This document reviews the use of lasers in non-surgical periodontal therapy. It discusses how lasers can be used to decontaminate and coagulate periodontal pockets to remove bacterial biofilms and support healing. Different types of lasers including diode, Nd:YAG, CO2, and erbium lasers are described. Treatment protocols involve using lasers for sulcular debridement and repeated decontamination of pockets over multiple appointments to thoroughly reduce the bacterial load and support tissue maturation. Lasers are shown to be bactericidal and improve periodontal health outcomes when used as an adjunct to conventional root debridement and as part of expanded infection therapy protocols.

1. LASER ASSISTED NONSURGICAL PERIODONTAL THERAPY :- A REVIEW
DR VIRAL I PATEL
MDS [periodontics], DLD [diploma laser dentistry]
Prof & Head
Dept Of Periodontology & Implantology
College Of Dental Sciences & Research Centre, Ahmedabad, Gujarat
ABSRTACT
Lasers fast becoming part of contemporary clinical practice and have since opened up vistas of
unprecedented patient care. Bacteria associated with periodontal disease are associated with an
increased risk of heart disease, diabetes, stroke, premature birth2,3 and respiratory infection in
susceptible individuals.4,5 This article discusses the use and benefits of lasers in treatment
planning and delivery of nonsurgical periodontal procedures.
Keywords: sulcular debridement, active phase I periodontal infection therapy, Laser
decontamination, Laser coagulation
INTRODUCTION
Periodontal disease are biofilm-initiated inflammatory conditions that impact the susceptible
individuals.6 The organization and activity of biofilm are important because biofilm is the first
component of periodontal disease targeted in therapy. Conventional nonsurgical therapies
addresses debriding the area of bacteria, endotoxins & hard deposits from the tooth structure to
restore gingival health.7 The advantages of lasers affect the bacteria directly and support the
body’s healing response. Incorporating lasers into conventional therapies helps accomplish
treatment objectives.
Aoki et al.8 determined that deposits and biofilm are more thoroughly removed and that a more
biocompatible surface is created for reattachment with an erbium [Er] laser versus conventional
methods.9 The Alexandrite laser also has been in development of for selective removal of
calculus from the root structure.10 The carbon dioxide [CO2] laser has been shown to increase
adherence of fibroblasts to root surfaces, and the fibroblast adherence is superior to conventional
techniques both in quantity of fibroblasts attached and in the quality of the attachment.11
Regardless of the instruments used, it is essential that contaminants are thoroughly removed from
the tooth structure in any periodontal therapy. Currant laser-assisted methods address the biofilm
of the tissue wall, supplementing conventional methods that address the tooth structure. It is
critical note that laser treatment is an addition to, not a replacement for, conventional periodontal
therapy.
Both in vitro and in vivo studies show that lasers are bactericidal.12,14 Although not specific to
certain bacteria, the argon [Ar] neodymium-doped yittrium-aliminium-garnet [Nd-YAG], and
diode lasers have strong absorption in darkly pigmented bacteria, causing a direct, increased
effect on the red and orange-complex bacteria associated with periodontitis.15

2. In laser assisted active phase I periodontal therapy, the diseased biofilm-infested tissues of
pocket are debrided. It has been shown that “ the diode laser assisted periodontal therapy
provided a bactericidal effect, reduced inflammation, and supported healing of periodontal
pocket through elimination of bacteria.12 Administering laser energy to the affected tissue at
specific, repeated intervals is key in targeting biofilm during therapy.
Lasers also have the ability to seal capillaries and lymphatics, reducing swelling at the treated
site and minimizing postoperative discomfort.18
Another benefit of laser-assisted procedures is the healing stimulated at the cellular level.19
Medrado et al.20 found that low-level laser treatment depresses the exudative phase while
enhancing the proliferative processes during active and chronic inflammation. Laser
photobiomodulation can activate the local blood circulation and stimulate proliferation of
endothelial cells.21,22 Wound healing is supported with reduced edema, PMN infiltrate, increased
fibroblasts, more and better organized collagen bundles.23
The treatment goal for nonsurgical periodontal therapy is decontamination and coagulation rather
than incising. In laser-assisted procedures, laser energy is absorbed by the chromophore and
transformed into photothermal energy.
TYPES OF LASERS USED IN ACTIVE PHASE I PERIODONTAL INFECTION
THERAPY
Argon
Diode
Nd:YAG
CO2
Erbium
ARGON LASER
514-nm wavelength higly absorbed in hemoglobin and melanin and have bactericidal properties,
particularly for Prevotella and Porphyromonas. 15,24 It uses fiberoptic delivery.
DIODE LASER
810-830 nm
940 nm
980 nm
1064 nm
Both 810-830 and 980 nm wavelength may be used for nonsurgical periodontal therapy. 980-nm
has more absorption in water than the other diode wavelengths, which may be an added benefit
to the laser interaction within the pocket. Diode lasers are bactericidal12,25,26 and aid in
coagulation.
Diode lasers may be operated in continuous-wave mode, with low settings and short application
time, or in a gated-pulse mode, with higher settings and longer application time.

3. NEODYMIUM:YAG [Nd:YAG] LASER
It is a free running pulse laser and also uses a fiberoptic delivery for contact or non-contact
mode. 1064 nm wavelength is most highly absorbed in melanin, less in hemoglobin, and slightly
in water. It is also bactericidal and provides excellent hemostasis.
MICROPULSED CO2 LASER
It is 10,600 nm wavelength and used in non-contact mode. Technique requires same care as any
other laser application for soft tissue: direct the laser energy away from the tooth structure.
ERBIUM FAMILY OF LASERS
Er-YAG 2940 nm
Er,Cr-YSGG [erbium-doped yittrium-scandium-gallium-garnet] 2780 nm
They are used for both hard and soft tissue applications. Quicker healing also is an advantage of
these wavelength.9 Studies have demonstrated significant population reduction of the periodontal
pathogens Porphyromonas Gingivalis and Actinobacillus [Aggregatibacter]
actinomycetemcomitans, as well as positive long term clinical results in attachment gain.9,13,16
TREATMENT PROTOCOLS FOR SOFT TISSUE LASERS IN ACTIVE PHASE I
PERIODONTAL INFECTION THERAPY
The objective of active phase I periodontal infection therapy is to remove biofilm and deposits
found above the gumline and within the pocket, whether on the tooth structure, on the tissue
wall, or in the crevicular fluids. These is accomplished through conventional SRP as well as
laser-assisted sulcular debridement. Sulcular debridement addresses the pocket wall for profound
decontamination and seals the capillaries and lymphatics through coagulation.
[A] SULCULAR DEBRIDEMENT WITH FIBEROPTIC LASER DELIVERY
Preprocedural Decontamination
It is a laser application done before any instrumentation even before probing, to affect the
bacteria within the sulcus, reducing the risk of bacterimia caused from instrumentation, and to
lower the microcount in aerosols created during ultrasonic instrumentation.27
The fiber is placed within the sulcus and is swept vertically and horizontally against the tissue
wall, away from the tooth with a smooth, flowing motion.
Decontamination
Laser decontamination removes the biofilm within the necrotic tissue of the periodontal pocket
wall. The laser energy interacts strongly with inflamed tissue components [from preferential
absorption by chromophores, which are more abundant in diseased tissue] and less strongly with
healthy tissue. This nonsurgical therapy uses very low settings and decontaminates rather than
cuts the tissue.10
Laser therapy should address sites presenting with inflammation and/or pocketing of 4 mm or
greater. Completion of laser decontamination is determined by laser parameters used, delivery
time, and clinical signs. Decontamination is accomplished with less mJ and more Hz than for
coagulation. A more inflamed pocket may require less average power because of increased
concentration of the laser’s preferred chromophores.

4. Coagulation
When biofilm has been removed, the second objective in active phase I periodontal infection
therapy is coagulation, sealing the capillaries and lymphatics of the healthy tissue. Coagulation
may inhibit the biofilm’s progression and it also counteracts the swelling that occurs with the
inflammatory process.
Coagulation is accomplished with increased mJ and decreased Hz compared with
decontamination. It also requires less time within the pocket and does not address every mm of
tissue.
After coagulation, firm digital pressure applied to areas with deep pockets will support the re-
adaptation of the tissue to the tooth and further enhance reattachment.
[B] SULCULAR DEBRIDEMENT WITH CO2 LASER
When the argon, diode, and Nd:YAG lasers employ a contact technique, the micorpulsed 10,600-
nm CO2 laser uses a defocused, noncontact technique. Marginal dehydration and pocket
decontamination are two steps applied in CO2 laser therapy.
Marginal dehydration will improve entry of the tip by drawing the tissue slightly away from the
tooth structure and the epithelium will be inhibited by this application.
The technique for decontamination involves placement of the laser’s defocusing tip 1 to 2 mm
only into pocket. Coagulation occurs simultaneously with decontamination.
EXPANDED PERIODONTAL INFECTION THERAPY
The expanded-therapy design for periodontal infection takes into consideration the severity of
the disease to be treated. This is structured with more appointments with shorter treatment times.
Advantages
Repeated reduction of microbial load within the pocket
Less patient fatigue
Decreased postoperative discomfort because smaller areas are treated
Repeated biofilm removal at the cervical portion of the tooth
Supports the healing process by retarding epithelium and allowing connective tissue growth
Disadvantages
More visits
Not practical for sedation appointments
Expanded infection therapy consists of following appointments
SEDATION APPOINTMENT
DEBRIDEMENT APPOINTMENT
LASER DECONTAMINATION APPOINTMENT
REINFECTION ASSESSMENT AND REEVALUATION

5. TABLE : SuggestedLaser Parameters for Nonsurgical Periodontal Therapy 5,28
LASER
TYPE
FIBER
DIAMETE
R
PREPROCEDURAL
DECONTAMINATIO
N
DEBRIDEMEN
T
COAGULATIO
N
Argon 300 microns No suggested parameters 05 watt, 0.05-
second pulse
duration, 0.2 sec
between pulses
0.7-0.8 W, 0.05-
sec pulse duration,
0.2 sec between
pulses
Diode 810
nm
300 micron
initiated
1.0 W, uninitiated fiber,
gated 50% duty cycle,
15 sec per tooth
0.4 W continuous
wave, 20 sec per
site
0.8 W,
continuous, 10 sec
per site
Nd:YAG
1064nm
300 micron No suggested parameters 30 mJ and 60 Hz,
1.8 W, 40 sec per
site
100 mJ & 20 Hz,
2.0 W, 20 sec per
site
Diode 980
nm
300 micron No suggested parameters 2.0 W pulsed 25
msec on/50 msec
off for avg power
of 0.7 W applied
20 sec/site or 0.4-
0.6 W, continuous
for 20 sec/site
0.8 W continuous
applied 10 sec/site
Micropulse
d CO2
Periotip
aperture: 0.5
mm
No suggested parameters 80 mJ [level 4],
50 Hz, 1.8-2.0 W,
avg of 24
sec/tooth
28 mJ, 30 Hz, 1
W, 350-microsec
pulse width, 0.31
msec off; avg of
24 sec/tooth
N/A
Er:YAG Tip diameter
0.6 mm
No suggested parameters 80 mJ, 30 Hz, 2.4
W avg power
with spray
N/A
Er,Cr:
YSGG
Tip diameter
0.6 mm
No suggested parameters 1.0 W [50
mJ/pulse]
N/A

6. SEDATION APPOINTMENT
It focuses only on definitive debridement of the teeth and decontamination of the tissues.
DEBRIDEMENT APPOINTMENT
It includes definitive removal of calculus and endotoxins on the tooth surfaces along with the
first application of laser decontamination of the diseased pocket walls.
LASER DECONTAMINATION APPOINTMENT
It is provided after thorough debridement of tooth structure, when continued decontamination of
the tissue wall, impairment of epithelium, and maturation of connective tissue are required.
The sessions are scheduled approximately 10 days apart after the last debridement plus lasing
session.
At the completion of the last laser decontamination appointment, the definitive therapy
appointment should be scheduled for 6, 8, or 12 weeks [longer interval allows attachment to
mature].
REINFECTION ASSESSMENT AND REEVALUATION
This appointment marks the completion of the active phase I periodontal infection therapy and
provides evaluative and therapeutic services. This appointment follows the last laser
decontamination appointment by 6 to 12 weeks and includes continued evaluation of daily care.
Laser decontamination in areas of inflammation and persistent pocketing completes the process
for the definitive therapy [reevaluation] appointment.
SUPPORTIVE PERIODONTAL THERAPY
This appointments maintain the body’s stabilization in oral health by eliminating or reducing
local microbial factors. Clinically, these involves preserving clinical attachment level,
maintaining alveolar bone height, eliminating inflammation, and ensuring comfortable function.
CONCLUSION
There are very few contraindications to laser treatment. Lasers may be used on children,
pregnant women, and immunocompromised patients. When used within parameters, lasers
provide gentle, yet profound decontamination at the target site and promote healing. Lasers are
bactericidal and improve indices related to periodontal health. They are excellent adjunct to
thorough root debridement and tissue rehabilitation.
Understanding applications and safe techniques of laser-assisted therapy provides a higher
standard of care.
It is critical note that laser treatment is an addition to, not a replacement for, conventional
periodontal therapy.

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