Lasers and its application in Periodontics.ppt

PRESENTED BY
DR. VAMSI LA VU
READER IN PERIODONTICS
SRI RA MA C HANDRA UNIVERSITY
UNDER THE GUIDANCE OF
PROF.R.SURESH ,
DEAN, PROFESSOR AND HEAD,
DEPARTMENT OF PERIODONTICS ,
FDS, SRU
Lasers and its
application in
Periodontics

Contents
 Introduction.
 Historical perspective.
 L-A-S-E-R.
 LASER terminology.
 LASER physics.
 LASER parts and delivery systems.
 LASER ‘s classification.
 LASER terminology and power calculations.
 Biologic rationale: LASER –tissue interactions.
 LASERS-
 Argon, Diode, Nd YAG, Ho-YAG, Er YAG, Co 2 laser.

Contents
 Laser Safety.
 Applications in dentistry.
 Clinical Applications in Periodontics.
 Literature review.
 Summary.
 Suggested readings.

Introduction- Electromagnetic spectrum

LIGHT
Properties:
 Includes multiple wavelength.
 Has divergence.
 Undergoes scattering.
 Has little energy.

LASER
L- Light
A- Amplification
S- Stimulated
E- Emission
R- Radiation

LASER light properties
 Monochromatic.
 Spatial and temporal coherence (in phase).
 Collimation
 Retains energy over considerable distances.

LASER physics
 How is it produced??

Historical perspective
 1917- Principle of stimulated emission by Albert Einstein. “Zur
Quantern Theorie der Strahlung”
 1954: Townes and Gordon- MASER.
 1957- Gordon Gould introduced the term LASER.
 1960- Theodore Maiman- First LASER- ruby – active medium.
 1961- Gas layer- Javan.- He-Ne laser.

Historical perspective
 1964- Nd YAG- Geusic.
 1965- Co2 Laser- Patel.
 1989- Myers and Myers-FDA approval for use of laser in
dentistry- Nd YAG laser.
 1990- Opthalmic application- ruby laser.
 1995- dental use started.

Parts of a LASER
 Active medium:
Gas , solid, liquid suspended in an optical cavity.
 Power supply: external energy source- flash lamp/
electrical energy.
 Optical resonator: mirrors for amplification.
 Cooling system, Control system, Delivery system.

Active medium
Phase Example
Gas Argon, Co2
Solid Diode
Solid Nd YAG
Solid Er YAG
Liquid Red dye
Usually defines laser type.

Lasing mechanism …
•“Population
inversion” is the
Key.
•Population inversion
– more number of
atoms are in the
excited state than
in ground state.

LASER Delivery systems
Delivery system type
Articulated arm Hollow tubes, 45 degree mirrors
Hollow waveguide Semi-rigid tube with internal reflective pathway
Optic fiber/ rigid tip Quartz-silica flexible fiber with quartz, sapphire
tip
Hand held unit Low power lasers.
Erbium family- fibers with low content of
OH ion are used. (eg) Zirconium fluoride

Modes of operation of LASER
 Continuous wave.(Eg) Diode, Co2 lasers
 Gated pulsed mode. (Eg) Diode, Co2 lasers. (Physical gating of
beam)
 Free running pulsed mode. (Eg) Nd YAG, Er YAG. (property of
the active medium)

LASER Terminology
 Joule: unit of energy (ability to do work).
 Watt: unit of power (rate of doing work).
 One watt= one joule per second.
 Frequency: number of complete oscillations per unit time of a
wave.
 Hertz: units of frequency in cycles per second.
(pulses per second).

Laser Terminology
 Pulsed lasers can be :
Free running (microsecond).
Q switched (nanosecond).
Mode locked (picosecond )
Single pulse (femtosecond).
 Average power: power on a sustained basis.
 Peak power: power level during the pulse.
 Power density: watts per cm2
 Energy density: Fluence: Joules/ cm2

Average power Peak power
 Average power = energy per
pulse ×No of pulses.
For example:
 Energy per pulse- 100mJ.
 No of pulses-20.
 Average power: 2.0 W
 Peak Power = Energy per
pulse divided by pulse
width.
For example:
 Energy per pulse- 100mJ.
 Pulse width-100 microsec.
 Peak power: 1000 W.
Laser power calculations

Laser operation parameters:
 Repetition rate.
 Power.
 Spot size. (fiber diameter/ lens diameter ).
 Energy density. (amount of energy delivered per unit area).
 Total energy.
 “Thermal relaxation time”

Focused De-focused
 Laser beam hits tissue
at its focal point-
narrowest diameter.
 Cutting mode
 Beam moved away
from its focal point.
 Wider area of tissue
affected as beam
diameter increases.
 Ablative mode.
 LLLT.
Laser operation parameters

Contact Non- contact
 Tip is in contact with
tissue.
 Concentrated delivery
of laser energy.
 Char tissue formation
at tip.
 Tactile feedback is
available
 Tip is kept 0.5 to 1 mm
away from tissue.
 Laser energy delivered
at the surface is
reduced.
 No feedback. Only
visual.
Laser Operation parameters

Biologic rationale for LASER use
LASER-tissue interactions

LASER-TISSUE INTERACTION:
1. Reflection.
2. Transmission.
3. Scattering.
4. Absorption.

Absorption characteristics of dental lasers
LASER Wavelength Type Chromophore
Alexandrite 377 nm Solid Calculus
Argon 488-515 nm Gas Hemoglobin,
melanin
He Ne 632 nm Gas Melanin
Diode 810-980 nm Solid Melanin,
hemoglobin.
Nd: YAG 1064 nm Solid Melanin, water
Ho: YAG 2120 nm Solid Water, HA.
Erbium family 2790-2940 nm Solid Water, HA.
Co2 9300, 9600,
10600 nm
Gas Water, HA.

LASER effects are due to:
 Photo thermal.
 Photochemical.
 Fluorescence.
 Photoacoustic.
 Biostimulation.
 Photodynamic.
 Photovaporolysis.
 Photo plasmolysis.

Photothermal effects
Tissue temperature (degree
celsius)
Observed effect
37-50 Hyperthermia
> 60 Coagulation, protein denaturation
70-90 Welding
100-150 Vaporization
>200 Carbonization

Photoacoustic
 The photoacoustic effect is a conversion between
light and acoustic waves due to absorption and
localized thermal excitation.
 When rapid pulses of light are incident on a sample
of matter, they can be absorbed and the resulting
energy will then be radiated as heat.
 This heat causes detectable sound waves due to
pressure variation in the surrounding medium.

Photovaporolysis Photoplasmolysis
 Ascendant heat levels-
phase transfer from
liquid to vapor.
 Tissue removed by
formation of
electrically charged
ions and particles in a
semi-gaseous high
energy state.
LASER effects

Photochemical Biostimulation
 Absorption by
chromophores-
 Tissue response in
terms of change of
covalent structure.
 Fluorescence of tissue.
 Photochemical effect.
 Believed to work towards
healing by stimulation of
factors and processes
involved in healing.
 Below surgical threshold.
 Useful for pain relief,
increased collagen
growth and anti-
inflammatory activity
LASER effects

Laser – soft tissue interaction

Laser- hard tissue interaction
“Spallation
”

Factors influencing laser-tissue
interactions
 Wavelength.
 Power.
 Spot size.
 Nature of tissue.
 Amount of chromophore.
 Mode of operation- continuous / pulsed.
 Exposure time.
 Power and energy density.
 Contact/ non contact mode.

Classification of LASER (Periodontology 2000, 2009)

Hard lasers Soft lasers
 High power.
 Direct interaction with
tissues.
 Surgical threshold
crossed.
 Low power lasers.
 Achieve the desired
effects through indirect
interaction.
 Surgical threshold not
crossed.
Classification- based on application

Classification of LASER- based on safety
 Based on the potential of the primary laser beam or
the reflected beam to cause biologic damage to the
eye or skin.
 Four basic classes:
 Class I.
 Class II: a,b
 Class III: a, b
 Class IV.

Classification of Lasers
Class I lasers
 Do not pose a health hazard.
 Beam is completely enclosed
and does not exit the
housing.
 Max power output: 1/10 th
of milliwatt
 Eg: CD player.
Class II Lasers:
 Visible light with low power
output.
 No hazard- blinking and
aversion reaction.
 Max power output is 1 mW.
 Eg: bar code scanner, laser
pointer
 Two subdivisions:
IIa: dangerous- >1000 sec.
IIb: ¼ th of second.

Laser’s classification
Class IIIa:
 Any wavelength.
 Max Output power: 0.1 to
0.5 W.
 Danger > ¼ th of a
second.
 Caution label.
Class IIIb:
 Hazard to eye- direct or
reflected beam,
irrespective of time of
exposure.
 Safe with matted surface
and no fire hazard.
 Max output power: 0.5 to
5W.

Classification of lasers
Class IV lasers:
 Hazardous for direct viewing and reflection.
 Max output power > 5 W.
 Fire and skin hazards.
 Use safety glasses
 Dental lasers are Class IIIb or Class IV lasers.

Argon laser
LASER characteristics
Wavelength 488 to 514 nm
Active medium Argon Gas
Delivery system Optical fiber
Mode of operation Continuous wave
Chromophore Melanin pigment
Applications Soft tissue only.
Pocket debridement and de-
epithelialization for GTR
“Laser Pocket thermolysis”: Finkbeiner 1995-
absorption by black pigmented bacteria- bacterial
load reduction in the periodontal pocket.

Diode laser
Wavelength 810 to 980 nm
Active medium Semi-conductor diode
Delivery system Optical fiber- quartz or silica
Mode of operation Continuous wave, gated pulsed mode.
Used in focused and de-focused modes.
Chromophore Melanin, hemoglobin.
Applications Primarily soft tissue applications- all
minor surgical procedures.

Nd:YAG laser
Wavelength 1064 nm
Active medium Neodymium in YAG crystal
Delivery system Optical fiber
Mode of operation Continuous wave, pulsed wave
Chromophore Hemoglobin,melanin, water
Applications Effective for soft and Hard tissue.
Causes more thermal damage
Earliest FDA approved laser for dental
use.
Nd:YAP 1340 nm, Black pigmented tissue
absorption.
Do not use for disinfection of implant surfaces- damage to sand blasted and acid
etched surfaces (Kreisler et al 2002).

Erbium family of lasers
 Er YAG- 2940 nm: Zharikov et al 1975.
 Er Cr YSGG- 2780 nm: Zharikov et al 1984 and Moulton et al
1988.
 1988: Phagdiwala: Er YAG laser: ability to ablate the dentinal
hard tissue.
 1989: Pulsed Erbium laser: Keller and Hibst- enamel , dentin
and bone.
 1995: Commercially available.
 1997: introduced for use in dentistry.

Erbium lasers contd……
Wavelength 2940 and 2780
Active medium Erbium ion embedded in YAG or
YSGG crystal
Delivery system Articulated arm, Hollow wave guide,
Water free compound like Zirconium
fluoride fiber with air and water in the
co-axial cable.
Mode of operation Continuous wave, free running pulsed
mode. Used in focused and de-focused
modes.
Chromophore Water, Hydroxyapatite
The laser beam gets absorbed by the water in the enamel, dentin, bone
and soft tissue and this results in a rapid explosive expansion of the
water – Hydrophotonic/ hydrokinetic effect.

Hydrokinetic effect
 “Waterlase”: used to describe the Er Cr YSGG lasers.
 Water plays a significant role in cutting ability of the
laser.
 Riziou and De Shazer,1994- concept of “accelerated
water”.
 Fried D et al 2002: did not find evidence of the
accelerated water concept.
 Hibst et al 2002: high speed photography: no scientific
basis of the hydrokinetic effect.

Co2 laser
Wavelength 9300, 9600, 10600 nm
Active medium Carbon dioxide Gas
Delivery system Articulated arm
Mode of operation Continuous wave, gated pulsed mode.
Used in focused and de-focused
modes.
Chromophore Water, Hydroxyapatite
Limitation: High risk of carbonization

LASER safety
 Regulatory
organizations:CDRH,
ANSI, OSHA.
 ANSI Z136.1 – 2000,
American National
Standard for the Safe Use
of Lasers
 Laser safety officer.
 Laser safety
mechanisms.
 Environment: warning
signs, restricted access,
reflective surface
minimized.
 High volume evacuation.
 Laser use
documentation.
 Training.
 Eye and tissue
protection.

Eye damage
Part of eye damaged Laser type
Corneal damage Er Cr YSGG, Ho YAG, Er YAG, Co2
Lens damage Diode, Nd YAG, Ho YAG, Er Cr YSGG, Er
YAG
Aqueous damage Ho YAG, Er Cr YSGG, Er YAG
Retinal damage Argon, He Ne, Diode, Nd YAG

Laser Safety Officer (LSO)
 Keeper of the key.
 Sets up SOP.
 Knowledge of
operational
characteristics.
 Supervises staff
education and training.
 Laser maintenance and
calibration.
 Posts warning signs.
 Oversees personal
protection.
 Incident reporting.
 Knowledge about
regulations.
 Regulates working area.

Safety mechanisms- LASER (ANSI guidelines)
 On/ off key lock switch.
 Safety interlock.
 Guarded footswitch.
 Emergency stop button.
 Remote interlock jack.
 Software diagnostics.
 System time-out.
 Do not use with
combustible gases.

Applications in dentistry
 Biopsy.
 Apicoectomy.
 Teeth preparation.
 Epulis fissuratum.
 Residual ridge
modification.
 Bleaching.
 Impaction.
 Pontic site preparation.
 Tori reduction.
 Soft tissue modification
around laminates.
 Impacted teeth
exposure- orthodontic
movement.
 Caries removal.
 Root canal disinfection.

Clinical Applications in Periodontics
 Initial non-surgical
pocket therapy.
 Frenectomy.
 Gingivectomy.
 Soft tissue grafting.
 De-epithelialization of
the gingival margin.
 Gingival troughing.
 Removal of granulation
tissue.
 Osseous recontouring.
 Crown lengthening.
 Second stage surgery-
implants.
 Peri-implantitis.
 Operculectomy.

Conventional methods LASER
 Bleeding- surgical field.
 Suturing.
 Local anaesthesia.
 Post-operative discomfort.
 Healing time.
 Post-operative complications.
 Infection.
 Periodontal dressings.
 Effective hemostasis.
 No sutures. (concept of tissue
welding).
 Topical anaesthetic- some
procedures.
 Faster healing.
 Minimal/no post operative
complications.
 Laser sterilization of wound site.
 Laser bandage.
Why Lasers in Periodontics…

Pro’s Con’s
 Hemostasis.
 Ablation.
 Detoxification.
 Bactericidal acitivity.
 Hard tissue damage-
some lasers.
 High cost.
 Risk of pulpal damage-
some lasers.
Lasers

Literature review on use of Lasers in:
1. Gingival soft tissue procedures.
2. Non surgical therapy
Basic studies.
Clinical Studies
3. Surgical pocket therapy.
Basic studies.
Clinical studies.
4. Applications in Implant Therapy
Basic studies.
Clinical studies.
6. Calculus detection system.
7. Low level laser therapy.
8. Photodynamic therapy.

Gingival soft tissue procedures
 Advantages of lasers over conventional and
electrocautery:
 Hemostasis.
 Ablation.
 Little wound contraction/ minimal scarring.
 Faster healing.
 Less post-operative discomfort.
 Less risk of damage to underlying structures as compared to
cautery.

 Indications:
 Gingivectomy.
 Gingivoplasty.
 Frenectomy/ frenotomy.
 Vestibuloplasty.
 Operculectomy.
 Depigmentation.
 Lasers used;
 Diode.
 Nd YAG.
 Er YAG.
 Co2.
Diode and Nd YAG: deep
penetration .
Er YAG, Co2: superficial
action.

Diode and Nd YAG:
 Effective for cutting and
reshaping of soft tissue.
 Good hemostasis
 Greater thermal effects.
 Thicker coagulated layer.
Co2 laser:
 Rapid ablation of soft tissue.
 Good hemostasis.
 Effective even for thick tissue.
 Risk of charring- thermal
damage.

Gingival soft tissue procedures.
Er YAG :
 Fine cutting can be done.
 Less hemostasis as
compared to other lasers.
 Very less thermal damage:
use with irrigation.
 Width of thermally
affected layer: 5-20
microns (Aoki et al 2005)
Er YAG:
 Safer even in thin tissues.
 Useful to remove
melanin and metal
tattoos.

Summary:
 Soft tissue surgery is one of the major indication.
 Co2, Nd Yag, Diode, Er YAG, Er Cr YSGG used.
 Perio-esthetic procedures: Er YAG, Er Cr YSGG is the safest
and most effective.

Non Surgical therapy
Introduction:
 Primarily aimed at efficient removal of plaque and
calculus and reduction of bacterial load,
inflammation.
 Conventional therapy limitations:
 Incomplete removal of calculus.
 Incomplete elimination of inflamed pocket lining.
Lasers used: Diode, Nd YAG, Er YAG, Co2 lasers.

Non-surgical therapy: Basic
studies

Sub- gingival calculus removal
Author and
Year
LASER Study design Observation
period
Findings
Cobb et al 1992 Nd YAG Exp (Laser,
Laser+ RP,
RP+Laser),
Control
(untreated).
Immediately after
treatment
Low effectiveness
of calculus
removal. Decrease
in no of bacteria.
Scharwz et al
2003
Diode Exp (Laser),
Control (SRP)
Immediately after
trmt.
Not effective for
calculus removal.
Thermal damage
to root surface.
Scharwz et al
2001
Er YAG Laser, no control Immediately after
trmt.
Smooth root
surface
morphology.
Effective calculus
removal. No
thermal damage
Scharwz et al
2003
Er YAG with
fluorescent
calculus detection
system
Exp (Laser),
Control (SRP-
hand scaler)
Immediately after
trmt .
Selective
subgingival
calculus removal.
No thermal
damage, less
cementum
removal.

Diode laser Nd YAG laser
 Dry or saline moistened root
surfaces- no detectable
alterations.
 Blood coated specimens-
charring (Kreisler M et al 2002).
 Morlock BJ et al 1992: surface pitting,
craters, melting, carbonization of root
surface.
 Spencer et al 1992, 1996: decrease in
protein/mineral ratio, production of
protein by-products.
 Trylovich DJ et al 1992: Nd YAG
treated root surface – not favorable for
fibroblast attachment.
 Thomas D et al 1994: Laser followed
by SRP- restores the biocompatibility
of root surface
Root surface alterations

Co2 laser Erbium family
 SpencerP, Cobb CM et al 1996:
 Carbonized layer on root
surface.
 Cyanamide , cyanate ions-
detected on the carbonized
layer- FTIS method.
 Gopin BW et al 1997: Char
layer inhibits periodontal soft
tissue attachment.
 Co2 laser contraindicated for
root surface treatment in
focused mode.
• Aoki et al 2000: Er YAG with
coolant:
 micro-irregular surface.
 No thermal effects such as
cracking, fissuring.
• Sasaki KM et al 2002: no
major chemical or
compositional change- on
root cementum or dentin.
• Biocompatability of root
surface: micro-irregularity
offers better attachment to
fibroblasts (Scharwz F et al
2003).
Root surface alterations

Bactericidal and Detoxification effects- Basic studies
Introduction:
 Mechanical therapy- incomplete removal of bacteria.
 Antibiotic therapy- ineffective in bio-film environment. Acts
against planktonic bacteria.
 All lasers have bactericidal activity. Mechanism of action may be
different. May need use of a photosensitizer dye.

Detoxification effects: Basic studies
Author and Year Laser Findings
Misra V et al 1999 Co2 Smear layer removal.
Crespi et al 2002 Co2 Root surface de-
contamination. Favorable
for cell attachment.
White JM et al 1991 Nd YAG De-contamination of
irradiated dentin
Fukuda M et al 1994 Nd YAG Inactivation of endotoxin
of periodontally diseased
root surface.
Ando Y et al 1996 Er YAG High bactericidal activity
at low energy settings
Yamaguchi et al 1997 Er YAG Removes LPS diffused
into root surface

Clinical Studies: Non surgical
therapy

LANAP- Laser Assisted New Attachment Procedure
 LANAP- similar to ENAP.
 Gold and Villardi 1994, safe application of the Nd YAG laser
for removal of pocket epithelium lining without carbonization of
the underlying connective tissue.
 Approved by FDA for use.
 Yukna et al 2007- case series- histologic study- new
cementum with new connective tissue attachment on
previously diseased root surface.

Author and
Year
Laser used Study design Observation
period
Findings
Ben Hatit et al
1996
Nd YAG RCT
SRP+ Laser, SRP
Immediately after,
2, 6 weeks and 10
weeks
Significantly
reduced post-
therapy levels of
bacteria following
adjunctive laser.
Liu et al 1999 Nd YAG RCT- split mouth.
Laser, Laser+ SRP
(6 weeks later)
and SRP + Laser
(6 weeks later).
12 weeks Less effectiveness
of laser treatment
in reducing IL-1
beta as compared
to SRP.
Miyazaki et al
2003
Nd YAG RCT (Laser vs
Ultrasonic)
1,4,12 weeks Similar results
between laser and
US- reductn of
P.ging and Il-1
beta levels.
Noguchi et al
2005
Nd YAG Laser, Laser+
local minocycline,
Laser+ povidone
iodine
1, 3 months Greater reduction
of bacteria on
laser+
minocycline
treated sites

Author and
Year
periods
Findings
Moritz et al
1997
Diode SRP+ Laser,
SRP
1,2 weeks High bacterial
reduction in
SRP+ laser as
compared to
SRP sites alone.
Moritz et al
1998
Diode SRP + Laser,
SRP + H2 O2
rinse
6 months Higher reductn
in bacterial,
BOP, PD in SRP
+ laser sites.
Kresiler et al
2005
Diode RCT, split
mouth design.
SRP + Laser,
SRP alone.
3 months Greater
reduction of PD
and attachment
gain in Laser
adjunct sites
Miyazaki et al
2003
Co2 RCT, Laser vs
ultrasonic
1,4,12 weeks No decrease of
P.ging and IL-1
in laser sites.
But significant
decrease in US
sites.

Author and
Year
period
Findings
Watanabe et al
1996
Er YAG Case series
(Laser only)
4 weeks Safe and
effective
calculus
removal .
Schwarz et al
2001
Er YAG Split mouth
design, RCT
(Laser vs SRP)
6 months Clinical
outcome similar
to SRP.
Sculean et al
2004
Er YAG RCT, split
mouth (Laser vs
Ultrasonic)
6 months Clinical
outcome similar
to Ultrasonic
scaling.
Tomasi et al
2006
Er YAG RCT, split
mouth (Laser vs
Ultrasonic)
6 months 1 month-
following
therapy, laser
treated sites-
better clinical
outcomes, no
difference in
microbiological
levels

 NdYAG and diode- useful as adjunct for pocket lining
elimination.
 Co2- not suitable for NST.
 Er YAG – most promising- calculus removal and de-
toxification. However, histologic studies not conclusive.
Summary of Lasers in Non Surgical therapy:

Surgical pocket therapy- Lasers
 Lasers used: Co2 and Erbium family
Involves use of lasers for
 calculus removal,
 osseous surgery,
 de-toxification of the root surface and bone,
 granulation tissue removal
Advantage of Laser:
Better access in furcation areas, hemostasis, less post-
operative discomfort, faster healing.

Surgical pocket therapy- basic
studies.

Author and
Year
Laser used Animal model Study Objective Findings
Nelson et al 1989 Er YAG Rabbit Irradiated tissue
characteristics
Found useful as a
bone cutting tool
Lewandrowski et
al 1996
Er YAG Rat Cutting efficiency
and tissue
characteristics
Comparable
thermal damage
as mechanical cut
bone. Normal
fracture healing.
Friesen et al 1999 Co2, Nd YAG Rat Tissue
characteristics
Residual
carbonized tissue
and thermal
necrosis.
Sasaki et al 2002 Co2 and Er YAG Rat Tissue
characteristics
Er YAG- Tissue
removal, no
charring. Two
distinct layers.
Co2- charring and
no tissue removal.
Stubinger et al
2007
Er YAG Clinical- human Depth control of
laser
Laser could not
offer precise
depth control in
preparing
osetotomies.

Surgical pocket therapy- clinical
studies

Author Laser used Study design Observation
period
Findings
Centty et al 1997 Co2 RCT, split mouth.
OFD+ Laser, OFD
alone
Biopsy during
surgery
Laser eliminated
significantly more
sulcular
epithelium than
conventional
surgery.
Schwarz et al
2003
Er YAG
( for root
conditioning)
RCT, split mouth.
OFD+ Laser+
EMD vs OFD+
EMD+EDTA
6 months No significant
difference by
using laser for
root conditioning
Sculean et al 2004 Er YAG
(granulation
tissue removal)
RCT, split mouth.
OFD+ Laser vs
OFD alone.
6 months No significant
difference
between two
groups in clinical
outcomes.
Gaspirc et al 2007 Er YAG
( bone defect
irradiation )
RCT, split mouth.
MWF+ laser vs
MWF alone
5 years Laser application-
greater gain in
attachment and
pocket depth
reduction.

Summary of Lasers in surgical pocket therapy:
 Co2 and Er YAG proposed for use.
 Erbium family is the best laser available for soft and
hard tissue surgery. Problem of depth control – yet
to be rectified.

Implant therapy- Management
of Peri-implantitis

Introduction:
Peri-implantitis – Management options-
 Conventional- plastic curettes and antibiotics.
 New option- Laser
Rationale:
 Disinfection and de-contamination of implant surface.
 Granulation tissue removal.
Lasers used: Diode, Co2, Erbium family.
Lasers contra-indicated: Nd YAG (Implant damage).

Studies on laser use for peri-
implantitis management

Author Laser used Study design Objective Findings
Schwarz et al
2006
Er YAG Clinical and
histological
Pocket
debridement
and de-
contamination
Clinical
improvements
at end of 6
months of
therapy is
similar to
conventional
therapy.
Deppe et al
2001
Co2 In vivo Decontaminatio
n
Safe for de-
contamination
of bone defects
around
implants.
Schwarz et al
2006
Er YAG In vivo Granulation
tissue removal
Laser better
than plastic
instruments
and antibiotics/
Ultrasonic
scalers.

Summary of Laser use in Peri-implantitis
management.
 Most recent studies agree upon effectiveness of
erbium lasers for granulation tissue removal and de-
contamination.

Subgingival calculus detection- Unique application for LASER
 Conventional method- tactile feel.
 Other development- visual- Perioscopy system.
 Latest: Er YAG laser with fluorescent feedback system for
calculus detection.
Rationale:
 Difference in the fluorescence emission properties of calculus
and dental hard tissue when subjected to irradiation with 655
nm diode laser.
 Commercially available as Key Laser III, Ka Vo, Germany.

Er YAG with Calculus detection system- 655 nm Diode laser

Studies- sub gingival calculus
detection system

Author and year Study design Objective Findings
Folwaczny M et al
2002
In vitro- extracted
teeth
Assess efficacy of
fluorescence
induced by 655
nmdiode laser to
detect subgingival
calculus
655 nm diode
laser- effective for
calculus detection
Krause F et al
2003
In vitro- histologic
study ( in presence
of saline/ blood)
Efficacy for
calculus detection
The laser
fluorescence
values co-relate
strongly with
calculus presence.
Scharwz F et al
2003
In vivo and in
vitro.
Er YAG with Diode
655 nm combined
Compare the new
system with SRP
for calculus
removal efficacy
Selective removal
of sub-gingival
calculus.
Sculean A et al
2004
Er YAG+ diode vs
SRP
Improvement of
clinical parameters
Similar results
with both systems
Tung OH et al
2008
Detection through the gingiva- based on autofluorescence- Ti
Sapphire laser

Studies on photodynamic
therapy in laser.

Introduction:
 The main objective of periodontal therapy: eliminate
the deposits of bacteria.
 Conventional mechanical therapy: incomplete
elimination due to
 Anatomical complexity of root.
 Deep periodontal pockets.

Photosensitizer dyes
 Toulidine blue O.
 Methylene blue.
 Poly-l-lysine chlorine e6.
 Pthalocyanin.
 Hematoporphyrins and others.

Anti- microbial photosensitizing agents and the wavelengths used.

RCT-
Photodynamic
therapy for
periodontitis
management

Summary of RCT trials for PDT in periodontitis:
 Various photosensitizer agents can be used.
 Diodes- preferred wavelength for photodynamic
therapy.
 PDT cannot be used as a monotherapy.
 PDT can be used as along with SRP for Non-
surgical therapy.
 PDT contributes to considerable decrease in BOP,
probing depth.

Low level laser Therapy (LLLT)

Biostimulation effects of low level laser:
 Reduction of discomfort / pain (Kreisler MB et al 2004).
 Promotion of wound healing (Qadri T et al 2005).
 Bone regeneration (Merli LA et al 2005).
 Suppression of inflammatory process. (Qadri T et al 2005).
 Activation of gingival and periodontal ligament fibroblast
(Kreisler M et al 2003), growth factor release (Saygun I et al
2007).
 Alteration of gene expression of inflammatory cytokines
(Safavi SM et al 2007).

Suggested reading
 Dental clinics of North America. “ Lasers in Clinical
dentistry”. Oct 2004. Vol 48. Issue 4.
 Application of antimicrobial photodynamic therapy
in periodontal and peri-implant diseases.
Periodontology 2000, Vol. 51, 2009, 109–140.
 Application of lasers in periodontics: true innovation
or myth? Periodontology 2000, Vol. 50, 2009, 90–
126.
 The impact of laser application on periodontal and
peri-implant wound healing. Periodontology 2000,
Vol. 51, 2009, 79–108

Lasers and its application in Periodontics.ppt

Lasers and its application in Periodontics.ppt

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