Lasers in dental practice

1. DENTAL LASERS
RAKESH CHANDRAN
REGISTRAR
SEFAKO MAKGATHO HEALTH SCIENCES UNIVERSITY

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Contents
Introduction.......................................................................................................................................4
Types of lasers................................................................................................................................5
Laser delivery devices(delivery tips) ................................................................................................7
Spot size.........................................................................................................................................7
Emission modes..............................................................................................................................8
Initiating the Fiber..........................................................................................................................8
Benefits and Draw backs of Dental Lasers.........................................................................................9
Lasers in dentistry.............................................................................................................................10
Laser-Assisted Nonsurgical Periodontal Therapy.................................................................................11
Disinfection and detoxification effects ...........................................................................................11
Sulcular Debridement with Fiberoptic Laser Delivery ......................................................................11
Decontamination..........................................................................................................................11
Coagulation..................................................................................................................................12
Postoperative Care .......................................................................................................................12
Treating Periimplant Mucositis and Periimplantitis .........................................................................13
Lasers in Surgical Periodontics...........................................................................................................13
Gingivectomy ...............................................................................................................................13
Frenectomy..................................................................................................................................14
Mucogingival Surgery....................................................................................................................14
Crown Lengthening.......................................................................................................................14
Periodontal Surgery ......................................................................................................................15
Laser-assisted new attachment procedure .....................................................................................16
Benefits of Erbium lasers...................................................................................................................16
Laser assisted Oral Medicine procedures ...........................................................................................18
Photobiomodulation(Lowlevel Laser Therapy)..................................................................................18
Antimicrobial photodynamic theory...................................................................................................20
Conclusion .......................................................................................................................................21
References.......................................................................................................................................22

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Introduction
The word laserisan acronym forlightamplificationbystimulatedemissionof radiation.
Light
Lightis a form of electromagneticenergythatexistsasa particle andthat travelsinwavesata constant
velocity.The basicunitof thisradiantenergyiscalledaphoton.The wavesof photonstravel at the
speedof lightandcan be definedbytwobasicproperties:amplitudeandwavelength.Amplitude is
definedasthe vertical heightof the wave fromthe zeroaxisto itspeakas it movesaroundthat axis.This
correlateswiththe amountof intensityinthe wave:the largerthe amplitude,the greaterthe amountof
potential workthatcouldbe performed.Forawave emittinglight,amplitude correlatestobrightness.A
joule (J) isa unitof energy;a useful quantityfordentistryisamillijoule (mJ),orone thousandth(10−3
) of
a joule (11000 J; 0.001 J).The secondpropertyof a wave iswavelength(λ),the horizontaldistance
betweenanytwocorrespondingpointsonthe wave.Thismeasurementisimportanttobothhow the
laserlightisdeliveredtothe surgical site andhow itreacts withtissue.Wavelengthismeasuredin
meters(m).Dental lasershave wavelengthsonthe orderof muchsmallerunits,usingterminologyof
eitherananometer(nm),one billionth(10−9
) of a meter,ormicrometer(alsomicron,[μorμm], one
millionth(10−6
) of a meter.
As wavestravel,theyrotate aroundthe zero axisa certainnumberof timespersecond;thisiscalled
oscillation.The numberof oscillationsperunittime isdefinedasfrequency.Frequencyismeasuredin
hertz(Hz);1 Hz equalsone oscillationpersecond.Frequencyisinverselyproportionaltowavelength:
the shorterthe wavelength,the higherthe frequency,andvice versa.Althoughhertzisaterm
commonlyfoundinphysics,itisalsousedtodescribe the numberof pulsespersecondof emittedlaser
energy.
Laser lightismonochromaticbecause it generatesabeamof a single color,whichisinvisible if its
wavelengthisoutside of the visiblepartof the spectrum.Inaddition,eachwave of laserlightis
coherent,oridentical inphysical sizeandshape.Thismeansthatthe amplitude andfrequencyof all the
wavesof photonsare identical.Thisresultsinthe productionof aspecificformof focused
electromagneticenergy.
The laserbeamsemittedfromsome instrumentsare collimated(allwavesparallel toeachother) overa
longdistance,but beamsproducedfromoptical fibersusuallydiverge atthe fibertip.All canbe
preciselyfocused,andthismonochromatic,coherentbeamof lightenergycanbe utilizedtoaccomplish
the treatmentobjective.Usingahouseholdfixture asanexample,a100-watt lampwill produce a
moderate amountof lightfora room area,withsome heat.On the otherhand,two watts(2 W) of laser
lightcan be usedfor precise excisionof afibromawhile providingadequatehemostasisatthe surgical
site,withoutdisturbingthe surroundingtissue.
Amplification
Amplificationisthe partof thisprocessthat occurs inside the laser.Identifyingthe componentsof a
laserinstrumentshowshowlaserlightisproduced.The centerof the laseriscalledthe lasercavity.The
followingthree componentsmake upthe lasercavity:
 Active medium

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 Pumpingmechanism
 Optical resonator
The active mediumiscomposedof chemical elements,molecules,orcompounds.Lasersare generically
namedforthe material of the active medium, whichcanbe (1) a containerof gas, such as a canisterof
carbon dioxide (CO2) gasina CO2 laser;(2) a solidcrystal,suchas a crystal of yttrium, aluminum, and
garnet(YAG) in an erbium(Er) YAG or a neodymium(Nd) YAGlaser;(3) a solid-statesemiconductor,
such as the semiconductorsfoundindiodelasers;or(4) a liquid,suchasfoundinsome medical laser
devices.
Surroundingthisactive mediumisanexcitationsource,suchasa flashlampstrobe device,electrical
circuit,electrical coil,orsimilarsource of energythatpumpsenergyintothe active medium.Whenthis
pumpingmechanismpumpsenergyintothe active medium, the energyisabsorbedbythe electronsin
the outermostshell of the active medium’satoms.These electronshave absorbedaspecificamountof
energytoreach the nextshell fartherfromthe nucleus,whichisata higherenergylevel.A “population
inversion”occurswhenmore of the electronsfromthe active mediumare inthe higherenergylevel
shell fartherfromthe nucleusthanare inthe groundstate.The electronsinthisexcitedstate then
spontaneouslygive off thatenergyinthe formof a photon.Thisiscalledspontaneousemission.
Completingthe lasercavityare twomirrors,one at eachendof the optical cavity,placedparallel toeach
other;or in the case of a semiconductor,twopolishedsurfacesateachend.These mirrorsor polished
surfacesact as optical resonators,reflectingthe wavesbackandforth,andhelptocollimate andamplify
the developingbeam.A coolingsystem,focusinglenses,andothercontrollingmechanismscomplete the
mechanical components.
StimulatedEmission
Stimulatedemissionisthe processbywhichlaserbeamsare producedinside the lasercavity.Einstein
usedthe conceptof quantumtheoryof physicsandfurthertheorizedthatanadditional quantumof
energymaybe absorbedbythe already-energizedatomandwouldresultinarelease of twoquanta.
Thisenergyisemitted,orradiated,asidentical photons,travelingasacoherentwave.These photonsin
turn are thenable toenergize more atomsina geometricprogression,whichfurthercausesthe
emissionof additional identical photons,resultinginanamplificationof the lightenergy,thusproducing
a laserbeam
Radiation
The lightwavesproducedbythe laser are a specificformof radiation,orelectromagneticenergy.The
electromagneticspectrumisthe entire collectionof wave energy,rangingfromgammarays,with
wavelengthsof 10 to 10−12
m, to radiowaves,withwavelengthsof thousandsof meters.
Types of lasers
Dental lasersemiteitheravisible-lightwavelengthoran invisible,infrared-lightwavelengthinthe
portionof the nonionizingspectrumcalledthermalradiation.
The followingfourdental laserinstrumentsemitvisiblelight:
 Argonlaser:blue wavelengthof 488 nm

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 Argonlaser:blue-greenwavelengthof 514 nm
 Frequency-doubledNd-dopedYAGlaser,alsocalledapotassiumtitanylphosphate(KTP) laser:
greenwavelengthof 532 nm
 Low-level lasers:rednonsurgical wavelengthsof 635 nm(forphotobiomodulation) and655 nm
(forcariesdetection)
Argonlasersare nolongermanufacturedasdental surgical instruments,althoughtheyare still usedfor
medical procedures.
Otherdental lasersemitinvisible laserlightinthe near,middle,andfarinfraredportionof the
electromagneticspectrum.Theseinclude photobiomodulationdevicesbetween800and 900 nm, as well
as surgical instruments,asfollows (Convissar,2010, Aoki etal.,2015):
 Diode lasers:variouswavelengthsbetween800 and1064 nmusinga semiconductoractive
mediumof galliumandarsenide;some devicesaddeitheraluminumorindium.
 Nd:YAGlaser:1064 nm
 Erbium-chromium–dopedyttrium-scandium-galliumgarnet(Er,Cr:YSGG) laser:2780 nm
 Er:YAG laser:2940 nm
 CO2 laser:10,600 nm
Classificationoflasers according to penetrationdepthin tissue.
One isa deeplypenetratingtype,inwhichthe laserlight penetratesandscattersdeeplyintothe tissue,
and the otheris a superficiallyabsorbedtype (shallowlypenetratingtype),inwhichthe laserlightdoes
not penetrate orscatterdeeply.CO2,carbondioxide;CW,continuouswave;Er,Cr:YSGG,erbium,
chromium-dopedyttrium-scandium-gallium-garnet;Er:YAG,erbium-dopedyttrium-aluminium-garnet;
Nd:YAG,neodymium-dopedyttrium-aluminium-garnet(Aoki etal.,2015, Convissar,2010).

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Laser delivery devices (delivery tips)
Laser energyshouldbe deliveredtothe surgical site bya methodthat isergonomicandprecise. Shorter-
wavelength instruments(e.g.,KTP,diode,Nd:YAG) have small, flexible fiberopticsystemswithbare glass
fibersthatdeliverthe laserenergytothe targettissue.Because the erbium andCO2laserwavelengths
are absorbedbywater,whichis a major componentof conventional glassfibers,these wavelengths
cannot passthroughthese fibers.Erbiumand CO2devicesthereforeare constructedwithspecial fibers
capable of transmittingthe wavelengths,withsemiflexible hollowwaveguides,orwith articulatedarms.
Some of these systemsemploysmall quartzorsapphire tipsthatattach to the laserdevice forcontact
withtargettissue;othersemploynoncontacttips.In addition,the erbiumlasersemployawaterspray
for coolinghardtissues.Lasersmayhave differentfiberdiameters,handpieces, andtips.The diameter
of the fiber, handpiece,andtipplaysasignificantrole inthe deliveryof energy (Convissar,2010).
All conventionaldental instrumentation,eitherhand orrotary, mustphysicallytouchthe tissue being
treated, givingthe operatorinstantfeedback.Asmentioned,dental laserscanbe usedeitherincontact
or out of contact. The fibertipcaneasilybe insertedintoaperiodontalpocket toremove small amounts
of granulomatoustissue.Innoncontactuse,the beamisaimedatthe target some distance away.This
modalityis useful forfollowingvarioustissue contours,butwiththe lossof tactile sensation,the
surgeonmustpay close attention tothe tissue interactionwiththe laserenergy.All the invisible-light
dental lasers(Nd:YAG,CO2,diode,erbium) are equippedwithseparate aimingbeams,whichcanbe
eitheralaseror a conventionallight.The aimingbeamisdeliveredcoaxiallyalongthe fiberor
waveguide andshowsthe operatorthe exactspotwhere the laserenergywill strikethe tissue
(Convissar,2010).
Spot size
The active beamis focusedbylenses.Withhollow waveguide orarticulated-armdelivery systems,there
isa precise spotat the pointwhere the energyisthe greatest.This focal pointisusedforincisionand
excisionsurgery.Forfiberopticdeliverysystems,the focal pointisator near the tipof the fiber,which
againhas the greatestenergy.ForCO2 lasers, whichare usedoutof contact, the focal pointmay be

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anywhere from1 mm to12 mmfrom the tissue surface,depending onthe handpiece beingused.When
the handpiece ismovedawayfromthe tissue andawayfromthe focal point,the beam isdefocused(out
of focus),becomes more divergent,andtherefore deliverslessenergytothe surgical site.Atasmall
divergentdistance,the beamcancovera widerarea,whichwouldbe useful in achievinghemostasis.At
a greaterdistance,the beamwill lose itseffectivenessbecausethe energywill dissipate (Convissar,
2010).
Emission modes
Dental laserdevicescanemitlightenergyintwomodalities asa functionof time:(1) constanton or (2)
pulsedonand off. The pulsedlaserscanbe furtherdividedintogated andfree-runningmodesin
deliveringenergytothe targettissue.Thus,three differentemissionmodesare described, asfollows
(Convissar,2010, Al-Falaki,2016):
1. Continuous-wave mode,meaningthatthe beamis emittedatonlyone powerlevel foraslongasthe
operatordepressesthe footswitch.
2. Gated-pulse mode,meaningthatthere are periodicalternationsof the laserenergy,similartoa
blinkinglight. Thismode isachievedbythe openingandclosingof a mechanical shutterinfrontof the
beampath of a continuous-waveemission.All surgicaldevicesthat operate incontinuouswavehave
thisgated-pulse feature. Some instrumentscanproduce pulsesasshortas microseconds(μsec) or
milliseconds(msec).Peakpowers of about10 to 50 timesthatof continuous-wave power
measurementsare produced,andcharringof the tissue canbe reduced.The more advancedunitshave
computer-controlledshuttersthatallow forthese very shortpulses.Manufacturershave coinedmany
termsto describe these shortpulse durations,including “superpulse”and“ultraspeed.”
3. Free-runningpulsedmode,sometimesreferredtoas true-pulsedmode.Thisemissionisuniquein
that large peakenergiesof laserlightare emittedforusually microseconds,followedbyarelativelylong
time inwhichthe laserisoff.For example,afree-runningpulsed laserwithpulse durationof 100 μsec
and pulsesdelivered at10 per secondmeansthatthe energyat the surgical site ispresentfor1/1000 of
a secondand absentforthe remaining99.9% of that second.Free-runningpulsed deviceshave arapidly
strobingflashlampthatpumps the active medium.Witheachpulse,highpeakpowers inhundredsor
thousandsof wattsare generated. However,becausethe pulse durationisshort,the average power
that the tissue experiencesissmall.Free-runningpulseddevicescannothave acontinuous-waveor
gatedpulse output.
True-pulsedlasersare pulsedasaresultof the actionof the pumpingmechanismwithinthe lasercavity.
Gated-pulse lasersare pulsedasa resultof a shutteroutside the lasercavity. Medical and scientificlaser
instrumentsare availablewith pulse durationsinthe nanosecond(one billionthof asecond) and
picosecond(one trillionthof asecond) andsmallerrange. These cangenerate tremendouspeakpowers,
but the calculated pulse energiesare small,allowingincreasedsurgical precision. Some instrumentscan
be controlledtoemita single pulse.
Initiating the Fiber
Initiatingthe fiberishelpfulwithsome laser-assistedhygiene proceduresbutisnotdesiredinothers.
Initiationof the fibertipisaccomplishedbyactivatingthe laserwhile touchingthe fibertoa dark
chromophore,suchas blackarticulatingpaper.Thiscoats1 to 2 mm of the fiber’send. The purpose isto
concentrate the energyat the fiber’ssurface,increasingthe photothermal interactionwith the tissue

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and accelerating debridement. Initiationisusedwithlasersof lowerfluence, particularlydiode lasers,
inthe decontaminationprocedure.Because aninitiatedfiberconcentratesthe laserenergyatthe point
of tissue contact,heatcan accumulate withinthe tissuesquickly.Applicationtime shouldbe limitedto
minimize collateraldamage insurroundingtissue.Lowersettingsare usedincontinuouswave fora
shorterdurationto accomplishdecontaminationof the pocketwall.Also,whenworkingwithfibrotic
tissue exhibitinglesschromophoricconcentration,initiationishelpful.
If the objective ispenetrationofthe laser energyinto the tissue beyondthe fiber,the fiber isnot
initiated.Anuninitiatedfiberisusedforpreprocedural decontaminationandcoagulation.The Nd:YAG,
a free-runningpulsedlaser,doesnotrequireinitiatingbecause of highpeakpowersandimmediate
interactionwiththe tissue.Argonanddiode lasersmaybe used inpulsedorcontinuouswave,withan
uninitiatedfiberforpreprocedural decontaminationandcoagulation.Continuous-wavemode requires
lessenergyandshorterapplicationtime tominimizeheataccumulationwithinthe tissue.The pulsed-
wave mode mayuse highersettingswithslightlylongertreatmenttimes.The off time betweenpulses
allowsheatdissipationwithinthe tissue(Convissar,2010).
Benefits and Draw backs of Dental Lasers
One of the mainbenefitsof usingdentallasersisthe abilityto interactselectivelyandpreciselywith
diseasedtissues.Lasersalsoallow the cliniciantoreduce the amountof bacteriaand otherpathogensin
the surgical fieldand,inthe case of soft tissue procedures,achievegoodhemostasiswithreducedneed
for sutures.Manyresearchershave shownthatthe ability of laserstoseal bloodvesselsandlymphatic
channelsresults inreducedpostoperative edema,whichinturnresultsinless postoperativediscomfort.
The hard tissue laserdevicescanselectivelyremove diseased toothstructure because a carious lesion
has much higher water content than healthytissue,and water is the primary absorber of that
wavelengthoflaser energy. These same devices show advantagesoverconventionalhigh-speed
handpiecesas theyinteractwiththe toothsurface;forexample,laseddentin hasnosmearlayer,and
the cavitypreparationhasbeendisinfected because of the bactericidalnature of laserenergy.
The disadvantagesof the currentdental laserinstruments are the relativelyhighcostandthe required
training.Because mostdental instrumentsare bothside cuttingandendcutting, amodificationof
clinical techniqueisrequiredwhen usinglasers,whichare almostexclusivelyendcutting.The clinician
mustpreventoverheatingof the tissue andguard againstair embolismcausedbyexcessive pressure of
air and watersprayduringlaserprocedures.Anotherdrawbackof erbiumlasersisthe inabilityto
remove metallicrestorations.
Benefitsof LaserTherapy
1. Changestissue responsepattern
2. Lack of traditional post-surgical effectsandseals bloodandlymphaticvessels
3. Laser will alsodecontaminate the surgical sitebothontissue surface andtodepthintarget
tissue (softandhardtissue)
4. Biostimulationoccurs,which speedsupmitochondrial metabolism resultinginfastertissue
regrowth
5. Dry and bloodlesssurgery(goodhemostasis)
6. Instantsterilizationof surgical site

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7. Reducedbacterimia
8. Reducedmechanical trauma
9. Minimal postoperative swelling&scarring
10. Minimal post-operativepain
Lasers in dentistry
Lasersare usedinvariousfieldsof dentistry.The mostcommonusesare givenbelow (Aoki etal.,2015,
van As,2015a, vanAs, 2015b, Al-Falaki,2016,Al-Falaki andCronshaw,2015, Al-Falaki etal.,2016, Berk
et al.,2005, Nagahara et al.,2013, CJ, 2015, Hakki etal.,2010a, Hakki et al.,2010b, Yilmazet al.,2010)
1. PERIODONTOLOGY
a. Gingivectomy
b. CrownLengthening
c. Frenectomy
d. Operculectomy
e. FibroticTissue removal
f. Gingivoplasty
g. Removal of GranulationTissue
h. Sulcularpocketde-epithelialisation
i. SulcularPocketDecontamination
2. IMPLANTOLOGY
a. Softtissue lasers
i. Hemostasis
ii. soft-tissueperi-implantre contouring
iii. Improvingwoundhealing
iv. treatmentof peri-implantitis.
b. Hard-tissue lasers
i. laser-assistedosteotomies
ii. improvementinearlyosseointegrationafterfixture placement.
3. ORAL MEDICINE
a. ApthousLesions
b. Solarcheilitis
c. HerpeticLesions
d. leukoplakia
e. Mucocele
f. Fibromaremoval
g. Melanosis
h. Lichenplanus

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4. GENERAL
a. WoundHealing
b. Bio-stimulation
c. Control of Bleeding
5. ENDODONTICSANDPROSTHODONTICS
a. Pulpotomy
b. Canal disinfection
c. TroughingforCrownPreparation
Laser-Assisted Nonsurgical Periodontal Therapy
Disinfection and detoxification effects
Nd:YAGlaserexhibitsselectiveabsorptioninpigments,itisconceivablethatthislaserwouldbe
effectivefordevitalizingsome of the pigmentedbacteria,suchasPorphyromonasgingivalis,thatare
associatedwithperiodontal disease.Moreover,lasersablate orinactivate toxicsubstances,suchas
bacterial endotoxins(lipopolysaccharide).Theseadditional decontaminationanddetoxificationeffects
may positivelyinfluence woundhealingof the treatedsite andofferseveral advantagesover
conventional mechanical treatment.Furthermore,itispossiblethatlaserirradiationof the rootsurface
mightprovide anantimicrobial effectandinhibitbacterialattachment/colonizationfollowingirradiation.
The effectwouldalsobe beneficialforhealingandmaintenance of periodontalpockets.Another
advantageousaspectof lasertherapyisitspotential systemiceffectwhenbacteremiafollowing
periodontal treatmentisprevented (Aoki etal.,2015).
Sulcular Debridement with Fiberoptic Laser Delivery
Preprocedural decontaminationisalaserapplicationdone before anyinstrumentation,evenprobing.
The objectivesare toaffectthe bacteriawithinthe sulcus,reducingthe riskof bacteremiacausedfrom
instrumentation,andtolowerthe microcountinaerosolscreatedduringultrasonicinstrumentation.
The technique usesverylowenergy.The fiberis placedwithinthe sulcusandissweptverticallyand
horizontally againstthe tissuewall,awayfromthe tooth,witha smooth,flowingmotion,for7to 8
secondsonthe lingual aspect,thenonthe buccal of each tooth’stissue wall.The benefitsof
preprocedural decontaminationare seeninthe reducedmicrobial translocationthroughthe circulatory
system.
Decontamination
Justas conventional rootdebridementremovesbiofilm andaccretionsfromthe hardtoothsurface,
laserdecontamination removesbiofilmwithinthe necrotictissueof the pocket wall.The laserenergy
interactsstronglywithinflamed tissue components(frompreferential absorptionbychromophores,
whichare more abundantindiseasedtissues)andless stronglywith healthytissue.Thisnonsurgical
therapyuses verylowsettingsanddecontaminatesratherthancutsthe tissue.

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Coagulation
Whenbiofilmhasbeenremoved,the secondobjective in active phase Iperiodontal infectiontherapyis
coagulation, sealingthe capillariesandlymphaticsof the healthytissue.As previouslynoted,biofilm
tendsto continue itsinvasionof the hosttissue throughthe vessels.Coagulationmayinhibit the
biofilm’sprogression.Italsocounteractsthe swelling thatoccurswiththe inflammatoryprocess.
Coagulationis accomplishedwithincreasedmJanddecreasedHzcompared withdecontamination.
Coagulationalsorequireslesstime withinthe pocketanddoesnotaddresseverymillimeterof tissue.
Postoperative Care
Afterlasing,allow the patienttorinse withwaterorwitha non–alcohol-basedrinse to freshenand
moistenthe mouth.A topical soothingagentsuch asvitaminE oil or aloe veramay be appliedwitha
glovedfingerorsterile cottonswabtothe areastreated.Firmadaptationof tissue tothe tooth with
digital pressure mayassistadhesion of fibrinbetweenthe tissueandtooth,particularlyfordeeper
pockets.
Postlaserirrigationisasubjectof debate.Althoughirrigation withchlorhexidineorothersolutionsis
usedinconventional treatmentasa final stepindisinfectingperiodontal pockets,the authorbelieves
that postlaserirrigationisunnecessary. Solutionsof chlorhexidine (≤0.12%) incontactwithwoundsites
for evenashort time couldhave serioustoxiceffectsongingivalfibroblasts. Otherstudiesreportthat
subgingival irrigationhasno significantadditive effectsonperiodontalhealing. Whenlasingis
completed,all the benefitsof profound decontaminationandcoagulationare inplace.Further
manipulationof the tissuesreintroducescontaminatedinstruments intothe pocketanddisruptsthe
fibrinclot. The final stepinpostoperative care isadvisingthe patient onwhatto expect,addressing
furtherconcerns,anddiscussing continuedself-care.Counsel the patientthatmild discomfortispossible
the first24 to 48 hours.Withlaser-assistednonsurgical periodontal therapy,discomfortis often
associatedmore withrootdebridementthanlasing. Excessive painmayindicate anotherissue and
shouldbe evaluated (Convissar,2010).
PatientCare Instructions after Laser-AssistedPeriodontal Therapy
1. Do noteat until numbnessisgone.
2. [Patientswhosmoke] Smokingcompromisesthe healingprocesses;refrainfromsmokingaslongas
possible (orpreferablytake opportunitytostopsmoking).
3. Avoidspicy,sharp,crunchyfoodsfor 24 hours.
4. Avoidalcohol-containingproductsfor24 hours.
5. Avoidseedsorhusksfor 3 to 5 days(or as directed).
6. Rinse withsaltwater(1tsp in8 oz of warm water) three timesdailyuntiltissuesare comfortable.
7. Any over-the-counterpainrelievermaybe takenasdirectedtomanage milddiscomfort.
8. More severe painshouldbe evaluatedbythe dentist.

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9. Thorough butgentle cleaningisessential tothe healingprocess.Inareastreated,use anextrasoft
toothbrushfor1 or 2 days,and flossgently.Regularbrushingandflossingmaybe done inall other
areas.
10. Oral irrigationmaybeginafter24 hours.Use a medium-low powersetting,directingthe water
streamat a 90-degree angle tothe tooth—notintothe pocket.Subgingival irrigationiscontraindicated
until furtherevaluation.
Treating Periimplant Mucositis and Periimplantitis
It isessential toremove biofilm onthe implantcollarandcrownusingspecializedinstruments for
implantcare.The periimplanttissue isthen decontaminated bylasing.Therapyshouldinvolveatleast
twosessions10 daysapart. Reappointatthe same interval until conditionsresolve. If the implantis
diagnosedas“failing,”wherethere isstill half the implantsupportedwithboneandnomobility,other
treatmentisnecessary.Lasertherapycanprovide immediate decontaminationof the surroundingtissue
as preparationfora surgical procedure.Nonsurgicaltherapyislimitedbecause of the inabilitytofully
addressthe biofilmonthe complex implantstructure.
Laserswithsofttissue applicationscanaccomplishtreatment of periimplantmucositisorperiimplantitis.
The technique of nonsurgical applicationdoesnotaimthe laserenergy directlytowardthe implant.Only
the softtissue isaddressed fordecontamination.The laserparametersusedfornonsurgical therapies
are muchlowerthanin surgical procedures. Some wavelengthsrequiremore attentionthanothers;for
example,awavelengthabsorbedindarkchromophores hasthe potential forgreaterthermal rise and
heattransfer. Whencoatedwithblood,the implantsurface couldaccumulate heat,whichwouldradiate
throughthe implantbodyto the bone.Animplantcoatedwithhydroxyapatitecould absorbanother
wavelength,resultinginamodifiedsurface. Highriskof surface alterationexistswiththe Nd:YAGlaser.
There ismuch lessriskwiththe CO2, Er:YAG, and Er,Cr:YSGG wavelengths.CO2laseruse inperiimplant
treatmentiswell documentedinthe literature.Effectivenessof treatment withthe erbiumfamilyis
contradictory.Effectivenesswith diodesisalsocontradictoryamongall fourdiode wavelengths.
Lasers in Surgical Periodontics
Gingivectomy
Initial incisionsforgingivectomiesare similartothat of usinga blade withan external bevel approach.
The distance of the incisionfromthe coronal gingival marginisbasedonpocketdepthandamountof
existingattachedgingiva.A gingivalchamfer(bevelededge)isachievedratherthana directrightangle
intothe gingiva.Thusthe initial cutismade slightlyapicallytothe pocketdepthmeasurement.A slow,
unidirectional handmotionisused,movingthe tipatan external bevel towardthe toothstructure.

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Cautionisnecessarywhenapproachingthe tooth,especiallynearrootstructure,because of the possible
laser–hardtissue interaction,whichcouldresultintissue damage.Decreasingthe powerwill prevent
this;if the powerisdecreased,however, multiple passesoverthe incisionlinemaybe necessaryto
complete the incision.Deliveringlaserenergyrepeatedlyovertissue thathasalreadybeenlasedmay
resultina greaterwidthof lateral thermal damage.Some cliniciansuse areflective barrier inthe sulcus
to preventthe wavelengthfrominteractingwiththe root.Placingathin,sterile #7wax spatulaor a
small periostealelevator, orevena piece ofmetal matrix band, inthe sulcusbetweenthe toothandthe
softtissue will preventanylaser energyfromdamagingthe hardtissue;the metal will reflectthe laser
energyawayfromthe tooth.Once the gingivahasbeenexcised,power drivenultrasonicscalingisused
to debride the rootsurface.
Frenectomy
The technique fora laserfrenectomyissimilartousinga blade.Local or topical anesthesiais
administered.The clinicianmakesamental outline of the frenectomyandthenbeginsatthe coronal
attachmentand movesthe lasertipunidirectionally,pullingonthe lipfortension.If the correct
parameters(spotsize,power,handspeed),are used,one passof the laserwill be sufficienttoseverall
the fibers.If multiplepassesare necessary,care mustbe takento ensure noexcessivelateral thermal
necrosisfromlasingalready-lasedtissue.The lasingiscontinuedtoundermine the muscle attachment
until the periosteumisreached.
To ensure minimal regrowthandfrenumrelapse,the periosteumshouldbe fenestratedwithahand
instrument.All lasersare effectiveforafrenectomywithsettingsaccordingtothe manufacturer.Care
mustbe takennotto char the tissue andcause thermal tissue damage.The erbiumlasercreatesa
woundthat mayhave some hemorrhage,sosealingthe woundwiththe bandage approachmaybe
required.Nosuturingordressingisnecessary.
Some cliniciansmayfollowanerbiumlaserprocedure withadiode,Nd:YAG,orCO2laserto achieve
coagulationif hemorrhage exists.Othersuse erbiumlasersettingsthatcreate a “laserbandage”
(settingsof lowwattage,nowater,some airwithfewerpulsespersecond).Inthe past,thislaser
bandage wasreferredtoas a “char layer”or an “eschar.” Althougholderlasersroutinelycreatedachar
layerbecause of theirhighfluences,newerlaserunitsrarelychartissue.
Mucogingival Surgery
Laserscan be usedinmucogingival proceduresforavarietyof therapies.Donormaterial canbe
acquiredfromthe palate or otherkeratinizedareasinthe oral cavitywithlasertherapy.Whendonor
material istakenfromthese areasusingblades,hemorrhagecanbe reducedsignificantlybyusinga
laserto “seal”the wound
Crown Lengthening
The clinicianusesasurgical guide/stentfabricatedtodetermine the apical extentof the gingival margin,
employingthe principlesof ideal widthandheightof respectivetoothtypes.Afterlocal anesthesiawith
infiltration,the followingstepscanbe performedwithmostdental laserswhenosseoussurgeryisnot
necessary:

16. 15
1. With the surgical guide inplace,anoutline of the initial incisioncanbe made withthe laser ina
slightlydefocusedmode.Aswithaconventionalblade-initiatedgingivectomy,the laserincisionis
startedslightlyapical tothe stentandat a 45-degree angle tocreate a gingival chamfer.
2. The stentcan be removedafterthe outline,andwiththe lasertipmovingslowlyinaunidirectional
manner,the tipis increasinglymovedtowardthe toothsurface.Cautionisnecessaryforpreservingthe
papillae foresthetics.
3. The now-free excisedcollarcanbe removedwithacurette andthe stentreplacedtocheckthe
accuracy of marginplacement.
4. With a relativelylowerwattage,the lasertipcannow be movedina sweepingmotiontosculptthe
marginand enhance the chamferandto decrease gingival thicknesstoa more knifelikearchitecture.
Placementof the lasersubgingivallyisnotnecessaryunlessosseoussurgeryisneededandthe erbium
laserisrequiredtoestablishthe biologicwidth.
5. The resultingwoundwill consistof minimal hemorrhage.Again,the “bandage technique”isusedat
the clinician’sdiscretion.
6. Postoperative care consistsof gentle brushingandantimicrobial rinsingfor2weeks.Placingasurgical
dressingisagainthe clinician’sdecision.After2 weeks,patientsreturntoconventional oral hygiene,
witha softbrush forsulcularcleaningandflossingforinterproximal hygiene.
Periodontal Surgery
The followingstepscanbe performed:
1. Excise supragingival pseudopocketingwitheitheraconventionalblade (e.g.,15/16 Kirland,1/2Orban
knife) ora laser.
2. Sculptthe incisedsurface todecrease the bulkygingiva;if usingablade forthe incisionratherthana
laser,use the laserto create hemostasis.
3. Beginningatthe coronal intrasulcularsurface,move the lasertipapicallyinaback-and-forthmotion
circumferentially. Thismovementshouldbe continueduntilproximitywiththe apical connective tissue
or osseouslevels.The lasersettingsare decreasedoverall inenergyoutputcomparedwithgingivectomy
settings.The clinicianwill note thatgranulationtissue ismoving outof the sulcusandshouldbe
removed.
4. When usinganerbiumlaser,the tipcan be placedparallel tothe root surface,where calculusand
possiblyrootendotoxinscanbe removed.The rootdebridementprocessiscompletedwithapower
drivendevice (e.g.,ultrasonic).
5. The final stepmayconsistof placingthe lasertipback intothe sulcusto decrease hemorrhage from
the woundarea andto create a clot fromheatactivationor biomodificationof the redbloodcells.The
rationale forcreatingthe clotis to create a barrierso that epitheliumfromthe coronal woundsurface
will notmigrate apicallyintothe surgical area.Thisallowsthe woundtobe populatedwithconnective
cells,enhancingnew attachment.

17. 16
Laser-assisted new attachment procedure
(LANAP;cementum-mediatedperiodontalligament,newattachmenttothe rootsurface in the absence
of longjunctional epithelium)
Thisis a single lasertreatmentusinga1064-nm free-runningpulsedneodymium-dopedyttrium-
aluminium-garnet(Nd:YAG) laserwithtypical periodontal-treatmentfollow up. Thistherapyisnota
nonsurgical procedure butrathera surgical one innature.(A) Bone soundingunderanesthesia to
identifybonydefectdepths.(B) Laserremoval of pocketepitheliumfromthe coronal tothe apical
direction toinitiate gingival flapreflectionat3.6–4.0 W (180– 200 mJ/pulse,20Hz, 100 ls).(C) Root-
surface instrumentation (debridement),typicallywithultrasonicscalers. Note intactconnective-tissue
rete ridges.(D) Bone modification/ intramarrowpenetrationtorelease stemcellsand growthfactors.
No granulationtissue removal.(E) Laser initiationof fibrinclotfromthe bottomof pocketcoronally at
3.6–4.0 W (180–200 mJ/pulse,20Hz, 650 ls).Generally, 200–300 J per toothare deliveredintotal for
the two laserapplicationscombined.(F) Flapssecuredtotoothand bone withfibrinclot.Nosutures
needed.(G) Occlusal adjustmenttorelievetraumaandremove damaging forces.(H) Anticipatedhealing
(Aoki etal.,2015).
Benefits of Erbium lasers
Woundhealingfollowingestheticsurgery
For estheticgingivalprocedures,anerbiumlasercan be more safelyutilizedbecause of itsminimal
thermal side effectsthanCO2,diode andNd: YAG lasers.Inparticular,use of watercoolingfurther
minimizesthermal effects.If small anddelicate contacttipsare used,the amountof softtissue ablated
withan Er:YAG lasercan be controlledwithmore precisionthanwiththe otherlasers;inaddition,with
lessthermal alterationof the treatedsurface,woundhealingcanbe more rapid (Aoki etal.,2015).
It isspeculatedthatphotobiomodulationeffects,suchaspromotionof cell proliferationand
differentiation,aswell asanti-inflammatoryeffects,are simultaneouslyproducedfollowinghigh-level
lasertherapy,andthat thisshouldpositivelymodulatewoundhealing(Aoki etal.,2015).

18. 17
Woundhealingfollowingbone (osseous) surgery
CO2 and Nd:YAGlaser-inducedosteotomydefects,whencomparedwiththose obtainedbyrotarybur,
exhibitadelayedhealingresponse,whichisprobablyrelatedtothe presence of residual charredtissues
inthe osseousdefect.The Er:YAGlaser(2,940 nm) and the Er,Cr:YSGG laser(2,780 nm),whenusedwith
saline watercooling,caneffectivelyablatebone tissue withminimal thermal changes.Evenwithout
watercooling,Er:YAG laserirradiationproducesnovisiblemajorthermal damage of bone tissue.Most
of the recentinvivostudiesindicatethatthe healingoutcomesfollowingEr:YAG or Er,Cr:YSGG laser
osteotomywithwatercoolingare comparable with,orevenbetterthan,those obtainedby
conventional mechanical osteotomy.Basedonevidence currentlyavailable,erbium-modifiedbone
tissue seemsnottointerfere significantlywiththe healingprocessandtreatmentoutcome.Therefore,
treatingbone surface duringbone-defectdebridementinflapsurgeryusingerbiumlasersisalso
accepted. (Aoki etal.,2015).
Biolase in non surgical and surgical managementof periodontitis
Pocketdepthsaroundinfectedteethtypicallyreducebyhalf aftera single applicationof the 2780 nm
laserina non-surgical protocol.Thistechnique involvesthe removalof infectedpocketlining,outer
epithelial removal,removal of granulationtissue,rootsurface debridementandlasermodification.Allof
these steps canbe achievedusinga500 um diameter60 degree radial firingperiodontal tip (Al-Falaki
and Cronshaw,2015).
Biolase in non surgical and surgical managementof periimplantitis
Studiessuggestthatvariouslaserwavelengthshave antimicrobial properties,clinicianshave employed
lasertechnologytodecontaminatefailingimplantsurfaces.Itismarginallypredictablethata laser-
treatedsurface will be free of microbial deposits,anorganicsmearlayer,anda receptive surface for
tissue regenerationHowever,recentstudiesdemonstrate promise forCO2;erbium, chromium–doped
yttrium-scandium-gallium-garnet(Er,Cr:YSGG);anddiode lasertherapiestorepairthe failingimplant.In
vitrostudieshave usedotherlaserwavelengthstodetermine the potentialforcharringof the implant
surface or increasedthermal changestothe implantitself.Althoughthereappearstobe noconsensus
on the mosteffective wavelengthintreatingperiimplantitis,evidence suggeststhatusinglaser
technologycanbe a beneficial adjunctinreversingthe failingimplant(Al-Falaki andCronshaw,2015).
FLAPLESSTECHNIQUE
The pocketswere treatedusinganEr,Cr:YSGG laserbyinsertinga14 mm long,500 μm diameterradial
firingtip(RFPT5) intothe pocket,at a settingof 1.5 W power,30 Hz,Water 50%, Air40%, 50 mj/pulse,
60 μs pulse duration(Hmode,shortpulse).The tipwasinsertedintothe pocketatan angle parallel to
the longaxisof the implant,asmuchas the anatomyallowed.Itwasfiredstartingfromthe base of the
pocket,inalternatingvertical andhorizontalslow sweepingmovements,workinguptothe gingival
margin,allowingwaterandlaserenergytocontactall surfacesof the implant.Thiswascontinueduntil
no furthergranulationtissuewasseentobe comingoutof the pocket,andno otherdebrisor residual
cementwasobserved.Thisstepcantake anywhere between5-15minutes,dependingonthe
surroundingbone lossandextentof the defect (Al-FalakiandCronshaw,2015).
FLAPPEDTECHNIQUE

19. 18
End-firingtip(MZ6,14 mm) at lasersettingsof 1.5 W, Water 75%, Air50%, 30 Hz, H mode,45-60 degree
angle relative tothe implantsurface.3.Decontaminationof the implantsurface usinganendfiringtip
(MZ6, 14 mm) at lasersettingsof 1 W, Water 75%, Air50% , 50 Hz, H mode,60 degree angle tocleanin
betweenthe threadseffectively (Al-Falaki andCronshaw,2015).
Laser assisted Oral Medicine procedures
Althoughthe diode,Nd.YAG,andtoa lesserextentthe erbiumwavelengthsmaybe usedinminoroffice
oral surgical procedures,the CO2laseristhe mostfrequentlyusedwavelengthforthese procedures.
The clinicianusesthe followingthree fundamentalphotothermal techniquestoperformvarious
intraoral procedures (Aoki etal.,2015) :
1. Incision/excisionsurgery
2. Ablation/vaporizationprocedures
3. Hemostasis/coagulationtechniques
A laserinfocuswill excise,incise,ablate,orcoagulate withthe mostefficiency.Whenthe laserisoutof
focus,there will be lessefficiencyin ablation/incision/excisionandmore efficiencyincoagulation.
Focusedmode iswhenthe focal pointof laserenergymakescontactwithtissue,maximizingthe power
perunitto a pin-pointedarea.Usingthe CO2laserin a focusedmode allowsforincreaseddepth,yet
producesan incisionthinnerthanascalpel,functioningasa “light”scalpel.
Tissue ablationandvaporizationisatechnique performedwithlasersindefocusedmode andachieved
by movingthe laserawayfromthe tissue beyondthe focal point,causinganincrease inspotsize that
directlydecreasespowerdensityanddepthof the cut.The absorbedenergyvaporizesthe tissueina
controlled,predictablemanner.Cryosurgeryandchemical peelingare similarbutunpredictable because
of theirinabilitytoachieve aconstantdepthandthe difficultyof applyingthesemodalitiesintraorally.
Laser vaporizationisthe safest,fastest,andmostpredictablesurgical modalityavailable today.The
ablationtechniqueisoftenusedtotreatdiscrete intraoral lesions,benignandpremalignantsurface
lesions,andinflammatorydisease,aswell asforcontouringgingival tissuesforfunctional andesthetic
purposes.The treatmentof these lesionsfrequentlyincludesthe managementof epithelial
hyperkeratosis,hyperplasia,dysplasia,lichenplanus,andnicotine stomatitis.
The hemostatictechnique isachievedbydefocusingthe laser,whichincreasesthe spotsize,dispersing
the energyovera widerarea.The laseris passedoverthe tissue until bleedingceases.Thissimple
exercise decreasesthe temperatureof the energyabsorbedbythe lasedtissues,causingcoagulation.
For directhemostasis,the laserbeamcanbe aimedata specificbleedingarea.These techniquesare
effectiveonlyif the surgical fieldremainsabsolutelydryof salivaandblood.Anysurroundingbodyfluids
will absorbthe energy,thusreducingthe laser’seffectonthe tissues
Photobiomodulation (Low level Laser Therapy)
High-level lasertreatment/therapycancause variousdegreesof thermal effectsontissues,including
coagulationandablationof softtissue,andremoval of hardtissue.Simultaneously,alow levelof energy

20. 19
penetratesorscattersintothe surroundingtissuesduringhigh-level lasertreatment.Low-level laser
treatmentstimulatestissues/cellswithoutproducingirreversiblethermal changesinthe tissues,
resultinginactivationorstimulation(photobiomodulation) of woundhealinginthe surroundingtissues.
Whenusinga high-level laserata low-energylevel,the thermal effectmayalsoinduce woundhealing,
as inthe purelylow-levellasereffectphotobiomodulation(PBM) (Aokietal.,2015, Mizutani etal.,2016,
Monzavi et al.,2016).
Clinical targetsof Lowlevel lasertherapyLLLT
 Site of lesion- Promote healingandremodellingandreduce inflammation
 Lymphnodes- toreduce inflammationandedema
 Nerves- toinduce analgesia
 Muscles- Triggerpointstoreduce painand relax contractedmuscle fibres
Mechanismof action
Most of the effectsof LLLT can be explainedbylightabsorptioninthe mitochondria.Everycell inthe
bodyhas considerable mitochondria(hundredsorthousandspercell).Mitochondriamake cellular
energy(adenosine triphosphate [ATP]) fromoxygenandpyruvate.lnstressedorischemictissues,
mitochondriamake theirownnitricoxide(mitochondrial nitricoxide [mtNO])whichcompeteswith
oxygen.The mtNObindstocytochrome c oxidase (CcO) (the terminal enzyme inthe electrontransport
chain) and displacesoxygen.Thisdisplacementof oxygenhastwonegative effects
- ReducedATPsynthesis
- increasedoxidativestress(leadingtoinflammationviathe inflammatory“masterswitch”NF-κβ
The effectof LLLT on hypoxic/stressedtissuescanbe describedinfourstages:
Primaryeffectof LLLT: Absorptionbycytochrome c oxidase
Cytochrome c oxidase (CcO) absorbsred andnear—infraredlight,andthe transferof lightenergyby
thisenzyme triggersaseriesof downstreameffects.

21. 20
Secondaryeffect:Modulationof ATP,nitricoxide,andreactive oxygenspecies
ChangesinATP,reactive oxygenspecies,andnitricoxidefollow lightabsorptionbyCcO.These effects
are redox state anddose dependent.Inhypoxicorotherwisestressedcellsithasbeenshownmany
timesthatfollowingLLLT,nitricoxide isreleased,ATPisincreased,andoxidativestressisreduced.
Tertiaryeffect:Downstreamintracellularresponses(genetranscriptionandcellularsignaling)
The downstreameffectsof LLLT releasednitricoxide,increasedATP,andreducedoxidative stressare
many.Theyare context- andcell type specific.Eitherdirectlyorindirectlythese biochemical
intermediatesaffectcomponentsinthe cytosol,cell membrane,andnucleusthatcontrol gene
transcriptionandsubsequentlycell proliferation,migration, necrosis,andinflammation.
Quaternaryeffect:Extracellular,indirect,distanteffects
Tissuesthathave not absorbedphotonscanalsobe affectedindirectlyviasecretionsfromcellsthat
have absorbedlight.Cellsinbloodandlymphcanbe activatedandtheytravel significantdistancesfrom
the treatmentareato have distant (systemic) effects.”These canbe autocrine,paracrine,andendocrine
effects(sometimesknownas"bystander"effects).
Settingand procedure for LLLT
The most commonwavelengthsforthese so-called“cold”or“soft”lasersisinthe 655 to 810 nm range.
Thus,diode lasersinthe 810 nm range,whenusedat low energies(0.1to0.5 W CW) can be usedfor a
varietyof benefitsforpatientsundergoingimplantsurgery.Whenlaserenergyisusedforatherapeutic
effect,adiffuse beamof energysize thatisoftenlargerinspotsize (largerhandpiece) isdeliveredtothe
tissue site overaperiodof time.The level of laserenergyislow enoughtohave a therapeuticeffect
withoutcausinganytissue destruction,andnow a verycommonname for thisprocedure islaser
phototherapy (vanAs,2015a, vanAs, 2015b).
LLLT may increase bone repairatearlystagesof healing.OtherresearchhasshownthatLLLT promoted
the osseointegrationof implantswithpoorinitial stability,particularlyinthe initial stagesof bone
healingandthatusingLLLT enhancedperiimplantbone repair,improvingstability,BIC,andnew bone
formationwhenusedevery48hoursfor 2 weeks
Antimicrobial photodynamic theory
Antimicrobialphotodynamictherapyusesa photosensitizer(indocyanine green -ICG) whichisdispensed
ina syringe intothe pocket,leftforaminute andrinsedbefore laserapplication (Helbo,2016, Monzavi
et al.,2016, Mizutani et al.,2016).
The chemical/physical processiscarriedoutin3 steps:
Step1: Stainingof the microorganisms.Thisisadiffusion-determiningstep, withmigrationand
attachmentof the dye molecules, onthe wall of the microorganisms.(charge attraction)

22. 21
Step2: Exposure andactivationof the photosensitizer. Thisisanenergy-controlledstep, determinedby
physical-optical properties, withexcitationof the sensitizermolecules, fromsingletstate totripletstate.
Step3: Oxygenradical formationanddestructionof the microorganisms.Exposure andactivationof the
photosensitiserleadstothe build-upof singlet-oxygenandanoxidative destructionof membranelipids
and enzymes.
The decisive factorisa questionof whichbiological targetmoleculesare reachedbythe radical
reactions:
In principle, all moleculesare affectedbysinglet-oxygen.However: Unsaturatedfattyacidsinthe
bacterial membranesare particularlysusceptible todamage.The body'sownhealthycellshave cellular
defencesagainstthe attackof radicals - so-calledcatalase orsuperoxidedismutase.Itisthusspecifically
the pathogenicbacteriathatare destroyedbyantimicrobial photodynamictherapy.Healthycellsare at
no risk!
Conclusion
There isstill controversyregarding the use of lasersaseitheranadjunctive ora stand-alone nonsurgical
periodontal therapy,and several questionsremainunansweredabouttheir effects,the American
Academyof Periodontologypublishedastatementonthe efficacy of lasersinthe nonsurgical treatment
of inflammatoryperiodontal disease.Itwasstatedthat there isminimal evidence tosupportthe use of a
laserfor the purpose of subgingivaldebridement, eitherasa monotherapyoradjunctive toscaling and
root planning(Smileyetal.,2015a, Smileyetal.,2015b).

23. 22
References
AL-FALAKI, R. 2016.The use of lasers in cosmetic periodontal procedures. Dentistry.
AL-FALAKI, R. & CRONSHAW, M. 2015.Minimally-invasiveflaplessand flapped management of peri-implantitis
usingEr,Cr:YSGG laser. Journal of laser-assisted dentistry.
AL-FALAKI, R., HUGHES, F. J. & WADIA, R. 2016.Minimally InvasiveTreatment of Infrabony Periodontal Defects
UsingDual-Wavelength Laser Therapy. International Scholarly Research Notices, 2016.
AOKI, A., MIZUTANI, K., SCHWARZ, F., SCULEAN, A., YUKNA, R. A., TAKASAKI, A. A., ROMANOS, G. E., TANIGUCHI,
Y., SASAKI, K. M., ZEREDO, J. L., KOSHY, G., COLUZZI, D. J., WHITE, J. M., ABIKO, Y., ISHIKAWA, I. & IZUMI,
Y. 2015.Periodontal and peri-implantwound healingfollowinglaser therapy. Periodontol 2000, 68, 217-
69.
BERK, G., ATICI, K. & BERK, N. 2005.Treatment of gingival pigmentation with Er, Cr: YSGG laser. J Oral Laser Appl, 5,
249-253.
CJ, W. 2015.Journal of Laser Assisted Dentistry, Spring2015.
CONVISSAR, R. A. 2010. Principles and Practice of Laser Dentistry, Elsevier Health Sciences.
HAKKI, S. S., BERK, G., DUNDAR, N., SAGLAM, M. & BERK, N. 2010a.Effects of root planingprocedures with hand
instrument or erbium, chromium:yttrium-scandium-gallium-garnetlaser irradiation on the root surfaces:a
comparativescanningelectron microscopy study. Lasers Med Sci, 25, 345-53.
HAKKI, S. S., KORKUSUZ, P., BERK, G., DUNDAR, N., SAGLAM, M., BOZKURT, B. & PURALI, N. 2010b.Comparison of
Er,Cr:YSGG laser and hand instrumentation on the attachment of periodontal ligament fibroblasts to
periodontally diseased rootsurfaces:an in vitro study. J Periodontol, 81, 1216-25.
HELBO. 2016.A laser product company [Online].Available:www.helbo.de [Accessed 25 June 2016].
MIZUTANI, K., AOKI, A., COLUZZI, D., YUKNA, R., WANG, C. Y., PAVLIC, V. & IZUMI, Y. 2016.Lasers in minimally
invasiveperiodontal and peri-implanttherapy. Periodontol 2000, 71, 185-212.
MONZAVI, A., CHINIPARDAZ, Z., MOUSAVI, M., FEKRAZAD, R., MOSLEMI, N., AZARIPOUR, A., BAGHERPASAND, O. &
CHINIFORUSH, N. 2016. Antimicrobial photodynamic therapy usingdiodelaser activated indocyanine
green as an adjunctin the treatment of chronic periodontitis:Arandomized clinical trial. Photodiagnosis
Photodyn Ther, 14, 93-7.
NAGAHARA, A., MITANI, A., FUKUDA, M., YAMAMOTO, H., TAHARA, K., MORITA, I., TING, C. C., WATANABE, T.,
FUJIMURA, T., OSAWA, K., SATO, S., TAKAHASHI, S., IWAMURA, Y., KUROYANAGI, T., KAWASHIMA, Y. &
NOGUCHI, T. 2013. Antimicrobial photodynamic therapy usinga diodelaser with a potential new
photosensitizer,indocyaninegreen-loaded nanospheres, may be effective for the clearanceof
Porphyromonas gingivalis. JPeriodontal Res, 48, 591-9.
SMILEY, C. J., TRACY, S. L., ABT, E., MICHALOWICZ, B. S., JOHN, M. T., GUNSOLLEY, J., COBB, C. M., ROSSMANN, J.,
HARREL, S. K., FORREST, J. L., HUJOEL, P. P., NORAIAN, K. W., GREENWELL, H., FRANTSVE-HAWLEY, J.,
ESTRICH, C. & HANSON, N. 2015a.Evidence-based clinical practiceguidelineon the nonsurgical treatment
of chronic periodontitis by means of scalingand rootplaningwith or without adjuncts. JAm Dent Assoc,
146, 525-35.
SMILEY, C. J., TRACY, S. L., ABT, E., MICHALOWICZ, B. S., JOHN, M. T., GUNSOLLEY, J., COBB, C. M., ROSSMANN, J.,
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VAN AS, G. 2015b.Lasers in ImplantDentistry, Part 2. Dentistry today, 34.
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Example of Charting and Documentation for Laser Periodontal Therapy
10-11-2009: Pt presentedforperiodontalinfectiontherapy(PIT) UR
Healthhistoryreviewed,nocontraindicationstotreatment.
Administered20%topical benzocainefollowedby2% lidocaine,withepi 1:100,000, 1.8 mL forlocal
anesthesiaof teeth#2-5.
Disclosed#5-8 andinstructedonspecificdailybiofilmremovaltechniques. Recommended:Bass
toothbrushtechnique twice dailyandaddingflosstocurrentroutine.Review flosstechnique furtherat
nextappointment.
Preprocedural laserdecontaminationwith980-nmdiode,uninitiated300-micronfiber,powerof 0.4
wattsin CW administeredapprox 16sec pertooth throughout.
Supragingival ultrasonicbiofilmremovalthroughout.
Manual andultrasonicdefinitivedebridementof #2-5.
Laser decontaminationof #2-5 withsame laserandfiber,2.0 wattsin PW on 25 msec/off 50 msecfor an
average powerof 0.7 W administeredapprox.20sec persite.Lasercoagulationfollowedwithpowerof
0.8 wattsin CW administeredapprox 10sec persite.
Laser-specificglasseswere wornbypatientandclinicianduringlaserprocedures.Noadverse reactions.
Postopinstructionsgiveninbothwrittenandverbal forms.
Nextvisit:PITforUL area.