keller U. Experimentalstudies of the application of theEr:YAG laser on dental hardsubstances. I. Measurements of theablation rate. Lasers Surg Med1989;9(4):338-344.

15. Sasaki KM, Aoki A, Ichinose S,Ishikawa I. Ultrastructural analysisof bone tissue irradiated by Er:YAGlaser. Lasers Surg Med2002;31(5):322-332.

16. Sasaki KM, Aoki A, Ichinose S,Yoshino T, Yamada S, Ishikawa I.Scanning electron microscopy andFourier transformed infrared spec-troscopy analysis of bone removalusing Er:YAG and CO2 lasers. JPeriodontol 2002; 73(6):643-652.

17. Pourzarandian A, Watanabe H, AokiA, Ichinose S, Sasaki KM, Nitta H,Ishikawa I. Histological and TEMexamination of early stages of bonehealing after Er:YAG laser irradia-tion. Photomed Laser Surg2004;22(4):342-350.

18. de Mello EDA, Pagnoncelli RM,Munin E, Filho MS’A, de Mello GPS,Arisawa EAL, de Oliveira MG.Comparative histological analysis ofbone healing of standardized bonedefects performed with the Er:YAGlaser and steel burs. Lasers Med Sci2008;23(3):253-260.

19. Watanabe H, Ishikawa I, Suzuki M,Hasegawa K. Clinical assessmentsof the erbium:YAG laser for softtissue surgery and scaling. J ClinLaser Med Surg 1996;14(2):67-75.

20. Cobb CM. Lasers in periodontics: Areview of the literature. JPeriodontol 2006;77(4):545-564.

21. Ando Y, Aoki A, Watanabe H,Ishikawa I. Bactericidal effect ofEr:YAG laser on periodontopathicbacteria. Lasers Surg Med1996;19(2):190-200.

22. Folwaczny M, Mehl A, Aggstaller H,Hickel R. Antimicrobial effects of2.94 µm Er:YAG laser radiation onroot surfaces: An in vitro study. JClin Periodontol 2002;29(1):73-78.

23. Derdilopoulou FV, Nonhoff J,Neumann K, Kielbassa AM.Microbiological findings after peri-odontal therapy using curettes,Er:YAG laser, sonic, and ultrasonicscalers. J Clin Periodontol2007;34(7):588-598.

24. Schwarz F, Sculean A, Berakdar M,Szathmari L, Georg T, Becker J. Invivo and in vitro effects of anEr:YAG laser, a GaAlAs diode laser,and scaling and root planing on peri-odontally diseased root surfaces: Acomparative histologic study. LasersSurg Med 2003;32(5):359-366.

25. Schwarz F, Sculean A, Georg T,Reich E. Periodontal treatment withan Er:YAG laser compared toscaling and root planing. Acontrolled clinical study. JPeriodontol 2001;72(3):361-367.

26. Ishikawa I, Aoki A, Takasaki AA.Potential applications oferbium:YAG laser in periodontics. JPeriodontal Res 2004;39(4); 275-285.

27. Ishikawa I, Sasaki KM, Aoki A,Watanabe H. Effects of Er:YAGlaser on periodontal therapy. J IntAcad Periodontol 2003;5(1):23-28.

28. Shlossman M, Knowler WC, PettittDJ, Genco RJ. Type 2 diabetesmellitus and periodontal disease. JAm Dent Assoc 1990;121(4):532-536.

29. American national standard for safeuse of lasers in health care facilities.ANSI Z136.3 – 2005. Orlando, Fla.:The Laser Institute of America,2005:52-54.

30. LIA guide to medical laser safety.1st ed. Orlando, Fla.: Laser Instituteof America, 1997.

31. Gaspirc B, Skaleric U. Clinical eval-uation of periodontal surgicaltreatment with an Er:YAG laser: 5-year results. J Periodontol2007:78(10):1864-1871.

32. Aoki A, Sasaki KM, Watanabe H,Ishikawa I. Lasers in nonsurgicalperiodontal therapy. Periodontology2000 2004;36:59-97.

33. Pourzarandian A, Watanabe H,Ruwanpura SMPM, Aoki A, NoguchiK, Ishikawa I. Er:YAG laser irradia-tion increases prostaglandin E2production via the induction ofcyclooxygenase-2 mRNA in humangingival fibroblasts. J PeriodontalRes 2005;40(2):182-186. ■■

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C LIN IC AL R EV IEW AN D C ASE R EPO RT

Levy

A Periodontal Health System:Diagnosis, Treatment, and RetentionArthur B. Levy, DMD, Chester, New JerseyJ Laser Dent 2009;17(1):21-26

INTRO D U C TIO NThe maintenance of periodontalhealth has long been a goal thathas seemed to elude some patients.With the increased use of moderntechnology we now have new toolsto fight this pervasive and costlyproblem. While caries attacks theprimary dentition and ravages theteeth of our youth, periodontaldisease is the most pervasiveproblem seen in patients after theeruption of all posterior teeth. Withthis in mind, the modern dentalpractitioner must seek out, recog-nize, and present treatment optionsfor eradication or at least control ofadult onset periodontal disease.

With the years of education,research, and training in perio -dontal therapy, both surgical andnonsurgical, clinicians need only toput together a systematic approachto the examination of each andevery patient followed by treatmentdirected from the data collected.With the results of such a system,we will be able to help our patientskeep their teeth for the rest of theirlives.

The goal of this article is topresent such a system that hasbeen successfully used in thisauthor’s practice for 15 years, andone that can be easily implementedin every office. With a combinationof high-tech, low-tech, or no-tech

treatment, we are now able toprovide health for each and everypatient that presents in our officefor treatment.

BASIC P R EMISEThe basic premise that guides perio-dontal treatment is that the therapyour practice provides can besuccessful only if our patientscontinue to care for themselves. The goals of our treatment are to:1. Create an environment where

active periodontal disease canheal.

2. Teach the patient an effectivemeans of keeping the perio -dontal structures clinicallyplaque- and bacteria-free. Thosehome care instructions aredetailed below.

3. Motivate the patient to performthe necessary cleaning steps ona continuing basis. Motivation isbased on the acquisition ofperio dontal health, lower costfor dental treatment, and lesschance of recurrence that wouldnecessitate retreatment atshorter intervals.Bacterial plaque left undis-

turbed will become calcified andthe bacterial component of thisplaque will attack the epitheliallining of the pocket, resulting inincreased bleeding, swelling, andinflammation adjacent to the bacte-

rial plaque. Left untreated, thisinflammatory destruction willmigrate apically, causing marginaland interseptal bone loss. As boneloss occurs, teeth become moresusceptible to the forces placed onthe teeth during both function andparafunction and become increas-ingly mobile, which then canaccelerate continual bone loss.1-2 Itis clear, then, that periodontaldisease is an advancing, progres-sive disease that isself-perpetuating until the cycle isstopped through interceptive treat-ment. We are able to achieve thisresult through creating an environ-ment in the mouth where thepatient can effectively remove allbacterial plaque each day. If we areable to identify the very early signsof disease, correct the environ-mental factors that start theinflammatory processes, we will beable to intercept the disease andprevent a continued inflammatorycycle.

INTERC EPTIV E D IAGNO SISAt every new or re-care visit, ourpatients need to be evaluated forearly signs of disease using all thetools at our disposal. Using neces-sary radiographs, clinical dentalevaluation, periodontal pocketcharting, oral cancer examination,as well as an occlusal contact eval-uation, we are able to identifypatients that are at risk for begin-ning on the periodontal diseasecycle.

This article’s focus is not to elab-orate on radiographic, clinical,occlusal, or oral cancer examina-tions; however, the periodontalpocket depth probing chart is of

Editor’s Note: This article describes a philosophy and protocol which Dr.Levy has successfully utilized for 15 years. He practices in New Jersey, aState whose Dental Practice Act disallows a hygienist from using a laser.Therefore, he employs a soft tissue laser adjunctively during his perio-dontal procedures. The reader is also referred to previously publishedarticles in this Journal for descriptions of laser use by registered dentalhygienists in initial treatment of periodontal disease.

primary importance3 during perio-dontal diagnosis. Through the useof such a chart, we can identifybleeding, suppuration, mobility, aswell as hard and soft tissue loss.Not only is this record an effectivediagnostic tool, but it can be usedas a chronologic monitor to docu-ment the advance or control of thedisease process.

During the history review, weshould be attentive to the patient’sstatements. Comments regarding abad taste, odor, bleeding, and looseteeth need to be reviewed andexamined further in order to avoidmissing clues that may lead to adefinitive diagnosis.

During the soft tissue examina-tion, a six-point pocket charting ofeach tooth will provide a baselineto evaluate pocket depth and helpdetermine the most appropriatetreatment for the patient. Ouroffice uses the STM® Probe (Pro-Dentec, Batesville, Ark.), a deviceoperated by one person thatrecords the pocket depth. Thisprobe is convenient to use and itprovides audible feedback, as wellas a paper tape used to documentthe exam in the patient’s computer-ized chart. Since the patient canhear the charting, he or she couldeasily relate increased tendernesson probing with deeper pocketdepths. The combination of pocketcharting, audible feedback, andtissue sensitivity enables thepatients to take part and share intheir diagnosis as well as ultimatetreatment.

Muscle palpation and visualexamination accompanied by alight-based examination of the oralstructures will assist in earlydetection and interception of oralcancer. We use a VELscope® (LEDDental Inc., White Rock, BritishColumbia, Canada) to evaluate thenaturally occurring variations influorescence to identify normalpatterns in the oral mucosa as wellas to pinpoint abnormal patterns.These abnormal patterns oftenhighlight early dysplastic changes

that would have been difficult orimpossible to detect with theunaided eye and that need furtherevaluation through follow-up,biopsy, or surgery.

After data collection, results areused to:1. determine the appropriate

course of treatment2. submit for insurance predeter-

mination of benefits3. follow treatment efficacy during

re-care visits.Once data collection has been

achieved, the individualized treat-ment protocol is developed next,with definitive results in mind.

R ESU LTS-BASED C LASSIF IC ATIO NThe patient is then given thespecifics of the disease according tothe following classifications:4

• Healthy; pockets 3 mm or lessand no bleeding or inflammation.

• Type I – Gingivitis; pockets 3 mmor less with bleeding on probingand inflammation with somedebris possibly present supragin-givally.

• Type II – Mild Periodontitis;pockets 4-6 mm with slight boneloss, bleeding on probing, inflam-mation and debris presentsubgingivally.

• Type III – ModeratePeriodontitis; pockets 6-7 mmwith bone loss, bleeding onprobing, inflammation and debrispresent subgingivally with somemobility and possible furcationinvolvement.

• Type IV – AdvancedPeriodontitis; pockets in the 7mm or greater range with heavybleeding on probing, inflamma-tion and suppuration, debrispresent supra- and subgingivallywith mobility and furcationinvolvement.

• Type V – RefractoryPeriodontitis; inflammation andpocket depths of 4 mm or greaterin a periodontium previouslytreated for periodontal disease.With these data-based classifica-

tions we are able to point out thedifference between disease andhealth as well as direct treatmentto the achievement of our goals fortreatment and periodontal tissuestability.

TR EATMENT P ROTO C O LSBased on the disease classification,the therapy will consist of specificprocedures.

HealthyThe patient receives a prophylaxis.

Type I: GingivitisThe patient receives conventionalscaling assisted by the use oftopical anesthesia. The laser isused adjunctively to reduce thebacterial presence. A thoroughprophylaxis and polishing isperformed and home care instruc-tion is given. This regimen consistsof brushing and flossing instructionfocused on intrasulcular brushing,and use of a rubber stimulator tipfocused on massaging the labialand lingual external surfaces of thepapillae as well as the marginalgingiva.

Type II: Mild PeriodontitisThe patient is treated through theuse of conventional scaling and rootplaning, assisted by the use oftopical anesthesia, and the use of alaser. The laser will disinfect thesulcular tissues, decrease the inci-dence and severity of bacterialmigration into the bloodstream andthroughout the body, and increasethe time that destructive bacteriawould take to repopulate the perio-dontium. This is of particularbenefit for patients with depressedimmune systems due to chronicmedical conditions.5 The pocketsare then rinsed with chlorhexidine,and a thorough prophylaxis andpolishing is performed. The homecare regimen described above istaught and supplemented withchlorhexidine application using therubber tip stimulator.

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Type III: ModeratePeriodontitisThe patient is treated very simi-larly to the Type II protocol above,that is: conventional scaling androot planing, assisted by the use oftopical anesthesia, laser sulculardebridement and disinfection, andchlorhexidine rinses. However theauthor has found that this type oftreatment alone may not reducethe pocket depths adequately tocreate a cleansable/maintainablegingival sulcus. If there are selectareas not amenable to pocketreduction, the author frequentlyuses locally applied antibiotics toslow the pathogen repopulation ofthe gingival sulcus and to promotegingival adherence to the rootsurface. In cases where initialpocket depths exceeded 3 mm andimmediate post-treatment laserdepths remain at 3 mm, antibiotic(ARESTIN®, OraPharma, Inc.,Warminster, Pa.) is placed to delaybacterial recolonization as well asto create a coagulum that willpromote healing in the periodontalsulcus. The author also performs agingivoplasty in those areas ofunsupported soft tissue to preventtissue movement and to alloweasier cleansing of the periodontalstructures.

Type IV: AdvancedPeriodontitisWith advanced disease as character-ized above, we first treat as a TypeIII, including scaling, root planing,laser therapy, and locally appliedantibiotics. After the initial thera-peutic regime, the patient isevaluated for residual periodontaldisease at 3 months and at regularintervals thereafter. After evalua-tion, if pocket depths are stillgreater than 5-7 mm and/ormobility measurements are 2+ ormore, immediate referral to a perio-dontist is discussed. (At the initialexamination the possibility forfurther specialist treatment of thepatient’s condition has already beendiscussed.) In most cases, patients

prefer to try the above therapy firstand evaluate the results for 3months before referral. In this way,initial therapy can be completed ina conservative manner and thepatient can be referred for selectiveareas of treatment where needed. Inthe author’s experience, there is areduced need for advanced surgeryfollowing the described treatment.An example of an exception wouldbe a free gingival grafting proce-dure, which are always referred to aperiodontal specialist’s office.

Type V: RefractoryPeriodontitisThe patient will be treatedaccording to the Type IV protocol,with a similar referral option, asdiscussed above.

A few words about laser treat-ment by a dental hygienist: Ifallowed by State Dental PracticeActs in the United States, sulculardebridement and disinfection canbe performed by a registered dentalhygienist, using a laser instrumentwith an indication for use for thatprocedure. We recommend that thehygienist achieve Academy of LaserDentistry Standard Proficiencybefore treating patients in thismanner. However, where State lawdoes not allow hygienist treatment,the patient must be treated by thedoctor who would perform lasersulcular debridement as well asany gingival reshaping needed.

C LIN IC AL C ASEA 69-year-old Caucasian malepresented with a chief complaint of

“bad breath and bleeding gums.”Medical history review revealedadult onset diabetes, high bloodpressure, as well as a medicallymanaged heart condition. Thepatient was currently taking a listof 8 medications prescribed tocontrol his multiple medical condi-tions. A clinical dental examinationrevealed a Type III (ModeratePeriodontitis) classification withselected areas of advanced disease.Dental treatment planning waspostponed in order to focus onimproving the periodontal statusand bringing the oral condition intoa maintainable condition.Radiographic evaluation wasconsistent with the clinical diag-nosis, showing no abscesses orcysts present. Limited restorativedentistry was performed to removecaries and place the patient in aholding pattern to allow for perio-dontal treatment. The discussionbelow will follow the completedtreatment as well as the resultsobtained.

The patient exhibited diseaseand proceeded with treatment,according to our protocol. Figures 1and 2 show the pretreatment viewsof the periodontium.

The patient’s treatmentconsisted of scaling, root planing,laser sulcular debridement, and alocally delivered intrasulcularantibiotic, as shown in Figure 3.The medication was placed intopockets that retained depthsgreater than 3 mm.

Treatment was completed(Figure 4) and the patient wasevaluated by visual inspection in 2

Figure 1: Pretreatment labial view

Figure 2: Pretreatment lingual view of themaxillary arch. Note the existing amalgamrestorations on teeth #7 and 10

weeks (Figures 5 and 6). At 6months, the tissue appeared

healthy (Figure 7). Unfortunately,the patient was not getting theresults from the instructed homecare regimen, and he was compro-mised by his diabetes and heart

medications. He understood thosefactors could significantly jeop-ardize the apparent success of thetherapy provided.

Laser-assisted scaling and rootplaning was performed in 5 sepa-rate visits at approximately 2-3week intervals. This enabled theauthor to evaluate each section asit was healing and perform anotherarea at the same visit. The lasertechnology used in the maxillaryarch was a 1064-nm Nd:YAG laser(dLase 300, American Dental Laser,Birmingham, Mich.) with 2.50Watts at 25 Hz and a 320-micronbare fiber. A 980-nm diode laser

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Figure 3: Application of antibiotic

Figure 4: Immediate postoperative viewfollowing laser therapy and antibioticapplication. Note that the laser providedgood tissue hemostasis. Care was takento avoid exposure of the amalgamrestorations to laser irradiation

Figure 5: Two weeks post-treatmentlabial view

Figure 6: Two weeks post-treatmentlingual anterior view

Figure 7: Six months post-treatmentlabial view. Note the patient’s home careis not satisfactory, but the periodontaltissues appear healthy

Figure 8a: Ten-month post-treatment and initial examination periodontal chart

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(Curative980®, OroScience, Inc.,Palo Alto, Calif.) at 1.2-1.5 Wattscontinuous wave with a 300-micronbare fiber was also used for thispatient in some areas of perio-dontal treatment. No significantdifference in results was seenbetween the two laser wavelengths.Anesthesia was used in most casesin compliance with the patient’sdesires.

Ten months after the initial

charting, and after Type IIItherapy without any soft tissuesurgery, the probing chart (Figures8a and 8b) showed significantpocket depth reduction. Figure 8ashows initial and 10-month depthsby comparison.

Two 10-month postoperativephotographs illustrate the perio-dontal health improvement. Figure9 shows the lingual maxillarytissue, which, compared to Figure

2, has better color and tone; andFigure 10 shows a 2-mm pocketdepth reduction on tooth #9 withno bleeding. Pocket resolution,although not ideal, was evident inspite of the compromised medicalhistory and less-than-ideal homecare compliance. It is necessary forus to recognize that control of thedisease process is a very elusiveconcept in periodontal therapy andthis technique, with its systematicapproach, has given this patient agood chance of improving the perio-dontal prognosis.

C O NC LU SIO NA systematized approach to exami-nation, diagnosis, categorization,and treatment has been presented.If this approach is followed on everypatient, clinicians may be able togreatly reduce the incidence as wellas the severity of perio-dontaldisease. Once diagnosed andtreated, the patient will still bearthe major share of responsibility forcontinued maintenance. As hasbeen stated previously, our patients’care is mostly in their hands. Wecannot do what a patient will undowith a lack of follow-through care.

Figure 9: View of maxillary anteriorlingual

Figure 10: Periodontal probe in place inpocket whose depth has been success-fully reduced

Figure 8b: Detailed, full-mouth, 10-month pocket depths are shown in the upper part ofthis figure. Note the statistics on the lower portion of the illustration show periodontalimprovement

Our goals must continue to beeducation, guidance, and as littleclinical intervention as necessary.

AU THO R B IO GR AP HYDr. Arthur Levy is a 1971 graduateof Fairleigh S. Dickinson UniversitySchool of Dental Medicine andcontinued his education in aGeneral Practice Residency in theNewark Beth Israel Medical Centerin Newark, New Jersey. He spenttwo years at the Malcolm GrowMedical Center in Washington, DCas a Prosthodontic Officer in theUnited States Air Force. Dr. Levywas an Associate ClinicalInstructor at Fairleigh S. DickinsonUniversity School of DentalMedicine from September 1976through May 1989, and haspublished and lectured worldwideon many topics including lasers indentistry. He currently maintains aprivate practice in Chester, NewJersey, where he practices laser-assisted Restorative and Cosmetic

Dentistry. Dr. Levy is a chartermember of the ALD and holdsAdvanced Proficiency in Nd:YAG aswell as a Master of the Academy ofLaser Dentistry certificate. He hasbeen active in numerous ALDcommittees including serving asChair of the InternationalRelations Committee for severalyears. He previously served on theALD Board of Directors at varioustimes in the preceding 15 years. In2007 Dr. Levy earned the ALDDistinguished Service Award. He ismarried to his wife of 28 years,Mitzi, and has 5 children and 7grandsons. Dr. Levy may becontacted by e-mail at [email protected].

Disclosure: Dr. Levy is currently alecturer for LED Dental, for which hereceives an honorarium. He is also astockholder in Lantis Laser. He was aclinical advisor for OroScience, andhad received one of the company’sdiode lasers for evaluation.

R EFER ENC ES1. Offenbacher S. Periodontal diseases:

Pathogenesis. Ann Periodontol1996;1(1):821-878.

2. Schenkein H; Research, Science andTherapy Committee of the AmericanAcademy of Periodontology. Thepathogenesis of periodontal diseases(informational paper). J Periodontol1999;70(4):457-470.

3. Apsey DJ, Kaciroti N, Loesche WJ.The diagnosis of periodontal diseasein private practice. J Periodontol2006;77(9):1572-1581.

4. Armitage GC; Research, Science andTherapy Committee of the AmericanAcademy of Periodontology. Positionpaper. Diagnosis of periodontaldiseases. J Periodontol2003;74(8):1237-1247. Erratum in: JPeriodontol 2004;75(5):779.

5. Kim J, Amar S. Periodontal diseaseand systemic conditions: A bidirec-tional relationship. Odontology2006;94(1):10-21. ■■

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Laser-Tissue Interaction IMichael D. Swick, DMD, Conneaut Lake, PennsylvaniaJ Laser Dent 2009;17(1):27-33

INTRO D U C TIO NLaser-tissue interaction is the useof light energy that is absorbed bythe tissue to produce a photobio-logical effect. Such effects can bemanifested as photodisruption,plasma induced-induced ablation,photoablation, thermal, and photo-chemical.1 The type ofphotobiological effect is largely afunction of the power density andpulse duration. The highest powerdensities and shortest pulse dura-tions produce photomechanicaleffects, and the lowest powerdensities in conjunction with thelongest pulse durations (contin-uous wave) producephotobiological effects.

As can be seen in Figure 1,power densities in the millions ofWatts per square centimeterproduce photodisruptive effects.These effects are characterized byshock waves, optical breakdown,and disruption of molecular bonds2

but have no clinical applicabilitywith the currently available dentallasers.

As the power density decreasesand pulse length increase, the nextinteractions are photothermaleffects, which include pathogendeactivation, coagulation, vaporiza-tion, and carbonization. Manynonsporulating bacteria are readilyinactivated at approximately 50°C,coagulation occurs at approxi-mately 60°C, vaporization at 100°C,and carbonization > 200°C.2-5 Theseare the predominant effectsconcerning most dental practi-tioners who use lasers. To be clear,however, surgical procedures ondental hard tissue, that is, toothstructure and bone, are mostaffected by both vaporization and

Figure1. Graphic representation of the relationship between tissue exposure time to alaser and the corresponding power density. The result is various photobiological effects.(Used with permission of Donald J. Coluzzi DDS, and based on Niemz1)

SYNO P SIS

It is imperative that the dental practitioner using dental lasers be

knowledgeable about the principles of laser-tissue interaction in

order to properly treat the dental patient. The use of the simple word

interaction can be deceptive because there are numerous factors

which, working together, will determine a successful clinical

outcome. Toward that end, this manuscript will consist of two sepa-

rate articles. The first one, presented here, will explain the

fundamental actions that laser energy has on dental tissues. The

second one, to be published in a future issue, will give details about

laser parameters.

carbonization; dental soft tissueinteracts at all of the abovetemperatures.

At the lowest power densitiesand longest pulses, includingcontinuous wave, the photochem-ical and biostimulatory effects arefound. The photochemical effectsinclude: composite curing, which iswell known to the dental profes-sion; photodynamic therapy, amodality in which a spectrallyadapted chromophore is injected orapplied as a photosensitizer andirradiated with an appropriatewavelength of light, causing thedesired reaction to occur only inthe irradiated area; and laser-induced fluorescence, a techniquewhere one wavelength of laserenergy is absorbed and is emittedat a slightly longer wavelength,6

thus enabling a receptor to assesstissue changes. This fluorescencecan be used for carious lesiondetection as well as mucosal cancerscreening.

The photobiomodulation effectsare accomplished with low energylevels and low thermal input andinclude, but are not limited to, bio -stimulation, pain relief, woundhealing, and collagen growth.7

Photobiomodulation effects deservean entire separate article and willbe given only a cursory mentionhere.

P HOTOTH ER MAL INTER-AC TIO NThe primary laser-tissue interac-tion for dentistry is a photothermalone.8 Several key definitions mustbe understood prior to studying thethermal interaction principles. Oneis that of vaporization, the conver-sion of water to steam in order tofacilitate tissue removal. Sincewater turns to a gas at a muchlower temperature than othercellular elements, vaporizing itbecomes a desirable end point inremoving tissue.

A second important definition isof ablation, which is the removal ofa segment of tissue by a thermal

interaction.9 The ablation crater issimply the area in which tissueremoval was accomplished byrapid heating of the interstitialand intracellular water to 100°C,causing vaporization.4 The laserimpact on soft tissue produces aconfiguration as shown in Figure2, which depicts different zones ofthermal effect. A similarly shapedablation crater is produced whenthe erbium family of lasers vapor-izes dental hard tissue.10 Duringsoft tissue surgical procedures, aresidue of this process, called coag-ulum, can adhere to the laser fiberor tip. This debris should be regu-larly removed since it caninterfere with visualization of theprocedure.

Another significant term is coag-ulation, the heating of the layer ofsoft tissue that is proximal to thearea of vaporization to denatureprotein and control bleeding.Coagulation occurs when the softtissue is heated to 60°C3 and iscaused in part by the initial laserstrike’s subsequent penetration ofthe photons which were notabsorbed in the ablation crater. Itis also a by-product of the conduc-

tion of the residual heat of vapor-ization to the underlying tissues.As will be discussed later, thisconduction is directly proportionalto the time the laser energy isapplied. This thermal result iseither good or bad depending onthe application and amount ofcoagulation present. With too littlecoagulation, bleeding and gingivalseepage could compromise visibilityof the surgical field; but too muchcoagulation can delay healing andcause postoperative discomfort. Inprocedures where immediatevascularization is desired, e.g., freegingival grafts, coagulation in anyamount can be deleterious. Ideally,the remaining tissue should bepink, not toasted or carbonized(charred).

Lastly, the laser clinician shouldunderstand carbonization, which isthe heating of tissue remnantsbeyond vaporization temperaturescausing a char layer to form whichcan be accompanied by an acutetemperature increase in thesurrounding tissue, due to theabsorption characteristics ofcarbon.11 Carbonization can occurin both hard and soft tissue.

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Figure 2: Graphic depiction of a typical soft tissue laser ablation (courtesy of Donald J.Coluzzi, DDS)

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Figure 3 shows an example of alaser incision, performed with an810-nm diode laser. The authorused these parameters to producethe resultant pink tissue: 30 Wattspeak power, 530 Hz, 100-µs pulsewidth at 1.58 Watts average power.

Figure 4 shows a laser gingivec-tomy with parameters popularlyemployed. A 980-nm diode laserwas used at 2 Watts continuouswave with a 400-µm fiber. The clin-ical view shows that when cuttingsubstantial amounts of connectivetissue at low powers in continuouswave mode, the operator willfrequently encounter what theauthor has termed as the “crèmebrûlée” effect. It is characterized bydesiccated connective tissue whichis hard and scratchy like the top ofa crème brûlée. Figure 5 shows ahistologic section of tissue from asimilar procedure and settings.

Figure 6 shows gingivalcontouring performed with a CO2laser at 8 Watts, continuous waveemission. The result is a carbonizedsurface, which some clinicians refer

to as a “laser bandage,” and use asan alternative to periodontaldressing.12 While both Figures 4and 6 depict tissue that iscarbonized, the techniques andlaser wavelengths were properlyused. However, the author’s prefer-ence for soft tissue surgery is toutilize higher powers, a shorterpulse duration, and water forcooling.

With knowledge of thephotothermal effects, the clinicianmust have an understanding howthese effects are transferred. Thereare three mechanisms of thermaltransfer: conduction, convection,and radiation. Two distinctlydifferent laser techniques havebeen developed based on the type ofthermal transfer that is utilized:

noncontact and contact. For softtissue procedures, radiant energyfrom the erbium and carbondioxide laser wavelengths is usedin a noncontact manner because oftheir high absorbance by water.Due to much lower tissue absorp-tion of the near-infraredwavelengths like diode andNd:YAG, radiant as well as conduc-tive energy is employed. Thisnecessitates a contact techniquewith some heat being derived fromthe fiber, sometimes called the hottip effect. Some clinicians advocatedepositing a small amount ofcarbon on the fiber tip to augmentthis hot tip effect and enhancevaporization. This technique isknown as activation or initiationand can be performed by activatingthe laser and touching the tip on apiece of articulating paper, forexample. For the best thermalprecision and to limit heating oflateral tissue, the amount of heatcontributed by the fiber itselfshould be kept to a minimum.11

Conduction is the transfer ofheat by direct molecular collision.According to Absten, “An areawhere conduction heating canbecome a problem is when laser isleft in contact with tissue for exces-sive periods of time because of low(power density) applications.Unwanted heat conducts from thetarget tissue into adjacent tissuesand may cause excessive thermalinjury by heat conduction …Adequate power (power density)minimizes this thermal conductionby allowing vaporization to proceedimmediately. The excess heat iscarried away in the laser plume toprevent conduction. Since adequatepower densities generally involvequicker vaporization times, thetime allowed for conduction alsodecreases.”13 This has direct impli-cation for the use of adequatepower and the correct exposuretime to achieve the most beneficialphotothermal effect possible duringa laser dental procedure.

Convection is the second mecha-

Figure 6: Immediate postoperative viewof soft tissue crown lengthening where acarbon dioxide laser was used in contin-uous wave (image courtesy of theAcademy of Laser Dentistry Educator’sCourse 2000).

Figure 4: Immediate postoperative viewof a laser gingivectomy where continuouswave mode was used (image from theauthor)

Figure 5: A histological section of a laserincision made by a 980-nm diode laser,400-µm fiber, 2 Watts continuous wave(CW), 5-second exposure (image fromthe author). Note the large zone ofthermal necrosis, depicted by the darkpurple tissue bordering the incision

Figure 3: Immediate postoperative viewof a laser incision on the mandibularanterior mucosa (image from the author)

nism of thermal transfer.Convection involves the heating ofcomparatively large amounts ofgases or liquids in relation to thetarget tissue. The value of convec-tion in laser therapy is the removalof the excess heat of vaporizationfrom the target tissue. As notedabove, the laser plume can serve asa method of removing heat; thusthe clinician should be carefulwhen submerging a tip or fiber intosoft tissue so that the plume canescape. The convective properties ofwater are extremely effective inremoving the excess heat of vapor-ization away from the hard tissuepreparation or surgical site.14

Similar to the precaution for softtissue, the clinician should removehard tissue in a manner thatavoids deep cratering so that thewater can freely flow around thesurgical site and the plume canescape. With near-infrared contactlaser techniques, where someconductive energy is used, theauthor reported the High Fluence(Swick) Technique for the 980-nmdiode laser in 2000 which useshigher fluences during soft tissuesurgery and water for cooling.15-16 Ahistological study showed thatwater for cooling merited furtherinvestigation.17

Radiation is the third mecha-nism of thermal transfer. It is thetransfer of energy by electromag-netic waves and is utilized in allnoncontact laser modalities and tovarying degrees in contact lasertechniques. Radiant transfer has noheat inherent in the beam itself.Heat is created only when thetarget tissue absorbs the trans-mitted radiation and converts it toheat. As mentioned above, erbiumand carbon dioxide laser modalitiesutilize radiant energy only in anoncontact technique, and thenear-infrared laser wavelengthsnecessitate the use of some amountof conductive energy (contact/hottip effect) in conjunction withradiant energy to facilitate vapor-ization.

LASER EN ERGYP RO PO GATIO N INT ISSU ELaser energy is emitted at a veryspecific wavelength. Wavelength isdefined as the distance of thelength of a wave between twocorresponding points, and eachwavelength has a unique effect onthe various components of thetarget tissue. Consideration mustbe given to what occurs from themoment the laser beam strikes thetissue until it dissipates.

Optical energy is propagated intissue by five different means:reflection, refraction, absorption,transmission, and scattering.

Reflection is defined as thereturning of electromagnetic radia-tion by surfaces upon which it isincident.18 Light is reflected at theinterface between air and thetarget tissue, and the law of reflec-tion states that the reflected angleequals the incident angle.18 Thislaw applies to specular reflectionwhich is created from a smoothpolished surface, one on which theirregularities are smaller than theincident wavelength. Diffuse reflec-

tion emanates from a roughsurface, or one on which the irregu-larities are comparable to or largerthan the incident beam and doesnot necessarily follow the law ofreflection.18 Clinically, a gold crowncould produce specular reflectionfrom a laser beam; but most of thereflected laser energy from dentaltissue is diffuse. Either type ofreflection can be reduced bykeeping the laser beam at a 90°angle to the target tissue; however,appropriate safety glasses arerequired during laser procedures toprotect against any reflection. [Thereader is directed to “Laser Safetyin Dentistry: A Position Paper” inthis issue (pages 39-49) for moreinformation.]

Refraction occurs when thedirection of the light changes dueto a speed change at the reflectingsurface because of different refrac-tive indices of the substances thelight passes through.18 This changein beam direction could have signif-icance when laser irradiation isreflected from an implant surfaceand strikes nontarget tissue, forexample. This refraction can be

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Figure 7: Absorption curves for various tissue components (courtesy of Donald J. Coluzzi,DDS, based on reference 21)

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reduced also by keeping the laserbeam at a 90° angle to the incidentsurface.

Absorption is the primarydesired laser-tissue interaction.Absorption requires a chromophore,an absorber of light.19

Chromophores have an affinity tocertain wavelengths of light, andthat attraction absorbs the energy,converting a portion of it into heat.In order to maximize the thermalreaction, there should be a closematch between the laser wave-length and the chromophore(s)present in the target tissue. Theprimary chromophores for intraoralsoft tissue ablation are hemoglobin,water, and melanin,19-20 while dentalhard tissue has water and hydroxy -apatite as chromophores.19 Ageneral absorption curve forcommonly used dental laser wave-lengths is shown in Figure 7.

Blood is comprised of 87% water,leaving 13% as other blood mate-rials: red blood cells, white bloodcells, and platelets. Red blood cellscomprise about 45% of that mate-rial. Hemoglobin andoxyhemoglobin account for nearlyall of the red blood cells’ volumeand are present in tissues atvarying percentages that are influ-enced by tissue type and the degreeof inflammation present in thetissue.22

The body is composed of approx-imately 60% water by weight23

although various tissues cancontain more or less. Generally, asshown in the Figure 7, the longerwavelengths have a much higheraffinity for water than do thevisible and near-infrared ones.However, there is some significantvariation in pure water absorptionamong the available near-infrareddental lasers, whose wavelengthsrange from approximately 800 to1064 nm. Gutknecht offers absorp-tion coefficient data showing 810nm (0.12 cm-1), 980 nm (0.68 cm-1),and 1064 nm (0.26 cm-1).24

However, all of these figures areseveral thousand times less than

that of the erbium (2780 nm, 2940nm) or carbon dioxide (10,600 nm)laser wavelengths as shown inFigure 7.

One consideration about theabsorption differences is that thecorresponding penetration of awavelength in water will be theinverse of the absorption. In otherwords, erbium laser energy pene-trates only a few microns into purewater, whereas the near-infraredlaser wavelengths mentioned abovecan penetrate several millimeters,although the 980-nm wavelengthhas approximately 50% less pene-tration than other infrared lasers.Figure 8 offers a compilation ofwater absorption and penetrationdepth, interpreted from data fromseveral sources.25-31 It should benoted that the graphic depictsabsorption in pure water, butdental tissue is composed of morecomponents so that the readershould interpret the curve bycomparing the coefficients of eachwavelength relative to each other

rather than looking at absolutenumbers. As mentioned earlier,absorption by oral tissue of aparticular wavelength of laser radi-ation depends on the relativeamounts of various chromophores(melanin, hemoglobin, hydroxyap-atite, water) present in the targettissue. However, the advantage of adeeper penetration depth, such asthat of the Nd:YAG laser (1064nm)32 and diode lasers, could bemore durable coagulation.33

Melanin is the dominant chro-mophore for the visible andnear-infrared lasers. The melaninabsorption curve in Figure 7demonstrates an approximately flatline among the near-infrared wave-lengths, which means thatabsorption is about equal in thoselasers. Melanocytes are found inthe basal layer of oral mucosalepithelium; however, the presenceof pigmentation varies greatlybetween and within individuals.Intraoral tissues such as gingiva,buccal mucosa, hard palate, and

Figure 8: Water absorption curve for available dental laser wavelengths, showing high-lights of a majority of commonly used instruments (810, 980, 1064, 2780, 2940, and10,600 nm). The right vertical scale shows corresponding penetration depth of thewavelength into pure water. (Courtesy of Donald J. Coluzzi, DDS, based on severalsources25-31)

tongue frequently display pigmen-tation.34

Transmission is the penetrationof light through the tissue with nolaser-tissue interaction. It occurs inthe absence of absorption but isinfluenced by the last interaction,scattering. Of course, penetrationcan aid in deeper coagulationwhere absorption occurs and alsoin allowing biostimulation effects toreach deeper levels of tissue, belowthe surgical site, which in theorycan promote healing or bone stimu-lation in periodontal repairs. Adisadvantage of excessive penetra-tion could possibly be a thermaleffect far from the immediatesurgical site, so deeply penetratinglaser wavelengths should be moni-tored carefully.

Scattering is the dominantinteraction in the near-infrared,35

because of those wavelengths’ rela-tively poor absorption by biologicaltissue. The predominant form ofscattering is elastic scattering,which is characterized by no loss inenergy of the photons.36 When scat-tering occurs, the photons changetheir directions, and this could leadto increased absorption.35

Scattering is often used incorrectlyto indicate the divergence of lightas it exits a fiber or the erraticdiffusion or spread of light as itexits a damaged or poorly cleavedfiber.

LASER O P ER ATINGPAR AMETER SAs discussed above, laser-tissueinteraction involves many factors.After the clinician determines thecomposition of the target tissue andselects the wavelength, the laseroperating parameters must be care-fully chosen. These are allcontrollable by the clinician andcomplement each other inproducing a beneficial clinicaloutcome and include:• Temporal Emission Mode, the

time-relative parameters of thelaser radiation’s delivery

• Power Density and Energy

Density delivered to the targetarea

• Power, both peak power andaverage power, as well as totalenergy

• Duration of exposure• Amount and type of cooling of the

target tissue• Other clinician-controllable

factors such as working distanceand type of handpiece tip

• Other nonlaser factors thatincrease operational efficiency.As was noted earlier, these

aspects will be discussed in asubsequent manuscript.

SU MMARYLaser-tissue interaction is multifac-eted, and is based on thefundamental physical characteris-tics of laser energy, the compositionof the target tissue, and the laseroperating parameters. In dentistry,the primary interaction is athermal one – the tissue tempera-ture is increased to achieve avariety of results. The laser clini-cian should have a goodunderstanding of these aspectsbefore patient treatment is initi-ated.

AU THO R B IO GR AP HYDr. Michael Swick is a generaldentist and has offices in AllisonPark and Conneaut Lake,Pennsylvania. He practices micro-dentistry, employing air abrasionand laser, working through asurgical operating microscope. Heholds an Advanced laser Proficiencyin the 980-nm and 2940-nm wave-lengths, and Standard Proficiency inCO2, Nd:YAG, 810-nm diode, 980-nmdiode, Er,Cr:YSGG, and Er:YAGwavelengths through the Academyof Laser Dentistry. He is also anAcademy of Laser Dentistry certi-fied educator as well as aRecognized Course Provider whoseStandard Proficiency courses areaccepted for Standard ProficiencyCertification through the Academyof Laser Dentistry. He is serving onthe Board of Directors of the

Academy of Laser Dentistry, and isa former chairman of the EducationCommittee. He also serves on theScience and Research Committee,and has served on the ScientificSessions and NominationsCommittees. Additionally, he holdscertification from St. Luke’s MedicalCenter in the Pinero Pre-cardiacSurgery Protocol with lasers. Dr.Swick is a former Fellow in theAmerican Society for LaserMedicine and Surgery, where he haspresented clinical papers. He haspresented more than 300 continuingeducation and hands-on courses ondental lasers, both nationally andinternationally. In addition, he haspresented clinical and scientificpapers for the Academy of LaserDentistry, European Society for Oral Laser Applications (ESOLA)/Deutsche Gesellschaft fürLaserzahnheilkunde (DGL),International Society for Lasers inDentistry (ISLD), and SPIE. Dr.Swick may be contacted by e-mail [email protected].

Disclosure: Dr. Swick has lectured,provided training, and consulted forthe BioLitec, HOYA ConBio, Sirona,Kavo, and Elexxion laser companiesas well as LED Dental on theVELScope and the Institute for LaserDentistry in Canada for whom he haslectured extensively on a per diembasis. He currently is a consultant,lecturer, and trainer for the Elexxionlaser company and he receives a perdiem for his efforts.

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3. Knappe V, Frank F, Rohde E.Principles of lasers and biophotoniceffects. Photomed Laser Surg2004;22(5):411-417.

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8. White JM, Goodis HE, Kudler JJ,Tran KT. Photothermal laser effectson intraoral soft tissue, teeth andbone in vitro. Proceedings of theISLD Third International Congresson Lasers in Dentistry, August 6-8,1992, Salt Lake City, Utah. SaltLake City: University of Utah,1992:189-190.

9. Miserendino LJ, Pick RM, editors.Lasers in dentistry. Chicago:Quintessence Publishing Co., Inc.,1995:315.

10. Rechmann P, Goldin DS, Hennig T.Er:YAG lasers in dentistry: Anoverview. In: Featherstone JDB,Rechmann P, Fried DS, editors.Lasers in dentistry IV, January 25-26, 1998, San Jose, Calif. Proc. SPIE3248. Bellingham, Wash.: SPIE –The International Society forOptical Engineering, 1998:2-13.

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24. Gutknecht N, Franzen R, SchippersM, Lampert F. Bactericidal effect of a980-nm diode laser in the root canalwall dentin of bovine teeth. J ClinLaser Med Surg 2004;22(1):9-13.

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31. Vogel A, Venugopalan V.Mechanisms of pulsed laser ablationof biological tissues. Chem Rev2003;103(2):577-644.

32. Perry DA, Goodis HE, White JM. Invitro study of the effects of Nd:YAGlaser probe parameters on bovineoral soft tissue excision. Lasers SurgMed 1997;20(1):39-46.


34. Winning TA, Townsend GC. Oralmucosal embryology and histology.Clin Dermatol 2000;18(5):499-511.

35. Near-infrared spectroscopy. ClareElwell and Jem Heben. UCL[University College London]Department of Medical Physics andBioengineering. Faculty ofEngineering Sciences. BiomedicalOptics Research Laboratory. [Web siteon the Internet.] c1999-2005 UCL[University College London]. [about 9p.] http://www.medphys.ucl.ac.uk/research/borg/research/NIR_topics/nirs.htm. Updated January 6, 1999.Accessed March 10, 2009.

36. Niemz MH. Laser-tissue interaction.Fundamentals and applications. 3rdenlarged ed. Berlin, Germany:Springer, 2007:19-43. ■■

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Er,Cr:YSGG Laser Use for Soft TissueManagement During the Restoration of anImplant: A Case ReportShawn Adibi, DDS, Houston, TexasJ Laser Dent 2009;17(1):34-36

INTRO D U C TIO NDespite some controversy about thelimitations in the applications oflasers in clinical dentistry,1 thereare many manufacturers of varioustypes and wavelengths on themarket available today.2 Thisarticle presents a clinical case thatfeatures an erbium,chromium:yttrium, scandium,gallium, garnet (Er,Cr:YSGG) laserthat is used in the process ofrestoring an implant. A majoradvantage of a laser over electro-surgery is that the laser minimizescollateral trauma to adjacenttissues,3 and an electrosurgery unitmust be used with great caution inthe proximity of an implant.4 Withthe use of scalpel and trephinecutting-type of instruments, themain drawback is the lack ofadequate control of bleeding.5-6

Various articles confirm the utilityof a laser for soft tissue surgery,7-8

and particularly for soft tissueuncovering of implant bodies.9

Moreover, an Er,Cr:YSGG laser hasshown successful clinical results forsoft tissue management.10

C ASE R EPO RTA 46-year old Caucasian femalepresented with a failed restoration

of the lower right second molar,which had been previously treatedwith root canal therapy andpresented with periapical peri-odontal involvement and class IImobility. The preoperativepanoramic film is shown in Figure 1.

After complete review of herdental and health history, severaloptions were presented, including aremovable restoration to replace theinvolved tooth. However, the patientpreferred replacement of the toothusing a single implant. Afterobtaining verbal and writtenconsent for extraction of tooth #31and surgical placement of anendosseous implant, 3.6 ml of lido-caine with 1:100,000 epinephrinewas administered, and the tooth wasremoved atraumatically.Immediately after extraction, a

series of chlorhexidine rinses andcurettage of the extraction site werecarefully accomplished to preparethe surgical site. A 5 x 10 mm root-form, one-piece implant (OCOBiomedical Inc., Albuquerque N.M.),was tapped into the socket of tooth#31, after osteotomy. After place-ment of the implant in the desiredlocation and trajectory, a syntheticabsorbable bone graft (ImpladentLtd., Holliswood, N.Y.) was placed toaugment and fill in defective wallsaround the taped implant. Then acontinuous suturing technique usinga 4-0 plain gut absorbable suture(Henry Schein, Inc., Palatine, Ill.)was used to close the surgical site.

Figure 1: Preoperative radiographshowing the lower right second molar tobe extracted

AB STR AC TSince the development of the rubylaser by Maiman in 1960, therehas been great interest amongdental practitioners, scientists, andpatients to use this technology tomake dental treatment morepleasant, and oral soft tissue usesare becoming more common indental offices. Safe use of lasersalso must be the underlying goalof proposed or future lasertherapy. With the availability andfuture development of differentlaser wavelengths and methods ofpulsing the laser energy, muchinterest is developing in thisgrowing field. This article discussesone of the newer and more usefulroles of dental lasers for soft tissuemanagement around implantfixtures. The author believes thatlaser applications such as the onedemonstrated will facilitateincreasing use of this technology.

SYNO P SIS

This article reviews the modes of action and clinical application of

novel caries detection methods including digital imaging fiber-optic

transillumination, laser fluorescence, quantitative light-induced laser

fluorescence, and alternating current impedance spectroscopy.

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The patient was given a remov-able partial denture as a temporaryrestoration. The partial was designedand adjusted to protect the implantduring the healing and integrationperiod. Four months postoperatively,clinical examination and radiographrevealed osseointegration of theimplant with mandibular bone radi-ographically evident in the surgicalsite (Figure 2). Since the partial fitpassively around the implant (Figure3), the gingiva had proliferatedaround the neck of the implant,which the author had expected andplanned to remove prior to theimpression procedure.

An Er,Cr:YSGG laser (Waterlase,Biolase Technology, Santa Clemente,Calif.), operating at 2780 nm, wasused to remove unwanted gingivalovergrowth using 1 Watt at 30pulses per second with a 15:20 air-to-water ratio in the soft tissue mode(Figure 4). High-speed vacuum evac-uation was used throughout theprocedure when laser emission wason. The patient, assistants, anddentist were protected with eyewearto block the specific laser wave-length at all times during thisprocedure. The gingival reshapingaround the implant abutment wasaccomplished by using only topicalanesthetic (TAC, Professional ArtsPharmacy, Lafayette, La.). It tookapproximately 60 seconds of irradia-tion to complete the gingivectomy todesired shape and form. In theauthor’s experience the procedurewas completed more rapidly and

with less discomfort than traditionalcord retractions, and Figure 5 showsthat good hemostasis was obtained.

The patient was very coopera-tive and comfortable during theprocedure. In the author’s opinion,the ability to create accurate inter-occlusal bite registrations andimpressions for fabrication of therestoration was much easierwithout the patient having anes-thesia. Two weeks post impression,an esthetic porcelain-fused-to-metalcrown #31 was delivered (Figure 6).

C O NC LU SIO NIn the author’s opinion, the laser-assisted procedure presented aboveis an example of improvement inpain control management,improved bleeding control, and anefficiently completed procedurerelative to other modalities thatthe author has used. In this case,the laser produced simple prepara-tion of soft tissues surrounding theimplant abutment which facilitatedmaking excellent impressions forthe final restoration.

AU THO R B IO GR AP HYDr. Shawn Adibi is an assistantclinical professor in theDepartment of Diagnostic Sciencesand the Department of RestorativeDentistry and Biomaterials at theUniversity of Texas Health ScienceCenter at Houston, Dental Branch.In addition to his teaching respon-sibilities, he also presentscontinuing education courses at theUniversity and was a co-author of arecently published article aboutlaser fibroma removal in thejournal General Dentistry. He holdsFellowship in the DentalOrganization for ConsciousSedation, Associate Fellowship andCertification from the WorldClinical Laser Institute, and certifi-cation of completion from theUniversity of Kentucky forAdvanced and ComprehensiveProgram on TemporomandibularDisorders and Orofacial Pain. Dr.Adibi may be contacted by e-mailat [email protected].

Disclosure: Dr. Adibi has no conflictsof interest to disclose.

Figure 2: Radiograph of osseointegratedone-piece implant, 4 months after place-ment

Figure 3: Preoperative clinical view ofgingival overgrowth on implant

Figure 4: Intraoperative clinical view ofgingivectomy immediately after incisionof the overlying tissue

Figure 5: Mirror view of the completedtissue preparation

Figure 6: Mirror view of the crownrestoration seated

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R EFER ENC ES1. Dederich DN, Bushick RD. Lasers in

dentistry: Separating science fromhype. J Am Dent Assoc2004;135(2):204-212.

2. Coluzzi DJ. Fundamentals of lasersin dentistry: Basic science, tissueinteraction, and instrumentation. JLaser Dent 2008;16(Spec Issue):4-10.

3. Manni JG. Dental applications ofadvanced lasers (DAALtm).Burlington, Mass.: JGM Associates,Inc., 2007:B-1 - B-8.

4. Christensen GJ. Soft-tissue cuttingwith laser versus electrosurgery. JAm Dent Assoc 2008;139(7):981-984.

5. Manni JG. Dental applications ofadvanced lasers (DAALtm).Burlington, Mass.: JGM Associates,Inc., 2007:2-9 - 2-11.

6. Parker S. Lasers and soft tissue:‘Fixed’ soft tissue surgery. Br Dent J2007;202(5):247-253.

7. Braswell LD. Soft tissue contouringas periodontal plastic surgery. CurrOpin Cosmet Dent 1997;4:22-28.

8. Magid KS, Strauss RA. Laser usefor esthetic soft tissue modification.Dent Clin North Am 2007;51(2):525-545.

9. Aoki A, Mizutani K, Takasaki AA,Sasaki KM, Nagai S, Schwarz F,Yoshida I, Eguro T, Zeredo JL, IzumiY. Current status of clinical laserapplications in periodontal therapy.Gen Dent 2008;56(7):674-687; Quiz688-689, 767. Erratum in: Gen Dent2009;57(1):94.

10. Jetter C. Soft-tissue manage-ment using an Er,Cr:YSGG laserduring restorative procedures.Compend Contin Educ Dent2008;29(1):46-49. ■■

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The Removal of Porcelain VeneersUsing an Er:YAG Laser: A Report of Two CasesAlfred D. Wyatt, Jr., DMD, College Park, GeorgiaJ Laser Dent 2009;17(1):37-38

INTRO D U C TIO NThe Er:YAG laser, operating at2940 nm, is highly absorbed inwater and has indications for useon dental hard tissues. Duringrestorative procedures, this lasercan remove most existingcomposite resin materials. Theauthor has used this laser wave-length to facilitate the removal ofexisting porcelain veneer restora-tions. In so doing, the treatmentobjectives include preserving theunderlying tooth structure, possiblykeeping the porcelain veneerintact, and providing a conservativemechanism for removal of the resincement.

C LIN IC AL C ASESThe first case involved treatment ofa 48-year-old black female whoseprevious veneers exhibited discol-oration, marginal breakdown, andan unaesthetic appearance (Figure1). The patient was willing to haveeither veneers or full-coverageporcelain crowns for the enhance-ment of her smile. Her medicalhistory was unremarkable.

An Er:YAG laser (DELightTM,

HOYA ConBio, Fremont, Calif.) wasused to perform the procedure withsettings of 30 Hz and 180 mJ (5.4Watts). A 600-micron, 30-degree tipwas aimed slightly defocused fromthe center of the target area andmoved in a constant up-and-downmotion for 2 minutes. The techniqueresulted in the complete dislodging

of the veneer, fully intact. Based onthe condition of the underlyingtooth structure, the patient chose tohave full-coverage porcelain crowns,shown in Figure 2.

The second case involved a 49-year-old black female whosemedical history was unremarkable.Two weeks previously, veneerswere placed on her lower anteriorteeth by another practitioner toclose diastemas. The patient wasunhappy with the results andwished the veneers to be redone(Figure 3).

The case presented several chal-lenges. There was difficultygauging the distance between theteeth prior to the veneers beingremoved, the gingival topographywas uneven and asymmetrical, andthe mesial-distal to incisal-gingivalratio gave the appearance of shortclinical crowns. All of these factorswere explained to the patient priorto the veneer removal to make heraware of these obstacles toachieving a satisfactory result.

The first step was to performcrown lengthening to create addi-tional clinical crown height. The

Figure 1: Preoperative view showing veneerrestorations in need of replacement

Figure 3: Preoperative view of recentveneer placement on the mandibularanterior area

Figure 2: Treatment completed with full-coverage porcelain crowns placed

SYNO P SIS

The removal of porcelain veneers from teeth can sometimes be a

challenge. Indications for removal include but are not limited to

defective and discolored old restorations, improperly placed restora-

tions, and poor shade matching. The purpose of this article is to

evaluate two cases in which an Er:YAG laser was used as the method

of choice for veneer removal.

gingival modification was performedwith an 810-nm diode laser(DioDentTM, HOYA ConBio), 1 Wattcontinuous wave with a 400-micronquartz fiber in contact mode. Theprocedure lasted 11 minutes, and theimmediate postoperative view isshown in Figure 4. Subsequent tothe above crown lengthening, theEr:YAG laser was used with theidentical settings of the first case toremove the veneers. Figure 5 showsthe laser handpiece held perpendi-cular to the labial surface of theveneer, and the laser energy is acti-vated and directed through theporcelain veneer. In this instance, theveneers did not remain intact, butbroke into fragments as they sepa-rated from the underlying toothstructure. It took approximately 11minutes to remove the veneers andcement from the teeth with the laser.

The new veneer preparationswere refined (Figure 6) and impressions were taken for 6

new restorations. The new porce-lain veneers were tried in for fitverification and patient approval.They were inserted using clearshade cement (Nexus, KerrCorporation, Orange, Calif.), andthe final postoperative view isshown in Figure 7.

D ISC U SSIO NThe basis for the clinical effective-ness of this procedure lies in theassumption that the laser energy istransmitted through the veneer andabsorbed by the resin-based lutingcement. The relatively high Er:YAGlaser power (5.4 W), the relativethinness of the porcelain veneer, andits partial translucency lead to aplausible explanation of the mecha-nism of action. However, the readeris reminded that the power settingused could remove additional toothstructure after the cement isablated. Thus the practitionershould carefully observe the process.

In comparing the two cases, ques-tions arise as to why the veneers

separated from the teeth differently.There are two possible explanations.In Case I, the laser energy may nothave been absorbed by the porcelainbut traveled through to ablate theunderlying cement. This would haveallowed the veneer not to bedamaged as it released from thetooth. In Case II, the veneer mate-rial may have had some entrappedwater which absorbed the energy ofthe Er:YAG laser, causing thedisruption of the integrity of thestructure. The author thus theorizesthat the composition of the twoveneers may have been different.

In conclusion, it is the author’sopinion that the Er:YAG laser couldbe used as a viable alternative forthe removal of porcelain laminateveneers. In some instances theauthor has been able to remove theveneers whole, intact, and efficiently.Also, use of the laser might aid inthe conservation of underlying toothstructure when compared to a high-speed handpiece.

AU THO R B IO GR AP HYDr. Alfred Wyatt, Jr. is an assistantprofessor of oral rehabilitation at theMedical College of Georgia School ofDentistry and is in private practicein College Park, Georgia. He hasattained Advanced Proficiency /Educator Status with the ALD andis on the ALD Board of Directors. Heuses Er:YAG (2940 nm) and diode(810 nm) lasers in his practice. Dr.Wyatt may be contacted by e-mail [email protected].

Disclosure: Dr. Wyatt lectures forLED Dental and receives compensa-tion. ■■

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Figure 4: Immediate postoperative viewafter the diode laser was used to performsoft tissue crown lengthening

Figure 5: Er:YAG laser beginning toremove the porcelain

Figure 6: Preparations for new restora-tions completed

Figure 7: Veneer restorations completed

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Laser Safety in Dentistry: A Position PaperLaser Safety Committee, Academy of Laser Dentistry

Caroline Sweeney, MBA, MA, BSc, OTR (Committee Chair);

Donald J. Coluzzi, DDS; Penny Parker, RDN; Steven P.A. Parker, BDS, LDS, MFGDP;

John G. Sulewski, MA; Joel M. White, DDS, MSJ Laser Dent 2009;17(1):39-49

SU MMARYLaser use in general dental prac-tice has grown considerably overthe past 20 years, both in numbersand scope of use. The registeredlaser owner is responsible forensuring that all personnel have athorough knowledge of laser safety.

There exists a duty of care to all

dental health care professionals inthe application of lasers in clinicalpractice. Such regulations mayexist through federal and/or inter-national standards. The duty ofcare extends to all staff as well aspatients.

General and specific measuresmust be employed to ensure the

Sweeney et al.

AB STR AC TIn oral health care, the numberand range of laser-based technolo-gies have expanded enormouslyover the past two decades. Thescope of this paper is to alert thedental professional to the extent,application, and responsibilitiesassociated with safety when usinglasers designed for use in dentistry.By far, the majority of laser instru-ments are within the private(nonhospital) clinic setting. Laseruse extends from those proce-dures of a diagnostic ornonsurgical (biostimulatory orphotochemical) nature, to morepowerful devices that are used insurgical procedures. Low-poweredlasers may deliver energy of a fewmillijoules, whereas surgical lasersmay have pulsed emission modescapable of peak power delivery inexcess of 1,000 Watts. Laser radia-tion can be dangerous, because itis concentrated and powerful.

This paper draws upon the stan-dards outlined (either explicitly orimplicitly with regard to dentistry)by the InternationalElectrotechnical Commission (IEC60825-1, Edition 2.0, 2007-03.Safety of laser products – Part 1:Equipment classification andrequirements) and the AmericanNational Standards Institute ANSIZ136.1 – 2007 American NationalStandard for Safe Use of Lasersand ANSI Z136.3 – 2005 AmericanNational Standard for the Safe Useof Lasers in Health Care Facilities.

In addition, interpretation of thesestandards complements the coreof knowledge outlined in theCurriculum Guidelines andStandards for Dental LaserEducation that is required by thecertification examinations of theAcademy of Laser Dentistry.

GLO SSARY

ANSI: American National Standards Institute. A not-for-profit organi-zation, founded in 1918, that oversees the administration andcoordination of the United States private sector voluntary standardi-zation system.

OSHA: Occupational Safety and Health Administration. A division ofthe U.S. Department of Labor, OSHA serves to ensure safety andhealth in the workplace. Created in 1971.

FDA: The U.S. Food and Drug Administration, a division of the U.S.Department of Health and Human Services. Founded through consol-idation in 1930. The FDA enacts the provisions of the Federal Food,Drug and Cosmetic Act (rev. 2004). The FDA Center for Devices andRadiological Health (CDRH) is responsible for the premarketapproval of all medical devices, as well as overseeing the manufac-turing, performance and safety of these devices.

IEC: International Electrotechnical Commission. Founded in 1906,the IEC is a not-for-profit, nongovernmental international organiza-tion that prepares and publishes international standards for allelectrical, electronic, and related technologies. The headquarters arein Geneva, Switzerland.

Editor’s Note: This the second of a series of position papers, written bythe Science and Research Committee of the Academy of Laser Dentistry, onthe uses of lasers in dentistry. This paper on laser safety was approved bythe Academy’s Board of Directors in February 2009. Of course, changes intechnology may dictate revision of this manuscript; however, the funda-mental principle of the safe use of a laser instrument will remain constant.

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safe use of lasers in dentistry.Laser safety is applicable

according to the class of laser beingused.

INTRO D U C TIO NThere is a basic requirement of theclinician and associated staff toensure that laser use is carried outwithin a safe environment. Key tothis requirement is an under-standing of the device being used,laser physics, and adherence tofederal, national, and internationalstatutes. These regulations mayapply either specifically to laseruse or within broader health andsafety legislation.

Laser safety considerations areproportional to established andrecognized risk. The potentialmaximum power output will definea basic approach, but specific tomore powerful lasers are measurestaken to address additional risks oflaser damage to nontarget oraltissue, skin, and eyes. Such damagemay be the result of direct expo-sure to the laser beam or throughthe combustion of chemicals, gases,and materials used in dentistry.The protection of those personnelinvolved in laser treatment –patient and staff – is a primeconsideration, but it is also impor-tant to consider those measuresrequired to safeguard against anyrisk events.

History can provide us withrecords of injuries occurring topeople due to lasers. The U.S. mili-tary, FDA, U.S. Department ofEnergy, U.K. Medicines andHealthcare Regulatory Agency, andRockwell Laser Industries, to namea few, maintain logs of laser-relatedincidents through their device-reporting mechanisms. Thefollowing anecdotes provide us withsome insight into the extent ofinjuries and consequences of suchaccidents. Incidents include lasersthat fail to stop after the foot pedalhas been released; burns to lips,tongue and cheeks; firemenentering a surgery in response to a

smoke alarm, unaware that a laserwas in operation.1 Other incidentsinclude injuries due to the laserbeam being reflected off a droplet.1

Incidents specific to eyes include aninjury because the manufacturersent the doctor the wrong gogglesspecific to the laser wavelengthbeing used and the doctor did notdouble-check the eyewear designa-tion.2 Another recorded incident

involved a university assistantsuing for $39 million after shesustained a laser eye injury in alaboratory setting. A key factor inher case was that the professorswere reported as not adhering towearing the safety goggles, givingsubordinates the impression thatthe protective eyewear was notnecessary. The assistant settled for$1 million.3 These are just some

Sweeney et al.

Table 1: Laser Classification, Power Output, and Risk Analysis4

Laser Class MaximumOutput

Use inDentistry

PossibleHazard

SafetyMeasures

Class I 40 µWatts(blue)

Laser cariesdetection No implicit risk Blink response

Class IM 400 µWatts(red) Scanner

Possible riskwith magnifiedbeam (Class IM)

Laser safetylabels

Class II 1.0 milliWatt Aiming beamsPossible riskwith directviewing

Sight aversionresponse

Class IIM Laser cariesdetection

Significant riskwith magnifiedbeam (Class IIM)

Laser safetylabels

Class IIIR

Visible 5.0milliWatts Aiming beams Eye damage Safety eyewear

Invisible 2.0milliWatts

Low-levellasers

Eye damage Safety personnel

Class IIIB

0.5 Watt

Photodynamicantimicrobialchemotherapydevices

Maximum output maypose slight fireand skin risk

Training forClass IIIR andIIIB lasers

Mucosal scan-ning chemo-fluorescentdevices

Class IV

No upper limit All surgicallasers

Eye and skindamage

Nontarget tissue damage

Fire hazard

Plume hazard

Safety eyewear

Safety personnel

Training andlocal rules

Possible registration to comply withnational regulations

examples of the nature of laserinjuries that can occur, the majorityof which can be traced back to pooradherence to established safetyprotocols.

LASER CLASSIFIC ATIONSAll lasers used in dentistry are cate-gorized with regard to the potentialfor damage, extending from Class Ilasers, which may pose no implicitrisk, to Class IV lasers for which allsafety measures are applicable.4

Regardless of the class of laserbeing used, it is advised that oneshould never look directly into alaser beam, even if it is consideredto be “eye-safe.” The classificationascends from Class I through ClassIV, with Class I being consideredeye-safe and Class IV being themost dangerous. However, with theincreased use of magnificationdevices – loupes and microscopes –there is a potential for laser beamsto be magnified and/or focused.Consequently, Class IM and ClassIIM contain refinements.

Class IIIR and IIIB lasers aregenerally low-level instruments,whose wavelengths are in the redpart of the electromagnetic spec-trum and whose energy range liesbetween 1 and 500 milliWatts.They require safety personnel tomonitor the Nominal Hazard Zone(NHZ), eye protection, and training.Class IIIR was recognized to

include those continuous-wavelasers that may emit up to fivetimes the power of Class I and IIlasers.5 These lasers pose signifi-cant risk of eye damage, and theeyewear must be rated atminimum Optical Density (OD) inthe United States (U.S.) orEuropean L6A standard. It is thelaser manufacturer’s responsibilityto provide the numerical value ofthe OD, in the operator’s manual,specific to the laser being used.

Table 1 provides an outline ofthe basic classes of lasers, thedelineated emission parameters,examples of uses of each classwithin dentistry, risks posed tounprotected tissue, and safetymeasures. For clarification, itshould be noted that the blinkresponse is one of the responsesthat is encompassed within theaversion response. The aversionresponse consists of blinking andturning one’s head away from thebeam path.

Class IV lasers, which aresurgical devices, require safetypersonnel to monitor the NHZ, eyeprotection, and training. Theselasers pose significant risk ofdamage to eyes, any nontargettissue, and can produce plumehazards. Plume, in the context ofthis paper, is defined as thegaseous by-products and debrisfrom laser-tissue interaction. It can

have a smoky appearance or becompletely invisible to the nakedeye. With Class IV lasers, eyewearmust be rated at a minimum OD 5.

It is the laser manufacturer’sresponsibility to ensure that thedevice class is clearly marked onthe laser machine and in certaincountries it is required to post suchinformation at all access points tothe area in which the laser is beingoperated. It is the responsibility ofthe Laser Safety Officer (LSO) toensure that the safety measuresappropriate to each laser class areapplied and made known to allstaff. It is not the manufacturer’sresponsibility to provide the dentistwith training in this aspect.However, in the United States,federal regulations require manu-facturers to provide certain safetyinformation related to their laser inthe laser operator’s manual. Thecomputation, in feet or meters, ofthe NHZ of the laser is a calcula-tion that is generally beyond thescope of the dentist or LSO.Monitoring and calculating theNHZ are two different issues. It isthe manufacturers’ responsibility tocalculate what the NHZ distance isand have that information postedin the operator’s manual. It is theLSO’s responsibility to read themanual, ensure that the NHZaround the laser in the dental prac-tice is identified, and personneladhere to the safety measures.

HAZAR D SLaser devices, regardless of

class, should be handled with care.With regard to those classes – IIIBand IV – that pose predictable orinstantaneous risk, there aredangers associated not only withthe laser beam itself, but alsoarising from the device (electrical,cables, air and/or water supplies)and chemicals either associatedwith the laser or the ablation oftarget tissue. Laser hazards may belisted as follows:• Optical• Nontarget oral tissue

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GLO SSARY

NHZ: Nominal Hazard Zone. This is the space within which theMaximum Permissible Exposure (MPE) is being exceeded.

MPE: Maximum Permissible Exposure. This represents a value ofexposure to laser energy above which a risk of target damage mayoccur. MPE values are applied to the unprotected eye and skin.

OD: Optical Density. The ability of the glass or polycarbonate shieldto attenuate the laser beam. The opacity of the protective filter.6

NOHD: Nominal Ocular Hazard Distance. That distance from theemission port of the laser beyond which any exposure is within MPEvalues.

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• Skin• Chemical• Fire• Other collective hazards.

The concept of laser beam colli-mation may be consideredtheoretical, as in practice mostlaser beams exiting a deliverysystem will undergo some diver-gence with distance. Based on thepower output, amount of diver-gence, and beam diameter andconfiguration, a Nominal OcularHazard Distance (NOHD) can beassessed.7

The possible risk to humantissue is assessed with regard tothe Maximum PermissibleExposure (MPE). This is a value ofexposure limit above which tissuedamage may occur. The MPE valuecan be applied relative to laserwavelength, power output, beamdiameter, possible focusing of thebeam, and target and nontargettissue or structures.8-9

Within a certain space around aClass IV laser, the level of laserradiation that a person is beingexposed to is above the MPE.Within this area, called theNominal Hazard Zone (NHZ),protective measures must be taken.Many factors determine how largethe NHZ area is. For example, an810-nm diode laser with amaximum power output of 3 Wattswill have a different NHZ thananother 810-nm diode laser with 5Watts of maximum output power.Therefore, it is not correct to saythat the NHZ for an 810-nm diodelaser is, for example, 8 feet for alldiode lasers. The same can also besaid for other laser wavelengths; itis incorrect to say that the NHZ forall Er:YAG lasers is 2 feet. Themanufacturer has the responsi-bility of informing the dentist andLSO of the dental laser’s specificNHZ by publishing this informa-tion in the operator’s manual.

EYE HAZAR D SThe eye is composed of pigmentedand nonpigmented tissue that will

absorb incident laser radiationrelative to the wavelength beingused. Damage from a laser beammay be due to direct exposure ofthe unprotected eye or diffusereflection and is ever-present inthose situations where wavelength-specific protective eyewear is notworn. Damage also depends on thetype of laser being used, since afree-running pulsed laser willcause more damage than a contin-uous laser of equal power.10 This isbecause the output power of a free-running pulsed laser can achievehigh peak power surges in a shortpulse followed by long off-timedurations. Its peak power is consid-erably greater than its averageoutput power. For a continuous-wave laser, the output power andthe peak power are the same,regardless of whether it is used ina continuous or gated mode. Inaddition, the ability of the eye’slens to focus incident light maysignificantly increase the hazardposed by those wavelengths thatmay enter the eye.11 In current clin-ical dental use, shorter laserwavelengths (visible to near-infrared, 400-1400 nm), beingrelatively nonabsorbed by water,may result in retinal burns in thearea of the optic disc. Some visiblewavelengths may selectivelydamage green or red cones in the

retina, producing color blindness.In addition, the 700-1400-nm wave-lengths can cause lens damage.

The second group of wave-lengths, the longer wavelengths(mid to far-infrared, 1,400-10,600nm) have high absorption in water,and corneal, aqueous, and lensdamage is associated with thesewavelengths.12

Consequently, it is mandatorythat all personnel (clinician, assis-tant, and patient) within thecontrolled area of Class IIIB, IIIR,and IV laser use should employsuitable eye protection during laserprocedures. Measures must betaken to protect the eyes of thestaff and patients when the MPE isexceeded, i.e., when the dentallaser is on and people are withinthe NHZ. Eyewear should beconstructed of wavelength-specificmaterial to attenuate the laserenergy or to contain the energywithin MPE values. Standards thatspecify the nature and suitability oflaser protective eyewear arecontained in ANSI (ANSI Z136.1 –2007) for North American users,EN 207/208 for European users,and IEC (IEC 60825) for all otherregions. The manufacturer’s markmust be imprinted on the eyewear.The wavelength or wavelengthsthat the protective eyewear isspecific for must be stamped on the

Figure 1: Prime risk structures of the eye at risk vs. laser wavelength (nm). Graphicproduced by Dr. Steven Parker.

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glass or side shields. If the eyewearis marked as 810 nm – 2890 nm,then this means that the eyesexposed to all wavelengths betweenthese two outer limits areprotected. If one line states 810 nmand then underneath 2890 nm isstamped, it means that eyes areprotected only against these twowavelengths and no protection isprovided for wavelengths inbetween.

In addition, the OD is requiredto be stamped clearly onto the glassor polycarbonate side frames forNorth America while references tothe OD, CE mark, operation mode(DIR), protective grade (L6A), andDirect Impact Number (DIN) aredisplayed in Europe.

Please refer to the glossaryprovided for additional information.Practitioners using loupes must

wear the appropriate protectiveinsert or shield. Glasses andgoggles must cover the entire peri-orbital region, be free of anysurface scratches or damage, andbe fitted with suitable side panelsto prevent diffuse laser beam entry.Practitioners using a microscopemust fit the appropriate filters andmaintain close eye contact with theoculars.

The protocol for use is “patientfirst on and last off.” This meansthat as soon as the patient isseated in the dental chair, he or sheis to put on the appropriate lasereyewear, which is not to be takenoff until the patient is leaving thedental operatory at the end of theprocedure. The dental operatorypersonnel must don the eyewearprior to the laser being turned onand not take them off until the

laser is switched off or put intostandby mode.

Care must be taken whencleaning laser eyewear and sideshields so that their protectivecoating is not destroyed. Theeyewear should be washed withantibacterial soap and dried with asoft cotton cloth in between proce-dures and patients. Disinfectingsolutions generally applied to dentalsurfaces are too caustic and shouldbe avoided. The eyewear must beinspected frequently to determinewhether there is any breakdown(lifting / cracking / flaking) of theprotective material that wouldrender the eyewear to be useless.

NO NTARGET O R ALT ISSU E HAZAR D SThe constraints of the oral cavitypose specific risks in access and

GLO SSARY

DIR: Ability of the glass orpolycarbonate to attenuate thebeam relative to the emissionmode of the laser for whichthe eyewear is intended, usingcoding “D” (continuous mode),“I” (pulsed mode) , “R” (Q-switched mode).

L6A: Defines the suitability forthe eyewear within clinical,industrial, or research condi-tions.

DIN: Direct Impact Number. Astandard for the glass or poly-carbonate shield against beamdamage, relative to a 10-secexposure (continuous wave) or100 pulses ( free-runningpulsed emission mode).

CE Mark: “Conformité Euro-péenne” license approved fordistribution and use within theEuropean Community CEMarking Directive (93/68/EEC)1993.

Table 2: Eye and Skin Hazards of Dental Lasers13

LASER EYE STRUCTURE EYE DAMAGE SKIN

Argon 488-514 nm Retina Retinal Lesion

PhotosensitiveReactions (400-700 nm)

Excessive Dryness

Blisters

Burns14

Caries detectionand oral pathologycytofluorescentdevices 630-900 nm

See below* Retinal Lesion

Lens (above 700 nm)

Retinal Burn andCataract (above 700 nm)

Diode 810-980 nmRetina Retinal Burn

Lens Cataract

Nd:YAG 1064 nmRetina Retinal Burn

Lens Cataract

Ho:YAG 2100 nm

Lens Cataract

Aqueous Humor Aqueous Flare

Cornea Corneal Burn

Er,Cr:YSGG 2780 nm

Lens Cataract


Cornea Corneal Burn

Er:YAG 2940 nm

Lens Cataract


Cornea Corneal Burn

CO2 10,600 nm Cornea Corneal Burn

* Class I and II caries-detection lasers may become hazardous to the retinawhen viewed through optical aids, e.g., eye loupes and microscopes, as suchmagnification instruments can make a diverging beam more hazardous.15

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accidental damage to adjacent ornontarget tissue. The close approxi-mation of multiple chromophores(molecular compounds that absorblight or laser energy such as hemo-globin, water, hydroxyapatite, andmelanin in oral tissue)16 demandscare during the use of any surgicallaser wavelength to avoid uninten-tional vaporization of other tissues.During any surgical ablation proce-dure using laser energy, attentionis required to focus the beam ontothe target tissue and avoid acci-dently damaging adjacent tissues.Anodized, dull, nonreflective, ormatte-finished instruments shouldbe employed. Coated (i.e., ebonized)instruments should be inspectedregularly to ensure integrity of thecoating.17 Glass mirrors should notbe used because they absorb heatfrom the laser energy and mayshatter. Stainless steel or rhodiummirrors may be used safely,providing measures are taken tominimize possible unwanted reflec-tion.

Parallel monitoring of the adja-cent tissues by all dental staffpresent at the time of treatment isto be ensured. Assistants need to betrained in recognizing adverse orunexpected tissue change as theyplay a role in monitoring the dentalsituation, especially if the dentist isusing a microscope or other acces-sory that might reduce theclinician’s wider field of vision.

SKIN HAZAR D SAny potential for damage to theskin through inadvertent exposureto Class III B and IV lasers will berelative to the ablation threshold ofthe skin structure and the incidentlaser energy. Subablative powerlevels will pose little threat, otherthan reversible tissue warming.Visible and near-infrared wave-lengths (400-1400 nm) have thepotential to pass through theepidermis into the superficial anddeeper structures respectively. Mid-to far-infrared wavelengths (1400-10,600 nm) will interact with

surface structures. The governingfactor in structural damage is theparticular laser wavelength’sabsorptive potential relative to thetissue elements (chromophores)such as pigment (shorter wave-lengths) and water (longerwavelengths), together with thepower density value of the laserbeam, duration of laser exposure,and spot size.18-21 It is importantthat all those involved in the use ofClass IIIB and IV lasers areadequately protected against inad-vertent skin exposure.

C H EMIC AL HAZAR D SLaser plume poses a significanthazard22 and occurs as a result of the development of aerosol by-products due to laser-tissueinteraction. These products cancontain particulate organic andinorganic matter including viruses,toxic gases, and chemicals. This isnot unique to lasers, as it has beenknown that surgical instruments,such as electrosurgical equipmentand dental handpieces, createsurgical debris. American NationalStandard for the Safe Use of Lasersin Health Care Facilities statesthat the hazard area for laser-generated airborne contaminates(LGACs) may be greater than thelaser’s identified NHZ.23 Examplesof the products contained in LGACinclude human papilloma virus,human immunodeficiency virus(suspected), carbon monoxide,hydrogen cyanide, formaldehyde,benzene, acrolein, bacterial spores,and cancer cells.24

Of particular importance inrestorative dental procedures, otherhazardous products may be presentin the plume.25 During removal ofcomposite resin with an erbiumlaser, along with the ejected wholeresin particles, small amounts offree methacrylate monomer can beproduced. Furthermore, althoughnot an indication for use, directingthe erbium laser’s energy ontoamalgam can produce mercuryvapor, according to an in vitro

study.26 This same precaution alsoapplies to other lasers.

The hazard presented by theLGACs may include eye irritation,nausea, breathing difficulties,vomiting, and chest tightnesstogether with the possibility oftransfer of infective bacteria andviruses.24, 27-29 To combat such risk,regular surgical protective clothingmust be employed and specific fine-mesh face masks capable offiltering 0.1-micron particles mustbe worn.30 Use of high-speed evacu-ation must also be used. It hasbeen determined that for carbondioxide laser surgery, the evacua-tion tube should be held as close as1 cm from the target site; at 2 cm,the evacuation ratio had dimin-ished by 50%.31

F IR E HAZAR D SThe high temperatures that arepossible in the use of Class IV andcertain Class IIIB lasers can them-selves either cause ignition ofmaterial and gases or promoteflash-point ignition. ANSI Z136.3has allowed gaseous conscioussedation procedures, such as theuse of a nosepiece to deliver oxygenand nitrous oxide mixtures to beused during laser operation.However, a closed-circuit deliverysystem must be used and a scav-enging system must be connectedto the high-volume evacuation tominimize gas leakage.Within the NHZ, use of aerosols,alcohol-soaked gauze, and alcohol-based anesthetics are to beavoided.32 Consequently, it is impor-tant to request that the patientremove any lip products that maycontain an oil-based substance thatis considered flammable, such aspetroleum jelly. Additionally, tissuecleansing or preparation agentsthat contain alcohol or other flam-mable chemicals carry specific riskof burning during laser use. If thepatient carries an oxygen tank,then the laser should not beutilized for the dental procedure,unless the patient will remain

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comfortable with the oxygen turnedoff and the nose cannula removedduring the laser portion of theprocedure.

With general anesthetic proce-dures, there are three aspects to beconsidered:1. Ignition sources (of which lasers

are an example)2. Fuel sources (gauze, drapes,

preparation fluids, alcohol, andanesthetic gases)

3. Oxygen-enriched atmosphere(more than 21% oxygen).33

The laser energies used in tissueablation may surpass the flashpoint of some anesthetic aromatichydrocarbons used in general anes-thesia, and the presence of oxygenand nitrous oxide will support anycombustion. Many materials thatare not normally flammable mayburn in an oxygen-enriched atmos-phere.34 Endotracheal tubes needparticular consideration to preventthe laser beam from burning a holein the tube and combusting with thegases. Consequently, the tubesshould be resistant to the laserbeam and have suitable coating, awavelength-specific reflectivecoating if possible, to prevent thepossibility of combustion of thematerial and subsequent airwayburns.35 Care should also be takento prevent the build-up of blood ontoendotracheal tubing, as this maylead to an increased fire hazard.36

OTH ER HAZAR D SAdditional hazards associated withlaser use include service andmechanical hazards. Potentialservice hazards include electrical,water, and air supply lines andcables, as well as connectors andfilters. The laser should be servicedregularly according to the manufac-turer’s recommendations and onlyby qualified personnel.37 The practi-tioner should inspect the supplylines and cables, clean and main-tain the external portions of thelaser, and change necessary filtersor other user-serviceable items. Inaddition, many surgical lasers use

a coaxial air or water supply whichmay be under pressure. No attemptshould be made to access internalparts of the machine during use.Capacitors can retain an energycharge, even when the laser is nolonger connected to the electricalsupply outlet.

Mechanical hazards includemoving parts (e.g., articulatingarms). Laser machines employ multi-level safety features (fusible plugs,interlocks, pressure relief valves, andwarning lights) to inactivate themachine in the event of a componentfailure. Additional hazards may existsuch as heavy articulated-armdelivery systems or the risk ofneedle-stick injury with fine quartzfiber-optic tips. Care must be takenaround the cables and wires associ-ated with the laser, as tripping overand wrenching these cables andfibers can be dangerous. Somemachines are portable and, whenmoved, should be reassembledcompletely, ensuring stability.

IN FEC T IO N C O NTRO LIn the United States, the Centersfor Disease Control and Prevention(CDC) have established infectioncontrol guidelines in a 2003

Morbidity and Mortality WeeklyReport.38 Lasers in dental practicesare to be considered as anotherdental instrument. Dental practi-tioners and their team must followstandard precautions. Standardprecautions include use of personalprotective equipment (PPE) (e.g.,gloves, masks, protective eyewearor face shield, and gowns) intendedto prevent skin and mucousmembrane exposures.39

Specific to lasers, any reusablefibers and tips must be heat-steril-ized along with their handpieces,and not wiped with a high-leveldisinfectant. Any debris on the endof the tip must be removed and/orcleaved off the end of the fiber toensure effective sterilization. Theoperator’s manual should containrecommendations about the sterili-zation process. For example, it issuggested that one does not ster-ilize the high-speed, lubricateddental handpieces at the same timeas the laser fibers so as to elimi-nate the possibility of oil from thehandpieces leaking through the bagonto the fibers.32 Disposable tipsmust be put into sharps containers,along with cleaved pieces of thefiber. Plastic or metal cannulas

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GLO SSARY

Critical Instrument: Any instrument that penetrates soft tissue,contacts bone, enters into or contacts the bloodstream, or othernormally sterile tissue. Examples include surgical instruments, peri-odontal scalers, and scalpel blades.38

Semicritical Instrument: Any instrument that does not penetrate softtissue, contact bone, bloodstream, or sterile tissue but can contactmucous membranes. Although dental handpieces are consideredsemicritical, the U.S. Centers for Disease Control and Prevention statethat they should be heat-sterilized and not high-level disinfected.38

High-Level Disinfection: Process that inactivates vegetative bacteria,myobacteria, fungi, and viruses but not high numbers of bacterialspores.39

Sterilization: Use of a physical or chemical procedure to destroy allmicroorganisms including substantial numbers of resistant bacterialspores.39

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fitted to the handpiece and used toposition the fiber optic should bedisposed of in regular trash.Removable or wipeable barriers arerecommended to be placed overoperational controls on the laser.Care should be shown to the possi-bility of contamination of all laserhardware; protective sleeves andbarriers (e.g., syringe covers, sensorprotector sheaths, transparentuniversal sticky barrier covers)should be utilized where possible.The laser and surfaces within thedental environment should bewiped with high-level disinfectantfollowing the procedure. Anycleaver used on a contaminatedfiber should also be heat-sterilized.

ENGIN EER INGC O NTRO LSThrough successive internationallyagreed regulations, laser devices(specifically but not exclusivelyClass IIIB and IV) have built-insafety features. These regulationsare designed to prevent unautho-rized use and protect thoseinvolved in laser applications.Engineering controls are set inplace by the manufacturer and arealways preferred, where possible,over administrative controls. Safetyfeatures include the following:• Locked unit panels to prevent

unauthorized access to internalmachinery

• Covered foot switch, to preventaccidental operation

• Delayed response from the footswitch (to prevent accidentaloperation, e.g., unintentionalstepping on the foot switch)

• Casters, if present, must be lock-able

• Remote interlocks. These consti-tute a connection between aclosed door and the laser. Shouldthe door be opened during laseroperation, the remote interlockwill shut down the laser

• Key or password protection toprevent the laser from beingoperated when authorizedpersonnel are not present

• Emission port shutters toprevent laser emission until thecorrect delivery system isattached

• Emergency stop switch or button– visible and easily located sothat the laser can be shut downin an instant without the oper-ator having to go through alengthy process

• Control panel and display toensure correct emission parame-ters are set

• Laser software diagnostics anderror messages. Internal systemswithin the laser that shut downoperations when any componentthat is not functioning correctlyis detected

• Specific laser standby and laser-emission modes

• Time-lapsed default to standbymode so that if a laser left in“ready” mode is not used within acertain time frame, the laser willrevert to “standby” mode.Stepping on the foot switch in“standby” mode will not initiatethe laser to operate

• Audible sound that is distinctiveto the laser when it is in opera-tion

• Visible signs on the laser, such aslights which warn whether thelaser is in standby mode or isbeing used.

AD MIN ISTR ATIV EC O NTRO LSIn addition to the manufacturer’sengineering controls, additionalsafety measures are also requiredin order to minimize the risk of anadverse event. In this context, anadverse event is defined a seriousand undesirable experience oroutcome (including death, life-threatening injury, disability,hospitalization, and intervention toprevent those outcomes) thatresults from a dental lasermarketed in accordance with thestandards32 set forth by the regula-tions governing its use within thatspecific country or region. It isessential that all surgical lasers be

used with responsibility and dueregard to their potential safetyrisk. These administrative policiessupplement the aforementionedmechanisms in order to facilitate asafe laser environment and requirethe appointment of a Laser SafetyOfficer (LSO) to oversee theirimplementation. Policies include:• Establishing written Standard

Operating Procedures (SOPs) forthe dental practice, as requiredby ANSI Z136.1 – 2007 and othernational standards as they mayapply

• The appointment of an LSO withspecific responsibilities, asfollows:• Serves as the “keeper of the

key” to secure the key in a safeplace when the laser is not inoperation

• Authorized to shut down laseroperation. This authority is tobe recognized and respected inthe dental office regardless ofthe dental employee positionheld by the LSO

• Keeps current with safety stan-dards, such as OSHA, ANSI,IEC (or those of the appropriatecountry) through educationalmeetings and literature review,and updates this informationwith the dental practice

• Supervises the education andtraining of the dental team

• Assists with evaluation when anew laser is needed

• Understands the operationalcharacteristics of the laser(s) inthe practice

• Using the manufacturer’s NHZ,identifies this area within thedental office in accordance withthe laser being used

• Ensures correct warning signsare posted at every entrywayinto the operatory in which thelaser is being used

• Ensures that the laser signsare taken down after the proce-dure is completed, and not leftup as “wallpaper”

• Oversees the protectiveeyewear

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• Ensures the correct wave-length-specific eyewear is beingworn within the NOHD

• Ensures that the policy ofpatient eyewear “first-on andlast-off” is adhered to. Thepolicy for the dental team is“on before the laser is initiatedand off after the laser applica-tion is finished,” and the laseris turned off or placed instandby mode

• Ensures the laser is beingoperated by authorizedpersonnel only

• Understands the operationalcharacteristics of the laser(s)

• Knows the output limitationsof the device

• Determines the controlled areaand the potential hazard andnonhazard zones

• Ensures laser maintenance,beam alignment, and calibra-tion

• Is familiar with the biologicaland other potential hazards ofthe laser

• Supervises medical surveil-lance and incident reporting

• Keeps a log of recorded laseruse and parameters employed

• Ensures proper test-firing ofthe laser prior to admission ofthe patient into the operatory.

Laser test-firing is a safetymeasure designed to establish thatthe laser is working correctly andthat there is patency of the deliverysystem. Test-firing should becarried out by the clinician or LSOprior to every procedure and beforethe patient is admitted to thecontrolled area. Protective eyewearis worn and all other safety meas-ures met. The laser is directedtoward a suitable absorbent mate-rial (e.g., water for longerwavelengths – 1400-11,000 nm, anddark-colored paper for short wave-lengths – 400-1400 nm) andoperated at the lowest powersetting for the laser being used.Test-firing will demonstrate thatthe laser is functioning properly, allconnections are securely in place,

the delivery system is notdamaged, and the laser beam ispatent.

It is necessary to define acontrolled area, within which allsafety aspects pertaining to laseruse are enforced. The LSO mustfollow the operator’s manualregarding the dimensions or limitsof the controlled area. Dentalclinics with multichair, open-planenvironments need to address thephysical dimensions and adminis-trations of their controlled area ingreater detail. Within thecontrolled area, all surfaces shouldbe nonreflective, and measuresshould be taken to ensure that allsupply cables for the laser alongwith its delicate delivery system

are protected from inadvertentdamage. A fire extinguisher shouldbe sited for easy access.

The LSO is required to overseethe training of the entire dentalteam with regard to lasers,including the nonuser and adminis-trative staff. It is imperative thatnonuser team members in thedental office are educated at somelevel with regard to the laser equip-ment and have received training onaspects of laser safety as they applyto their dental office. Regulatoryagencies recognize the essentialnature of appropriate training inlaser use40-43 and there is an impliednecessity that clinicians shouldreceive training as part of theirduty of care and dental licensing.

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FU RTH ER R EAD ING

Further reading is recommended in order to ensure that the clinicianis complying with national, federal, or regional regulations:

ANSI Z136.1 – 2007 American national standard for safe use oflasers. Published by the Laser Institute of America (LIA). Contact:Laser Institute of America, 13501 Ingenuity Drive, Suite 128, Orlando,Florida 32826 USA, www.laserinstitute.org

OSHA (USA). Guidelines for laser safety and hazard assessment (STD01-05-001-PUB 8-1.7). U.S. Department of Labor – OccupationalSafety and Health Administration. Contact: www.osha.gov.

International Electrotechnical Commission (IEC). A wide range ofpublications relating to laser use and safety. Contact: www.iec.ch.

Laser Institute of America. CLSOs’ best practices in laser safety. 1sted. Laser Institute of America 2008. ISBN 978-0-912035-90-1Contact: Laser Institute of America, 13501 Ingenuity Drive, Suite 128,Orlando, Florida 32826 USA, www.laserinstitute.org.

MHRA (UK). Device bulletin. Guidance on the safe use of lasers,intense light source systems and LEDs in medical, surgical, dentaland aesthetic practices. DB2008(03)April 2008. Contact: Medicinesand Healthcare products Regulatory Agency, 10-2 Market Towers, 1Nine Elms Lane, London SW8 5NQ United Kingdom,www.mhra.gov.uk.

Moseley H, Davies B. Biomedical laser safety. Part D3.5 in: Webb C,Jones J, editors. Handbook of laser technology and applications.Volume III: Applications. Bristol, U.K.: Institute of Physics PublishingLtd., 2004:2155-2179.

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The Standard OperatingProcedure is a living, written docu-ment that outlines the existenceand identity of laser devices withina given practice setting, personnelauthorized to use the laser, andsafety measures to address thehazards associated with the lasersin that particular dental practice.It contains all the local andnational rules, including those setout in the aforementioned adminis-trative controls. In the UnitedStates, ANSI Z136.1 – 2007requires every dental practice witha laser to have such a documentand many countries or regions havesimilar requirements.

The Academy of Laser Dentistryadopted the Curriculum Guidelinesand Standards for Dental LaserEducation which defines a core ofknowledge appropriate to the safeuse of lasers in dentistry. All thoseclinicians passing proficiency exam-inations with the Academy willsatisfy an acceptable level ofcompetence in laser safety, andnonclinicians may take proficiencyexaminations to be recognized aslaser safety officers.

C O NC LU SIO NLaser use in dentistry is proven tobe beneficial in treating a widerange of dental conditions as wellas a therapeutic tool in tissuemanagement. The dynamics of laserenergy beams pose general risks tonon-oral tissues and the immediateenvironment of such use must bedeemed at risk from direct or scat-tered exposure. Safety measureshave been devised to safeguardthose personnel – staff and patients– who may be involved in dentaltreatment using lasers. Most safetymeasures are the product of officialregulatory bodies such as ANSI,OSHA, FDA, and IEC, but addi-tional measures may be the productof individual needs within partic-ular dental offices and consequentlyrecorded in local rules. The readeris encouraged to consult these regu-latory bodies as they may apply on

a national or regional basis, toensure a correct and responsiblecompliance with all laser safetymeasures in the treatment of dentalpatients. The analysis of generaland specific risk during laser usehas been addressed through manystatutory instruments and all clin-ical procedures should be measuredagainst such standards, in order tooffer the maximum protection forthe patient, clinical staff, and thosewithin the immediate environment.

AU THO R B IO GR AP HYAs business manager for the dentaloffice of Dr. Peter Pang, Ms.Caroline Sweeney is responsible forthe effective operation and promo-tion of the laser practice. Degreesin Business and Science combinedwith 18 years of experience in themedical/dental field provide herwith a unique foundation for thisrole. As a faculty member of theSanta Rosa Junior College dentalauxiliary program, she plays anactive part in encouraging studentsto embrace advancements indentistry. She has achievedAdvanced Proficiency in 3 laserwavelengths and is the chair of theLaser Safety Committee for theAcademy of Laser Dentistry. Ms. Sweeney may be contacted by e-mail at [email protected].

Disclosure: Ms. Sweeney receives asalary for being an adjunct facultymember at the Santa Rosa JuniorCollege. She does not receive anycompensation for lecturing with Dr.Peter Pang.

R EFER ENC ES1. Moseley H. Operator error is the

key factor contributing to medicallaser accidents. Lasers Med Sci2004;19(2):105-111.

2. Adverse event report. Available at:U.S. Food and Drug Administration.Center for Devices and RadiologicalHealth. Adverse event report.Candela Corp. Vbeam laser derma-tology laser. (05/02/2002)

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=397304. AccessedMarch 15, 2009.

3. Barat K. Laser safety management.Boca Raton, Fla: CRC Press/Taylor& Francis Group, LLC, 2006:129.

4. American national standard for thesafe use of lasers. ANSI Z136.1 –2007. Orlando, Fla: The LaserInstitute of America, 2007:1.2, 2-3.

5. IEC 60825-1, Safety of laser prod-ucts – Part 1: Equipmentclassification and requirement.Geneva: InternationalElectrotechnical Commission,Edition 20;2007-03.

6. Laser Institute of America. CLSOs’best practices in laser safety. 1st ed.Orlando, Fla: The Laser Institute ofAmerica, 2008:23.

7. Marshall WJ, Conner PW. Fieldlaser hazard calculations. HealthPhys 1987;52(1):27-37.

8. McKenzie AL. Safety with surgicallasers. J Med Eng Technol1984;8(5):207-214.

9. IEC TR 60825-9:1999-10, Safety oflaser products – Part 9: Compilationof maximum permissible exposure toincoherent optical radiation. Geneva:International ElectrotechnicalCommission, First Edition, 1999.

10. Harris MD, Lincoln AE, Amoroso PJ,Stuck B, Sliney D. Laser eye injuriesin military occupations. Aviat SpaceEnviron Med 2003;74(9):947-952

11. Lund DJ, Edsall P, Stuck BE,Schulmeister K. Variation of laser-induced retinal injury thresholdswith retinal irradiated area: 0.1-sduration, 514-nm exposures. JBiomed Opt 2007;12(2):024023-1-7.

12. Parker P. Laser Safety – Changes toregulations as to use. J Acad LaserDent 2006;14(1):32-34.

13. Dorros G, Seeley D. Understandinglasers. A basic manual for medicalpractitioners including an extensivebibliography of medical applica-tions. Mount Kisco, N.Y.: FuturaPublishing Co., Inc.,1991:64-67.

14. Laser Institute of America. Lasersafety guide. 11th ed. Orlando, Fla:The Laser Institute of America,2007:6.

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15. American national standard for thesafe use of lasers. ANSI Z136.1 –2007. Orlando, Fla: The LaserInstitute of America, 2007:10.

16. Manni JG. Dental applications ofadvanced lasers (DAALTM).Burlington, Mass.: JGM Associates,Inc., 2007:2-17 – 2-21, 5-5.

17. Association of periOperativeRegistered Nurses RecommendedPractices Committee. Recommendedpractices for laser safety in practicesettings. AORN J 2004;79(4):836,838, 841-844.

18. Nanni C. Complications of lasersurgery. Dermatol Clin1997;15(3):521-534.

19. Handley JM. Adverse events associ-ated with nonablative cutaneousvisible and infrared laser treatment.J Am Acad Dermatol2006;55(3):482-489.

20. Laor Y, Simpson CL, Klein E, Fine S.The pathology of laser irradiation ofthe skin and body wall of the mouse.Am J Pathol 1965;47(4):643-663.

21. Youker SR, Ammirati CT. Practicalaspects of laser safety. Facial PlastSurg 2001;17(3):155-163.

22. Bigony L. Risks associated withexposure to surgical smoke plume: Areview of the literature. AORN J2007;86(6):1013-1024.

23. American national standard for safeuse of lasers in health care facilities.ANSI Z136.3 – 2005. Orlando, Fla:The Laser Institute of America,2005:7.4.1:19

24. Laser plumes – Health care facili-ties. Available at: Canadian Centerfor Occupational Health and Safety.Laser plumes – Health care facili-ties. http://www.ccohs.ca/oshanswers/phys_agents/laser_plume.html. Updated February22, 2005. Accessed March 15, 2009.

25. Conforti PF, Prasad M, Garrison BJ.Simulations of laser ablation ofpoly(methyl methacrylate): Fluenceversus number of photons. J PhysChem C 2007;111(32):12024-12030.

26. Pioch T, Matthias J. Mercury vaporrelease from dental amalgam afterlaser treatment. Eur J Oral Sci1998;106(1):600-602.

27. Jacques A. The laser plume: Is it ahealth hazard? Can Oper RoomNurs J 1989;7(3):5-9.

28. Alp E, Bijl D, Bleichrodt RP,Hansson B, Voss A. Surgical smokeand infection control. J Hosp Infect2006;62(1):1-5.

29. Blustein D, Blustein J. Occupationalexposure to laser surgery generatedair contaminants. WMJ1998;97(4):52-55.

30. Derrick JL, Li PTY, Tang SPY,Gomersall CD. Protecting staffagainst airborne viral particles: Invivo efficiency of laser masks. JHosp Infect 2006;64(3):278-281.

31. Fisher RW. Laser smoke in the oper-ating room. Biomed Technol Today1987;191-194.

32. Piccione PJ. Dental laser safety.Dent Clin North Am 2004;48(4):795-807.

33. Daane SP, Toth BA. Fire in the oper-ating room: Principles andprevention. Plast Reconstr Surg2005;115(5):73e-75e.

34. Simpson JI, Wolf GL. Flammability ofesophageal stethoscopes, nasogastrictubes, feeding tubes, and nasopharyn-geal airways in oxygen- and nitrousoxide-enriched atmospheres. AnesthAnalg 1988;67(11):1093-1095.

35. Walker P, Temperley A, Thelfo S,Hazelgrove A. Avoidance of laserignition of endotracheal tubes bywrapping in aluminum foil tape.Anaesth Intensive Care2004;32(1):108-112.

36. Sosis MB, Pritikin JB, CaldarelliDD. The effect of blood on laser-resistant endotracheal tubecombustion. Laryngoscope1994;104(7):829-831.

37. American national standard for safeuse of lasers. ANSI Z136.1 – 2007.Orlando, Fla: The Laser Institute ofAmerica, 2007:7.2.1.1:55.

38. Centers for Disease Control andPrevention. Guidelines for infectioncontrol in dental health-care settings– 2003. MMWR 2003;52(No.RR-17).

39. Centers for Disease Control andPrevention. Guidelines for infectioncontrol in dental health-care settings– 2003. MMWR 2003;52(No.RR-17):5-6.

40. Chuang F. Center for BiophotonicsScience and Technology (CBST).Conf Proc IEEE Eng Med Biol Soc2004;7:5123.

41. Toon S. Doctors using lasers riskproblems without proper training,protection. Occup Health Saf1988;57(7):30.

42. Akbar-Khanzadeh F, Wagner OD.Safety and health program assess-ment in relation to the number andtype of safety and health violations.AIHAJ 2001;62(5):605-610.

43. Hattin HC. Laser safety in healthcare facilities: A national standardof Canada. J Clin Eng1994;19(3):218-221. ■■

Sweeney et al.

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICESU.S. Food and Drug Administration

Center for Devices and Radiological Health10903 New Hampshire Avenue

FDA Shared Use Bldg 2, Room 2047Silver Spring, MD 20993-0002

Proceedings of the ALD/FDA 2008 JointSymposium on Lasers and Light-BasedTechnology Utilization in DentistrySilver Spring, Maryland • Monday, December 8, 2008 8:00 a.m. – 5:00 p.m.Donald J. Coluzzi, DDS, Portola Valley, CaliforniaJ Laser Dent 2009;17(1):50-57

OV ERV IEW AN DED U C ATIO NALP U R PO SEThe Academy of Laser Dentistry(ALD) and the United States Foodand Drug Administration (FDA),Center for Devices and RadiologicalHealth (CDRH) coordinated a day-long series of presentations inSilver Spring, Maryland, thatfocused on how lasers and light-based technologies interact withoral tissues, the impact theypresently have in the practice ofdentistry, and some of the currentresearch of these technologies thatcould lead to new future surgical,preventive, diagnostic, and healingapplications. The presenters weresome of the most respected andleading professionals in theirrespective fields and include prac-ticing clinicians, academicians, andresearchers from around thecountry.

The morning session includeddiscussions on how lasers weredeveloped for dentistry, theirimpact on soft and hard tissues,their use in preventive applica-tions, and their role in the practiceof dental hygiene. A visible lightsource used for screening of oralsoft tissue and a laser opticalcoherence tomography device werepresented as novel diagnosticinstruments.

The afternoon series continuedwith the research and potential useof low-power lasers or incoherentsources that produce regenerativetherapy to a wide spectrum ofmedical and dental problems.Finally there was a short opensession for discussions with audi-ence participation on the day’stopics.

The audience of approximately50 individuals included dentists,academicians, researchers, govern-ment and military professionals,and representatives of relateddental organizations.

P R ESENTATIO N S AN DB IO GR AP H IESThere were 12 presentations and aclosing discussion session. Theabstracts and speaker biographiesare listed below in the order inwhich they appeared on theprogram.

PRESENTATION 1: WELCOME AND

INTRODUCTIONS. THE ROLES AND MISSIONS OF THE

ALD AND THE FDAWelcome: Ronald W. Waynant, PhDSenior Optical Engineer,

FDA/CDRHPresenter and Moderator: Donald J.

Coluzzi, DDSEditor-in-Chief, The Journal of

Laser Dentistry,

Past President of the Academy ofLaser Dentistry

AbstractA brief overview of the Academy ofLaser Dentistry will be presented.Highlights include a short descrip-tion of the history and mission of theALD, the make-up of the administra-tion, executive committee, board ofdirectors, and working committees.

BiographyDr. Ronald W. Waynant is a senioroptical engineer at the Food andDrug Administration, Rockville, Md.He was an adjunct professor of elec-trical engineering at the CatholicUniversity of America, Washington,DC and taught a graduate-levellaser course for 14 years there. Hecurrently serves on the advisoryboard to the Catholic UniversityDepartment of ElectricalEngineering. He is now an adjunctassociate professor at the UniformedServices University for the HealthSciences in Bethesda. Md. Mostrecently, he has been working onlaser therapy mechanisms andvarious sources for and uses of lasertherapy. He is also interested inlaser medicine, infrared fiber optics,and laser-generated X-rays formedical imaging. Dr. Waynant hasedited six books in the electro-opticsand laser medical areas and four

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SYMPO SIU M P RO C EED INGS

Proceedings of the ALD/FDA 2008 Joint Symposium

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special issues of IEEE Journal ofSpecial Topics in QuantumElectronics. He has organized eightconferences for the EngineeringConferences International organiza-tion on lasers, laser medicine, andlaser therapy. He has also served onIEEE Lasers and Electro-OpticsSociety (IEEE LEOS) Board ofGovernors for 20 years. His researchwork in the past 15 years has beenfunded by agencies such as the AirForce Office of Scientific Research(AFOSR), Office of Naval Research(ONR), Defense Advanced ResearchProjects Agency (DARPA), andNational Science Foundation (NSF).He is an Elected Fellow of theAmerican Institute of Medical andBiological Engineers (1996), anElected Fellow of the Institute ofElectrical and Electronic Engineers(1987), an Elected Fellow of theOptical Society of America (1988), anElected Fellow of American Societyfor Laser Medicine and Surgery andcurrently a member of the Board ofDirectors, and an Elected Fellow ofthe Washington Academy ofSciences. He has published morethan 110 journal papers and hasgiven more than 120 presentations.He also has 10 patents. He hasrecently retired as editor-in-chief ofthe IEEE Circuits & Devices maga-zine after 20 years. Dr. Waynantmay be contacted by e-mail [email protected].

Disclosure: Dr. Waynant hasCooperative Research andDevelopment Agreements (CRADAs)with Raydiance and NanoSonic. Hereceives a small amount of fundingfrom NanoSonic. Both of theseCRADAs have been approved by FDAand signed by the Commissioner.

BiographyDr. Donald Coluzzi, a 1970 grad-uate of the University of SouthernCalifornia School of Dentistry, is anassociate clinical professor in theDepartment of Preventive andRestorative Dental Sciences at theUniversity of California San

Francisco School of Dentistry. He isa charter member and past presi-dent of the Academy of LaserDentistry, and is currently theeditor-in-chief of the Journal ofLaser Dentistry. He has used dentallasers since early 1991. He hasAdvanced Proficiency in Nd:YAGand Er:YAG laser wavelengths. Dr.Coluzzi is the 1999 recipient of theLeon Goldman Award for ClinicalExcellence and the 2006Distinguished Service Award fromthe Academy, a Fellow of theAmerican College of Dentists, and aMaster of the Academy of LaserDentistry. Dr. Coluzzi has deliveredpresentations on lasers worldwide,co-authored two books, andpublished several peer-reviewedarticles. Dr. Coluzzi may becontacted by e-mail at [email protected].

Disclosure: Dr. Coluzzi has no dualcommitments as defined in the ALDDisclosure Policy. He is being reim-bursed for travel and hotel expensesby the Academy of Laser Dentistry.

PRESENTATION 2: AN OVERVIEW

AND HISTORY OF THE IMPACT

LASER TECHNOLOGIES IN

DENTISTRY

THE HISTORY AND OVERVIEW OF

LASERS IN DENTISTRY

Terry D. Myers, DDS, PastPresident of the InternationalAcademy of Laser Dentistry

AbstractThe presentation will provide theaudience with a historical overviewof the U.S. dental laser market. Itwill set the stage for the remainderof the 2008 Joint Symposiumspeakers. The two-part presenta-tion will first review the significantFDA marketing clearances begin-ning with Sunrise Technologies’soft tissue clearance of May 1990.The second segment will concen-trate on the U.S. dental lasermarket and the factors that helpedplace over 28,000 instruments indental offices.

BiographyDr. Terry Myers has beenresearching the use of lasers indentistry since 1983. His earlywork resulted in the developmentof the Nd:YAG dental laser, whichhe invented and patented with hisophthalmologist brother, Dr.William D. Myers. It is the firstlaser in the world designedspecially for general clinicaldentistry. Since graduation fromthe University of Detroit DentalSchool in 1973, Dr. Myers hasmaintained a private practice inthe metro Detroit area of Michigan.He has held teaching positions atvarious universities in the Detroitarea and is currently an adjunctassociate professor, University ofDetroit Mercy School of Dentistry.He also has interests in veterinarydentistry, and has delivered dentalcare at the Detroit ZoologicalParks. Dr. Myers has authored arti-cles on his work and is aninternationally recognized speaker,having conducted hundreds of laserdentistry and air abrasion lecturesand workshops throughout theworld. Dr. Myers may be contactedby e-mail at [email protected].

Disclosure: Dr. Myers is cofounderand president of Incisive, LLC. He isbeing reimbursed for travel and hotelexpenses by the Academy of LaserDentistry.

PRESENTATION 3: LASER

INTERACTIONS WITH SOFT AND

HARD ORAL TISSUES AND THEIR

APPLICATIONS

Michael Swick, DMDMember, Board of Directors of the


AbstractLaser-tissue interaction will becovered as a review for the atten-dees. The emphasis will be on areview of the interactions whichrelate most notably to dentistryand common dental usage. Thenear-, mid-, and far-infrared rangesare applied daily in many dental


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practices worldwide as a result ofthe applicability, availability, andaffordability of present laser units.The myriad of applications will bediscussed and demonstrated withthe use of microscopic, high-defini-tion video taken through a surgicaloperating microscope.

BiographyDr. Michael Swick is a generaldentist and has offices in AllisonPark and Conneaut Lake,Pennsylvania. He practices micro-dentistry using air abrasion andlasers, working through a surgicaloperating microscope. He holds anAdvanced Proficiency in the 980-nm and 2940-nm laser wavelengthsand standard proficiency in CO2,Nd:YAG, 810-nm diode, 980-nmdiode, Er,Cr:YSGG, and Er:YAGlaser wavelengths through theAcademy of Laser Dentistry. He isan Academy of Laser Dentistrycertified educator as well as aRecognized Course Provider whoseStandard Proficiency laser coursesare accepted for StandardProficiency Certification throughthe Academy of Laser Dentistry. Heis currently serving on the board ofdirectors of the Academy of LaserDentistry, has served as thechairman of the Educationcommittee, served on the Scienceand Research, Scientific Sessions,Nominating, and Constitution andBylaws Committees. Additionally,he holds certification from St.Luke’s Medical Center in thePinero Precardiac Surgery Protocolwith lasers. Dr. Swick is a formerFellow in the American Society forLaser Medicine and Surgery wherehe has presented clinical papers.He has presented more than 350continuing education and hands-oncourses in dental lasers, bothnationally and internationally. Inaddition he has presented clinicaland scientific papers for the ALD,European Society for Oral LaserApplications (ESOLA)/DeutscheGesellschaft fürLaserzahnheilkunde (DGL),

International Society for Lasers inDentistry (ISLD), and SPIE. Dr.Swick may be contacted by e-mailat [email protected].

Disclosure: Dr. Swick has lectured,provided training, and consulted forthe BioLitec, HOYA ConBio, Sirona,Kavo, and Elexxion laser companiesas well as LED Dental on theVELScope and the Institute for LaserDentistry in Canada for whom he haslectured extensively on a per diembasis. He currently is a consultant,lecturer, and trainer for the Elexxionlaser company and he receives a perdiem for his efforts. He is being reim-bursed for travel and hotel expensesby the Academy of Laser Dentistry.

PRESENTATION 4: PREVENTIVE

APPLICATIONS

Peter Rechmann, Prof. Dr. Med.Dent. DDS, PhD

President of the Academy of LaserDentistry

Professor and Director, ClinicalSciences Research Group,University of California SanFrancisco School of Dentistry

AbstractThis presentation will discuss twodifferent areas where lasers can beused for preventive applications indentistry. One is enhancing cariesresistance of dental hard tissuesafter laser irradiation, the otherrelates to the use of lasers toprevent or slow the progression ofperiodontal disease. The successfuluse of a 9.6-µm CO2 short-pulsedlaser in caries prevention in labora-tory studies as well as in clinicaltrials will be presented. A historicalbackground and comparisons to theuse of other laser wavelengths forthis indication will be offered. Inthe second part of the presentationthe selective and efficient removalof microbial plaque and calculus inlaboratory studies with lasers emit-ting in the blue spectral region willbe reported. The clinical advan-tages of this application and itsrelevance in periodontal prevention

and therapy will be described.

BiographyDr. Peter Rechmann was originallya faculty member in theDepartment of Oral Surgery andOral Medicine at Heinrich-Heine-University in Düsseldorf, Germany.Since 2001, he has been at theUniversity of California at SanFrancisco, Department ofPreventive and Restorative DentalSciences, where he is currently aprofessor in the Division ofProsthodontics as well as theDirector of the Clinical SciencesResearch Group. Dr. Rechmann hasmore than 25 years of experience inclinical research and use of dentallasers. He currently serves as presi-dent of the Academy of LaserDentistry. Dr. Rechmann may becontacted by e-mail at [email protected].

Disclosure: Dr. Rechmann hasresearch grants from the NationalInstitutes of Health (NIH). He has aconsulting relationship and patentlicensing agreements with LaresResearch and affirms that these rela-tionships will not influence hisobjectivity. In this presentation the9.6-µm CO2 laser for enhancement ofcaries resistance is unlabeled andinvestigational as is the Alexandritelaser – for micro plaque/calculusremoval and the argon laser in labo-ratory use. He is being reimbursed fortravel and hotel expenses by theAcademy of Laser Dentistry.

PRESENTATION 5: THE UTILIZATION

OF LIGHT-BASED TECHNOLOGIES IN

THE PRACTICE OF DENTAL HYGIENE

Angie Mott, RDHMember, Board of Directors of the


AbstractThis presentation including casestudies and statistics will allow theattendees to see how a soft tissuedental laser in the hands of adental hygienist can be a tool thatprovides wonderful treatment


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options to allow the ultimate dentalhealth. These case studies willshow the steps taken to reduce thebacterial levels and restore themouth to an optimal healthy situa-tion as well as show how pain andswelling can be reduced with a softtissue laser related with a herpeticlesion. Dental hygienists have agreat opportunity to be in a co-diagnosis position. A dentalhygienist should utilize other diag-nostic aids, such as oral cancerevaluations, propose alternativeperiodontal treatment options,suggest restorative options thatwould contribute to overall dentalhealth, and present any otherpertinent patient issues to thedoctor.

BiographyAngie Mott has been a clinicalhygienist for more than 20 years.She is a member of the Academy ofLaser Dentistry, where sheobtained her Advanced Proficiencyand Educator Status, and receivedher ALD Recognized CourseProvider in 2007 and herMastership with ALD in 2008. Shecurrently serves as auxiliary chairfor the ALD Board of Directors andserves on the Regulatory Affairs,Education, Membership,Advertising, and Scientific Sessionscommittees. Angie is a pastpresenter for the ALD and has hadarticles published in RDH and JPHmagazines. She has worked withNd:YAG soft tissue lasers since2000, and diode soft tissue laserssince 2005. Ms. Mott may becontacted by e-mail [email protected].

Disclosure: Ms. Mott has no finan-cial relationship with anyorganization or company relative tothis presentation. She has in the pastreceived honoraria or payment forconsultation services from IvoclarVivadent and Biolase Technology. Sheis being reimbursed for travel andhotel expenses by the Academy ofLaser Dentistry.

PRESENTATION 6: TISSUE

FLUORESCENCE

(AUTOFLUORESCENCE) ROLE IN THE

DIAGNOSTIC PROCESS

Scott D. Benjamin, DDSVice-Chair, Education Committee of

the Academy of Laser DentistryWorking Group Chairman, ADA

Standards Committee on DentalProducts on Dental Lasers

AbstractThe accurate evaluation andassessment of the patient’s condi-tion is the foundation of allhealthcare decisions and is crucialin attaining successful outcomesand sustaining a high quality oflife. This presentation reviews thebasic science of autofluorescenceand how it relates in oral screen-ings. In addition, it will discusssome of the various modalitiesutilizing autofluorescence in evalu-ating the tissue and othersubstances in the oral cavity.Although the emphasis will be onthe oral cavity, it will also include ahistorical account and examples oftissue autofluorescence in generaland present current techniques forthe visualization of fluorescence inthe lung, cervix, and skin. The talkis designed to illustrate the scienceand biophotonic mechanismsresponsible for tissue autofluores-cence and its correlation withabnormal conditions.

Tissue autofluorescence isproduced by fluorophores in theoral cavity when stimulated withexcitation light. In the case of bluelight excitation, important epithe-lial fluorophores include thereduced form of nicotinamideadenine dinucleotide (NADH) andthe oxidized form of flavin adeninedinucleotide (FAD) while importantstromal fluorophores includecollagen and elastin cross links.Also the fluorophore porphyrin, abacterial endotoxin, has an autoflu-orescence emission if appropriatelyinterrogated with light energywhen evaluating both the hard andsoft tissues of the oral cavity. The

presentation will review thecurrent understanding of the rela-tive contributions thesefluorophores have when the fluo-rescent signal is observed andillustrate how the signal changeswith disease processes.

The presentation will alsodiscuss some of the noninvasivemodalities used in screening theoral cavity that illuminate the oralstructures with visible light andallow for the observance of theresultant fluorescent response thatis detected with the use of special-ized filters, and how thisinformation can be utilized by theclinician in the diagnostic process.

BiographyDr. Scott Benjamin is in privatepractice in rural upstate New York, avisiting professor at the StateUniversity of New York (SUNY) atBuffalo School of Dental Medicine,and a research associate at the NewYork University College of Dentistry.He is an internationally recognizedlecturer on oral cancer and advanceddental technologies and haspublished more than 150 articles ondental technology in over a dozenpublications. Dr. Benjamin ispresently a member of the editorialboard of several prestigious peer-reviewed dental journals. He in anactive member and Working Groupchairman of both the AmericanDental Association StandardsCommittee on Dental Products(ADA-SCDP) and Dental Informatics(ADA-SCDI). Dr. Benjamin was aparticipant in the World HealthOrganization’s (WHO) CollaboratingCentre for Oral Cancer andPrecancer Working Group on“Potentially Malignant Oral MucosalLesions and Conditions: Terminology,Classification, Diagnosis, andPrognosis.” Dr. Benjamin maycontacted by e-mail [email protected].

Disclosure: Dr. Benjamin has been aclinical consultant, advisor, andlecturer receiving honoraria for LED


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Medical Diagnostics Inc., Vancouver,British Columbia, Canada andSirona Dental Systems LLC,Charlotte, NC. He has also lecturedfor several laser and advanced dentaltechnology companies for which hehas received honoraria. He is beingreimbursed for travel and hotelexpenses by the Academy of LaserDentistry.

PRESENTATION 7: OPTICAL

COHERENCE TOMOGRAPHY (OCT)DIAGNOSTIC IMAGING

Craig Gimbel, DDSPast President of the Academy of

Laser Dentistry

AbstractOptical Coherence Tomography(OCT) is a new type of opticalimaging that captures high-resolu-tion, cross-sectional 2D and 3Dimages of the internal microstruc-ture of oral hard and soft tissue, aswell as dental restorative mate-rials. By measuring thebackscattering of 1310-nm light,image resolutions of 10 um can becaptured in situ and in real-time ona computer monitor. It is analogousto ultrasound B, except that it usesnoninvasive light instead of sound.The unique features of this tech-nology enable a broad range ofclinical and research applicationsin dentistry. Very early demineral-ization due to a carious lesion canbe imaged and then followed asremineralization occurs. Otherimaging capabilities includedysplasias and microstructuraldefects of the tooth and restorativematerial, early periodontal disease,dysplasias and precancerouslesions, endodontics, vertical rootfractures, and orthodontics. OCTcan speed up research by nothaving to rely on tissue removal.“Optical biopsies” permit frequentmonitoring of oral tissue pathologyand restorative material. Theresultant images provide quantita-tive and qualitative information ofhigh sensitivity and specificity forthe clinician and researcher.

BiographyDr. Craig Gimbel is the immediatepast president of the Academy ofLaser Dentistry. In 1993-1997, hewas a principal investigator for thefirst FDA human hard tissue clin-ical trials for the erbium:YAG laserin dentistry. He was the recipient ofthe T. H. Maiman Award for excel-lence in dental laser research in2002. Since 2002, Dr. Gimbel hasbeen working on the developmentof optical coherence tomography fordentistry and had a peer-reviewedmanuscript on this subject recentlypublished in General Dentistry. Dr.Gimbel may be contacted by e-mailat [email protected].

Disclosure: Dr. Gimbel is an ownerof and vice president of clinicalaffairs for Lantis Laser, Inc. Thecompany has patent licensing agree-ments with Lawrence LivermoreNational Lab/University ofCalifornia, Massachusetts Institute ofTechnology, University of Florida, andAxsun, Inc. Optical CoherenceTomography for dentistry is presentlyinvestigational as a diagnostic aid.He is being reimbursed for travel andhotel expenses by the Academy ofLaser Dentistry.

PRESENTATION 8: MECHANISMS OF

LOW-LEVEL LIGHT THERAPY

(LLLT)Michael R. Hamblin, PhDAssociate Professor, Harvard

Medical SchoolPrincipal Investigator, Wellman

Center for Photomedicine atMassachusetts General Hospital

AbstractThis presentation will focus on themolecular and cellular mechanismsinvolved in low-level light therapy(LLLT). It is thought that red andnear-infrared photons are absorbedby cytochrome c oxidase (unit fourin the mitochondrial respiratorychain) and small concentrations ofinhibitory nitric oxide may bephoto-dissociated, therebyincreasing respiration and ATP.

Coincidentally with the increase inelectron transport and in ATP,there has also been observed byintracellular fluorescent probes andelectron spin resonance an increasein intracellular reactive oxygenspecies (ROS) such as superoxide,hydrogen peroxide, singlet oxygen,and hydroxyl radical. ROS scav-engers, antioxidants and ROSquenchers block many LLLTprocesses. It has been proposedthat light between 400 and 500 nmmay produce ROS by a photosensi-tization process involving flavins,while longer wavelengths maydirectly produce ROS from themitochondria. Several redox-sensi-tive transcription factors areknown such as NF-kB and AP1,that are able to initiate transcrip-tion of genes involved in protectiveresponses to oxidative stress. Itmay be the case that LLLT can bepro-oxidant in the short-term, butanti-oxidant in the long-term.

BiographyDr. Michael Hamblin is a principalinvestigator at the Wellman Centerfor Photomedicine atMassachusetts General Hospitaland an associate professor ofDermatology at Harvard MedicalSchool. He was trained as asynthetic organic chemist andreceived his PhD from TrentUniversity in England. Hisresearch interests lie in the areasof photodynamic therapy (PDT) forinfections, cancer, and heartdisease and in low-level lighttherapy (LLLT) for wound healing,arthritis, traumatic brain injury,and hair regrowth. He haspublished more than 90 peer-reviewed articles, over 100conference proceedings, book chap-ters and international abstracts,and holds 8 patents. He has editedthe most recent and comprehensivetextbook on PDT entitled Advancesin Photodynamic Therapy: Basic,Translational, and Clinical. He hasdeveloped an interest in elucidatingthe basic molecular and cellular


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mechanisms of LLLT, and for thepast four years has chaired anannual conference at SPIE entitled“Mechanisms for Low-Level LightTherapy.” Dr. Hamblin may becontacted by e-mail [email protected].

Disclosure: Dr. Hamblin’s laboratoryhas received sponsored researchsupport from Palomar MedicalTechnologies Inc, Laser Hair Therapyof North America, and LexingtonInternational. Dr. Hamblin hasreceived consulting fees from the lasttwo companies and is on the scientificadvisory board of LexingtonInternational.

PRESENTATION 9: LIGHT

MODULATES DNA, RNA, AND

PROTEIN EXPRESSION IN THE

NERVOUS SYSTEM

Juanita J. Anders, PhDProfessor, Department of Anatomy,

Physiology, and Genetics,Uniformed Services University of

the Health Sciences

AbstractThis presentation will focus onchanges in mRNA and DNAexpression in the nervous systemsfollowing injury and light therapy.The ability of light to alter themRNA expression in progenitorcells will also be presented.

BiographyDr. Juanita Anders is a professor ofAnatomy, Physiology, and Geneticsat the Uniformed ServicesUniversity of the Health Sciences(USUHS). She also has a secondaryappointment as professor ofNeuroscience at USUHS. Shereceived her PhD in Anatomy fromthe University of Maryland MedicalSchool and specializes in peripheraland central nervous system injuryand repair mechanisms. While atthe National Institutes of Health inthe Laboratory of Neuropathologyand Neuroanatomical Sciences,National Institute of NeurologicalDisorders and Stroke (NINDS), she

specialized in glial/neuronal inter-action in normal and injurednervous tissue. Since joiningUSUHS, her research interestshave expanded to the use of lightas a noninvasive therapy for deeptissue injuries and the interactionof light with pluripotent cells. Herresearch on the use of light appliednoninvasively for repair of spinalcord injury has received interna-tional attention. She is recognizedas an expert in light therapy andhas been invited to speak and chairsessions at numerous internationallaser conferences. Dr. Anders serveson the Executive Councils andScientific Advisory Boards ofseveral laser societies. She is alsothe Basic Sciences representativeon the Board of ASLMS. She is thepast president of the NorthAmerican Association for LaserTherapy and a founding member ofthe International Academy of LaserMedicine and Surgery. She serveson the Editorial Boards ofPhotomedicine and Laser Surgeryand Lasers in Surgery andMedicine and as a reviewer forseveral other journals. She haspublished more than 50 peer-reviewed articles. Dr. Anders maybe contacted by e-mail [email protected].

Disclosure: Dr. Anders has no dualcommitments as defined in the ALDDisclosure Policy. In the course of thispresentation she will discuss the ThorLaser, an investigational device usedto irradiate spinal cords.

PRESENTATION 10: LLLT-ACTIVATED TGF-BETA: AMOLECULAR MEDIATOR IN ORAL

WOUND HEALING AND DENTINAL

REPAIR

Praveen R. Arany, BDS, MDSHarvard School of Dental Medicine

AbstractThe ability of laser light to modu-late specific biological processeshas been well documented but theprecise molecular mechanisms

mediating these photobiologicalinteractions remain an area ofintense investigation. This presen-tation will cover two aspects oflaser biological interaction withemphasis on the molecular path-ways involved in oral woundhealing and dentinal tissue repair.We recently published the resultsof our clinical trial with 30 patientsin an oral tooth-extraction woundhealing model using a 904-nmGaAs laser (Oralaser 1010, Oralia,Konstanz, Germany), assessinghealing parameters using routinehistopathology and immuno-staining (Arany PR, Nayak RS,Hallikerimath S, Limaye AM, KaleAD, Kondaiah P. Activation oflatent TGF-beta1 by low-powerlaser in vitro correlates withincreased TFG-beta1 levels inlaser-enhanced wound healing.Wound Rep Regen 2007, 15(6):866-874). We observed a betterorganized healing response inlaser-irradiated oral tissues thatcorrelated with an increasedexpression of TGF-beta1 immedi-ately after laser irradiation. Wealso demonstrated the ability of thelow-power near-infrared laser irra-diation to activate the latentTGF-beta complexes in vitro atvarying fluences using an isoform-specific enzyme-linkedimmunosorbent assay (ELISA) anda reporter-based (p3TP-lux) assaysystem. I will present some of ourlatest data further characterizingthe precise photomolecular mecha-nism affecting the latent TGF-betaactivation process by LLLT. I havebeen studying the role of specificgrowth factors and physical nichein determining odontogenic differ-entiation. Interestingly, TGF-betashave been shown to be key regula-tors in dentin differentiation. Ihave been using a combination ofscaffold approaches, morphogencues, and stem cells to explore therole of low-level laser therapy(LLLT) in activating the latentTGF-beta complex and drivedentinal differentiation in vitro.


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These experiments are directedtoward addressing the rationale ofLLLT as a clinical treatmentmodality in pulp capping anddesensitization procedures with thehope that understanding the basicmechanisms will improve the effi-cacy of these treatments in clinicalcare. In summary, I will presentevidence of a potential molecularmechanism for laser photobiomodu-lation in its ability to activatelatent TGF-beta complexes.

BiographyDr. Praveen Arany trained as adentist and oral pathologist inIndia and did his postdoctoralfellowships in molecular and cellbiology at the Indian Institute ofSciences, Bangalore and theNational Cancer Institute, NIH,Bethesda. He is presently pursuingan interdisciplinary joint PhD-Residency program across variousHarvard institutions including theHarvard School of Dental Medicine,Harvard Medical School, HarvardSchool of Engineering & AppliedSciences, and the Brigham andWomen’s Hospital. His presentresearch is focused on under-standing the intricate signalingmechanisms involved in sensingand responding to external cuesduring development, woundhealing, and regeneration as wellas the loss of these regulatedprocesses during carcinogenesis.Dr. Arany may be contacted by e-mail at [email protected].

Disclosure: Dr. Arany has no dualcommitments as defined in the ALDDisclosure Policy. In the course of thispresentation he will discuss the 904-nm laser, an investigational deviceused for oral wound healing.

PRESENTATION 11: NEAR-INFRARED

LED PHOTOBIOMODULATION TO

ENHANCE BONE DENSITY AND

OSTEOINTEGRATION

Jerry Bouquot, DDS, MSDProfessor & Chair, Department of

Diagnostic Sciences,

University of Texas, Dental Branchat Houston

AbstractDental implants must be placed inhealthy bone for successful osteoin-tegration and stability. Low bonedensity (LBD) and ischemicallydamaged, desiccated bone both havea poor ability to remodel and are,therefore, contraindications forimplants. Readily available diag-nostic imaging devices, includingdental radiographs, lack the abilityto adequately identify such bone.QUS (through-transmission ultra-sound) is specifically cleared by theFDA to safely identify LBD anddehydrated bone and has a very low(< 3%) false positive rate.Furthermore, near-infrared light-emitting diode (NIR-LED) “therapy”or photobiomodulation has beenshown in cultured cells and animalmodels to stimulate bone healingand production. This presentationwill summarize the results of a clin-ical investigation which used QUSto determine the efficacy of NIR-LED phototherapy to increase bonedensity and/or hydration ofabnormal alveolar bone. It will alsoreview the literature on NIR-LEDuse in healthy and diseased tissues,as well the results of a very recentin vitro experiment evaluating theattachment of osteoblasts to tita-nium implant material with andwithout NIR-LED use.

In vivo investigation of bonedensity change: A cohort of 68patients received LED therapy(OsseoPulse, version 1.0, BioluxResearch Ltd., Vancouver, BritishColumbia, Canada; 15 minutesdaily for 3 months) to 294 QUSpositive edentulous alveolar sites ofLBD/desiccation. Before and afterQUS, scans were graded blindly bytwo independent observers (5-pointscale: 0 = normal bone, 4 = mostsevere), after calibration, andcompared using matched pairanalysis. After NID-LED photo-modulation the average gradeimproved from 2.43 to 1.33 (44.3%

improvement), with 42% of sitesreturning to completely normalbone and 18.4% returning to grade1. The mean difference (improve-ment of bone quality) of -1.11 wasvery statistically significant(matched pair analysis: Standarderror 0.06914; t-Ratio -15.9896;Degree of freedom (DF) 293; proba-bility [t] less than 0.0001; 95%confidence interval 0.558-1.242).NIR-LED therapy seems to holdgood potential for improving alve-olar bone prior to implantplacement, but long-term improve-ment must be evaluated, as mustactual implant stability.

In vitro investigation of jawboneosteoblastic proliferation andattachment to titanium implantmaterial: Cells derived from humanmandibular bone were exposed toNID-LED at doses of 1 or 2 J/cm2

and then seeded onto titaniumdiscs. Nonexposed cultures servedas controls. After 3 and 6 h, cellswere stained and those attached tothe titanium were counted via lightmicroscope. Additionally, the effectof LED on cell proliferation wasexamined after 48, 72, and 96 h;cells were cultured on titaniumspecimens for 24 h and thenexposed to LED for three consecu-tive days. Cell proliferation wasdetermined by cell counts via lightmicroscopy. Mean transit time(MTT) analyses were alsoperformed to determine cellularattachment and proliferation.

Cellular attachment was signifi-cantly enhanced (p < 0.05) byNIR-LED irradiation at doses of 1and 2 J/cm2 after 3 and 6 h. Theproliferation assays showed highercell proliferation (p < 0.05) in irradi-ated group at doses of 1 and 2 J/cm2

after 72 and 96 h with agreementbetween cell counting and MTTanalyses. Attachment and prolifera-tion of human osteoblast-like cellscultured on titanium implant mate-rial appear to be significantlyenhanced by NIR-LED irradiation,suggesting a future use for thistechnology in alveolar implants.


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BiographyDr. Jerry Bouquot is professor andchair of the Department ofDiagnostic Sciences, University ofTexas Dental Branch at Houston.He has been a chair in twodifferent dental schools for a totalof 23 years and is a diplomat andpast president of the AmericanBoard of Oral & MaxillofacialPathology. He has more than 2decades of research experience inischemic alveolar bone problemsand his research was used to obtainFDA clearance for the firstthrough-transmission ultrasound(QUS) device for dentistry. He andhis co-investigators have alsopresented their research resultsrelating to the use of LED photo-biomodulation on bone density andosteoblastic activity at national andinternational scientific meetings.Dr. Bouquot may be contacted by e-mail at [email protected].

Disclosure: Dr. Bouquot has no dualcommitments as defined in the ALDDisclosure Policy. In the course of

this presentation he will discuss theOsseoPulse laser, an investigationaldevice used to deliver NIR-LED tothe jaw.

PRESENTATION 12: FDA PHYSICS

DIVISION’S RESEARCH ON LIGHT-BASED TECHNOLOGY

Ronald Waynant, PhDSenior Optical Engineer, U.S. Food

and Drug Administration,Rockville, Maryland

AbstractThis presentation will discuss FDAresearch into the mechanism oflaser therapy over the last eightyears including results with devicescovering a wide wavelength range,the discovery of hydrogen peroxideas a major product when lightinteracts with cell cultures, and themeasurement of hydrogen peroxide.This work will also touch on ourbelief that the bystander effectnoted in radiobiology experimentsalso stems from a similar mecha-nism produced by typicalradiobiology sources and our efforts

to confirm this activity. We will alsomention our thoughts of ways toextend our results in cell cultures tointeractions in animals andhumans perhaps leading to meas-urements of the status of ourimmune system.

Biography and DisclosureDetails are listed above.

CLOSING: OPEN FORUM DISCUSSION

“THE FUTURE AND WHERE DO WE

GO FROM HERE?”Donald J. Coluzzi, DDS, Moderator

SummaryAll of the presentations were well-received and each prompted somediscussion. The closing sessionfeatured an interchange ofthoughts about the FDA’s regula-tory process particularly as itapplies to marketing clearances.The ALD collected evaluations fromsome of the participants and all ofthe feedback was very positive forthe program contents and theoverall experience. ■■


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R ESEARC H AB STR AC TS

In his description of two clinical cases (37-38), Dr.Alfred Wyatt, Jr. utilizes an Er:YAG laser to assist withthe removal of porcelain veneers. He indicates theprocedure lies in the assumption that the laser energyis transmitted through the veneer and absorbed by theresin-based luting cement.

Few published reports exist concerning the use oferbium lasers for this application. Three relatedabstracts are shown below. Two private practitioners,Patrick Broome and Steven Spitz, independently reporton their results when using an Er,Cr:YSGG laser toremove porcelain veneers. A research team led by YukoWatanabe from the Nippon Dental University in Tokyorelates their experience on the effects of Er:YAG laserirradiation on a variety of restorative materials,including porcelain.

Central to the ability of erbium lasers to removeporcelain veneers is the extent to which the laser lightis transmitted through the ceramic material. Moststudies focusing on the translucency of or light trans-mission through dental porcelains have examinedvarious conventional halogen curing lights typicallyoperating in the range of approximately 400 to 500 nm,or light-emitting diode (LED) devices, to assess poly-merization efficacy.1-8 The abstract of one such study isreproduced below. In this case, a group of investigatorsfrom the Federal University of Minas Gerais in Brazilused the incident light from two light cure units(Optilux models 401 and 403, Demetron/Kerr, Danbury,Conn.) in their study of light transmission throughporcelain of varying thicknesses and shades. In anotherstudy, Broadbelt and colleagues1 noted a high degree oflight scattering in dental porcelains, and that transmit-tance increased with incident wavelength, throughtheir investigated upper parameter of 700 nm. Furtherspectrophotometric analysis of the transmission ofadditional wavelengths of light through porcelain, andsubsequent absorption into and debonding of theunderlying luting composite, is warranted.

For U.S. readers, no laser has been cleared by theU.S. Food and Drug Administration for removal ofporcelain veneers.

As always, clinicians are advised to review thespecific indications for use of their lasers and to reviewtheir operator manuals for guidance on operatingparameters before attempting similar techniques ontheir patients.

R EFER ENC ES1. Broadbelt RH, O’Brien WJ, Fan PL. Translucency of dental

porcelains. J Dent Res 1980;59(1):70-75.

2. Chan KC, Boyer DB. Curing light-activated compositecement through porcelain. J Dent Res 1989;68(3):476-480.

3. Frentzen M, Kolymbaris K, Braun A. Variables affectingtransmittance of LED curing light through restaurativematerials. ConsEuro2003, Across European Borders,Prevention, Restoration and Aesthetics. Triannual Meetingof the European Federation of Conservative Dentistry(EFCD) and 17 Annual Meeting of the German Society forConservative Dentistry (DGZ), June 5-7, 2003, Munich,Germany. Clin Oral Investig 2004;8(1):S9, Abstract 22

4. Ilie N, Hickel R. Correlation between ceramics translu-cency and polymerization efficiency through ceramics. DentMater 2008;24(7):908-914.

5. Koch A, Kroeger M, Hartung M, Manetsberger I, HillerKA, Schmalz G, Friedl KH. Influence of ceramic translu-cency on curing efficacy of different light-curing units. JAdhes Dent 2007;9(5):449-462.

6. O’Keefe KL, Pease PL, Herrin HK. Variables affecting thespectral transmittance of light through porcelain veneersamples. J Prosthet Dent 1991;66(4):434-438.

7. Rasetto FH, Driscoll CF, Prestipino V, Masri R, vonFraunhofer JA. Light transmission through all-ceramicdental materials: A pilot study. J Prosthet Dent2005;91(5):441-446.

8. Watts DC, Cash AJ. Analysis of optical transmission by400-500 nm visible light into aesthetic dental biomaterials.J Dent 1994;22(2):112-117. ■■

Editor’s Note: The following four abstracts are offered as topics of current interest. Readers are

invited to submit to the editor inquiries concerning laser-related scientific topics for possible

inclusion in future issues. We’ll scan the literature and present relevant abstracts.

TH E U SE O F ER B IU M LASER S

TO R EMOV E PO RC ELAIN V EN EER S

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The practice of prosthodontics takes all concepts ofdentistry and integrates effective comprehensive treat-ment planning. The practice will necessarily include awide variety of patients seeking a diverse range of care.These include individuals who are highly fearful ofdentistry and have long-term neglected care and thosewho have complex medical histories and require morespecialized, advanced procedures. Some also havephobias and/or allergies to anesthetics. Lasers havebecome an integral part of treatment for these patients.Procedures such as class I through V restorations,crown and veneer preparations, gingival contouring,including surgical placement, can be performedcomfortably and effectively, often with little or no anes-thesia…When removing bonded porcelain restorationsin the past, a high-speed drill with a diamond bur wasthe only option. With laser technology, the restorationcan now be removed without cutting it off. The laser

energy passes through porcelain glass unaffected and isabsorbed by the water molecules present in the adhe-sive. It appears that this debonding occurs at thesilane-resin interface because the underlying toothstructure appears to be unaffected. The technique takesapproximately 5 to 30 seconds for feldspathic, and 2seconds to 2 minutes for pressed, as the time will varyupon the thickness of the restoration. The restorationcan often be removed intact, which can aid the lab tech-nician on color matching. [The described case] shows afractured restoration on the lower right later incisor.Beginning at the gingival aspect, [a 2780-nmEr,Cr:YSGG laser, Waterlase, Biolase Technology,Irvine, Calif., at] 4 W, 20% water and 40% air, was usedto initiate removal, and the process proceeds quickly,with minimal removal of any tooth structure.

Copyright 2008 Alpha Omega International Dental Fraternity. Published by Elsevier B.V. ■■

LASER S IN P RO STHO D O NTIC S :C LIN IC AL REALIT IES OF A DENTAL LASER IN A PROSTHODONTIC PRAC TIC E

Steven D. Spitz, DMDBoston, Massachusetts

Alpha Omegan 2008;101(4):188-194

Adhesive bonding lies at the core of aestheticdentistry and involves various restorative materialsthat can be used to “mimic” nature. When the removalof a bonded porcelain restoration is necessary, a high-speed handpiece with a diamond bur has been the onlyoption for clinicians to facilitate removal and reveal theremaining tooth structure. By using minimally invasivelaser technology, however, the clinician may remove abonded restoration without cutting it off by simplyreversing the light- or dual-cure resin chemical reac-tion. Feldspathic and/or pressed ceramic restorationscan be removed via an Er,Cr:YSGG laser (i.e.,Waterlase MD, Biolase, Irvine, Calif.), which selectivelyinteracts [with] water molecules in the adhesive resin

and hybrid zone. Laser energy passes through porcelainglass unaffected and is absorbed by the water mole-cules present in the adhesive. Clinical observationsindicate that the debonding occurs at the silane-resininterface since the denatured resin remains attached tothe tooth structure and the restoration debondswithout any residual resin attached to its innersurface. The water molecules are selectively excited,thus causing delamination of the restoration. Oncebond failure occurs, the restoration can be removed –often in one piece – and the original preparation maybe accessed without underlying tooth structureremoval.

Copyright 2007 Montage Media Corporation ■■

U TILIZATIO N O F AN ER ,C R :YSGG LASERFO R TH E R EMOVAL O F ALL- C ER AMIC R ESTO R ATIO N S

Patrick J. Broome, DMD, MBACharlotte, North Carolina

Pract Proced Aesthet Dent 2007;19(1):23-25.

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Objective. This study evaluates the effect of shadeand thickness of porcelain in light transmission.Methods. One hundred and twenty-eight disks ofDuceram® porcelain were made to combine fourdifferent thicknesses (1.5; 2.0; 3.0; 4.0 mm) and eightshades (A1; A4; B1; B4; C1; C4; D2; D4). A digital powermeter (Newport Optical Power Meter®) was used tomeasure light transmission. The porcelain transmissioncoefficient was calculated using Lambert-Beer law, tc =Ce-αd, where tc is the transmission coefficient, C thecontribution factor of the reflection coefficient, e aconstant, α the absorption coefficient and d is thesample thickness. Results. The transmission coefficientsdid not vary statistically in relation to the two visiblelight-curing units studied. From all the samples, thecolors A1 and D2, thickness 1.5 mm, presented thehighest percentages of transmission (8%) and theshades, A4, B4 and C4, thickness 4 mm, the lowest

(0.5%). The relationship between the Naperian loga-rithm of the transmission coefficient and the samplesthickness followed the Lambert-Beer law. The linearadjustment of the experimental points of the two vari-ables, showed the absorption coefficient (α) and theconstant value related to the reflection (C) of eachporcelain shade. The reflection coefficient values of allshades did not vary statistically among themselves.Significance. For most shades there was a significantdecrease in light transmission as the sample porcelainthickness increased. For the same thickness mostshades presented statistical difference between thetransmission coefficients. However, the larger the thick-ness, the higher the number of shades which,statistically, showed no difference.

Copyright 2006 Academy of Dental Materials. Published by Elsevier Ltd. ■■

LIGHT TR AN SMISSIO N TH RO U GH PO RC ELAIN

Rogéli T.R.C. Peixoto, Vanessa Maria F. Paulinelli, Herbert H. Sander, Marcos D. Lanza,

Luiz Alberto Cury, Luiz Thadeu A. PolettoFederal University of Minas Gerais, Belo Horizonte, Brazil

Dent Mater 2007;23(11):1363-1368

The Er:YAG laser has been used to treat dentaldecay. The purpose of this study was to observe themorphological surface changes of new types of tooth-colored restorative materials irradiated with Er:YAGlaser and to analyze the changes using electron probemicroanalysis (EPMA). The specimens were preparedfrom 5 tooth-colored restorative materials (porcelain,castable ceramics, hybrid ceramics, ceromer material,and polymer glass). Each specimen was irradiated witha fine water mist under the following conditions:energy, 300 mJ; pulse frequency, 1 Hz; focal distance, 12mm; and total pulse, 1 shot/3 shot. The surfaces of thespecimens were examined and analyzed by EPMA. Thewidth and depth of the craters produced on the surface

by Er:YAG laser irradiation were measured with ameasuring scope. The data were analyzed by ANOVAand Tukey’s q-test. The results were as follows: 1.Porcelain and castable ceramics were not affected bythe Er:YAG laser irradiation. 2. The Er:YAG laser irra-diation was able to ablate the hybrid ceramics, ceromermaterial and polymer glass. These surfaces had acrater form. The degree of ablation was significantlydifferent among these three materials. 3. EPMA obser-vation revealed that the Er:YAG laser irradiationcaused filler particles of hybrid ceramics, ceromermaterial and polymer glass to protrude from thesurface of the craters.

Copyright 1999 The Society of The Nippon Dental University ■■

TH E EFFEC TS O F TH E ER :YAG LASER IR R AD IATIO NO N TH E N EW T YP E R ESTO R ATIV E MATER IALS

Yuko Watanabe, Toru Eguro, Toru Maeda, Hisayoshi TanakaThe Nippon Dental University School of Dentistry at Tokyo

Shigaku (Odontology) 1999;87(3):329-339

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Dr. Arthur Levy presents a protocol for the adjunc-tive use of a soft tissue laser for treatment ofperiodontal disease (21-26). To complement his perspec-tive, readers may wish to examine the following articlesrelated to laser treatment of periodontal disease thathave appeared in previous issues of Wavelengths andthe Journal.

1. Barr RE, Evans D. Nd:YAG laser sulcular debridement(soft tissue curettage). Wavelengths 1997;5(3):6-7.

2. Brister J. Treatment of acute marginal gingivitis incipientperiodontitis utilizing the Nd:YAG soft tissue laser. J AcadLaser Dent 2004;12(2):12-14.

3. Casper P. Peaks and valleys: A three-year case studyexamining the use of diode laser-assisted periodontaltherapy. J Acad Laser Dent 2004;12(4):17-19.

4. Coluzzi DJ. Laser-assisted sulcular debridement.Wavelengths 2001;9(3):19.

5. Coluzzi DJ, Raffetto N. Laser curettage as adjunctive treat-ment of moderate periodontal disease. Wavelengths1997;5(3):4-5.

6. Deruyter B. Nd:YAG laser adjunctive treatment of perio -dontitis. J Acad Laser Dent 2006;14(3):19-22.

7. Deruyter B. Periodontal recontouring (localized juvenileperiodontitis) using an Nd:YAG (1064 nm) laser. J AcadLaser Dent 2006;14(4):21-24.

8. Gutierrez T. Nd:YAG laser soft tissue therapy combinedwith conventional osseous surgery. Wavelengths1999;7(3):4, 21.

9. Maddox S. Treatment of class IV periodontal disease usinga 820-nm diode laser. Wavelengths 2003;11(3):22-24.

10. Maddox S. Treatment of class IV periodontal disease usinga diode laser (820 nm). Wavelengths 2004;12(1):17-19.

11. Maestas LB. Nd:YAG laser curettage as an adjunctivetreatment of Class III periodontal disease. Wavelengths2001;9(3):19.

12. Maestas LB. Nd:YAG laser curettage as an adjunctivetreatment of Class IV periodontal disease. Wavelengths2001;9(3):18, 23.

13. Maestas LB. Nd:YAG laser curettage as an adjunctivetreatment of Type III moderate periodontitis. Wavelengths2001;9(3):19.

14. McMahon JL. Nd:YAG laser-assisted treatment of acuteperiodontal disease: Case 2. J Acad Laser Dent2005;13(2):25-28.

15. McMahon JL. Nd:YAG laser-assisted treatment of chronicperiodontal disease: Case 1. J Acad Laser Dent2005;13(2):21-24.

16. Molinaro SM. Nd:YAG laser gingivoplasty, pocket depthreduction and curettage. Wavelengths 1998;6(4):7-9.

17. Mott AS. Nd:YAG laser-assisted treatment of chronic perio -dontal disease: Case 1. J Acad Laser Dent2005;13(2):13-16.

18. Mott AS. Nd:YAG laser-assisted treatment of chronic perio -dontal disease: Case 2. J Acad Laser Dent2005;13(2):17-20.

19. Payas G. Clinical applications of Er:YAG, CO2, and diodelasers for frenectomy, caries removal, and sulcular debride-ment. J Acad Laser Dent 2006;14(1):16-20.

20. Raffetto N. “The good, the bad, and the ugly”: 810-830-nmdiode laser therapy for the periodontal patient whosmokes. J Laser Dent 2008;16(3):131-135.

21. Smith ML. Nd:YAG laser use in treatment of moderatechronic periodontitis. J Laser Dent 2007;15(3):144-150.

22. Smith ML. Nd:YAG laser-assisted treatment of moderatechronic periodontitis. J Laser Dent 2008;16(1):23-29.

23. Smith ML. Nd:YAG laser-assisted treatment of moderatechronic periodontitis and Nd:YAG laser treatment of twoaphthous ulcerative lesions. J Laser Dent 2008;16(2):93-100.

24. Yung F. Curettage and buccal frenectomy utilizing a 980-nm diode laser. Wavelengths 2003;11(3):14-16. ■■

LASER TR EATMENT O F

P ER IO D O NTAL D ISEASE

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C O NTIN U ING ED U C ATIO N

JO U R NAL O F LASER D ENTISTRY

Continuing Education Program

The Journal of Laser Dentistry’sContinuing Dental EducationProgram offers readers an opportu-nity to earn one CE self-instructionalcredit for one of the articles in thisissue. Read the specified article andthen select the most correct answerto each of the questions below. If youcorrectly answer 7 of the 10 ques-tions on the test (for a score of 70%),you earn one credit hour. Theanswer form must be completed asdirected in the instructions; other-wise, it will not be processed.

This program is developed byrepresentatives of the Academy ofLaser Dentistry’s Science andResearch committee and is providedas a benefit to ALD members at noadditional charge. Nonmembersare also eligible to participate for a$20 administrative fee per issue.Answers to this exercise will be

published in a future issue.Please photocopy and legibly

complete the registration formas well as the answer sheet andevaluation form on page 64 andmail it (along with the quarterly$20 administrative fee if you arenot an ALD member) to:

The Journal of Laser DentistryDepartment of Continuing

EducationP.O. Box 8667Coral Springs, FL 33075

Payment may be by check drawnon a U.S. bank, money order, orVISA or MasterCard. Please keepa copy of your answers for yourrecords. ALD will not return youranswer sheet. Answers to the testwill be published in a future issueof the Journal. ALD will send an

indication of the status of your CEcredit within 90 days of thepublished due date (July 31, 2009).

Your test is graded by represen-tatives of the Academy of LaserDentistry, an ADA CERP recog-nized provider.

You will be notified by mail ofyour test score(s) and the numberof credits awarded. You must thenforward the information to yourstate dental board or agency forlicensure purposes. Individualswho score less than 70% willreceive a letter.

Answers to these tests are dueon or before July 31, 2009.

Please call the Academy of LaserDentistry (954) 346-3776 if you haveany questions about this program.

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Educational ObjectivesUpon successful completion of

this module, you will be able to:• Specify the major photobiological

effect of surgical lasers used indentistry, and describe the mainfactors that influence this effect.

• Define photobiomodulation andspecify how such effects areproduced by lasers.

• Define the terms vaporization,ablation, coagulation, carboniza-tion, conduction, convection, andradiation.

• Specify at which temperaturespathogen deactivation, coagula-tion, vaporization, andcarbonization occur.

• Identify which dental laser wave-length is most strongly absorbedby water.

• Describe how thermal laser-tissue interaction may bemaximized.

Test Questions1. The type of photobiological effect

produced by a laser is primarilydependent on the:a. laser’s delivery system and

handpiece tipb. laser’s power density and

duration of exposurec. water content of the target

tissued. degree of fluorescence of the

target tissue

2. The predominant photobiologicaleffect of currently availabledental surgical lasers is:a. photodisruptionb. photoablativec. plasma-induced ablationd. thermal

3. Photobiomodulation effects areproduced by:a. power densities in excess of

1,000 Watts per squarecentimeter

b. low energy levels and lowthermal input

c. exposure durations less thanone millisecond

d. tissue temperatures in excessof 100 degrees Celsius

4. Ablation is defined as:a. removal of a segment of tissue

by a thermal interactionb. nonthermal disruption of the

tissuec. coagulation of proteinsd. biostimulation of connective

tissue

5. Vaporization occurs at whichtemperature?a. 50 degrees Celsiusb. 60 degrees Celsiusc. 100 degrees Celsiusd. 200 degrees Celsius

6. Coagulation of soft tissue occursat which temperature?a. 50 degrees Celsiusb. 60 degrees Celsiusc. 100 degrees Celsiusd. 200 degrees Celsius

7. Conduction is:a. transfer of heat by radiationb. removal of tissue by photodis-

ruptionc. absorption of heat during

noncontact proceduresd. transfer of heat by direct

molecular collision

8. Radiation is:a. transfer of heat by direct

conductionb. utilization of the heat of the

laser beamc. transfer of energy by electro-

magnetic wavesd. reflectance of laser energy

from the target tissue

9. In order to maximize the thermallaser-tissue interaction, which ofthe following is required?a. the laser wavelength should

be closely matched to thetissue’s chromophore(s)

b. the laser must be used in acontinuous-wave mode

c. only far-infrared laser wave-lengths should be used

d. the laser energy should betotally transmitted throughthe tissue

10. Of the currently availabledental laser wavelengths listedbelow, the maximum waterabsorption occurs with which ofthe following?a. 810 nmb. 980 nmc. 2,940 nmd. 10,600 nm

AC AD EMY O F LASER D ENTISTRY • SELF-IN STR U C TIO N P RO GR AM NO . 1711Subject Code: 497

Laser-Tissue Interaction IMichael Swick, DMD

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Place an X in the box correspon-ding to the answer you believe ismost correct.

A B C D

1. ❑ ❑ ❑ ❑

2. ❑ ❑ ❑ ❑

3. ❑ ❑ ❑ ❑

4. ❑ ❑ ❑ ❑

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Program Evaluation — Test 1711Please evaluate this article.

Poor = 1 to Excellent = 5

Clarity of objectives _____

Usefulness of the content _____

Benefit to your clinical practice _____

Quality of the manuscript _____

Usefulness of the references _____

Quality of the illustrations _____

Relevance of the illustrations_____

Clarity of the questions _____

Relevance of the questions _____

The article presented new information _____

Program achieved its educational objectives _____

How many minutes did it take you to read the article and complete the test? _____

Please list future CE topic preferences:

AN SWER SH EET FO R TEST 1711Laser-Tissue Interaction I

Michael Swick, DMDSubject Code: 497

C O NTIN U ING ED U C ATIO N C R ED IT R EGISTR ATIO N FO R M

Please print or type clearly. The certificate will be issued from the information given.

First Name Initial Last Name

Degree AGD Number (if applicable)

Street Address Suite

City State or Province Postal Code

Daytime Telephone Number with Area Code Fax Number with Area Code

E-mail Address

Nonmembers only: I wish to pay the $20 administrative fee by the following method:❑ Check #__________________ ❑ VISA ❑ MasterCard

Credit Card # Expiration Date

Name on Card Signature

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AN SWER S TO P R EV IO U S C E P RO GR AMS

Test questions with correctanswers underlined

1. The use of laser energy in theablation of dental hard tissue isan example of:a. photochemical interactionb. photothermal interactionc. photobiomodulationd. photogenic interaction

2. Several factors contribute to theefficient erbium laser ablation ofdental hard tissue. Among theseare the:a. laser’s delivery systemb. power density at the ablation

sitec. type of anesthesia used on

the patientd. amount of preconditioning of

the laser tip

3. The principal laser wavelengthsused in tooth preparation areEr:YAG and Er,Cr:YSGG. Theirrespective wavelengths are:a. 2,100 nm and 2,780 nmb. 2,100 nm and 2,940 nmc. 2,780 nm and 2,940 nmd. 2,940 nm and 9,600 nm

4. The erbium laser wavelengthshave a:a. high absorption by waterb. low absorption by waterc. very high absorption by

hydroxyapatited. very low absorption by collagen

5. The surface of dentin after expo-sure to either Er:YAG orEr,Cr:YSGG laser irradiationhas the following characteristics:a. a smear layer and closed

tubulesb. a smear layer and open

tubulesc. absence of a smear layerd. presence of carbonization

6. A co-axial water spray duringerbium laser preparation ofenamel and dentin is necessarybecause the spray:a. serves to aim the laser beam

at the targetb. cools the laser tipc. aids in desensitizing the

tooth structured. helps to disperse debris and

ablation products

7. Erbium laser irradiation ofenamel and dentin results in amicro-cavitated surface. Thissurface:a. should be desensitized to

avoid pulpal damageb. is ideal for bonding composite

resinc. requires additional acid-etch

techniques to minimize earlymarginal breakdown of thecomposite restoration

d. should be protected with acavity liner prior to restora-tion

8. Each of the following is a safetyconsideration when usingerbium laser wavelengthsEXCEPT one. Which one is thisEXCEPTION?a. wavelength- and device-

specific protection glasses forthe doctor, the assistant, andpatient to prevent eyedamage

b. appropriate face-masks toavoid plume aspiration

c. high-speed evacuation ofplume and debris to removepotentially harmful combus-tion byproducts

d. encasement of the laser tip ina wavelength-specific shieldto minimize unwanted beamdiversion

9. Which of the following statementsis true? Erbium laser energy:a. has greater absorption in

demineralized tooth structurethan in healthy tooth struc-ture

b. is so efficiently absorbed thatno debris accumulates in adeep preparation

c. has greater absorption inhealthy tooth structure thanin demineralized tooth struc-ture

d. does not cause any thermalrise in the target tissue

10. Studies of the pulpal tempera-ture rise when using erbiumlasers confirm the following:a. temperature rise is rapid

with each pulse and careshould be taken to avoiddamage

b. pulpal temperature rise iswithin 5 degrees Celsiusabove normal

c. pulpal temperature rise isapproximately the same aswith an air turbine

d. erbium laser wavelengthsinduce photobiomodulationwhich keeps the temperaturerise within normal limits

Answer Sheet for Test 1621

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AC AD EMY O F LASER D ENTISTRY • SELF-IN STR U C TIO N P RO GR AM NO . 16 21Subject Code: 250

Clinical Considerations for the Use of Er:YAG Lasers in Restorative DentistryGiuseppe Iaria, Dr. Prof. Med. Dent., Steven P.A. Parker, BDS, LDS RCS, MGGDP

J Laser Dent 2008;16(2)


1. Which of the following state-ments is true? Peri-implantitis:a. manifests as an inflammation

of the structures surroundingan implant fixture

b. is a disease of soft tissuedestruction only

c. has clinical signs similar to acarious lesion

d. cannot be treated with a laser

2. One of the major factorscontributing to peri-implantitis isthe:a. design and shape of the

implant fixtureb. specific tooth that is being

replaced by the implantc. amount of bacterial exposure

to the implantd. length of time that the

implant has been allowed toosseo-integrate

3. The development of peri-implan-titis can occur because of:a. the quantity of bone

surrounding the area wherethe implant is to be placed

b. the initial depth of theosteotomy

c. the thermal trauma to theperiodontium during theosteotomy

d. a postoperative complication

4. Clinical signs of peri-implantitisinclude:a. marginal discrepancy of the

restorationb. bleeding or purulence from

the gingival tissuec. loosening of the restoration

from the abutmentd. fracture of the mechanical

connection between therestoration and the abutment

5. Which of the following is a ther-apeutic treatment ofperi-implantitis?a. removal of the implant

fixture and restorationb. occlusal adjustment of the

restorationc. removal of the granulation

tissue with plastic curettesd. supragingival prophylaxis

with pumice

6. The Er:YAG laser can be usedfor the treatment of peri-implan-titis because this device:a. is highly absorbed by the

metallic surface of theimplant fixture

b. can reshape the body of theimplant fixture

c. produces very high tempera-tures in the osseous tissue

d. can vaporize the existinginflammatory granulationtissue

7. The Er:YAG laser can be usedfor dental osseous surgicalprocedures because it:a. instantly provides coagula-

tion of the osseous tissueb. will remove only healthy

osseous tissue and not theinflammatory material

c. is effective in removing necroticand healthy osseous tissue

d. will regenerate neededosseous tissue

8. The Er:YAG laser can be useddirectly on the implant surfacebecause it:a. has no damaging effect on the

implant screw areas at lowenergy settings

b. can be used to remove someof the screw threads

c. will recrystallize the metallicsurface of the implant toharden it

d. will not disturb the biofilmthat adheres to the implant

9. According to the peri-implantitistreatment plan described in thearticle, the Er:YAG laser will beused for:a. carving the occlusal surface of

the implant restorationb. making a pilot hole for the

osteotomyc. preparing the donor gingival

graft sited. ablating the soft and hard

tissue in the periodontaldefect

10. According to the peri-implan-titis treatment sequencedescribed in this article:a. a free gingival graft was

placed over ablated softtissue

b. a xenograft bone substitutematerial was placed into thecleaned defect

c. the soft granulation tissuewas removed with handinstruments

d. the implant fixture wasremoved


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Peri-Implantitis Therapy with an Er:YAG LaserAvi Reyhanian, DDS and Donald J. Coluzzi, DDS


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1. Lasers are an effective alternativefor treating pulps in pediatricteeth without the need to:a. use local anestheticsb. use tooth isolationc. introduce chemicalsd. sedate the patient

2. A pulpotomy is defined as:a. the removal of the coronal

pulp of a toothb. the removal of very deep

dentinal cariesc. a root canal procedure for

pulp tissue that is irre-versibly infected or necroticdue to caries or trauma

d. placement of calciumhydroxide paste on thehealthy dentin

3. A concern when using formocre-osol for pulpotomy treatment ofprimary teeth is that:a. formocreosol may be absorbed

and distributed throughoutthe child’s body withinminutes of its use at thepulpotomy site

b. the child may have extremepain immediately after thetooth is treated

c. the child may complain of aburning sensation after thetooth is treated

d. formocreosol may get on anddiscolor the child’s skin if thechild moves

4. When a laser is utilized toperform a pulpotomy, which ofthe following statementsapplies?a. the laser should not be used

on children under the age ofone year

b. the laser should not be usedon permanent teeth

c. the laser treatment’s successis similar to that achievedwith chemical pulp therapy

d. A carbon dioxide laser is thepreferred wavelength for alaser pulp treatment

5. Which of the following is true forEr:YAG laser pulpotomy treat-ment? The laser:a. should be used with the tip

placed 5 mm from the pulpchamber

b. can be utilized for a pulpo-tomy as an alternative toelectrosurgical therapy

c. is always used to removetooth structure for access tothe pulp chamber

d. is always used without anylocal anesthetic

6. When the Er:YAG laser is usedfor pulp therapy, which of thefollowing applies?a. only the child patient

requires laser safety glassesb. everyone within the operating

area is required to use lasersafety glasses

c. no one in the operating arearequires laser safety glasses,since the Er:YAG laser isharmless to the eyes

d. only the dentist is required touse laser glasses since thechild’s mouth is so small thelaser beam stays within thechild’s oral cavity

7. A successful pulpotomy on aprimary tooth should last:a. one yearb. five yearsc. ten yearsd. until the permanent tooth

normally erupts

8. As indicated in the publishedcase study, successful pulpotomytherapy using the Er:YAG laserrequires a power setting ofapproximately:a. 4 Wattsb. 6 Wattsc. 0.75 Wattd. 1.65 Watts

9. Which of following is requiredwhen using the Er:YAG laser fora pulpotomy on a pediatricpatient?a. high-volume evacuationb. premedication for the patientc. use of loupes or a microscoped. presence of the patient’s

parent in the operatory

10. The Er:YAG laser can be usedto treat:a. only posterior primary and

permanent teethb. only anterior primary teethc. only vital teethd. both vital and non vital

primary teeth


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Use of an Er:YAG Laser for Pulpotomies in Vital and Nonvital Primary TeethLawrence Kotlow, DDSJ Laser Dent 2008;16(2)


1. The currently available laserwavelength(s) that have clinicalindications for use in performingosseous surgery is (are):a. all diodesb. Nd:YAGc. carbon dioxided. Er,Cr:YSGG and Er:YAG

2. The wavelengths utilized forosseous surgery are absorbed bythe chromophores in bone,including:a. hemoglobin and oxyhemoglobinb. water and the hyrdroxyl

group of hydroxyapatitec. phosphate and nitrate groupsd. melanin and xanthophyll

3. When an osteotomy for the place-ment of an implant fixture isperformed with a laser, which ofthe following statements is true?a. the laser has an advantage

because it can much morerapidly prepare the site thansize-matched burs

b. the water spray used for coolingthe tissue is easily directed intoeven the deepest preparationswith conventional tips

c. the end-cutting laser beamdoes not allow for a measureddevelopment of a three-dimensional preparation

d. studies have shown signifi-cant disrupted healing oflaser-prepared osteotomiescompared to the control group

4. To avoid damage to osseoustissue with a laser, themaximum temperature to whichbone should be raised duringosseous surgery is:a. 47 degrees Celsiusb. 42 degrees Celsiusc. 80 degrees Celsiusd. 57 degrees Celsius

5. The application of laser energyon the metal implant should beaccomplished under which of thefollowing considerations:a. Use a laser with a power

density of several thousandWatts per pulse

b. Use a laser with a high peakpower per pulse without awater spray

c. Use a laser in continuous-wave mode with an averagepower of approximately 1.0 W

d. Use a laser that causesdetectable disruption of thecoated implant surface

6. Which of the following state-ments applies to second-stageuncovering of an implantfixture? The procedure:a. should not be performed with

a laser because of the laser’spotential to harm the fixture

b. can be performed with anycommercially available laserwavelength

c. should not be performed witha laser because of the laser’spotential to damage the peri-odontium

d. can be performed only withfiber-delivered lasers withwater spray

7. According to the author, second-stage uncovering of the implantwith a laser:a. can be performed without

regard to the thickness andvascularity of the soft tissue

b. should be performed at astarting average power of 4-5Watts

c. starts with removing a smallcone of tissue until near-contactwith the implant is made

d. should produce rapid buildupof carbonized material on thesoft tissue surface and the tipof the laser

8. Which of the following wasdemonstrated in the article’saccompanying clinical case

examples of second-stage uncov-ering of the implant fixture?a. the choice of laser wavelength

is irrelevant, as long as theproper parameters are utilized

b. the laser clearly damaged theperiodontium

c. excessive soft tissue must notbe removed with a laser

d. a laser cannot be used tocontour the gingival tissueafter uncovering the implant

9. The generally accepted definitionof the term peri-implantitis is:a. the acute inflammation of only

the marginal gingival tissueadjacent to a functional implant

b. inflammatory reactions withloss of supporting bone intissues surrounding a func-tional implant

c. the loosening of the implantabutment

d. disintegration of the restora-tive material on theabutment crown

10. In the treatment of peri-implan-titis, which of the following is true?a. the presence of biofilm on the

implant surface causes noconcern

b. removal of granulation tissueis not recommended by theauthor

c. occlusal loading is neveranalyzed

d. pathogen reduction is aprimary step


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The Use of Laser Energy in ImplantologySteven P.A. Parker, BDS, LDS RCS, MFGDP


The Official Journal of the Academy of Laser Dentistry ... · † Case Report: Removal of Porcelain...

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Transcript of The Official Journal of the Academy of Laser Dentistry ... · † Case Report: Removal of Porcelain...