Lasers in Dentistry Current Concepts
Lasers in Dentistry Current Concepts
Donald J. Coluzzi
Steven P. A. Parker Editors
Lasers in
Dentistry—
Current Concepts
Second Edition
Textbooks in Contemporary Dentistry
This textbook series presents the most recent advances in all fields of dentistry, with the aim of bridging the
gap between basic science and clinical practice. It will equip readers with an excellent knowledge of how to
provide optimal care reflecting current understanding and utilizing the latest materials and techniques. Each
volume is written by internationally respected experts in the field who ensure that information is conveyed in
a concise, consistent, and readily intelligible manner with the aid of a wealth of informative illustrations.
Textbooks in Contemporary Dentistry will be especially valuable for advanced students, practitioners in the
early stages of their career, and university instructors.
Donald J. Coluzzi • Steven P. A. Parker
Editors
Lasers in Dentistry—
Current Concepts
Second Edition
Editors
Donald J. Coluzzi Steven P. A. Parker
Preventive and Restorative Dental Sciences Faculty of Health and Life Sciences
School of Dentistry, University of California De Montfort University
San Francisco, CA, USA Leicester, UK
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2017, 2023
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Preface
The first laser specifically designed for dentistry was introduced in 1989 and used a
crystal of neodymium-doped yttrium aluminum garnet (Nd:YAG) as its core active
medium. Low average power photonic energy produced by this laser was delivered
through a small-diameter optic fiber to target oral tissue. Such technology had been
developed for use in medicine since 1975, and carbon dioxide (CO2) lasers were com-
monly employed during the 1980s for general and oral surgery.
Nowadays, approximately 15% of dentists worldwide own lasers, and there are
about 30 indications for their use in dental treatment. Whether used in addition to or
instead of conventional instrumentation, lasers provide many unique patient benefits.
This textbook is intended to provide information about the basic science and tissue
interactions of dental lasers and display the most current examples of clinical use in
every dental discipline. The clinical cases were chosen to show the results of proper
laser use for a particular procedure, and the accompanying text explains the rationale,
advantages, and precautions of that use, documented with numerous citations.
Research studies continue to provide collaborative evidence demonstrating the effi-
cacy of today’s instrumentations. Furthermore, other investigations will enumerate
novel clinical applications, and hopefully new laser wavelengths will be explored,
developed to deliver highly specific power configurations to optimize laser-tissue
interaction.
We are proud of the phenomenal success of the 2017 first edition of this textbook.
Through the almost 7 years that have passed, the use of laser photonic energy, in all its
power range applications, has continued to expand. Throughout the world, clinicians
are discovering the wide array of clinical applications—diagnostics, photochemistry,
sub-ablative photobiomodulation, and ablative surgical adjunctive use—and the ease
with which these applications can deliver added benefits.
It is a testimony to the innovation of laser manufacturers, and to the worldwide
research community and dental and oral clinicians, that both the number and variety
of lasers continue to expand.
This book continues to be the product of those many highly respected dental clini-
cians, along with those in academia and involved in research throughout the world,
and we are grateful for their efforts and their friendship. To those who have gone
before, we say “thank you,” and those new authors, we are appreciative of your effort
in contributing.
Most importantly, we acknowledge the love, understanding, and support of our
spouses, Catherine Coluzzi and Penny Parker.
We hope that you enjoy the book.
Donald J. Coluzzi
Steven P. A. Parker
Portola Valley, CA, USA
Harrogate, North Yorkshire, UK
VII
Contents
3 Laser-Tissue Interaction.................................................................................................................35
Steven P. A. Parker
9 Laser-Assisted Endodontics.........................................................................................................291
Roy George and Laurence J. Walsh
Glossary.......................................................................................................................................................................572
Index 577
IX
Contributors
Akira Aoki, DDS, PhD Department of Periodontology, Graduate School of Medical and Den-
tal Sciences, Tokyo Medical and Dental University, Tokyo, Japan
e-mail: [email protected]
Konstantinos Arapostathis, DDS, MSc, PhD Pediatric Dentistry Department, Aristotle Uni-
versity of Thessaloniki, Thessaloniki, Greece
e-mail: [email protected]
Ali Borzabadi-Farahani, DDS, MScD, MOrth RCS (Ed) Craniofacial and Special Care Ortho-
dontics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
University of Warwick, Warwick, UK
e-mail: [email protected]
Donald J. Coluzzi, DDS Preventive and Restorative Dental Sciences, School of Dentistry, Uni-
versity of California, San Francisco, CA, USA
e-mail: [email protected]
Mark Cronshaw, BSc, BDS, LDS RCS (Eng), MSc Private Practice, Cowes, Isle of Wight, UK
e-mail: [email protected]
Daniel Fried, PhD Preventive and Restorative Dental Sciences, School of Dentistry, University
of California, San Francisco, CA, USA
e-mail: [email protected]
Roy George, BDS, MDS, PhD(QLD), ADC School of Dentistry and Oral Health, Griffith Uni-
versity, Nathan, QLD, Australia
e-mail: [email protected]
Omar Hamadah, DDS, MSc, PhD Oral Medicine Department, The Faculty of Dental Medi-
cine, Damascus University, Damascus, Syria
e-mail: [email protected]
Kenneth Luk, BDS, DGDP(UK), MGD(HK), MSc, PhD Private Practice, Hong Kong, China
e-mail: [email protected]
XI
Editors and Contributors
Shally Mahajan, BDS, MDS Department of Dentistry, Dr Ram Manohar Lohia Institute of
Medical Sciences, Lucknow, India
e-mail: [email protected]
Robert J. Miller, DDS Department of Oral Implantology, Atlantic Coast Dental Research
Clinic, Palm Beach, FL, USA
Private Practice, Delray Beach, FL, USA
e-mail: [email protected], [email protected]
Alex Mathews Muruppel, BDS, MDS, Dipl. LAS. DENT., FPFA Department of Laser Surgery
and Laser Therapy, Faculty of Medicine and Dentistry, University of Genoa, Genoa, Italy
Rajas Dental College and Hospital, Kanyakumari, Tamil Nadu, India
Private Practice, Trivandrum, Kerala, India
e-mail: [email protected]
Steven P.A. Parker, BDS, LDS RCS, FCGDent, PhD Faculty of Health and Social Sciences, De
Montfort University, Leicester, UK
e-mail: [email protected]
Peter Rechmann, DMD, PhD, Prof. Dr. med. dent. Division of Prosthodontics, Preventive and
Restorative Dental Sciences, School of Dentistry, University of California San Francisco,
San Francisco, CA, USA
e-mail: [email protected]
Wayne Selting, DDS, BS, MS Private Practice, Colorado Springs, CO, USA
e-mail: [email protected]
Laurence J. Walsh, BDSc, PhD, DDSc, GCEd University of Queensland, St. Lucia, QLD,
Australia
e-mail: [email protected]
Lasers in Dentistry:
Where to Begin?
Shally Mahajan, Vipul Srivastava, and Donald J. Coluzzi
Contents
1.1 Introduction – 4
1.7 Marketing – 13
1.11 Conclusion – 18
References – 18
Core Message dence of the safe and effective use of lasers, there is a
1 Over a few decades, lasers have not only emerged as high growing number of practitioners embracing the technol-
technology instrument but also as very helpful tool in all ogy and appreciating how their patients can benefit.
aspects of our daily lives. They have been slowly incorpo- The question in this chapter’s title may be properly
rated into the world of dentistry with their wide applica- expanded into, “why buy a laser and what do I need to
tions that have embraced all aspects of our profession. know when I buy it?” The following sections should pro-
When given a choice, patients come to accept a treatment vide many details for that answer.
that is oriented at maximum tissue preservation, high qual-
ity, minimally invasive, and comfortable, with minimum
postoperative care and complications. Fortunately, a prac- 1.2 A Buyer’s Guide for Choosing a Laser
tice that utilizes lasers can be termed patient friendly as it
fulfills all of those goals. Moreover, the clinician can be While investigating a product for our personal use or a
proud of adhering to evidence-based techniques. The pur- piece of equipment for our practice, several aspects
pose of this chapter is to discuss some of the benefits of should be considered to avoid any regret later. As a clini-
adopting lasers into a dental practice; what the clinician cian, we should assess what value the equipment is going
must know before purchasing a laser; and concepts of rev- to add to our practice. A careful analysis should include
enue generation. Moreover, a practitioner who is appre- all related features, benefits, assets, and liabilities. A well
hensive about adopting this technology should also find thought out decision leads to a better business operation
information to help in making a decision to purchase. and good management. Hasty decisions can lead to
financial distress and instability in career and unneces-
sary emotional stress. Similarly, before investing in a
1.1 Introduction laser, we can ask the following questions:
55 What are the safety features? Lasers can interact rap- fibers can lose some transmissive capability over time;
idly and precisely with tissue so safety should also be some handpieces have mirrors or other components
of universal concern. The operator must have a sound that degrade. Protective glasses can be scratched or
knowledge of all the aspects of laser safety. These are damaged from repeated use. On the other hand, the
summarized here but will be covered in detail in 7 active medium of the laser and other internal parts
Chap. 5. All dental lasers are well equipped with built generally show little or no wear throughout the life of
in safety features subject to rigorous rules. Some the laser. While the tip cost is a small percentage of
examples of these features are: an emergency stop the fee, other items can be a significant economic fac-
button, emission port shutters to prevent laser emis- tor for the practice. In every case, the manufacturer
sion until the correct delivery system is attached, cov- should be able to service the unit, update any soft-
ered foot-switch to prevent accidental operation, a ware, and offer replacement parts when necessary.
control panel that allows selection of the emission 55 How are the parts sterilized or disinfected? Steriliza-
parameters such as average power, pulse details, tion and disinfection are essential aspects of every
amount of air and/or water needed, audible or visual dental treatment and should never be compromised.
signs of laser emission, locked unit panels to prevent It is extremely important to follow the manufactur-
unauthorized access to internal components, key or er’s instructions for infection control to prevent any
password protection, and remote inter-locks to mini- cross contamination from patient to patient. Some
mize the risk of accidental exposure. A visible aiming components of a laser, especially those are in direct
beam for invisible wavelengths must be clear and contact with oral tissues, are either autoclavable or
bright. Clearly, the practitioner must be familiar with disposable. The handpiece is an example of the for-
these protective items, and a laser safety officer must mer, and the single use tips are disposable. Other
be appointed to supervise the laser’s operation. areas, like the control panel and the delivery system
55 What is the cost of operation? Aside from the initial can be protected with barriers and subsequently dis-
investment of the device, each procedure will have a infected with standard spray on liquids. The protec-
cost while performing a procedure. Some items or tive safety glasses can also be disinfected.
accessories are single use. An example is a tip for a
diode laser; these tips are available in multiple diam-
eters and lengths. One tip can generally be used for 1.3 Integrating a Laser into Your Practice
one patient visit although treatment of multiple areas
may require more than one tip. Other components are Lasers have provided a new cutting-edge technology to
designed as long lasting but could require replace- the dental world. It is truly amazing to think about how
ment. An example is the delivery system itself. Optical such an investment like this could have such a huge
Lasers in Dentistry: Where to Begin?
7 1
impact on clinical practice. Incorporating lasers into minor surgical procedures like an immediate loading
conventional therapies helps in better prognosis and implant or second-stage implant uncovering.
treatment outcomes. Lasers began as alternatives for Not only is there a clean dry operating site, but
soft tissue oral surgery and have expanded into all the improved visualization will save time for the
aspects of dentistry: orthodontics, endodontics, oral other steps of the treatment. All this will save your
and maxillofacial surgery, periodontics, aesthetic den- time. Also, by differentiating your practice, you’ll
tistry, restorative dentistry, prosthodontics, dental attract a more educated cliental. Patients associate
implantology, and pediatric dentistry. In addition, low- laser procedures as less invasive leading to a better
level lasers can be used as adjuncts to treat chronic overall dental experience, and once treated will refer
pathologies and within photodynamic therapy to treat their families and friends. There is easy return of
infectious disease. investment as the procedures are made simpler and
Several factors are presented for consideration about easier.
how a laser can be incorporated into a practice:
55 Identify your practice. The first and perhaps fore-
most concept before buying a laser is to identify how
you practice. Your treatment planning is based on
the patient’s oral health conditions and the goals of
your care will help improve or maintain that health
as well as meeting their expectations. Your clinical
experience and scope of practice usually determines
which procedures you perform, and a list of those
should be studied so that you can begin to choose a
laser instrument. Likewise, you may have thought
about the addition of other newer treatments that
will expand your services. Those could affect the type
of laser you purchase.
55 Analyze what procedures do you currently perform
that can be assisted with laser technology. A dental
laser can help you provide a higher level of care. In
restorative dental procedures, management of soft 55 Think about which procedures that you do not per-
tissue is simplified because the tedious and painful form that you would like to provide if you had a laser.
placement of retraction cord can be eliminated. Bet- Within your scope of practice, there are procedures
ter impressions are possible for indirect restorations that can be accomplished with dental lasers in your
such as crowns and bridges, and clearer margins near office that you previously may have referred to a spe-
the gingiva are revealed for optical scanning. Class V cialist, and/or did not offer your patients. Of course,
carious lesions can be prepared at or near the subgin- proper training is necessary before you begin any
gival level with excellent hemostasis. This ensures an procedure and is especially important when you are
improved bond for composite materials and ulti- attempting a new one. However, understanding the
mately results in better aesthetics and a longer last- fundamentals of the wavelength and watching the
ing restoration. Two minutes of disinfection interaction as it happens will provide clinical experi-
treatment of an aphthous ulcer brings immediate ence and confidence for the clinician to continue
relief to the patient who may have been suffering for offer additional treatment options at chairside.
days. Excellent hemostasis can be achieved during
8 S. Mahajan et al.
courtesy Dr S. Parker
Endodontic therapy can be aided by both laser infants, and revising the frenum in a child’s diastema
debridement and pathogen reduction. Examples of to aid proper tooth positioning. Oral surgical proce-
laser soft tissue excisions are numerous: a removal dures treatment of oral mucositis fibrosis, lichen pla-
fibrous tissue in an irritation fibroma, epulis in the nus, and leukoplakia can also be performed. Lasers
soft tissues of patients wearing removal prosthodon- can also be used to for aesthetic enhancement of the
tic appliances, operculectomy treatment of an patient’s smile by minor recontouring of gingival tis-
unerupted tooth, a frenectomy to prevent further sue, laser tooth whitening, and removal of depig-
adult periodontal problems, releasing a tongue tie in mentation in the soft tissues.
courtesy Dr S. Parker
Lasers in Dentistry: Where to Begin?
9 1
Osseous crown lengthening for the treatment of either surgical or non-surgical, and they are some-
altered passive eruption or to obtain adequate tooth times termed high level and low level, respectively. .
structure for a restoration can proceed with the all- Figure 1.1 the basic categories of those classifica-
tissue lasers [4]. During the initial alignment phase tions. After analyzing your practice’s procedures, you
of orthodontic treatment, photobiomodulation can become familiar with how each available laser
(PBM) formerly known as Low Level Laser Therapy could be utilized.
(LLLT) can be used since it has shown to accelerate 55 Prioritize your clinical needs with respect to how a
the tooth movement and also to relieve the discom- laser’s use would be of benefit. In a modern dental
fort occurred during the initial arch-wire changes [5]. office, a patient has certain expectations: treatment
That PBM effect can be used in patients with brux- should be less painful, more precise, less invasive
ism, temporomandibular joint disease, acute abscess with less bleeding, better healing, and fewer appoint-
areas, and many more applications [6]. Some of the ments. Fortunately, the practice of dentistry has been
biggest hurdles while taking diagnostic records like revolutionized and modernized so that our proce-
impression-making and intraoral radiographs, is gag dures have become more patient-friendly. With the
reflex, which can be particularly strong in some incorporation of this device, an anxious patient feels
patients. Low-level lasers are a boon in such cases, more confident, there is noise free or no vibration of
using lower doses of laser energy helps in minimizing the drill or smell of conventional dental care, and
the reflex [7]. When all these benefits explained in with the fact that much of the treatment can be per-
detail, there is no doubt the patient will accept the formed with “no anesthesia” or “needle-free” den-
planned treatment. The increased revenue also helps tistry. These factors could transform patients who
to satisfy a further return on the initial cost of the were resistant to conventional treatment into ones
laser. who readily accept treatment. Also in the future, we
55 There are several choices of laser instruments. There can expect more referrals to the practice, thus, lasers
are many lasers available for purchase. Their avail- proving to be a safe investment and a true value for
ability can be dependent on regional regulations of the money.
sales and clearances, along with support of service If your practice is focused on oral hygiene main-
and training. There are world-wide standard and tenance including sulcular debridement, prosthodon-
consistent classifications so that basic choices can be tic or restorative soft tissue management such as
made. A generic division describes dental lasers as gingival troughing, or aesthetic procedures involving
.. Fig. 1.1 A graphic representation of the type of dental lasers. The surgical lasers will not perform those procedures. Recent studies
surgical lasers have output power sufficient for incision, excision, show that surgical devices do have some capabilities for photobio-
ablation, and coagulation of dental tissues, whereas the non- modulation
10 S. Mahajan et al.
gingival recontouring, gingival depigmentation, and because of the minimal water content. The 9.3μm
1 laser whitening), a diode or an Nd:YAG laser would carbon dioxide’s photons react primarily with car-
be ideal. The small diameter fiber optic contact deliv- bonated hydroxyapatite, so that tooth structure can
ery can be safely used on soft tissue with minimal be easily ablated. In addition, the laser’s output can
interaction with hard tissue. For the restorative prac- be a factor during treatment. Some procedures need
tice and conservative dentistry, the erbium family only minimum energy levels; an example would be
(Er,Cr:YSGG, 2780 nm and Er:YAG, 2940 nm) and when desensitizing an aphthous ulcer. Likewise, pho-
the 9300 nm carbon dioxide lasers offer a wonderful tobiomodulation effects are performed at power den-
alternative and adjunct to the dental bur. A specialty sities well below any threshold of surgical cutting. In
practice that is mainly focused on oral and maxillofa- contrast, tooth preparation requires very high peak
cial surgical procedures, or periodontal surgery, the powers and very short pulses for efficient removal of
afore mentioned all tissue lasers perform osseous sur- the mineralized material without thermal damage.
gery safely and rapidly while minimizing potential Therefore, before investing, all the factors just
thermal damage to adjacent tissues and the blood discussed should help the clinician to identify what
supply. In addition to those instruments, the 10,600 kind of laser is best suited for one’s practice.
nm carbon dioxide laser is often used for precise and
rapid cutting during soft tissue surgery.
The clinician is constantly assessing and assimi- 1.4 Sales, Training, and Company Support
lating patient’s needs and satisfaction while deciding
on the proper treatment [8]. When choosing to add a 1. The laser manufacturer is engaged in a highly
laser to the procedure’s protocol, certain wavelengths competitive business with a limited market of
have advantages over others. To be clear, any of the purchasers. The sales team must be transparent
available laser wavelengths suitable for soft tissue and honest about their product’s performance
treatment. But if the dentist treats both soft and hard and avoid unrealistic assurances about everything
tissues, only the erbium or the 9300 nm carbon diox- from clinical efficacy to availability and shipping
ide instruments will currently provide necessary time for the device. The company’s representa-
energy and tissue interaction for those dental proce- tives should have a sound knowledge of the laser’s
dures. operation so that they can initially demonstrate
55 There is no single perfect laser wavelength. Cur- how the laser is set up along with knowing how to
rently, there are over two dozen indications for use of help in case of troubleshooting a problem.
the various dental wavelengths, as listed in the differ- Customer support representatives should be
ent manufacturer’s operating manuals. There are available to answer questions and solve problems.
often many discussions in the profession about which
laser is the best, as well as debates about how all
lasers are the same. It should be clear that although
similarities exist, every laser wavelength has some
unique properties compared to another. When asked
the question about which laser is best, a proper
answer could be, “the one you know how to use in
your practice!”
One thing which must not be forgotten is that
there is “no perfect Laser.” It is simply because the
absorption characteristics of the photonic emission
by a particular wavelength are different for the same
tissues. Although every laser can be used for soft tis-
sue surgery, a very fibrous area will be difficult to cut
with a diode laser but will be easily incised with car-
bon dioxide. On the other hand, a diode can perform 2. Training and continuing education opportuni-
aesthetic contouring of gingiva adjacent to a natural ties must be available. Some companies have
tooth without interacting with the healthy enamel, formed institutes that provide training for basic
but the 10.6μm carbon dioxide wavelength could and advanced procedures, along with such fea-
damage that same enamel. Erbium lasers are very tures as educational resources, a discussion
highly absorbed by water, which allows the easy forum, examples of clinical cases, and other
removal of a carious lesion. However, highly fluori- digital learning. Others sponsor courses and
dated enamel can be more challenging to ablate workshops during larger dental conferences.
Lasers in Dentistry: Where to Begin?
11 1
3. It would be useful to know how long the par- stipulate what repairs are covered in specific cir-
ticular device has been commercially available cumstances.
for purchase as well as to learn about the com- 7. The laser’s operation is governed by software
pany’s track record of efficiency, reliability, and control of the internal components. Many com-
service. Some companies have a global market, panies offer updated versions of their software
but local support in your country or state would and may include them in the purchase price.
be very desirable. Regional dental suppliers can Likewise, some of the hardware may undergo
also represent the company to provide sales and modification and it would be prudent to deter-
service. Since those suppliers already have a mine if any retrofitting or upgrades are appro-
relationship with the dental practice, this could priate and available for the model of laser
facilitate good support. purchased.
4. The operating manual enclosed with the laser is
the guidebook for its use and describes the clin-
ical procedures for which the device may be
used. This is sometimes termed “indication for 1.5 Education and Knowledge
use,” and simply means that there is solid evi-
dence for safety and effectiveness, as opposed 1. A prudent question to ask is “how much train-
to “off label” treatment. All sections should be ing and do I need?” The simple answer is that
well written. Instructions should include the you should continue to acquire knowledge all
range of operating parameters for each proce- during your dental career. The elusive secret to
dure for the wavelength’s use. Those settings are success has always been to achieve better quality
always guidelines and suggestions for modifica- of patient care. That achievement can only be
tion should be listed. Factors such as beam found with life-long learning. It starts with the
diameter versus output power, approximate sessions offered by the laser manufacturer after
time of exposure, and varying tissue interaction purchase. Unfortunately, some of these are sim-
must be considered. The steps necessary for the ply didactic lectures available on playback
assembly and disassembly of the delivery sys- media. Hands-on simulated exercises on animal
tem should describe every detail. The care and tissue followed by over the shoulder supervised
maintenance of each component of the laser patient care are very superior learning methods.
should be illustrated. Warnings, precautions, Whichever methods of initial training are taken,
and troubleshooting procedures should be simple procedures performed with minimum
explained, along with contact information for power settings will help to overcome your fears
support. and increase the level of your skills. Observing
5. As previously mentioned, there are various the rate of tissue interaction and the progress of
accessories necessary for using a laser. These reaching the treatment objective may appear to
include delivery system tips, foot control pedals, be at a slower pace than you first expected. Your
keys, interlocks, and protective eyewear. The patience will be rewarded; in fact, a slow sweep-
initial and replacement cost of these items as ing motion for tissue removal is usually pre-
well as any maintenance and availability should ferred. Moreover, you will avoid unnecessary
be noted. In some cases, accessories are optional thermal damage while precisely cutting and
and have additional costs. Those can negate an contouring tissue; and that will produce a suc-
initial attractive initial price of the laser itself. cessful outcome. That continuing journey
Likewise, maintenance can be included for a toward mastering how a procedure is performed
period of time in the purchase, but a contract can bring you a lot of satisfaction. During that
for service beyond that may incur a fee. time, your range of comfort with all procedures
6. The warranty period should be clearly stated, will certainly increase.
and the dentist-purchaser should thoroughly 2. For continuing education about the use of
understand the terms and conditions. Lasers lasers in dentistry, several opportunities are
are designed for precision delivery of photonic available. Local study clubs and regional acad-
energy and the device is generally well con- emies have regularly scheduled meetings where
structed. However, any portion can be damaged members can share information. Many major
with normal use and accidental breakage can dental conferences feature presentations and
occur. Warranty is a promise provided by the workshop courses. There are university affili-
manufacturer to repair or replace the instru- ated programs which offer both information
ment within a specified time. That promise may and assess competency. Advanced programs,
12 S. Mahajan et al.
Fellowship, Mastership, and MSc programs are Dental Laser Education,” was developed in
1 offered in many countries. A document entitled 1993 and is often used as a reference for these
“Curriculum Guidelines and Standards for learning opportunities [9].
3. Finding a mentor would be a bonus for any 55 Certain agencies control the manufacturer
laser clinician. There is no faster way to improve and their products, but do not control the
your skills and knowledge then to have some- practice of dentistry. One example is the
one to guide you as you work on your goals. United States Food and Drug Administra-
That person should have the right attitude tion through its Center for Devices and
about teaching along with the experience to Radiologic Health regulates the construc-
demonstrate the proper way to perform the tion of the laser to ensure compliance with
procedure while correcting any of your defi- medical device legislation. That same agency
ciencies. Your confidence in delivering care will awards the manufacturer a marketing clear-
also increase. In addition, you can gain insights ance for a procedure which states that the
about new techniques and treatments. treatment where the laser is used will be safe
4. Another question that can be asked is “what are and effective.
the rules for laser use?” The response is that The International Electrotechnical
various regulatory agencies exist to ensure safe Commission prepares and publishes inter-
and efficacious use of lasers for the health and national standards for all electrical, elec-
welfare of patients. The practitioner must have tronic, and related technologies that includes
knowledge of those regulations and comply regulations and conformity assessment for
with their provisions. A review of those is pre- lasers in a similar manner to the Food and
sented here and will be detailed in the chapter Drug Administration.
on laser safety. Both organizations strongly influence
55 Regional or local bodies issue a license to regulatory agencies in other countries.
practice dentistry to a properly qualified 55 Currently, there is no common agreement
dentist. That allows the dentist to offer den- about what defines a proper credential for a
tal care according to the scope of practice— dental laser practitioner. Some local licens-
i.e., the general or specialty services that are ing jurisdictions have a course requirement.
provided. That care is delivered in a manner A small number of dental schools have
that is based on the practitioner’s training, introduced laser care into the pre-doctoral
education, and clinical experience. It should curriculum.
be remembered that “laser dentistry” is not 5. Evidence-based dental practice comprises an
a recognized specialty; in contrast, it is a equal combination of the integration of clini-
description of using an instrument during a cally relevant scientific evidence, the clinician’s
procedure. experience, and the patient’s treatment needs
Lasers in Dentistry: Where to Begin?
13 1
and experience. Regarding dental lasers, the
peer-reviewed literature offers an abundance of
studies, clinical cases, and meta-analysis. Some
reviews proclaim controversies that exist with
regard to superiority of incorporating lasers
into the treatment protocol. However, many
manuscripts using controlled clinical studies do
show effectiveness of these instruments. The
laser practitioner should be familiar with as
much of the literature, published articles, case
reports, and scientific reviews that are readily
available online or offline. Less reliable blogs
and forums can offer information and network-
ing about personal experiences. All of those
resources contribute to evidence that has a
place in the hierarchy of learning. The knowl-
edge of how a particular wavelength would 1.7 Marketing
serve the purpose will be very beneficial to the
success of your practice. One of the secrets to a successful practice lies in its mar-
keting. Marketing is a process by which a product or
service is introduced and promoted to potential custom-
ers [10]. It is the best means to make people aware of the
1.6 Investing in Your Team quality of service being provided. The overall marketing
umbrella covers advertising, public relations, promo-
Nurturing your employees is an important part of creat- tions, and sales.
ing an engaged workforce. Invest in their personal and There are mainly three methods of marketing,
professional development and it will pay handsome div- namely: online, offline, and word-of-mouth. The latter is
idends down the line by giving you a happy, capable, and sometimes termed “internal marketing.” Online market-
productive team in an optimized practice. Your patients ing uses the Internet, e- mail, social networking websites,
will immediately notice the professional and friendly and blogs as online channels for delivering marketing
atmosphere where you have created a healthy working content to the public. Offline marketing is disseminated
environment with a caring and holistic approach toward through the “conventional” media: radio, television,
their treatment. and print ads. Word-of-mouth marketing is the best of
Everyone on your staff from the receptionist and the three approaches for any dental office. The starting
administrators at the front desk to the clinical team of point is that the staff or team must have knowledge of
assistants, hygienists, and other associated doctors must the practice. A written strategic plan composed of a
be educated about dental lasers. vision, mission statement, goals, and objectives will cer-
With proper training and experience, they can tainly provide a framework for that knowledge. Each
answer any of the patient inquiries about how a laser employee should be able to articulate the fact that the
might be used for treatment. They can increase the entire office constantly stays updated with current inno-
patients’ awareness of the advantages and limitations vations and procures the latest technology to ensure the
of the technology. They can also address any apprehen- best treatment, care, in a comfortable environment. That
sion about a procedure. Interestingly, many people are in turn will clearly influence how the patient will speak
familiar with lasers because of previous medical proce- about the practice, encouraging friends, neighbors, and
dures; and a few have expressed a misunderstanding relatives to seek dental care there.
about the word radiation as it represents the last letter For the best results, all three modalities should be
in the laser acronym. Regarding the latter, a well- incorporated in a marketing plan. For the first two por-
informed staff member can clarify the fact that dental tions, you also may consider promoters, publicists, and
lasers do indeed emit radiation in the thermal portion professional marketing outlets to support any of your
of the electromagnetic spectrum and not in the ionizing large-scale promotion efforts. Obviously, a budget must be
portion used for radiographs. The entire team would prepared so that the dollars necessary for any of the above
benefit by attending an introductory course about the are well spent. However, word of mouth marketing usually
use of lasers in dentistry as well as being actively inter- just involves spending some time inside the office to ensure
ested in other continuing education offerings. a consistent and high standard of delivery of dental care.
14 S. Mahajan et al.
a b
1
c d e
f g h
j k
.. Fig. 1.2 a Pre-operative view of hyperplastic tissue present dur- ative view of interproximal carious lesions. g Immediate postopera-
ing orthodontic therapy. b Postoperative view showing tissue tive view of the new restorations. Both teeth were prepared with the
removal, with more normal periodontium. c A pre-operative view of laser instead of the dental handpiece. h Pre-operative view of pig-
a wide maxillary diastema with frenum involvement. d Photo depict- mentation on the mucosa. i Postoperative view showing the pigment
ing the healed frenum revision, gingivectomy, and good p rogression removed. j Pre-operative view of a benign irritation fibroma. k Post-
of orthodontic alignment. e A photobiomodulation laser is used for operative view showing healed area
the treatment of temporomandibular joint inflammation. f Pre-oper-
Lasers in Dentistry: Where to Begin?
17 1
1.9 Limitations of Laser Dentistry 1.10 Enjoying Benefits of Laser Dentistry
Contents
2.1 Light – 21
2.1.1 rigins and Curiosities of Light – 21
O
2.1.2 The Duality of Light – 21
2.1.3 Properties of Light and Laser Energy – 22
2.2 Emission – 22
2.2.1 S pontaneous Emission – 22
2.2.2 Stimulated Emission – 22
2.3 Amplification – 22
2.4 Radiation – 23
2.9 Terminology – 31
2.9.1 E nergy and Fluence – 31
2.9.2 Power and Power Density – 31
2.10 Conclusion – 33
References – 33
Laser and Light Fundamentals
21 2
Core Message observing how the common chemical silver chloride
The word LASER is an acronym for Light Amplification changes color when exposed to sunlight [5]. The British
by Stimulated Emission of Radiation. The theory was physicist Michael Faraday produced evidence that light
postulated by Albert Einstein in 1916. A brief description and electromagnetism were related [6]. In 1865, his
of each of those five words will begin to explain the Scottish colleague James Maxwell then explained elec-
unique qualities of a laser instrument. tromagnetic radiation: that is electricity, magnetism,
Once the laser beam is created, it is delivered to the and light are in fact interrelated in the same phenome-
target tissue. Furthermore, each device has certain con- non [7]. His discovery quantified the different wave-
trols that the clinician can operate during the procedure. lengths of radiation and thus helped to explain our
An understanding of these fundamentals will become current understanding of the existence of light in more
the foundation for further elaboration of the basic con- than just the visible spectrum of Newton’s colors. In
cepts of how lasers are used in dentistry. 1895, Wilhelm Roentgen, a German professor of phys-
ics, added X radiation to the electromagnetic spectrum,
after studying many experiments from colleagues such
2.1 Light as Philipp Lenard and Nikola Tesla [8]. He used the ter-
minology of “X” to signify an unknown quantity. A
2.1.1 Origins and Curiosities of Light theoretical physicist Max Planck, also from Germany,
proposed that light energy is emitted in packets he
The word light has been used for many centuries, includ- termed “quanta” in 1900 [9]. He formulated an equation
ing biblical references such as in the beginning sentences that gave a relationship between energy and wavelength
of the Book of Genesis. Early civilization seemed to or frequency. In 1905, the German scientist Albert
understand that the cycle of day and night with the sun, Einstein discovered what he termed the photoelectric
the moon, and the stars produced differences in ambient effect. He observed that shining light on many metals
brightness. Historical investigations into the nature of causes them to emit electrons, and he termed them pho-
light produced interesting and sometimes conflicting toelectrons. He then deduced that the beam of light is
studies. Ancient people were curious about this bright- not just a wave traveling through space but must also be
ness: the Greek philosopher, Pythagoras, began to composed of discrete packets of energy, as described by
develop wave equations about 400 BC. Over a century Planck. Einstein called these tiny particles photons [10]
later, the Greek mathematician Euclid claimed that light thus crystallizing the particle-wave dual nature of light.
is emitted in rays from the eye; he then proclaimed the
law of reflection of those waves. It took until 1021 for a
mathematician from Basra, Ibn al-Haytham, to correct 2.1.2 The Duality of Light
the concept and prove that light enters rather than ema-
nates from the eye. In addition, al-Haytham postulated Based on the discoveries and arguments over the last
that there are tiny particles of energy coming from the three millennia, it can now be stated that light is a form
Sun that produce light. In 1672, British physicist Issac of electromagnetic energy with a dual nature. It behaves
Newton was studying the laws of reflection and refrac- as a particle and travels in waves at a constant velocity.
tion and concluded that light was made of particles, The basic packet or quantum of this particle of radiant
which he called “corpuscles” [1]. He concluded that light energy is called a photon [11]; a photon is a stable par-
is a combination of seven colored particles—violet, ticle that only exists when moving at the speed of light in
indigo, blue, green, yellow, orange, and red (in keeping a vacuum. By implication of the theory of relativity, it
with the belief that seven is a mystical number). Those has no mass. When decelerated, it no longer exists, and
particles combine to produce “white” light [2]. A few its energy is transformed.
years later in 1678, the Dutch physicist Christiaan The wave of photons that travels at the speed of light
Huygens insisted that light was made up only of waves can be defined by two basic properties, as shown in
and published the “Huygens’ Principle” [3]. As history . Fig. 2.1. The first is amplitude, which is defined as the
would have it, both Newton and Huygens were at best vertical height of the wave oscillation from the zero axis
half correct. to its peak. This correlates to the amount of energy car-
Over a hundred years later, new discoveries of light ried in the wave: the larger the amplitude, the greater the
emerged. In 1800, William Herschel, a German born amount of energy available that can do useful work. The
musician and astronomer, moved to England and inves- second property of a wave is wavelength, which is the
tigated individual temperatures of the visible color. horizontal distance between any two corresponding
From those experiments, he discovered infrared light [4]. points on the wave. This measurement is very important
Johann Ritter, from a region of Eastern Europe now both in respect to how the laser energy is delivered to the
known as Poland, discovered ultraviolet light in 1801, by tissue and what the interaction will be. Wavelength is
22 D. J. Coluzzi
400 - 700nm
2000nm 3000nm
InGaN Nd:YAP
445nm Nd:YAG 1340nm
AlGaAs
1064nm Er:YAG CO2
GaN 810nm InGaAsP
532nm 2940nm 9300,
1064nm
InGaAs Er,Cr:YSGG 10600nm
Caries Detect 655nm
Visible PBM 980nm 2780nm
Invisible PBM InGaAsP 940nm
.. Fig. 2.2 A graphic showing the currently available dental wave- also include the composition of the active medium which produces
lengths’ position on the visible and invisible non-ionizing portion of that wavelength. PBM is an abbreviation for photobiomodulation,
the Electromagnetic Spectrum. Note that most of the wavelengths and those instruments use various active media
.. Fig. 2.3 General schematic of a laser. The active medium can be tive and the opposite one is partially transmissive. When a sufficient
solid state (like Nd:YAG) or a gas (like Carbon Dioxide). The pump- population inversion is present, laser photonic energy is produced
ing mechanism provides the initial energy and the resonator consists and focused by lenses
of the active medium and axial mirrors. One mirror is totally reflec-
.. Fig. 2.4 Schematic of a single (individual) diode laser wafer. example, a reflective coating is applied to opposite ends of the wafer.
There are layers of positively and negatively charged compounds, In the right area are examples of lenses and prisms that would be
pumped by electricity. The white layer with the yellow arrows repre- placed at the emission end of an array of wafers to produce useful
sents the active layer where stimulated emission takes place. In this powers of diode laser photonic energy
Laser and Light Fundamentals
27 2
.. Table 2.1 Currently available visible spectrum dental lasers. The type of laser and its emission spectrum is listed in column 1;
column 2 indicates the general usage in dentistry; column 3 describes the active medium; column 4 shows the emission mode with the
following abbreviations: CW continuous wave, GP acquired pulse
Type of laser and emission General uses Active medium Wave- Emis-
spectrum length sion
(nm) mode
Semiconductor diode, visible Soft tissue surgical procedures, Indium Gallium Nitride 445 CW, GP
blue tooth whitening
Semiconductor diode, visible Soft tissue procedures, tooth Gallium Nitride 532 CW, GP
green whitening
Low power output lasers, Photobiomodulation therapy Variations of Gallium Arsenide or 600–670 CW, GP
visible red light emission (PBM), photodynamic therapy Indium Gallium Arsenide Phospho-
semiconductor or gas lasers (PDT), or carious lesion detection rus diodes
. Table 2.2 Currently available invisible infrared dental lasers. Note that the term, “surgical” is applied to those lasers with
sufficient output power. There is increasing evidence that any wavelength can produce a PBM effect. The type of laser and its
emission spectrum is listed in column 1; column 2 indicates the general usage in dentistry; column 3 describes the active medium;
column 4 shows the emission mode with the following abbreviations: CW continuous wave, GP acquired pulse, FRP free-running
pulse
Low power output Photobiomodulation therapy Variations of Aluminum Gallium 800–900 CW, GP
lasers, (invisible) near (PBM), photodynamic therapy Arsenide diodes
infrared (PDT)
Semiconductor diode, Soft tissue surgical procedures Aluminum Gallium Arsenide 800–830 CW, GP
near infrared
Semiconductor diode, Soft tissue surgical procedures Indium Gallium Arsenide Phosphorus 940 CW, GP
near infrared
Semiconductor diode, Soft tissue surgical procedures Indium Gallium Arsenide 980 CW, GP
near infrared
Semiconductor diode, Soft tissue surgical procedures Indium Gallium Arsenide Phosphorus 1064 CW, GP
near infrared
Solid state, near infrared Soft tissue surgical procedures Neodymium-doped yttrium aluminum 1064 FRP
garnet (Nd:YAG)
Solid state, near infrared Soft tissue surgical procedures, Neodymium-doped yttrium aluminum 1340 FRP
endontic procedures perovskite (Nd:YAP)
Solid state, mid infrared Soft tissue surgical procedures, Erbium, chromium-doped yttrium 2780 FRP
hard tissue surgical procedures scandium gallium garnet (Er,Cr:YSGG)
Solid state, mid infrared Soft tissue surgical procedures, Erbium-doped yttrium aluminum 2940 FRP
hard tissue surgical procedures garnet (Er:YAG)
Gas, far infrared Soft tissue surgical procedures, Carbon Dioxide (CO2) laser, with an 9300 GP
hard tissue surgical procedures active medium isotopic gas
Gas, far infrared Soft tissue surgical procedures Carbon Dioxide (CO2) laser with an 10,600 CW, GP
active medium of a mixture of gases
28 D. J. Coluzzi
2.6 History of Laser Development direct the beam toward the tissue when not directly touch-
ing it. Other lasers in these wavelengths use tip-less (and
After Einstein’s laser theory was published, experiments therefore non-contact) delivery systems. In addition, the
erbium lasers and the 9.3 μm Carbon Dioxide laser employ
2 to build a device didn’t appear until the 1950s. Charles
a water spray for cooling hard tissue.
Townes of Columbia University in New York began
working with a microwave amplification in 1951. In
1957, another Columbia graduate student Gordon
Gould described in his laboratory notebook the basic 2.7.1 Optical Fiber
idea of how to build a laser. That was considered the
first time the term was used. The first laser was built by An optical glass fiber usually made of quartz-silica. This
Dr. Theodore Maiman in 1960 at Hughes laboratory glass core conducts the laser beam along its length. A
[16]. He used a 1 × 2 cm synthetic ruby cylinder for the thin polyamide coating surrounds the core to contain
active medium, photographic flash lamps for the pump- the light, and a pliable thicker jacket covers both to pro-
ing mechanism, and produced a brilliant red light pulsed tect the integrity of the system. A specific connector
emission. At the end of that year, three other scientists couples the fiber to the laser instrument; a handpiece
at Bell labs developed the helium-neon gas laser with a and tip are added to the operative end. . Figure 2.5a
continuous output of red light. Other wavelength shows the components of a bare optical fober, the hand-
instruments were rapidly developed during that decade. piece, and the canula. . Figure 2.5b shows the assem-
Notable is the 1964 invention of the Carbon Dioxide bled fiber-optic delivery system. In . Fig. 2.5c, a
laser, with a 10.6 μm wavelength, by Kumar Patel; and, permanently sealed fiber-optic cable and coupled hand-
in the same year, the Nd:YAG laser was built by Joseph piece are pictured. . Figure 2.5d depicts disposable
Geusic and Richard Smith, all at Bell labs. In the spring glass tips that are then coupled to the end of that perma-
of 1970, a team of Russian and American scientists nently sealed fiber system, and the complete assembly is
independently developed a continuous wave room tem- shown in . Fig. 2.5e. The handpiece in . Fig. 2.5f can
perature semiconductor laser [17]. The first laser specifi- be coupled to an optical fiber to produce a photobio-
cally designed for dentistry was marketed in 1989 [18]. modulation effect. . Figure 2.5g shows a hand-held
low output power laser and tip that is used for photoac-
tivated disinfection.
2.7 Laser Delivery Systems
Laser energy can be delivered to the surgical site by var- 2.7.2 Hollow Waveguide
ious means that should be ergonomic and precise. There
are three general modalities: A hollow waveguide is a jacketed flexible tube. The inter-
55 An optical fiber nal surface has a reflective coating like silver iodide to
55 A hollow waveguide allow the beam’s transmission. A series of protective
55 An articulated arm jackets complete the system. The waveguide is connected
to the emission port on the laser, and a handpiece and
Shorter wavelength instruments, such as KTP, diode, optional tip is connected to the operative end.
and Nd:YAG lasers, have small, flexible fiber-optic sys- . Figure 2.6 shows a typical hollow waveguide and
tems with bare glass fibers or disposable tips that deliver handpiece assembly.
the laser energy to the target tissue through a handpiece.
A few low-powered diode lasers are offered as “hand-
held” units with disposable glass tips. Photobiomodula- 2.7.3 Articulated Arm
tion (PBM) effects can be efficiently produced by using a
handpiece with a much larger beam diameter than is An articulated arm, consisting of a series of reflective
used for surgical procedures. hollow tubes with pivoting internally mirrored joints
Erbium devices are constructed with more rigid glass along its length. The arm has a counterweight to provide
fibers, semi-flexible hollow waveguides, or articulated ease in movement. The laser emission port is coupled
arms. Carbon Dioxide lasers use waveguides or articulated with the first tube, and a handpiece and optional tip is
arms. Some of the erbium systems employ small quartz or added to the operative end of the distal tube.
sapphire tips and Carbon Dioxide instruments employ . Figure 2.7a depicts the basic arm assembly, and
metal cylinders that attach to the handpiece. All of the tips . Fig. 2.7b shows the handpiece without a tip, typical
are used in contact with target tissue although they can for this delivery system.
Laser and Light Fundamentals
29 2
a b
e f g
.. Fig. 2.5 a A bare optical fiber, handpiece, and canula. b Assem- delivery system with a disposable tip. f A handpiece that can be used
bled bare fiber delivery system. c Permanently sealed fiber-optic for PBM. g A hand-held laser and disposable tip that can be used for
cable and handpiece. d Disposable tips. e Assembled fiber-optic photodisinfection
2.7.4 Contact and Non-contact Procedures sional surgery. For the optic fiber, the focal point is at or
near the tip of the fiber, which again has the greatest
All conventional dental instrumentation, either hand or energy. When the handpiece is moved away from the tis-
rotary, must physically touch the tissue being treated, sue and away from the focal point, the beam is defo-
giving the operator instant feedback. As mentioned, cused, and becomes more divergent. At a small divergent
dental lasers can be used either in contact or out of con- distance, the beam can cover a wider area, which would
tact. Clinically, a laser used in contact can provide easy be useful in achieving hemostasis. At a greater distance
access to otherwise difficult to reach areas of tissue. The away, the beam will lose its effectiveness because the
fiber tip can easily be inserted into a periodontal pocket energy will dissipate. This concept will be further dis-
to remove small amounts of granulation tissue, for cussed in 7 Sect. 2.8.
example. In non-contact, the beam is aimed at the target
at some distance away from it. This modality is useful
for following various tissue contours, but the loss of tac- 2.7.5 Aiming Beam
tile sensation demands that the surgeon pays close atten-
tion to the tissue interaction with the laser energy. All the invisible dental lasers are equipped with a sepa-
The active beam is focused by lenses. With the hol- rate aiming beam, which can either be laser or conven-
low waveguide or articulated arm, there will be a precise tional light. The aiming beam is delivered co-axially
spot at the focal point where the energy is the greatest, along the fiber or waveguide and shows the operator the
and that spot should be used for incisional and exci- exact spot where the laser energy will be focused.
30 D. J. Coluzzi
.. Fig. 2.9 This graphic shows the difference between Power Den-
sity areas using a 300 μm tip/beam size and a 600 μm tip/beam size.
.. Fig. 2.8 This graphic shows the relationship between peak and
The smaller fiber has a larger area of interaction because of the
average power along with the emission cycle. The pulses of laser
larger Power Density calculation
energy in light blue bars. The individual pulse duration is 0.025 s and
the pulse interval is 0.075 s. Each pulse has a peak power of 6 W, but
the average power is 1.5 W, due to the emission cycle of 25%
Laser-Tissue Interaction
Steven P. A. Parker
Contents
3.1 Introduction – 36
References – 61
.. Fig. 3.1 Laser-assisted oral tissue surgery is photothermal in rapid temperature rise, protein denaturation and water vaporization.
nature. Incident (photonic) energy is absorbed by target tissue ele- This constitutes an example of photoablation
ments (chromophores), relative to the laser wavelength. This leads to
together with the coherence of the beam, will offer selec- cuit. The resistance of the wire leads to thermal conver-
tive tissue interaction of high quality; the collimation sion of the electrical (EM) energy. At this induced higher
and ability to focus the beam will define a degree of energy state of the light filament, the volatility of con-
accuracy and power density. stituent electrons gives rise to higher thermal energy and
. Figure 3.1 provides clinical examples of predict- emission of such energy as light.
able laser-tissue interaction. Laser photonic energy assumes the production of
high-energy photons from an energized source, whereby
each photon scribes an identical waveform, and each
3.2 Photonic Energy photon has identical energy value. Plank and Einstein
had established an inverse relation between wavelength
The emission of a single photon from an atom is the and photonic energy, a direct proportional relationship
result of a shift in the energy status of that origin. Plank between photonic energy and frequency, and Neils Bohr
proposed that all matter existed in a state of energy rela- paved a way for the “quantum” (amount) nature of
tive to extremes of a lower (ground) state and a higher emitted photons to be calculated; thus, it provided a pre-
(energized) state, commensurate with entropic physical dictable base for the development of the maser and
form [4]. Boltzmann, through his theories on thermody- optical-maser, or laser.
namics [5], readily accounted a direct relationship The energy of emitted photons is expressed in Joules,
between matter, energy and temperature. Put simply, an or more conveniently, electron-volt eV (energy derived
electric light filament at room temperature is a dull, inert by acceleration through a PD of 1 V). Since photonic
wire but rapidly heats when energized by an electric cir- energy is related to wavelength (λ), photons emitted
38 S. P. A. Parker
.. Fig. 3.2 An overview of the manipulation of incident photonic energy, such as laser light as an adjunct to screening, diagnostic and
therapeutic clinical activity
cause cell apoptosis through oxidative stress. Such 3.4 Basics of Photothermolysis
action can be commonly seen in photodynamic ther-
apies where an intermediary chemical—photosensi- Incident photonic irradiation directed onto target tissue
tiser—is employed to direct energy transfer to target will behave in one of the four main ways: transmission,
tissue sites [10, 11]. reflection, scatter and absorption. The defining criteria
Electron transfer reactions are highly important can be simply summarized as dependent on the nature
in the host cell mitochondrial respiratory chain [12], of the target tissue and wavelength of the incident beam
where the principal chromophores involved in laser (hence the predictability of absorption or transmission),
therapy are thought to be situated. An additional nature of the tissue and its heterogeneity (hence the
photochemistry pathway that can occur after the scope for scatter) and angle of the beam incident to the
absorption of a red or NIR photon within a host cell tissue surface (incident beam angle < total reflective
is the dissociation of a non-covalent bound ligand angle) wherein reflection may have predominant effects
from a binding site on a metal containing co-factor (. Fig. 3.3).
in an enzyme. The most likely candidate for this Oral hard and soft tissue is complex and heteroge-
pathway is the binding of nitric oxide to the iron- nous, anisotropic and of varying degrees of thickness,
containing and copper-containing redox centers in commensurate with structural anatomy. Within such tis-
unit IV of the mitochondrial respiratory chain, sue, component elements may be found that represent
known as cytochrome c oxidase. Such action may key molecules capable of selective absorption of pho-
induce an increase in cell pH and production of ATP tonic energy; within the visible EM spectrum, such mol-
and has been cited as basic cellular theory in photo- ecules are termed chromophores, and with longer (IR)
biomodulation with low-level lasers. spectra, a terminology of absorptive tissue element may
40 S. P. A. Parker
.. Fig. 3.3 Summary of the basic interactive phenomena of inci- tissue that there may be multiple and complex degrees of each inter-
dent laser energy and target tissue. Such is the variance in tissue active phenomenon
structure and heterogeneity commonly found in oral hard and soft
be adopted. Examples are protein/amino acid-based stance. The optical properties of tissue will determine
molecular groups, such as collagen, keratin and non- the penetration into tissue of the radiant energy from a
structural proteins such as melanin, hemoglobin in both laser source. Absorption coefficient is inversely propor-
its oxygenated and non-oxygenated (HbO2 and Hb) tional to transmittance, and the depth of penetration of
forms. Dental and osseous tissues are based upon the photons within a given chromophore will reduce as the
calcium phosphate complex referred to as hydroxyapa- absorption coefficient increases.
tite (HA) found as a structural crystal in bone and the Each chromosome has molecular structure and for
carbonated lattice crystal as a mineral component of each there is a “ground state” which defines the struc-
enamel and dentine (CHA). Water—as the intra-cellular ture, atomic configuration and interatomic binding
medium base of cell cytoplasm, a component of circu- energy at body temperature [13]. If external energy is
lating blood and plasma, a free molecule in interstitial applied, a point may be reached when molecular vibra-
tissue structure or as a hydroxyl (OH−) radical as part of tion is sufficient to overcome the forces binding atoms or
the hydroxyapatite molecule—represents a major ubiq- molecules together. Examples include protein dissocia-
uitous molecular group of varying degrees of absorptive tion and water vaporization. True photonic ablation of
potential relative to incident photonic wavelength. a target molecule therefore represents incident energy
. Figure 3.4 demonstrates a graphical interpretation of sufficient to break interatomic binding forces and is
the interaction of ascending photonic wavelengths with termed dissociation energy. . Table 3.2 provides exam-
each of the major tissue chromophores that are found in ples of commonly found chromophore molecules and
oral and dental tissues. The term adopted as a measure- the dissociation energy value required to break the inter-
ment of the level of energy absorption by a chromo- atomic bond.
phore is absorption coefficient—considered as a measure As is evident from data in . Table 3.1, almost none
of the rate of decrease in the intensity of electromag- of the popular laser photonic energies is capable of
netic radiation (as light) as it passes through a given sub- direct intra-molecular bond cleavage and one may be
Laser-Tissue Interaction
41 3
.. Fig. 3.4 Absorption coefficient curves for commonly found chromophores, relative to incident photonic wavelength
.. Fig. 3.6 Manipulation of incident beam power over area to enable the power density effect to be a major factor in delivering predictable
and powerful laser-tissue interaction
power in the beam concentrated to a small spot, the As has been seen elsewhere, the predominant tempo-
effects are much more dramatic. The use of a magnify- ral emission mode is a Gaussian distribution, and this
ing glass to concentrate the sun’s rays is a simple exam- lends itself readily to being brought to a focal spot. With
ple of power density. Power (energy per second) is an control over the area of irradiation, the concept of
expression of a laser’s ability to do work, and when mea- power density as a prime factor in laser-tissue interac-
sured over the area exposed to the beam, it will be read- tion becomes valid. Even in those conditions where
ily acknowledged that the greater the concentration of there is little if any direct absorption, the concentration
photons, the greater the level of potential interaction. of laser power in ever-higher values over ever-shorter
Consequently, for any given laser delivery system, reduce time periods gives rise to power density of such magni-
the spot size of the beam and one can expect to speed up tude that photodisruption and photoionization of tar-
the interaction—assuming that all other parameters get molecules can occur.
remain constant [18]. Technology has much to deliver in terms of future
“Power density” (PD) is the delivery of energy developments, but already it is possible to see predict-
through time divided by the area of the exposed tissue; able laser-tissue interaction involving PD of values of
it is expressed in W/cm2. 106+ W/cm2 for microsecond periods and even shorter,
The output of any laser over time is expressed as enabling photovaporization of interstitial water in
average power and equates to the total number of Watts tooth tissue and consequent disruption of the crystal-
delivered per second. For a continuous wave emission line solids.
laser, the average power will equal the maximum output; Nowhere within this discussion does the influence of
for a micro-pulsed free-running emission, the average laser wavelength occur. Of course, the harmonization of
power output may be of the order of a few Watts, but incident wavelength, its inherent energy value and selec-
due to the active photonic emission only lasting a pos- tive absorption within a suitable target chromosome will
sible 20% of each second, there will be peaks of energy. remain as empirical in our understanding of interaction
A typical free-running emission laser, such as Nd:YAG concepts; but as we have already seen, the continuous
or Er:YAG, may deliver an average power value of 3.0 bombardment of a target tissue with photons of a suit-
W, but due to the pulse width of 150 μs, there will be ably absorbed wavelength will lead to thermal rise and
peak power bursts of 1000+ W [19]. eventually sufficient heat to effect physical change in the
44 S. P. A. Parker
tissue. Such processes take time, and the risk of collat- is the core of understanding of photobiomodulation.
eral thermal damage becomes an ever-present threat. To With ever-shortening time and an ascending level of
deliver sufficient energy in a form of concentration of power density, not only do irreversible physical
both area of exposure and time must be seen as a dis- changes occur in tissue, but with exposure times of
tinct advantage. micro- and nanoseconds, even with relatively low
As our understanding develops, there evolves the average power values, the effects on the target can also
3 interaction of three components to predictive laser- be spectacularly rapid and without leaving a “thermal
tissue interaction: the absorptive potential of the target thumbprint.”
tissue, relative to the incident laser wavelength; sec- For any given laser-tissue interaction, assuming
ondly, the transfer of energy—from initial photonic that absorption can occur through the equation of
energy and delivery (emission) mode of the laser, power density with exposure time may enable the cli-
together with power density and time of exposure; and nician to influence the type of interaction that occurs.
thirdly, the availability of thermal relaxation to enable It has already been established that at everyday levels
the target tissue to avoid progressive overheating. of power delivery in dentistry, the predominant effect
Thermal relaxation is inherent with free-running pulsed is tissue ablation through thermal rise—photother-
emission modes and impossible to deliver with continu- molysis. By reducing the exposure time to millisec-
ous-wave emission modes. The clinician would there- onds and microseconds, successively higher peak
fore need to be aware of the potential for thermal power density above 108 W/cm2 can be obtained. At
damage and allow sufficient time and respite periods to such powerful levels, the intensity of energy is so great
enable the tissue to recover. that electromagnetic fields developed around the
In . Fig. 3.7, the relationship between PD and interaction are sufficient to tear target molecules
exposure time is represented with reference to an apart—photoplasmolysis [20]. Reference to the work
ascending physical change in the target tissue. Very of Boulnois and the graphic representation of laser-
low irradiance over extended periods may give rise to tissue interaction can be seen as an ascending phe-
subtle stimulation of biochemical pathways associ- nomenon and product of ultrashort exposure time
ated with tissue heath and reparative capabilities and and megawatt peak power [21].
.. Fig. 3.7 Relationship of incident photonic power density and exposure time. (Source: Boulnois J-L. Laser Med. Sci. 1986;(1):47–66 [21])
Laser-Tissue Interaction
45 3
3.7 Thermal Rise and Thermal Relaxation vaporization leads to visible signs of tissue desicca-
tion, structural shrinkage and predisposition to
In considering the broadest concepts of photothermal rapid heating and carbonization.
action and regardless of the laser system used for a soft 55 Carbonization: As laser-assisted surgery proceeds,
tissue surgical application, the effects may be broadly the risk remains to be the potential for tissue heating
classified as follows: that leads to the production of end-stage molecular
55 Tissue heating: To a non-destructive level, the warm- destruction and residual carbon. It is generally con-
ing of tissue may be a desired total effect (as part of sidered to be at temperatures around 200 °C,
a biomodulation therapy) or may occur at some dis- although the actual rise may be considerably higher.
tance from an ablation site, along a thermal gradient Carbonization would only occur as a result of either
within the tissue. This latter example is covered in an inappropriate high dose, relative to the parame-
greater detail later. ters consistent with a desired surgical outcome, or
55 Tissue coagulation: Over a period of time, the tem- the application of laser photonic energy over exces-
perature rise in soft tissue at or above 45 °C will con- sive time, resulting in opportunity for destructive col-
stitute “destructive heating,” i.e., amounting to lateral effects. The characteristic visual sign is the
progressive irreversible change. At about 50 °C, bac- development of black residue associated with the
teria can be demonstrated to achieve a state of deac- soft tissue incision.
tivation, with tissue protein denaturation occurring By far, the consequence of such development is
at around 60 °C. Within this zone of thermal rise, the the preferential absorption in carbon residue of (in
walls of small-diameter vessels (arterioles, venules effect) all incident EM photonic wavelengths. This is
and lymphatics) within the irradiated area will the basis of the “black body” concepts of preferen-
undergo structural change of vessel walls and lead to tial absorption and characterized by the re-emission
progressive blood and lymph coagulation. Depen- of multi-wavelength, incandescent near-IR thermal
dant on the wavelength of the laser used and concen- radiation; in consequence, the carbonized tissue con-
tration of chromophores specific to that wavelength, tinues to absorb incident laser energy and becomes
a concept of “selective photothermolysis” can be the source of thermal conductive energy that signifi-
considered, such as in the ablation of melanin in cantly contributes to collateral damage during soft
diode laser-assisted gingival de-pigmentation. tissue surgery.
55 Vaporization: At normal atmospheric pressure (1 55 Photoacoustic phenomena: As has been seen already,
Bar), vaporization of water occurs at 100 °C. Within incident coherent photonic energy can be subject to
soft tissue, the vaporization of water will accompany conversion into other forms of energy, notably ther-
existing protein denaturation that may have occurred mal in the dominant effect of photothermolysis.
at a lower temperature. The phenomenon of water With the instantaneous phase change of water from
vaporization is accompanied by volumetric change stable liquid to vapor, the volume change can give
and expansion in the ratio of 1:1600 as the liquid is rise to a cavitation phenomenon and consequent
vaporized to steam. With short wavelengths (visible shock wave. Additionally, the energy may be changed
and near IR), the structural change in soft tissue col- to sound, and this may be witnessed with mid-IR
lagen scaffolding would allow water vaporization to interaction with tissue and the “popping” sound
occur as part of the overall ablation process. With often heard. True photoacoustic effects are used else-
mid-IR erbium family wavelengths, the scenario is where in medicine and surgery in procedures such as
often very different owing to the poor absorption of lithotripsy, where kidney and gallstones are frag-
these wavelengths in pigmented tissue, the limitation mented using indirect shock waves; in maxilla-facial
of thermal rise in the tissue when a co-axial water surgery, a similar approach has been reported to
spray is being used and the FRP emission mode of assist in the fragmentation and subsequent safe pas-
the lasers with associated high peak power values, sage of sialoliths within the submandibular gland
and with the extremely high absorption of these [22, 23].
wavelengths in water, the vaporization is often more
dynamic and accompanied by audible “popping.” Given the current limitations of laser emission param-
When erbium lasers are used on soft tissue with- eters and the consequence that by far the greater conse-
out water spray, or when CO2 laser wavelengths are quence of laser-tissue interaction is photothermal shift
used (often without water spray), the vaporization is and temperature rise, the ablation of target tissue can
reflective of a more “thermal” exchange, where the be severely compromised by excessive thermal rise and
heating of the tissue as well as the absorption of the a build-up of the ablation residue that may rapidly
photons in water occurs. Often, the result of such overheat.
46 S. P. A. Parker
The effects of thermal rise can be both subtle and ablated tissue and through the correct management of
dramatic—depending on the rate of warming. heat rise and debridement, the risk of unwanted ther-
. Figure 3.8 provides a tabulated outline of the effects mal damage can be avoided. In hard tissue manage-
that temperature rise may have, relative to both the ment, the concepts of ablation and thermal zones will
visual change and the biological change (the latter as be discussed with specific reference to tooth cavity
may be applied to soft tissue). In addition, the varying preparation.
3 stages of thermal rise have been investigated and pro- Thermal relaxation time can be deduced mathemati-
vide opportunity to influence the structural changes in cally [24] as the time taken for the irradiated tissue to
the tissue and the effect of heat on associated bacterial dissipate about 63% of the incident thermal energy. It is
cells. Irradiated tissue should not be regarded as sterile, additionally related to the area of the irradiated tissue
although there will be significant pathogen reduction at and thermal diffusivity and bulk of the tissue.
the site of maximum laser-tissue interaction. Thermal damage time is the time required, for the
Two concepts of ablation may be considered: a zone entire target, including the primary chromophore (e.g.,
of tissue removal/permanent change preceded by an melanin) and the surrounding target (e.g., gingiva), to
“ablation” front and a second advancing line denoting cool by about 63%. It includes cooling of the primary
the permanent effect of change rendered by thermal chromophore as well as the entire target.
rise—a “thermal” front. In an ideal situation, the Extinction length is the thickness of material neces-
“ablation” front will denote the predicted volume of sary to absorb 98% of incident energy.
.. Fig. 3.10 Graphic representation of visible and near-IR laser photonic energy interaction with oral soft tissue. (Graphics: S. Parker after
Fisher J.C. 1993)
.. Fig. 3.12 Histological representation of two laser wavelengths (diode 810 nm and Er:YAG 2940 nm interaction with pig mucosa in vitro).
This demonstrates the progressive crater-shaped incision with shorter wavelengths and a “V”-shaped incision with longer wavelengths
.. Fig. 3.13 Graphic representation of far-IR (and potentially mid-IR) laser photonic energy interaction with oral soft tissue. (Graphics:
S. Parker after Fisher J.C. 1993)
Laser-Tissue Interaction
51 3
the lack of post-operative inflammation and uneventful neath [38]. Additionally, studies with longer wavelengths
healing. Inasmuch as many claims are anecdotal, often show that there is a lack of fibroblast alignment associ-
if not always, the need for dressings or sutures can be ated with the incision line and consequent reduced tissue
avoided, and irrespective of the laser wavelength shrinkage through scarring [39]. Such findings are often
employed, all soft tissue healing will be by secondary borne out in the clinical setting.
intention in that it will be impossible to oppose the cut
tissue edges to their original alignment. Of note, how-
ever, is the phenomenon of lack of post-incisional con- 3.9 aser Photonic Energy and Target Oral
L
tamination by bacteria, due to a possible sterility of the Hard Tissue
cut surface [37] but certainly through the protective layer
of coagulum of plasma and blood products—a tena- Oral hard tissue includes cortical and trabecular (cancel-
cious film that allows early healing to take place under- lous) bone and components of deciduous and perma-
nent teeth (enamel, dentine, cementum). Within this
group, it acknowledges the association of dental caries,
being the predominant reason why teeth are subject to
surgical intervention.
In common with laser-tissue interaction mechanisms
described above, the current limitations of operating
parameters of those lasers that are commercially avail-
able in dentistry center on the targeting of chromo-
phores within the host tissue.
From the development of early lasers to ablate den-
tal hard tissue, the predominant chromophore has been
water—both interstitial “whole molecular” water and
OH− radicals forming part of the carbonated hydroxy-
apatite molecule ([Ca10(PO4)6−Y(CO3)Z(OH)2] + H2O).
Prime tissue groupings of oral hard tissue are listed by
percentage of constituent structural elements [40, 41] in
. Table 3.4.
.. Fig. 3.14 Clinical example of a mucosal incision using a CO2 Absorption curves for both water and carbonated
laser. In the absence of a water spray, note the build-up of eschar,
which can be easily removed with damp gauze to minimize thermal
hydroxyapatite between wavelengths of approximately
damage 3.0 and 10 μm are graphically listed in . Fig. 3.16. The
.. Fig. 3.15 At the point of surgical ablation of tissue, two intra- temperature provides tissue stimulation. The other gradient—scat-
tissue gradients predominate. One is a thermal gradient, and with ter—can produce a similar point-at-distance stimulation wherein
distance, a reduction in temperature will define a point where the biomodulation effects predominate
52 S. P. A. Parker
.. Fig. 3.16 Absorption peaks for water and CHA exist coincidentally for both Er,Cr:YSGG and Er:YAG wavelengths. High absorption
exists in the phosphate group of CHA, coincident with CO2 at 9300 and 9600 nm. (Source: Parker S. BDJ 2007;202(8);445–454)
Laser-Tissue Interaction
53 3
.. Fig. 3.17 In vitro exposure of molar tooth to CO2 laser irradiation and SEM examination. Globules of melted and re-solidified (amor-
phous) hydroxyapatite are present, with large voids and gross disruption of structure. Average power 1.5 W CW with no water spray
derangement of the surrounding crystal lattice. Both such temperatures would lead to direct pulpal damage
erbium (erbium YAG, erbium chromium YSGG) laser through heat conduction.
wavelengths have free-running pulsed emission modes In consequence, the interactions of high-intensity
(pulse width 50–150 μs), which give rise to high peak laser irradiation with bone and dental hard tissues are
power levels (>1000 W). Such power levels result in an the result of a photothermal action [44] targeting both
instantaneous, explosive vaporization of the water con- molecular and interstitial water.
tent of enamel and dentine, which leads to dissociation With an appropriate laser wavelength such as the
of the tissue and ejection of micro-fragments [43]. Er,Cr:YSGG (2780 nm) and Er:YAG (2940 nm) and
The increased water content of caries results in rapid operating parameters configured to maximize interac-
and preferential ablation of such material compared to tion, together with adequate coaxial water spray, the
normal enamel and dentine; to some extent, this may outcome is completely different. With both enamel and
allow cavity preparation to be accomplished with a more dentine, the outcome of the “explosive” vaporization
conservative preservation of intact dental tissue. and ejection of tooth fragments results in a clean-cut
Sustained exposure of hydroxyapatite and carbon- surface, without smear layer often associated with rotary
ated hydroxyapatite to laser irradiance will quickly ren- instrumentation. Due to the outward dissipation of
der the structure to overheating, first to drive off any energy, there is minimal thermal rise within the structure
residual water and then to rapidly melt the mineral and of the tooth and conduction to the pulp.
produce signs of carbonization (. Fig. 3.17). It is evi- The fragmented appearance of cut enamel
dent that sufficient heat may be produced to cause the (. Fig. 3.18) especially was historically thought to
melting of hydroxyapatite (several hundred degrees enhance the facility for bonding of restorative resins and
Celsius) and associated thermal cracking. Of course, composites without the need for acid etching. However,
54 S. P. A. Parker
.. Fig. 3.18 SEM examination of tooth structure exposed to surface. Lower images L and R—similar cut surface of dentine,
Er:YAG laser irradiation. Top images L and R—enamel structure showing absence of smear layer and open tubules
showing evidence of dislocation and some fragmentation of the cut
many studies have highlighted the fragility of the cut sive temperature rise and help wash away debris as a
margin in enamel and subsequent failure of the restora- result of ablation. In addition, commercial models of
tion margin as weakened tooth fragments gave way both lasers use coaxial water spray to aid dispersal of
under tensile stress, with resulting failure and secondary ablated tissue and to cool the target [48], in a process
caries risk [45, 46]. called “water augmentation” [49]. According to this
Mid-IR laser beam interaction with enamel (and to study, when dental hard tissues are irradiated with
some extent also with dentine and bone) is a combina- Er,Cr:YSGG and Er:YAG emission wavelengths with an
tion of temperature and pressure [47]. Both can be seen additional thin water layer, the cutting efficiency
to rise rapidly during the pulse train of a clinical abla- increases at the same time that the pulp temperature
tion procedure. The increase in volume as water vapor- decreases. However, the thickness of water layer should
izes (1:1600) is significant and will give rise to significant be well controlled to avoid a compromise in cutting effi-
rise in pressure just prior to the explosive dislocation of ciency and the blurring of the visual field.
the enamel structure. As pressure rises, the continued As a liquid, water has a moderately high surface ten-
vaporization leads to increase in temperature, resulting sion (72.8 mN/m at 20 °C), and this accounts for the
within the micro-confines of the interaction in “super- intact film that may surround the tooth surface during
heating” of the water and temperatures of several hun- water-augmented laser irradiation. In a further study
dred degrees Celsius. [50], the influence of water thickness was investigated.
Furthermore, there are additional characteristics of During ablation, the stream of photons is emitted in
laser ablation of hard tissue, surrounding the use of a free-running train of microsecond pulses (>100 μs),
coaxial water, a necessary component to both aid exces- and any water between the laser delivery tip and the tar-
Laser-Tissue Interaction
55 3
.. Fig. 3.19 Diagrammatic influence of the tip-to-tissue distance and influence of a contiguous water film, facilitating laser-induced cavita-
tion phenomena. (Adapted S. Parker from: Mir M, Gutknecht N, et al. Lasers Med Sci (2009) 24:365–374 [50])
get would be vaporized during the first >30 μs of each 55 In, for example, 140 μs pulses, after approximately
pulse, allowing successive photons to interact with the 20–30 μs of the start of the pulse curve, a plume of
target. If the tip-to-target distance is greater than the vapor (comparable with a cloud) covers the tissue
distance wherein the integrity of the water meniscus is surface.
maintained, the photon stream will pass through air 55 The suction force exerted by the collapsing bubble
before interacting with water at the surface of the tissue. and by the impact of the high-velocity jet generated
However, in circumstances where the delivery tip is during bubble collapse results in tissue ablation.
close enough to the tissue surface and due to the surface
tension of the water, a continuous envelopment of that It remains to be seen to what extent this contributes to
distance occurs, the vaporization of the water film hap- the “classic” understanding of 3.0 μm-mediated hard
pens as before, but the vapor is contained within a rap- tissue ablation, but it is worthy of note that superheating
idly expanding bubble; as it collapses, it gives rise to a of the vapor and hyperbaric pressure phenomena play a
cavitation phenomenon, and associated pressure waves part.
may be sufficient (50–100 MPa) to initiate laser-induced In consideration of the ever-changing nature of avail-
“tripsy” (disintegration) of the tooth surface able technology and its incorporation into laser wave-
(. Fig. 3.19). length choice, a precise irradiation parameter must be
This concept is exciting and in common with the chosen in order to avoid collateral damage. This has
similar phenomenon of laser-induced cavitation in water importance no more than in terms of hard dental mor-
using wavelengths at 3.0 μm that may occur in endodon- phological damage, such as surface carbonization or
tic and laser-assisted osteotomy procedures. With refer- cracking, which could produce structural and aesthetic
ence to the study by Mir et al. above [50], the staging can damage and post-operative complications such as tran-
be summarized as follows: sient pulpitis. Moreover, the energy densities used must
55 Energy intensity in the first pulses leads to absorp- be safe with regard to pulp and periodontal tissue vitality
tion in the first μm layers of water opposite to the tip. [51]. Studies have indicated that temperature increments
55 Bubble formation with higher output energy density above 5.6 °C can be considered potentially threatening to
bubble dimensions were not clear, and a cloud- the vitality of the pulp [52], and increments in excess of
shaped appearance of laser-water interactions was 16 °C can result in complete pulpal necrosis [53]. In com-
recorded. parison with rotary instrumentation, pulpal temperature
56 S. P. A. Parker
rise is minimal when erbium laser wavelengths are 3.10 Laser Interaction with Dental Caries
employed in cavity preparation [54].
Until recently, the commercially available CO2 laser Key to the efficient and safe laser-assisted removal of
has been predominately a soft tissue ablation tool. The caries would be the facility to selectively ablate decayed
CW and gated CW emission modes of the 10,600 nm dental tissue without causing injury to surrounding
wavelength, together with an absence of coaxial water to tooth tissue or pulp. Caries removal should be within
3 aid tissue cooling and disperse ablation debris, give rise the desired outcome of complementary aesthetic resto-
to rapid overheating of tooth tissue, cracking, carbon- ration of the tooth.
ization and melting, which has made its use in restor- Prior to the development of the erbium family of
ative dentistry impossible [55–57]. lasers, the limited laser wavelengths and technology
However, due to the “four-level” nature of photon available within dental application meant that only visi-
generation within the laser cavity, three major wave- ble and near-IR lasers (diode and Nd:YAG), together
length emissions occur—at 9300, 9600 and 10,600 nm. with CO2 10,600 nm wavelength, could be investigated.
The longer wavelength is easier to manipulate from a Due to the rapid heat build-up with the available laser
technical point of view and has predominated the avail- delivery parameters, attempts to remove (pigmented)
ability of CO2 laser in clinical therapy. Absorption in dental caries received only limited success [67–69].
water is a strong feature at this far-IR range, but the With the use of 3.0 μm wavelengths, the high absorp-
shorter 9300 and 9600 wavelengths are also strongly tion in water has transformed interaction. Caries as a
absorbed in the phosphate radical of the hydroxyapatite demineralised residue of bacteriogenic acid action on
molecule. Investigation into this laser-tissue interaction enamel and dentine has varied structure but predomi-
has spanned almost 20 years [58], and in consequence, nately a much higher water content than normal tooth
with a shorter CO2 wavelength and manipulation of the structure. Interaction of laser photonic energy with this
emission to allow microsecond bursts together with a material will allow some selective ablation relative to the
coaxial water spray to minimize heat generation, the tooth tissue, and this remains a major advantage of
interaction is both more positive and clinically accept- lasers over more conventional rotary instrumentation
able [59]. [70, 71]. Additional positive indications support the
If pulse durations in the range of 5–20 μs are used, development of the new generation of micro-pulsed
efficient ablation occurs with minimal peripheral CO2 lasers and the ability to utilize the absorption on
thermal damage [60, 61], and this has now resulted in a water at this wavelength. This has been the subject of
(for instance) commercially available laser unit emitting intense research and investigation by the group at UCSF
at 9300 nm with a specimen pulse duration of 10–15 μs in San Francisco, USA [72, 73].
and repetition rate of 300 Hz, demonstrating that
enamel and dentine surfaces can be rapidly ablated by
such lasers with minimal peripheral thermal and 3.11 Caries Prevention
mechanical damage and without excessive heat accumu-
lation [62, 63]. Laser-tissue interaction with hard dental tissue may
Commercial pressures may dictate the direction and pose difficult challenges relative to the wavelength and
speed of investigation into laser-tissue interaction with operating parameters, and this has been outlined above.
dental hard tissue that is based upon concepts of power Peripheral to the blunt outcome of thermal damage
density and pulse width as predominant factors to mini- potential has been the careful application of several
mize collateral thermal damage, as opposed to the pure wavelengths to achieve a thermally mediated change in
selection of chromophore-related laser wavelengths. By the carbonated hydroxyapatite structure of enamel, to
way of an example, in a most recent published investiga- change the crystal lattice to a more acid-resistant amor-
tion, a diode-pumped, thin-disk femtosecond laser phous “glass-like” state. This change has been shown to
(wavelength 1025 nm, pulse width 400 fs) was used for occur with injudicious laser use on hard tissue, but with
the ablation of enamel and dentin. Laser fluence, scan- care, a number of studies [74–78] have proposed that
ning line spacing and ablation depth all significantly many laser wavelengths may be manipulated to provide
affected femtosecond laser ablation efficiency and were caries resistance in non-diseased teeth.
predominant in comparison with the intuitively inap-
propriate choice of a near-IR laser wavelength of
1025 nm [64]. 3.12 Laser-Tissue Interaction with Bone
As may be seen with the erbium family of lasers at
3.0 μm, there is also the potential for easy disruption The structure of osseous tissue of the maxilla and man-
and ablation of composite restorative materials, and this dible resembles that of dentine in terms of proportional
has been the subject of published data [65, 66]. ratios of mineral, protein and water (. Table 3.4). Bone
Laser-Tissue Interaction
57 3
.. Fig. 3.20 SEM representation of laser interaction with osseous damage beyond the cut margin. Compare this to the image at lower
tissue. Top left, right and lower left images relate to ascending mag- right, using Nd:YAG (1064 nm), where apatite melting and large
nification of Er:YAG (2940 nm) with porcine rib bone in vitro. The thermally induced voids are visible
cut is clean with minimal evidence of tissue disruption and thermal
is a much more dynamic tissue with reference to cell preferred choice for laser bone ablation when compared
activity and turnover, compared to tooth tissue, and to other wavelengths [80].
care must be observed to respect the potential for dis-
ruptive consequences of using inappropriate laser
parameters. Although early reports of supportive use of 3.13 Laser-Tissue Photofluorescence
CO2 (10,600 nm) laser wavelength in surgical bone man-
agement are recorded [79], the potential for photother- In an earlier section of this chapter, it was defined that
molysis and collateral damage remains high. Laser fluorescence, as a form of sub-ablative laser-tissue inter-
ablation of bone with erbium laser wavelengths (2780 action, is a luminescence or re-emission of light in which
and 2940 nm) with high absorption in water defines a the molecular absorption of a photon triggers the emis-
level of selective ablation through the vaporization of sion of another photon with a longer wavelength. In
water and tissue structure disruption, and in this way, absorbing incident photonic energy, some of that energy
laser ablation of bone proceeds in a similar fashion to is expended and the difference between the absorbed
that seen in laser-mediated tooth tissue ablation. The and emitted photons ends up as molecular vibrations or
higher water content and lower density of bone com- heat. With re-emission, that energy loss is seen as a lon-
pared to enamel allow faster cutting, through disloca- ger wavelength. This event is governed by the biophysi-
tion of hydroxyapatite and cleavage of the collagen cal nature of tissue molecules involved (termed
matrix (. Fig. 3.20). This ease of cutting places the use fluorophores) and as such can be the basis for optical
of Er:YAG and Er,Cr:YSGG laser wavelengths as the scanning techniques used in caries detection in enamel
58 S. P. A. Parker
.. Table 3.5 Common fluorophores found within the oral cavity and dentistry. Each fluorophore is capable of excitation at specific
light wavelength, and corresponding re-emission measurement can prove helpful in differential diagnosis of tissue change
Autofluorescence wavelength?
Fluorophore Excitation (nm) Fluorescence peak Comments
and dentine and tomographic techniques in the scan- 55 Cell metabolism may increase with malignant
ning of soft tissue for neoplastic change. changes, which changes the balance between fluores-
The oral cavity provides substantial opportunity for cent NADH (increase) and non-fluorescent NAD+
scanning and fluorescence techniques, due to the ease of (decrease).
access of oral structures and the database of the excita-
tion and emission wavelengths of individual tissue ele- Many studies have been performed to investigate photo-
ments as well as non-biologic materials that may have dynamic diagnosis and fluorescence techniques in the
use in dentistry [81]. In . Table 3.5, it may be seen that oral cavity. These studies may be grouped in an attempt
through the choice of precise monochromatic laser to address specific criteria of relevance in clinical assess-
wavelengths, predominately in the visible spectral range, ment of neoplastic soft tissue change:
the resultant re-emission would help to provide analysis 1. Whether autofluorescence imaging is capable of pro-
of the target composition. A specific example might be viding a higher contrast between a lesion and healthy
that whereas healthy enamel exposed to a blue incident tissue than white light or tactile and visual inspec-
irradiation re-emits as a green color, the presence of por- tion? This is certainly the case for flat, early lesions
phyrin (pigment component of dental caries) re-emits at [83, 84].
a longer red-brown color and would allow differentia- 2. Whether autofluorescence imaging is helpful in dif-
tion diagnosis of dental caries to be made. ferentiating between different lesion types, in partic-
Fluorescent and photodynamic diagnosis may pro- ular between benign, dysplastic and malignant
vide screening facility or part of a hierarchical series of lesions? Overall, the specificity of autofluorescence
tissue investigation and must be regarded as an adjunct imaging for distinguishing (pre) malignant from
to a range of investigations—direct visual, microscopic benign lesions does not seem to be very promising
and histologic examination, and genetic analysis—to [85, 86].
provide support to the clinician, especially within the 3. The detection of unknown lesions and unknown
field of soft tissue health screening [82]. extensions of known lesions, which would be useful
In oral soft tissue structure, disease changes the con- for tumor demarcation: Indications have indeed been
centration of the fluorophores as well as the light scat- found that autofluorescence imaging is capable of
tering and absorption properties of the tissue, due to detecting invisible lesions or invisible tumor exten-
changes in blood concentration, collagen content and sions [87, 88].
epithelial thickness. Such effects may be seen as follows:
55 Recorded fluorescence signal will be lower in the case Autofluorescence imaging might be appropriate as an
of hyperplasia—the epithelial layer shields the easy-to-use, sensitive and inexpensive method for lesion
strongly fluorescent collagen layer. detection, although further research is still necessary. In
55 Excessive keratin production by lesions may produce general, autofluorescence imaging may give good results
an increase in autofluorescence intensity. for the distinction of lesions from normal mucosa. How-
Laser-Tissue Interaction
59 3
ever, suspect lesions of the oral mucosa must be sub- than the red. The principal tissue chromophores (hemo-
jected to biopsy and other investigations, and certainly, globin and melanin) have high absorption bands at
it is inappropriate to place autofluorescence investiga- shorter wavelengths, tissue scattering of light is higher at
tion in any role other than as an adjunctive scanning shorter wavelengths and water strongly absorbs infrared
technique. If possible, autofluorescence spectroscopy light at wavelengths >1100 nm.
could be used to find the optimal, most dysplastic loca- Wavelengths in the 600–700 nm range are chosen for
tion for biopsy, although the literature shows that auto- treating superficial tissue, and those between 780 and
fluorescence is not specific enough for this purpose. 950 nm are chosen for deeper seated tissues, due to lon-
An allied area of laser-tissue interaction and spectro- ger optical penetration distances through tissue with the
scopic analysis of re-emission is Raman scattering. This latter group. Beam coherence is maintained as the laser
is a special, very weak form of light scattering in which beam penetrates the tissue and along with polarization
energy is lost or gained to a molecule through a phe- may be an important factor in allowing the laser to
nomenon known as inelastic scattering, where the fre- effectively treat deeper tissues.
quency of photons in monochromatic light changes Incident photons of wavelengths as referenced above
upon interaction with a tissue sample under investiga- are absorbed into mitochondria and cell membranes of
tion. The frequency (frequency and photon energy are the target cells. Photonic energy is incorporated into a
inversely proportional) of the re-emitted photons is molecule to increase kinetic energy, activate or deacti-
shifted up or down in comparison with original mono- vate enzymes or alter physical or chemical properties of
chromatic frequency, and this is called the Raman effect. main macromolecules.
This shift provides information about vibrational, rota- Growth factor response within cells and tissue may
tional and other low-frequency transitions in molecules. be seen as a result of increased ATP and protein synthe-
Raman spectroscopy can be used to study solid, liq- sis [91], change in cell membrane permeability to Ca2+
uid and gaseous samples. Vibrational information is uptake and cell proliferation, and overall, a cascade of
specific to the chemical bonds and symmetry of mole- metabolic “downstream” effects results in physiological
cules. Therefore, it provides a fingerprint by which the changes resulting in improved tissue repair, faster reso-
molecule can be identified and has an important role lution of the inflammatory response and a reduction in
within the area of tissue photo-analysis as it impacts dis- pain [92].
ease and health. In summary, the results of laser-tissue interaction
that promote PBM may be seen within three clinical
areas of benefit—anti-inflammatory effects [93], analge-
3.14 Laser-Tissue Interaction sic and pain suppression effects [94] and effects that pro-
and Photobiomodulation mote healing in the irradiated tissue [95].
Investigation into pain response during surgical laser
Photobiomodulation (PBM) is the manipulation of cel- use has revealed findings that are inconsistent with many
lular behavior using low-intensity light sources and the anecdotal reports and may provide an opportunity for
delivery of laser therapy (application of photonic energy the essential subjective aspects of patient receptiveness
at specific wavelengths) to induce a biological response to be accepted. Pain is a defence mechanism, and pain
through energy transfer. Sub-ablative photonic energy perception is innate and subjective. Equally, all stimuli
delivered into the tissue modulates biological processes applied to excess will result in pain.
within that tissue and within the biological system of Pain perception is multi-factorial and may be influ-
which that tissue is a part. Key to the limits of benefit is enced through the following, either singularly or in com-
the restriction of laser operating parameters to ensure bination:
that PBM has no appreciable thermal effect in irradiated 55 Emotion: fear, anxiety, stress syndrome, excitement
tissue. 55 Awareness: trust, previous experience, conditioning,
Phototherapy is characterized by its ability to induce e.g., hypnosis, activity subordination
photo-biological processes in cells [89]. This conforms 55 Threshold potential: age, infirmity, drugs, alcohol,
to the first law of photobiology (light absorption by spe- social factors
cific molecular chromophores). There is a so-called opti-
cal window in tissue (approx. 650–1100 nm), where the The avoidance of pain during restorative and dental
effective tissue penetration of light is maximized. The surgical procedures remains a strong factor in promot-
use of PBM therapy in patients almost exclusively ing patient acceptance of treatment, and many studies
involves red and near-infrared light (600–1100 nm) [90]. have been carried out to evaluate this in terms of
The absorption and scattering of light in tissue are laser-
tissue interaction [96–98]. The use of the
both much higher in the blue region of the spectrum Nd:YAG (1064 nm) laser in developing pulpal analge-
60 S. P. A. Parker
sia, possibly through interference with the “gate the- 3.15 Conclusion
ory” of neural stimulus propagation, was an early
mainstay benefit of this laser following its launch into An overview has been presented to explore the physical
dental practice in 1990. However, investigation into and biological aspects of interaction of laser photonic
the subjectivity or placebo effect has rendered its energy with target oral hard and soft tissue. Any incon-
application inconsistent [99–101]. Chaiyavej et al. sistency may be viewed in terms of the precise mecha-
3 found that Er:YAG laser use, similar to rotary bur cut- nisms governing molecular energy dynamics but also the
ting of tooth tissue, caused neural response in both A great diversity in tissue types and their close approxima-
and C intra-dental fibers [102]. tion within the oral cavity. The clinician is faced with
Perhaps of greater significance in exploring this area technical challenges in manipulating any given laser
may be the lack of tactile and thermal stimulation com- wavelength to employ it as broadly as possible during
pared to rotary instrumentation during laser-assisted clinical procedures; the additional facility of power den-
restorative dentistry. In seeking to understand the essen- sity phenomena in helping to initiate an essentially pho-
tially anecdotal reports of soft tissue surgery using laser tothermal event may help to deliver predictable and
photonic energy in what is a thermally based inter- precise surgical outcomes. In . Fig. 3.21, it is possible
change, there is the patient-centered factor of trust in to appreciate the complex yet interconnected relation-
the operator, together with a possible harmonization of ship that exists between incident laser choice and oper-
micro-pulsed free-running emissions with regeneration ating parameters, the consequent gradient of effects that
potential of acetylcholine at synaptic junctions within result from such choice and how the laser-tissue effects
the sensory neurone. so produced can represent a breadth of clinical applica-
It is without question that when used correctly and tion— in terms of both therapy and diagnosis. The pho-
with recommended operating parameters to maximize ton distribution and concentration (fluence) delivered
laser-tissue interaction, laser-assisted surgical proce- will influence the degree of (essentially) photothermal
dures on soft and hard tissue are less physically injurious effect and consequent reaction of the target tissue. At
when compared to both scalpel and rotary bur. Patient low fluences, the benefits can be seen as diagnostic value
acceptance, peer pressure and a general acceptance of and PBM (photochemical) effects; at higher fluences
“hi-tech” approach to treatment may all propose an (with the same laser wavelength or another), the photo-
enhancement of tolerance of sensory stimulation. thermal interaction predominates with ablative and per-
.. Fig. 3.21 Summary of laser-tissue interaction to demonstrate the breadth of application, relative to photon delivery
Laser-Tissue Interaction
61 3
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65 4
Contents
References – 96
Laser Operating Parameters for Hard and Soft Tissue, Surgical and PBM Management
67 4
Core Message every second. That is, 4,080,000,000,000,000,000 pho-
New technologies introduced into clinical dentistry in tons are released each second. On the other hand, an
recent years have added immeasurably to the quality of Er:YAG laser at 2940 nm must produce 14.799 quintil-
care that may be provided. Lasers, dental implants, CAD/ lion photons in a second [1]. Photons exert their influ-
CAM, and motorized endodontics have all improved ence on tissue through absorption by cellular elements,
clinical outcomes but require a significant investment in and that absorption is highly dependent on wavelength.
hardware and, most importantly, education to under-
stand concepts and protocols. As with all medical instru-
mentation, it is not enough to follow basic guidelines or 4.1.2 Wavelength
“preset” parameters in approaching each patient situa-
tion. A deep understanding of the technology, how it As an electron drops from one orbital to one of lower
interacts with the patient’s tissues, and what variables are energy, a precise amount of photonic energy is
important to consider are necessary for a successful clini- released producing a specific wavelength. Every laser
cal outcome. is capable of generating and does generate several
Of the four technologies mentioned above, lasers are, wavelengths. The resonant cavity is designed to
perhaps, the easiest to abuse. Without basic education, it dampen unwanted wavelengths through destructive
is nearly impossible for a clinician to accomplish the first interference leaving only the desired output to be
successful case of implant placement, CAM/CAD crown amplified and emitted.
fabrication, or motorized endodontic treatment.
However, with a manufacturer-provided user’s manual, a
dentist with a new laser may push a button that says “gin- 4.1.3 The Laser
givectomy” and attempt a procedure.
The purpose of this chapter is to explore the parame-Every laser produces only one predominant wavelength
of photons. The laser is usually identified by its active
ters that are important, and in some cases critical, to suc-
medium and host material. The active medium is a mate-
cessful laser therapy. This discussion then leads to insights
into specific lasers and tissues. rial that can absorb photons of energy and then release
As has been presented, various lasers can be used forthem when stimulated further by more photons. Many
different materials have been shown to produce this
surgical treatment of both hard and soft tissues. In addi-
unique “stimulated emission.” Lasers are designated
tion, photonic energy can be injected into tissue to affect
therefore as solid state, gas, semiconductor, and liquid,
cellular metabolism beneficially. In each of these therapies,
applied energy density, its wavelength, and the time overbased on the material used.
which it is applied represent critical factors affecting the Solid-state lasers are most commonly trivalent rare
outcome. earth ions such as neodymium (Nd) and erbium (Er).
The host material suspends the active ions and com-
prises the majority of the laser crystal. They are most
4.1 Intrinsic Properties commonly grown-crystal structures such as yttrium alu-
minum garnet abbreviated as YAG [2]. This combina-
A number of parameters are dictated by design deci- tion of elements accounts for the naming convention of
sions during the manufacture of any clinical laser. They Er:YAG and Nd:YAG.
cannot be chosen or controlled by the operator and Gas lasers consist of a combination of gases. Carbon
must be accepted with their benefits and shortcomings. dioxide lasers are actually a mixture of approximately
one part carbon dioxide combined with four parts nitro-
gen as the active medium distributed in approximately
4.1.1 The Photon five parts helium as the host material.
Liquid or so called dye lasers use fluorescein, mala-
A photon is a quantum of electromagnetic energy and chite green, coumarin, or rhodamine as the active
has been discussed extensively in previous chapters. All medium suspended in water, alcohol, or glycol as a host
photons are certainly not alike. The amount of energy in material. They have the great advantage of being “tune-
each photon is determined by the wavelength or, more able” from approximately 365 to 1000 nm and, because
precisely, the wavelength is determined by the photonic of the inherent cooling provided by the liquid medium,
energy released. can produce as much as 20 W of continuous wave out-
The number of photons generated by a laser is mind- put and 1.4 kW of pulsed output. Unfortunately, they
boggling. If an 810 nm diode laser is set to deliver 1 W are bulky, complex, and expensive and are not currently
of output power, 4.08 quintillion photons are produced used in dental applications [3].
68 W. Selting
a b c
.. Fig. 4.2 The output from the laser fiber in a is obviously nonuni- the output profile of an Er:YAG quartz. The vertical axis indicates
form. The plot in b depicts power density at different points across relative energy density. (Photo courtesy of Frank Yung DDS)
the beam and is approximately Gaussian in cross section. c Depicts
a b
.. Fig. 4.3 a A 400 μm diameter optical fiber can be tied in a knot long as the protective polyamide coating is present, the same fiber
and still transmit most of the laser energy. The red color visible in can be bent at nearly a 90° angle without breaking
the knot indicates that a small number of photons are escaping. b As
a b
c d
.. Fig. 4.4 The output from different laser devices is not the same. a Optical fiber or laser tip, b tipless delivery system, c laser pointer or
flattop handpiece, d radial firing laser tip
amount, the area on which the delivered photons impact 55 Irradiance is another term for power density.
increases rapidly with distance. The influence of this 55 Energy density (measured in J/cm2) is calculated as
divergence on power density is of great significance and the power density in W/cm2 multiplied by the total
will be discussed in detail later in this chapter. time of illumination.
55 Fluence is another term for energy density.
able number of photons since each photon contains a power (the rate of doing work) is increased to 6 J/s (W)
different amount of energy based on its wavelength. and is applied for just 10 s, the same 60 J of total energy
Power is the rate of producing energy. It is the num- will have produced.
ber of joules created in each second of time and is desig- Since average power, peak power, energy per pulse,
nated in joules per second. A watt is simply an pulse width, and pulse frequency are so interrelated,
abbreviated word to mean “joule per second.” If 1 J/s or they will be discussed as a parameter group interspersed
W is produced and continues to be produced for 10 s, with examples.
then 10 J of total energy will have been produced. If Average power represents the total energy produced
energy continues to be produced at this rate for 60 s, 60 J in 1 s, no matter how uniformly that happens within
of total energy will have been produced. If instead the that length of time. A continuous-wave laser produces a
74 W. Selting
constant number of photons for each time increment While . Figs. 4.6 and 4.7 are both erbium lasers,
that it is activated while a pulsed laser produces pho- their control features are distinctly different. The
tons in short bursts ranging from femtoseconds to mil- Er,Cr:YSGG laser shown in . Fig. 4.6 allows control
liseconds. of average power. The pulse width is selected as “H” for
The average power would seem to be provided on hard tissue and represents a pulse width of 60 μs. The
two of the three laser control displays in . Figs. 4.5, laser displays the pulse repetition rate (15 pulses per sec-
4.6, and 4.7, but a very important distinction must be ond). The peak power is adjusted by the laser to provide
made. With a diode laser, the power displayed is usually this output although it cannot be directly controlled.
(but not always) the peak power. The diode laser in There is no indication of the energy produced in each
. Fig. 4.5 allows direct control of the output power, but pulse.
the power displayed is the “continuous wave” output The Er:YAG laser in . Fig. 4.7 allows control of
rather than the average power. Any time that this laser is energy per pulse and pulse frequency. While average
emitting photons, it is emitting 2 W of peak power. power is indicated on the display, it is not directly con-
In variable-gated mode, independent selection of off- trollable. If the amount of energy contained in each
time and on-time is provided and results in vastly differ- pulse and the number of pulses in each second are
ent average power for a given indicated power. If the known, the average power is calculated as the total of all
laser is “on” for 20 ms and “off ” for 80 ms, then it is on these pulses in 1 s:
for 20% of the time:
Poweravg = Energy per pulse × Number of pulses per second
Percentage of "on − time" = 20 ms / ( 20 ms + 80 ms )
= 20 ms / 100 ms = 0.2 = 20%
4.2.2 Peak Power
Average power is then calculated as:
Peak power represents the maximum instantaneous
Poweravg = powerindicated × percentage of " on − time " power that the laser produces at any single time. In a
= 2 W × 20% = 0.4 W continuous-wave laser, the peak power does not
change from that selected on the user interface, no
If the lengths of the on and off periods are changed but matter what other parameters are changed. As has
stay in the same ratio, average power will be the same. been discussed, it is the value displayed by the diode
. Figure 4.8 illustrates these concepts. laser in . Fig. 4.5.
Peak power will always be the same as that indicated With pulsed lasers such as all dental erbium and
on this display, no matter what magnitude or ratio of Nd:YAG lasers, peak power is dramatically affected by
“on” and “off ” times are selected. the interrelated control of average power, energy per
Laser Operating Parameters for Hard and Soft Tissue, Surgical and PBM Management
75 4
.. Fig. 4.8 Calculated peak and average power produced at the settings with the diode laser shown in . Fig. 4.5
pulse, pulse width, and pulse frequency. If these param- Energy / pulse = Total energy per second /
eters are not known, they can be calculated. number of pulses containing that energy
Peak power can be calculated as:
Powerpeak = Energy per pulse / pulse width Energy / pulse = 4 J / s / 15 pulses per second
= 0= .267 J / pulse 267 mJ / pulse
4.2.3 Pulse Energy At the same time, if average power were to be set to 8 W
and there were 30 pulses per second:
Some manufacturers allow direct control of the total
amount of energy in each pulse instead of controlling
Energy / pulse = 8 J / s / 30 pulses per second
the average power. By necessity, if the pulse energy is
= 0= .267 J / pulse 267 mJ / pulse
held constant, altering the pulse width will change the
peak power. . Figure 4.9 illustrates this concept. It is
based on the Er:YAG laser shown in . Fig. 4.7. In each The energy per pulse is the same even though the aver-
case, the energy per pulse is the same. If that energy is age power is doubled.
delivered in one-half the time, the power or rate of deliv-
ery must be doubled.
Some pulsed lasers do not allow direct control of 4.2.4 Pulse Width
pulse energy but, instead, provide selection of average
output power. This output results in vastly different In most pulsed lasers, selection of several different pulse
pulse energy and peak power as illustrated in the follow- widths is provided. As an example:
ing example. For the control panel shown in . Fig. 4.6:
In . Fig. 4.6, if average power is set to 4 W and 55 “H” = “hard tissue” = 60 μs
there are 15 pulses per second: 55 “S” = “soft tissue” = 700 μs
76 W. Selting
For the control panel shown in . Fig. 4.7: 4.2.6 Diameter of the Final Emitting Device
55 “SSP” = “super-short pulse” = 50 μs
55 “MSP” = “medium short pulse” = 100 μs The number of photons that strike an individual cell
55 “SP” = “short pulse” = 300 μs and their associated energy is one of the primary deter-
55 “LP” = “long pulse” = 600 μs minants of tissue effect. Power density or fluence is a
55 “VLP” = “very long pulse” = 1000 μs critical factor in determining laser-tissue interaction.
55 “QSP” = “quantum square pulse” = a unique pulse Power density is, by definition, the number of pho-
train not relevant to this discussion tons passing through a specific area in each second of
time. A 400 μm laser fiber has a cross-sectional area of:
. Table 4.2 Average power density in W/cm2 with different fiber size and power setting
laser-tissue interaction. In the example of the Er:YAG individual target cell. As laser energy exits an optical
laser in . Fig. 4.7, using an 800 μm diameter tip, pro- fiber or a quartz or sapphire tip, it diverges quite signifi-
ducing 1000 mJ of energy per pulse with a pulse width cantly.
of 50 μs and 50 pps will deposit a mind-boggling peak The applied energy is distributed over an increasing
power density of 4,000,000 W/cm2 into the target tissue area as the tip-to-tissue distance increases, dramatically
with an average power density of 10,000 W/cm2. These affecting power density at a cellular level as shown in
calculations are illustrated in Appendix. . Fig. 4.10. Power density can be diminished by 95%
with only 5 mm of tip-to-tissue distance. This is further
demonstrated in . Fig. 4.11. When using this standard
4.2.7 Tip-to-Tissue or Focus-to-Tissue delivery system, the repeatable application of an appro-
Distance priate energy density is extremely technique and opera-
tor sensitive.
Under many circumstances, the optical fiber tip, quartz . Table 4.3 illustrates how significantly the power
tip, or sapphire tip is held at some distance away from density changes with just minor changes in the tip-to-
the tissue. In addition, there are a number of erbium and tissue distance. It is also apparent that the effect of
carbon dioxide lasers that are routinely used without a beam divergence is far greater with smaller diameter
tip but rely on focused laser energy as discussed in emitting devices. A collimated beam eliminates this
7 Sect. 4.1.6 above. With a tipless system, the smallest destructive divergence but is only possible to produce if
spot diameter and, consequently, highest power density a lens is the final element in the path of the laser energy
exist at the point of focus. All measurements of distance as it is emitted
are referenced to that point. All concepts associated with beam divergence from a
Tip-to-tissue distance, or the comparable focus-to- flat-ended tip apply to tipless systems with distances
tissue distance, provides yet another parameter that dra- being measured from the focal point as demonstrated in
matically affects the density of photons striking an . Fig. 4.12.
78 W. Selting
a b
.. Fig. 4.11 Power density at tip-to-tissue distances of 30 mm a and 1 mm b with an identical 1 W of applied diode laser power
.. Table 4.3 Average power density at 1 W laser output for different tip diameters and tip-to-tissue distances assuming an 8° per
side beam divergence
4.2.8 Auxiliary Water If the laser tip is completely submerged, water is evac-
uated from the laser path by a slightly different phenom-
All erbium lasers, together with the 9300 nm CO2 laser, enon. When laser energy strikes the water directly in front
have the ability to spray water on the tissue during treat- of the tip, it once again causes vaporization. An air bub-
ment. In the case of hard tissue, this spray is used to cool ble is created, as shown in . Fig. 4.14, which pushes the
the tooth or bone and remove debris from the ablation water out of the way allowing energy from the remainder
site. Without extrinsic water, the tooth will overheat of the pulse to strike the tooth surface and cause ablation.
under repeated pulses and ablation may cease. Nahen and Vogel [13] showed that such a bubble
Er:YAG laser energy is absorbed in approximately forms in the first 10–20 μs of the laser pulse. The balance
0.8 μm of water [8–10]. Logic suggests that, if auxiliary of the pulse energy is then able to ablate as though no
water is used, all energy will be absorbed by overlying water is even present. Nearly all of the laser energy
water before it can reach the tissue surface and no abla- strikes the tooth surface unimpeded allowing excellent
tion will occur. On the other hand, without extrinsic ablation. As the bubble collapses between each pulse,
water, charring will rapidly occur and ablation will cease the newly ablated surface is bathed in water, thus cool-
with significant damage to the tooth. ing, cleaning, and rehydrating the structure.
In practice, other principles resolve this issue [11]. Within limits, the thickness of the water layer is of
When laser energy strikes the surface of a water film, it is little consequence. The bubble formed has a finite size
rapidly absorbed causing vaporization. This rapid phase estimated by the author from ultra-speed photographs,
change occurring in a few microseconds creates a shock such as in . Fig. 4.15, to be approximately 3 mm in
wave of very significant magnitude generating pressures length.
of a few hundred atmospheres. This shock wave displaces When only a water mist is used, any droplets in the
water at the point of contact creating an open channel to path of the laser energy are rapidly vaporized allowing
the underlying tooth surface [12] as shown in . Fig. 4.13. passage of subsequent energy.
Laser Operating Parameters for Hard and Soft Tissue, Surgical and PBM Management
79 4
.. Fig. 4.12 The effect of focus-to-tissue distance on spot diameter tances from the focus point are the same as those from the tip in
and, therefore, on power density. These calculations are based on a . Fig. 4.10. Consequently, the calculated values are identical
beam divergence of 8° per side angle. It is evident that all of the dis-
In an experiment to verify the theoretical concepts In addition, applying energy with the tip completely
discussed above, the flow rate of irrigation water was submerged in water has no detrimental effects on abla-
controlled at 1, 2, 4, 8, 16, and 24 mL/min while the tip- tion efficiency as long as the laser tip is within about
to-tissue distance was held at 0.5 mm. Other samples 2 mm of the tissue surface.
were ablated completely submerged in water at the same At low irrigation water flow rates, the possibility of
controlled distance [11]. dehydration and charring is significant. Without water
. Figure 4.16 shows that Er:YAG ablation efficiency coolant, residual heat quickly dehydrates the enamel
is essentially independent of irrigation water flow rate. making further ablation inefficient or impossible. At the
80 W. Selting
25
Tip completely
submerged
20
in water
Ablation (mg)
15
10
0
0 10 20 30 40
Water flow rate (ml/min)
.. Fig. 4.16 Effect of irrigation water flow rate on Er:YAG laser .. Fig. 4.17 Effect of irrigation water flow rate on Er:YAG laser
ablation of enamel. Tip-to-tissue distance was constant at 0.5 mm. ablation of enamel. Without irrigation, hydroxyapatite absorbs laser
The volume of irrigation water has a minimal effect on ablation effi- energy causing progressive desiccation, overheating, and carboniza-
ciency tion
same time, a layer of exploded hydroxyapatite particles composition, and enhance adhesion to restorative
covers the enamel surface and absorbs some of the materials.
energy of the next energy pulse, heating this unwanted A flow of at least 8 mL/min is needed to minimize
layer significantly. adverse effects. Since flows of up to 24 mL/min have
. Figure 4.17 shows enamel ablated without water. been shown to have no negative effect on laser abla-
Thermal damage results in carbonization, cracking, tion efficiency, it is prudent to use 8–24 mL/min to
and a loss of laser ablation effectiveness. Water spray ensure adequate hydration. In fact, it can be argued
both cools the tooth and washes away the debris. that using the maximum amount of water possible is
Irrigation also serves to enhance ablation rate and effi- an appropriate strategy. However, ultimately, site visi-
ciency, improve surface morphology, alter chemical bility by the dentist as well as patient tolerance for
Laser Operating Parameters for Hard and Soft Tissue, Surgical and PBM Management
81 4
.. Fig. 4.18 The energy
density striking individual cells
is calculated by dividing the
total energy delivered by the
total area irradiated
large water volumes will dictate the water flow rate 4.3 Further Calculated Parameters
used.
Super-pulsed CO2 lasers also use auxiliary water to Having adjusted laser parameters in accordance with an
cool the tooth or bone and remove debris from the abla- established protocol, it is instructive to understand the
tion site, and it is vital to effective use of this modality. nature of the resulting energy applied to the target. Average
Water is not used with continuous-wave CO2 lasers since power, peak power, fluence (energy density), and irradi-
it would absorb all the energy in the scenario discussed ance (power density) all have a very significant effect on the
in the second paragraph of this section. target tissue. Further parameters are also important.
b c
a b
.. Fig. 4.21 Energy from both erbium lasers a and b as well as diode lasers c interacts with composite resins and dental acrylic materials at
commonly used power levels
Laser Operating Parameters for Hard and Soft Tissue, Surgical and PBM Management
85 4
4.5 Soft Tissue Surgery Considerations soft tissue procedures. Both the Er:YAG and the
Er,Cr:YSGG lasers are absorbed efficiently in a few
microns of tissue. Since little energy is transferred to the
4.5.1 ost Appropriate Laser for Soft
M surrounding area, little collateral tissue damage occurs.
Tissue Procedures Because of this same property, these lasers do not pro-
duce significant hemostasis from thermal absorption at
All of the existing dental lasers can surgically incise soft the incision margins.
tissue. Finally, the CO2 laser has primary chromophores of
The diode laser is the most popular dental laser with water and collagen, making it a useful soft tissue laser.
thousands in use in dental offices around the world. Its action is very superficial but produces melting of col-
They are attractive because they are small, lightweight, lagen as well as explosion of tissue through steam gen-
low maintenance, durable, and relatively inexpensive. eration. Since this energy is delivered via a noncontact
While a valuable tool, these devices are plagued by a handpiece, precision is more difficult to achieve.
very significant shortcoming. They are very poorly
absorbed in soft tissue. With diode lasers ranging from
approximately 808 to 1064 nm, melanin, hemoglobin, 4.5.2 Fiber Initiation Consideration
and protein are the primary chromophores. However,
water which makes up more than 70% of most tissues is While diode lasers are poor soft tissue lasers, they are
not a chromophore and produces almost no interaction small and relatively inexpensive. The optical fiber deliv-
at diode wavelengths. This suggests that the diode is a ery system is flexible and very maneuverable allowing
poor laser for incising soft tissue. access to hard-to-reach areas of the oral cavity. Fiber
Since the laser energy spreads through a large area initiation provides a technique to circumvent this laser’s
of tissue, the risk of significant collateral damage is shortcomings.
high. On the other hand, this energy is highly An energy-absorbing material is applied to the end
absorbed in blood so causes excellent coagulation of the fiber as shown in . Fig. 4.22 in a process called
and hemostasis. initiation or activation. Material is transferred to the
The Nd:YAG laser at 1064 nm suffers from the same fiber end creating a thin layer that absorbs subsequent
poor absorption as all diode lasers, again suggesting that laser energy.
this is not a good laser for incising soft tissue. Its advan- When the laser is activated, this thin layer absorbs
tage lies in its very high peak power with short pulse the emitted photons and is rapidly heated to several
width providing thermal containment and moderate hundred degrees. This “hot tip” is used to melt proteins,
ablation with very good hemostasis. Nd:YAG lasers are thus separating the tissue. The argument is often made
more complex and considerably more expensive than that this technique is similar to electrosurgery or apply-
diode lasers. ing a heated instrument. However, because only the thin
Erbium lasers have a primary chromophore of water, layer of absorbent material is heated, the thermal energy
which is the most abundant constituent of biological tis- is concentrated and there is significantly less collateral
sue making them an excellent choice to perform surgical thermal damage than with these other modalities.
a b
.. Fig. 4.22 The technical process of initiation is shown in a while the resulting coat on the fiber end is shown in b
86 W. Selting
While each laser manufacturer has suggestions for 4.5.5 Precooling of Tissue
proper fiber initiation, the following technique has been
shown to provide superior results: Collateral damage occurs through the prolonged heat-
55 Adjust the laser to a very low power setting of less ing of cells. A study by Simanovskii et al. [23] asserted
than 0.5 W. that mammalian cells can survive a temperature increase
55 Touch the fiber tip to articulating paper without acti- to 42–47 °C for prolonged periods of time. Above this
vating the laser. point, the length of time at higher temperatures becomes
55 Activate the laser momentarily until a perforation is a critical variable. Cells can only survive at 70 °C for
4 seen in the articulating paper. about 1 s and 130 °C for 300 μs. Since optical fiber tip
55 Repeat at least eight times. temperature can exceed 800 °C, it becomes apparent
55 Observe the aiming beam against a surface. If it is that this is the source of damage.
still clearly visible, repeat more times. The margins of a surgical excision will be rapidly
heated although not to this level. It has been shown
that approximately 350 μm of collateral tissue death
4.5.3 Effect of Fiber Size may occur [24]. Precooling the tissue with an air/water
spray can reduce, but certainly not eliminate, collat-
As has been discussed in 7 Sect. 4.2.6 above and eral damage. Frequent cooling during procedures is
. Table 4.2, smaller fiber diameters significantly also considered to be of benefit. However, using a
increase power density and positively affect the ability constant flow of water during surgery is not recom-
of the laser to incise tissue. However, fibers with a diam- mended. Vision will be compromised, and, more
eter smaller than 400 μm are very flexible affecting the importantly, thermal energy will be diffused over the
ability to cut precisely and are at higher risk of sponta- tissue surface scalding a superficial layer as shown in
neous fracture. . Fig. 4.24.
.. Fig. 4.24 Three cuts all performed with a 940 nm diode laser at 1
W, CW. The bottom cut done with no precooling and air or water
irrigation. Note the significant collateral damage. The middle cut
was performed with air directed over the surface. Speed of cut was
slower but as effective with much less collateral damage. Applying an
.. Fig. 4.23 During clinical application, tissue adheres to the fiber air/water spray during treatment in the top cut caused significant
tip. It in turn is heated causing collateral tissue damage surface cell death. (Courtesy of Dr. Mark Cronshaw)
Laser Operating Parameters for Hard and Soft Tissue, Surgical and PBM Management
87 4
4.6 Photobiomodulation Considerations absorbed. When treating a muscle or a temporoman-
dibular joint, energy reaching the target cells is predict-
It is well established that, in general, photobiomodula- ably and drastically reduced. . Figure 4.25 is a
tion can have a positive effect on tissue [25–27]. However, presentation of energy reaching cells deep within the tis-
photonic energy must reach target cells at the appropri- sue.
ate intensity to be effective. This energy density is widely
accepted to be between 3 and 10 J/cm2, relative to the
individual cell surface, in accordance with the Arndt- 4.6.4 ffect of Lesion Depth and Tissue
E
Schultz law [28, 29]. At less than 3 J/cm2, there is insuf- Type on Parameter Calculations
ficient energy absorbed by the cell to increase its
metabolism, while densities of more than 10 J/cm2 Many of the anatomic structures that are purported to
appear to inhibit cellular function. benefit from low-level laser therapy such as the TMJ or
While energy is applied on a macroscopic level, the joint bursa are located at some distance within the sur-
interaction with tissue occurs on a subcellular level [30]. rounding tissue. . Figure 4.26 suggests that, at 5 mm
Ideally, each individual cell in the path of the applied into representative tissue ranging from beef muscle
energy should be illuminated with the same number of (similar to human muscle) to beef liver (similar to highly
photons within this range. The positive effects of photo- vascularized tissue), energy density has decreased to
biomodulation are very strongly associated with the about 10% of its surface value.
density of photons striking the cells. Unfortunately, a
method of delivering photons to a group of individual
cells, often deep within a tissue mass, in a uniform and 4.6.5 Cautionary Considerations
predictable manner has been lacking.
Arany et al. [33] state that a skin temperature increase to
greater than 45 °C is phototoxic. While it is tempting to
4.6.1 ost Appropriate Laser
M apply large amounts of energy in a short period of time
for Photobiomodulation in order to stimulate deep structures and to speed treat-
ment, very negative unintended consequences may occur
Between approximately 600 and 1200 nm, very few in overlying tissues.
absorbing chromophores exist allowing laser energy to Of all the protocols for laser use in dentistry, pho-
penetrate deeply into the tissue mass. This range of tobiomodulation is at the greatest risk of misunder-
wavelengths has been labeled the “optical window” [31] stood technique and unintended consequences.
and is exploited in most photobiomodulation protocols. Unfortunately, there is no direct visual feedback of
In general, diode lasers are the most appropriate laser effectiveness leaving the clinician to rely on an under-
for this application. standing of parameters.
While not settled science, the currently accepted
guidelines recommend applying a fluence of 100 mW/
4.6.2 Recommended Parameters cm2 and a total cellular dose of 3–10 J/cm2.
There are several unique devices available for apply-
Further chapters will explore the intricacies of dosage in ing therapeutic doses including large-diameter
photobiomodulation. The energy density at the cellular (8–10 mm) optical fibers, rectangular therapy/bleaching
level is a key determinant of biostimulation and appears handpieces, and flattop handpieces. Many clinicians use
to be between 3 and 10 J/cm2 depending on the cell type the expedient of a surgical optical fiber held at a dis-
and should be applied at a rate of approximately tance from the tissue surface as a perceived equivalent.
100 mW/cm2. However, these devices can produce very different tissue
For lesions on the surface of tissue, calculation of exposure.
the appropriate dose is rudimentary. However, as energy If 1 W of power is applied through a 400 μm fiber
enters tissue, it is moderately absorbed and highly scat- from a distance of 10 mm for 30 s as it is moved over a
tered reducing the effective dose. tissue area of 2 cm2, the result is:
=
Fluence 1=
W / 2 cm 2 0.5 W / cm 2 = 500 mW / cm 2
4.6.3 istribution of Applied Energy
D
in a Tissue Volume Irradiance = 0.5 W / cm 2 × 30 s = 15 J / cm 2
As energy penetrates a tissue mass, it is absorbed and Applying the same parameters through an 8 mm diam-
widely scattered. Bashkatov [32] asserted that photons eter PBM handpiece in contact without movement
are 100 times more likely to be scattered than to be results in:
88 W. Selting
.. Fig. 4.25 All tissue areas in red exceed the optimal range and This semicircular band is about 4 mm wide directly in front of the
experience bioinhibition and perhaps even irreversible cellular dam- handpiece tapering down to about 1 mm wide on the periphery.
age. This zone extends about 3.5 mm into the tissue. Biostimulation Beyond that band, the tissue cells would be perhaps warmed a little
would occur from 10 J/cm2 to about 3 J/cm2 as depicted in yellow. bit with no discernable photobiomodulation effect
.. Fig. 4.29 This laser contains both a 2940 nm Er:YAG laser and to find the value. It allows control of pulse energy and pulse fre-
a 1064 nm Nd:YAG laser. In erbium mode, it allows selection of six quency. The resulting average power is displayed but not directly
different pulse widths. However, the operator must refer to a manual selectable
Peak Power
Peak power represents the maximum instantaneous
power that the laser produces.
Peak power can be calculated as:
Powerpeak = energy per pulse / pulse width .. Fig. 4.31 Basic geometry establishes the relationship between
different variables in a right triangle
=
Powerpeak 0=
.267 J / 0.00006 s 4444 W (O) of 2 mm and an angle (x), from geometry
(. Fig. 4.31):
Tip Area O = A × tan ( x )
Commonly available tips for this laser are cylindrical,
tapered, and chisel shaped. While calculating the area, O = 2 mm × tan (12° )
divergence and spot area for chisel tips are beyond this
discussion, and the diameter of the output end of a O = 2 mm × 0.2126 = 0.425 mm
tapered tip can be treated the same as a cylindrical tip as
calculated below. Spot radius at tissue = tip radius + opposite
Assuming the use of a 600 μm diameter cylindrical = 0.03 + 0.0425 = 0.0725 cm
tip allows the following calculations:
Tip area is the radius squared of the tip multiplied by π: Spot diameter at tissue = 0.145 cm
.. Fig. 4.32 This is a depiction of the various values calculated to determine the spot area at the tissue with a divergent beam
Average Power
This erbium laser indicates an average output power of
4.7.3 True Pulsed Laser with Control of 3 W. In this case, it is not directly adjustable but is inter-
Pulse Energy (. Fig. 4.29) nally calculated by the laser. It can be calculated as
shown below:
Pulse Width Poweravg = energy per pulse
Pulse width is established by choosing one of the six val- × number of pulses per second
ues available—choosing the SSP mode selects a pulse
width of 50 μs. Poweravg = 0.2 J / pulse × 15 pulses per second = 3.0 W
Laser Operating Parameters for Hard and Soft Tissue, Surgical and PBM Management
95 4
Peak Power Total energy = poweravg × time = 3 W × 30 s = 90 J
Peak power represents the maximum instantaneous
power that the laser produces.
Peak power can be calculated as: Energy Density
Powerpeak = energy per pulse / pulse width If the fiber tip is held stationary in one location, the
energy density is calculated as:
=
Powerpeak 0=
.200 J / 0.00005 s 4000 W Energy densityavg = poweravg × time / area
= 3 W × 30 s / 0.0165 cm 2
Tip Area = 5455 J / cm 2
As with the Er,Cr:YSGG laser discussed above, com-
monly available tips for this laser are cylindrical, tapered, Energy density peak = powerpeak × time / area
and chisel shaped. All calculations below are based on = 4000 W × 30 s / 0.0165 cm 2
the use of a 600 mm diameter tip at a tip-to-tissue dis-
tance of 2 mm. The resulting calculations will be identi- = 8, 080, 000 J / cm 2
cal to those above.
Assuming the use of a 600 μm diameter cylindrical Assumptions
tip allows the following calculations: Several assumptions are made in these calculations:
Tip area is the radius squared of the tip multiplied by π: 55 Output is assumed to be uniform over the radiated
area. In practice, this is rarely true since a Gaussian
Tip area = 300 µ m × 300 µ m × 3.14159 output is normally produced.
= 0.03 cm × 0.03 cm × 3.14159 = 0.00283 cm 2 55 Output is assumed to be uniform over time. That is,
each pulse is assumed to rise instantaneously from
A tip that tapers from 1200 to 600 μm at the output end zero to the peak power being produced. Again, this is
would have the same tip area of 0.00283 cm2. rarely true.
As before, at a tip-to-tissue distance of 2 mm with a 55 Output is assumed to be constant over the duration
12° beam divergence per side angle: of the pulse. In fact, as shown in this chapter,
. Fig. 4.27 of this text, the true output varies sig-
Spot area at tissue = π × r 2 nificantly and must be averaged for these calcula-
= 3.14159 × 0.0725 cm × 0.0725 cm tions.
= 0.0165 cm 2 55 The output is assumed to be the same as that dis-
played on the interface screen. Laser manufacturers
are careful to point out in their technical specifica-
Power Density tions that most parameters are only guaranteed to be
Power density is the total energy in joules passing within about 20% of the stated value.
through a specific area in 1 s of time. With the attached 55 Actual spot diameter is as calculated. Because of the
600 μm laser fiber and a tip-to-tissue distance of 12°, Gaussian nature of the beam cross section, a portion
this erbium laser produces: of the photons will strike tissue outside of the calcu-
lated area.
Power densityavg = poweravg / area
Summary
= 3=
W / 0.0165 cm 2 182 W / cm 2
The calculations presented here are based on representa-
tive values as shown on actual dental lasers for all
Power densitypeak = powerpeak / area
parameters. By substituting actual known values for the
= 4000 W / 0.0165 cm 2 laser being used into the equations, it is possible to
= 242, 424 W / cm 2 determine appropriate parameters. In general, all
continuous-wave lasers can be assessed using the set of
calculations in Sect. 4.7.1, while true pulsed lasers can
Total Energy be analyzed using calculations in Sects. 4.7.2 and 4.7.3
depending on which parameters are displayed or can be
The total amount of energy delivered to the tissue dur-
selected.
ing a 30-s treatment is:
96 W. Selting
Contents
5.1 Introduction – 99
References – 124
Laser Safety in Dentistry
99 5
Core Message Additional laser photonic sources may be directed to
Laser use in general dental practice has grown consider- initiate intermediate photochemical action within an
ably since first introduced in 1989, reflected both in num- applied photosensitive dye or bleaching gel. The funda-
bers of machines and the scope of usage. As with other mental safety aspect is defined not by the specific applied
areas of primary healthcare, general and specific mea- photonic dose associated with a chosen procedure, but
sures must be employed to ensure the safe use of lasers in by the risk associated with the Class of laser being
dentistry. Regulations—specific to lasers or within the employed; thus, the application of, for example, PBM
licenced scope of practice—apply a duty of care to all using a Class IV laser source would nevertheless man-
dental healthcare professionals in the application of date full safety protection measures.
lasers in clinical practice. Such laser regulations may exist To deliver controlled, predictable, and positive laser-
through the adoption of international standards and/or assisted change represents the ideal of the dental clini-
through National or Regional legislation. The duty of cian in providing such treatment. However, inappropriate
care extends to all staff as well as patients. The registered energy levels and/or delivery of laser photonic beam to
laser owner or lead clinician is responsible for ensuring non-target tissue can represent a risk, in turn maybe suf-
that all staff personnel have a thorough knowledge of ficient to cause irreparable and permanent damage. For
laser safety. Additional devolved responsibility may be dental professionals, this may occur within the oral cav-
applied to the laser safety officer (LSO)—also referred to ity, to circumoral and facial skin structure or, most
as laser safety supervisor (LSS). importantly to the structures of the unprotected eye.
Laser safety measures relate primarily according to As the purchase and use of lasers in dentistry contin-
the Class of laser being used. Within the range of laser ues to grow, so must concern for laser safety. Failing to
photonic devices, there is an ascending classification from wear available eye protection is one of the most frequent
I to IV, to denote an ascending level of power output. contributing factors to laser injuries [1]. Within such
Sub-classes relevant to laser operation may be applied to risk and pertinent to the use of lasers in general, laser
those instances where adjunctive optical magnification safety measures are delineated for interpretation and
(loupes, microscope, etc.) are employed. Specific irradia- application in the workplace, such as within the dental
tion safety risks apply to the unprotected eye and skin, operatory.
according to the laser class and emission wavelength. In a systematic review of papers relevant to beam
Non-beam risks also exist, including those posed by the and non-beam medical laser hazards, together with
laser plume. access to the Rockwell Laser Industries Laser Accident
It is considered therefore—from advisory to manda- Database, it was concluded that occupational hazards
tory, depending on prevailing regulations—that those per- associated with medical laser applications remain poorly
sonnel involved in the delivery of clinical laser therapy understood and uncharacterized. There are relatively
should undergo training sufficient to alert them to their few published accounts of laser accidents; they tend to
responsibility. Prime among this responsibility is to any suffer from the problem of reliance on self-reporting.
patient receiving such therapy to receive adequate mea- Eye injuries, skin burns, injuries related to the onset of
sures to safeguard risk from photonic energy that is capa- fires, and electric shock have been reported in relation to
ble of risk to unprotected ocular and non-target tissue. medical laser use. It is probable that both acute and
chronic health effects have been experienced by medical
personnel as a result of exposure to laser generated air
5.1 Introduction contaminants (plume) [2].
A more substantial study of laser-related injuries
LASER—coherent, single wavelength, non-ionizing reported on risk factors but was not limited to medical
electromagnetic radiation is a comparatively intense laser application [3]. Four database sources within the
form of light energy; a potential may exist for such United States—Center for Devices and Radiological
energy, directed at biological tissue to be absorbed—in Health of the US Food and Drug Administration
part or totally—and give rise to structural change within (FDA), Rockwell Laser Industries (RLI), the US Army’s
the tissue. Lasers used in dentistry are configured to Laser Accidents and Incidents Registry (LAIR) and the
deliver photonic energy that would mostly convert to Federal Aviation Administration (FAA) safety report-
thermal change within tissue, and it is this thermal rise ing system—revealed a total of 869 injuries and deaths.
that may be sufficient to progress through tissue warm- Of these where injury or death occurred, a total of 663
ing (seen with sub-ablative photobiomodulation, PBM) (52%) were located in some type of medical facility.
to a level and above, where irreversible change such as It may seem innocuous to the dental professional
protein denaturation and water vaporization may occur new laser user that safety is a key objective to protect the
(seen with surgical hard and soft tissue lasers). patient and clinical team. Useful lessons can often be
100 P. J. Parker and S. P. A. Parker
learned from studying laser accidents and although often as part of laws and regulations that might apply
most countries require such accidents to be reported to within the workplace (. Fig. 5.1) [7–9].
the relevant authority, often such information is not IEC, formed in 1906 is responsible for the develop-
accessible to laser users. The risk of such accidents may
ment of world standards for the electrical and electron-
be reduced by performing a risk assessment and this is ics area and is composed of the national committees
often a legal requirement, such as in the countries of the
from countries around the world. In 1930, the IEC
European Union and United Kingdom [4, 5]. established electrical units under a system commonly
In a paper that reported laser-associated accidents known as the “Système International,” or SI for short.
within medical practice [6], 12 incidents were reported.In 1974, the IEC created Technical Committee 76, to
Simple errors relating to the operation of laser equip- address standards relating to lasers, with a particular
ment accounted for five of the reported incidents; in focus on safety. This committee developed a four-class
5 four incidents, there was temporary or permanent dam- system for lasers that was the global reference, later
age to the operator’s eye, but of greater significance was
modified in 2002.
the reporting of three incidents where the laser emission The American National Standards Institute (ANSI)
caused either direct inflammation of gauze and drapes developed in parallel although initially unconnected to
or damage to endotracheal tubing that led to potentiallythe IEC (. Fig. 5.2). ANSI was originally established in
fatal airway fires in an anesthetized patient. The paper1919 as the American Engineering Standards Committee
suggested that operator error was at fault in 67% of theand created the International Standards Association
incidents reported and that equipment fault (25%), (ISA), an organization that would eventually become
laser-induced fire (25%), and broken delivery fiber (17%)
the International Organization for Standardization
constituted the (avoidable) risks in these unfortunate (ISO). In 1969, ANSI adopted its present name.
accidents. The ANSI Federation also initiated what has now
It is only when viewed in the context of permanent become an annual series of discussions with the
and possibly life-threatening risk to the clinician and European Committee for Standardization (CEN), the
attendant staff but more so, the patient that the impor-European Committee for Electro-technical
tance of knowledge and appreciation of laser safety Standardization (CENELEC), and the European
issues must be acknowledged. Telecommunications Standards Institute (ETSI).
The United States has always had its own regulation
on lasers (known as FDA CFR 21 1040.10). This is a US
5.2 Regulatory Framework government regulation and is written into US law. As an
interpretation of recommendations, the ANSI Z136
The regulatory framework governing the safe use of series is recognized by the Occupational Safety and
lasers may be seen as a hierarchical devolvement, most Health Administration (OSHA) as the authoritative
referenced through the I.E.C. (International Electro- series of laser safety in United States.
technical Commission) and A.N.S.I. (American An important ANSI Federation member and accred-
National Standards Institute). From these organizations ited standards developer, the Laser Institute of America
and their representation, National Regulations may (LIA) is the professional society dedicated to fostering
apply—either as specific statutory instruments or more lasers, laser applications, and laser safety worldwide. In
2005, the LIA published ANSI Z136.4—Recommended uation and to aid the determination of user control
Practice for Laser Safety Measurements for Hazard measures.
Evaluation. This provides guidance for optical measure- 55 To establish requirements for the manufacturer to
ments associated with laser safety requirements. supply information so that proper precautions can
In addition, the US Food and Drug Administration be adopted.
(FDA) informed laser product manufacturers that the 55 To ensure, through labels and instructions, adequate
US FDA would henceforth accept IEC classification warning to individuals of hazards associated with
and labeling [10]. accessible radiation from laser products.
In addition to other activities, IEC publishes 55 To reduce the possibility of injury by minimizing
International Standards, Technical Specifications, unnecessary accessible radiation and to give
Technical Reports, Publicly Available Specifications improved control of the laser radiation hazards
(PAS) and Guides. Most pertinent to laser and (some through protective features.
aspects of) light emitting diode (LED) safety is the pub-
lication IEC 60825 (European variant EN 60825) which From such broad regulation, safety and risk assessment
has been published in several formats with revisions when using lasers and LED equipment in clinical dental
from 1994 to 2017 [11]. surgery can be devolved to include [12]:
The Standard IEC (EN) 60825-1 “Safety of laser 55 Suitability for use, clinical parameters
products Part 1: Equipment classification, requirements 55 Administrative code, record keeping
and user’s guide” sets out regulation governing the fol- 55 Safety features of laser, laser maintenance
lowing: 55 Environment safety, patient safety
55 To introduce a system of classification of lasers and 55 Laser Safety Officer, Laser Protection Advisor
laser products emitting radiation in the wavelength
range 180 nm to 1 mm according to their degree of . Table 5.1 provides a glossary of terminology associ-
optical radiation hazard in order to aid hazard eval- ated with aspects of laser safety.
102 P. J. Parker and S. P. A. Parker
Laser classification I–IV Laser/LED unit capability of ascending laser beam emission power, relative to the safety risk
posed. I—low; IV—high.
Aversion response Blinking of the eye, or movement of the head to avoid exposure to a bright light. Approximately
0.25 s.
Accessible emission limits (AEL) Maximum accessible level of laser radiation permitted within a particular laser class.
Maximum permissible exposure The level of laser radiation to which a person may be exposed without hazardous effect or adverse
5 (MPE) biological changes in the eye or skin.
Nominal hazard zone (NHZ) Aka Nominal Ocular Hazard Zone. Area within which the level of the direct, reflected, or
scattered radiation during normal operation exceeds the applicable MPE.
Controlled area Area within which occupancy and activity is subject to control and supervision for the purpose of
protection from laser radiation hazards.
Intra-beam viewing Exposure of the eye to all or part of a laser beam.
Specular reflection A mirror-like reflection of a laser beam, with or without loss of beam fluence.
Diffuse reflection Change in the spatial (area) distribution of a laser beam when it is reflected in multiple directions
by a rough or matt surface.
American National Standards US Regulations governing areas of laser safety pertinent to clinical laser dentistry.
Institute (ANSI) ANSI Z Z 136.1—Safe use of lasers
136.1,2,3,4,7 Z 136.2—Safe use of optical fiber communication systems utilizing laser diode and LED sources
Z 136.3—Safe use of lasers in healthcare
Z 136.4—Recommended practice for laser safety measurements for Hazard evaluation
Z 136.7—Testing and labeling of laser protective equipment
International Electro-technical Broad range specifications relating to laser manufacture and use
Commission (IEC) IEC
60825 + updates
5.3 Laser Classification 55 Class IIIA: Intermediate power lasers. Some limited
controls are usually recommended.
Lasers and laser systems are divided into four major 55 Class IIIB: Moderate power lasers. In general, Class
classifications according to their potential to cause bio- IIIB lasers will not be a fire hazard, nor are they gener-
logical damage to the eye or skin. The purpose of these ally capable of producing a hazardous diffuse reflec-
classifications is to warn users of the hazards associated tion. However, specific controls are recommended.
with the laser and LED relative to the Accessible 55 Class IV: High-power lasers are hazardous to view
Emission Limits (AEL). These limits are based on laser under any condition (directly or diffusely scattered)
output energy or power, radiation wavelengths, expo- and are a potential fire hazard and a skin hazard.
sure duration, and cross-sectional area of the laser beam Significant controls are required of Class IV laser
at the point of interest. facilities.
Prior to 2002, the classification of lasers ran from I
to IV, with Class IV to include surgical lasers. From 2002, this classification has been refined and
55 Class I: Laser products are generally exempt from adopted by the IEC. The revision was prompted by
radiation hazard controls during operation and as increasing sophistication in laser technology, together
such do not pose any specific risk in normal usage. with the increased adoption of magnification devices as
55 Class II: Low-power visible lasers that emit above adjuncts to operative medicine and dentistry—operat-
Class I levels but at a radiant power not above ing microscopes, loupes, etc. In general, LEDs would be
1 mW. The concept is that the human aversion reac- in the lower Classes (I, IM, II, IIM, IIIR), but very
tion (blink response) to bright light will protect a exceptionally may be Class IIIB. As such, this classifica-
person. Only limited controls are specified. tion will be examined in greater detail.
Laser Safety in Dentistry
103 5
The IEC Laser classifications are summarized as fol- reflex). Class IIM lasers may be hazardous if viewed
lows: with the aid of optical instruments. As with Class
Fundamental to the classification and inherent risk IM, this applies to laser beams with a large diameter
of tissue damage of a laser, the power density (irradi- or large divergence, for which the amount of light
ance—W/m2) of an incident laser beam and its relation passing through the pupil cannot exceed the limits
to a notional maximum tissue tolerance, may be for Class II.
expressed in terms of Maximum Permissible Exposure 55 Class IIIR: Moderate power lasers (CW: up to
(MPE). However, the computed MPE limit may be 5 mW) for visible wavelengths (400–700 nm). Up to a
exceeded for a given laser irrespective of its AEL—for factor of five over maximum allowable exposure of
example, the possibility of visual damage associated Class II lasers for other wavelengths. A Class IIIR
with extended direct laser pointer irradiation. laser is considered safe if handled carefully, with
55 Class I: Class I lasers are safe under all operating restricted beam viewing. With a Class IIIR laser, the
conditions. There is no risk to eyes or skin. This MPE can be exceeded, but with a low risk of injury.
means the maximum permissible exposure (MPE) Visible continuous lasers in Class IIIR are limited to
cannot be exceeded when viewing a laser with the 5 mW. For other wavelengths and for pulsed lasers,
naked eye or with the aid of typical magnifying optics other limits apply.
(e.g., telescope or microscope). To verify compliance, Since the exposure limits (MPEs) for the eye are
the standard specifies the aperture and distance cor- the direct basis for the AEL (accessible emission
responding to the naked eye, a typical telescope view- limits) for the laser product safety classes Class I,
ing a collimated beam, and a typical microscope IM, II, IIM, and IIIR, any changes in the MPE will
viewing a divergent beam. Class I lasers may consist also result in equivalent changes of the AEL values
of a higher power laser housed within an enclosure. and thus in the permitted output powers for these
55 Class IM: Class IM lasers are not capable of produc- classes [14].
ing hazardous exposure under normal operating 55 Class IIIB: Moderate power lasers (CW: up to
conditions but may be hazardous if viewed with the 500 mW, Pulsed up to 30 mJ) in wavelength range of
aid of optical instruments—magnifying optics such 300 nm to far infrared. Direct eye exposure to Class
as microscopes and telescopes. IIIB lasers is hazardous; however, diffusely scattered
Class IM lasers produce large-diameter beams, or radiation is generally safe. Direct exposure to skin is
beams that are divergent. The MPE for a Class IM a potential hazard.
laser cannot normally be exceeded unless focusing or The AEL for continuous lasers in the wavelength
imaging optics are used to narrow the beam. Given range from 300 nm to far infrared is 500 mW. For
the nominal higher photonic energy of shorter wave- pulsed lasers between 400 and 700 nm, the limit is
lengths, the maximum power delivery of Class I and 30 mJ. Other limits apply to other wavelengths and
IM must not exceed 40 μW (blue) or 400 μW (red). to ultrashort pulsed lasers. Protective eyewear is
55 Class IC: Under IEC 60825:2014, a new Class IC is typically required where direct viewing of a class
defined where C stands for “contact” but in some IIIB laser beam may occur. Class IIIB lasers must
interpretations also stands for “conditional” [13]. be equipped with a key switch and a safety inter-
Currently, the class is limited to products intended lock.
for the treatment of the skin or internal tissue in con- 55 Class IV: High-power lasers (CW: above 500 mW).
tact or close to the skin where the product is designed Class IV is the highest and most dangerous class of
to be safe for the eye. laser, including all lasers that exceed the Class IIIB
55 Class II: Class II lasers are limited to 1 mW continu- AEL. By definition, a Class IV laser can burn the
ous wave (CW), or more if the emission time is less skin, or cause devastating and permanent eye dam-
than 0.25 s or if the light is not spatially coherent. A age as a result of direct, diffuse or indirect beam
Class II laser is safe because the blink reflex will limit viewing. Class IV lasers are also a potential fire haz-
the exposure to no more than 0.25 s. It only applies ard.
to visible-light lasers (400–700 nm). Intentional sup- These hazards may also apply to indirect or
pression of the blink reflex could lead to eye injury. non-specular reflections of the beam, even from
Many laser pointers and measuring instruments are apparently matt surfaces and therefore great care
Class II. There is no hazard from exposure to diffuse must be taken to control the beam path. Class IV
radiation. lasers must be equipped with a key switch and a
55 Class IIM: Low-power lasers (CW: up to 1 mW) in safety interlock.
visible wavelength range (400–700 nm). Class IIM
lasers are not hazardous under normal operating A summary of laser classes commonly used in clinical
conditions because of the aversion reaction (blink dentistry is shown in . Table 5.2.
104 P. J. Parker and S. P. A. Parker
Laser class Maximum output Use in dentistry Possible hazard Safety measures
Class II 1.0 milli-Watt (mW) Laser caries detection Possible risk with direct viewing Sight aversion response
Class IIM Aiming beams Significant risk with magnified beam Laser safety labels
(Class IIM)
5 Class IIIR Visible: 5.0 mW Some low-level lasers. Eye damage Safety eyewear
Invisible: 2.0 mW Aiming beams. Safety personnel
Class III 500 mW (0.5 W) Low-level lasers Eye damage—direct or specular Training for Class IIIR
Maximum output may pose slight fire/ and IIIB lasers
skin risk
Class IV No upper limit All surgical lasers Eye/skin damage Safety eyewear
Non-target tissue Safety personnel
Fire hazard Training/local rules
Plume hazard Possible registration with
Possible ionizing effects with UV lasers National regulations
5.4 Hazards of Laser Beams sue interaction may be viewed as photothermal in that
incident photonic energy is absorbed by chromophore
A laser injury can be defined as an event causing (a) molecules, raising the molecular energy level and lead-
physical harm or damage, (b) physiological dysfunction, ing to disruption, relative to ascending power density
(c) an adverse surgical outcome, resulting directly from and target tissue ablation threshold [15]. With regard to
the laser energy, or a consequence of the device’s inher- laser safety, it must be appreciated that absorption is but
ent technology, or (d) a second treatment procedure to one of the basic physical phenomena associated with
correct the first procedure. laser–tissue interaction. Absorption confers the maxi-
Discussion as to all aspects of laser hazard and risk mal interaction, with scatter as an associated,
assessment when using laser devices, will acknowledge quantitatively less-precise energy transfer. Additional
the over-riding importance and relevance of those more- phenomena are not associated with energy transfer to
powerful lasers classes of IIIB and IV. the exposed tissue are laser beam reflection and trans-
The risk posed by coherent light irradiation may be mission. All four interactions may occur simultaneously
assessed with regard to the following: in non-homogenized tissue and pose a mixture of threats
1. The laser wavelength that must be nullified through adequate safety measures.
2. The power intensity of the incident laser irradiation
3. Optical risks
4. Non-target oral tissue 5.4.2 The Power of the Irradiation
5. Non-target skin
6. Inhalation and laser plume risks This will be related to the amount of energy delivered
7. Other Associated Risks: Hazards—mechanical, over time, together with consideration of the area of tis-
chemical, fire, sterilization sue that is exposed to the beam. In consequence, the
power density of the beam may represent a threshold
above which irreversible change may occur in tissue
5.4.1 The Laser Wavelength exposed to the beam. As was seen in . Table 5.1, the
classification of lasers sets out the upper limit of power
In clinical dentistry, the range of laser wavelengths falls delivered. In addition, the potential for the laser to
within 370 and 10,600 nm, i.e., from the blue visible limit deliver pulsed irradiation may influence the maximum
to the far infrared, non-ionizing spectrum. All laser tis- power achievable (peak power).
Laser Safety in Dentistry
105 5
5.4.3 Optical Risks of the order of 100,000 times. Hence, a collimated beam
of 1 W/cm2 at the cornea will focus to an area on the
The unprotected eye is generally regarded as the organ retina with an irradiance of 100 kW/cm2.
at greatest risk from accidental laser exposure. Several Due to the action of the lens, incident beams will be
cases of laser-induced eye injuries have been docu- focused on the macula and its fovea; if these areas are
mented [16–19]. For any given laser beam that exceeds damaged by laser radiation, substantial loss of vision
an output value in excess of the MPE of ocular tissue, a can result.
risk pertains that must be anticipated, and safety proto- Laser wavelengths outside the retinal hazard region
cols of eye protection employed. (1400–10,600 nm) may give rise to injury to the anterior
An important natural reflex in limiting the poten- region of the unprotected eye. Injury to the cornea is
tial for contact and injury to the eye is blinking. The normally very superficial, involving only the corneal epi-
eyelid response time is of the order of 0.2 and 0.25 s thelium and with the cornea’s high metabolic rate, repair
and is cited as a significant natural aversion response occurs within a day or two and total recovery of vision
to visible lasers within Class I and II. Of course, key to will occur. However, if significant injury occurs in deeper
this protective mechanism is the word “visible.” It will corneal layers, in the stroma or endothelium, corneal
have no beneficial effect with beams of wavelengths scars can result, leading to possible permanent loss of
outside the visible spectrum and in addition, some vision.
laser beam intensities are so great that injury can The types of damage sustained by non-protected
occur faster than the protective action of the eyelid ocular structures exposed to laser beams of varying
reflex [20]. wavelengths are listed in . Table 5.3.
Laser hazards to the eye depend most predominantly Optical risks therefore assume a “worse case” sce-
upon wavelength [21, 22] as shown in . Fig. 5.3. nario and the choice of maximum permitted exposure
As described above, laser photonic energy cannot values defines objective quantifiable levels of risk,
damage tissue unless the light energy is able to be expressed in irradiance terms (W/cm2) that would be
absorbed within that structure. Visible and near-infrared measured at the cornea [24]. . Table 5.4 provides a
wavelengths, which can be transmitted through clear range of values by wavelength. In order to provide per-
ocular media can, subject to MPE levels be absorbed in spective, the values are expressed within three possible
the retina and cause significant damage. Lasers operat- time-related scenarios that may be applicable to laser
ing between 400 and 1400 nm are particularly danger- use in dentistry:
ous; the high collimation of the incident beam permits 55 0.25 second: The human aversion time for bright-
the rays to be focused to an extremely small spot on the light stimuli (the blink reflex).
retina with most of the light being absorbed by melanin 55 10 seconds: The time period chosen by the ANSI Z
pigments in the pigment epithelium just behind the pho- 136.1 committees represents the optimum “worst-
toreceptors [23], causing burns in the retina. This spec- case” time period for ocular exposures to infrared
tral band of wavelengths is often referred to as the (principally near-infrared) laser sources.
retinal hazard region since the increased concentration 55 30,000 seconds: The time period that represents a full
of light after entering the eye and falling on the retina is 1-day (8-h) occupational exposure.
.. Fig. 5.3 Graphic representation of potential risk to regions of the unprotected eye, relative to incident laser wavelength in nanometers
106 P. J. Parker and S. P. A. Parker
According to regulations, for lasers operating in a The length of exposure may be instantaneous or may
pulsed emission mode, the MPE value was calculated by be cumulative over a period of time. Direct exposure to
considering the most restrictive among the following the laser beam would maximize the risk but of concern
conditions: (a) the MPE from a single pulse within a would be those instances where the beam may be
train of pulses does not exceed the MPE for a single reflected. . Figure 5.5 provides an overview of risk in
pulse; (b) the average exposure for a complete pulse train these events.
(of constant amplitude) during a time interval shall not
exceed the MPE values for a single pulse as given in the
standard [25]. 5.4.4 Non-target Oral Tissue
Of particular note is the substantially higher value
of MPE in the region of 3.0 μm—Er:YAG laser. This The oral cavity may present significant challenge in
5 may be accounted for through the intensely high absorp- terms of access and non-intentional/function-related
tion of this wavelength in water—<1.0 μm in corneal movements of structural components in the conscious
surface depth [26]. dental patient. Often the visualization and access for the
In summary, coherent laser photonic beams pose sig- treatment of individual teeth and areas of supporting
nificant risk to the unprotected eye and to some extent tissues is compromised by restriction in space together
non-target tissue and skin (. Fig. 5.4). with involuntary movement of the cheeks, lips, and
tongue. Care should always be taken to ensure free and
easy identification of and access to the treatment site,
together with planned manipulation of the laser delivery
.. Table 5.3 Types of damage sustained by non-protected handpiece and tip prior to operation and firing of the
ocular structures exposed to laser beams of varying incident laser.
wavelengths
Oral tissue is anisotropic and non-homogeneous,
Incident laser Pathological effect
and this may impact the absorption characteristics when
wavelength using a laser; certainly, this may pose a risk where adja-
cent non-target oral tissue has a higher absorption coef-
315–400 nm (UV-A) Photochemical cataract (clouding of ficient than the target tissue. An example may be where
the eye lens) high peak-power mid IR irradiation of a cervical tooth
400–780 nm (visible) Photochemical damage to the cavity encroaching and causing collateral damage to
retina, retinal burn adjacent gingival tissue, or unintentional transmission
780–1400 nm (near-IR) Cataract, retinal burn of near-IR and visible wavelengths through tooth tissue
to the pulp.
1.4–3.0 μm (mid-IR) Aqueous flare (protein in the
aqueous humor), cataract, corneal
Additional risk may be posed to non-target oral tis-
burn sue through reflection phenomena. Many instruments
used in dentistry are metal and in many instances the
3.0–10.6 μm (far-IR) Corneal burn
clinician will operate using a mouth mirror. Direct
reflection or specular (diffuse) reflection of the incident
.. Table 5.4 MPE values for unprotected eye exposure to laser wavelengths
Erythema (Sunburn)
Ultraviolet B (280–315 nm) Photokeratitis Accelerated Skin Aging
Increased Pigmentation
Corneal Burn
Infrared B (1400–3000 nm) Aqueous Flare Skin Burn
IR Cataract
.. Fig. 5.4 Potential damaging effects to irradiated unprotected ocular and dermal tissue, relative to photobiological spectral domain.
(Source: IEC (EN) 60825-1 “Safety of laser products Part 1: Equipment classification, requirements and user’s guide”)
laser beam may expose non-target oral tissue to ablative of high photon scatter at these wavelengths may com-
beam fluences and may not be detected at the time of the pound the risk.
treatment. Moist oral tissue may lead to specular reflec- The most common trans-dermal exposure using
tion. lasers that may affect dentists may occur during sub-
Care should be taken when using hollow metal deliv- ablative photobiomodulation techniques as adjunct to
ery tips where such may come to lie against non-target TMJ and associated muscular dysfunction conditions or
structures such as the lips or tongue. It is likely that such facial pain syndromes. In view of the use of near-IR
tips may become extremely hot when no co-axial water wavelengths as preferred in these treatments, some rec-
spray is used and may cause direct thermal burns to the ommendations suggest relatively high fluences to allow
tissue being retracted. the deep penetration of the energy into the TMJ area.
Care should therefore be taken to ensure surface irradi-
ance of the skin does not lead to structural damage and
5.4.5 Non-target Skin dosage modified to accommodate differing skin types,
racial differences, and those who may have drug-
The potential for risk to skin from laser photonic energy associated skin hypersensitivity.
is considered low in terms of dental treatment. There
may be specific scope of practice limits to a dentist deliv-
ering clinical (surgical) treatment beyond the vermillion 5.4.6 Inhalation and Laser Plume Risks
border of the patient’s lips. As such, the need for protec-
tive measures is not as high as would be applicable to A by-product of the surgical ablation of target oral tis-
facial cosmetic and dermatological laser procedures. sue is the production of the so-called laser plume. This
Notwithstanding, the varying absorption coeffi- represents a significant hazard in breathing airborne
cients of pigmented and non-pigmented structures will contaminants produced during the laser vaporization of
predispose to varying depths of penetration, as shown tissues. Studies of the production of both the chemical
in . Fig. 5.6. The greater level of depth is seen with toxicity of photothermolysis products and the potential
near-IR wavelengths and the additional phenomenon viability of infectious particulates (e.g., viral fragments)
108 P. J. Parker and S. P. A. Parker
.. Fig. 5.5 List of laser Classes (IEC post-2002) with attendant risk exposure. Risk posed during reflection scenario and risk to unpro-
that each may pose. “t” denotes instantaneous risk—both unpro- tected skin are also represented
tected eye and when using magnification devices. “T” denotes longer
.. Fig. 5.6 Schematic showing superficial skin structure and penetration of laser photonic energy relative to wavelength
Laser Safety in Dentistry
109 5
have shown cause for concern unless efficient aspiration, . Figure 5.7 provides a summary of the mecha-
local exhaust ventilation, and operating staff facial pro- nisms associated with surgical ablation of target tissue
tection measures are employed. Although many associ- and variables that might influence the degree of laser-
ated factors may provide some influence, the amount of tissue interaction. The components of the plume pro-
plume produced and volume of contaminants will be duced will depend upon the type and constituent
related to incident laser power, nature of target tissue, structure of the target tissue. Effects on the operator,
laser emission mode (CW, FRP), and co-axial supplies support staff, and patient will be minimized through
such as water and air spray [27–30]. adequate protective measures.
As summarized in . Fig. 5.7, investigation into the
components of the laser plume has shown a number of
chemicals—water vapor, hydrocarbon gases, carbon 5.4.7 ther Associated Hazards: Service
O
monoxide and dioxide, together with metal fumes, par- Hazards
ticulate organic and inorganic matter, bacteria and viral
bodies [31–34]. The hazard presented by the laser plume Most laser systems involve high potential, high current
may include eye irritation, nausea, and breathing diffi- electrical supplies. Early lasers used three-phase mains
culties, together with the possibility of transfer of infec- electrical supply, but this is no longer necessary for units
tive bacteria and viruses [35, 36]. used in dentistry. However, even with compact units the
In dentistry, additional aspects of plume produc- risk from electrocution is significant and the most seri-
tion and control may be seen in terms of the site of ous accidents reported with lasers have been due to elec-
interaction and potential for airborne chemicals and trocution [41]. Safe manufacturing practices offer
bacteria [37], the use or otherwise of co-axial water adequate protection from these hazards and insulation,
spray [38] and the potential for using near-IR lasers shielding, grounding, and housing of high voltage elec-
that could be operated on soft tissue within a film of trical components provide adequate protection under
water that acts as a shield [39]. In any event, to combat most circumstances from electrical injury. No attempt
the risks associated with the laser plume, eye protec- should be made to access internal parts of the machine
tion, specific fine-mesh face masks capable of filtering during use.
0.1-μm particles should be worn and the spread of the Installation of laser equipment should always be per-
plume minimized through the use of high-speed suc- formed by qualified personnel and not by the dentist.
tion aspiration that is capable of close-circuit filtration The laser should be serviced regularly according to man-
[40]. In addition, normal surgical protective clothing ufacturer’s recommendations and only by qualified per-
must also be employed. sonnel.
110 P. J. Parker and S. P. A. Parker
Many surgical lasers will have electrical, water, air can themselves either cause ignition of material and
and supply cabling, connectors, and filters in close prox- gases or promote flash-point ignition. Some of the com-
imity. Co-axial air or water supply may be under pres- mon flammable materials found in the dental treatment
sure. The practitioner should inspect the supply lines areas are clothing, paper products, plastic, waxes, and
and cables, clean and maintain the external portions of resins. Liquids used as adjuncts to restorative materials
the laser, and change necessary filters or other user ser- may include ethanol, acetone, methyl methacrylate,
viceable items. other solvents.
Toxic fumes released as a result of combustion of
Mechanical Hazards flammable materials present an additional hazard. With
As referenced earlier, the construction and safe operat- regard to certain lasers, for example, gas lasers, there are
ing of all laser machines is governed by strict criteria risks associated with possible leakage of active medium
5 [11, 42]. Engineering controls are normally designed and components [43, 44].
built into the laser equipment to provide safety. Modern With general anesthetic or gaseous anesthetic-
laser machines employ multi-level safety features (fusible sustained conscious sedation techniques, significant
plugs, interlocks, pressure relief valves, warning lights, risks exist relative to the sustainability of explosion or
etc.) to inactivate the machine in the event of a compo- fire [45]. Any combustion requires an ignition source
nent failure. and a Class IV surgical laser is an example; the field tem-
Mechanical hazards and safety mechanisms may be perature during soft tissue ablation may reach several
listed as follows [12]: hundred degrees and the build-up of debris on delivery
Laser device hardware: tips may exceed that temperature to a point above the
55 Locked unit panels to prevent unauthorized access flash-point of chemicals and equipment. Such high-
to internal machinery. temperature ignition may burn with a blue flame, and
55 Control panel to ensure correct emission parameters. this may be very difficult to spot under intense operating
55 Emission port shutters to prevent laser emission lights. Additionally, and more dangerously the ignition
until the correct delivery system is attached. may occur within the respiratory airway and be deliv-
55 Covered footswitch to prevent accidental operation. ered deeper through forced inhalation.
55 Remote interlocks to govern against accidental With a laser as an ignition source, the presence of
access to the operatory by unauthorized and non- fuel sources (gauze, drapes, prep fluids, alcohol, and
protected personnel. anesthetic gases) may be commonplace items within a
55 Casters, if present, must be lockable. dental operatory. Greater risk is further posed when an
oxygen-enriched atmosphere (above 20%) is used in
During laser use: anesthetic and sedation techniques.
55 Key or password protection. When disabled (key or Rubber-based endotracheal tubes should be avoided
code removed), the laser cannot be operated. to prevent the possibility of combustion of the material
55 Laser software diagnostics and error messages. and subsequent airway burns, either through coatings of
55 Display of parameters. non-reflective, non-absorbent material or cuffed tubes
55 Audible or visual signs of laser emission—recom- to prevent leakage of anesthetic gases. With gaseous
mended as an area control for Class IIIB laser opera- conscious sedation procedures, such as the use of a
tion. Such a warning system is mandatory for Class nosepiece to deliver oxygen/nitrous oxide mixtures, it is
IV lasers. recommended to use a closed-circuit delivery system
55 Specific stand-by and laser-emission modes. and scavenging system. A summary of risk and hazards
55 Time-lapsed default to stand-by mode Class IV associated with laser use is provided in . Fig. 5.8.
lasers require a permanently attached beam stop or
attenuator which can reduce the output emission to a Other Hazards: Sterilization
level at or below the appropriate MPE level when the There exists a risk of damage posed by those personnel
laser system is on “standby.” working in close proximity to the laser. Care should be
55 Emergency “Stop” button. shown to the possibility of contamination of all laser
55 Additional hazards may exist however, due to heavy hardware and protective sleeves and screens used where
articulated arm delivery systems or the risk of possible, any components that may contact the surgical
needle-stick injury with fine quartz optic fiber cables. site subject to bagging and autoclaving or disposal in a
safe container. Especially, care must be exercised in the
manipulation of quartz optic fibers and details of safety
Chemical and Fire Hazards measures should be entered in the local rules.
In the presence of flammable materials, lasers may pose It is considered a “best practice” approach to utilize
significant hazards. The high temperatures that are pos- a tray system for instruments used during laser-assisted
sible in the use of Class IV and certain Class IIIB lasers procedures and to rotate such through a “sterile” to
Laser Safety in Dentistry
111 5
5.5.1 Controlled Area
tional measures to provide attenuation of lasers being being performed. All personnel within the controlled
used and generally provide assistance and advice regard- area shall wear appropriate eye protection before the
ing all laser, LED, and intense pulsed light units within laser device is switched on. The laser delivery system
the practice of dentistry. is assembled and minimum operating parameters are
chosen. The laser is directed away from the eyes and
a suitable absorption medium should be used. The
5.5.2 aser Safety Officer (LSO) (aka Laser
L laser is fired within that medium so that the beam is
Safety Supervisor: LSS) attenuated.
Some authorities believe that this would be an
The LSO is appointed to ensure that all safety aspects of ideal opportunity to establish the level (if any) of
power loss through the laser delivery system. The use
5 laser use are identified and enforced (see also 7 Sect.
of an approved laser power meter allows the LSO to
5.6). Ideally, the LSO could be a suitably trained and
qualified dental surgery assistant. check the parameter display on the laser control
The LSO standing duties refer to the minimum level panel and to check the value against the meter read-
of responsibility: ing. Associated with this check is the opportunity
55 Read the manufacturers’ instructions concerning with many laser units to use a calibration port on the
installation and use of the laser equipment. Confirm laser as part of the set-up procedure.
the Class of the laser. For visible and near-infrared wavelengths, a suit-
55 Be familiar with and oversee maintenance protocols able medium would be pigmented/dark articulating
for laser equipment. paper and for longer mid and far-infrared wave-
55 Train other staff in the safe use of lasers. lengths (Erbium family and Carbon Dioxide) the
55 Maintain an adverse effects reporting system. suitable medium should be water. See . Fig. 5.9.
The objectives of the laser test fire are to check
LSO responsibilities during laser use include: the following:
55 Define and oversee the controlled area specific to the 55 Test operational ability of the machine
laser being used and limit unauthorized access. 55 Test the cleave of delivery quartz fiber (where appro-
55 Post appropriate warning signs at all points of access priate)
to the controlled area. 55 Demonstrate patency of delivery mechanism
55 Make sure that laser equipment is properly assem- 55 Demonstrate patency of aiming beam/co-axial air/
bled for use, together with all disposables. Carry out water
or supervise a “test fire” of all laser equipment before
the patient enters the controlled area. In this way, it can be satisfied that the laser is in operat-
55 Recommend appropriate personal protective equip- ing mode for the chosen clinical procedure.
ment such as eye wear and protective clothing (suit- 2. Skin protection may not be a prime risk factor for
able face masks, gowns, etc.). the dentist working within the oral cavity. For those
55 Maintain a log of all laser procedures carried out to ablative procedures within the vermilion border of
include the patient details, the procedure performed, the lips, care should be observed to avoid encroach-
and laser operating parameters employed. ing beyond the target tissue, especially with mid and
55 Assume overall control for laser use and interrupt far-infrared wavelengths and shorter wavelengths
the procedure if any safety measure is infringed. operating at high power. Shielding of skin can be
employed, using damp gauze to minimize the possi-
bility of collateral damage.
5.5.3 Laser Protection and Sterility . Figure 5.10 provides an example of laser hand-
piece selection (Lumenis Corp., Israel). Metal deliv-
Earlier sections of this chapter have dealt with the beam ery conduits are potentially liable to overheating and
hazards that exist to unprotected biological tissue. Key care should be taken when using these delivery mech-
measures to be adopted should include the following: anisms for intraoral soft tissue surgery and the metal
1. The test fire procedure is designed to allow all work- conduit rests against the lips and peri-oral skin.
ing components of the laser to be checked before 3. Eye protection for all persons within the controlled
attempting the clinical procedure on the patient. It is area is mandatory with all Class IV lasers and any
obligatory for the LSO or dentist to carry this out other laser Classes as advised by individual manufac-
before admitting the patient to the operatory and all turers and regulatory agencies (see . Fig. 5.5).
safety measures—warning signs door/window pro- Regulations that specify the nature and suitability of
tection and interlocks employed, to prevent unau- laser protective eyewear are contained in ANSI Z
thorized access as though a laser procedure was 136.1 and IEC 60825 (EN 207/208) documentation.
Laser Safety in Dentistry
113 5
.. Fig. 5.9 Laser test fire. Using minimum laser operating parame- paper. Bottom left: water for (mid IR) Erbium YAG and bottom
ters, the beam is directed into a suitable attenuation medium. Top right: water for CO2 wavelengths
center: for visible and NIR wavelengths pigmented articulating
.. Fig. 5.11 Optical density (OD) value of laser beam attenuation, corresponding % reduction in transmission and relevance to wavelength-
specific eyewear suitability. An OD value of 5.0 may be considered a minimum safe level of incident laser beam attenuation
.. Fig. 5.13 Additional data pertaining to eyewear suitability, as may be found relative to intended level of protection and specific use
.. Fig. 5.14 Example of surgical loupes with wavelength-specific tion may benefit from liaison with equipment manufacturer and esti-
inserts, designed to fit on the inner aspect of the eyewear between the mation of through-transmission of the laser beam within an SLR
loupe lens and the operator’s eye. Surgical microscope laser protec- prismatic microscope
In the same manner and with the same breadth of at a distance of 5 cm from the objective lens of a dental
laser classes, dental practitioners using an operating microscope. Each eye protector was made into a flat disc,
microscope to facilitate high-definition observation which was fixed on the lens of the microscope. The filters
of laser surgery must fit the appropriate filters and were placed in front of the objective lens or behind the eye
maintain close eye contact with the oculars. The fol- lens. Transmitted energy through the microscope with or
lowing is taken from a published paper (Saegusa H, without the filters was measured. No transmitted laser
Watanabe S, et al. 2010) to investigate the effective- energy was detected when using matched eye protectors.
ness of wavelength- specific ocular filters with an Mismatched eye protectors were not effective for shutting
operating microscope [48]: out laser energy, especially for Nd:YAG and diode lasers.
None or very little laser energy was detected through the
»» The aim of this study was to investigate the safety of laser microscope even without any laser filter. Matched filters
use under the dental microscope. Nd:YAG, Er:YAG and
shut out all laser energy irrespective of their positions.
diode lasers were used. The end of the tips was positioned
116 P. J. Parker and S. P. A. Parker
The current trend in dental hard tissue surgical with how their laser use is regulated in their country or
ablation has witnessed a growing development of region and in many countries, laser manufacturers and
ultrashort, pulsed irradiance of target tissue. The suppliers have a legal duty to inform. Subject to Federal
delivery of femto- and pico-second pulses of 0.4– or National Regulations that may apply, clinical/medical
3.0 μm range coherent EM waves takes us far away practices offering Class IIIB and IV laser treatment
from conventional understanding of wavelength-tar- must appoint a Laser Protection Advisor (LPA) and/or
geted chromophore absorption in target tissue. a Laser Safety Officer (LSO) [52, 53].
Although average power delivery of laser photonic The LPA is usually a medical physicist who will
energy may be very low, such is the peak power advise on:
achieved by individual photon bursts within 10−12 s 55 NOHD, Controlled Area/Safe Access
and possibly 10−15 s, that fluence values and hence 55 Maximum Permissible Exposure (MPE) levels; Pro-
5 ablation capability is transformed. With such devel- tective equipment
opments, laser-tissue interaction becomes ever-more 55 Normal operating procedures; safety checks; safe
plasma-mediated as opposed to photothermal in working methods
nature. Some investigation has shown that the mod- 55 Authorized user’s responsibilities
ern laser eye protection seems to be robust except for 55 Prevention of use by unauthorized persons
the irradiance possible with ultrashort laser pulse 55 Adverse incident procedures
exposure [49]. As always, it is incumbent upon the 55 Procedure in the event of equipment failure
laser protection advisor and laser safety officer to
ensure that protective eyewear is appropriate to the The support of a laser protection advisor (LPA) would
laser being used and the procedure being carried out. overcome any doubts that may arise through interpreta-
tion of any regulations as applied to a given country or
region.
5.6 Training of Staff Using Lasers All healthcare establishments should have written
local rules specific to each clinical application and for
As has been seen throughout this chapter, in accordance each laser, IPL (Intense Pulsed Light) and LED device.
with all Federal, National, and local regulations that All staff involved in the use of these devices should read
may pertain, the responsibility of the lead clinician shall the local rules and sign them to indicate that they have
be to ensure the protection of the patient and operatory been understood. This should be undertaken before
personnel and prevent inadvertent exposure of others staff use the equipment.
during laser emission. In some countries, this responsi- The following summarizes a “best practice” approach
bility is part-devolved through the senior personnel in to laser safety in dental practice:
charge of the dental clinic, as part of broader over- Appointment of a laser safety officer (LSO), suitably
reaching statute governing care standards in healthcare trained and aware of responsibilities (. Fig. 5.15). As
[50]. Despite the nature of assumed responsibility for referenced earlier, general responsibilities of the LSO
patient safety, the day-to-day approach to its observance shall include the reading and understanding of the laser
must be measurable in qualitative and quantitative operating manual, with specific regard to suitability as
terms. Through this approach not only should a written to use, operating settings by procedure, “set up” and “set
protocol exist but also staff performance within such down” procedures as applied to a specific laser and laser
protocol should continue to develop a “best practice” safety features.
approach to laser safety with audit-driven refinement at The Laser Safety Officer/Laser Safety Supervisor 1 is
regular intervals. The prime tenet of any structured laser defined as:
safety program should be the protection of the patient
from inadvertent harm during laser-mediated clinical
»» One who has the authority to monitor and enforce the
control of laser hazards and effect the knowledgeable
dental care. It is vital that all staff involved in the patient/
evaluation and control of laser hazards.
client’s treatment are aware of each other’s role during
treatment. Good communication between staff is essen- The LPO/LSS [52] is usually an employee of the laser
tial. establishment. Drawing upon the recommendations ref-
Regulatory agencies recognize the essential nature of erenced in Ref. [52], the following provides an overview
appropriate training in laser use and there is an implied of applicable duty and responsibility:
necessity that clinicians should receive training as part 55 If a service is performed on a laser product with an
of their duty of care and dental licencing [51]. It would enclosed Class IIIB or Class IV laser, it is necessary
be incumbent upon the laser user to acquaint themselves to designate an LSO.
Laser Safety in Dentistry
117 5
.. Fig. 5.15 Summary of responsibility and duties of a Laser Protection Advisor (LPA) and Laser Safety Officer/Supervisor (LSO/LSS).
Subject to Federal or National Regulations that may apply
55 The Laser Safety Officer is also responsible for estab- should be regularly reviewed, and appropriate action
lishing, monitoring, and enforcing laser controls, as taken to inform the laser protection advisor or laser pro-
well as evaluating laser hazards. tection supervisor of all issues. . Figure 5.16 provides a
55 The Laser Safety Officer must ensure that all employ- summary of protocols, applicable to successive laser class
ees who operate, maintain, or service laser products and within the scope of a trained laser safety officer.
are properly trained. Identify and eliminate all environmental risks. Apply
55 The LPS/LSO is responsible for ensuring that all laser warning signs, at the boundaries of the controlled
laser/IPL authorized users comply with the Local area. Such laser warning signs must meet approved stan-
Rules and that the Local Rules document is followed dards as applied through IEC/ANSI regulations and
on a day-to-day basis. might include the laser wavelength being used, the need
55 In the event of an incident or near-miss, the LSO for eye protection, as well as over-riding precaution
should inform the LPA. against unauthorized access. Arm all remote interlocks
if applicable.
Above all, the Class of laser being used must be estab- Test fire the laser prior to admission of the patient
lished, together with the nature of visual operating within the controlled area. Following this, the laser is
enhancement (loupes/operating microscope) as they deactivated, and the patient admitted.
may impact upon the safe non-risk (relative to MPE) The surgeon/practitioner shall choose the laser oper-
levels and need for specific laser safety measures. ating parameters appropriate for the intended treat-
The LSO (under direction of the LPA if required by ment, commensurate with a policy of minimal power
National regulation) must define the Nominal Hazard values to achieve the desired clinical outcome. The LSO
(safe ocular) Zone (NHZ). In practice, any operatory shall closely monitor and assess the procedure and
confined by (non-transparent, physically intact) walls advise or adjust those operating parameters.
and doors would satisfy this requirement, but any “open Commensurate with need defined by laser Class, the
plan” operatory should adopt a protocol whereby adja- patient and personnel within the controlled area (NHZ)
cent areas are marked by signs to limit traffic and alert shall wear appropriate eyewear. Adjunctive safety mea-
others to the need for caution. sures—suitable filtration masks, gloves, and high-speed
The LSO should ensure the laser is appropriate to the suction shall be employed. Non-target tissue shall be
proposed clinical procedure, is properly maintained and suitably protected (tissue retraction, use of non-reflective
assembled. Accessories (optical fibers, tips, connectors, instruments, wet gauze).
etc.) must be suitable for both the make and model of The LSO shall be authorized to abort the procedure
device that they are to be used with. Only use the acces- in the event of detected risk. The prime responsibility
sories in accordance with the manufacturer’s instruc- shall be the safety of the patient.
tions. Additionally, equipment error messages or fault An adverse effect is defined as one that causes injury
should be recorded in the equipment fault log. The log or death through direct use of the laser and will involve
118 P. J. Parker and S. P. A. Parker
.. Fig. 5.16 A summary of action protocols relating to laser ownership and clinical use. “Red” areas would be mandatory, relative to appli-
cable IEC/ANSI regulations and regions that apply such. Frequency and date of each protocol should be recorded in the Practice Local Rules
regulatory agency notification, according to national With those delivery systems that use quartz optic
use. Additional effects reporting may require access to fibers, appropriate cleaving techniques should be
emergency clinical services in the event of eye or skin employed to remove damaged or contaminated elements
damage. and thorough cleaning before autoclaving. The cleaved
Suitable sterilization control measures should be piece must be disposed into the “sharps” container and
employed. Reasonable measures should be employed to regard given to disposal of plastic delivery tips. Many
minimize risk of cross-infection, but minimally to fiber delivery units have optic cabling as part of the
include the use of protective barriers, chemical and assembly and the outer sheath will require regular check-
autoclaving sterilization procedures. ing to ensure sufficient quartz fiber is available to pass
The Standard of Care dictates that any part of the through the handpiece. This checking should be done
dental laser that contacts the oral tissues and/or the prior to “bagging” (if applicable) and autoclaving of the
bloodstream must either be heat sterilized or if a single- delivery cable. Other laser units have fiber tip inserts
use device be properly disposed. Portions of the laser which may be deemed as single-use or re-usable. In these
that can contact the oral tissues must be disinfected with cases, the manufacturer’s recommendations must be fol-
a suitable chemical agent. lowed to minimize the risk of cross-contamination
Optimally, instruments should be employed through between successive patient treatment sessions.
a tray system. Most clinicians will be used to employ- Smoke plumes—minimizing harmful effects [9]. The
ing specific protocols to recognize “dirty,” “clean,” and LSO shall take precautionary action to reduce, if not
“sterile” in relation to dental instrumentation. Steam remove the plume. The amount of smoke plume and
autoclaves are mandatory as part of a re-cycling of other deleterious matter generated varies with the proce-
adjunctive non-consumable instruments; most will use dure being undertaken, nature and type of target tissue,
metal trays which can be used as part of the correct technique employed, duration of energy applied to tis-
storage of sterile elements. Additional to some recom- sue and laser emission mode used to vaporize the tissue.
mended sterilization protocols, “dishwasher” style dis- Staff involved in procedures resulting in smoke plumes
infecting units may deliver pre-autoclave cycles capable should be educated on how they are produced and how
of destroying prions and removing proteinaceous to reduce or eliminate exposure.
debris. It should be the responsibility of the lead clini- Training by suitably qualified in-house personnel or
cian to avail of all supporting advice as would apply to smoke evacuator manufacturers should be considered.
which parts of the laser may be disposable and if re- The most effective way of protecting clinical personnel
usable, what cleansing, disinfecting, and sterilization and patients from inhaling the constituents of the smoke
treatments are recommended and applicable. plume is to use either a stand-alone smoke evacuator or
Laser Safety in Dentistry
119 5
an evacuation system that is incorporated into the laser 5.7.2 Nature of Hazards to Persons
system. All smoke evacuators should have a high-
efficiency filter that collects all smoke generated during The laser can injure the skin and eyes from both the
the procedure. direct and scattered beams. The aiming beam may also
Medical vacuum systems (operating theater wall suc- be hazardous. Safe use of the laser depends on people
tion systems) are not suitable for smoke plume removal. strictly following the rules:
The accumulation of particles over time eventually The operating beam(s) is (are): X Laser Type, at
decreases suction capability in theater evacuation sys- operating wavelength(s) of X nm. It (they) constitutes
tems. All evacuated airborne particles are deposited into an appreciable hazard.
a central vacuum system, which can become blocked The device(s) aiming beam is a low-powered diode
and bacteria can then multiply. laser and operates in the visible region of the EMS (X
All clinical staff within the controlled area and espe- nm). It is designated as a Class I laser.
cially involved in the clinical procedure should wear (Other wavelengths to be specified).
well-fitting, high filtration-efficiency face masks (e.g.,
particulate respirators that filter particles of 0.1 μm in
size) during all laser procedures. Standard surgical face 5.7.3 Laser Device(s)
masks are not sufficient to act as the primary method of
particle filtration. 1. Name of the laser
Record the laser-assisted procedure in the patient’s 2. Any other Class IV laser (unspecified)
notes. It is advisable and may be mandatory to keep an
additional log of laser use, to record each clinical proce-
dure according to laser, wavelength, operating parame- 5.7.4 Laser Authorized Users
ters, and clinical outcome.
1. Dr. NAME
2. Manufacturer’s/Supplier’s Representative(s)
5.7 Local Rules
The following is taken from the 2015 publication 5.7.5 Laser Protection Advisor
“Lasers, intense light source systems and LEDs in medi-
cal, surgical, dental and aesthetic practices” in which the 1. As appointed by Regulatory Authority
author acted as dental consultant to the United
Kingdom Medicines and Healthcare products
Regulatory Agency [54]. 5.7.6 Laser Safety Officer
Local rules should be related to a risk assessment.
They should contain the working practices, procedures, 1. NAME
and information required to address the hazards and
risks identified in that assessment.
The local rules should be prominently displayed in 5.7.7 ersonnel Authorized to Assist
P
the laser/IPL room or the theater office. in the Operation of the Laser(s)
All authorized users, assisting staff, or other individ-
uals who work within the delivery of laser treatment 1. NAME
should read the local rules then sign the associated form 2. Any other assistant, following training by Laser Pro-
to show that they have understood them and agree to tection Supervisor(s)
follow them.
Example of local rules:
5.7.8 ontrolled Area Designation
C
and Access
5.7.1 ocal Rules for the Use of the “X”
L
Laser in “X” Dental Practice/Dental The room in which the laser is used is designated a “con-
Clinic Premises trolled area,” and the laser should only be used in this
area. Approved warning signs should be fitted to the
Dental Surgery: NAME, ADDRESS. door.
120 P. J. Parker and S. P. A. Parker
A notice should be fixed to the laser indicating that 5.7.10 Operation of Equipment
its use is subject to the local rules.
The controlled area is the dental surgery in which the 1. The laser(s) may only be operated by an authorized
laser(s) is (are) installed. The controlled area shall be user (see above).
that area as designated by the Laser Protection Adviser, 2. Keys required to activate laser equipment may only
in accordance with the safe use of laser(s) and respective be held by authorized user(s). Keys should be
nominal ocular hazard distance(s). The controlled area marked “LASER—for authorized use only” and
shall be enforced only during such times as the laser is in should be stored in the safe.
clinical use. A sign shall be placed on the outside of the 3. The operating beam should never be activated
surgery door during the periods when the laser(s) is (are) unless accurately aimed at the operating site.
in use.
5 Protective spectacles or goggles must be worn by
Exception to this is during the “test fire” of the laser
to be used, which shall be under the strict supervi-
operator, assistant, and patient and visitors whose pres- sion of the laser safety officer and in accordance
ence is required. Eyewear must be wavelength specific to with safe practice regulations.
attenuate emitted laser light of laser in use. The laser 4. Neither the aiming nor operating beam(s) shall be
safety officer shall be responsible for ensuring that pro- directed toward the eyes of the operator, assistant(s),
tective eyewear shall be worn prior to activation of the or patient.
laser and during all emission periods. 5. When not in use for a treatment procedure, the laser
shall be switched to “stand-by” mode.
6. When not in use for treatment, the laser shall be
5.7.9 estriction of Use to Authorized
R switched off, by use of the operating key or screen
Persons command.
7. The laser(s) shall not be used in the presence of
The equipment should only be used by an authorized anesthetic gases, or other explosive gases or liq-
user. Responsibilities and duties of laser protection uids.
supervisors shall be to: 8. The operating beam shall not be directed toward
55 Ensure that the local rules are followed. amalgam restorations, since these are prone to
55 Inform the laser protection adviser if they consider vaporize, or other shiny surfaces, especially metal.
that the existing rules require amending. 9. The operator/laser safety officer shall be responsible
55 Ensure that the register of authorized users is main- for ensuring that other individuals present at opera-
tained and that the correct procedure for authoriza- tion are sufficiently trained in laser safety and is
tion has been undertaken. responsible for the safety of any visitors within the
55 Obtain written statements from each authorized user controlled area.
that they have read and understood the local rules 10. When the laser is to be used, anyone who does not
and send copies of statements to the laser protection need to be present should leave the controlled area.
adviser. 11. All operators must sign statements that they have
55 Ensure that only authorized users operate the laser. read and understood the local rules. Assistants must
55 Inform the laser protection adviser as soon as possi- sign statements that they have read and understood
ble in the event of an incident occurring. the local rules. These will be filed by the Laser
55 Seek assistance from the laser protection adviser on Protection Supervisor.
the safety implication when a change in operating
procedure is envisaged.
5.7.11 Accidents Involving Eyes
The laser protection supervisor, in consultation with the
laser protection adviser, can decide if another person is Should a person’s unprotected eyes be exposed to radia-
suitable to use the equipment. Their name can be added tion from a laser beam, an arrangement exists between
to the register, provided the person has signed a state- us (Dental Practice NAME) and the consultant oph-
ment that they have read and understood the local rules. thalmologist at NAME Hospital, who will carry out an
A copy of the signed statement should be sent to the examination within 24 h of the accident occurring.
laser protection adviser. Consultant: NAME. Tel: X.
Laser Safety in Dentistry
121 5
Copy of report to be sent to: Dentist defence indem- the control of the laser hazards that may be poten-
nifier/manufacturer/H & S contact as regulated. tially involved.
All accidents arising from inadvertent and non- 55 The name and contact number of the appointed ser-
target laser radiation must be reported in the first vice agent.
instance to the Laser Protection Advisor.
Contents
References – 161
Laser Assisted Diagnostics
129 6
Core Message field of lasers and their use in medicine and dentistry.
An objective and accurate diagnosis is an essential and These techniques could be applicable to soft tissue and
key component in the formulation of safe, comprehensive hard tissue in various clinical scenarios and even branch
management, and treatment of dental patients. The out to the treatment of specific conditions as in the case
framework of such diagnosis should be based on clear of photodynamic therapy (PDT). However, some tech-
criteria, applied with sound diagnostic methodologies niques continue to be expensive and hence not all of the
which can assess, grade, and detect the presenting symp- benefits of these methods have been universally available
toms of any individual case. Various diagnostic yet.
approaches therefore play an essential part in developing It is intriguing to note that though there is indeed a
a provisional and final diagnosis, from which treatment veritable list of laser assisted techniques in diagnosis the
modalities and strategy can then be planned and imple- scientific basis of all these boils down to light-related
mented. phenomena like Fluorescence, Phosphorescence, and
The dental clinician plays a pivotal role in being a Spectroscopy. Such physical outcomes of incident irra-
skilled examiner, a physician, and a surgeon, all of which diation of target material have been the subject of pio-
is dependent upon each patient’s needs and desired treat- neering work by investigators such as George Gabriel
ment outcome. The oral cavity and its varied range of Stokes (1852) [1] and Sir Chandrasekhara Venkata
both hard and soft tissues coupled with the concomitant Raman (1930) [2, 3].
host of microbial flora is easily subject to pathology that Stokes in his treatise, “On the Change of
may be a simple, single tissue disease or extending to ana- Refrangibility of Light” [1], reported the ability of min-
tomical, regional, or may render multi-structural tissue eral calcium difluoride, CaF2 (fluorspar), and uranium
change. Hence, the role of an appropriate and accurate glass to convert incident invisible (UV) light beyond the
diagnosis cannot be understated. violet end of the visible spectrum into re-emitted blue
Specifically, diagnostic techniques should ideally be light. He coined the word fluorescence (being light from
simple, cost-effective, non-invasive, reproducible, mea- fluorite) taking a leaf out of the term opalescence being
surable, and most importantly should be in tandem derived from the color change of hydrated silica, SiO2.
with advancing scientific research and technology. The Similarly, Sir C.V. Raman’s seminal work [2, 3] on the
diagnostic technique should have application within inelastic scattering of light led to the development of
hard dental disease as well as soft tissue pathology and spectroscopic techniques which could detect vibrational
should ideally be available within a general dental prac- and rotational changes caused in a molecule by pho-
tice setting. tonic energy and therefore even lend a description to the
Laser photonic energy has been shown to interact with molecular framework of a particular material.
oral tissues and within a sub-ablative power envelope may Photochemical changes induced by lasers and the
provide measurable data to assist the clinician in distin- subsequent vibrational and radiational relaxation
guishing between healthy and diseased tissue and further- evoked in molecules would give distinctive information
more can quantify or assay the disease process and can on their constitutional make up and led to the develop-
even provide for time related monitoring of the potential ment of a myriad of diagnostic techniques [4]. The high
disease progress. intensity energy of laser light allowed easy excitation of
This chapter sets out the underlying science of laser any molecule and furthermore differentiation from
fluorescence and its integration and application within a spontaneous radiation induced by absorption of back-
hierarchy of diagnostic measures in the assessment of oral ground low intensity ordinary sources of light was sim-
disease. ple and unambiguous. Thus the phenomenon of
Florescence and Phosphorescence and spectroscopic
techniques are the basis and foundational fundamental
6.1 Introduction in these diagnostic methods. Hence to enrich our under-
standing of these methods, we would first dwell on the
Lasers when applied to the realm of diagnostic sciences theoretical processes of these phenomena.
signify minimally invasive techniques that provide
unparalleled precision and accuracy. An illustration
would be the case of optical biopsies that provide elabo- 6.2 Basics of Fluorescence
rate and miniscule details of tissue without actually hav- and Phosphorescence
ing to physically injure the patient by having to take a
sample to do so. The varied plethora of techniques All matter around us is in a state of vibration, such
available today is testament to the concerted and dedi- vibration is the resultant effect of electrons within con-
cated research work, in tandem with the growth of the stituent atoms in a molecule being in constant transla-
130 A. M. Muruppel and D. Fried
z
y Orbital quantum number
x
• Shape of electron cloud / orbit
Px
6
x
• Direction of electron cloud / orbit
P
tional and rotational motion. Blank [5] writes that all responding to the vibration’s frequency, ν, according to
organisms have an endogenous electromagnetic field the relation, E = hν (where h is Planck’s constant)
(EEMF) albeit of very low intensity (below 1 Hz up to (. Fig. 6.2).
1015 Hz). Cellular processes like enzymatic peroxida- The term “Ground state” applies to the normal elec-
tion, ATP production, the Krebs cycle, and natural tronic state of an atom or molecule where the electron
luminophores in nucleic acids and proteins generate an has stable and paired spins. However, it will still have a
electromagnetic field [6]. normal rotational and vibrational energy characteristic
The energy levels that dictate such translational and to the element or molecular bond.
rotational motion is “quantized” (M. Planck, N. Bohr) The term “Excited state” on the other hand refers to
and are described according to discrete quantities of a higher energy level to which an electron has climbed
energy that the electron has according to the four quan- subsequent to absorption of a quantum of energy. The
tum numbers that characterize the electron according to “lifetime” of the excited state would vary according to
(1) radius of distance from the atomic nucleus— the quantum of energy gained or mode of excitation.
Principal Quantum Number, (2) orbital angular momen- Eventually de-excitation can occur by radiating a quan-
tum of the electron as s, p, d, or f—Orbital Quantum tum of energy (fluorescence or phosphorescence), by
Number, (3) direction of the electron cloud vector rela- expending the gained quantum of energy as vibration
tive to an electric field—Orientation Quantum number, and heat, internal conversion, or intersystem crossing.
(4) electron spin or angular momentum (the electron has
an intrinsic magnetic moment directed along its spin
axis)—Spin Quantum Number (. Fig. 6.1). 6.2.1 Light as an Oscillating Electric Field
Note: Electrons normally are configured in atomic
orbitals as pairs with opposite spins within the same Thus, a quantum of energy, for example, from an incom-
orbital. ing “green” photon (for illustration sake) could excite an
Such molecular vibration could be increased by exci- electron of a target atom that is in a ground state if the
tation caused by absorbing a quantum of energy, E, cor- frequency of the light wave equals the natural frequency
Laser Assisted Diagnostics
131 6
of free vibrations of the atom. This excitation can lead
to the electron absorbing the energy of the green pho-
ton, leaving its paired electron (having opposite spin) in
y the ground state, and forming an excited singlet state
n erg (. Fig. 6.3).
Ele
ctro b se
ne or Interaction strength between the incoming photon
mit abs
s en on and the molecule depends on various factors such as the
erg ctr field dipole, induced dipole strength, and the distance
y Ele
between them, and most importantly it is imperative
K L that the frequency (ν) of oscillating field of the molecule
M N must “match” the electronic oscillation frequency of the
incoming photon [7, 8].
It is termed as a singlet state as even in the excited
state the electron still has the paired and opposite spin to
its counterpart electron which is in the ground state.
Thereafter, the excited singlet electron loses some of its
absorbed energy through vibrational relaxation which is
dissipated as a small packet of heat called a “phonon.”
It now only has a lesser amount of energy left and hence
.. Fig. 6.2 Excitation and de-excitation of electrons—absorption emits a longer wavelength, yellow photon and returns to
occurs when an incident photon’s energy couples with the electron in the ground state by internal conversion. Internal conver-
the ground state (non-excited state) and goes to an excited state sion is a term used to describe the transition of an
(higher energy level). Emission occurs when the electron “decays”
excited singlet state electron back to its paired counter-
from the excited state or sheds the energy it gained to return to the
ground state part in the ground state dissipating some of the energy
Intersystem
crossing Non-radiative
relaxation
(triplet)
Quenching
Phosphorescence
5
3 (10-3–102 s)
Non-radiative S0 2
relaxation 1
0
Ground state
.. Fig. 6.3 Jablonski energy diagram—excitation → S0 + hνex → S2, radiative relaxation occurs by internal conversion or intersystem
de excitation → S2 − S0 [Stokes Shift (non-radiative relaxation − heat crossing, but could also occur by intermolecular energy transfer as
(vibrations)] + hvem → fluorescence + HEAT. Radiational relaxation quenching when the energy is consumed (collisional or complex for-
of the electron occurs from an excited state (light is liberated) by mation) or when a new excited species is created it is called photosen-
fluorescence- radiative decay from an excited singlet state, or sitization
phosphorescence-radiative decay from an excited triplet state. Non-
132 A. M. Muruppel and D. Fried
60
Excited state
electronic
transistions
6 40
20
Ground state
S0
vibrational
0 energy levels
33.3 25.0 20.0 16.7 14.3
Wavenumber (cm-1 x 10-3)
.. Fig. 6.4 Mirror image rule where though the spectrum changes phore. Adaptation of this rule is useful in estimating the radiative
according to the wavelength of the excitation light the absorption lifetime, excitation levels and absorptive levels of any particular fluo-
and emission spectrum is diametrically the same for the same fluoro- rophore in diagnostics
through vibration. The difference in energy levels phores as “molecules that transform their electronic
between the absorbed (excitation) and emitted light, energy levels after light absorption.” Similarly, a mole-
termed as Stokes shift is due to the energy lost as vibra- cule or chemical compound that can re-emit light upon
tional relaxation in internal conversion (The phenome- light excitation could be called a fluorophore.
non, in general, where there is the absorption of higher Fluorophores could be constituted by aromatic groups,
energy (shorter wavelength) light and emission of lower or plane or cyclic molecules, for example—conjugated
energy (longer wavelength) light is termed fluorescence. dyes and fluorescent proteins. They can be excited by
It is short lived in the realm of 10−9 to 10−7 s. laser light of specific wavelength and can be used to
Another possibility is when absorption of high stain target tissues and/or cells in several diagnostic and
energy photonic energy drives an electron to an excited therapeutic techniques.
state wherein it even changes its spin. It is now no longer Fluorescence and its excitation follow certain princi-
paired with its counterpart in the ground state and ples such as the Mirror Image rule which states that the
undergoes what is termed as the “forbidden transition” emission spectrum is independent of the excitation
to an excited triplet state. Now a relaxation to the ground wavelength as vibrational energy level spacing is similar
state is very slow giving rise to a phenomenon called for the ground state and excited state of the fluorophore
phosphorescence. The unpaired excited electron called a and the fluorescence spectrum would strongly resemble
free radical is chemically highly reactive and its pathway the mirror image of the absorption spectrum for that
of relaxation to a ground state is called intersystem fluorophore for any wavelength of excitation light. In
crossing. Phosphorescence and intersystem crossing other words, the emission spectrum of a fluorophore
occur in the region of 10−3 to 102 s. It is longer lived and would be the mirror image of its absorption spectrum. It
more persistent than fluorescence [9]. has clinical significance in estimating the radiative life-
Specific molecules in tissue can be easily excited by time of a photosensitizer dye (. Fig. 6.4).
photonic energy of a particular wavelength. Such mole- However, there are exceptions to this rule too.
cules or substances are termed as Chromophores. Resonance fluorescence (electron absorbs two photons
Waynant [10] defines a chromophore as “a substance or instead of one) leads to the emission of a shorter wave-
specific target tissue that serves as an attractant for a length of higher energy light than what was absorbed. In
laser photon.” Arnat and Rigau [11] terms chromo- terms of spectroscopic principles such a decrease in
Laser Assisted Diagnostics
133 6
ROS/Superoxide anions
S1
S1
T1 Free
radical
T0
S0
.. Fig. 6.5 Pathways of de-excitation of a photosensitizer through cytotoxic species which are used therapeutically against bacteria or
fluorescence (singlet) or phosphorescence (triplet) in photodynamic even cancer cells
therapy (PDT). Excited singlet states or triplet states give rise to
wavelength of emitted light is called blue shift. Whereas, which is highly polar and have energy carriers such as
usually in fluorescence, there is an increase in the wave- ATP and also macromolecules of proteins having transi-
length (lower energy) of the emitted light, virtually dem- tion metal complexes. The polar nature of water and
onstrating a shift to the red end of the spectrum and is dissolved tissue oxygen can make it highly reactive with
called a red shift. In practical terms, a redshift would fluorophores in the triplet state, leading to the formation
entail a lower frequency and lower photon energy of free radicals (singlet oxygen) that are toxic to cells.
whereas a blue shift means a higher frequency and Fluorophores in the triplet state can also react directly
higher photon energy of the emitted light. In summa- with the above-mentioned biological molecules too
tion, redshift or blue shift describes the relative differ- through sequential decay and effect oxidation of cell
ence between the absorbed and emitted wavelengths (or structures [14]. Such a compound which is capable of
frequency) of a fluorophore. causing light-induced reactions in other sensitive and
Michael Kasha’s rule states that photon emission receptive molecules is called a photosensitizer. A photo-
(from fluorescence or phosphorescence) would occur in sensitizer has also been termed as a “spectrally adapted
appreciable yield only from the lowest excited state. chromophore” as it can be activated only by light of a
Sergei I. Vavilov modified this dictum and stated that the specific wavelength [14].
quantum yield of luminescence is generally independent Foote [15] (though first proposed by, H. Kautsky in
of the excitation wavelength. This has clinical signifi- 1939) classified the subsequent chemical reactions that
cance in that the fluorescence yield is proportional to the ensue after light activation of the photosensitizer as
fluorescence lifetime Φ = photons emitted/photon either Type 1 or Type 2. Typically, Type I reactions
absorbed. involve a direct interaction of the photosensitizer and
Understanding of these basic phenomena is impor- the surrounding molecule and the creation of a free rad-
tant as they would serve as the basic mechanisms for the ical. The commission of the photosensitizer into a long-
formation of excited singlet states such as singlet oxygen lived triplet state (milliseconds to several seconds) allows
in photobiomodulation and even the formation of long- it to then react with other biological molecules (other
lived excited triplet states such as superoxide formation than oxygen) leading to the production of hydroxyl and
in photodynamic therapy (PDT) or photo-activated che- superoxide anions. On the other hand, Type II reaction
motherapy (PACT). entails transfer of energy from the photosensitizer to
Biological tissues are composed of dipole structures oxygen producing a singlet state of oxygen [14]
like enzymes, ionic pumps, nuclear material and nucleo- (. Fig. 6.5).
tide molecules, polar molecules like water and bound Singlet oxygen reacts readily with cellular constitu-
electrons which can be stimulated chiefly by the electric ents like amino acids in proteins such as tryptophan,
field of light (as biologic tissues are not magnetic, they tyrosine, histidine, cysteine, and methionine and gua-
are not much affected by the magnetic field of light) [12, nine bases of DNA and RNA, and also in unsaturated
13]. Tissues are composed of 70% or more of water lipids, including cholesterol and unsaturated fatty acids
134 A. M. Muruppel and D. Fried
between neoplastic and non-neoplastic tissue with a sen- Ghadially and Neish studying squamous cell carcinoma
sitivity and specificity of 96%. in rabbits that established endogenous PP IX as the main
Shin et al. [31] in 2010 described the various diagnos- fluorophore responsible for red autofluorescence [36].
tic techniques in vogue today like ViziLite (Zila Yuanlong et al. (1987) [37] showed that squamous
Pharmaceuticals, USA) which has chemiluminescent cell cancer tissues when exposed to 365 nm Xenon ion-
blue light source and can detect pathologic changes pulsed laser showed fluorescence at 630 and 690 nm at
however studies are yet undecided about its accuracy. 89% correlation with the traditional biopsy method.
The VELscope or Visually Enhanced Lesion Scope Koenig and Schneckenburger [38] continued these inves-
(LED Dental, USA) invented by M. Suyama is a hand- tigations using the 364-nm argon laser with a fiber-
held device that is designed for the diagnosis of oral pre- optical sensor and elicited autofluorescence at 673 nm in
cancerous, cancerous, or pathologic lesions using the skin and in subcutaneously transplanted solid
fluorescent light of 400–600 nm. It works on the notion Ehrlich carcinoma of mice at 638 and 680 nm, and at
that normal mucosa would appear green or pale green 635 nm in patients with squamous cell carcinoma.
6 due to autofluorescence and a pathologic or neoplastic
lesion would appear brownish to black. It is based on
the concept of visual autofluorescence as opposed to the
autofluorescence imaging techniques described earlier in 6.4 Optical Coherence Tomography
this text. It can however aid a practitioner in identifying
and delineating cancerous or precancerous lesions.
However, it is quite subjective as it relies heavily on the 6.4.1 Optical Biopsy
judgment, training, and experience of the practitioner,
false positives with benign lesions may also occur as Optical Coherence Tomography (OCT), a modality
they may also have connective tissue changes leading to adapted from ophthalmology (Naohiro Tanno and David
a change in autofluorescence of tissues. A range of stud- Huang 1991) is a non-invasive, live, imaging technique
ies have been designed to evaluate the efficacy of this that provides three-dimensional high-resolution (10–
device and the results have been ambiguous. 15μm) images to a depth of ~2 mm. Literally, it allows the
Lane et al. [32] was the first group to investigate the diagnosis of pathology in tissue by optical methods with-
VElscope device in 2006 and reported a sensitivity of out actually physically harvesting it from a patient surgi-
98% and specificity of 100%. Subsequently, Poh et al. cally [39]. It is based on the principle of back scattered
[33] did their evaluations on 20 patients from whom they light analyzed through low coherence interferometry,
derived 122 oral mucosa biopsies and reported a sensi- which in simple terms means that the light scattering
tivity of 97% and specificity of 94%. Poh [34] designed a back off a surface is superimposed (as constructive inter-
similar study a year later in 2007 with another team and ference and destructive interference) to develop useful
published a report that out of a total of 60 patients who diagnostic data. The back scattered (reflected) light from
underwent surgery for oral cancer, 7 patients (25%) of the substrate generates a low coherence beam from differ-
the 22 control-group patients experienced recurrence, ing depth levels (depending on tissue structures in the vol-
while none of the 38 patients where the surgeon was ume being imaged) to the interferometer (. Fig. 6.6).
guided by the visual fluorescence (VELscope) to place a The optical data from each single scan point is interpreted
10 mm margin of excision experienced recurrence. by the interferometer as an interference pattern and
However, studies done by McNamara et al. [35] in 2012 recorded as a depth profile (A-scan) whereas in a linear
on 42 patients do not concur with the previous studies scan across the sample delivers cross-sectional (B-scan)
and stated that visual examination was better than visual data. The images can be based on spectral domain scans
fluorescence by VELscope. of a single focus or swept laser light sources where light
Cancer diagnosis through autofluorescence could of varying frequencies can be emitted sequentially.
also be based on the detection of porphyrin or its deriva- The light is directed along two arms, a reference arm
tives in neoplastic tissues. There are various porphyrin- (mirror) and a sample/substrate arm using a handheld
related fluorophores in the tissue such as protoporphyrin (X-Y) scanning device similar to an endoscopic probe
IX (PP IX), coproporphyrin III (CP III), uroporphyrin (. Fig. 6.7). The source of light typically is a near-
III (UP III), and hematoporphyrin IX (HP IX). Strong infrared diode lasers operating in continuous wave or a
red fluorescence of porphyrins when exposed to UV short pulsed femtosecond laser and is used in tandem
light was reported as early as 1924 by Policard in sarco- with time domain or frequency domain interferometers
mas of rats. This would later on develop into the founda- (. Fig. 6.8).
tional work of photodynamic therapy (PDT). It was not Normal and pathologic tissue can be visualized in
until 1942 when Auler and Banzer demonstrated hema- three-dimensional images with differing contrast as the
toporphyrin in malignant cells and later in 1960 when spatial differences in refractive index of different tissue
Laser Assisted Diagnostics
137 6
constituents changes with depth and hence this varia-
Handheld probe tion lends the depth and difference to images.
Furthermore, it allows qualitative morphological imag-
ing of skin in vivo and can help in diagnosis of precan-
cerous or cancerous lesions of the skin [40]. Optical
biopsies from this modality has led to the diagnosis of
Laser beam Reflected light
neoplastic lesions of both non-melanoma skin cancers
Epithelium (NMSC) like basal cell carcinoma and squamous cell
carcinoma [41–45] and also melanomas [46, 47].
OCT has also been used in the diagnosis of mucosal
lesions of the oral cavity. Adegun et al. (2012) [48]
applied OCT for the diagnosis of epithelial dysplasia
and compared B-Scan images to histological sections.
Connective tissue The relevance and significance of this study, they stated
was that the choice of determining the anatomic site for
obtaining the biopsy is subjective to the clinician and
.. Fig. 6.6 Light from a laser source generates backscatter depend- hence the diagnosis also would vary, and hence OCT
ing on tissue components at various depth levels. This is analyzed by provided non-invasive technique that could in the future
a low coherence interferometer that generates depth-wise i nformation direct the practitioner to selecting the appropriate site
or a series of cross-sectional images according to tissue constituents
that cause the back scatter at different levels
for taking the biopsy only if necessary and prompted by
Laser Source
Sample arm
Spectrometer
.. Fig. 6.7 The components of optical coherence tomography— ence mirror. The light from both arms are recombined and the spec-
which consists of a scanner probe which has the laser light source is trum analyzed by computer. CCD charge coupled device, CMOS
directed along two arms by a beam splitter, one from the sample complementary-symmetry metal-oxide semiconductor
(recorded by CCD detectors or CMOS imaging) and from a refer-
138 A. M. Muruppel and D. Fried
Beam
Beam splitter
M2 M2
splitter
Tissue
OCT profile
the OCT image. The results showed a poor correlation ther by stating that this analysis (of the interaction
between OCT images and actual biopsies in the case of between matter and radiation) can be with any region of
moderate and severe dysplasia. Adegun et al. in the fol- the electromagnetic spectrum. Therefore, the range of
lowing year (2013) [49] had evaluated OCT in the diag- spectroscopy techniques available can be based on any
nosis of vesiculobulbous mucosal lesions compared to particular wavelength region and also could be based on
normal mucosa or fibroepithelial polyps using a modal- absorption of a wavelength region of the electromag-
ity called “scaled intensity drop” a two-dimensional netic spectrum or by thermal emission caused by a par-
imaging mode. The results showed that SID was indeed ticular wavelength.
able to discriminate between fluid filled and solid tissue While most spectroscopy techniques deal with elec-
with a sensitivity and specificity of 80%. tronic transitions of molecules and band spectra related
However, other diagnostic modalities may also be to their respective absorption, Atomic Emission
used similarly and deliver an optical biopsy such as Spectroscopy, and Atomic Fluorescence Spectroscopy
multi-photon excitation microscopy which is essentially catalogues the emission from an excited atom and hence
a type of fluorescence microscopy which works on the in plain terms are able to give information regarding spe-
principle that two photon excitation can induce fluores- cific elements in a compound and their concentration.
cence emission at much shorter wavelengths like those Atomic Emission Spectroscopy is able to characterize the
of fluorophores like NADPH which usually fluoresce to particular wavelength (color) emitted from an excited
UV light. Masters et al. [50] reported the use of this atom and is based on the principle that the number of
technique with a 730 nm, 100 mW, Ti:Sapphire femto- excited atoms is proportional to the emitted energy. The
second laser at an average power on 10–15 mW with a sample is thermally excited using a flame or plasma.
galvanometer-driven scanner. They concluded that they These techniques are founded on the observation of
were able to obtain a sample to an image depth of 100μm Josef Fraunhofer in 1817 that the spectrum of solar
and that this technique could be applied to obtain deep radiation had a continuous spectrum of numerous dark
sections for in vivo optical biopsies. Elastic Scattering lines (he designated the dark lines with letters). Later,
Spectroscopy (ESS), Raman Spectroscopy, and Laser- Gustav Kirchhoff in 1859 showed that the absorption of
Induced Breakdown Spectroscopy are other modalities solar radiation by sodium atoms gave the D line at
for taking an optical biopsy. 589 nm.
Molecular absorption of UV/VIS light leads to an
excitation that is depicted by an increase in vibrational
6.5 Spectroscopic Techniques energy and the subsequent emitted wavelength could be
measured as against the absorbed wavelength in tech-
Skoog and Holler [51] define spectroscopy as the study niques of absorption spectrometry such as Atomic
of the interaction between matter and electromagnetic Absorption Spectroscopy (displays these as black lines
radiation. Helmenstine [52] refines this definition fur- on a white background). Laser-induced breakdown
Laser Assisted Diagnostics
139 6
spectroscopy (LIBS) is a type of atomic emission spec- Spectroscopic measurements of scattered light are
troscopy where a highly energetic focused laser pulse is applied in the case of techniques such as Raman
the excitation source which atomizes the substrate to Spectroscopy.
form plasma. This plasma would have a characteristic
atomic or molecular signature of the substrate.
Kumar et al. (2004) [53] had demonstrated the use of 6.6 I nelastic Scattering of Light vs Elastic
LIBS in vivo in canine hemangiomas and showed that (Rayleigh) Scattering
calcium and potassium and copper and potassium levels
were different in tumor cells compared to the normal Elastic scattering suggests that the scattered light has the
cells. same energy as the incident light and the particle on
Kanawade et al. (2015) [54] applied LIBS for the dif- which it was incident is much smaller than the wave-
ferentiation of tissues by analyzing their basic atomic length of the light. This is based on Rayleigh’s law which
composition as against the National Institute of states that scattering is inversely proportional to the
Standards and Technology (NIST) [55] data base using fourth power of wavelength, which means that shorter
and Excimer Laser 193 nm, 28 ns pulses at 10 Hz, 0.6 × the wavelength (violet, blue) the greater will be the scat-
0.4 mm spot size, and energy/pulse 38 mJ on fat, muscle, ter [14].
nerve, and skin tissue samples from pig source. They Conversely inelastic scattering would cause a change
proved that emission intensity ratios of Na to C, K to in the frequency and wavelength of the incident light in
Na, and O to C ratios could be used to differentiate that there is a transfer of energy toward vibrational
between tissues and that this information could be used states of the molecule. This transfer of energy enables
for future application in minimally invasive laser-guided the molecule to reach higher (excited) “virtual” vibra-
surgeries. tional states and as a result there would an equal and
Photoluminescence spectroscopy specifically assays proportional decrease in energy from the scattered light
the fluorescent (fluorescent quantum yield) or phospho- than its incident energy. This would increase the wave-
rescent (phosphorescent quantum yield) pathways of length (redshift) of the scattered light and the difference
relaxation and dates back to the mid-1800s. The spectra in energy would correspond to the difference between
depict the intensity of the emitted radiation as a func- the vibrational states of the molecule. This is called
tion of either the excitation (excitation spectra) wave- Stokes shift.
length or the emission (emission spectra) wavelength. However, in such a situation, when the incident pho-
Excitation spectra shows the emission at a given fixed ton was to hit a molecule which is already in its excited
wavelength while varying the excitation wavelength. vibrational state then the scattered photon would have
Whereas the emission spectra show the intensity of the more energy than the incident and hence it would have a
emitted radiation when a fixed wavelength is used to shorter wavelength (blue shift) thereafter. This is termed
excite the sample. as anti-Stokes shift (. Figs. 6.9 and . 6.10).
Virtual level
Energy
3
2
1
0
Reflectance Fluorescence Raman scattering
140 A. M. Muruppel and D. Fried
CCD camera
CCD camera
Spectrometer
.. Fig. 6.10 The diagnostic setup for Raman Spectrometry. The scattered light from the source to the spectrometer), and a spectrom-
excitation source can be a Diode Laser, a fiber-optic sampling probe eter detector. (Reproduced from Beier B.D. et al. (2012), AMB
(which directs the laser light to the source and also channelizes the Express 2012, 2:35, © 2012, Beier et al. [56]; licensee Springer)
tion of caries as well as susceptibility of the patient and Previously in 2004, Chan et al. [72] had demonstrated
designation of preventive measures. The inspiration for the successful use of Confocal Laser Tweezers Raman
such work though dates back to the work of Puppels Spectroscopy in identification of single bacillus spores
[61–63], Nelson [64], Sperry [64], Manoharan and using a 50 mW Argon Laser. Later, the same research
Ghiamati [65–67] in the early 1900s who first used this team headed by Chan in 2008 [73] demonstrated the
technique for the identification of bacteria. The choice application of LTRS using 10 mW, 633 nm He–Ne laser
of bacteria used in these studies are indeed obvious as S. (both as excitation and optical trapping) in differentiat-
mutans is implicated as one of the primary causative ing between T and B cells of young leukemic patients
organisms and S. sanguis, and S. gordonii are secondary with an accuracy of 95% in the case of normal cells and
causative agents in dental caries. 90% in classifying cells according to their respective
Chan et al. in 2006 [68] had used the same principle types. Huang et al. [74] employed a similar technique of
with over 98.3% accuracy in the identification of neo- microfluidic Raman tweezers using 785 nm diode laser
plastic cells and differentiation of live healthy hemato- source (this wavelength is preferred as there is very less
poietic cells and later with 97% accuracy using Laser water absorption at this range and hence damage to
Tweezers Raman spectroscopy (LTRS) with a 30 mW optically trapped cells is prevented) in quantifying the
633-nm He–Ne laser as an excitation source [69]. levels of pyridine-2,6-dicarboxylic acid (dipicolinic acid
LTRS utilizes a single beam of infrared lasers to ana- or DPA) chelate with calcium ion (Ca-DPA) in bacillus
lyze a cell several microns away from any other substrate, spores. Ca-DPA levels have been correlated with spore
virtually as an optical tweezer, thereby precluding any resistance and stability in a medium [75]. The study
other background signals. This is based on the principle showed that identification of individual bacillus spores
of “optical trapping or optical levitation” described by was possible without altering individual spores with a
Ashkin and Dziedzic [70] (using a 120 mW argon laser) laser exposure time up to 20 s beyond 20 s there was the
where viruses, bacteria, or cells in gaseous or liquid release of DPA as all bands disappeared from the
media are virtually held at a focal point of the laser Raman spectrum [76].
beam where the scattering and intensity of the laser The microfluidic technique is a flow cytometry like
radiation is at a balance. Prerequisite to this process is patented technique developed by the researchers them-
that the biologic (or otherwise) particle being “trapped” selves which comprised a square quartz capillary tube
should have a refractive index that is higher than the sur- (50μm by 50μm; 5 cm long) with two connecting cham-
rounding medium. “Optical trapping” works on the bers, one with the spore sample and the other with water.
principle that a gradient force proportional to the inten- A precise flow pump controlled the flow that would
sity of the laser beam draws high refractive index parti- deliver individual spores to the focal point of the laser
cles toward the beam axis but repels low refractive index where optical trapping of the spore would give the
particles away from its axis. The laser bean could virtu- Raman spectrum and then the flow was immediately
ally suspend a particle as the radiational field counter- turned off so that the spore is held for Raman acquisi-
balances the gravitational forces on a particle. (Magneto tion. Once the Raman spectrum is obtained, the flow is
optical trap, Dipole trap) [71] turned on again, while the laser beam is blocked for a
142 A. M. Muruppel and D. Fried
short time (~10 ms) and when it is turned back on the information and inference regarding cariogenicity and
measured spore flows away from the trap toward the its progression too.
waste chamber. Now the system can receive the next Raman Spectroscopy (which uses continuous wave
spore in the flow. The above procedure is repeated until lasers rely on spontaneous emission) could be clarified
200 individual spores are evaluated. into a much more amplified, efficient, coherent signal
Nearly a decade back, Ellis and Goodacre (2006) free of background fluorescence by Coherent Anti-
[77] in a critical review of a diverse range of research Stokes Raman Scattering (CARS) and Stimulated
work had discussed the possibility of using Raman Raman Scattering (SRS) which uses two pulsed laser
Spectroscopy and allied techniques like Fourier sources to excite the sample (instead of a single CW
Transform Infrared Spectroscopy in a range of applica- source). One pulsed laser source initiates the Raman
tions such as in the diagnosis of cancer (prostrate and Scattering (pump) and Stokes shift whereas the second
cervical), leukemia, arthritis, and even in the identifica- source is specifically tuned to the frequency of a single
tion of metabolic markers of diabetes and in reproduc- peak on the spectrum bringing about a blue shifted sig-
6 tive biology. Mahadevan-Jansen et al. (2014) [78] had nal that is exponentially stronger than the original
discussed the capability and potential of Raman spec- Raman signal and can be used for specific imaging and
troscopy to detect biochemical changes in cancer cells isolation of known molecules.
such as the increase in nucleic acid content, glycogen, CARS has been used for the specific and quantitative
and collagen. intracellular identification of lipid molecules in living
Nguyen et al. (2016) [79] successfully employed cells. Nan et al. (2006) [81] have been able to correlate
Raman Spectroscopy in the in vivo verification of tissue this to the tracking of Hepatitis C virus whose pathoge-
margins between normal and neoplastic tissues in soft nicity is closely linked to its insidious ability to be con-
tissue sarcomas with a sensitivity of 89.5% and specific- cealed in triglyceride-rich lipoprotein particles. They
ity of 96.4%. They used a portable Raman spectroscopy used two pulsed Ti:Sapphire lasers with a repetition rate
device with a handheld probe, 400μm excitation fiber of 80 MHz, 2 ps pulse width and pump wavelength at
and seven 300μm collection fibers excited at 785 nm, 711 nm and Raman resonance (Stokes shift) wavelength
providing information to a depth of 700μm. This tech- at 892 nm. CARS had been employed using fiber-optic
nique, they reported, allows for more accurate appraisal delivery by Buschman et al. in 2000 [82] and thereafter
of designing margins in surgical resection of tumors. by subsequently Mostaco-Guidolin et al. in 2010 [83] in
Raman spectroscopy when combined with intuitive animal studies of myocardial infarction prone, Watanabe
computer-aided statistical analysis of the spectra by heritable, hyperlipidaemic rabbits for detection of ath-
Multivariate Analyses (MVA) such as Principal erosclerosis in ex vivo samples (dissected arteries) using
Component Analysis (PCA), Hierarchical Cluster Ti:Sapphire oscillator at 800 nm (for Raman resonance)
Analysis (HCA), Discrimination Function Analysis 100 fs pulse duration and a 532 nm 7.25 W green laser
(DFA), or geometric based Vertex Component Analysis provided the pumping. They were able to establish a cor-
(VCA) give a clearer and composite picture leading to relation between the severity of atherosclerosis and age
the interpretation, classification, and diagnosis of the of the animals. Significantly, Motz et al. in 2006 [84]
sample under study. demonstrated (830 nm diode laser) in vivo usage of
In related work by Escoriza et al. in 2000 [80], Raman Raman Spectroscopy on diagnosis of atherosclerosis in
Spectroscopy was successfully employed to discriminate femoral bypass and breast lumpectomy surgeries. CARS
and differentiate between viable and non-viable cells of has also been used for the identification and imaging of
Escherichia coli and Staphylococcus epidermidis. The bacterial spores.
study demonstrated a sensitivity of Raman Spectroscopy Another technique for amplification of the Raman
to differentiate viable and non-viable cells up to 86% signal (by 14 or 15 orders of magnitude) is Surface-
and was able to discriminate between species with accu- enhanced Raman scattering (SERS) spectroscopy.
racy of 87%. Zhang et al. in 2003 [85] used a 632 nm He–Ne laser to
Raman spectroscopy provides a unique fingerprint detect low concentration of dipicolinic acid (DPA).
that differentiates the biochemical molecular alterations
between the samples. Most interestingly, Beier et al. in
2012 [56] showed that this technique lends further depth 6.7.2 hoice of Wavelength in Raman
C
to the diagnosis by giving actual information on the dif- Spectroscopy
ference in spatial positioning of the different bacterial
species in the three-dimensional network of the biofilm. These studies mentioned illustrate the range of differing
Such essential constitutive differences can build up a excitation wavelengths used by the various research
three-dimensional mosaic of the complex microbial groups using differing techniques across the decades.
structure such as of a biofilm and could give unique However, the common feature is that the wavelength
Laser Assisted Diagnostics
143 6
chosen for Raman spectroscopy are mostly in the red or
near-infrared region. This is because shorter wavelength
particularly below 600 nm will elicit considerable back-
ground autofluorescence from cells which can confound
and confuse results and also because cells typically have
chromophores (proteins, amino acids, nucleic acids, etc.)
which will absorb shorter wavelengths and cause cellular
alteration or even cell damage (opticution). A key fea-
ture of Raman spectroscopy is that is non-invasive and
gives real-time, vital information of living cells.
Wavelengths between 600 and 900 nm have low water
absorption and elicit more scattering. Blue or green
wavelengths have also been used by some studies, but
notably these are on fixed cells or ex vivo tissues and not
in live homeostasis state of tissues.
Dental caries is often overlooked or continues unde- .. Fig. 6.12 FOTI image—transillumination depicts the carious
tected owing to the insidious nature of the lesion. areas as darker areas contrasted against sound enamel. (Reproduced
Radiographic detection often requires at least around from J. Gomez [90], BMC Oral Health 2015, 15(Suppl 1):S3 under
30% of demineralization to warrant detection and uses the terms of the Creative Commons Attribution License (7 http://
ionizing radiation [86]. Early detection of incipient car- creativecommons.org/licenses/by/4.0), © 2015)
ies (non-cavitated—“white spot”) avoids the use of inva-
sive restorative modalities. Incipient caries has a 52 patients having Class II carious lesions. They con-
sub-surface second layer which is very porous and can cluded that though DIFOTI does significantly detect
extend to a depth of 100–250μm whereas a cavitated the lesion depth (particularly smaller lesions, in com-
lesion can extend up to 1.5 mm or deeper. parison to radiographs the technique was less accurate.
They add that as DIFOTI had a sensitivity and specific-
ity lower than visual examination, however they
remarked that it can be a useful adjunct to radiographic
6.8.1 Fiber-Optic Transillumination (FOTI) diagnosis [89].
and Digital Imaging Fiber-Optic Electroconductivity measurement (ECM) is based
Transillumination (DIFOTI) on the principle that sound tooth surfaces will have little
or no conductivity whereas areas which have demineral-
Fiber-Optic Transillumination (FOTI) and Digital ization due to caries would have conductivity propor-
Imaging Fiber-Optic Transillumination (DIFOTI) are tional to the extent of demineralization. It involves
transillumination techniques. DIFOTI uses high inten- covering the tooth surface with a conducting medium
sity light from a fiber-optic device source to illuminate a and measuring conductivity using a probe. But this tech-
tooth and the backscattered light is captured by a digital nique had a lot of false positives and lack of specificity.
camera and analyzed by a computer. Carious enamel Reports from literature average its accuracy to around
and dentin would scatter light more than sound tooth 80% [91]. The ECM could be used to predict the proba-
structure and appear darker (. Fig. 6.12). This tech- bility that a sealant or a sealant restoration would be
nique has the advantage that it precludes the use of ion- required within 18–24 months after eruption [92].
izing X-radiation and also provides diagnosis in real-time A related technique is electrochemical impedance
and studies have shown that DIFOTI has a higher sensi- spectroscopy (EIS) which is based on the application of
tivity than conventional radiography. The technique electric currents of differing frequencies to detect cari-
relies heavily on the judgment of the practitioner and ous lesions. Dental hard tissues have their own charac-
suffers from a lot of variability. It does not describe the teristic electrical signature, and these reference values
lesion depth or severity and this has been reported in a can be used to detect carious tooth structure as com-
study by Young and Featherstone (2005) [87]. pared to normal enamel and dentin. The demineraliza-
Bin-Shuwaish et al. (2008) [88] evaluated the accu- tion caused by the carious process renders the tooth
racy of DIFOTI as against Digital Radiography using structure to be porous and subsequently permeated by
complementary metal-oxide silicon (CMOS) sensor in fluids replete with ions, which in turn therefore would
144 A. M. Muruppel and D. Fried
increase the electrical conductivity of carious teeth. approval, that Calcivis is a relevant and efficient method
Simply stated the carious teeth structure would have a of caries diagnosis, however further research through
higher electrical conductivity than sound and healthy elegant, peer-reviewed and randomized controlled trials
teeth. Likewise sound dentin which is naturally more is still wanting before this diagnostic modality could
porous and has dentinal fluid within itself would have become fully accepted by practitioners and the profes-
more electrical conductivity than sound enamel itself. sion in general [99].
AC Impedance Spectroscopy Technique (ACIST,
CarieScan Pro™ orangedental, Biberach, Germany)
uses a sensor tip that passes a low magnitude (micro 6.8.3 uantitative Light Fluorescence
Q
amp) electrical current through the tooth (enamel, den- and Laser Fluorescence
tin, or pulp) to elicit the resistance to electrical current (DIAGNOdent, KaVo)
(impedance) and using an algorithm grades that data
into a numeral score (0–100) that depicts the compara- Based on the technique developed by Bjelkhagen and
6 tive mineral density or caries status of the tooth being Sundström (1981) [100] and later applied clinically
examined [93–96]. in vivo in conjunction with de Jong (1995) [101], quanti-
On the other hand, laser assisted diagnostic tech- tative light-induced fluorescence (QLF) traditionally
niques lend the advantage and accuracy of early detec- used Argon laser light at 488 nm to induce fluorescence
tion by assessing biochemical and fluorescent changes in in a tooth. More recently, QLF devices use an arc lamp
tooth structure. Following on the work of Bommer in or xenon lamp that generates light at 370 nm light (290–
1927 using UV light to detect plaque on tooth, Benedict 488, violet-blue) that is then transmitted through optical
in 1928 and Hartles and Leaver in 1953 and later fiber into a handpiece and captured using a charge cou-
Armstrong in 1963 examined the fluorescence of healthy pled device (CCD) camera [102]. The display of natural
and carious dentin samples under UV light. However, it fluorescence of the tooth would contrast against dark
was Alfano who reported the fluorescence of carious areas of caries where the tooth’s natural fluorescence is
teeth at 550 nm on excitation at 488 nm, these founda- impeded. The fluorescence generated from the tooth by
tional works led on to the development of newer and the exciting light would then be filtered by a high pass
still emerging diagnostic techniques in hard tissues [17]. filter which allows only wavelengths greater than 520 nm
to be detected. Karlsson and Tranaeus stated that QLF
can detect carious lesions on occlusal and smooth sur-
6.8.2 Bioluminescence faces to a depth of 500μm [103].
Saliva, plaque and hypoplastic areas would skew the
Initial studies by Jablonski-Momineni, Moos et al. in results; nonetheless, an application of QLF that is not so
2016–2018 proposed that the bioluminescence (480 nm, widely researched is that it can detect red fluorescence
Blue light Phosphorescence) emitted by a photoprotein from bacteria in plaque [103]. But the technique was not
(calcium-sensitive photoprotein aequorin—CSP— able to specifically differentiate between caries, hypopla-
aequorin WO/2008/075081) on reacting with the higher sia, and similar conditions. Another serious limitation
level of free calcium ions released as a result of the of this technique is that it is not able to differentiate or
demineralization process in an active caries site can be detect lesions extending into dentin [104].
used to detect progressing carious lesions. The authors An application based on the same concept of auto-
investigated the effectiveness of this system (Calcivis, fluorescence is Soprocare (Acteon, France) which uses
Ltd., UK) in an in vitro study on extracted teeth and light at 450 nm from three diode lasers in a clinical
found that this novel method demonstrated high diag- handpiece and elicits autofluorescence from the tooth
nostic credibility over visual or tactile methods [97]. that is recorded by a high magnification camera to detect
Longbottom, Vernon, Pitts (who are the original caries or even from plaque and can even detect gingival
inventors of this system) et al. further investigated biolu- inflammation. Rechmann et al. (2014) [105] reported the
minescence as a diagnostic modality of caries in 2020– use of this device recently. The device has a period mode
2021 through a couple of in vitro studies and they that detects plaque in an orange to red gradient and gin-
reported that bioluminescence is not affected by stains or gival inflammation in a magenta color and a caries
other factors that can affect fluorescent signals and can mode that could detect carious areas as red fluorescent
therefore effectively detect an active carious lesion and regions. In their study on 55 subjects and 638 teeth, they
that the bioluminescence thus detected is also directly compared the Soprocare autofluorescence grading of
proportional to the intensity of the caries lesion [98]. plaque and gingival inflammation, to conventional
A blinded study was conducted by Pitts, Shank, grading methods such as Loe and Silness index for gin-
Longbottom et al. in 2020 that confirmed, through FDA gival inflammation and a plaque index, which was a
Laser Assisted Diagnostics
145 6
.. Fig. 6.13 Soprocare b
autofluorescence showing a
Carious tooth in daylight mode.
b The Soprocare handpiece with
three blue light emitting diode a c
lasers. c Carious tooth in blue
light autofluorescence.
(Courtesy Dr. Niladri Maiti)
Turesky Modification of the Quigley Hein Plaque Index. Barberia et al. (2008) [108] reported a specificity of
They concluded that the autofluorescence method of 89% in a convenience sample of 320 molar teeth in
Soprocare correlated well to the clinical evaluation children aged 6–14 years where the Diagnodent was
methods for plaque and gingival inflammation able to successfully diagnose carious lesions with a
(. Fig. 6.13). high sensitivity of 0.89 in primary molars but 0.40 in
Drancourt, Roger-Leroi et al. compared the efficacy permanent molar teeth and a specificity of 0.87 over-
(sensitivity and specificity) of autofluorescence all. Lussi et al. (2001) [109] in a previous clinical study
(Soprocare) and bioluminescence (Calcivis) to detect car- had showed that Diagnodent was not able to clearly
ies in occlusal surfaces of extracted teeth, the study showed differentiate between superficial and deep dentinal
both methodologies being nearly equally efficient wherein caries.
Sporolife showed a higher sensitivity whereas Calcivis
showed a better specificity in detecting caries [106].
In the technique of laser fluorescence (DIAGNOdent, 6.8.4 ifferences Between QLF
D
KaVo), longitudinal laser light at 655 nm is directed at and Diagnodent
the tooth substrate and the reflected fluorescence from
bacterially produced porphyrins is detected and mea- QLF uses a much shorter wavelength at 488 nm and is
sured (much like the detection of sarcomas described by designed to detect and receive 540 nm autofluorescent
P Policard as early as 1924). This technique was devel- light from the enamel (it filters out the shorter wave-
oped based on the work of Hibst and Gall. The amount length scattered light suing a 520 nm filter).
of fluorescence produced can be graded (0–99) and cor- The Diagnodent uses a longer wavelength 655 nm
related to the extent of caries (5–25 enamel caries, dentin light and measures fluorescence intensity (uses a 680 nm
caries greater than 35). Dental plaque, stains, calculus, filter).
and deposits could influence and interfere with the diag- Diagnodent can be related to dentinal decay but
nostic results of this modality. Various studies have given QLF results cannot correlate with dentinal decay.
different sets of validity and accuracy to the Diagnodent’s QLF measures the amount of induced natural (auto-
assessment and specificity, but most of them are in vitro fluorescence) fluorescence from the tooth structure, par-
and cannot perhaps be directly extrapolated to clinical ticularly enamel; hence, it is better suited for detection
practice as such studies do not simulate clinical scenar- of early lesions and more so on smooth surfaces rather
ios. In a clinical situation, Diagnodent readings may be than occlusal or in fissures [110]. This autofluorescence
adversely affected by stains, calculus, or even develop- decreases according to the severity (demineralization) of
mental or mineralization anomalies of teeth [107]. the carious lesion.
146 A. M. Muruppel and D. Fried
Diagnodent detects and grades fluorescence released perhaps is not until the carious lesion has considerably
from metabolites and organic molecules such as proto- progressed with an accompanying quantum of mineral
porphyrin IX and coporphyrin IX released by bacteria loss from the teeth whereas this diagnostic technique is
which absorbs the red laser light (655 nm) of Diagnodent. even able to identify changes in crystallinity such as ori-
It can hence even monitor the progression of the lesion entation and symmetry of crystals of the tooth struc-
[104, 109]. ture.
Sürme, Kara et al. [111] in 2019 in an in vitro study Raman spectroscopy has found useful indication
on extracted teeth assessed the diagnostic efficiency of also in the detection of fluorosis and manifestations of
three different diagnostic modalities, namely Alternating developmental disorders such as amelogenesis imper-
Current Impedance Spectroscopy Technique (ACIST, fecta and characterization of the mineral phases in cal-
CarieScan Pro™ orangedental, Biberach, Germany), culus. The fluorophores that could be detected by
near-infrared light transillumination (NILT, Raman Spectroscopy are also produced by various
DIAGNOcam) and fluorescence (DIAGNOdent) in groups of bacteria too, hence detection of plaque or
6 detecting occlusal caries. They found that ACIST was incipient carious lesions is also possible.
comparatively not as effective as fluorescent methods in Raman spectroscopy has been applied experimen-
both permanent and deciduous teeth but the NILT tally for the compositional assessment of bone by evalu-
(Diagnocam) was more accurate than the fluorescent ating bone mineral characteristics and collagen.
methods of DIAGNOdent. Makowski et al. in 2013 [115] used phase matching (for
Iranzo-Cortés et al. [112] in 2019 in their meta- polarization control) with Confocal Raman microscope
analysis compared the sensitivity, specificity, and overall at 785 nm on cadaveric specimens of femur bone of
diagnostic ability of DIAGNOdent (KaVo) and both genders in a diverse age group of 48–96. They
VistaProof (Durr Dental) to detect frank caries lesions found that phase matching (to quantify the phase and
(cavitated). They concluded that though both method- amplitude Raman peaks of bone) to reduce polarization
ologies are efficacious and cogent with “moderate to bias could give specific diagnostic information related to
high” sensitivity and specificity; however, they recom- peak rations of bone composition like mineral to colla-
mended that both methods should be adjunct to tradi- gen ratios; however, they added that optimizing polar-
tional methods of caries diagnosis. Furthermore, the ization is necessary for specific discrimination between
results also show VistaProof to have a higher sensitivity bone characteristics.
and specificity than DIAGNOdent. Raman spectroscopy is unique and unparalleled in
Mitchell, Zaku et al. [113] in 2021 evaluated the effi- caries detection as it allows for wide spatial resolution
ciency of DIAGNOdent (KaVo) in diagnosis of root and thus early diagnosis of caries. A range of studies
caries through a prospective in vivo study. They reported have been conducted in this area in the past decade com-
that DIAGNOdent was most accurate in detecting paring this technique to conventional methods and
active root caries with a 95% confidence interval. They other spectroscopic methods and has lent a lot of clarity
recommended that DIAGNOdent could be reliably used to this technique-sensitive area of diagnosis. Ko et al.
for detecting root caries with a high sensitivity and spec- (2005) [116] discussed a technique combining the high
ificity. resolution, (20μm) [121], morphological imaging of
OCT with the biochemical and molecular specificity of
Raman spectroscopy in the diagnosis of dental caries.
The OCT images were acquired using a diode laser
American Association of Dental Consultants (AADC)
850 nm, spot size 10–20μm at 750 μmW and Raman
position statement [114] on laser fluorescence in caries
spectroscopic data was acquired using an 830 nm diode
diagnosis based on the studies and clinical trials con-
ducted states that, “laser fluorescence can be used as an
laser at 24–52 mW from tooth samples extracted for
orthodontics reasons (caries free and with incipient car-
adjunct to traditional caries detection methods and
ies). While OCT images lend morphological depth as to
not used as a primary diagnostic tool.”
the extent and spread of the carious lesion, Raman
Spectroscopy could diagnose even early and incipient
caries through biochemical changes (. Table 6.2).
De Carvalho et al. (2013) [117] compared Raman
6.8.5 Raman Spectroscopy in Hard Tissues spectroscopic techniques to Laser Fluorescence
(Diagnodent) measurements on teeth having smooth
Raman spectroscopy has varied non-invasive diagnostic surface carious lesions and non-carious lesions. Raman
applications for oral hard tissues. The precision of such Spectra were obtained using a 785 nm, 500 mW diode
techniques makes it invaluable in the early diagnosis of laser with a 20 s exposure time. They concluded that the
carious lesions. Tactile, visual, or radiographic detection Diagnodent could not detect subtle changes in mineral
Laser Assisted Diagnostics
147 6
579, 590, 608, 614 cm−1 Phosphate PO43− Ko et al. (2005) [116]
(Asymmetric bending ν4)
∼960 cm−14 Symmetric stretching (ν1) Phosphate hydroxyapatite Ko et al. (2005) [116]
de Carvalho et al. (2013) [117]
1023, 1043, 1046 cm−1, 1052, Asymmetric stretching vibration PO43− (ν3) Ko et al. (2005) [116]
1069 cm–1071 cm−1 Coello (2015) [118]
1069 cm−1 Symmetric stretching mode of CO3-type B (ν1) Boskey et al. (2005) [119]
1104 cm−1 Symmetric stretching mode of CO3-type A (ν1) Boskey et al. (2005) [119]
2941 cm−1 Lipids and proteins (C–H and C–H2 groups) Coello et al. (2015) [118]
content such as in an incipient carious lesion and had a and inorganic) of peritubular and intertubular dentine.
lower sensitivity as compared to the specific detection of Xu and Wang (2012) [120] cleared the confusion regard-
mineral changes by Raman Spectroscopy. The ing the collagenous or non-collagenous nature of the
Diagnodent was able to detect organic changes much peritubular dentine and composition of the intertubular
more than inorganic changes and this they felt corrobo- dentin using micro-Raman spectroscopy (μmRs) with a
rates the finding of earlier studies regarding the suitabil- He–Ne (632.8 nm) laser, 60 s, and atomic force
ity of Diagnodent for initial detection of caries. microscopy (AFM). They proved that the peritubular
Coello et al. (2015) [118] proposed diagnostic quan- dentine was hypermineralized with respect to the inter-
titative mineralization indices of teeth through Raman tubular dentin with a mineral: matrix ratio three times
spectroscopy with the objective of establishing a diag- higher than the intertubular dentin. The study showed
nostic scale with regard to demineralization. Raman that the peritubular dentin had an inorganic content of
Spectra was obtained using an Nd:YAG laser at 96% (organic content of 4%) as compared to the inor-
1500 mW, from different zones of extracted teeth. They ganic content of 88% (organic content of 12%) for inter-
concluded that the ability of Raman Spectroscopy to tubular dentine though the crystalline nature of the
assess and differentiate the organic and inorganic areas peritubular dentin was much similar to the intertubular
of the tooth qualifies it to assess demineralization of the dentine.
tooth. The MIb (Mineralization Index bending) and
MIs (Mineralization Index stretching) indices, which
they suggested, were able to diagnose even initial demin- 6.8.6 WIR and NIR Imaging of Tooth
S
eralization and demonstrated the value of Raman Surfaces
Spectroscopy in this area. Thus Raman Spectroscopy
can be a convenient and effective modality in diagnosis Short wavelength infrared (SWIR) imaging is ideally
and monitoring of diseases like fluorosis and amelogen- suited for screening for dental caries, due to the high
esis imperfecta. transparency of enamel, the lack of interference of stains
Similarly, Raman Spectroscopy was able to deepen and the high contrast between sound and demineralized
our understanding of the chemical composition and tissues. It is also well suited for imaging cracks in teeth,
make up of dentine, particularly in laying to rest the identifying composite restorations, and assessing lesion
speculation about the composition and make up (organic activity. Light scattering in dental enamel decreases
148 A. M. Muruppel and D. Fried
markedly with increasing wavelength and is orders of An important advantage of imaging in the SWIR is
magnitude lower at SWIR wavelengths. It is common that the organic molecules responsible for stains on
practice today to define the near-infrared (NIR) as 700– teeth do not absorb light at longer wavelengths [128,
1000 nm and the short wavelength infrared (SWIR) as 129]. This is of particular importance in the stained pits
1000–2600 nm; however, the entire range has been and fissures of the tooth occlusal surface. It is necessary
referred to as the NIR in the past. Light scattering in to use wavelengths greater than 1200 nm to avoid sig-
dental enamel is high at UV wavelengths and decreases nificant interference from stains on tooth surfaces [130].
by two orders of magnitude from 543 to 1300 nm and the Therefore, stains can be easily differentiated from actual
wavelength dependence suggests that scattering is domi- demineralization at SWIR wavelengths. At visible and
nated by Rayleigh scattering due to the small crystals of NIR wavelengths stains interfere to such a degree that
enamel that are much smaller than the wavelength [122]. absorption due to stains contributes more to the lesion
A plot of the attenuation of light in enamel and water is contrast than increased scattering due to demineraliza-
shown in . Fig. 6.14 as a function of wavelength from tion [131]. Lesion contrast increases from the visible
400 to 2000 nm [122, 124, 125]. Light attenuation range where it is negative to extremely high positive val-
increases beyond 1300 nm due to a rise in light absorp- ues beyond 1700 nm [130]. Since it is impractical to
tion by water. Further studies suggest that the scattering remove stains from the deep grooves and fissures on
coefficient of enamel continues to decrease beyond tooth occlusal surfaces, lack of interference from stains
1300 nm [126]. Light scattering increases by orders of at longer SWIR wavelengths is a significant advantage.
magnitude upon demineralization due to the formation . Figure 6.15 shows three reflectance images of a tooth
of small pores in the enamel that highly scatter light with occlusal decay at 400–700, 1300, and 1450 nm.
[127]. This change in light scattering produces large dif- Sound areas of the tooth get darker with increasing
ferences in the contrast between sound and demineral- wavelength yielding extremely high contrast of deminer-
ized enamel particularly at longer wavelengths where the alization at wavelengths beyond 1400 nm [129]. Also
light scattering in sound enamel is low. Light scattering notable is that the stains in the visible light image domi-
remains high in dentin with increasing wavelength due to nate the lesion contrast, producing negative contrast,
the strong scattering by the dentinal tubules that are i.e., the demineralized areas appear darker as opposed
larger than the wavelength of light [122]. Light scattering to appearing lighter. A plot of the mean lesion contrast
in dentin does increase with demineralization producing as a function of wavelength is shown in . Fig. 6.15 for
measurable contrast between sound and demineralized occlusal lesions on 55 extracted teeth. The mean con-
dentin but the contrast is not as high as it is for enamel. trast was negative at visible wavelengths (400–700 nm)
Laser Assisted Diagnostics
149 6
and at 850 nm and increased significantly for each wave- [133–137], the specificity of radiographs is above 90%,
length range [130]. therefore it is a suitable standard for comparison. In
Reflectance and multiple geometries of transillumi- addition to proximal transillumination, a novel occlusal
nation are practical for imaging teeth for the detection imaging geometry, occlusal transillumination, was also
of caries lesions on tooth proximal and occlusal sur- employed to detect interproximal lesions in vivo [132,
faces. SWIR imaging offers many advantages over radi- 138]. Further clinical studies showed the usefulness of
ography and conventional visual and tactile methods for SWIR reflectance imaging and that the diagnostic per-
the detection of dental caries in addition to reduced formance of SWIR imaging was better than radiographs
exposure to ionizing radiation. SWIR clinical imaging for both occlusal and interproximal lesions [138, 139].
studies were first carried out more than a dozen years Lesions on proximal surfaces located well below the
ago. Interproximal lesions that appeared on radiographs tooth surface can be imaged with high contrast in SWIR
could be detected with SWIR proximal and occlusal reflectance as can be seen in . Fig. 6.16. A tooth with a
transillumination with similar sensitivity [132]. Even large interproximal lesion that is not visible in the color
though the sensitivity of radiographs is not very high image is visible in both reflectance and transillumination
SWIR images with high contrast. This tooth was also
diagnosed with occlusal decay in the stained central
groove based on visual and tactile examination but that
appears to be a false positive. No demineralization was
visible with either SWIR imaging or optical coherence
tomography [139]. The reflectance and transillumina-
tion images in . Fig. 6.16 were taken with two separate
SWIR reflectance and transillumination devices. It is
feasible to combine both devices in a single multispec-
tral SWIR reflectance and transillumination system and
the images shown in . Fig. 6.17 were taken with a
device that acquires simultaneous SWIR reflectance and
transillumination images [140].
Even though studies indicate the contrast of demin-
eralization is much higher at SWIR wavelengths than at
NIR wavelengths and that the sound enamel is more
transparent [141], all the currently available commercial
devices utilize shorter NIR wavelengths. This is most
likely due to the higher cost of InGaAs imaging arrays
compared to Si imaging arrays. The first commercially
available NIR imaging device called the Diagnocam
from Kavo (Biberach, Germany) uses an occlusal trans-
.. Fig. 6.15 Visible (400–700 nm), NIR and SWIR reflectance illumination probe with 780 nm light [142, 143]. The
images of an extracted tooth with occlusal decay. Plot of the lesion shorter wavelength allows the use of a less expensive
contrast as a function of wavelength for 55 teeth with occlusal decay.
The contrast of demineralization should be positive in reflectance.
silicon detector as opposed to InGaAs-based detectors.
All bars are significantly different (p < 0.05) [130] It is also important to point out that stains still interfere
.. Fig. 6.16 Color, SWIR reflectance at 1600 nm, SWIR transillumination at 1300 nm images for one tooth with suspected occlusal and
proximal decay [139]
150 A. M. Muruppel and D. Fried
a b
c d
.. Fig. 6.17 a Color, b SWIR reflectance at 1600 nm, c microCT and d transillumination at 1300 nm images for one tooth with occlusal
decay. Arrows point to lesion. SWIR images acquired with dual SWIR transillumination/reflectance device [140]
at 780 nm so stains are still a potential problem with dentin is still relatively high. Better visualization can
shorter wavelength NIR devices [130]. The first commer- lead to more precise methods for removal, preserving
cial NIR reflectance system operating at 850 nm was the healthy tissues. One possible approach is to use lasers for
Vistacam iX Proxi from Durr Dental (Bietigheim- the selective removal of calculus without damaging the
Bissingen, Germany) [144]. cementum [148–150]. SWIR images at wavelengths
Root caries is an increasing problem with our aging beyond 1400 nm may be ideally suited for the image-
population [145, 146]. Imaging root caries at SWIR guided laser removal of both root caries and calculus
wavelengths may be equally advantageous due to the [151, 152].
lack of interference of stains beyond 1200 nm and SWIR imaging modalities are ideally suited for the
increased suppression of the reflectivity from the sound detection of demineralization adjacent to and beneath
dentin due to higher water absorption which increases restorative materials due to the high transparency of
markedly beyond 1400 nm [147]. . Figure 6.18 shows enamel and dental composites to SWIR light. Dentists
SWIR images of the root surfaces of an extracted tooth spend more time replacing restorations than placing
with lesions and calculus. The amount of light reflected new ones [153]. The lack of interference from stains is
(backscattered) from the underlying dentin depends on also a significant advantage in imaging secondary caries
the ratio of scattering to absorption. Therefore, wave- since composites often become stained masking the
lengths with higher water absorption can yield high peripheral demineralization. Composite restorative
lesion contrast even though the light scattering in sound materials have unique spectral signatures in the SWIR
Laser Assisted Diagnostics
151 6
a b
c d
.. Fig. 6.18 a Color, b SWIR reflectance at 1600 nm, c microCT and d transillumination at 1300 nm images for one tooth with occlusal
decay. Arrows point to lesion. SWIR images acquired with dual SWIR transillumination/reflectance device [147]
resulting from combination absorption bands that can Cracks in teeth are an important problem in den-
be exploited for differentiating tooth structure and other tistry; they may cause a large range of symptoms and
type of composites. The most prominent dental resin lead to the loss of healthy tooth structure [160]. Cracks
absorption bands lie at 1171, 1400, 1440, 1620, and can originate from coronal tooth structure or from
1700 nm and result from overtones and combinations of within the root, and they may occur in both horizontal
the fundamental mid-IR vibrational bands from C–H, and vertical directions on the crown and/or root.
N–H, and O–H groups found in both resin and water Ultrasound can also potentially be used to locate cracks
[154, 155]. The overall visualization of the restoration [161]. Since tooth enamel is most transparent at 1300 nm,
boundaries can be enhanced when viewed at different SWIR reflectance and transillumination imaging is ide-
SWIR wavelengths [156, 157]. The ability to distinguish ally suited for imaging cracks in teeth [162]. Crack for-
between composite, sound enamel and demineralized mation and propagation can be imaged in real-time
enamel is necessary for both the detection of secondary during laser irradiation using SWIR transillumination
decay and the replacement of restorations with minimal [162–164]. Sapra, Darbar et al. used an 810 nm diode
loss of sound tissue structure. Tooth-color-matched res- laser (1 W, CW, 200μm, 5 mm distance, 1 mm/s) in an
torations manifest very high contrast with sound tooth in vivo prospective study over 4 years in 12 patients who
structure at SWIR wavelengths coincident with high had sharp dull or aching pain on biting and release, they
water absorption. SWIR light is attenuated to a lesser concluded that the laser can be complementary to con-
degree in composite due to the lower water content of ventional diagnostic methods in identifying and allow-
composite compared to enamel and dentin. This can ing early treatment of teeth with cracks [165].
also enable the selective removal of composite by lasers Many caries lesions that are detected have been
[158, 159]. arrested or are undergoing remineralization and do not
152 A. M. Muruppel and D. Fried
require intervention. As lesions become arrested by min- an imaging depth of up to 2–3 mm. The dentin showed
eral deposition or remineralization, the permeability of different back scattering patterns between carious and
the mineralized surface layer decreases. Studies have sound dentin and in attrited dentin there was a low
shown that permeability changes can be monitored attenuation coefficient because of the sclerosed dentinal
using quantitative light fluorescence (QLF) [166–168], tubules. Makishi et al. (2011) [184] and Bakhsh et al.
thermal and SWIR reflectance imaging [169–172] dur- (2011) [185] had used the same modality for evaluation
ing lesion dehydration. In vivo studies using QLF [169] of marginal adaptation of resin-based restorations in
and thermal imaging have been reported [172]. A small Class I cavities. The authors report that gaps up to even
increase in the surface layer thickness can lead in large a half micron could be detected by SS OCT.
changes in permeability [173]. Changes in the lesion En face OCT, a time-domain OCT technique, is a
contrast during drying are particularly high at wave- newer advancement that provides the ability to precisely
lengths coincident with water absorption bands near localize lesions by giving transverse (cross sectional)
1450 and 1950 nm suggesting that those wavelengths are images of layers at a specified even microscopic depth.
6 optimal for the assessment of lesion activity on tooth Todea et al. (2010) [186] used en face OCT to evaluate
coronal surface [174, 175]. and compare the quality of endodontic treatment
between diode laser assisted (980 nm), Nd:YAG laser
assisted (1064 nm), and conventional groups of extracted
6.8.7 Optical Coherence Tomography teeth. They found that though all the groups had obtu-
in Hard tissues ration defect the laser groups had significantly lesser
defects compared to the conventional group and that en
OCT or its newer adapted advanced versions provides face OCT allowed a precise, non-invasive, diagnostic
for varied and versatile applications in hard tissues such evaluation.
as the detection of caries and even marginal gaps of res- Most papers published regarding OCT imaging den-
torations or cracks in teeth. Shimada (2012, 2015) [176] tal hard tissues involves OCT imaging at 1300 nm where
illustrated this in his review article. there is deeper optical penetration due to the higher
Polarization-sensitive OCT (PS-OCT), a functional transparency of enamel. Longer wavelengths beyond
OCT technique, with near-infrared excitation could give 1300 nm have been investigated to achieve higher perfor-
structural and positional information based on birefrin- mance for imaging hard tissues, but higher performance
gence of the sample and polarization of back scattered has not yet been established at these wavelengths [187,
light [177]. PS-OCT can detail dental carious lesions 188]. There have been several review articles regarding
and give images which potentially can even monitor the the use of OCT imaging to image hard and soft tissues
progression of lesions over time [178]. in the oral cavity [189–194]. The first images of the soft
Wang et al. (1999) [179] had shown that PS-OCT and hard tissue structures of the oral cavity were
using 856 nm, 0.8 W diode laser, could be applied toward acquired by Colston et al. [195, 196]. Feldchtein et al.
the investigations of enamel and dentin by analyzing [197] presented the first clinical images of dental hard
their intrinsic birefringence. They were able to deter- tissues and restorations. OCT can be used to measure
mine refractive index values of enamel and dentin but the reflectivity within dental hard tissues to a depth of
though banded birefringence of enamel crystals was up to 3–4 mm in enamel and 1–2 mm in dentin. OCT is
seen up to the enamel dentin junction, considerable scat- valuable for obtaining high-resolution images of lesion
tering and anisotropy in dentine was observed with no structure and severity to aid diagnosis (. Fig. 6.19).
birefringence and resolution of finer features [180]. Baumgartner et al. [199, 200] presented the first
Gossage et al. (2003) [181] had stated that this was due polarization-sensitive (PS-OCT) images of dental caries.
to speckle interference (in dentinal structures such as PS-OCT images are typically processed in the form of
collagen—form birefringence) and that speckle noise phase and intensity images [201, 202], such images best
prevents resolution of structures and gives only sub- show variations in the birefringence of the tissues. Later
resolution features. PS-OCT measurements demonstrated the advantage of
However, dentin of attrited teeth were investigated using the cross polarization images (CP-OCT) to quan-
successfully by Mandurah et al. (2015) [182] using Swept tify lesion severity and track changes in lesion severity
Source-OCT in extracted teeth, where a 1310 nm laser over time [203]. Cross polarization is useful for enhanc-
(use of longer wavelength gives greater penetration and ing the contrast of demineralization and for reducing
more resolution of the deeper layers) with higher fre- the interference of the strong surface reflection that can
quency scanning speeds of 20 kHz provides better axial inhibit the resolution of structures near the tooth sur-
(11μm) and lateral resolution (17μm). Shimada et al. face [200, 203–204]. This is demonstrated in . Fig. 6.20.
(2010) [183] had shown that this technique could deliver CP-OCT and PS-OCT are particularly useful for moni-
Laser Assisted Diagnostics
153 6
a b
c d e
.. Fig. 6.19 OCT tomographic images of a premolar with inter- ent depths (z) from the tooth surface. Yellow arrow is a small occlu-
proximal lesions and occlusal decay at 1310 nm showing: a the over- sal lesion that penetrates to the DEJ and the blue + green arrows are
all reflectivity, b optical cross section or b-scan image (xz plane) from interproximal lesions. White bar is 1 mm [198]
mesial to distal surfaces and c–e en face images (xy plane) at differ-
toring the repair or remineralization of caries lesions by Many clinicians are primarily interested in the lesion
resolving the formation of a distinct highly mineralized depth so that they can decide whether a restoration is
transparent surface zone indicative of a reduction in necessary. The ability of radiographs to detect occlusal
lesion activity and lesion arrest [205–207]. lesions is extremely poor with an accuracy of ~50% [213,
High-speed Fourier domain OCT systems (FD- 214]. The failure to correctly diagnose occlusal lesions
OCT) have long since replaced the early time-domain that don’t appear on radiographs is a major problem
OCT systems (TD-OCT). For TD-OCT, the sensitivity and likely results in many unnecessary cavity prepara-
(signal to noise) decreases markedly with increased scan tions. OCT is ideally suited for monitoring and improv-
rate, this limits the maximum scanning rate to 1–2 kHz. ing the diagnosis of occlusal lesions. Lesions spread
This is not a problem with the FD-OCT systems and laterally under the enamel upon contacting the more
very high scanning rates can be achieved exceeding soluble softer dentin. Therefore, OCT can be used to
100 kHz. Galvanometers or Microelectromechanical determine if occlusal lesions have penetrated to the
(MEMS) scanning mirrors can be used to scan the beam underlying dentin by detecting the lateral spread across
in two dimensions to acquire 3D images of entire teeth the dentinal-enamel junction (DEJ), and this approach
in a 1–2 s as can be seen in . Fig. 6.19 [198]. Almost all has been successfully demonstrated clinically [139, 215].
OCT systems available today utilize either swept-source Interproximal lesions can also be imaged from the occlu-
(SS-OCT) or spectral domain (SD-OCT) systems [209– sal surface as can be seen in . Fig. 6.19 and the depth
212]. SD-OCT systems are very popular for from the proximal surface can be measured to assess the
Ophthalmology and for Dermatology, but they have had penetration depth.
limited applicability to dentistry since it has been diffi- OCT has also been used successfully to measure
cult to achieve high axial resolution while maintaining demineralization on dentin and on root surfaces (cemen-
the higher scanning ranges needed for dentistry, 7 mm tum) [216–218]. . Figure 6.21 shows an OCT scan of
of depth is needed to scan tooth occlusal surfaces and the root surface of a tooth with a root caries lesion and
the high refractive index of enamel (1.63) further with dental calculus. Cementum has lower reflectivity
restricts the scanning range. than dentin in OCT images, making it possible to iden-
154 A. M. Muruppel and D. Fried
a b
c d
.. Fig. 6.20 a Co-polarization ||—PS-OCT, b ⊥—PS-OCT images sound enamel is white in the TMR image, mineral loss appears black
(red-yellow color table), c TMR, and d PLM images of an artificial in PLM. L indicates lesion position [208]
lesion produced in an occlusal surface. Mineral loss is black and
Samek et al. (2001) [242] used a Q-switched Nd:YAG of water, protein, and lipid to mineral, offering some
laser, 1064 nm at 20 Hz, 4–8 ns pulses, with pulse energy level of selectivity without additional feedback. In the
10–30 mJ on 159 carious and healthy extracted teeth visible range, stains in caries lesions also have increased
and even in vivo on the molar tooth of a volunteer. They absorption. Several studies report the selective removal
confirmed that LIBS along with pattern recognition of caries lesions using various lasers including the
algorithms like discriminant analysis is able to positively Nd:YAG [263, 264], Er:YAG [265], frequency-doubled
identify between carious and healthy tooth structure to alexandrite (377-nm), frequency-tripled Nd:YAG (355-
a precision of 100–200μm laterally and 10μm in depth. nm) [266, 267], and excimer [268] based on increased
They inferred that this is possible through analysis of absorption of stains. The same principle can be applied
the spectra of matrix elements such as Ca or P and non- for the removal of calculus from tooth surfaces using UV
matrix elements like Li, Sr, Ba, Na, Mg, Zn, and C using and visible laser pulses [149, 269]. However, stains are
pattern recognition algorithms. They stated that in cari- not a good indicator of demineralization, and the min-
ous tooth structure there would be a decrease in matrix eral gradients in caries lesions are highly variable, and it
6 elements and an increase in non-matrix elements. is often necessary to remove sound tissues to reach the
LIBS has found varied applications [243] in the underlying body of the lesion. In addition, the laser
breakdown (Fang et al. 2005) [244], qualitative and should be able to remove both sound and demineralized
quantitative characterization of urinary and kidney enamel and dentin efficiently in order to be commercially
stones [245–247], or gall bladder stones and even the viable. Therefore, a more practical approach is to choose
analysis of fluids [248] like those containing glucose or a laser with a wavelength and pulse duration that effi-
organic matter. ciently removes sound enamel, and employ some form of
sensor, either optical, spectral, or acoustic in nature that
can be used to discriminate between sound and deminer-
6.9 Guided Selective Laser Ablation alized tooth structure and composite materials.
A major advantage of lasers is that they can be inte-
New sensors and imaging devices have been developed grated with computer-controlled scanning systems for
over the past three decades for acoustic, spectral, and high precision and selectivity. Lasers have been used for
optical feedback that are well suited for guiding laser many years for computer-aided design/machining (CAD/
systems for the selective removal of dental caries, com- CAM). It is clinically feasible to use high-speed com-
posite restorative materials, and calculus from tooth sur- puter-controlled scanning systems to selectively remove
faces. New and more sensitive optical methods of caries dental caries and composite restorative materials using
imaging have recently become available that allow acqui- spectral and image guidance. Robotic procedures in
sition of 2 and 3-dimensional images of lesion position, medicine are now commonplace, however few if any
depth, activity, and severity on tooth surfaces [194, 249– robotic procedures have been developed for dental appli-
251]. Such imaging systems are ideally suited for integra- cations. Lasers are ideally suited for automated control
tion with computer-controlled laser scanning systems. and after more than two decades of research, carbon
Over the past 50 years, the nature of dental caries dioxide, and erbium lasers are now both cleared by the
has changed with the majority of new lesions occurring FDA for caries removal. However, these lasers are still
in the pits and fissures of the occlusal surfaces [252, used clinically in a similar fashion to the conventional
253]. Demineralization in these areas may harbor an dental handpiece used for mechanical removal in which
active biofilm [254], and it can reduce the adhesive prop- the laser handpiece is handheld and visually guided. The
erties to sealants [255–257]. Lasers are ideally suited for potential for integration with spectral, image, and acous-
the selective removal of demineralized tissue in the pits tic guidance systems and automated control systems for
and fissures of the occlusal surfaces and for the thermal precision and selective removal of caries and restorative
sterilization of such surfaces [258]. If needed lasers can materials has not yet been realized.
also be used to selectively remove composite sealants
from the pits and fissures with minimal loss of sound
enamel [259, 260]. 6.9.1 Acoustic Feedback
Selective ablation can be achieved by simply tuning
the laser to a wavelength that has a lower ablation thresh- One of the first feedback mechanisms investigated was
old for specific tissue components [261, 262]. acoustic feedback. A complaint most often voiced by
Demineralized dental hard tissues are typically removed dentists with respect to hard tissue ablation is the loss of
at higher rates than sound tissues due to the higher ratio tactile feedback. Tactile contact provides the dentist with
Laser Assisted Diagnostics
157 6
important feedback with respect to discrimination of spectrometers have become available that are relatively
carious vs. non-carious tissue and control of cutting rate. inexpensive and can be readily interfaced with laser
Basic acoustic feedback can be used to determine if the ablation systems. This method has been proposed to dif-
laser is efficiently cutting tissue, whether it is cutting ferentiate between caries and sound tooth structure
enamel, dentin, or carious tissue and if there is excessive [242, 279, 280]. However, there are high concentrations
risk of acoustic damage due to too high of a fluence [270– of calcium in both sound and demineralized dental hard
272]. This mechanism can be implemented just by train- tissues and spectral guidance does not work for the
ing the clinician to recognize the appropriate acoustic removal of caries lesions [281], and an alternative image-
signatures. Measurement of the photoacoustic response guided approach is required to remove caries lesions.
(acoustic response to pulsed laser impact) provides a sim- Dental composites are used as restorative materials
ple tool for measuring the relative absorption of carious for filling cavities, shaping, and covering teeth for aes-
and non-carious dental hard tissue [266, 273, 276]. thetic purposes, and as adhesives. Dentists spend more
Additionally, it is a sensitive method for detecting the time replacing existing restorations that fail due to
respective ablation thresholds for various tissues [272]. microleakage and secondary caries than they do placing
Pigmented caries has been selectively removed by new restorations. Tooth-colored restorations are diffi-
visible and near-IR (NIR) lasers [275, 276]. Erbium cult to differentiate from the surrounding tooth struc-
laser wavelengths are highly absorbed by water and its ture and adhere strongly to the underlying enamel and
water-mediated ablation is a highly explosive process. dentin making them challenging to remove without
Monitoring the magnitude of the photoacoustic signal damaging tooth structure. Excessive amounts of healthy
as a function of the number of laser pulses provides tooth structure are often removed to ensure complete
important information about the evolving absorption removal of the composite. Multiple studies have shown
characteristics of the tissue. During ablation of graphite that spectral feedback can be used effectively to discrim-
with the Nd:YAG laser, the signal is initially high due to inate between the ablation of dental composite adhe-
the strong absorption. Photoacoustic magnitude falls of sive/restorative materials and dental hard tissues
gradually as a crater is formed and the surface topogra- [282–286]. Lasers are ideally suited for selective ablation
phy changes markedly. For dentin, there is initially a of failed restorations and sealants, removing composite
weak signal due to the poor absorption, followed by an adhesives such as residual composite left after debond-
increase in absorption as the protein chars creating a ing orthodontic brackets [283], and for the repair of aes-
highly absorbing target. After reaching maximum inten- thetic bonding [287].
sity, the signal drops after the char have been removed Spectral analysis of the plume has revealed that the
and an ablation crater has formed. Thermal modifica- distinctive high intensity calcium emission line at 605 nm
tion of the tissue changes its absorption characteristics found in dental hard tissues can be used to differentiate
and crater formation increases the irradiated surface tissues rich in hydroxyapatite (i.e., dentin and enamel)
area (decreases incident fluence). Therefore, the photo- from composite [259, 260, 266] (. Fig. 6.23). Composite
acoustic response is an excellent tool for determining restorative materials lack calcium and thus lack the cal-
both the onset of ablation and subsequent “stallout” cium emission lines that are very strong between 580 and
after thermal modification of the tissue. Even though 650 nm which gives the plume a distinct red appearance.
this method of feedback was developed more than Similar results can be achieved faster and cheaper by
30 years ago, it does not appear that there have been any substituting the spectrometer with a pair of filtered pho-
successful attempts in dentistry to couple acoustic feed- todiodes. Spectral guided selective removal of dental
back with laser scanning for selective ablation. composite was demonstrated in vivo in a small clinical
study [288, 289] using a CO2 laser with an articulating
arm, galvanometer, and two diodes with narrow band-
6.9.2 Spectral Guided Feedback pass filters at 620 and 540 nm (. Fig. 6.23).
a b c f g
d e
.. Fig. 6.25 Mandibular molar accessed with truss design. a–c Vis- location (red) from the occlusal viewpoint post cutting with the CO2
ible microscope images showing pre-ablation a, post laser access b, laser d and post crown down procedure e. f, g Volumetric renderings
and post crown down c. d, e CBCT volumetric renderings indicating showing mesial-distal f and buccal-lingual g views [315]
positioning of the laser preparations (yellow) in relation to orifice
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current clinical and research applications in dentistry. CU
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Dent J. 2014;37:123–36.
173 7
Photobiomodulation Therapy
Within Clinical Dentistry:
Theoretical and Applied
Concepts
Mark Cronshaw and Valina Mylona
Contents
References – 227
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
175 7
Core Message 7.1 rinciples of Action: Historical
P
Photobiomodulation therapy (PBMT), formerly known Perspectives
as low-level laser therapy, is the targeted application of
light for therapeutic purposes at a low level below that Radiant solar energy is essential to sustain the majority
associated with damage to structural proteins. This may of living organisms as without light there is no source of
be a laser or a broader spectrum light source such as a photonic energy to drive photosynthesis nor is there the
light-emitting diode (LED), which may selectively achieve primordial photothermal source to enable the enzyme
changes in subcellular, local, regional and centrally medi- processes of all but the hardiest of life forms. The cap-
ated systemic processes associated with healing, repair ture by plant chlorophyll of incident photonic exposure
and the regeneration of tissues [1, 2]. In addition to the in the visible to near-infra-red spectrum of light enables
potential benefits of the promotion of an increase in cel- the fixation of gaseous CO2 into carbohydrates which
lular numbers by mitosis and a corresponding increase in then in turn become the substrate for the controlled
the production of important matrix materials such as col- release of the captured solar energy to form key cellular
lagen and bone along with an enhanced vasculature, there biochemicals via the Krebs cycle and the mitochondrial
can also be seen resolution of inflammation and the miti- electron transport chain. Aside from the Calvin reaction
gation, up to inhibition of pain [3, 4]. Furthermore, ther- which is a magnesium-based carbon capture process
apeutic photonic conditioning of tissues as a prequel or associated with photosynthesis, there are also many
synchronous to exposure to a noxious stimulus such as other photon transduction mechanisms which can result
chemotherapy or radiotherapy can increase cellular stress in energy capture. These include other photochemical
resistance against apoptosis [5, 6]. Given the very wide processes as well as photoelectric, photothermal, photo-
range of possible applications, PBMT has excited consid- magnetic and photomechanical effects and photofluo-
erable interest across a multitude of possible applications, rescence [10–13].
as an adjunct to augment the normal procedures in clini- The history of using light and color for health and
cal dentistry [7, 8]. Following over 50 years of research at healing (heliotherapy) can be traced back thousands of
the level of cellular, animal and more recently human years in human history. Virtually all ancient civilizations
clinical trials, there is a considerable published evidence (China, India, Egypt, Greece, Meso-America) imple-
base. To date the broader integration of this approach as mented the use of sunlight or colored light in healing.
a tool to assist the dental team to optimize a clinical inter- Indian medical literature dating back to 1500 BC
vention has been slow to be adopted. Given the extent of describes a treatment combining herbs with natural sun-
the current knowledge base which is rapidly expanding light to treat non-pigmented skin areas. Buddhist litera-
due to the heightened awareness of the potential value of ture from about 200 AD and tenth-century Chinese
this approach to enhanced healing and tissue manage- documents made similar references. The nineteenth cen-
ment, it is inevitable that PBMT will in time become a tury saw a resurgence of this concept with the use of
standard evidence-based procedure in daily clinical prac- colored light sources for the promotion of wound heal-
tice. In this chapter we provide a contemporary overview ing and pain reduction [7, 14, 15].
of this important subject with a particular view to help Niels Finsen (Denmark) developed the first artificial
guide the clinician with an interest in learning the pro- light source for the purpose of treating lupus vulgaris.
cesses involved to safely and successfully explore the He received the Nobel Prize in Physiology or Medicine
potential merits of this approach to patient care. in 1903 [16–18].
Key clinical points are drawn from the many wave- The latter half of the twentieth century witnessed a
lengths in the visible to far infra-red that have been associ- rediscovery of the science by researchers including
ated with positive healing events. Additionally, PBM may Gurwitsch (Russia), Mester (Hungary), Karu (Russia),
be best viewed as a multiphase therapy where at lower end Fröhlich and Popp (Germany) [10, 19–21].
dosimetry there is an increase in cellular activity whereas at In the early 1800s, Christian von Grotthus and John
a higher level there can be inhibition of cellular function Draper formulated the first law of photochemistry,
which may be beneficial in pain relief [9]. The interest in which states that only the light absorbed by a substance
regard to the mechanisms of action of PBM is relevant in can produce a photochemical change. This has been
respect of the understanding required to more deliberately adapted and adopted as the first law of photobiology
direct the delivered photonic energy to achieve the desired which requires that there is a cellular receiver for the
beneficial effects. This may impact on the choices made in transfer of energy from the incident photons to effect
respect to parameters as well as the clinician’s choice of change [22, 23]. The site of absorption has been referred
clinical device. to as a chromophore which is the part of a molecule
176 M. Cronshaw and V. Mylona
responsible for its color within the visible spectrum. 7.2 rinciples of Action: Cellular
P
There are molecules such as water which are colorless Perspectives
yet are high absorbers with some wavelengths. The use
of the term chromophore in the context of energy trans- To optimize success in PBMT, it is essential to have an
fer in PBM is not strictly accurate; however it has been understanding of optical transport processes in biologi-
broadly adopted within the PBM literature. cal tissues, plus some knowledge of the optical proper-
Professor Endre Mester is credited with the discov- ties of different wavelengths and an appreciation of
ery of the biological effects of low-power lasers. He per- photonic energy transduction pathways [31–33]. On a
formed early science experiments on the biological cellular basis, all eukaryote cells are photoreactive as
effects of laser irradiation. While applying lasers to the indeed are many unicellular organisms such as bacteria
backs of shaven mice, Mester noticed that the shaved and Archaeans. Eukaryote cells compose the essential
hair grew back more quickly on the treated group than base units of all multicellular organisms and are distin-
the untreated group [24]. guished by the presence of a nucleus as well as by cellu-
PBM therapy (PBMT) through the application of lar organelles, including mitochondria. The mitochondria
photonic energy works on the principle of inducing a are generally regarded as one of the more important
7 biological response through energy transfer. Such non- recipients for the applied photons in PBMT [34, 35].
ablative photonic energy delivered into tissues modu- Mitochondria are the active sites for the manufacture of
lates biological processes within that tissue and within adenosine triphosphate (ATP) which is the essential
the biological system of which that tissue is a compo- energy currency used by the cell to drive metabolic pro-
nent part. It is a source of some debate, however, which cesses associated with protein and fatty acid manufac-
concerns the thermal rise in irradiated cells or tissue, ture and catabolism. Mitochondria are also pivotal to
bearing in mind that because of absorption, photonic the nitrogen-based urea cycle, as well as being an impor-
energy will impart increased target molecular activity. tant center for the regulation of calcium ions plus the
However, within a correct incident dose, PBM has no production of nitric oxide (NO) and the collateral man-
detrimental thermal effects in irradiated tissue [25]. ufacture as a side product of aerobic and anaerobic
The medical benefits of the therapeutic application metabolism of reactive oxygen species (ROS) [36, 37].
of photons to patients initially may seem a strange idea. Furthermore, mitochondria are sites of high molecular
However, human physiology is highly responsive to light activity from which the cells derive a source of heat,
as evidenced by the circadian rhythm which is entrained enabling a carefully regulated system of endothermic
through bright light. Specialized retinal receptors are metabolism [9, 38–40]. Given the central role played by
activated by bright light which via axonal stimulation of mitochondria in the anabolism and catabolism of pro-
the suprachiasmatic nucleus results in the inhibition of teins and fatty acids as well as the many other key aspects
the production of melatonin in the pineal gland. of eukaryote metabolism, the capacity to influence mito-
Disruption to the normal diurnal rhythm of a daytime chondrial activity by exposure to light has attracted con-
reduction and a nighttime rise in CNS melatonin levels siderable attention in the PBM literature. The wider
results in disturbance to sleep patterns as may be experi- recognition of the importance of mitochondria in health
enced by long haul travelers with so called jet lag. Also, and disease has resulted in very considerable cross disci-
irregularity in the normal daytime sympathetic as pline investigations from scientists including cell biolo-
opposed to nighttime parasympathetic nervous system gists, pharmacologists, biochemists, oncologists and
physiological activity cycle has been associated with an researchers into degenerative CNS conditions, including
increased risk for night workers of developing metabolic Alzheimer’s and Parkinson’s disease along with many
syndrome and possibly an increased risk of developing other disorders [9, 41].
some types of cancer. A further example of human The intracellular aspects of cellular regulation repre-
photo-reactivity is lack of exposure to ultraviolet “B” sent a heavily researched area which has revealed an
(UVB) 280–315 nm light, which is absent during the extraordinarily complex system of checks and balances.
winter months in the northern hemisphere. This results In respect of PBMT, a good deal of attention has
in vitamin D deficiency with a consequence of negative focused on the inner mitochondrial membrane and loca-
impacts on the immune system as well as on bone tion of an array of five principal units (I–V) known as
metabolism. Furthermore, light can impact on mood as the electron transport chain (ETC). The functions of the
the production of some key neurochemicals including ETC include the manufacture at unit V of ATP by
serotonin, dopamine and adrenaline is depleted in the means of a “molecular turbine” driven by a stream of
shorter daylight periods of winter predisposing some protons, built up across the mitochondrial inner mem-
individuals to clinical depression [26–30]. brane from the core central matrix by the biochemical
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
177 7
activities of the preceding four units. In the literature pathways of specific applied wavelengths in the red to
there is a considerable emphasis on the prime impor- NIR. Current thinking proposes that there are very
tance of unit 1 V of the ETC, which is a cupric–ferrous many potential targets for photon transduction includ-
(Cu–Fe) proteinaceous enzyme cluster called cyto- ing water. Biological tissues have a high water content
chrome c oxidase (CCO). The selective absorption of with an average adult male body comprising around
incoming red to near-infra-red (NIR) light by the alpha 55% by volume water, a female at a slightly higher
1-haem and haem-3 units of this 13-subunit complex water content of around 60% and a newborn baby who
was proposed in 1998 as the central step in the increase can have as high a water content as 85% [54]. Bulk
in activity of the ETC observed with the production of water is not generally a barrier to onward transmission
more ATP, along with increases in the mitochondrial of light irradiation to wavelengths in the blue to NIR
membrane potential and oxygen consumption [4, 42, range as water has both low absorption and is a low
43]. Furthermore, it was proposed that nitric oxide is a scattering medium to visible to NIR wavelengths of
key cellular regulator of CCO due to the NO competi- light. The exception to this is the 980 nm wavelength
tively binding to oxygen ion sites within CCO in hypoxic which has a small but significant absorption peak for
and stressed cells, thus reducing CCO activity. It has water [55, 56].
been shown that the inhibitory NO can be displaced In close proximity to hydrophobic molecules, water
from the oxygen binding sites by light-induced photo- has been proposed to form a semirigid nanostructure
dissociation, enabling an increase in aerobic metabolism microlayer which may be photoreactive. Sommer has
with a resultant increase in ATP output [44–48]. suggested an interesting hypothesis that combines the
Unit IV is one of the sites of manufacture of NO by idea of nanostructured water acting as a photon receiver,
nitrite reductase. PBM using a 590 nm LED was found with the well-established response to irradiation of
to promote NO synthesis catalyzed by CCO and NO is increased production of ATP observed in mitochondria
a potent vasodilator. NO acts as a secondary messenger, [57, 58]. ATP synthase (unit V of the ETC) is a mem-
able to modulate the activity of enzymes such as guany- brane protein complex composed of two interconnected
lyl cyclase that synthesizes cyclic guanosine monophos- rotary molecular motors powered by the flow of protons
phate (cGMP) starting from guanosine-5′-triphosphate generated by the electron transport chain driving the
(GTP). cGMP relaxes smooth muscle of tissues and primary F0 rotor across the mitochondrial membrane.
blood vessels, inducing vasodilation that leads to an The F0 rotor is connected to the second F1 rotor, which
increased blood flow as well as improved lymphatic produces ATP from ADP and phosphate. The hypothe-
drainage [49–51]. sis is that a photoinduced reduction in the viscosity of
However, some of the concepts of this neat theoreti- nanostructure water surrounding the mitochondrial
cal encapsulation of PBM activation have been subject membrane will allow these rotors to turn faster and
to re-evaluation following more recent research. Lima therefore create more ATP (. Fig. 7.1).
et al., for example, characterized two different cell lines There are many potential subcellular sites for the
that lack the fully assembled CCO enzyme. PBM at absorption of light including flavins, porphyrins, nuclear
660 nm was still found to be effective in promoting mito- chromatin, cytochromes, opsins, cryptochromes and
sis along with an increase in ATP production. The long- transient reactive vanilloid potential membrane ion
standing concept that the optimal wavelengths for PBM gates (TRPVs). Examples of endogenous chromophores
are in the red to near-infra-red range due to their affinity are melanin, hemoglobin (oxyhemoglobin, de-
for CCO has been challenged as the peak absorption of oxyhemoglobin and methemoglobin), protein, peptide
CCO corresponds to 82% for the 415 nm and 26.7% for bonds, aromatic amino acids, urocanic acid and biliru-
the 540 nm whereas the 660 nm absorbs around 8.7% bin [34]. One common thread to these sites of energy
and the 810 nm 16.2%. A contrary effect of a reduction transference is the presence of pigmented materials,
in ATP production by irradiation with the 415 nm blue which by virtue of their molecular density as well as the
wavelength as opposed to the increase observed with red content of transition metals such as iron/copper con-
to NIR sources implies that strong absorption by CCO taining compounds are broad band receivers of visible
may not be the intrinsic cause of the ATP upregulation. to NIR light. Should the resonant frequency of the
In respect of Lane’s hypothesis, PBM has been identified incoming photons coincide with the valence band width
as a trigger for new enzymic activity at CCO to produce of the target, this can drive electrons into a higher
NO. However, this process depends on the presence of a valence band. In addition, any energy in excess of this
sufficient supply of nitrite which may not be present in value results in an increase in molecular vibration which
significant amounts in all cells and tissues [52, 53]. is expressed in the form of heat [32]. Many transition
Newer theories of PBM action have moved away metals are broad band receivers of photonic energy
from the earlier concepts of optimal photochemical resulting in photoelectrical and photothermal effects as
178 M. Cronshaw and V. Mylona
.. Fig. 7.1 The electron transport chain is a five-unit complex which can prove damaging to essential elements of the cell. Protec-
found in the inner mitochondrial membrane plates (cristae) separat- tive elements include key antioxidant enzymes, plus in cells with a
ing the inner core of the mitochondrion (matrix) from the intermem- high rate of metabolic activity, there may be a category of transmem-
brane space. A proton gradient is built up across the two brane proton transporters called uncoupling proteins (UCPs) which
compartments of the mitochondrion with an electron flow to unit V can act as a safety mechanism to reduce mitochondrial production
which permits the flow of protons back into the matrix which drives of ATP. Each of the elements of the ETC is photosensitive and as
the twin molecular rotors culminating the phosphorylation of ADP such is regarded as key operand in the cytochemistry associated with
into ATP. A by-product of this process is reactive oxygen species PBM. (Graphics by S. Parker)
(ROS) which are carefully regulated to avoid excessive build up
well as photomagnetic, photofluorescent and photome- In the event that the photon stream is delivered as a
chanical events. gated pulse, this can result in photomechanical (photo-
In addition to the potential selective photochemical acoustic) induced changes in cell membrane permeabil-
stimulus of CCO and any lower-level photothermal ity. It has been postulated that a low hertz gated pulse
effects, transition metals are electron acceptors as well as may result in a photomechanical pressure wave that can
donors. Also, there can be changes in the valence band temporarily produce a cell membrane conformational
of electrons depending on the resonant frequency of the change that can open membrane-bound ion gates. In
incoming photon wavelength coinciding with the chro- nerves this could interfere with the sodium–potassium
mophore. These effects can result in electron flow, or pump, and this mechanism has been proposed to be a
alternatively the activated state of the higher energized contributory factor to a reduction of transmission along
electrons may result in the release of a further photon as an axon by a wave of depolarization [2, 61].
it decays to its ground state. In the case of a metastable The potential energy of a photon is expressed by the
valence band, this may result in phosphorescence rather term electron volt which is the amount of energy neces-
than the more rapid decay observed in fluorescence. sary to move an electron through a 1 V electrical field.
These effects may seem esoteric; however this type of There is an inverse relation between energy and wave-
induced secondary photon release is recognized as being length as shorter wavelengths have a higher cycle fre-
a trigger for synchronized mitosis [59]. A further effect quency and an associated higher-energy electromagnetic
on metal containing compounds of photonic exposure field. In consequence, the effects of a shorter-wavelength
is the realignment of dipoles, and this photomagnetic photon striking a molecular target are markedly differ-
effect may change the configuration of enzymes’ open- ent to a longer wavelength as the shorter wavelengths on
ing and closing binding sites, hence changing the activity absorption can have a more pronounced electromag-
of the enzyme as well as possibly opening membrane- netic effect. To break molecular bonds requires an
bound ion gates [60]. amount of energy which if sufficient can result in a pho-
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
179 7
.. Fig. 7.2 The dissociation energy required to break chemical ble of ionization of DNA base pairs within chromosomes and are
bonds (eV) is higher than the eV available from single photons from not considered mutagenic. (Source: Mó, O., Yáñez, M., Eckert-
laser wavelengths commonly used for PBMT. Except on the occasion Maksić, M., Maksić, Z.B., Alkorta, I., Elguero, J. (2005). Periodic
of the simultaneous collision of two photons of the same wavelength trends in bond dissociation energies. A theoretical study. The Journal
at an absorbing molecule, there is insufficient energy to break molec- of Physical Chemistry A109, pp. 4359–4365)
ular bonds. Hence visible to far-infra-red wavelengths are not capa-
tochemical change. As can be seen in the table below in and cumulative lower levels of ROS production, a sig-
the red to NIR wavelengths, there is insufficient energy naling cascade is instigated which ultimately leads to the
to break the chemical bonds of many common tissue phosphorylation of IκB, an inhibitor of the pro-
constituents [62]. However, the repeated and accumu- inflammatory transcription factor nuclear factor kappa
lated energy of a stream of photons can result in photo- B (NFκB). In its inactive state, IκB is bound to NFκB in
thermal effects due to an indirect kinetic effect the cytoplasm; however, once phosphorylated, IκB dis-
consequent to an increase in elastic and inelastic molec- sociates from NFκB and is targeted to the proteasome
ular vibration. It is recognized that although the red to for degradation. This then allows the translocation of
near-infra-red wavelengths are less than the threshold free NFκB to the nucleus binding to DNA and initiates
eV necessary to break chemical bonds, indirect a series of gene transcription changes, mRNA produc-
photochemical-induced effects such as an increase in the tion and the downstream expression of key cytokines,
production of NO are observed [63] (. Fig. 7.2). chemokines and growth factors including interleukin 8
One of the by-products of aerobic and anaerobic (IL-8), IL-6 and vascular endothelial growth factor
metabolism is reactive oxygen species (ROS). Persistently (VEGF) which promotes the growth of new blood ves-
elevated higher levels of ROS are damaging to cells and sels. Another gene directly regulated by NFκB activa-
tissues and are considered a major cause of the symp- tion is cyclooxygenase-2 (COX-2). Its main role is to
toms of many diseases and conditions as well as being catalyze the conversion of cell membrane-bound
associated with some of the degenerative changes seen arachidonic acid to prostaglandins including PGE2. It is
in aging. However, this does not mean that ROS are interesting to note that some of these factors such as
entirely detrimental to cells and tissues. It has been IL-6 and PGE2 are pro-inflammatory which in respect
found that lower-level short-duration increases in ROS of the observed effects of PBM to promote good-quality
production can be beneficial [37, 64, 65]. healing and repair with the good resolution of inflam-
ROS have a number of positive roles one of which is mation may at first sight seem contradictory. However,
to act as important cellular signalers. On short bursts the absence of inflammation is associated with poor
180 M. Cronshaw and V. Mylona
healing as the acute inflammatory response is the pri- oxidant systems to reduce the ROS activates a sequence
mary trigger for the processes associated with cellular mediated by ATF-4 resulting in calcium ions being
repair. Any short-term uptick in inflammation is released from deposits in the endoplasmic reticulum.
however mitigated by the photoinduced generation of Elevated cytoplasmic calcium ions activate opening of
pro-healing growth factors such as transforming growth the mitochondrial transport pore which in parallel with
factors beta (TGFs-β) and VEGF, an increase in oxida- the actions of the HSP cascade effectively closes down
tive metabolism, mitosis and the increased expression of mitochondrial activity and places the cell into a tempo-
genes associated with the resolution of inflammation. In rary form of stasis. There is an increase in the produc-
an in vivo animal and in vitro tissue culture investigation tion and activity of ATPase with a corresponding
of cellular photon transduction pathways, Arany et al. reduction in the availability of ATP, plus there are
employed a laser emitting a wavelength of 904 nm with changes in the actinic cellular skeleton which result in
radiant exposure outputs ranging from 0.1 to 6 J/cm2 the translocation of mitochondria away from sites of
and concluded that PBM was able to activate latent key activity such as synaptic junctions. Temporary
TGF-β1. TGFs-β have a crucial role in tissue healing reversible changes are also seen in the axonal mem-
and can be activated by a range of stimuli including heat branes with the appearance of structures referred to as
7 and pH changes [66, 67]. axonal varices which may impede the progression of an
Intra-mitochondrial ROS arise primarily at units I axonal wave of depolarization [69]. This photon-
and III of the ETC, and there are multiple systems to induced inhibition of cellular metabolism is a protective
regulate excess ROS levels which unchecked can cause response to the stimulus, and these pathways have been
irreversible tissue damage. ROS are highly chemically proposed to be in part some of the underlying mecha-
active and can result in the formation of toxic reactive nisms associated with photon-induced bio-inhibition of
nitrosyl species. Unregulated this results in damage to axons resulting in analgesia.
proteins and fatty acids associated with cellular mem- ATF-4 and HSP70 act to protect cellular and tissue
branes with consequences in the progressive degrada- integrity enabling a cell repair and tissue protection
tion of cellular function. Production of ROS is response which increases cellular resistance to stress that
associated with both low and high levels of activation could otherwise result in apoptosis.
of the ETC. Manganese superoxide dismutase (SOD) The ETC is not 100% efficient as there is some leak-
within the mitochondria, as well as cupric–zinc SOD in age of electrons and protons back across from the inner
the cytoplasm, converts the potentially harmful ROS membrane space into the mitochondrial matrix. This
ions into hydrogen peroxide, and there are other highly occurs by virtue of two mechanisms: One is basal medi-
active protective antioxidants, including catalase, gluta- ated by the catalytic activity of adenine nucleotide trans-
thione reductase, vitamin C, coenzyme Q10, resveratrol location associated with free fatty acids in the inner
and melatonin, amongst others. ROS levels can how- mitochondrial membrane. The other is inducible cour-
ever rise beyond the immediate shielding capacity of the tesy of a group of proton transporters related to the
cellular systems resulting in elevated levels building in superfamily of transmembrane proteins associated with
the cytosol and the mitochondrial matrix. Should the the transfer and carriage of metabolites. Brown adipose
levels of ROS continue to increase, this can potentially tissue was the first to be identified as possessing these
prove highly toxic, and an initial regulatory response inducible proton carriers, which are referred to as
results in an adaptive stress reaction mediated by the uncoupling proteins (UCPs). The presence of UCPs has
endoplasmic reticulum (ER) via a stress-induced pro- subsequently been identified in many organs of high
tein called activated transforming factor 4 (ATF-4) [68]. metabolic activity as well as muscle tissue sites. The
The potential for phototoxicity was investigated by UCPs open passage for protons away from the inner
Khan and Arany in a murine model from which a path- mitochondrial membrane back into the matrix, which
way was characterized involving a system of chaperone results in an elevation of temperature and a reduction in
proteins referred to as heat stress proteins (HSPs) which the inner membrane electrical gradient. The reduced
act in concert with ATF-4. The outcome of higher-dose availability of inner membrane protons and the associ-
photo-irradiation was identified to be temperature ated reduced electrical membrane gradient result in a
related where even a mild increase in temperature reduced efficiency in production of ATP by the ETC. It
quickly inactivated the ROS-buffering enzymes catalase is the current consensus opinion that elevated levels of
and glutathione reductase and also resulted in strong ROS act as an initiator for the manufacture and activity
activation of the heat stress protein (HSP) chaperone of the UCPs [70–73]. The UCP response to elevated
system. In response to photon-induced temperature ROS levels has been suggested to be a further
elevations, an increase in ROS levels was noted which contributory factor to the mechanisms of photoinduced
when in excess of the capacity of the cells’ normal anti- analgesia [9] (. Fig. 7.3).
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
181 7
.. Fig. 7.3 Reverse electron transfer can occur on elevation of ROS cert with the HSPs offers some protection of the cell from metabolic
levels resulting in re-formation of ubiquinone (unit 1 of the ETC) from stress. These processes have been proposed to be contributory elements
ubiquinol in response to an increase in ROS. Also, in the presence of to improving cellular resistance to recurrent stressors (pre-condition-
UCPs, the proton gradient can move back into the mitochondrial ing) as well possibly as contributory factors to the mechanisms associ-
matrix bypassing unit V. This results in an elevation of the matrix tem- ated with photoinduced analgesia (Graphics S. Parker Reproduced
perature with the activation of HSPs, a depletion of ATP and decou- from Scialò F, Fernández-Ayala DJ, Sanz A. Role of mitochondrial
pling of the ETC resulting in anaerobic metabolism. The cytoplasmic reverse electron transport in ROS signaling: potential roles in health
levels of ROS rise with the resultant activation of ATF-4 which in con- and disease. Frontiers in physiology. 2017 Jun 27;8:428)
.. Fig. 7.4 In vitro porcine muscle comparison of surface ΔT val- Cronshaw et al. Photothermal aspects of high energy photobio-
ues as a function of wavelength (λ). Average power 2.0 W/cm2 modulation therapies: an in vitro investigation. Biomedicines
(continuous wave). Surface thermal rises exceed the 6.0 °C thresh- 2023, 11, 1634 [56])
old limit for all wavelengths except 810 nm. (Reproduced from
To a lesser degree, there is caution attached to the use anticipated to have a positive effect on cellular produc-
of the 650 and 1064 nm sources, as again these wave- tivity and metabolism. However, above a 2 °C increase in
lengths can be associated with a significant rise in tissue temperature, a protective response is activated by an evo-
temperature with extended use. However, all these wave- lutionary primordial system common to all eukaryotes
lengths can be of use subject to training, as the operator of heat stress proteins (HSPs) [78]. Primordial pre-
needs to be aware of the methods to avoid surface and eukaryote life was based on a variety of cycles of metab-
sub-surface tissue overheating by means of a good tech- olism, including aerobic and anaerobic respiration, as
nique of application, as discussed later in this chapter. well as sulfur metabolism in single-cell Archaeans and
To avoid a rapid rise in surface temperature, the use bacteria. The evolution or adoption of the mitochon-
of the shorter wavelengths such as the 445 nm (blue) drial Krebs cycle and ETC by the early eukaryotes pro-
laser requires low output power <100 mW and a corre- vided a lot of additional adenosine triphosphate
sponding low irradiance 50–100 mW/cm2 for brief peri- (ATP)-generating capacity. In addition, as this is an exo-
ods of exposure. Due to the high energy of the blue end thermic reaction, the essential platform was built that
of the spectrum, the high superficial absorption and provided the added energy that could sustain the build-
rapid thermal rise seen with the shorter-wavelength ing of more complex organisms, resulting in m ulticellular
sources, the utility of this end of the spectrum is at pres- species. Control over cellular temperature is a highly
ent limited for PBMT. conserved feature of eukaryote cytochemistry. The ther-
By convention PBMT is defined as not being primar- mal aspects of mitochondrial metabolism are conven-
ily a significant photothermal effect resultant in adverse tionally denied a role in PBM, on the grounds that by
irreversible changes to structural proteins. However, definition PBM is a nonthermal event. This premise,
some localized heat is generated, and a small highly however, may be true in respect of distinguishing the
localized thermal rise within the cell and subcellular physiological effects of heat compared to light. However,
structures can result in a range of interesting responses. the selective absorption by elements of the ETC may
At an elevation of temperature of 1–2 °C, slight warm- produce a localized increase in the intracellular tempera-
ing of tissues has been found by the dermatology com- ture [38, 79, 80]. The HSP system protects against ther-
munity to be associated with good-quality healing mal damage to part formed proteins and enables the cell
[74–77]. All enzyme functions are promoted by a small to conserve the partially built materials. A cellular
increment in temperature, and this may reasonably be response is elicited which reduces cellular activity, includ-
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
183 7
ing the downregulation of the activity of the ETC. Once On entering the deeper layers of the dermis, some
the adverse thermal stimulus has been removed, the cell photons can travel straight through the tissues (so called
can then revert to normal functional physiology without ballistic photons). Some ricochet off and are deflected
harm, providing the duration was not too long and the by tissue sub-constituents such as tissue boundaries,
peak of the thermal insult not too high [68, 81]. organelles and collagen which results in the phenome-
The microthermal aspects of PBM have not yet been non of scatter. With a coherent (laser) light source where
comprehensively investigated. Beckham et al. found that all the photons are in the same phase and wavelength,
a thermal rise to 43 °C was a safe and effective primer should photons collide, this results in localized amplifi-
for the stimulation of the production of HSPs. This pre- cation and the phenomenon of speckling where bright
conditioning of the cells resulted in an increase in viabil- spots of light can be seen which are a characteristic of
ity and a corresponding reduction in apoptosis on later lasers observable in the visible range. Some of the scat-
laser exposure to much higher temperatures. We explore tered photons can then travel onward (so called snake
the issues around the safe administration of PBMT later photons). Scattered photons can be directed in different
in this chapter [6]. directions once they hit particles within the tissues. The
coincidence of the incoming photon stream from the
surface source plus the photons deflected back by scatter
7.5 Optical Transport Pathways to the dermal–epidermal boundary result in a higher flu-
and the Relation to Wavelength ence in the immediate sub-surface layers of the tissues
than that applied at the surface [83]. Depending on
Light striking the surface of tissues can be transmitted, wavelength absorption, this can result in a significant
reflected, refracted, absorbed or scattered. Optical trans- reduction in optical delivery to depth and may cumula-
mission into the tissues depends on a number of factors tively lead to a higher temperature at this immediate
including the angle of incidence which with a more sub-surface tissue level compared to the surface.
oblique angle results in an increase in reflection ranging The anisotropy factor (g) is a function of the angle at
from 2% to 7% [31, 32] (. Fig. 7.5). which photons are scattered. In most tissues this is
On entering the tissues, the increased optical density mostly a forward direction in the red to NIR wavelength
of the medium changes the direction of the incident range, although there can also be some scatter back
beam and there can be internal reflection and optical toward the source; this results in energy losses to deeper
loss to deeper tissues (remission) at the epidermal–der- tissue layers and radiant exitance. Shorter wavelengths
mal boundary. 400–600 nm are highly absorbed by proteins and pig-
.. Fig. 7.5 Optical transport through biological tissues results in it can reasonably be expected to deliver 2–10% of the surface applied
high power losses to deeper layers within the first few millimeters of to a depth of 1 cm using wavelengths in the red to NIR. (Reproduced
application at the surface. Outcome variables include the thickness from Cronshaw et al. Photobiomodulation dose parameters in den-
of the epithelium, skin pigmentation, wavelength applied, angle of tistry: a systematic review and meta-analysis. Dentistry Journal.
incidence at the surface and the consistency of the tissues. In general 2020 Oct 6;8(4):114 [82])
184 M. Cronshaw and V. Mylona
.. Fig. 7.7 Q-PBM tissue/cellular signaling with visible/IR λ. biomodulation Therapy: a Narrative Review. Mol Neurobiol. 2018
(Graphics by S. Parker taken from Salehpour F, Mahmoudi J, Aug;55(8):6601–6636. 7 https://doi.org/10.1007/s12035-017-0852-4
Kamari F, Sadigh-Eteghad S, Rasta SH, Hamblin MR. Brain Photo- [87])
analgesic effects of the 2780 nm Er,Cr:YSGG laser, as ject to adequate training, as consistent good-quality
well as clinical and histological evidence of good-quality healing can be observed across the full spectrum of
healing associated with the 10,600 nm CO2 laser [86, 95, clinical surgical lasers currently adopted in contempo-
96]. As a collateral effect of using a surgical diode, rary clinics. The collateral benefits of surgical laser
erbium or CO2 laser, it is likely that there are PBM integration into routine clinical practice include a dual
effects despite the limited optical penetration possible advantage of precise controlled tissue manipulation
consequent to the very high remission of these wave- along with excellent quality healing, repair and the
lengths. Contrary effects have been described for many capacity to promote regeneration of damaged or lost
wavelengths and there are many apparent conflicts in tissues. This “two for one” benefit is seen as being in
reported outcomes. Resolution of optimized parameters part a consequence of the action of photons below the
for PBMT is reliant on high standards of experimental dosimetry threshold to damage tissues; this effects pos-
design and reportage which require a thorough appreci- itive cellular physiological pathways which include an
ation of the optical physics associated with dosimetry, increase in stress resistance and the promotion of
as discussed below. highly productive aerobic metabolism, angiogenesis
and mitosis [86]. The observed tissue healing response
outside the immediate surgical zone of destruction is
7.6 rinciples of Action: Clinical
P marked by a reduction in acute inflammation with an
Perspectives associated amelioration of postsurgical pain and swell-
ing [97]. The enhanced quality of the wound resolution
All clinical dental lasers have the capacity to demon- in contrast to the conventional scalpel, drill and suture
strate an associated positive tissue outcome subject to surgical approaches is entirely remarkable and to the
the knowledge of the operator to deliver the energy in suitably trained clinician represents a major gain
a deliberate and safe fashion. All surgical lasers are toward the desired clinical outcome as well as facilitat-
recognized as being a good choice of tool to use sub- ing the patient journey (. Fig. 7.8).
186 M. Cronshaw and V. Mylona
.. Fig. 7.8 Clinical case: childhood trauma is a regular cause of as well as reduce the peak and duration of the physiological response
urgent care attention. PBMT can assist in the mitigation of the acute to injury. The reduction in pain and swelling plus the enhanced qual-
inflammatory phase associated with primary wound healing. Also an ity of the final repair make PBMT a highly useful clinical modality.
early intervention can improve the viability of the damaged tissues (Images: days 1–20)
.. Fig. 7.9 Two at tissue-level dose ranges with the effects of stimu- Feeling the heat: evolutionary and microbial basis for the analgesic
lation or inhibition have been identified. This multiphasic response mechanisms of photobiomodulation therapy. Photobiomodulation,
to dose is seen frequently in pharmacy and PBMT has been com- Photomedicine, and Laser Surgery. 2019 Sep 1;37(9):517–26 [9])
pared to being a drug equivalent. (Adapted from Cronshaw et al.
lem of calculating the correct dose has been com- . Fig. 7.9). There is a commonality of the stimulatory
pounded by confusion on what constitutes the delivered or inhibitory/protective PBM effects on all cellular types
dose. The correct scientific term for the 2D planar where the contrary effects of positive or negative
energy/cm2 is radiant exposure and for the 2D power/ responses can be observed in the two therapeutic dose
cm2 is irradiance. The irradiance is in essence the inten- windows in the red to NIR wavelength range.
sity of the light, and as discussed below, along with the In respect of radiant exposure (J/cm2), a joule is a
accumulated delivery of the correct dose (J/cm2), the joule regardless of wavelength. However, in respect of
rate of delivery (W) and the intensity of the source (W/ spectral energy (J/nm), there is a considerable difference
cm2) are of prime importance. The delivered dose is time between wavelengths. For example, a 405 nm source has
dependent on the power output to the area exposed, so, an eV of 3.06, whereas a 810 nm source has an eV of
for example, 0.5 W/cm2 represents 0.5 J/cm2 delivered in around 1.53. The molecular effects of the absorption of
1 s. The dose (fluence) is the accumulated radiant expo- a more highly energetic 405 nm photon are highly likely
sure J/cm2 × time; hence to deliver 5 J/cm2 at an output to be quite different to that achieved by the more pedes-
power of 0.5 W to an area of 1 cm2, it takes 10 × trian 810 nm photon. In consequence, is it necessary to
0.5 = 10 s [105]. take into consideration wavelength when we are select-
In PBMT it is recognized that in the red to NIR ing a unit dose? A recent in vitro cellular study by Young
wavelengths, the optimal accumulated dose at target tis- et al. investigated comparative PBM dosing using a vari-
sue level to stimulate cellular activity is in the range of ety of wavelengths [107]. By amending the treatment
2–8 J/cm2. Less than this, dose very little happens and exposure time to allow for the differences in individual
beyond this in the range of 10–30 J/cm2, a contrary photon energy, a comparable positive stimulatory effect
effect of bio-inhibition has been identified. Although at could be seen across wavelengths in the range of 447–
higher dosimetry the positive aspects of PBM of an 1064 nm. A proposal was made to use a new unified unit
increase in cellular activity are absent, higher range of dose using the 810 nm as a baseline reference unit
treatments have been associated with pain relief as well from which a calibration factor could be applied to cal-
as an increase in cellular stress resistance [6, 9, 106]. As culate the appropriate photon eV adjusted radiant expo-
this may be the desired clinical objective, it has been pro- sure. At the time of writing, the majority of PBMT
posed that rather than viewing PBM dosimetry as a devices in use adopt the 600–1100 nm waveband, and
binary all-or-none biphasic response, it is more useful the difference in dosimetry within this range is of the
practically to consider it as a multiphasic response (see order of ±10%. At target cell level, given this relatively
188 M. Cronshaw and V. Mylona
small order of difference, it is advisable with the red to ters. It is accepted that the optimum cellular levels for
NIR to adopt a median of 5 J/cm2 for biostimulatory photo-biostimulation of time accumulated radiant
effects, which is approximately in the middle of the exposure is 5 J/cm2. The question arises as to the impor-
accepted range of 2–8 J/cm2. For pain relief it is recom- tance of the rate of delivery which is expressed as watts
mended to apply at target level around 15 J/cm2 as a safe (power) and the concentration of the watts to a unit area
median dose for red to NIR wavelengths [9, 108]. which is described as irradiance (W/cm2). As 1 W is 1 J
In the case of sub-surface targets, it is necessary to delivered in 1 s and the required dose is 5 J/cm2, can the
take into account the energy losses due to reflection, dose be delivered rapidly as say 5 W for 1 s? In short, the
refraction, radiant exitance, absorption and scatter. In answer is no, as the rate of energy delivery has a consid-
an in vivo study by Alvarenga et al. of gingival tissues erable influence on cellular response. Also, at an output
transilluminated by a 660 nm laser source, it was found power greater than 250 mW, if the area of exposure is
that at 5 mm in depth, there was approximately a 50% smaller than 0.5 cm2, the outcome may be harmful.
attenuation (energy loss) to that applied at the surface Short-duration high-dose delivery or the inappropriate
[109]. Across the red to NIR range, it is reasonable to use of a fine diameter probe can easily overload the bio-
expect 2–10% of the surface applied energy to reach logical capacity of the tissues to respond favorably to
7 1 cm in depth [83, 110–112]. As a result, to achieve the the stimulus to the extent of triggering irreversible cel-
required dose at depth demands the application of more lular damage as opposed to the benefits associated with
energy at the tissue surface to compensate for this high PBM [113, 114].
energy loss. At deeper depths beyond 1 cm below the Many first-generation dedicated PBMT devices have
surface, it becomes progressively more difficult to deliver a low power output range typically in the vicinity of
the required dose either without an excessively long 1–300 mW. A typical set of delivery probes offer glass
treatment time or with higher output power device optical guides of 4–6 mm in diameter with a correspond-
adverse photothermal effects in the surface tissues. ing surface area of 0.04–0.3 cm2. At an output power of
Fortunately, in dentistry the majority of tissue targets 40 mW, a 4-mm-diameter probe can deliver
are in the surface to 1 cm in depth range. 40 mW/0.04 cm2 = 1 W/cm2. This would at first sight
appear consistent with the dosimetry recommendations,
as in 5 s this would apparently deliver 5 × 1 J = 5 J/cm2.
7.9 Dose Delivery: Global Issues However, in reality at a power output of 40 mW in 5 s,
the device delivers 5 × 40 mW = 200 mJ to a very small
There are a number of important considerations to be area of 0.04 cm2. As the tip surface area is 0.04 cm2, to
addressed prior to the practical aspects of administering cover an area of 1 cm2 requires either multiple point
the dose. First of all, the operator must decide the objec- applications or a scanning movement to treat an area of
tive: stimulation of cellular activity or pain relief. Next is 1 cm2 which is 25 × the tip area of 0.04 cm2. As a result,
the location and approximate size of the target: for the total treatment area time to deliver 5 J/cm2 becomes
example, pain relief associated with a small aphthous 125 s.
ulcer will require a much-reduced overall dose compared Regrettably confusion over the relation between out-
to the objective of pain relief for a temporomandibular put power (W), irradiance (W/cm2) and total delivered
disorder (TMD). An aphthous ulcer is a small and radiant exposure (J/cm2) has been the source of many
superficial target, whereas myalgia associated with errors in clinical trials resulting in an outcome of a null
TMD may involve larger areas of sub-surface muscle or very low-level beneficial effects [82, 115].
and multiple muscle groups. Clearly it takes longer to It is of great importance that there is recognition of
treat a larger target, particularly with the added compli- the many sources of potential error in past research to
cation of compensating for the energy losses expected permit the evidence base to progress. A recent system-
with delivery of the dose to depth. atic review found that the majority of studies do not
Having determined the treatment objective, location indicate the use of a power meter to confirm that the
and approximate area of the treatment sites, the next power output of the device matches that on the device
decision is to choose the optimum tool to deliver the display. There are many possible sources of power losses,
required dose. This may be dictated by the restrictions and the use of a power meter must become a standard
imposed on the equipment available for the operator to approach to validate the experimental outcome. In addi-
use. This can be critically evaluated according to wave- tion, it is essential to provide details of the applied
length, range of output power and size of the applicator parameters to permit critical evaluation and possible
probes (. Fig. 7.10). acceptance at the level of peer review as well as repro-
It is essential to consider the issue of time-dependent duction of the outcome by later researchers. The dia-
energy delivery and power output as the rate (power = W) gram below summarizes the suggested reportage of
and intensity (irradiance = W/cm2) are critical parame- parameters in future PBM studies (. Fig. 7.11):
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
189 7
.. Fig. 7.10 The choice of dose delivery may depend on access, ters to prescribe the correct dose are the optical spot size at the tar-
availability and size and depth of the target tissues. A representative get, the output power of the device, the spectral beam profile and the
selection more commonly available is shown in the images. Other emission mode (gated vs. continuous mode)
devices may be provided by the manufacturer, and the key parame-
.. Fig. 7.11 Laser emission Type of study—such as Sample Blinding (single / double
and interactive parameters.
RCT size/groups/control/randomization blinding)
(Source: Parker S. Laser
Photonic Energy Delivery in
Clinical Dentistry: Scrutiny of
Parameter Variables. PhD Laser used—emission Delivery system Fibre, Waveguide, Gaussian / ’’Flat top’’
Thesis 2023, pp. 152 [116])
wavelength (nm) Articulated Arm beam x-section
Emission mode (CW, Power meter used and output Mean, median, max
Gated-CW, FRP) calibrated / min power (W)
Target tissue / lesion Tip to tissue distance (mm) Irradiated ‘‘spot’’ size
dimensions (mm) / (cm2)
Target tissue depth
(mm)
Fluence / Radiant Irradiation / Power density (W/cm2) Total energy delivered (J)
exposure (J/cm2)
7.10 Optical Spot Size of Applicators tical operator facility to deliver sufficient energy to
larger targets at depth is significantly reduced with a
Given the inherent difficulties in dose delivery associ- smaller optical spot size by comparison to the usage of
ated with low power output devices and small diameter a larger surface area delivery tool. A minimum surface
optical delivery probes, it is noteworthy that this type of spot size of 1 cm2 is advisable, and for larger target areas,
delivery equipment has been used in many successful a greater than 1 cm2 surface spot size applicator can be
clinical trials. However, in a recent systematic review, a useful to spare precious time as well as help deliver suf-
comparative analysis of reported outcomes and the rela- ficient energy to the required depth. However, although
tion to optic surface spot sizes applied found clear evi- larger surface spot applicators 3–7 cm2 are available,
dence demonstrating that the use of small diameter these require a higher output power to achieve the same
probes <5 mm in diameter is associated with less consis- irradiance, and the operator must have an appreciation
tent reported clinical success, in the treatment of both of the significance of the spectral beam profile of the
superficial and deeper-seated pathologies [56, 82, 108]. source as well as an understanding of the importance of
In recognition of the potential added clinical out- a good application technique [56].
come gain of PBMT, many surgical diode lasers have Many surgical lasers are supplied by the manufactur-
7 been re-tasked for the purpose as an additional nonsur- ers with a handpiece designed to be used in conjunction
gical treatment modality. The standard configuration of with a high strength peroxide gel for laser-assisted tooth
surgical lasers is designed to confine the energy to a very whitening. The surface area of these tools varies between
small point of application typically of 300–400 μm in manufacturers and typically falls into the range of 2.8–
diameter, to focus the output power (high irradiance) to 4.0 cm2. By measuring the optic window area, the opera-
a level sufficient to generate localized heat at tempera- tor can set the output power of the laser to deliver an
tures above 100 °C, resulting in the separation of the tis- average irradiance in close proximity to the surface of
sue by photothermolysis. As biological tissues show the target of 250–500 mW/cm2. For example, with a sur-
signs of damage at sustained tissue temperatures above face area of 2.8 cm2, by setting the output power at
45 °C, in contrast to surgery, it is important for PBMT 1.4 W, the energy is delivered to a total treatment area of
to keep the irradiance (W/cm2) low [68, 81, 117]. This 2.8 cm2 at an average irradiance of 0.5 W/cm2. At this
can be achieved by setting the power output to a larger setting the device will deliver in 10 s 10 × 0.5 W = 5 J/
area of exposure to keep the irradiance at between 250 cm2 which corresponds to a tissue surface delivered dose
and 500 mW/cm2. It is important to avoid confining the of 14 J to an area of 2.8 cm2 = 5 J/cm2.
energy emission to a small point at the site of applica- In recognition of the rising use of surgical diode
tion, and this can be achieved by use of a surgical hand- lasers for PBMT, a number of manufacturers have pro-
piece with or without a narrow diameter surgical tip at a duced some custom PBM peripheral delivery tools.
distance from the treatment site. There are some interesting designs to assist dose delivery
The surgical handpiece with or without a tip can be a including larger surface spot sizes of up to 7 cm2+.
convenient way to deliver radiant energy to small areas Larger applicators can be of considerable value should
as well as offering good ergonomics in confined intra- it be necessary to treat larger areas and volumes of tis-
oral areas. The beam emission is divergent by around sue, for example, in the management of myalgia associ-
16–18°. The visible spectrum aiming beam can be used ated with temporomandibular disorders (TMD).
to assist the operator in creating the required sized spot Because this condition may involve multiple larger tar-
at the tissue surface. With an area of approximately get muscle sites, it is possible to reduce the total treat-
1 cm2, the delivered dose can then be calculated by mul- ment times as with a larger applicator more tissue is
tiplying the output power by the time of exposure. To treated in the same unit of time. An added bonus to
take an example, with a 250 mW output power delivered using medium- to larger-sized optic delivery devices is
over 20 s to an area of 1 cm2, the total energy delivered that as previously mentioned, the evidence base sup-
to the area is 20 × 250 mW = 5 J/cm2. ports a more consistent positive treatment outcome by
Some devices are provided with custom glass optic comparison to smaller optic probes, especially with sub-
guides for PBM. The diameter of these tips is typically surface conditions. This may be due to the delivery of
between 4 and 8 mm, and if held in contact with the tis- photons to a greater volume of target tissue at depth
sues, this delivery device covers an area at the surface of (. Fig. 7.12).
between 0.04 and 0.5 cm2. This type of tip can be held in Aside from re-tasked surgical diode lasers, there are
close proximity to the treatment area; however as dis- many custom PBMT devices. Many of these devices are
cussed earlier, if the area of the lesion is much larger designed for sports physiotherapy applications to treat
than the tip, the treatment time has to be multiplied to deep tissue injuries over large treatment areas; however,
ensure sufficient energy delivery. Furthermore, the prac- they can be easily adapted to dentistry as well as other
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
191 7
.. Fig. 7.12 Beam profilometer images of the spectral power distri- area of exposure. (Adapted from Parker S et al. Photobiomodulation
bution on transillumination through lean muscle porcine tissue sam- delivery parameters in dentistry: an evidence-based approach. Pho-
ples. On the left upper and lower: 3D render and 2D images of a tobiomodulation, Photomedicine, and Laser Surgery. 2022 Jan
four-probe small spot size array. On the right upper and lower: 3D 1;40(1):42–50 [108])
render and 2D image of a single large spot size device to the same
medical applications. Given the considerable rise in 7.11 Spectral Beam Profile
interest amongst practitioners of the value of PBMT,
this is a rapidly expanding range of equipment. There The majority of optical spot size applicators result in a
are a variety of interesting design features available Gaussian optical beam spectral profile, and this can
intended by manufacturers to assist the operator. complicate calculations of safe delivery parameters,
Amongst the original designs are clusters of multiple especially with larger surface spot sizes 2–7 cm2+. With
low output diode lasers which may include LEDs as well a Gaussian device, the power distribution typically gen-
as simultaneous irradiation with lasers of mixed wave- erates a peak in the mid-third of the beam (. Fig. 7.13).
lengths. There are also high output power devices asso- Most therapeutic laser systems use a base transmis-
ciated with multiple simultaneous wavelength delivery sion emission mode (TEM00) with a typical beam diver-
lasers and applicators which can vary in size for a single gence angle of around 16°. Aside from the uneven
spot size of 12 cm2 or more. The more sophisticated energy distribution across the beam, beam divergence
delivery peripherals have an inbuilt thermal camera can complicate dosimetry if care is not taken by the cli-
which enables the operator to avoid overheating the sur- nician to achieve the desired surface spot size, and in this
face overlying a deeper placed target. The user interface respect the visible aiming beam can be helpful, or a
can assist the operator in selecting the manufacturers’ spacer may be used to assist the clinician to deliver the
recommended parameters and offers guidance in deliv- dose to a predetermined surface spot size.
ery techniques. The relative merits of the very many It is possible to modify the optics of the output spec-
designs available are, at the time of writing, a matter of tral beam profile to create a collimated and even beam
opinion rather than proven notwithstanding the many across the beam diameter. These so called “flat-top”
claims made by competing manufacturers. For the more devices contain internal optic prisms which convert the
experienced practitioner seeking an advanced PBMT inherent Gaussian shape of the beam to an even profile.
machine given the current evidence base at the time of Also, by the use of internal lenses, the beam is corrected
writing, there is no consensus on an ideal configuration. to prevent beam divergence and to create an even energy
This is an area of vigorous continued research efforts, distribution with a beam to an area maintained even at
and we discuss this further at the end of this chapter (see a distance from the target (see images below). The merits
7 Sect. 7.38–7.40). of the “flat-top” concept in respect of dose delivery are
192 M. Cronshaw and V. Mylona
a b
7 .. Fig. 7.13 3D rendering of optical beam spatial profiles. a Gauss- Jerusalem, Israel. Reproduced from Cronshaw M et al. Photother-
ian beam. b Flat top. Spot size: 1 cm2. (Images of sources taken with mal aspects of high energy photobiomodulation therapies: an
an Ophir beam profilometer, Beamgage v5.5 Ophir Optronics, LLC, in vitro investigation. Biomedicines 2023, 11, 1634 [56])
68.2%
95.5%
.. Fig. 7.15 Vertical and cross section of a Gaussian beam source beam is available in the peripheral third. (Reproduced from Cron-
showing mean values of power distribution across the beam. The shaw M et al. Photothermal aspects of high energy photobiomodu-
power distribution of a Gaussian beam device is typically around lation therapies: an in vitro investigation. Biomedicines 2023, 11,
68% in the mid-third of the beam, whereas in the next third of the 1634 [56])
beam, around 27% of the power is available, and only ca. 5% of the
a b c d
.. Fig. 7.16 a Gaussian beam profilometer 3D render of a 4-cm- across the entire area of 12.5 cm2 is 0.5 W/cm2. However, as indi-
diameter applicator with a surface beam area of 12.5 cm2. b Approx- cated above the average irradiance in the central area is 1.05 W/cm2
imately 68% of the power is concentrated in the mid-third of the with a further peak within the innermost central zone in excess of
beam, with around 27% in the mid-third and under 5% in the outer 2.1 W/cm2. (Reproduced from Cronshaw M et al. Photothermal
third. c In the mid-third of the beam, the area is around 4.2 cm2 and aspects of high energy photobiomodulation therapies: an in vitro
the power further progresses to a peak in the mid-third of this cen- investigation. Biomedicines 2023, 11, 1634 [56])
tral area. d At a power output of 6.25 W, the average irradiance
placed target. Progressively steeper temperature rises The disadvantages of the “flat-top” devices are that
above this threshold can culminate in cellular dysfunc- the currently available optic spot sizes are restricted to
tion, a process that can ultimately result in apoptosis 1 cm2, so in contrast to a larger spot size Gaussian appli-
with associated tissue damage. cator, it can require extended treatment times to cover
By contrast the “flat-top” devices maintain an even large target areas. Newer and larger 5-cm-diameter flat-
power distribution across the target tissue. This avoids top applicators have been developed although there is
the inherent dosimetry problems associated with larger limited manufacturer fiber attachment compatibility of
Gaussian beam devices. In addition, the evidence base this type of peripheral attachment [123]. Pending fur-
suggests the use of a higher output power of 1 W/cm2 ther research, the merits of the flat-top concept in con-
may be possible with an 810 nm source. There is some trast to a Gaussian beam device have yet to be proven
limited evidence from in vitro studies that show a reduc- clinically, although the authors view this as an emergent
tion in peak surface temperatures on this higher level of technology with some supportive in vitro and animal
irradiance in contrast to a Gaussian device [56]. Also, studies.
the optical footprint up to a depth of around 1 cm may Larger spot size Gaussian and flat-top devices are
be wider as well as a little deeper [122]. increasingly being adopted in clinical practice, and there
194 M. Cronshaw and V. Mylona
7
.. Fig. 7.17 Larger optical spot size devices have a significant-sized large applicators as in the central area due to the Gaussian effect the
core central third area. As the average irradiance in this central zone beam continues to peak. The suggested dose tables above are the
is an average of 2 × the overall average irradiance, this may lead to author’s preferred best current recommendations
over-dosimetry of the core area. This is particularly relevant to very
is an evident need for safe evidence-based guidelines on this way, although the average power is relatively low,
dosimetry. The parameters recommended in . Fig. 7.17 the peak power and the peak power density can reach
below are formulated on the author’s published research high values up to 300 W although with an accumulated
and our own laboratory analyses. Given the wide range time of less than 1% of the total time.
of body morphs and other compounding factors such as The peak power density deriving from this kind of
pigmentation, we offer these parameters as indicative emission mode modulation is intended to lead to a
rather than prescriptive. To stay up to date with current deeper distribution of energy inside the tissue without
best recommended clinical practice, we support and appreciable thermal increase.
advocate membership of esteemed international expert However recent studies indicate that although the
authorities such as WALT (World Association for peak power may be very high which promotes the deliv-
Photobiomodulation Therapy, 7 www.waltpbm.org) ery of photons to a greater depth, the difference is of the
and WFLD (World Federation for Laser Dentistry, order of a few millimeters compared to lower hertz or
7 https://wfldlaser.com). continuous delivery emissions. Also, the accumulated
time required to deliver the required dose at depth may
need extended periods of surface application.
7.12 Emission Modes The lasers operating in this manner are called “super-
pulsed,” and some devices offer the possibility to deliver
The laser beam can be emitted with different modes packages of “pulses” called “pulse trains.”
(. Fig. 7.18) that are substantially “pulsed” (FRP In 2010 Hashmi et al. published a meta-analysis of
lasers) and “gated” or “chopped,” a mechanical or elec- peer-reviewed literature about the effects of pulsing in
trical interruption of a continuous wave with a given PBM [61]. The conclusion was that, all being equal,
frequency (e.g., diode lasers). pulsed light seems to be superior to CW light for wound
However, it is common to find that the term “pulse” healing, while CW light seems to be superior for nerve
is erroneously and indifferently ascribed to both the regeneration. However due to inconsistency in the
modes. The diode lasers used in dentistry cannot achieve reportage of parameters in the literature, there is no
high peak power when used in continuous wave mode or consensus about the clinical relevance of pulsed or gated
gated mode, due to the intrinsic characteristics of the emission compared to continuous emission to determine
semiconductors (too much heat generation destroys the accepted protocols [117, 124, 125]. There is some limited
semiconductors). evidence to support the superiority of a low hertz gated
Therefore, in some devices the electrical pumping pulse train which is thought to create a photomechani-
system is modulated to produce very short Ton (micro- cal shock wave and which opens membrane-bound ion
and nanoseconds), with a frequency up to 40,000 Hz. In gates, reducing axonal activity. This mechanism has
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
195 7
.. Fig. 7.18 Laser emission modes define the photonic source as may be ultrashort “superpulsed” (<50 μs); as intermittent “pulse
being delivered as a continuous stream; as an interrupted “gated” trains” which may be of variable peak power (not shown)
pattern (on and off); as high peak power short-duration pulses which
been proposed to explain the apparent benefits of this the central third of the beam [56]. The rate of move-
gated approach in pain management, as axonal trans- ment depends on the size of the optic footprint and the
mission of a wave of depolarization is impeded by a loss corresponding irradiance, and, as a general rule, high
of cross membrane electrical potential. A further sug- output larger surface spot size devices (3 cm2+) require
gestion is that a pulsed approach at around 5 kHz may an ascending more rapid rate of movement, compared
coincide with the natural resonance frequency of the to a slower sweeping action with smaller devices. As
axon triggering blockade of axonal gates (gate control movement covers larger areas of tissue, it is an impor-
theory) [125–127]. tant calculation to determine the size of the target as
well as the area treated, as with a smaller lesion such as
a herpetic eruption or an aphthous ulcer, the use of a
7.13 Optical Delivery Techniques scanning movement can involve covering a larger area
than the size of the lesion. It is beneficial to cover the
A number of approaches to dose administration have wider area as there may be an associated peripheral
been advocated including the application of a static spot area of inflammatory swelling beyond the boundaries
applicator in contact with the surface as well as noncon- of the lesion, and at the dosimetry recommended here,
tact methods [114]. Some authors recommend applying no adverse effects can be expected from exposed nor-
physical pressure to indent the tissues again with a static mal collateral tissues. Patients may notice some gentle
contact. This is intended to shorten the optical path warmth associated with the treatment, and it is our
length as well as reduce the presence of blood which has observation that at surface temperatures of around
been suggested as a high absorbent of 600–1100 nm 44 °C+, patients will complain that the tissues can feel
light. Also, optical scanning techniques are described a little hot. Clearly at that point, it is appropriate to let
whereby the treatment area is painted with a moving the tissues cool a little before further proceeding. A fur-
beam [56, 128, 129]. Furthermore, some applicator ther consideration for deeper sub-surface targets is that
devices as previously mentioned have multiple small intervening subcutaneous fat deposits are a high scat-
lasers which may be interspersed with some LED devices tering medium and can be associated with heat accu-
in a cluster handpiece. Also, as previously mentioned mulation as well as a diminution of dose delivery to
there are many shapes and sizes of peripheral applica- depth. Incremental treatments may be necessary in the
tors (see . Fig. 7.10). presence of thick keratinised tissues especially in asso-
In respect of recommended technique, it is advisable ciation with dense skin pigmentation [33, 55, 130, 131].
to use a surface optic spot of around 1 cm2+ for any- To help overcome these potential difficulties in the pres-
thing other than very small lesions (. Fig. 7.19). ence of thick tissues and dense deposits of melanin, the
The adoption of a scanning method is recom- use of wavelengths longer than 800 nm combined with
mended for a surface spot size of 1 cm2+, as this can a larger optical surface spot size of 1 cm2+ is recom-
dissipate excess heat build up in the tissues exposed to mended (. Fig. 7.20).
196 M. Cronshaw and V. Mylona
.. Fig. 7.21 Graphic a, standard healing. Graphic b, healing with optimizing the biological capacity for regeneration. (Graphics
adjunctive PBMT. PBM affects the peak and duration of the acute source: Adapted S. Parker from Enoch S., Price P. Cellular, molecu-
inflammatory tissue response to trauma or infection. There is also an lar and biochemical differences in the pathophysiology of healing
increase in cellular volumes with an associated increase in matrix between acute wounds, chronic wounds and wounds in the aged.
production. This positively impacts on the quality of the final repair 7 www.worldwidewounds.com, Aug 2004 [149])
becomes relatively anaerobic, and the tissues become nerve axonal depolarization. Mediated by the spine and
more acidic due to the cells entering into a glycolytic the CNS, there are amplification circuits such that a
anaerobic cycle of metabolism associated with the local trigger can increase to involve regional axons
increased production of lactic acid. Histamine is affecting the segment, as well as on occasion resulting in
released from mast cells, and there is a step increase in activation and stimulation of other branches of the
production of a number of pro-inflammatory cytokines same cranial nerve and producing cross arch effects. In
including IL-1β, IL-6 and TNF-alpha, along with bra- addition, motor nerves may become involved producing
dykinin, substance P and CGRP. Along with the classic an increase in muscular tonicity which can manifest
signs of acute inflammation, there is also an associated itself as trismus as the muscle may lock into spasm
reduction in the threshold required to trigger sensory (. Fig. 7.22).
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
199 7
.. Fig. 7.22 Biological mediators associated with PBM exposure. (Source: Adapted S. Parker from Kim WS, Calderhead RG. Is light-
emitting diode phototherapy (LED-LLLT) really effective? Laser Ther 2011;20:205–15 [151])
Healing cannot occur in the absence of the acute opportunity for the clinician to optimize the clinical
inflammatory response, and it is a common observation outcome of an intervention. PBMT may be used as
that immunocompromised patients, including those on part of an integrated approach to tissue management
systemic steroids, have a tendency to heal poorly. The based on sound clinical principles of the need to elimi-
acute inflammatory response is primarily a defensive pro- nate infection, to remove failed wound healing matri-
tective response intended to prevent trauma to damaged ces, to stabilize the replacement primary wound matrix
tissues, as well as to mitigate the potential for infection to as well as to mitigate the acute inflammatory response
spread beyond the primary wound site. Furthermore, as while stimulating the vasculature to provide good
mentioned earlier it is the essential primary trigger to ini- drainage along with an enriched blood supply [152,
tiate the sequences essential to healing, repair and regen- 153]. As a supportive therapy, PBM improves cellular
eration of damaged tissues. However, an excessive viability to surgical trauma and other tissue stressors
inflammatory response is debilitating to patients, for such as cancer radiotherapy or cytotoxic chemotherapy
example, the marked angular swelling associated with a and also stimulates a powerful immune response
traumatic procedure such as a third molar extraction or directed toward wound resolution. At re-care visits,
an apicoectomy. On the other hand, an impaired response further increments of PBM may be administered in
due to immune suppression can result in failed wound order to increase the volume of matrix production by
healing which may be associated with chronic inflamma- the cellular optimization of aerobic metabolism as well
tion and the progressive loss of functional tissues. Also as an increase in cell volumes [154–157]. Also, PBM
failed wound healing may be associated with persistent pre-conditioning and re-care PBM applications can
infection. For example, the progressive loss of bone and improve the biological capacity of tissues to repair in
supporting periodontal tissues seen in untreated or medically compromised patients with systemic illnesses
poorly managed adult chronic periodontal disease is a as well as the elderly who may have a reduced immune
consequence of chronic inflammation perpetuated by a response along with underlying multiple age-related
persistent pathogenic biofilm (. Fig. 7.23). inflammatory disorders such as diabetes, cardiovascu-
As an adjunctive tool to surgery, PBMT supports lar disease, chronic respiratory diseases, etc. [158, 159]
good-quality healing and repair and represents an (. Fig. 7.24).
200 M. Cronshaw and V. Mylona
.. Fig. 7.23 Summary of PBM effects derived from wavelength-specific incident photonic energy. (Graphic: S. Parker)
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
201 7
.. Fig. 7.24 The range of medical applications under investigation for PBM is very extensive. Many conditions are inflammatory in nature,
and as such PBM offers great potential as a safe, highly localized and nontoxic therapeutic modality. (Graphic: S. Parker)
7.16 Photobiomodulation Therapy, Stem phate, calcium sulfate and natural growth promoters
Cells and Regenerative Therapies such as enamel matrix derivative.
Given the properties identified with PBMT of an
Arising from the disparate specialties of oral surgery, increase in cellular viability, stimulation of cellular activ-
endodontics, periodontics, orthodontics and restorative ities and mitosis along with an increase in productive
dentistry, there is considerable interest in regenerative matrix manufacture of collagen and bone along with the
procedures to enhance the quality of healing and repair promotion of angiogenesis and axonal regrowth, there is
as well as to supplement tissues previously lost due to considerable interest within the literature to explore the
disease or trauma. A number of approaches have been potential of the addition of PBMT as an adjunct to
adopted including the utilization of autologous-derived established regenerative procedures. Coupled with the
growth factors and natural tissue matrices such as anti-inflammatory, analgesic and enhanced viability
platelet-rich fibrin and tissue grafting. In addition, there effects observed with PBM, there are very many poten-
are many exogenous human- and animal-derived osseo- tial clinical advantages that may be gained by the inte-
inductive grafting materials, synthetic collagen matrices gration of this nontoxic therapy to very many aspects of
plus grafting materials such as beta tri-calcium phos- routine and specialist dental care. Notwithstanding
202 M. Cronshaw and V. Mylona
extensive published peer-reviewed cellular, animal and present with a diminished capacity to heal and repair
increasing numbers of human clinical trials, PBM is still [174, 175]. Hence wound management is a critical factor
at the stage of continued evaluation; despite the very in any attempt to regenerate tissues as this relies on the
many positive reports, there is as yet no agreement on essential requirements to eliminate infection, remove
consistent clinical procedures, although current best failed wound healing matrices and create a new bio-
practice evidence-based guidelines have been issued by scaffold with a good collateral blood supply.
the World Association for Photobiomodulation Therapy As previously described above, PBM has very many
(WALT). positive attributes which in combination with a well-
One aspect of PBM that has attracted interest is in designed and well-executed surgical technique offer
the potential of PBMT to enhance the number and great potential to enhanced healing, repair and regener-
activities of stem cells [160–163]. PBM has been demon- ation. In particular regard to stem cells, PBM has been
strated in vitro and in animal studies to stimulate stem found to increase the proliferation of stem cells as well
cells with a resultant increase in their migration, prolif- as increase their viability. In addition, there is also an
eration, differentiation and protein expression. The out- increase in stem cell metabolism with a continued
come of tissue engineering to repair or regenerate tissues increase in activities of the derived cellular phenotypes.
7 can be affected by three critical factors: cells, scaffolds For example, Arany found PBMT promoted the increase
and signaling mediators [164–166]. Stem cells may be in numbers of pre-odontoblasts producing `a corre-
derived from a number of sources including autologous sponding increase in the production of new dentine in a
human dental pulp stem cells (hDPSCs), stem cells from murine model. Similarly, Fekrazad et al. noted an
the apical papilla (SCAPs) and bone marrow-derived increase in new dentine formation [164].
stem cells (BMSCs) amongst other sources including
blood-derived stem cells separated from whole blood by
fractional centrifugation. Various types of mesenchymal 7.17 Clinical Aspects
stem cells may be immediately harvested after the extrac-
tion of permanent teeth or the natural shedding of The application of PBM in human regenerative therapies
deciduous teeth, and oral tissues represent an excellent is being explored as an aid to improve the viability of vital
source of stem cells for therapeutic purposes [167, 168]. exposed pulpal tissues. Also, the endodontic community
Stem cells can differentiate into the specialized cell is investigating the possibilities of promoting apex forma-
types required for regeneration of tissues such as odon- tion in immature nonvital teeth with open apices. For
toblasts, osteoblasts, chondroblasts, fibroblasts, etc. example, Moreira et al. noted the formation of a new
However, cellular losses during the extraction and place- odontoblast-like area in proximity to dentinal tubules in a
ment along with variability in the differentiation abilities model of regenerative apexification [176]. Zaccara et al.
and activities of the stem cell grafts have led to a lack of found that PBM can regulate histone acetylation signal-
predictability and a compromised efficacy of these tech- ing of human dental pulp stem cells (hDPSCs) [177]. Via
niques [169]. Various factors have been demonstrated to an increase in nuclear-expressed modifying factors, this
regulate the stem cell properties, such as tissue origin results in an increased expression of genes associated with
(inflamed or not), donor age (the younger, the better), the improved viability of hDPSCs. Matsui et al. associ-
culture conditions (culture media, pH, temperature lev- ated PBMT with an increase in mineralization with a step
els and available oxygen) and the presence or absence of increase in the levels of bone morphogenic proteins,
growth factors [170]. Stem cell transplantations may osteocalcin and alkaline phosphatase [178–180]. Similar
lead to a very low engraftment rate, as their survival outcomes were noted by Suzuki et al. in an animal model
after placement into inflamed tissues is short, with a of orthodontic tooth movement. PBMT was found to
24 h half-life [9]. The therapeutic benefits of stem cell increase the number of osteoclasts present on the pressure
therapies are associated with the paracrine secretion of side, while there was a corresponding increase in the num-
soluble mediators, cytokines, secretomes, peptides, pro- ber of osteoblasts on the tension side. Aside from the his-
teins, metabolites and micro-RNA, along with extracel- tomorphometric analysis, this interesting study applied an
lular vesicles such as exosomes [167, 171]. immunohistochemistry analysis of RANKL/OPG and
Also, regulation of the immune system is a critical tartrate-resistant acid phosphatase (TRAP) activity. This
factor required in order to induce tissue regeneration further correlated the histological findings of increased
[172, 173]. Elevated levels of reactive oxygen species osteoclast activity in the test group on the pressure side
(ROS) are produced as a response to the oxidative stress (elevated levels of RANKL and TRAP) and increased
associated with an inflamed area, which may have detri- bone apposition and osteoblast activity on the tension
mental effects on the surrounding tissues. Chronic side (an increase in OPG). Furthermore, the rate of orth-
inflammation is recognized to be associated with persis- odontic tooth movement was found to be increased by
tent infection, and senescent reparative cells may be around 40% compared to the control [181] (. Fig. 7.25).
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
203 7
.. Fig. 7.25 PBM affects all cellular types and promotes increases in cellular actions including motility, matrix production and cellular
volumes via mitosis. (Graphic: S. Parker)
As PBMT can impact on many aspects of wound heal- interfere with some physiological and pathological con-
ing, the integration with approaches to enhanced tissue ditions, or from the possibility of electromagnetic inter-
repair and regeneration including stem cells is antici- ferences with some obsolete implantable devices, such as
pated to become an established adjunctive procedure to pacemakers or ICD (implantable cardiac defibrillators).
optimize the benefits and overcome the above-mentioned However, there is no evidence of an effective risk for all
drawbacks of the current standard techniques. the situations listed below:
55 Thyroid, gonads
55 Hemorrhage
7.18 Safety Issues Associated with PBMT 55 Pregnancy (abdomen)
55 Immunosuppressant treatments
Any intense light source can cause optical damage, and 55 Epilepsy (subject to adequate optical protection in
most particularly with the usage of wavelengths outside gated modes)
the visible range, wavelength-appropriate protective 55 Bone growth plates in children
eyewear is a mandatory requirement. In regard to 55 Neuropathies
broader band low output power LED devices, the bio- 55 Hematological disorders
hazard potential is not nil, and caution is advised par-
ticularly with higher output power devices >50 mW Concerns have however been expressed at the wisdom of
outside of the normal visual spectrum. The operator applying a therapy recognized to stimulate cellular divi-
must not be lulled into a false sense of security in the sion, increase cellular resistance to stress and promote
mistaken belief that optical protection is not required lymphatic drainage in patients with a current suspicious
with lower output power laser or LED devices, and the lesion [182, 183]. Similarly, is it safe to treat patients with
reader is directed to the section on optical safety earlier a history of a prior malignancy or those with higher risk
in this text where this topic is comprehensively covered factors, for example, those with a high alcohol intake,
(see Chap. 5). smokers or those with signs of extant human papilloma
Most of the contraindications and precautions viral infections? Regrettably cancers in one form or
(listed below) arise from the possibility that the biostim- another affect around one in three of the population at
ulating and immunomodulating effects of PBMT could one time or another. Given the high incidence of malig-
204 M. Cronshaw and V. Mylona
nancies, is PBMT an additional risk factor and do spe- in vivo murine study of mice bearing breast cancer
cial precautions need to be taken? tumors. A single application of PBMT resulted in com-
It is accepted that shorter wavelengths in the ultravi- plete regression of the tumors as a response to overdose
olet range 10–400 nm are an environmental risk factor of the cancerous cells [186].
for squamous cell carcinomas, melanomas and basal cell Another approach to provide adjunctive support
carcinomas. However, sun avoiders in contrast to those using PBM relies on taking advantage of a differential
with the highest sun exposure have a reduced life expec- effect of photon transduction between malignant cancer
tancy of 0.6–2.1 years which is a comparable risk to cells compared to the effects seen on healthy normal
smoking [184]. Visible to NIR wavelengths and beyond cells. This involves combining PBM with an additional
have insufficient eV to break chemical bonds in cytotoxic anticancer therapy, so that it increases the kill-
DNA. Direct damage to DNA can be caused by elevated ing of cancer cells while at the same time protecting nor-
levels of ROS; however phototoxic doses of laser wave- mal healthy cells. Although this remains an area of
lengths longer than UV do not cause plasmid DNA continued research at present, there are some published
cleavage. This subject was investigated in a study of pho- articles that support this approach as an anticancer
totoxicity by Khan et al. using a murine model applying strategy.
7 an 810 nm laser source at sublethal doses. Both the cel- For example, there are reports that PBM can poten-
lular and the animal research in this high-quality study tiate the killing of cancer cells by photodynamic therapy
showed no evidence of genotoxic damage. Although and also by radiation therapy. Within the confines of
high NIR doses could be phototoxic, there was no evi- their experimental studies to date, PBM increases cell
dence of a genotoxic or mutagenic harm, and it was con- death in cancer cells in response to cytotoxic stimuli. As
cluded that the 810 nm laser is safe for clinical an added benefit in normal cells, PBM exerts a protec-
applications [68]. tive effect as is well known in the case of neurotoxins, for
A number of tissue culture and animal studies have example, as well as increasing stress resistance to ther-
demonstrated a PBM stimulatory effect on tumor activ- mal- and radiation-induced damage as discussed earlier
ity. However, in contrast to these few in vitro cellular in relation to the concept of PBM pre-conditioning.
studies and transgenic animal studies that show an As for human clinical studies, patients receiving
increase in tumor cell growth, there are other studies PBMT have been found to have a significant improved
which show precisely the opposite. In the absence of het- complete response to treatment in comparison to those
erogenous tissues including a viable immune system in a in a placebo group. Also, there is no evidence of field
monoculture, the biostimulation of the few tumor cell effects or an increase in recurrence in patients treated
lines that show this effect in vitro would be subject to an with PBMT.
in vivo invigorated host immune response. There are In conclusion, the evidence supports the safety of
other associated effects of PBM such as vasodilatation PBMT as an adjunctive measure to assist patients
which change the chemistry of the tissues away from an undergoing chemoradiation therapies for some forms
acidic pro-inflammatory area to an aerobic zone sur- of cancers. There appear to be regional benefits to this
rounding the cancerous tissues. For example, Ottaviani approach which may improve the prognosis and
et al. found that PBMT inhibits tumor growth by pro- reduce morbidity. Direct irradiation may be of benefit
moting immune surveillance and vessel normalization. at high doses, and the current evidence base supports
In a mouse model of melanoma, three different protocols the use of PBMT as an adjunct to standard cancer
of PBM were applied (660 nm, 50 mW/cm2, 3 J/cm2; therapies [187–190]. Due to theoretical concerns at the
800 nm or 970 nm, 200 mW/cm2, 6 J/cm2, once a day for possibility of promoting a tumor to grow, PBMT is
4 days). It was found that all could reduce tumor growth not advised as a stand-alone measure on a known or
and increase the recruitment of immune cells, in particu- suspect lesion.
lar T lymphocytes and dendritic cells secreting type I
interferons. PBM also reduced the number of highly
angiogenic macrophages within the tumor mass which 7.19 Clinical Management by Condition
may be of benefit to control tumor progression [185].
By contrast, the clinical outcome value of animal PBM affects all cellular types, and as discussed earlier,
models using transgenic species with a xenograft or a dependent on dosimetry, effects achievable can vary
non-syngeneic immunodeficient murine model is open from photoinduced stimulation of cellular physiology
to question. to photoinduced analgesia. In considering the pro-
A further approach to eliminate cancerous cells by cesses attached to clinical care, it is recommended to
high-intensity laser irradiation has been investigated by adopt a decision process as exemplified for the condi-
use of a He–Ne 632 nm laser delivering 1200 J/cm2 at tion of chemotherapy-associated oral mucositis below
500 mW/cm2 using an in vitro cell culture model an (. Fig. 7.26).
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
205 7
.. Fig. 7.26 Processes associated with PBM are the same for all to compensate for energy losses at depth by a factor of 10× for a spot
conditions. The example demonstrates the treatment flow chart for size of around 1 cm2 and 5× for larger spot sizes greater than 3 cm2.
chemotherapy-related oral mucositis. The dosimetry shown could (Reproduced from Cronshaw, M.; Parker, S.; Anagnostaki, E.;
equally apply to any superficial condition, for instance, aphthous Mylona, V.; Lynch, E.; Grootveld, M. Photobiomodulation and oral
ulceration or a herpetic eruption. If the condition is associated with mucositis: A systematic review. Dentistry 2020. 8:87 [191])
a sub-surface target, it is advisable to increase the dose at the surface
As there is an essential similarity of the cellular as a surgical handpiece, it may be possible to use the vis-
response to equivalent radiant exposure, rather than the ible aiming beam as a visual guide to creating a spot size
operator concentrating on a specific condition, it is more of around 1 cm2.
pragmatic to consider the desired outcome. The essen- Having determined the treatment objective of bios-
tial issues to decide are the treatment objectives, the timulation or bio-inhibition (pain relief) and the issue
location of the target tissues and the area to treat. Next, of target location of surface or sub-surface, the opera-
it is a matter of deciding which peripheral applicator tor can then consider the required output power. In
may be best, and in this respect the operator needs to accordance with current guidance, it is recommended
consider the issue of the size of the treatment area, as a to keep the average irradiance at or below 0.5 W/cm2.
larger surface area applicator may save a significant As discussed earlier larger applicators require a higher
amount of treatment time but a smaller intraoral target overall power output to sustain the irradiance required.
may be best dealt with employing a smaller tool such as The power output of the device is easily determined for
a surgical handpiece or a custom glass guide. The critical any optic spot area as the power required is half of the
parameter is the area of tissue exposed as in the absence area. So, for instance, a 4-cm-diameter applicator has
of a collimating lens system, the beam is inherently an area of 12.5 cm2, and the required device power out-
divergent. For this reason, some devices have a spacer put for 0.5 W/cm2 is 12.5/2 = 6.25 W. As 0.5 W/cm2
attached to the handpiece which permits some standard- delivers in 1 s 0.5 J/cm2, to deliver 5 J, it takes 10 ×
ization of area dosimetry. With smaller applicators such 0.5 = 10 s.
206 M. Cronshaw and V. Mylona
7.20 Temporomandibular Joint Disorders spinal tract resulting in radiating pain behind the eye on
the affected side which typically starts in and around the
Temporomandibular disorders are a group of musculo- zygoma along the line of the maxilla to the temporo-
skeletal disorders that cause facial pains with a high mandibular joint [146]. Diagnosis is by exclusion of
prevalence in both sexes. Symptoms are variable: pain, radiographic or visual evidence of infection, as well as
joint noises including clicking or popping and crack- bimanual palpation of the joints and muscles in search
ling, functional limitations up to articular disc displace- of trigger points. It can be useful to measure the inter-
ment without reduction or dislocation. There are many incisal maximum opening which may be reduced signifi-
causes—parafunctions, joint overload caused by cantly from the normal range of 32–35 mm+. It can be
impaired occlusion, stress, musculoskeletal diseases, difficult to discriminate between odontogenic and myo-
trauma or acute and chronic inflammatory joint genic pain, as the patient may have been subject in the
diseases [192]. past to multiple root canal treatments and extractions in
The standard treatment of these disorders is multi- attempts to relieve the patient of previous acute episodes
disciplinary and is aimed at the control of pain symp- of pain. The application of PBM which successfully
toms through drug therapy, as well as at treating the ameliorates pain clearly indicates a myogenic rather
7 functional limitation through physiotherapy treatment than odontogenic origin and may be viewed as a useful
of the masticatory muscles, stress control, using cogni- diagnostic measure. There are other clinical signs that
tive behavioral therapy, massage and relaxation tech- can support a provisional diagnosis of myalgia associ-
niques, occlusal splints up to complex surgical and ated with TMD. These include flattened cusps, cervical
prosthetic rehabilitation. abfractions and associated enamel cracks, abnormal
PBM has been used to relieve pain for temporoman- temperature sensitivity and hyperacuity particularly to
dibular disorders, alone or in combination with conven- cold, the presence of mandibular tori plus a scalloped
tional therapies such as physiotherapy exercises and tongue and particularly in males enlarged muscles of
occlusal splints [193–195]. Pre-auricular, intra-auricular mastication. In addition, there may be signs of prema-
and intraoral and extraoral maxillary points in the rear ture incisal wear with obvious shiny wear facets, some
maxillary area are potential therapeutic targets, along highly localized periodontal bone loss and increased
with associated muscle groups affected by the symptoms mobility of teeth trapped in a traumatic constricted
which may be treated identified on palpation as trigger envelope of masticatory function. Patients may or may
points. Published outcome data report diode lasers with not be aware of nocturnal parafunction which may be a
a wavelength of between 650 and 1000 nm, with fluences contributory cause along with life stress and some pre-
of between 1.5 and 140 J/cm2. Treatments are usually scription medications such as SSRI antidepressants to a
repeated two or three times a week until the symptoms pattern of nighttime bruxism, muscular hypertrophy
have disappeared [196]. and disturbance of sleep. Patients may be aware of fre-
The term temporomandibular disorder (TMD) cov- quently awakening with headaches and stiff muscles
ers a wide range of disorders of the temporomandibular around the head and neck. There may also be a history
joint with or without associated issues manifest in the of frequent fracture of both restored and previously
muscles of mastication. TMD can be classified into intact teeth. The clinical manifestations of these disor-
three types: myofascial pain, internal derangement of ders can include pain, malocclusion, midline deviation,
the joint and degenerative joint disease. Of the three joint noises and locking of the joint due to a displaced
types, patients most commonly present to their primary disc limiting mandibular movements.
care dentist with acute or chronic pain associated with Given a provisional diagnosis of myalgia-related
muscle groups including the lateral pterygoid, trapezius, TMD, PBM can be a highly useful measure as it can act
sternocleidomastoid, masseter, temporalis and the pos- as a palliative to the pain as well as relieve the trismus.
terior belly of the digastric muscles [197]. The pain may Furthermore, on successfully reducing the acute dis-
be severe and can be associated with trismus limiting the comfort, patients are receptive to proposals toward
patient’s ability to chew or open normally. This type of occlusal support and rehabilitation which may involve
neuromuscular pain can be limited to one or two muscle the use of various types of intraoral splint as well as, in
groups or can involve multiple points which can be iden- some more complex cases, restoration of functional
tified by digital palpation to identify trigger points. This capacity involving a multidisciplinary approach (ortho-
type of pain is called myalgia and is caused by hyperto- dontics, implants, etc.).
nicity of the affected muscle which contracts into spasm. As a noninvasive and harmless intervention, PBMT
This restricts blood flow into the affected area resulting has attracted increased interest in recent years [199–202].
in anaerobic tissues associated with lactic acid build up The application of a coherent laser to extra- or intra-
[198]. Axonal nociceptor amplification can occur via the orally transilluminate the affected muscle groups can
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
207 7
a b c
.. Fig. 7.27 A 38-year-old patient presented with pain and trismus Biolase, CA). A slow sweeping scanning motion was adopted to an
associated with a pericoronitis at UR8. The treatment objectives area encompassing the length of the zygomatic arch and the area
were to relieve pain, improve the oxygenated blood supply to the immediately overlying the condylar head. This corresponded to
affected area, improve lymphatic drainage and reduce the muscle approximately 3 × the area of the chosen applicator. A surface dose
spasm associated with the right lateral pterygoid muscle. Initial of 50 J/cm2 was applied to each area which amounted to a total
opening was limited at the measured inter-incisal tip distance at delivered surface dose of 1050 J to an area of 21 cm2. The delivery
22 mm. A 7.1 cm2 area applicator was applied to the zygomatic arch applicator has an adjustable plastic spacer which when set at the
region adjacent to the underlying lateral pterygoid muscle. An maximum range results in a 7.1 cm2 area of exposure. (Deep Tissue
output power of 3.5 W was set using a 940 nm diode laser (Epic X, Handpiece, Biolase, CA, USA)
produce vasodilation, as well as at high doses of radiant found after irradiation using 940 nm diode laser three
exposure to a temporary reversible disruption of neuro- times weekly over a period of 3 weeks [203].
nal physiology. This contributes toward laser-assisted As for clinical PBM irradiation protocols, there is at
analgesia plus an anti-inflammatory effect with positive present no consensus, and a heterogeneity is observed
effects on painful muscles and joints. Mechanical injury concerning the radiant exposure, time of irradiation,
to the TMJ, inclusive of ischemia–reperfusion, generates emission mode, the number and frequency of sessions
reactive oxygen species (ROS) in the articular TMJ tis- and the target application areas.
sues. PBMT decreases ROS generation with an increase Based on a synthesis of systematic reviews and meta-
in the production of adenosine triphosphate (ATP) in analyses, the following clinical suggestions are proposed
the mitochondria. Karic et al. in a recent in vitro study (. Fig. 7.27):
investigated the potential for promoting the differentia- 55 Radiant exposure: in the range of 35–100 J/cm2
tion of chondrocytes and fibroblasts on a biodegradable 55 Two sessions per week
polylactide disc with human adipose-derived stem cells. 55 Eight to 12 sessions
This novel approach is intended to address the potential 55 Exposure time: variable depending on the size of
for the management of disc degenerative changes associ- applicator used and the number of muscle and TMJ
ated with TMD by use of a graft consisting of a PBM- sites treated
treated stem cell-impregnated bio-scaffold. A 55 Continuous wave (CW) mode
considerable increase in both chondrocytes and fibro- 55 Multiple points of irradiation on the affected TMJ
blasts plus an increase in the production of ATP was and muscles
208 M. Cronshaw and V. Mylona
Facial pain is a real challenge for the clinician, both in Dental traumas consequent to falls, bicycle accidents,
terms of diagnosis and treatment. In the management sports activities, playground accidents, etc. are frequent
of persistent moderate to severe atypical facial pain fol- causes for emergency attendance to primary care clini-
lowing a comprehensive medical assessment to exclude cians. The consequential injuries include varying degrees
other causes, a multidisciplinary approach may be of fractured maxillary central incisors, luxation, avul-
required. This may include cryotherapy, ultrasound, sion and lacerations. There may be marked swelling and
shock wave therapy, physiotherapy, acupuncture plus bruising, pain and traumatic occlusion due to sub-
medications such as amitriptyline, gabapentin and low- luxation plus fractured restorations including anterior
dose diazepam. Pains secondary to specific causes, such crowns and bridgework. The immediate management
as inflammation, infection, trauma, cancer, neurological challenge to the clinician may be compounded due to
degenerative lesions or abnormal contact of nerve and soft tissue swelling and trismus limiting access for intra-
vascular structures (trigeminal neuralgia), are different oral radiography as well as any urgently required essen-
from atypical or idiopathic facial pain, whose classifica- tial stabilization therapies. Acute inflamed tissues are
7 tion is diagnosis by exclusion and PBMT offers an addi- less responsive to local anesthesia due to changes in the
tional option for treatment of difficult cases which tissue chemistry which become acidic due to the drop in
otherwise are managed by symptoms often in combina- oxygen tension with a resultant reduction in conversion
tion with psychological support. of the local anesthetic to its active form. Many of the
Referred pain may be excruciating with secondary pro-inflammatory factors such as PGE2, IL-1β, IL-6,
symptoms such as paresthesia, paroxysmal response to TNF-alpha, histamine, bradykinin, substance P, etc. are
minimal stimuli (allodynia) and depressive syndromes. nocio-inductive resulting in increased axonal activity
These conditions have a high social cost both for the which by mediation via the spine and the CNS may
number of working days lost and for the cost of drugs result in regional pain and on occasion trismus due to
and imaging techniques needed to arrive to a diagnosis; conscription and activation of motor neurons [66, 98,
for this reason, the search for effective treatments with 146, 147].
few adverse effects is important. PBMT’s analgesic effect PBMT offers considerable near-immediate benefits
has been well studied and can be applied to various as it is a vasodilator resulting in an increase in oxygen-
forms of facial pain in association or not with drug and/ ated blood in the tissues as well as an increase in lym-
or conventional instrumental therapies. phatic drainage. Also, at higher end dosimetry, it is
Experimental studies on animals have investigated possible to inhibit axonal transmission helping to palli-
different fluences, and it has been noted that low flu- ate pain. Faced with an acute injury, this offers obvious
ences around 4.5 J/cm2 are beneficial at a cellular level clinical gains to both patient and clinician as aside from
on reducing inflammatory mediators. High fluences can the mitigation of pain and acute swelling, it becomes
generate a temporary axonal block with an associated easier to take intraoral radiographs plus provides any
extended area of vasodilatation, plus there can be a essential immediate stabilization treatments.
reduction in the levels of important spinal and CNS Furthermore, an early intervention with PBM can
mediators of pain, such as substance P and CGRP, plus shorten the acute inflammatory phase and assist in a
there can be an increase in the manufacture of endoge- good quality of healing, repair and regeneration of
nous opiates such as β-endorphin [204, 205]. damaged tissues [206–208] (. Figs. 7.28, 7.29 and 7.30).
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
209 7
a b
c d
e f
.. Fig. 7.28 Facial trauma results in a marked acute inflammatory response which can be disfiguring as well as being associated with pain
and reduced function. As illustrated PBMT offers considerable benefits to ameliorate the trauma and promotes good wound resolution
.. Fig. 7.29 Burns may be deeply damaging to sensitive tissues and a severe burn often may require complex surgical procedures such as
tissue grafting. PBMT improves the viability of the damaged tissues, stimulates repair and can greatly simplify patient management
210 M. Cronshaw and V. Mylona
.. Fig. 7.30 (1) Four-year-old patient, with a traumatic painful diations every other day. Immediate analgesic action, complete heal-
lesion: biting following local anesthesia—treatment performed with ing after eight sessions. (3) Fifty-year-old patient: delayed healing
diode laser 645 nm, fluence 4 J/cm2, average power 5 mW, spot diam- after implant positioning and GBR, with fixture exposure—treat-
eter 2 mm, power density 0.16 W/cm2, CW, spot technique, 25 s per ment performed with diode laser 810 nm, fluence 4 J/cm2, average
point, irradiations every other day. Immediate analgesic action, power 0.3 W, spot diameter 6 mm, power density 1.07 W/cm2, CW,
complete healing after five sessions. (2) Five-year-old patient, with a spot technique, 4 s per point, irradiations every other day, five ses-
traumatic lesion with bone exposure (impact against the wooden sions to trigger and to speed up the healing process. Complete heal-
edge of a pencil)—treatment performed with diode laser 904 nm, ing after a month. (Cases courtesy of Dr E. Romagnoli and Dr A
fluence 4 J/cm2, average power 0.28 W, spot diameter 5 mm, power Cafaro, Italy)
density 1.4 W/cm2, superpulsed, spot technique, 3 s per point, irra-
7.23 PBMT in Oral Medicine Precipitating factors have been associated with hor-
monal imbalance, nutrition deficiencies (vitamin B12),
Oral medicine is concerned with the diagnosis and treat- specific drugs, food allergies, stress and mechanical inju-
ment of diseases affecting the maxillofacial region and ries which may contribute to the occurrence of
especially the oral cavity; the symptoms maybe local RAS. Furthermore, it has been reported that a sensitiv-
expressions of systemic diseases or specific illnesses of the ity to sodium lauryl sulfate (SLS) which is a common
region, and it is the link between dentistry and internal constituent of toothpastes may be an important cause.
medicine. PBMT, by virtue of its analgesic, anti- Aphthae tend to heal spontaneously in 10–15 days.
inflammatory effect and its ability to promote the regen- They may be single or multiple, scattered in several
eration of tissues, is particularly useful in the treatment of areas, and the pain can be intense enough to prevent
many pathological conditions of the oral cavity, especially feeding, speech and oral hygiene.
in erosive manifestations of the oral mucosa [209]. There are many aids designed to reduce the symp-
toms and speed the healing of these injuries, such as
painkillers, herbal or hyaluronic acid gels, topical corti-
7.24 Recurrent Aphthous Stomatitis (RAS) costeroids and oral vitamin B12. Also a SLS-free denti-
frice is advisable.
Aphthae are ulcerations that vary in size (from a few In literature there are many studies that have inves-
millimeters to over a centimeter), affecting the oral non- tigated the efficacy of PBMT in the treatment of RAS,
keratinised mucosa; they are painful, have a rounded and there is consensus that PBM laser treatment pro-
appearance, are gray/white in color and have an ery- vides a good pain control. This can be achieved from
thematous rim. The etiology remains unknown; how- a single application and there is better wound resolu-
ever, predisposing factors have been proposed as tion compared to other therapies or placebo groups
consequential to an immune system dysfunction. [210–216].
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
211 7
Diode lasers of various wavelengths (450–980 nm) The choice of PBM as a treatment method has been
with fluences of between 2 and 10 J/cm2 with different recommended to mitigate pain and reduce inflamma-
treatment times according to the setting have been used. tion. Also, there can be stimulation of wound resolution
A suggested protocol can be adopted from the recom- and it is possible to arrest the progress of an early attack
mendations made for oral mucositis (see . Fig. 7.26). with a prompt PBM intervention.
Regarding the management by PBM treatment on
herpes labialis lesions, it has been suggested to employ
7.25 Herpes Simplex wavelengths in the range of 632–980 nm with an applied
fluence of 4–10 J/cm2. There are many suggested proto-
Herpes simplex virus (HSV) is a common infection and cols some with multiple sessions and irradiation points
has two types. Type 1 (HSV-1) is the most frequent in the during the different phases from the incipient prodromal
oral cavity, where its prevalence is from 60% to 90%. to the crusty lesion stage. The recommended protocols
The virus can travel along the nerve sensory axons are drawn from a limited number of studies in the litera-
and cause chronic latent infection. Following primary ture [217–226]. The author’s preferred approach based
infection it can remain latent in the trigeminal ganglion, on clinical experience is to employ a high-intensity ther-
and visible eruptions can recur triggered by fluctuations apy. Employing a 1 cm2 optical spot size, the affected
in the immune system, bright sunlight and physical area can be irradiated with a scanning motion to avoid
stress. The progression of this lesion includes five stages: excess heat accumulation. An output power of 0.5 W
prodromal, vesicle, pustules or ulcers, crust and healing. with wavelengths in the range 800–980 nm for 100 s
Herpes labialis can be characterized as a benign, self- delivers a fluence of around 50 J/cm2. This high-energy
limiting lesion, which is spontaneously healed after treatment arrests the viral progress and at sub-surface
10 days after the first vesicles present [6]. levels promotes vasodilatation and stimulation of the
Concerning treatment, topical and systemic antiviral immune system. Furthermore, patients experience good
medications, such as acyclovir and valacyclovir, are pain relief with prompt resolution of the condition. The
widely used. However, although these may alleviate the validation of this approach however requires formal
progress of the infection, there is a variable incidence of studies and evaluation under controlled circumstances,
inevitable recurrence. and as with so many aspects of dental science, more
Until the stage of formation of a surface crust, the studies are required!
area is painful, and treatment is usually symptomatic A further promising treatment approach combines
with antiviral drugs (for large lesions or immunosup- the beneficial effects of aPDT (methylene blue + 660 nm)
pressed patients), emollient creams, anesthetic oint- and PBM (660 nm). The former is performed in the
ments, painkillers and anti-inflammatory drugs which vesicular phase, while the latter may offer benefits in the
may be required, according to the gravity of the case. healing phase (. Fig. 7.31).
212 M. Cronshaw and V. Mylona
.. Fig. 7.31 (1) Fifteen-year-old patient, with a painful major aph- 1.4 W/cm2, superpulsed, spot technique, 3 s per point, irradiations
thae—treatment performed with diode laser 904 nm, fluence 4 J/cm2, every other day, immediate analgesic action and complete healing
average power 0.28 W, spot diameter 5 mm, power density 1.4 W/ after four sessions. (3) Twenty-six-year-old patient, with herpes sim-
cm2, superpulsed, spot technique, 3 s per point, irradiations every plex labialis—treatment performed with diode laser 810 nm, fluence
other day, immediate analgesic action and complete healing after 4 J/cm2, average power 0.3 W, spot diameter 6 mm, power density
four sessions. (2) Seventeen-year-old patient, with a painful major 1.07 W/cm2, CW, spot technique, 4 s per point, irradiations every
aphthae—treatment performed with diode laser 904 nm, fluence 4 J/ other day. Complete healing after five sessions. (Cases courtesy of Dr
cm2, average power 0.28 W, spot diameter 5 mm, power density E. Romagnoli and Dr A. Cafaro, Italy)
.. Fig. 7.32 (1) Fifty-eight-year-old patient with oral lichen planus bone fractures. The patient is undergoing a therapy with bisphos-
(erosive form, unresponsive to topical steroids)—treatment per- phonates by injection, with a high risk of oral necrosis of the jaw
formed with diode laser 980 nm, fluence 4 J/cm2, average power Preventive treatment, following dental extractions, performed with
0.3 W, spot diameter 6 mm, power density 1.07 W/cm2, CW, spot diode laser 904 nm, fluence 4 J/cm2, average power 0.28 W, spot
technique, 4 s per point, irradiations every other day, appreciable diameter 5 mm, power density 1.4 W/cm2, superpulsed, spot tech-
remission after 16 sessions (cases courtesy of Dr E. Romagnoli and nique, 3 s per point, irradiations every other day, six sessions. Com-
Dr A Cafaro, Italy). (2) Sixty-year-old patient, assuming high doses plete healing after a month (cases courtesy of Dr E. Romagnoli and
of steroids and immunosuppressive drugs for a severe form of auto- Dr A Cafaro, Italy)
immune hepatitis, with consequent osteoporosis and spontaneous
The action of PBMT on bone, studied both in vitro exclusion; it is chronic clinical entity characterized by
and in vivo, is performed through the proliferation and burning or itching that affects the oral mucosa and peri-
differentiation of osteoblasts with increased calcium salt oral regions with a generally bilateral and symmetric
deposits which accelerate calcification, through the acti- distribution. Symptoms such as dysgeusia and xerosto-
vation of MCM genes (minichromosome maintenance mia may accompany the burning sensation but without
proteins) regulated by DNA replication and through clinical and laboratory data that may suggest the combi-
type I collagen formation. The most commonly used nation of an organic disease.
wavelengths are in the range between 650 and 1064 nm, The physiopathology of BMS is not entirely clear; it
and power density is between 5 and 150 mW/cm2, is believed that dysfunctions in the central nervous sys-
30–60 s per point, and fluence between 0.3 and 9 J/cm2. tem, such as different processing by the brain of nocicep-
For 1064 nm wavelength, the parameters used are as fol- tive and thermal stimuli and dysregulation of the
lows: power 1.25 W, frequency 15 Hz, fiber 320 μm, PD dopaminergic nigrostriatal system, may represent plau-
1562.5 W/cm2 and fluence 7 J/cm2 [111]. On average, sible causes of oral burning. There is growing evidence in
laser sessions are performed two or three times per week the most recent scientific literature that links the BMS to
(. Fig. 7.32). a peripheral neuropathic mechanism. Histopathological
studies show a lower density of epithelial and sub-
papillary nerve fibers with axonal degeneration and an
7.28 Burning Mouth Syndrome (BMS) increase in the level of receptor mediators in charge of
the processing of nociceptive response in patients with
Burning mouth syndrome (BMS) has been classified as BMS compared to a control population. The tongue is
a distinct disease in 2004 by the International Headache the most frequently affected site.
Society, which defined the primary form as “a feeling of There is no effective treatment plan; patients get some
intraoral burning sensation for which no medical or benefit by the use of anxiolytic drugs, anticonvulsants,
dental cause can be found.” The diagnosis is mainly by herbal remedies, acupuncture and psycho- behavioral
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
215 7
techniques. In recent years PBMT has also been used. incidence in head and neck radiotherapy (HNRT). OM is
The use of PBM has been explored for the management also associated as a common complication (40%) of the
of BMS, due to its analgesic, anti-inflammatory and bio- management of many other types of cancer chemother-
stimulatory effects. Also, PBM can affect the microcircu- apy treatment. The pathology of OM is associated with
lation by vasodilation. Also, it has been shown that PBM pro-inflammatory pathways consequent upon the chemo-
can decrease the level of stress and salivary cortisol in therapeutically and radiotherapy-induced disruption of
BMS patients. The positive results in the treatment of basal cells of the oral surface epithelium. Subsequent
BMS reported after laser treatments are due to the action infection of the exposed dermal layers elicits an acute
that laser radiation has on pain control, through the inflammatory response via increased cyclooxygenase pro-
release of endorphins, as well as preventing the arrival of duction of prostaglandin E2, an upregulation of nuclear
ascending nociceptive stimulus to the higher cortical cen- factor kappa B and interleukin 6, histamine release and
ters; a reduction of TNF-α and of IL-6 levels in saliva of increases in the production of bradykinin and substance
patients after PBMT has also been reported. P. This results in severe pain and swelling, which can be
The wide diversity of the parameters used varied difficult to manage in already debilitated patients.
from large numbers of in-contact small probe applica- There is a large body of evidence demonstrating the
tions (“points”) to scanning techniques with large diam- efficacy of PBM for preventing OM in certain cancer
eter spot sizes 1 cm2+. The lasers applied have a patient populations, as recently outlined by the
wavelength between 630 and 980 nm, power set from 40 Multinational Association of Supportive Care in
to 300 mW and fluences from 0.4 to 176 J/cm2. The ses- Cancer/International Society of Oral Oncology
sions are performed one or two times a week for up to (MASCC/ISOO). Building on these, the WALT group
ten total treatments [249–267]. outlines evidence and prescribed PBM treatment param-
Recent systematic reviews do support the benefits of eters for prophylactic and therapeutic use in supportive
PBMT for this condition although the order of differ- care for radiodermatitis, dysphagia, xerostomia, dysgeu-
ence is relatively small as expressed as a statistical mea- sia, trismus, mucosal and bone necrosis, lymphedema,
sure. Given the heterogeneity of approaches, it is not hand–foot syndrome, alopecia, oral and dermatologic
possible to make an evidence-based recommendation. chronic graft-versus-host disease, voice/speech altera-
However, the stability of the results over time and the tions, peripheral neuropathy and late fibrosis amongst
effective reduction of inflammation mediators also sug- cancer survivors [270, 271].
gest that there is a real photobiomodulating action. PBM parameters using low-level lasers or light-
emitting diodes (LEDs) in cancer supportive care are
usually within the red and near-infra-red (NIR) wave-
7.29 Chemoradiation-Induced Mucositis length range between 600 nanometers (nm) and around
1000 nm, with an irradiance from 5 to 150 mW/cm2
Oral mucositis (OM) is a common consequence of che- [7]. The duration of application varies according to
motherapeutic drug infusion, as well as head and neck the site, usually within 30–60 s per point. The thera-
radiotherapy (HNRT). A few days after such treatment peutic dosage varies between 4 and 12 J/cm2. Higher
has commenced, the patient complains of soreness, and end dosimetry is generally reserved for pain manage-
the oral tissues appear red and smooth. Rapidly, the integ- ment as opposed to the prophylaxis (reduces inci-
rity of the mucosa breaks down, and ulceration occurs at dence) and the promotion of healing of extant lesions.
sites on the buccal mucosa, ventral lingual mucosa, soft In recent years, LEDs with wavelengths in the red or
palate and the inner aspects of the lips and the floor of the NIR regions have been adopted as a prophylactic mea-
mouth. Unfortunately, associated pain is intense, and OM sure due to their safety, relatively low cost and suit-
can severely impair oral functions including speech and ability for home use.
feeding [99]. This may lead to a requirement to discon- In regard to management protocols, best evidence-
tinue cancer therapy, despite the increased risk of treat- based practice recommends prophylactic application as
ment failure. The serious morbidity that can arise from a prequel or on the same day as the medical intervention
this clinical problem is associated with extended hospital- (chemo- or radiotherapy). This is repeated as required to
based care needs, together with a high degree of patient coincide with further active intervention treatments. The
pain. Following extended multicenter clinical trials and area of exposure is the oropharynx, and administration
multiple systematic reviews, the joint task force of the of the dose is amenable either to multiple small point
Multinational Association of Supportive Care in Cancer/ applications or to a larger optic beam device. There is
International Society of Oral Oncology (MASCC/ISOO) some limited evidence supporting the benefits of a larger
has agreed new updated guidelines [268–270]. optical spot size, and indeed from a practical aspect, it is
OM occurs in over 80% of patients undergoing hema- simpler and quicker to irradiate larger areas of tissues in
topoietic stem cell therapy (HSCT), in addition to a high contrast to a small probe tool [191].
216 M. Cronshaw and V. Mylona
.. Fig. 7.33 A marked reduction following high-energy PBMT in a laser photobiomodulation therapy for immediate pain relief of
10-point numerical rating scale (NRS) after chemotherapy (CT) and/ refractory oral mucositis. Oral Diseases. 2023 May 19 [272])
7 or radiotherapy (RT). (Reproduced from Finfter O et al. High-power
The management of any extant lesions poses a The causes of injury of the IAN and the lingual nerve
dilemma as higher dosimetry PBM is effective at sup- are third molar surgery, implantology, endodontics, orth-
pressing pain. However, the promotion of healing is best odontic surgery and regional anesthesia (dental causes)
served by a lower dose window. As a possible clinical but also operations for the removal of benign or malignant
solution to this, a dosimetry flow chart has been sug- growths or operations concerning the salivary glands. The
gested and this is reproduced above (. Fig. 7.26). resulting symptomatology is variable, and complete
Higher-level dosimetry has been subject to some con- absence of sensitivity (anesthesia) of the innervation dis-
temporary studies, and the research outcome offers sup- trict can be observed, or a decrease in sensitivity (hypoes-
port to the benefits for analgesia of a higher-intensity thesia), sometimes accompanied by disabling pain
therapy for good pain relief. (hyperesthesia) with a significant decrease in quality of life.
In a study by Finfter et al., PBMT was administered Some lesions tend to resolve spontaneously in 2–3 months,
intraorally using a 940 nm Indium–Gallium–Arsenide– especially if the cause is compressive and the cause (e.g.,
Phosphorus (InGaAsP) semiconductor diode laser (Epic pressure on the mandibular canal or edema) is removed; if
X, Biolase, Irvine, California, United States) [272]. A deep the damage is partial in an estimated 6–8 months’ time, a
tissue handpiece with a defocused spot size of 1 cm2 was partial recovery of the nerve due to spontaneous nerve
applied with rapid rotatory movements over the ulcerated regeneration from the proximal to the distal stump can be
areas (but not over the tumor bed in cases of oral cancer) expected. In the case of complete rescission, a reconstruc-
at a distance of 1 cm from the tissue. Each lesion was tive microsurgical intervention can be attempted.
treated for 90 s. The parameters were as follows: 3 W with Drug therapy (high-dose corticosteroids with gastric
a duty cycle of 50% and pulse duration = 20 ms with a coverage and neuroprotective drugs) should be started as
pulse interval = 20 ms. The irradiance was measured 1 cm early as possible to get a quick resolution of edema and
from the laser aperture as 1.42 W/cm2. Patients reported allow recovery of cell function; if pain relieving pharma-
an immediate decrease in pain following 94% (74 of 79) of ceuticals therapies are required potent analgesics (clon-
the PBM sessions, and after 61% (48 sessions), the pain azepam, gabapentin, carbamazepine) can be used.
reduction was over 50%. No occurrences of increased In the literature, there are studies showing that the
pain post-PBM were documented (. Fig. 7.33). use of PBMT can be helpful in the management of
peripheral nerve injury both in speeding up the regen-
eration of the nerve fiber and in control of pain [13,
273–276]. In vitro studies and animal model studies have
7.30 eripheral Neurological Lesions
P shown an increase in the number of axons, Schwann
(Paresthesia, Anesthesia, cells and myelin, in the groups subjected to PBMT com-
Hyperesthesia) pared to control groups. An increase in metabolism in
neurons was also observed, with increased production
Injuries of the inferior alveolar nerve, its branches and of basic fibroblast growth factor (bFGF) and neuronal
the lingual nerve are the major peripheral neurological growth factor (NGF) eGAP-43 (protein associated with
lesions of oral interest. It is rare in everyday clinical peripheral axonal regeneration) [277].
practice to come across lesions to other nerve branches, The laser used is included in the range between
as they are mainly due to complications following maxil- 660 and 980 nm; the choice of the most suitable wave-
lofacial surgery. length depends on the depth of penetration in relation
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
217 7
a
.. Fig. 7.34 a, b The neurotrophic effects of PBMT can be highly useful in efforts to promote axonal regrowth. (Case: Dr Despoina
Chatzistavrianou and Dr Lochana Nanayakkara, UK)
to the anatomic site where the damage occurred. (ten sessions), irradiating the area affected by the nerve
Fluences that have given the best results are between injury, after mapping, both intraorally and extraorally
0.2 J/cm2 and 12 J/cm2, treatment with repeatable cycles [278–281] (. Fig. 7.34).
218 M. Cronshaw and V. Mylona
.. Fig. 7.35 (1) Seventy-year-old cardiopathic patient with a drug- enty-six-year-old patient, with Sjögren’s syndrome, assuming sys-
induced hyperplasia and gingival painful inflammation (antihyper- temic steroids. Allergic reaction to chlorhexidine. Treatment
tensive drug, non-replaceable). The patient was unable to wear the performed with diode laser 980 nm, fluence 4 J/cm2, average power
removable prosthesis. Treatment performed with diode laser 810 nm, 0.3 W, spot diameter 6 mm, power density 1.07 W/cm2, CW, spot
fluence 4 J/cm2, average power 0.3 W, spot diameter 6 mm, power technique, 4 s per point, irradiations every other day. Almost com-
density 1.07 W/cm2, CW, spot technique, 4 s per point, irradiations plete healing after 2 weeks (six sessions). (Cases courtesy of Dr
every other day, appreciable improvement after six sessions. (2) Sev- E. Romagnoli and Dr A Cafaro, Italy)
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
219 7
7.32 PBMT and Bone To validate the effectiveness of PBMT on osteo-
blasts, the activity of mitochondria was measured; after
The bone tissue is a dynamic and plastic biological tis- biostimulation with a 830 nm laser and fluence of 3 J/
sue characterized by considerable hardness and cm2, an increase of cell proliferation by 30–50% was
strength. It modulates its structure as a result of organic observed [291]. The wavelengths commonly used are in
and mechanical stimuli, has the function of support the range of near infra-red (deep penetration) with flu-
and protection for the body and the internal organs, is ences between 2 and 5 J/cm2.
a mineral salts reserve (calcium, 95%), contains the The possibility to obtain an enhanced bone healing
bone marrow and serves as insertion for the muscles. It offers advantages in the treatment of surgical wounds in
is composed of an organic component rich in cells which the bone tissue is involved, after dental extrac-
(osteoprogenitor cells, osteoblasts, osteocytes, osteo- tions, after oral surgery in general, for the osseointegra-
clasts), of the extracellular matrix rich in amorphous tion of implants and in intrabony defects subject to
substance and collagen type I, which gives strength and periodontal surgery.
elasticity, and of a part rich in minerals and inorganic
salts (calcium phosphate and magnesium, sodium
nitrate, potassium and manganese) which determine
the hardness. The bone tissue is subject to a number of 7.33 PBMT and Implantology
structural and functional changes due to age, nutrition
and subjective conditions such as drug therapies. The success of implant therapy is the result of many fac-
Bone is a tissue with a high regenerative potential: tors and depends both on the health of the soft tissue,
healing of fractures is a clear example of this character- the requirement for good osseous support and the con-
istic. The physiological mechanism of regeneration nective/implants interface. PBMT has many potential
occurs through sequences activated by molecular and applications as an adjunct to all aspects of surgical man-
cellular factors and is similar to the healing of other agement. This ranges from the preservation of bone at
types of tissue: there is an initial inflammatory phase, extraction sites, the optimization of bone and soft tissue
followed by reparative phase and the remodeling phase. grafting plus the mitigation of postoperative pain and
In the bone wound, a hematoma is formed that swelling. Furthermore, there may be benefits to increase
favors the supply of inflammatory cells (macrophages, success in osseointegration and improved primary
monocytes, lymphocytes and nucleated polymorphic) implant stability. With an aging population, more
that induce the production of bone morphogenetic pro- patients in a mature age bracket are requesting implants
teins (BMPs) and growth factors. These in turn infiltrate as a restorative option, and as over 50% of patients over
the surrounding bone resulting in the formation of gran- the age of 50 have a systemic disorder, any measure that
ulation tissue rich in newly formed vessels in which mes- may improve the prognosis deserves to be welcomed.
enchymal progenitor cells are recalled. During the Regrettably as in many areas of progressive dental clini-
reparative phase, the derived mesenchymal cells (mono- cal practice, the evidence base is far behind the clinical
cytes and fibroblasts) begin to differentiate into bone experience. Hence, we are at present largely but not
cells and osteoblasts, which secrete the collagen matrix entirely at the lower levels of evidence base pending
rich in fiber that creates a bridge between the various more well-designed clinical RCTs.
edges of the wound and leads to the formation of oste- At the level of histomorphometric, genomic and
oid tissue, on which the mineral component is deposited. proteomic analyses, there is a considerable volume of
In the phase of tissue remodeling, the newly formed evidence-based data on the effects of PBMT on cellular
bone assumes the characteristics of the native bone in metabolism. Given the extensive knowledge base into
terms of shape, structure and mechanical strength; this PBMT, its safety and efficacy, it is useful to share clinical
process occurs in 3–6 months [287]. experiences pending the further development of the evi-
It has been observed that the use of anti-inflammatory dence base (see . Figs. 7.36, 7.37 and 7.38).
drugs in the first phase can impede bone healing, and Many of the studies available in the literature on
the use of tobacco can inhibit the formation of the sup- implants have been performed on animal models [292,
porting stroma of newly formed vessels. 293]. These indicate a much increased early resistance to
The effect of PBMT on bone tissue has been studied implant removal, and the histology clearly shows good
both in vitro and in vivo demonstrating an increase in early osseointegration which implies improved primary
the synthesis of osteoblasts, modulation of inflamma- stability.
tion and production of TGF-β which includes the BMP, The wavelengths used vary in the range of red and
one of the important factors that regulate the prolifera- near infra-red with fluences ranging from 2 to 92 J/cm2,
tion and differentiation of new bone. A decrease in mainly with values between 3 and 8 J/cm2 with daily
osteoclast activity [288–291] has also been noted. applications or every 48 h during first weeks after implant
220 M. Cronshaw and V. Mylona
a b c
e f
g h i
.. Fig. 7.36 An emergent treatment modality is to apply two dif- osseous regeneration. The diode wavelengths are used to decon-
ferent wavelengths. Due to high absorption in water, the erbium taminate the site as well as to photobiomodulate the socket area.
wavelengths are highly useful for minimally invasive hard and soft Also, there is an anti-inflammatory action and there is vasodilata-
tissue surgery. Also, they decontaminate the surgical site and tion which promotes a good oxygenated blood supply to the
erbium lasers are recognized to have PBM benefits in promoting surgical wound site
placement. The caveat to the dosimetry used in these ani- osseointegration may be relevant for immediate loading
mal studies is that due to differences in human tissue of implants or for implants with a poor initial stability
thicknesses and a corresponding increase in attenuation [293–297]. A further application relates to the manage-
of the beam, it is recommended in patient care to increase ment of peri-implantitis where for sure the added bonus
the surface dosimetry to compensate (see . Fig. 7.17). of enhanced wound healing capacity is a benefit in an
However, the possibility to speed up the early phases of otherwise difficult to manage clinical situation [298–301].
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
221 7
a b c d
e f g h
.. Fig. 7.38 Peri-implantitis at UL2 associated with a 9 mm pocket, using a 940 nm 1 cm2 spot size at 0.5 W CW for 100 s with a scanning
pus and bleeding on probing a; debridement with a zirconium radial motion. This procedure was also conducted after the flapless surgery
firing tip to remove peri-implant granulation tissue and disrupt bio- 8 months prior e; pre-op radiograph f; post-op view at 8 months: new
film b; a side firing sapphire tip debrides the implant threads c; heal- bone formation g; final view: healing at 1 month after the tissue graft
ing at 8 months d; a tissue graft was placed and PBMT performed h. (Case: Dr R Al-Falaki, UK)
222 M. Cronshaw and V. Mylona
Parameters:
910 nm 160mW output power
Spot size: 0.5cm 2.
Applied buccal and palatal to the
teeth with separators in place .
Delivered energy: 18J/tooth as
divided doses.
Total treatment time (6 points of
application on 3 teeth) 360s.
.. Fig. 7.39 A single application of PBMT at the time of orthodon- laser therapy on experimental orthodontic pain caused by elasto-
tic separator placement eliminated pain in the test group. (Repro- meric separators: a randomized controlled clinical trial. Lasers in
duced from Marini I et al. The effect of diode superpulsed low-level Medical Science. 2015 Jan;30:35–41 [312])
7.36 Acceleration of Orthodontic Tooth analysis, this interesting study applied an immunohisto-
Movement (OTM) chemistry analysis of RANKL/OPG and tartrate-
resistant acid phosphatase (TRAP) activity which
On the application of an orthodontic force, a rapid further correlated the histological findings of increased
acute inflammatory tissue response is elicited. The sub- osteoclast activity in the test group on the pressure side
sequent application of phototherapy apparently opti- (elevated levels of RANKL and TRAP) and increased
mizes the cellular response permitting an increase in bone apposition and osteoblast activity on the tension
bone metabolism. Studies conducted in animal models side (an increase in OPG). Furthermore, the rate of
using rats, dogs and rabbits have shown promise that OTM was found to be increased by around 40% com-
laser and LED phototherapy can improve OTM [313]. pared to the control.
Measures applied in the animal studies have included The animal studies represent a substantial body of
histology assessing bone density and volume, the prolif- evidence-based research [2]; however there is no agree-
eration of osteoclasts and osteoblasts, the number of ment on laser or LED wavelength, duration of treat-
capillaries and changes in the number of inflammatory ment, frequency of treatment, irradiance (W/cm2)
cells. Also, by usage of monoclonal antibodies, there applied or total dose (fluence). Faced with a heteroge-
have been immunohistochemical measures for impor- neous set of experimental studies based on a variety of
tant cytokines involved in bone remodeling such as animal models ranging from rats, dogs to rabbits, it is
osteoprotegerin (OPG) and the receptor activator of not possible to extrapolate the results to human sub-
nuclear factor-KB ligand (RANKL). The majority jects. The animal studies are however highly supportive
of the animal studies have used metrics on movement of of a possible future role for photobiomodulation as an
the adult first molar in rats and dogs although perhaps effective tool in accelerated bone metabolism in relation
controversially a few of the studies used movement of to OTM [327–333].
the rat incisor as the experimental model. Also, there are There is some limited clinical evidence supporting
studies looking at the effects on the mid maxillary suture PBM to accelerate OTM, and an increase of 20–40%
in rapid maxillary expansion augmented with laser or has been identified in a number of systematic reviews
LED phototherapy. The majority of the animal studies [314–317]. However due to the heterogeneity of the
showed that the application of lasers in the wavelengths parameters plus issues related to the design of the stud-
of 650–940 nm increased the rate of tooth movement ies, it is not at this stage possible to give evidence-based
2–3× compared to control groups. In addition this out- guidelines. One key problem is the logistical aspect of
come was supported by histological evidence of the need for frequent visits as this calls on good patient
increased cellular activity and significant signs of an compliance plus added clinical time. In an attempt to
increase in bone remodeling compared to control [181]. overcome this problem, home administration patient
In an animal study by Suzuki et al. [181], laser pho- LED devices have been developed. However, regrettably
totherapy was found to increase the number of osteo- there is a lack of supporting good-quality blinded RCTs
clasts present on the pressure side, while there was a to evaluate the benefits of this novel approach, and the
corresponding increase in the number of osteoblasts on clinical value of this type of appliance has yet to be
the tension side. Aside from the histomorphometric established (. Fig. 7.40).
224 M. Cronshaw and V. Mylona
.. Fig. 7.40 Laser application in orthodontics (fixed appliance and points per tooth (mesial, distal, apical, vestibular side and lingual or
removable aligner). Treatments performed with diode laser 904 nm, palatal side). Irradiations every 15 days. (Case courtesy of Dr
fluence 5.6 J/cm2, average power 0.28 W, spot diameter 5 mm, power E. Romagnoli and Dr A. Cafaro, Italy)
density 1.4 W/cm2, superpulsed, spot technique, 4 s per point. Six
7.37 PBMT and Dentin Hypersensitivity remineralising agents (calcium phosphate + casein), fill-
ings with composite resins or glass ionomer cements and
One of the most common requests for dental examina- laser applications.
tion concerns increased tooth sensitivity, mainly per- The action of PBMT on dentin hypersensitivity
ceived as painful sensation due to thermal, tactile, acts mainly on the control of the associated pain mod-
osmotic or chemical stimuli. Excluding the most typical ifying the transmission of the nociceptive stimulus to
disease of the teeth (caries and its complications), dental the pulp, and by stimulating the normal cellular func-
hypersensitivity is established over time for dentine tions, the laser can promote the production of tertiary
exposure due to factors such as gingival retraction or dentin, obliterating the dentinal tubules from the inside
enamel erosion. The treatment of this condition involves [318–323].
the removal of the predisposing factors (incongruous In a recent systematic review (2021), Mendes et al.
brushing, saliva hyperacidity, eating disorders, parafunc- included 14 studies employing wavelengths in the range
tions—teeth grinding and clenching—diseases of dental of 780–2780 nm with a delivered fluence/tooth of
hard tissue, gastrooesophageal reflux disease, etc.). 10–60 J/cm2. Given that low-power diode lasers were
Several agents are used with the purpose of sealing included in this review with high-power free-running
the open dentinal tubules responsible for the painful neodymium and erbium lasers, it is notable that the
sensations, administered as home therapy or in the dosimetry employed falls within the suggested range for
office. The patient should be properly instructed on photoinduced analgesia [325].
proper oral hygiene techniques, on the limitation of After cleansing the area to be treated, the irradiation
acidic foods and drinks and on the use of toothpastes is performed perpendicular to the sensitive area, in three
and mouthwashes containing fluoride or specific for points (mesial, distal, central), repeating the sessions
dentin sensitivity. In-office professional therapies involve every 48–72 h until symptoms disappear. It is important
the use of fluoride varnishes, pastes containing oxalates, to apply any surface desensitiser after the laser therapy
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
225 7
.. Fig. 7.41 PBMT compared favorably in outcome with the den- sitivity Treatments by Photobiomodulation Therapy, Nd:YAG and
tinal heat fusion technique employed. (Reproduced from Nammour Nd:YAP Lasers. Life. 2022 Dec;12(12):1996 [324])
S, et al.. Twelve-Month Follow-Up of Different Dentinal Hypersen-
to optimize the adjunctive benefits (Dr E. Anagnostaki, of surface modification and pulpal photobiomodula-
personal communication). tion. The details of the optimal evidence-based approach
In respect of the literature, there are articles that find are elusive at present. However, in the absence of a con-
PBMT is comparable in outcome to applications of flu- sensus approach to treatment, it is apparent that many
oride gel and gel containing potassium and PBMT. A different wavelengths and parameters can prove highly
recent (2022) randomized controlled trial (RCT) showed effective [95, 96, 322, 326].
that the combination of potassium nitrate gel and PBM Also, the properties associated with PBM may be
with 808 nm and 35 J/cm2 fluence for three sessions able to attenuate the damage and inflammation caused
every 72 h could significantly reduce sensitivity [325]. in pulp tissue by in-office bleaching agents. A systematic
Similarly, a RCT compared the usage of a 660 nm review by Carneiro et al. (2022) identified six studies
diode laser to both Nd:YAG and Nd:YAP high peak investigating the potential benefits of PBMT to post-
power free-running pulsed lasers. The neodymium lasers bleaching sensitivity [326]. All reported success; how-
were both used to fuse and seal the open dentinal tubules ever there was no consensus on the parameters or the
in a single visit, whereas the 660 nm diode laser was used timing of the intervention, i.e., whether before, after-
for repeated PBM 2 × weekly for 2 weeks. Both wards or both. The majority of the studies advocate the
approaches resulted in a significant reduction in dentinal adjunctive post-PBMT use of high-fluoride dentifrices.
sensitivity; however the best outcome was found in the The wavelengths employed ranged from 660 to 810 nm
PBM red laser group [324] (. Fig. 7.41). with a fluence in the range of 12–60 J/cm2. Given the
There may be different modes of operation between heterogeneity of the studies, it did not prove possible to
the low-power and high-power devices. High-power conduct a meta-analysis. In respect of other PBM treat-
lasers with a small spot size can generate significant heat ment modalities, pre-conditioning has been found to be
which may melt the superficial apertures of the open beneficial in improving cellular viability and reducing
dentinal tubules. There will also most likely be a dehy- the production of pro-inflammatory cytokines. The
drating effect which will render the dentinal-treated sur- weight of current available evidence is insufficient to
faces more absorbent of any subsequently applied offer guidelines on the prophylaxis of post-bleaching
topical dentine desensitisers. It is accepted however that sensitivity. However, this approach is likely to further
Er,Cr:YSGG lasers can have an analgesic effect and develop as the outcome of the current studies is encour-
there may be a dual effect with high-power laser systems aging.
226 M. Cronshaw and V. Mylona
7.38 Future Perspectives time of writing, this type of appliance is still unproven.
As for larger clinic-based units, these are available as flat
There is a considerable body of evidence base in respect panel-type devices which can be multiwavelength as well
of the PBM effects on biochemistry, immunology, gene as intraoral applicators. There is active current research
transcription pathways and the histopathology associ- assessing the benefits of this type of appliances for man-
ated with damaged and diseased tissues. However, aging conditions such as oral mucositis as well as expos-
PBMT has not as yet achieved a high level of accep- ing large areas of tissues for some other oncology-related
tance as a useful adjunctive process in routine clinical conditions. It is the authors’ expectation that LEDs will
care. As more well-designed studies are being accepted become proven useful clinical tools. However, there are
into the peer-reviewed literature, there is an increased major differences between the energistic state of a broad
awareness of the therapeutic potential of this nontoxic band noncoherent light source and a laser which poses a
and gentle approach to mitigate pain and inflammation challenge to the optical transport of photons to depth.
and to take advantage of the promotion of the optimal Although LEDs may prove highly useful for some super-
biological capacity of the tissues to heal, repair and ficial conditions, it is probable LEDs may not be opti-
regenerate. The processes associated clinical with PBMT mal for deeper tissue work, particularly if higher
7 entail a transferable skill which requires some dedicated dosimetry associated with pain management is required.
training; however this is not overly complicated and can As an alternative option to re-tasked extant dental
be learned by any member of the clinical team including surgical diode lasers, there are dedicated to PBMT
hygienists and therapists along with dental surgeons. devices some with user interfaces and supported didac-
The level of interest within the clinical community to tic instruction intended to induct the new adopter.
enhance clinical results, minimize iatrogenic pain and Although many highly sophisticated devices are cur-
ease the patient journey improving compliance will rently available, the market for this type of more special-
inevitably result in PBMT being adopted as a routine ized equipment is directed primarily toward the
procedure. In respect of standardization of equipment physiotherapy community rather than in dentistry. One
including wavelengths and peripheral applicators, most trend amongst the more advanced manufacturers for the
existing surgical diode lasers can already be adapted to physiotherapy community is to provide the ability to
the task dependent on the operator’s knowledge and deliver multiple wavelengths simultaneously along a
ability to work with what equipment is on hand. Due to coaxial fiber. Also, the range of peripheral applicators is
variations in wavelengths and other inherent properties considerable, plus there are added built-in devices such
of the device, this may pose a challenge to a new adopter as thermal cameras to help prevent hyperthermia of
of PBMT. superficial tissues exposed to high output power sources.
The opportunity for discerning clinicians to adopt As the dental applications become more widely adopted,
PBMT to good effect within the current knowledge base it is to be expected that the manufacturers will respond
is limited only by the need for practical and didactic by building units dedicated to dentistry. Aside from
training. Given the ascending rise in awareness and thermography the range of wavelengths currently
interest in the already established effects of PBM on cel- adopted for PBMT may include visible blue to green
lular and tissue metabolism, there are challenges ahead which offer some added benefits to the discerning prac-
to satisfy the requirements of the evidence-based clinical titioner. Shorter wavelengths carry more energy and
community to offer standardized protocols. However, at may offer the ability to combine an antiviral, antifungal
the time of writing, PBM is the most active topic of sci- or antibacterial action with PBM as part of a mixture of
entific research papers on lasers in dentistry with over wavelengths. This may be a direct photonic response or
5000 publications accepted in the peer-reviewed litera- perhaps could be used in conjunction with a photosensi-
ture in the past 5 years alone. In combination with the tiser. Furthermore, as an adjunct to specialist care,
use of regenerative materials such as autologous stem PBMT has great potential in the management of medi-
cells, the value of PBMT to clinical dental care is antici- cally compromised patients as well as in the care of con-
pated to be a key topic which will have a considerable ditions otherwise difficult to manage such as xerostomia.
impact on the patient outcome of many common treat- As a multifunctional clinical appliance with applications
ment modalities. as diverse as disinfection, aPDT, the coagulation of
LED appliances for home administration of PBMT venous anomalies, tooth whitening as well as the many
as well as larger clinic-based units are currently avail- healing, regenerative, anti-inflammatory and analgesic
able. For sure the attraction for patients to be able to PBM treatment modalities, this type of specialized
self-administer low dosimetry PBMT at home is a great equipment will become a commonplace element in all
concept as it solves a logistical issue. However at the modern dental clinics.
Photobiomodulation Therapy Within Clinical Dentistry: Theoretical and Applied Concepts
227 7
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237 II
Contents
8.20 Protocol for Tooth Analgesia with the Erbium Laser – 267
8.28 The Use of the CO2 Laser with Hard Dental Tissues – 275
8.32 Air Quality in a Dental Clinic During Er:YAG Laser Use – 281
8.33 Conclusion – 282
References – 282
Laser Use in Dental Caries Management
241 8
Core Message
.. Table 8.1 Advantages associated with hard/soft tissue
This chapter explores the range of benefits that relate to laser use
laser-assisted oral hard tissue management and details
aspects of each wavelength in delivering adjunctive ther- Hard tissue laser advantages
apy. Of the currently available wavelengths of dental lasers,
at the moment, only three can be used for hard tissue. •
To be used on the hard tissue components of the tooth, on
the bone and on soft tissues
55 “Erbium” lasers available on the market can have two
different wavelengths: 2940 nm erbium yttrium- •
Possibility to cut soft tissues at the same time during cavity
aluminum- garnet (Er:YAG) and 2780 nm erbium, preparation (i.e., gingivoplasty or pulp exposure treatment
during conservative therapy)
chromium: yttrium-scandium-gallium-garnet
(Er,Cr:YSGG), and their use is gradually increasing in • Minimally invasive
dental practices as an alternative or as a complemen- • Reduced or no need for local anesthesia
tary tool versus traditional dental treatments.
•
Suitable for preparation of very small cavities, without
55 During the last 15 years, researchers have developed a
unnecessary removal of sound tissues
variation of the carbon dioxide CO2 laser, traditionally
used for soft tissue surgery, into a powerful hard tissue • Precision and accuracy in ablation on hard tissues
laser. The emission wavelength is 9300 nm, and the per- •
Less noise associated with ablation compared to dental drill,
formance within clinical use in restorative dentistry is no vibration, non-contact
very promising. • Ablation/excision selectivity of decayed hard tissues
• Limited risk of iatrogenic damage
These innovative properties can be easily perceived by • No smear layer in hard tissues
comparing the use of these wavelengths and traditional •
Tissue decontamination due to bacteria removal from
techniques, envisaging the use of a high-speed hand- dentin tubules
piece and of a diamond bur, or alternative ones, for
•
Less noise associated with ablation compared to dental drill,
example, techniques such as air-abrasion or the use of no vibration, non-contact
decayed material dissolving gels. Thanks to its clear
advantage, in restorative dentistry, every dentist can eas- • Ablation/excision selectivity of decayed hard tissues
ily exploit the important characteristics that are revolu- • No tissue/pulp heating
tionizing dentistry. • No hard tissue cracking
This type of laser perfectly fits the Minimally Invasive
Dentistry (MID) philosophy. The experience reported •
Increased useful surface for bonding (micro-retentive
surface)
by the patient during its use for cavity preparation is
completely different from the one when a rotary dental •
Inhibition of dental demineralization with lower cario-
drill is used to prepare a decay lesion. . Table 8.1 out- receptivity
lines the many advantages claimed during the use of a •
Tissue decontamination due to bacteria removal from
laser suitable for both hard and soft tissue surgical man- dentin tubules
agement. In most cases, local anesthesia through injec- • Biomodulation effect
tion is not required, because the erbium laser triggers an
• No tissue/pulp heating
analgesic effect in just a few seconds. This laser allows
pain-free ablation of hard tissues. Furthermore, no • No hard tissue cracking
vibration is felt as there is no bur working in contact • Limited coagulation effect on soft tissues
with the surface, and thus the patient does not hear the
• Working area on soft tissues remains clean
traditional noise of the dental drill. However, the opera-
tor has to accept a learning curve, because the use of • No smear layer in hard tissues
these wavelengths is neither intuitive nor immediate. A
period of time is required to develop the optimal dis-
tance of the handpiece vis-à-vis the dental surface to be used with the dental drill are still more efficient and fast
treated. By working “contactless,” it is optimal to place in removing dental tissues. Preparing a cavity using a
the laser tip at about 1 mm in order to maximize abla- dental drill is much quicker. Burs ensure optimal con-
tion. Furthermore, the operator must have an in-depth trol, and their use is more intuitive as all dentists are
knowledge on how to set and modify the various param- trained in their use. However, burs are more aggressive,
eters (among which are energy output per pulse, fre- non-selective, they generate intense vibration which may
quency of pulses, and the air/water ratio for coaxial be harmful to the tooth structure, and they may cause
cooling irrigation) [1]. However, high- or low-speed burs cracking and pulp heat damage. Furthermore, during
242 R. Poli et al.
a b
c d
e f
.. Fig. 8.1 a Small cavity on occlusal side of tooth #15. b Detail of 2 W, 15 Hz, 133 mJ E/pulse, peak power 831 W, average power den-
cavity on tooth #15. c Preparation with Er:YAG laser (Pulsar with sity 323 W/cm2, peak power density 136.336 W/cm2, total energy
wavelength of 2940 nm by LAMBDA Dr. Smile, Italy). Enamel 239 J, pulse width 160 μs, 1 mm tip-to-tissue distance, 50% water
settings: angulated handpiece, sapphire tip diameter 600 μm, length (18 mL/min), 80% air, total treatment time 120 s. d Detail of cavity
12 mm, 2.6 W, 10 Hz, 260 mJ E/pulse, peak power 1625 W, average after enamel preparation. e Detail of cavity after dentin preparation.
power density 426 W/cm2, peak power density 266.521 W/cm2, total f Completed composite restoration on tooth #15 (acid etching with
energy 468 J, pulse width 160 μs, 1 mm tip-to-tissue distance, 60% orthophosphoric acid 37%), OptiBond FL total-etch adhesive sys-
water (20 mL/min), 100% air, total treatment time 180 s. Dentin and tem (Kerr, Orange, CA, USA), composite material (IPS Empress
smear layer settings: sapphire tip diameter 600 μm, length 12 mm, Direct Ivoclar Vivadent). (Procedure by Dr. Riccardo Poli)
244 R. Poli et al.
8.2 Affinity with Water air translated into better cutting efficiency of the dentin
compared to a higher percentage. Although it is not pos-
Both erbium laser wavelengths (2780 and 2940 nm) have sible to determine from the article the exact amount and
high affinity with water [5, 6]. Given the ubiquitous pres- volume of air corresponding to 50% and 70% in the
ence of water in human tissue and where water is a com- spray, a possible explanation of this phenomenon is that
ponent of dental restorative materials, it may be seen too much air might displace the cooling water, so caus-
that the greater the percentage content, the higher rate ing a reduction in ablation efficiency. In the case of
of absorption. Considering that the laser beam penetra- removal of deep carious dentin near the pulp, Shinkai
tion is inversely related to absorption, incident laser et al. [12] recommended to use a higher percentage of air
radiation does not spread much in depth, thus the beam in the spray in order to reduce the ablation and preserve
can penetrate dental tissues by only a few microns (for the pulp integrity. The volume of ablation per impulse
the wavelength of 2940 nm it is 7 μm into the enamel depends significantly on the variability of the amount of
and 5 μm into the dentin, while for the wavelength of water contained.
2780 nm it is 21 μm into the enamel and 15 μm into the
dentin) [7–11]. If the tissue has high water content (i.e.,
soft tissues vs hard tissues, dentin vs enamel, deciduous 8.3 The Level of Laser Energy
dentin vs permanent one, decayed dentin vs health den-
Erbium lasers are equipped with coaxial integrated irri-
8 tin), the energy of erbium lasers could more easily cause
explosive ablation at lower energy levels. The average gation systems through an air/water spray. This allows
threshold level at which ablation of hard tissues occurs to cool off targeted tissues, to keep the working area
is about 8–11 J/cm2 for the Er:YAG laser and about clean as it is key to prevent damages and thermal altera-
10–14 J/cm2 for the Er,Cr:YSGG laser [10]. This phe- tions on the cavity surface and on the tooth pulp. The
nomenon forms the basis of selective laser ablation; operator should be able to accurately choose laser
both erbium lasers more easily ablate the more hydrated parameters in order to efficiently perform the ablation
tissue vis-à-vis the one with the lowest water content, without damaging the surrounding healthy tissues. The
and thus it is more effective on decayed dentin and pre- first decisive factor is represented by the level of laser
serves the healthy tissue surrounding it. This is the rea- energy. It is always good practice to use minimum effi-
son why laser parameters will have to be adjusted cient value to obtain adequate excision. Excessive energy
according to water content, for example, by reducing the may damage the dental surface by altering, for example,
beam energy used for a deciduous tooth vs what one the possibility of performing a good adhesive technique
would do to perform the ablation of a permanent tooth. of composites [13]. The removal of a tissue occurs with
An appropriate maxim would be to use a minimum dose a specific level of energy starting from the “threshold”
parameter to deliver an optimal outcome. The energy value. Below it, no excision will occur, but there could be
threshold value that can allow a clinically efficient abla- important structural or micro-structural modifications
tion of hard dental tissues is as follows: [14–18]. The chosen energy level can also be addressed
55 About 125 mJ (100–150 mJ) for primary dentin and toward a smaller or bigger surface. If the chosen level of
decayed tissues energy is spread on a small surface, it will be easier to
55 About 150 mJ (100–200 mJ) for permanent dentin obtain the ablation effect vis-à-vis when the energy is
and primary enamel spread on a bigger surface [14]. In fact, if the same
55 About 225 mJ (200–250 mJ) for permanent enamel amount of energy is spread on a bigger surface, the
amount of energy per surface unit will be smaller and
With regard to posterior teeth, or if tissues are highly may be unsuitable to achieve the ablation threshold
calcified with less water content, it could be necessary to energy density (fluence) level capable of interacting with
further increase energy parameters (up to about 350 mJ/ target tissue. By placing the tip in contact with the tissue,
pulse for healthy enamel). The speed of the laser cutting fluence will be maximum; delivery tip withdrawal from
could be affected by numerous laser irradiation param- the tissue surface and increasing the distance we reduce
eters such as energy density, frequency, water-ratio, and it by about 70% at 0.5 mm, by 52% at 1 mm, by 32% at
air-ratio in spray. Shinkai et al. [12] have shown that the 2 mm, by 22% at 3 mm, and so forth. Obviously, the
depth of cut with 50% air is significantly deeper than greater the energy density, the greater the interaction
when cut with 70% air. When the value of the air/water between laser and target tissue. Furthermore, this
ratio was between 50% and 70%, a lower percentage of parameter can change by using, for example, a fiber or a
Laser Use in Dental Caries Management
245 8
tip with a different diameter. If the tip diameter is larger, tion of tooth tissue but sufficient for the ablation of cal-
the energy is spread over a larger target surface, com- culus, which is richer in water than cementum. This can
pared to a tip with a smaller diameter, and thus, the sub- be particularly useful in periodontology, as it can help
sequent effect will be less. On the other hand, above the the root debridement and scaling. At 1.3 W of average
threshold of 150–200 mJ, there would be a proportional power (65 mJ/pulse, fluence 640 J/cm2, peak power
increase of the excision, but also an increase in the risk 406 W), harder calculus is ablated. At 1.7 W of average
of structural thermal alterations, especially if the air/ power (85 mJ/pulse, fluence 836 J/cm2, peak power
water spray cooling is insufficient [19–21]. In such event, 531 W), the ablation of cementum on root surface is
these alterations concern a surface depth of a few tenths possible. This can be considered the average ablation
of microns. Photonic energy is measured in Joules (J) threshold level at which the restorative dentistry takes
and its density in J/cm2. The energy density (fluence), place. At 3 W of average power (150 mJ/pulse, fluence
measured in J/cm2, is an important factor that deter- 1476 J/cm2, peak power 938 W), the ablation threshold
mines the ablation selectivity of hard tissues. As previ- of cervical enamel is reached; however, only at 4–5 W
ously stated, each hard tissue type has an ablation (200–250 mJ/pulse, fluence 1968–2460 J/cm2, peak
threshold related to the amount of water that is con- power 1250–1563 W) is the ablation of harder occlusal
tained in it. The greater the water percentage, the easier enamel possible, which contains less water than any
the ablation will be. In an empirical research, we can set other dental tissue and so needs more energy to be
the Er:YAG laser using a tip of diameter of 600 μm, at removed. The ablation threshold of dentin is reached at
20 Hz, and coaxial coolant/dispersant water of 60% and 2–2.5 W of average power (100–125 mJ/pulse, fluence
air at 100%. By just changing the energy per pulse, we 984–1230 J/cm2, peak power 625–781 W). Additionally,
can demonstrate that we need increasing energy/pulse in decayed tissues are much more hydrated than healthy
order to ablate harder and harder tissues of the same tissue counterparts, and similarly, primary tissues are
individual tooth. With 0.5–0.8 W of average power (25– less structured, less organized and richer in water than
40 mJ/pulse, fluence 246–394 J/cm2, peak power 156– permanent ones, so both categories require lower param-
250 W), there is no ablation of any tissue, because with eters.
such power levels, the amount of energy is insufficient to . Figure 8.2a–g demonstrates a laser-assisted treat-
vaporize water. At 1 W of average power (50 mJ/pulse, ment of a carious lesion involving enamel and dentin of
fluence 492 J/cm2, peak power 313 W), there is no abla- tooth #13 on distal occlusal sides.
246 R. Poli et al.
b c
d e
.. Fig. 8.2 a Intra-oral X-ray taken before the cavity preparation. sity 327 W/cm2, peak power density 136.336 W/cm2, total energy
Carious lesion involving enamel and dentin of tooth #13 on distal 359 J, pulse width 160 μs, 1 mm tip-to-tissue distance, 50% water
occlusal sides. b–d Cavity preparation with Er:YAG laser (Pulsar (18 mL/min), 80% air, total treatment time 120 s. e Detail of cavity
with wavelength of 2940 nm by LAMBDA Dr. Smile, Italy). Enamel after completed preparation. It is necessary to rectify and bevel
settings: angulated handpiece, sapphire tip diameter 600 μm, length enamel margins and following with etching, adhesive, and composite
12 mm, 4 W, 15 Hz, 267 mJ E/pulse, peak power 1669 W, average stratification steps (acid etching with orthophosphoric acid 37%,
power density 657 W/cm2, peak power density 273.696 W/cm2, total OptiBond FL total-etch adhesive system (Kerr, Orange, CA, USA),
energy 721 J, pulse width 160 μs, 1 mm tip-to-tissue distance, 40% composite material (IPS Empress Direct Ivoclar Vivadent). f Com-
water (16 mL/min), 100% air, total treatment time 180 s. Dentin and posite reconstruction completed. g Final X-ray after restoration on
smear layer settings: sapphire tip diameter 600 μm, length 12 mm, tooth #13. (Procedure by Dr. Riccardo Poli)
2 W, 15 Hz, 133 mJ E/pulse, peak power 831 W, average power den-
Laser Use in Dental Caries Management
247 8
f g
8.4 Pulse Dynamics and Frequency action between erbium energy and tooth tissue can
create a series of chemical and structural modifications
Erbium laser radiation is through a free running pulse that are important to consider as there are clinical
(FRP) train, inherently derived from the high intensity aspects involved in them. All these surface changes can
frequency of excitation energy applied to the laser active affect the adhesion process and hamper the reconstruc-
medium. The number of pulses released per second is tion duration but can also be useful because the changes
termed frequency (or pulse frequency). This value is can increase micro-hardness, the acid resistance and
expressed as Hertz (Hz or pps, i.e., pulses per second). reduce the caries incidence.
The larger the number of pulses per unit time, the greater
and quicker the interaction with the target tissue will be,
because a larger amount of energy is transferred to it. 8.5 Remineralization Effect
The amount of energy that is released per unit time
identifies the power, i.e., the energy of each pulse times Loss of enamel can be caused by different processes in
the number of pulses per second. It is measured in Watts the oral cavity, namely attrition, erosion, abrasion, and
(W). Thus, power depends on the ratio between energy tooth decay. Dental caries occurs due to the presence of
and the number of pulses per second (W = J/pulse × acids, which are a result of bacterial carbohydrate
Hz). When energy is provided through a short pulse (a metabolism, mineral loss occurs, and eventual cavity
pulse duration of about 50–150 μs), a high amount of development. Once a cavity is formed, enamel cannot be
energy interacts with the tissue in a fraction of a second repaired in a natural way and tooth restoration is neces-
and this means achieving huge power value. Each pulse sary; enamel resistance against acid attack is viewed as a
can, however, achieve a maximum power (peak power) significant preventive measure. The effectiveness of fluo-
which has a major impact on the tissue. Interaction with ride for the prevention of dental caries has been clearly
a target is greater if the peak power is high. The shorter established in several studies as it enhances resistance to
the pulse duration, the lower the degree of energy con- acid attack through the transformation of hydroxyapa-
verted into heat. As a consequence, thermal interaction tite (HA) to fluorapatite, and at the same time, it reduces
and the damage to tooth tissues following temperature the ability of bacteria to produce acid, having joint bac-
increase will be reduced. The irradiated enamel and den- tericide and remineralizing effects. Fluoride is added to
tin surface appearance is very similar to that of etched several remineralizing agents available on the market in
tooth tissue: without smear layer, clean, wavy, micro- order to improve the ability of fluoride to restore the
rough, irregular valleys and peaks, more pronounced balance of minerals of the dental structure, such as
when the applied energy is higher. Irradiated dentin casein phosphopeptide-amorphous calcium phosphate
results in open tubules; greater ablation occurs within (CPP-ACP) and HA, among others. The anti-cariogenic
the intertubular area as it is very hydrated, leaving peri- properties of such remineralizing agents are explained
tubular areas more elevated and pronounced. The inter- by their mineral contribution to the dental structure—
248 R. Poli et al.
calcium (Ca) and phosphorus (P) ions, which inhibit 55 Decrease of CO3
demineralization and promote remineralization, result- 55 Lower ratio CO3/PO4
ing in the restoration of the dental surface. Some studies 55 Acid phosphate ions condense to form pyrophos-
have tested Er:YAG laser irradiation at lower energy phate ions (more stable, less soluble).
densities and have shown significant inhibition of
enamel demineralization. It has been reported that Ulusoy et al. [32] have proposed to use erbium lasers to
lasers can increase resistance to enamel acids, and when prevent enamel and dentin demineralization by laser-
it is associated with fluoride, both are reported to work induced prevention of demineralization, by which erbium
in synergy, achieving a reduction of the solubility of laser irradiation causes thermal changes in enamel result-
enamel. Currently, other remineralizing agents have ing in chemical and/or morphological structure altera-
been shown to effectively inhibit enamel demineraliza- tions without ablation. The main mechanisms that lead
tion [22, 23]. The chemical modifications of the irradi- to a less-soluble and more caries-resistant enamel struc-
ated tooth surface happen during irradiation with ture are decreased carbonate and hydroxyl groups and
ablative and also sub-ablative parameters. According to organic matrix decomposition. The loss of calcium car-
literature, the chemical analysis of post-irradiated den- bonates increases the degree of enamel crystallinity with
tal structure with Er,Cr:YSGG lasers demonstrated a an improvement in its structural proprieties. Lasers used
calcium ion increase and hydroxyapatite crystal reorga- at sub-ablative energy level in combination with tradi-
nization after laser irradiation, due to enamel thermal tional prophylaxis resulted in an increased caries preven-
8 effects [24]. This was later confirmed by Geraldo- tion effectiveness compared with prophylaxis alone or to
Martins et al. (erbium increases enamel acid resistance untreated teeth [33]. According to Abbasi et al. [34], the
by +23% with Er,Cr:YSGG using 0.25 W, 62.5 J/cm2, no mechanisms behind increased enamel resistance against
cooling with air/water) [16]. The exact mechanism lead- acid after laser application include:
ing to enamel gain acid resistance is not entirely 55 Decreased enamel permeability via melting and
explained; some authors attributed this to heating the reforming enamel surface crystals.
surface (so causing structural and chemical changes), to 55 Decreased enamel solubility by forming compounds
vaporization of water, organic matrix, and inorganic with more resistance against solubility like tetra cal-
components, to other interactions (photochemical cium diphosphate monoxide.
effects or non-linear interactions), leading to less-soluble 55 Decreased enamel solubility by changing enamel
enamel, structural changes that reduced permeability, or structure like reducing water and carbonate content
dental enamel melting. Depending on the temperature and increasing hydroxyl ions, forming pyrophos-
following laser irradiation, different effects on dental phates, and breaking up protein chains [35].
enamel are produced that could result in decreased 55 It was also reported that small spaces are created
enamel solubility and increased acid resistance [10, 17, inside the enamel by laser irradiation. Calcium,
18, 25, 26]. The above-mentioned changes happen even phosphor, and fluoride ions are trapped inside them
without an objective surface melting, but it is not sur- and deposit in enamel [36].
prising that even at low energy densities, the superficial
layers temperature of enamel can reach values above Apart from the mineral content changes, in literature
400 °C [19]. there are also other mechanisms advocated to explain
The effect of heat on hard tissues can be summarized the lower carious lesion incidence following the laser
in: irradiation of the tooth. Ying et al. demonstrated a par-
Decrease of water content and condensation of H tial decomposition of the organic matrix of the enamel
phosphate ions (HPO42−) with formation of pyrophos- during irradiation, with blockage of the inter- and intra-
phate [20, 27, 28]. prismatic spaces and tubular blockage. They considered
55 At 200–400 °C inhibition of HA dissolution this as a possible reason of ion diffusion compromise in
55 At 300–350 °C progressive increase of structural OH enamel with retardation of demineralization [21]. The
55 At 350 °C protein decomposition [29] ideal erbium laser parameters to inhibit demineraliza-
55 At 400–650 °C reduction of carbonate ions (CO32−) tion have not been clearly determined. The laser param-
55 At 400–800 °C enamel organic matrix evaporation eters vary among studies and there is no consensus in
55 At 800–1200 °C HA melting [30] literature regarding which is the best [16]; low energy
densities applied for a short time can cause only water
The main chemical alterations due to laser energy that heating, vaporization, and pressure increase inside the
are responsible of micro-hardness increase and greater enamel, without promoting melting or recrystallization
acid resistance are [31] as follows: on enamel structure. The laser effects on dental enamel
55 Increase of Ca and P ions become more evident as power increases and indeed a
55 Different ratio Ca/P high power leads to undesired alterations, if not
Laser Use in Dental Caries Management
249 8
unwanted ablation. Parameters should be tested because action. Similar conclusions have been reached by Subra-
irradiation conditions have already been shown to cause maniam and Pandey [42] who stated that Erbium Laser
greater protective effects against erosion, and the irradiation of primary teeth followed by CPP-ACP
increase in the resistance of enamel to acid demineral- application increased surface micro-hardness of enamel
ization is highly dependent on laser parameters such as (compared to negative and positive controls and CPP-
pulse duration, energy density, and the number of over- ACP only) making it more resistant to acid challenge
lapped pulses [37]. Thus, it is necessary to establish the than normal enamel. At the moment, research into the
ideal parameter to the clinical use of the laser that pro- combination of erbium and CPP-ACP is still conflic-
motes the highest acid resistance with the lowest possi- tual, and their results are not uniform [43]. More
ble energy settings [38]. According to literature, recently, Yassaei et al. [44] confirmed the previously
laser-assisted remineralization is a further mechanism referred studies by irradiating tested teeth with Er:YAG
able to reduce cario-receptivity. Remineralization is the 2.94 nm, 80 mJ/pulse, 4 Hz, 10 s, 20 mm tip-to-tissue,
process through which Ca and PO4 ions, delivered from sweeping motion, with air and water cooling. They
an external source to the tooth, are deposited inside obtained a mineral loss due to in vitro acid challenge
crystalline structure gaps of demineralized enamel, pro- of—68% in the control group,—36% in CPP-ACP with-
ducing an increase of crystalline lattice [39]. This is the out fluoride + Er irradiation, and—32% in CPP-ACP
best approach for noncavitated white spot lesions due to with fluoride + Er irradiation. Conversely, in 2019
caries process. Several chemical agents have been using Yilmaz et al. [45] had promising remineralization results
for this purpose: fluoride, arginine, hydroxyapatite, bio from the use of several chemical substances or from the
glasses, casein phosphopeptide ACP (amorphous cal- Er:YAG irradiation alone, but the combination among
cium phosphate), and citrate ACP. All these agents them didn’t show a notable impact in terms of eroded
improve caries prevention, remineralization, inhibit enamel improvement. For this reason, it is still sharable
demineralization, attenuate dentinal sensitivity, contrast the affirmation of Ramalho et al. [46] in their literature
erosion, and have antibacterial activity. The combina- review that “long-term clinical studies are necessary to
tion laser-chemical agent seems promising in augment- validate this application because literature continues to
ing the tooth intake of minerals. Every laser wavelength be controversial.” Areas at the restored cavity—healthy
has been investigated with variable results, including surface margins can become demineralized in case of a
CO2, Nd:YAG, argon, diodes, and Er:YAG lasers. Zezell shift to acidic conditions. Evidence shows that laser
et al. [40] in a year—long double-blind crossover study irradiation can prevent mineral loss and demineraliza-
evaluated the effects of Nd:YAG laser used with topical tion of the tooth structure due to the effect of acids
application of acidulated phosphate fluoride (APF) to present in the oral environment [47]. The CO2 and
prevent enamel demineralization in vivo. They obtained Er:YAG lasers alone seem to have no significant effect
a 39% reduction in caries in laser group compared with when used on hard tissues exposed to cariogenic solu-
control. The formation of white spot lesions was signifi- tion. However, lasers can exert a synergistic effect when
cantly less and they concluded that the combination of used with NaF varnish; fluoride varnish applied prior to
Nd:YAG and topical APF was effective for reducing the laser irradiation is supposed to confer further resistance
incidence of caries in vivo. Also Delbem et al. [41] found to the tooth structure and positively affect its hardness.
that Er:YAG laser use following the application of APF . Figure 8.3a–d provides detail of laser-assisted
influenced the deposition of calcium fluoride on the restorative treatment and placement of a Class I com-
enamel and exhibited a superficial anti-cariogenic posite restoration at tooth #31.
250 R. Poli et al.
a b
8
c d
.. Fig. 8.3 a Carious lesion on occlusal side of tooth #31. b Prepa- 369 W/cm2, peak power density 410.032 W/cm2, total energy 511 J,
ration of a class I cavity in tooth #31 (Er,Cr:YSGG Waterlase iPlus pulse width 60 μs, 7 mm tip-to-tissue distance, 50% water (14 mL/
laser with wavelength of 2780 nm by Biolase Technology, Irvine, min), 80% air. c At the end of the cavity preparation, enamel mar-
CA, USA). Turbo handpiece, diameter 900 μm. Enamel settings: gins are rectified and beveled. Then, etching, adhesion, and compos-
3 W, 15 Hz, 200 mJ E/pulse, peak power 3333 W, average power den- ite stratification are performed (acid etching with orthophosphoric
sity 492 W/cm2, peak power density 546.710 W/cm2, total energy acid 37%, OptiBond FL total-etch adhesive system (Kerr, Orange,
540 J, pulse width 60 μs, 7 mm tip-to-tissue distance, 60% water CA, USA), composite material (IPS Empress Direct Ivoclar Viva-
(18 mL/min), 60% air. Dentin and smear layer settings: 2.25 W, dent). d Composite reconstruction is completed. (Procedure by Dr.
15 Hz, 150 mJ E/pulse, peak power 2500 W, average power density Riccardo Poli)
8.6 Distance to the Target interact with the tissue; the speed of the movement
must be slower than the speed normally used with the
It is key that the operator works by holding the laser dental drill. During cavity preparation work, the tip is
handpiece at the correct distance from the target, in gradually inclined on the one side to obtain widening
order to optimize excision and treatment duration. [48]. As preparation proceeds, the tip must be posi-
Since the laser is contactless, excessive distance prevents tioned deeper to maintain the ideal distance vis-à-vis
efficient interaction with tissues. Furthermore, the hand the target, and thus obtain a high and continuous
piece must move slowly to allow the laser energy to energy density.
Laser Use in Dental Caries Management
251 8
8.7 The Problem of Laser Etching 1. Incomplete penetration of the bonding resin in the
area that was decalcified by the etching acid or fol-
Several authors have suggested the use of erbium lasers lowing the erbium laser effect. This gives rise to the
instead of acid as a pre-bonding conditioner. The use of formation of a weaker bonding area, which will be
energy values below the ablation threshold (sub-ablative) more sensitive to hydrolysis and infiltration.
allowing a micro-structural modification in dentin and 2. Stress generated at tooth/reconstruction interface
enamel, creates a very similar surface to that obtained level following polymerization shrinkage, or due to
with orthophosphoric acid. Erroneously, this effect has oral environment temperature fluctuations [71], or
been long defined “laser etching” in literature [36, 49–55]. due to cyclical phenomena of mechanical fatigue
As an example, recently Dilip et al. [56] proposed laser that are repeated during the masticatory load.
etching at 1.5 W/20 Hz because it achieved similar sur-
face roughness and shear bond strength compared to This poses a major concern since it may lead to microle-
conventional acid etching and could be a viable alterna- akage and ultimately failure of adhesive bond between
tive for surface preparation of enamel. Moreso, they pro- tooth substrate and restorative material [72]. Infiltration
posed lower power outputs in those clinical situations of bacteria or of fluids along the interface can cause
which demand lesser bond strength. The differences hydrolytic collapse, both of the adhesive resin and of the
between acid etching and surface etching by erbium laser collagen present in the hybrid layer, jeopardizing bond
are numerous. More precisely, it would be appropriate to stability between the resin and the dentin surface. The
use the term “laser conditioning” [57, 58]. Acid etching is minimum bond strength required at tooth- adhesive
a process that has been used for decades to facilitate com- interface to sustain the forces in oral environment is
posite adhesion. Even though there are some issues asso- 20 MPa [73]. Microleakage is the main factor of second-
ciated with it (excessive decalcification with alteration of ary decay and of reconstruction failure [74–76], and it is
the enamel-dentin ideal architecture for adhesion, higher at the basis of dentin hypersensitivity, discoloration,
susceptibility to secondary decay, tooth sensitivity, exces- and pulp damages. Composite as a restorative material
sive demineralization compared to the penetration ability has evolved to micro-filled, micro-hybrid, nanohybrid;
of adhesive system monomers), the results obtainable and from conventional methacrylate-based to silorane-
through orthophosphoric acid are widely predictable [28, based systems to decrease the inherent problem of
59]. With regard to the use of orthophosphoric acid at polymerization shrinkage associated with it [77]. Despite
34–38%, erbium lasers generate a more irregular surface; various advances in formulation of composite resin, the
the greater the energy and the lesser the frequency we problem of polymerization shrinkage has not been com-
respectively get deeper and more far-apart craters. Even pletely overcome. When the gingival margins of a tooth
if the final surface is very similar to the etched one, com- preparation are in dentin or cementum or both, and the
posite adhesion process to irradiated tooth hard tissues is resin is firmly anchored to the etched enamel at the other
a controversial phenomenon and its outcome should be margins, the material tends to pull away from the gingi-
further investigated as many authors deemed it of lower val margins during curing, because of polymerization
quality. In literature, data are quite contrasting and, shrinkage, resulting in formation of gap at that inter-
often times, adhesion values came out much lower than face. Various factors affecting the polymerization
those obtainable with the acid [53, 54, 60–64]. shrinkage include degree of conversion, light-curing
techniques, technique of composite placement, type of
matrices and wedges used, direct or indirect method of
8.8 Microleakage restoration, and beveling of margins [78]. An additional
cause of detachment between composite and tooth wall
Difficulties encountered by operators during the bond- is related to the shape of the prepared cavity. The greater
ing procedure between the composite and hard tooth tis- the number of walls (i.e., box-shaped cavities typical of
sues often translate into microleakages or the complete Class I of Black’s classification), the greater the relation-
detachment of the reconstruction from its seat [65]. ship between bonded surfaces vis-à-vis non-bonded
Microleakage can be defined as “the clinically undetect- ones. This principle is defined as C factor [79, 80]. C fac-
able passage of bacteria and bacterial products, fluids, tor is the ratio of bonded to non-bonded surface areas
molecules or ions from the oral environment along the and is related to the cavity preparation geometry. The
various gaps present in the cavity restoration interface” residual polymerization stress increases directly with
[66]. It creates a loss of marginal seal between the restor- this ratio. During curing, shrinkage leaves the bonded
ative material used for tooth filling and the tooth cavity cavity surfaces in state of stress and the non-bonded sur-
wall with the subsequent infiltration [67–70]. faces in relaxed state. Incremental build up reduces C
Among the causes of microleakage, we can mainly factor and hence the polymerization shrinkage. The hor-
take the following elements into account: izontal placement technique has been reported to
252 R. Poli et al.
increase the C factor. Therefore, following types of ficient compensation of stresses resulting from polymer-
incremental layering techniques are suggested [81]: ization shrinkage reduces the efficiency of the seal due
55 Oblique technique to the reduced initial strength of the composite-cervical
55 Successive cusp build-up technique dentin bond. Another type of leakage, termed “nanole-
55 Stratified layering technique akage,” was described by Sano et al. (1995) [70]. Con-
55 Split incremental horizontal layering cerns have been raised that aggressive etching of dentin
may cause demineralization to a depth that might be
If the entire composite simultaneously adheres to the inaccessible to complete resin impregnation. A collage-
walls, as it happens in the occlusal cavities of molars, nous band at the base of the hybrid layer would weaken
there will be many more cases of shrinkage-related the resin-dentin bond resulting in a pathway for nanole-
stress because the composite adhering to many walls at akage. This leakage occurs within the nanometer-sized
the same time, by contacting, generates even greater spaces around the collagen fibrils within the hybrid layer
stresses. On the other hand, if cavity tooth walls are just that have not been completely infiltrated by resin. It has
a few (i.e., interproximal preparations of Class II pre- been shown to occur both at the bottom of the hybrid
molars and molars), we would assist to reduced stress layer and/or scattered along its entire width, depending
since the part of non-adhering materials can compen- upon the bonding system employed [82]. This empha-
sate for polymerization shrinkage, releasing the effects sizes the importance of adhesive systems, their selection
toward the part free from constraints and, thus, there based on composition plays an important role
8 will be lesser risk of reconstruction detachment. Insuf- (. Table 8.3). It appears that bonding systems that etch
Self-etch 2 Silorane 2.7 Mild 49, 53a 53b, 64 Primer: phosphorylated methacrylates,
step Adhesive Vitrebond copolymer, bis-GMA, HEMA,
System water/ethanol solv., silane-treated silica
fillers
Bond: phosphorylated methacrylates,
hydrophobic DMA, TEGDMA, silane-
treated silica fillers
Self-etch 2 MegaBond 2.5 Mild – 69 Primer: Water, MDP, HEMA, hydrophilic
step system DMA, CQ, DET
Adhesive: Bis-GMA, MDP, HEMA,
Hydrophobic DMA, CQ, DET, silanated
colloidal silica
Self-etch 1 Xeno V <2.0 Moderate – 62 (enamel), Bifunctional acrylic amides, acidic acrylic
8 step (dentin) amide, functionalized phosphoric acid
ester, acrylic acid, water, tertiary butanol,
initiator, stabilizer
Self-etch 1 AdheSE 1.5 Moderate – 62 (enamel, Derivatives of bis-acrylamide, water,
step One dentin) bis-methacrylamide dihydrogen phosphate,
amino acid acrylamide, hydroxyalkyl meth-
acrylamide, highly dispersed silicon
dioxide, catalysts, and stabilizers
Self-etch 1 Clearfil S3 2.7 Mild 50, 51 62, 66 MDP, HEMA, Bis-GMA, hydrophobic
step Bond/Tri-S DMA, dl-camphorquinone, ethanol,
Bond (S3) colloidal silica, water, initiators, accelera-
tors
Self-etch 1 One Coat 2.0 Moderate – 64 UDMA, TEGDMA, HEMA phosphates,
step 7.0 Initiator system based on camphorquinone
Self-etch 1 Xeno Select <2.0 Moderate – 66 Bifunctional acryl resin with amide
step functions, acryloylamino alkylsulfonic
acid, “inverse” functionalized phosphoric
acid ester, camphorquinone, coinitiator,
butylated benzenediol, water, tert-butanol
Self-etch 1 Clearfil s3 2.7 Mild – 63 Bis-GMA, HEMA, ethanol, sodium
step Bond Plus fluoride, 10-MDP, hydrophilic aliphatic
DMA, hydrophobic aliphatic methacry-
late, colloidal silica, dl-camphorquinone,
accelerators, initiators, water
Self-etch 1 Futurabond 2 Moderate – 66 Organic acids, bis-GMA, HEMA,
step TMPTMA, camphorquinone, amines,
BHT, fluorides, nanofillers, ethanol
Self-etch 2 Etch and 0.76 Aggressive 48 – Primer/catalyst: pyrophosphate, HEMA,
bottle-1 Prime 3.0 initiators, stabilizers
step Bond: HEMA, ethanol, distilled water,
stabilizer
Self-etch 1 iBond 2.2 Mild 37 – Acetone/water based, fillers <1%,
step methacrylates
Mild >2, moderate 1–2, aggressive <1, HEMA hydroxyethylmethacrylate, GPDM glycero-phosphate dimethacrylate, PAMMmono
(2-metacryloxy ethyl) phthalate, TEGDMA triethylene glycol dimethacrylate, UDMA urethane dimethacrylate, Bis-GMA bisphenol
A-glycidyl methacrylate, PENTA dipentaerythritol pentaacrylate phosphate, DMA dimethacrylate, MDP methacryloyloxydecyl dihy-
drogen phosphate, TMPTMA trimethylolpropane trimethacrylate, MHP methacrylated phosphates, MDPB methacryloyloxydodecy-
lpyridinium bromide, Pyro-EMA phosphoric acid modified methacrylate, BHT butylated hydroxytoluene, PEM-F monofluoro
phosphazene modified methacrylate, CQ camphorquinone, DET diethyl tartrate
Laser Use in Dental Caries Management
255 8
deeper into dentin are likely to show higher degrees of border itself, to the relatively reduced number of tubules
nanoleakage. The clinical significance of nanoleakage in the first 200–300 μm of the gingival floor in the cavity,
definitely indicates the inability of the adhesive resin to and to the mainly organic nature of the gingival sub-
completely infiltrate the demineralized dentin, thereby strate” [88]. When present in the cervical margin, enamel
leaving behind pores and spaces. A poorly infiltrated is usually thin, a-prismatic, and less receptive to bond-
hybrid layer contains voids that predispose to accumu- ing. When polymerized, composite resin shrinks toward
lation of water and oral fluids which may accelerate the the upper adhesion site of the occlusal cavity margin,
degradation of the bond. When demineralized dentin is while it gets far apart from the weakest adhesion placed
fully infiltrated with resin, its modulus of elasticity is at the gingival margin level. Further, the micromorphol-
much higher than the values of the original demineral- ogy of the prepared tooth surface after cavity prepara-
ized dentin. If the hybrid layer fails to be penetrated tion plays a key role in predicting the adhesive bond
completely, its modulus of elasticity might fall in [89]. The bond strength of the adhesive system and
between that of adhesive resin and the un-infiltrated microleakage are the major factors for the success of
dentin collagen [83]. The larger marginal gap is usually restorations. Shear stresses are the main reason for
located on Class V gingival side and on the external resin-tooth bond failure in clinical situations, therefore
edge of the Class II gingival margin (V-shaped gap). researchers have suggested shear bond strength as a via-
This is due to a lesser capacity of the dentin sublayer ble method of assessment of clinical performance. Seal
and of cement at tooth neck to favor strong bonding at restoration margins is essential for longevity of resto-
with the resin by means of an adhesive system [60, 84, rations and is assessed by testing microleakage or mar-
85]. A width gap below about 1 μm does not allow bac- ginal gaps and cracks. Stresses are generated at
terial infiltration, but it may allow the spreading of tox- tooth-resin interface due to polymerization shrinkage,
ins and of other tooth potentially dangerous repetitive masticatory load, or temperature fluctuations,
bacteria-related substances (nanoleakage). When the thus it is imperative to include a thermocycling protocol
cervical margin is located on the limit line between root in in vitro studies to simulate closely the in vivo condi-
dentin and cement, the leakage problem becomes more tion [90]. Most of the studies in the current literature
relevant because adhesive systems become less efficient have used two-dimensional dye penetration test to assess
at the level of these substrates vis-à-vis when they are microleakage which is the most common method used
used on the enamel. The bonding process to dentin is in in vitro studies due to low cost and ease of use. Three-
much more technique-sensitive and substrate-sensitive. dimensional method used in a study does not require
The dentin substrate varies in microstructure in superfi- sectioning of sample and provides objective reading.
cial and deep layers; there is difference in micromor- Variations were seen in types of dyes (methylene blue,
phology of crown and root dentin with respect to silver nitrate, basic fuchsin, propylene glycol, acid red)
number of dentinal tubules; altogether these factors used in various microleakage studies but this does not
influence adhesion [86, 87]. The ability of adhesive sys- affect the results of studies [90].
tems to bind to hybridized cementum must be discussed. . Figure 8.4a–g provides details of laser-assisted
“Cervical margin leakage can be correlated to the restorative treatment and placement of a Class III com-
absence of dentin tubules in 100 μm within the cervical posite restoration at tooth #10.
256 R. Poli et al.
a b
c d
e f
.. Fig. 8.4 a Carious lesion on distal side of tooth #10. b Palatal power density 323 W/cm2, peak power density 136.336 W/cm2, total
side view of carious lesion on tooth #10. c Dental dam positioned. d energy 239 J, pulse width 160 μs, 7 mm tip-to-tissue distance, 50%
Preparation of a class III cavity in tooth #10 with Er:YAG laser water (18 mL/min), 80% air, total treatment time 120 s. e At the end
(Pulsar with wavelength of 2940 nm by LAMBDA Dr. Smile, Italy). of the cavity preparation, enamel margins are rectified and beveled.
Enamel settings: tipless (Boost) handpiece, 900 μm, 5.5 W, 20 Hz, Then, etching, adhesion and composite stratification are performed
275 mJ E/pulse, peak power 1719 W, average power density 902 W/ (acid etching with orthophosphoric acid 37%, OptiBond FL total-
cm2, peak power density 281.897 W/cm2, total energy 990 J, pulse etch adhesive system (Kerr, Orange, CA, USA), composite material
width 160 μs, 7 mm tip-to-tissue distance, 70% water (24 mL/min), (IPS Empress Direct Ivoclar Vivadent). f Composite reconstruction
100% air, total treatment time 180 s. Dentin and smear layer settings: is completed (buccal view). g Palatal view. (Procedure by Dr. Ricca-
900 μm, 2 W, 15 Hz, 133 mJ E/pulse, peak power 831 W, average rdo Poli)
Laser Use in Dental Caries Management
257 8
8.9 How to Increase Adhesion 55 Removal of the smear layer prior to bonding (etch-
and-rinse approach)
The adhesion and microleakage values depend on the 55 Use of bonding agents that can penetrate the smear
type of adhesive system and etching protocol used. layer and incorporate it into the hybrid layer (self-
There have been continuous efforts made to improve the etch approach)
adhesion of restorative material to enamel and dentin,
making it more user-friendly and less technique- Conventional etching technique uses 35% phosphoric
sensitive through alterations in chemical composition acid (pH 1.3) on both enamel and dentin in a total-etch
of adhesives and composites. Enamel etching results in approach, while self-etch technique involves a primer
three different micro morphologic patterns [91]. The which has a less acidic (pH 1.9) resin monomer and does
type I pattern involves the dissolution of prism cores not require rinsing-off of the tooth with water as done
without dissolution of prism peripheries. The type II in total-etch technique. The presence of thick smear lay-
etching pattern is the opposite of type I: the peripheral ers may buffer the acidic monomers of self-etch adhe-
enamel is dissolved, but the cores are left intact. Type sives, thus limiting the depth of resin infiltration in
III etching is less distinct than the other two patterns. It dentin. The manufacturers have attempted to alter the
includes areas that resemble the other patterns and concentration of acidic resin monomers to create deeper
areas whose topography is not related to enamel prism hybrid layers and better bond at the tooth- adhesive
morphology. An etching time of 60 s originally was rec- interface. The self-etch adhesives are classified based
ommended for permanent enamel using 30–40% phos- upon the acidity of their monomer as strong (pH <1),
phoric acid. Although a few studies have concluded that moderate (pH 1–2), and mild (pH >2) (. Table 8.3).
shorter etch times resulted in lower bond strengths, Some authors have shown a formation of thinner hybrid
other studies using scanning electron microscopy layer with etch and rinse adhesives on erbium laser
(SEM) showed that a 15-s etch resulted in a similar sur- ablated dentin when compared to acid-etched bur-cut
face roughness as that provided by a 60-s etch [89]. dentin. This may be due to the possible increase of cal-
Other in vitro studies have shown similar bond strengths cium and phosphorus since organic components are
and leakage for etching times of 15 and 60 s [92, 93]. selectively removed, denaturation of the collagen net-
Most recent clinical recommendations advise enamel work, and decrease of the dentin permeability, or due to
etching not exceeding 30 s and a very limited acid treat- the formation of a layer which has collagen fibers that
ment on dentin (up to 15 s). As measured in the labora- are poorly attached to the underlying dentin substrate.
tory, shear bond strengths of composite to phosphoric Further, the thermal effects of laser irradiation may also
acid-etched enamel usually exceed 20 megapascals extend into the dentin subsurface, thus impairing the
(MPa) and can range up to over 50 MPa, depending on inter-diffusion zone formation [98, 99]. Lately the focus
the test method used. Such bond strengths provide ade- has drifted toward investigating different types of self-
quate retention for a broad variety of procedures and etch adhesives and their effects on hybrid layer forma-
prevent leakage around enamel margins of restorations tion. In order to obtain better bonding conditions and
[94]. Studies of Nakabayashi et al. [95] have shown the facilitate monomers’ spreading within the demineralized
importance of hybrid layer in achieving a sufficient intertubular dentin, which was altered by laser irradia-
bond to dentin. This involves exposure of collagen tion, different post-irradiation dentin pre-treatments
fibrils of dentin by dissolution of its mineral phase fol- have been suggested for adhesion procedure.
lowed by infiltration with resin monomers and polymer- Among them, we point out the use of:
ization in situ. The formation of hybrid layer and its 55 Sodium hypochlorite at a concentration ranging
characteristics depend on the substrate morphological between 5% and 10%
features [96]. Thus, bonding systems have evolved over 55 Orthophosphoric acid at 33–38% with an extended
years to have a better control over formation of hybrid etching time [100]
layer according to the substrate and can be broadly 55 Polyacrylic acid (for glass ionomer material)
classified into etch-n-rinse and self-etch adhesives which 55 Chlorhexidine gluconate
are further classified as: Etch-and-rinse 3-step (fourth 55 Propolis
generation), etch-and-rinse 2-step (fifth generation), 55 Peroxide
self-etch adhesives 2-step (fifth generation), self-etch 55 Ozone gas
adhesives-1 step-2 bottle (sixth generation), and self-
etch adhesives-1 step-1 bottle (seventh generation) [97]. Sodium hypochlorite can be used to remove collagen
Two strategies are used to overcome the low attachment fiber frustules and dentin fragments modified by laser
strengths of the smear layer: interaction. In such a way, following its use, we obtain a
258 R. Poli et al.
clean surface, free from the alterations produced during due to higher water content but do not enlarge the den-
laser use (even if, thanks to the erbium laser, as we have tinal tubules. Transverse electron microscopic analysis
already flagged out, there is no smear layer). The exten- of erbium laser-irradiated dentin has shown that ther-
sion of the etching time by orthophosphoric acid appar- mal effects extend till deeper layers of dentin resulting in
ently does not promote better adhesion, but on the altered dentin subsurface of approximately 3–4 μm
contrary, it can generate an excessively etched tooth sur- thickness. There is a reduction in carbon to phosphorus
face. It is appropriate to consider that the irradiated ratio and formation of more stable compounds. The col-
tooth surface does not have smear layer, because the lagen fibrils beneath this layer are fused and do not dem-
erbium laser does not produce it, unlike what happens onstrate cross-banding which causes reduction or
when using the high-speed hand piece and the diamond complete elimination of interfibrillar spaces [60].
bur. For this reason, by performing the etching on hard Ablation of dentin melts collagen fibrils together, result-
tooth tissues, we obtain an immediate contact between ing in a lack of interfibrillar space that restricts resin dif-
acid and intra- and peritubular dentin. An excessive fusion into the subsurface of intertubular dentin,
contact between acid and tubules could, on the contrary causing a lack of penetration of the resin and even a
of what we would desire, completely destroy the dentin possible peeling off of the resin layer from the ablated
architecture favorable adhesion. There is no certain clin- dentin surface [105–107]. Erbium lasers used with exces-
ical proof that the different pre-treatments listed here sive parameters can furthermore have a harmful effect
could improve the action of adhesive systems for com- on hard tissues. The strength of resin-dentin bond in
8 posites. According to Arslan et al. [101], “No adverse erbium laser prepared cavities is due to the microme-
effect of different cavity disinfectants on microleakage chanical retention through formation of resin tags into
were found when etch-and-rinse adhesive system was demineralized dentin [108]. The use of phosphoric acid
used.” etching allows partial demineralization of highly miner-
alized peritubular dentin and enlargement of dentinal
tubules orifices and removes the weak laser modified
8.10 Why Adhesion Can Be Impaired layer. This promotes resin infiltration by increasing the
surface area and formation of funnel shaped resin tags
There are different possible explanations on why the where enlarged part is present at the tubule orifices [53].
composite adhesion strength to the irradiated dentin Bertrand et al. [53] have shown in their study the forma-
could be lower than the one achieved through phos- tion of surface irregularities and open dentinal tubules
phoric acid. The surface of cavity created by Erbium on Er:YAG irradiated dentin without subsequent acid
laser is different from that created by conventional etching which could be favorable to composite resin
method of rotary burs. Different researchers believe that bonding. On the contrary, the erbium laser is less effec-
the main mechanism causing insufficient bonding tive on peritubular dentin forming a crater-like surface
between irradiated dentin and composite is the collapse which may indicate a necessity for additional etching
and/or melting of collagen fiber network during laser procedure to expose collagen fibrils for resin infiltration
excision [102]. In fact, the considerable increase of tem- [103]. There are several parameters which may influence
perature following irradiation causing the instantaneous laser interaction with the dental hard tissues. Corona
vaporization of the water component of the mineralized et al. [109] have described the influence of energy den-
tooth matrix and of collagen fibers, initially spread and sity, number of pulses per second, and pulse energy on
supported in this framework, tends to collapse because dentin ablation. Besides this, time of irradiation, air/
they are no longer supported by the crystalline struc- water cooling, tip distance from tissue also play an
ture. The consequence will be a reduction of bonding important role in determining the micromorphology fol-
spreading within the network because the interfibrillar lowing ablation with laser and subsequent effect on
structure is reduced [102]. The substrate is free of debris bonding to adhesives [110]. Excessive laser energy values
and smear layer with micro-irregularities. There is loss can cause cracking in tooth dental tissues, surface melt-
of prismatic structure of enamel while dentinal surface ing, surface scaling and flacking, marked loss of intertu-
exhibits open dentinal tubules with more prominent bular dentin, and collagen melting [102, 105]. It has also
peritubular dentin than intertubular dentin [54, 103]. been thought that pulses could generate intense elastic
Thus, the hybrid layer will not be of optimal quality for waves inside tooth hard tissues during excision as a
adhesive procedures [102]. The main cause of reduced result of the interaction with the laser beam and due to
bond strengths with laser cavities in earlier literature has alternate thermal expansion and shrinkage. By occur-
been due to the use of single component adhesive with- ring inside a hard and stiff tissue, stress waves could
out etching with phosphoric acid [36, 53, 78, 104]. cause micro-cracking and fractures in the dentin thick-
Erbium lasers are more effective on peritubular dentin ness and at the dentin/composite interface level, nega-
Laser Use in Dental Caries Management
259 8
tively affecting adhesion strength [1, 107, 111]. Energy [121]. Omitting this step may result in a diminished wall
threshold of approximately 150–200 or 200–250 mJ is strength; it may cause incomplete adaptation of the
required for clinically effective ablation of permanent composite to the preparation margin, and a subsequent
dentin and enamel, respectively [110]. The erbium laser chipping of the reconstruction margin and/or the enamel
is more widely studied for the surface treatments at sub subjected to the masticatory load with subsequent
ablative energy thresholds as an alternative to conven- microleakage. Recent research took into account the
tional etching protocol where it causes modification in possibility that during irradiation by erbium laser, cal-
microstructure of enamel and dentin similar to that cium phosphate insoluble molecules could be formed,
achieved with application of orthophosphoric acid. The which would prevent optimal composite adhesion [102].
term “laser etching/laser conditioning” has been used On the other hand, authors believe that collagen dena-
for this phenomenon [112, 113]. It has to be mentioned turation during ablation causes an acid-resistant surface
that laser etching is an insufficient term; laser condition- containing charred granular structures or structures
ing is a more accurate term. Laser conditioning is a term covered with melted dentin particles. This denaturation
used to describe a reduced ablative effect obtained with could jeopardize infiltration of the adhesive system into
energy just above the threshold of ablation (15 J/cm2 for the dentin structure, and it could prevent the creation of
Er:YAG and 20 J/cm2 for Er;Cr:YSGG) [114]. While the hybrid layer [107, 122]. Such phenomena could con-
most of the literature shows a poor bond obtained after cern cement during Class II and V cavity preparation,
laser conditioning as compared to acid etching [60–62, because “when cement is reached by erbium irradiation,
115], the results are contradictory for the adhesive pro- it is altered, and a thin layer (5.7 μm) is formed. This can
tocol for dentin ablated with erbium lasers for cavity hamper hybridization because it becomes less affected
preparation. The authors have reported formation of by acid etching” [123]. If the resin cannot efficiently
fissured surface with water deficient non-apatite phases infiltrate into intra- and peritubular dentin, only shorter
that may be loosely adherent to underlying unaltered resin tags will be developed, without funnel shaped mor-
dentin surface which necessitates etching before restora- phology and lateral resin projections and this would
tion. Koiliniotou-Koumpia et al. [116] and Brulat et al. entail a damage to the resulting adhesion [53, 124, 125].
[54] found no improvement in adhesion values of self- When using this type of laser, the absence of the smear
etch adhesives on erbium laser ablated dentin while Lee layer, which is instead inevitably created during cavity
et al. [102] and Gurgan et al. [117] have stated compa- preparation with burs, allows the immediate exposure of
rable bond strengths in erbium laser prepared cavities in dentinal tubules and accentuates their permeability to
relation with conventional bur-prepared cavities. An dentin adhesives. Furthermore, the absence of smear
additional explanation of the weaker bond between plugs allows the passage of intra-tubular fluids to and
composite and dentin is represented by the deep craters from the pulp [125, 126]. “Loss of smear layer due to
that are created when laser energy is high: these valleys/ laser irradiation exposes the dentinal tubules and
hollows can prevent the optimal adaptation of the enhances the permeability of dentin adhesives. Intrinsic
reconstruction material to the cavity walls since the resin dentin wetness, as affected by pulpal pressure, could also
would not be able to fill deeper concavities [118]. affect the hydration state of dentin and the bond strength
Furthermore, there could be an uneven distribution of to dentin adhesives. Laser affects fluid perfusion of den-
the masticatory stress at adhesive-dentin interface [102, tin more than bur” [126]. It is important to take into
119, 120]. Additionally, Dunn et al. [61] underlined that account the fact that greater perfusion could make den-
“laser irradiation of enamel surfaces produced surface tin moister and for that reason it may interfere with
fissures and a union or blending of a distinctive etch pat- some adhesive systems, especially water-based ones
tern normally seen in acid-etched enamel.” This blend- which could end up being more diluted. The best way to
ing effect likely prevented the penetration of resin into avoid or minimize the impact of these surface altera-
enamel, resulting in lower enamel bond strength values. tions which may cause difficulties to achieve optimal
Er:YAG laser irradiation can obstruct the dentinal bonding is to reduce the laser energy for ablation to the
tubules and increase the dentin surface roughness which lowest efficient level, compatibly with the time required
can cause microbial plaque retention and increase the to completely remove the decay. Many authors [127]
risk of caries and periodontal disease [4]. It is very agree on the fact that after irradiation it is preferable to
important that at the end of cavity preparation, unsup- perform enamel acid etching by orthophosphoric acid in
ported enamel margins are removed, and margins are order to obtain an even micro-rough surface. Enamel
smoothed. This operation can be done at low power and laser conditioning, on the other hand, would not be use-
high-speed Er:YAG or Er,Cr:YSGG laser, or with hand ful. The use of an acid on the dentin could be positive as
tools (enamel cutter, excavators) or low or high-speed it would allow the removal of the top layer altered by the
tools with diamond or lamellar burs, or rubber tips erbium laser and exposes the network of collagen fibers
260 R. Poli et al.
which make up the ideal matrix required to create the leakage assessment. pH of adhesives plays a critical role
hybrid layer for the bonding process. However, research- in achieving predictable bond strength and marginal
ers’ opinions are quite contrasting. Thus, although dif- integrity if laser parameters are used within a particular
ferent acid application times are suggested, it would be range [142]. Varying laser parameters have been used in
appropriate not to exceed 30 s of contact time on the systematic review by Dua et al. [142]. Some studies have
enamel and 15 s on irradiated dentin. It is advisable to used very short pulse 100 μs with energy/pulse of 160 or
remember that since the smear layer is absent, phos- 200 or 250 or 300 mJ [85, 104, 143]; some have used lon-
phoric acid acts more rapidly on the mineralized crystal- ger pulse durations 400 μs with energy/pulse of 200 or
line structure of hard tooth tissues, in particular on 350 or 500 mJ [53, 54, 144], while others have used very
peritubular and intertubular dentin, and on collagen long pulse durations of up to 500 μs with energy/pulse
fibers. Other authors [128] advise to etch irradiated of 250 or 450 mJ [136, 145]. Nishimoto et al. [146] dem-
enamel for max 15 s and to avoid acid treatment on den- onstrated that increasing the pulse duration increases
tin at all. the depth of penetration of laser into dentin and
decreases the radius of cavities. It has been shown that
very long pulses have similar effect on surface morphol-
8.11 Adhesive Systems for Irradiated Hard ogy of dentin as that of conventional rotary drill dem-
Tissues onstrating thick and regular smear layer, which makes a
relatively stronger etching protocol imperative to
8
An extensive discussion has prompted the opportunity remove or modify smear layer [147]. Long pulse dura-
of completely eliminating the smear layer (etch-and- tion of 400 μs or up to 500 μs has shown bond strength
rinse technique, total etch) or to modify it through suit- and marginal integrity in laser prepared cavities compa-
able self-etch adhesive systems which would only rable or better than conventional cavities when only
remove one part of it and then maintain and exploit the etch and rinse or moderate self-etch adhesives have been
remaining part of it to create suitable substrate for used. Roebuck et al. [118] have demonstrated that a
bonding [111, 129–141]. With regard to adhesion deeper crater pattern is seen in erbium laser prepared
between composite materials and irradiated dentin, cavities with high energy per pulse. These valleys/hol-
research is still debating if it would be possible to obtain lows can prevent the optimal adaptation of the recon-
optimal bonding through an Etch and Rinse or through struction material to the cavity walls since the resin
self-etch adhesive systems. The results described in the would not be able to fill deeper concavities [118].
most recent literature are extremely contrasting and Er:YAG and Er,Cr:YSGG with wavelengths of 2940 and
contradictory. These adhesive systems were developed 2780 nm, respectively, have high absorption in water
keeping in mind the surface micromorphology created and hydroxyapatite. The Er:YAG has its peak absorp-
by conventional rotary instruments. De Moor and tion in water while the Er,Cr:YSGG wavelength has its
Delmé [1] concluded that acid etching with phosphoric absorption slightly more in apatite mineral than in
acid cannot be ignored on laser-irradiated enamel or water. Both the lasers create similar surface characteris-
dentin with respect to bond strength and marginal seal. tics, however since Er,Cr:YSGG has more absorption in
There was no value-added benefit of laser conditioning hydroxyapatite, it can cause modification in intertubu-
of the enamel after laser preparation. However, the data lar dentin making it more acid resistant. Also, this can
on dentin bonding protocol with currently available produce higher surface temperature despite the external
adhesives systems on the cavity surfaces created by water cooling which may affect the adhesion [148–150].
erbium lasers is still inconclusive. Truly diverse results The evaluation of bonding of the FLD to dentin
have been found in the existing literature regarding the showed that the combined use of Er:YAG and
adhesive protocols used with erbium laser to achieve Er,Cr:YSGG lasers with SBU-Single Bond Universal
bond strength and marginal integrity comparable to the and AEO-Adper Easy One on dentin surfaces improved
conventional method. This could be due to the differ- the dentinal bond strength of the FLD-Fuso Liquid
ence in pH and compositions of adhesives, difference in Dentin [150]. Most of the mild, moderate, and aggres-
substrate (enamel or dentin, superficial or deep dentin), sive adhesives have shown comparable or less microle-
laser parameters, type of wavelength, type of composite akage in laser group [142]. 1 mild adhesive and 2
used and the method of bond tests (shear bond or ten- moderate adhesives have shown microleakage higher in
sile bond or microtensile bond), and methods of micro- laser group [151, 152]. The adhesives used were Clearfil
Laser Use in Dental Caries Management
261 8
tri-S (water and ethanol based), AdheSE One (water deeper layers of dentin which exhibit fused collagen
based), and Xeno V (water and ethanol based), respec- fibrils and are loosely attached to the underlying dentin
tively. The self-etch adhesives combine etching and surface. This prevents the negative effect on the shear
priming steps. The etching solubilized calcium and bond strength in laser prepared cavities [136]. Some
phosphate ions from mineral component of dentin and studies have shown no significant difference between
suspends them in primer. The primer may be ethanol/ etch and rinse and self-etch adhesives on bond strength
acetone based or water and ethanol based. The low pH and marginal integrity of laser prepared cavities. The
of self-etch adhesives causes enlargement of dentinal aggressive self-etch adhesive and etch-n-rinse adhesive
tubules by dissolution of calcium and phosphates from create a similar surface for micromechanical retention
peritubular dentin, and the air drying of primer causes and form a thicker hybrid layer in lased dentin [158].
evaporation of volatile solvents, but there is no step of One study [159] in the systematic review by Dua et al.
rinsing, thus increasing the concentration of calcium compared the effect of self-etch adhesive and selective
and phosphates which may limit the infiltration depth etching on laser prepared cavities but found no signifi-
of the resin accounting for lower bond strengths with cant difference. The varying results in different studies
some self-etch adhesives (Xeno III—water and etha- with same adhesives could be due to difference in laser
nol). The limited effectiveness of mild acid monomers is parameters used or the difference in bonding substrate.
due to the insufficient demineralization of the superfi- Several studies [54, 147] have used Scotchbond MP for
cial laser modified dentin that contain more stable sur- bonding laser and bur-prepared cavities but in one
face and the subsurface which exhibit fused collagen research [113] the microleakage was more in laser group.
fibrils [148, 153]. iBond is a mild adhesive but has low On the contrary, another study [147] had shown micro-
filler content which is said to affect the bond strength to leakage similar in laser and bur group. This may be
dentin especially in laser prepared surfaces due to the because of additional beveling of enamel margins in
absence of smear layer. Tay et al. [154] have suggested study [147]. One study [160] has mechanically excavated
that inclusion of globular units of smear layer residues laser prepared cavity before etching and bonding with
in polymerized resin acts as true mineral filler fillers. an etch and rinse adhesive. It was suggested that this
10-MDP containing moderate self-etch adhesives may modify enamel and dentin surface by eliminating
Clearfil SE Bond and Clearfil Protect Bond have shown excessive roughness of enamel margins and remove the
comparable or better bond strengths and microleakage loosely attached, poorly crystallized dentin subsurface
in laser prepared cavities in all the studies where they and create some smear layer for improved adhesion. A
were assessed [54, 104, 136, 155, 156]. This functional different research [116] has analyzed cavities prepared
monomer 10-methacryloyloxydecyl dihydrogen phos- in both superficial and deep dentin. In deep dentin, the
phate causes minimal dissolution of smear plugs and bond strengths were significantly lower in laser treated
limits the opening of tubules. This reduces dentin per- group with both etch-and-rinse and self-etch adhesives
meability, facilitates penetration, impregnation, polym- as compared to bur-cut dentin. In superficial dentin—
erization, and entanglement of monomers with the bond strengths were significantly lower in laser-
demineralized dentin to form a relatively thick layer. It treated group bonded with etch-and-rinse adhesives
has hydroxyl groups which may form ionic bond with while it was similar to that in bur-cut dentin when
calcium in enamel and dentin [157]. The all-in-one bonded with self-etch adhesives.
nano-filled self-etch adhesive Clearfil tri-S Bond creates . Figure 8.5a–g depicts a laser-adjunctive restor-
a nano-interaction zone through ionic bond with the ative procedure in treating a disto-occlusal carious lesion
apatite of tooth structure. They do not diffuse into the at tooth #12 and placement of a composite restoration.
262 R. Poli et al.
a b
c d
e f
.. Fig. 8.5 a Occlusal view with distal carious lesion involving energy 359 J, pulse width 160 μs, 7 mm tip-to-tissue distance, 50%
enamel and dentin on tooth #12. b Dental rubber dam isolation. c water (18 mL/min), 80% air, total treatment time 120 s. d Detail of
Cavity preparation with Er:YAG laser (Pulsar with wavelength of cavity after completed preparation. e Rectification and beveling of
2940 nm by LAMBDA Dr. Smile, Italy). Enamel settings: tipless enamel margins. Positioning of matrix, wedge, and hook. Acid
(Boost) handpiece, 900 μm, 3.8 W, 15 Hz, 250 mJ E/pulse, peak etching, adhesive, and composite stratification steps (acid etching
power 1563 W, average power density 589 W/cm2, peak power den- with orthophosphoric acid 37%, OptiBond FL total-etch adhesive
sity 245.610 W/cm2, total energy 675 J, pulse width 160 μs, 7 mm system (Kerr, Orange, CA, USA), composite material (IPS
tip-to-tissue distance, 70% water (24 mL/min), 100% air, total Empress Direct Ivoclar Vivadent). f Composite reconstruction
treatment time 180 s. Dentin and smear layer settings: 900 μm, and polishing completed. g View after dental dam removal of
2 W, 15 Hz, 133 mJ E/pulse, peak power 831 W, average power composite reconstruction on tooth #12. (Procedure by Dr. Ricca-
density 314 W/cm2, peak power density 130.664 W/cm2, total rdo Poli)
Laser Use in Dental Caries Management
263 8
8.12 Decontamination Effect cially in cavities where the floor is in close proximity
with a pulp horn. Amasyali et al. during erbium use on
One big advantage in laser dentistry is represented by the contrary had no temperature increase but obtained
the decontamination effect of tissues. Also, during a its reduction by −2 °C in the Er:YAG laser group [170].
restorative treatment, the operator performs dentin dis- It is obviously indispensable to use energy levels com-
infection by vaporizing water of bacteria (bactericidal patible with efficient excision and without being exces-
action), thus decontaminating the cavity [161–164]. As sively traumatic or harmful for the tooth architecture.
affirmed by Hibst et al., “Bacteria below surface are
killed during laser cavity preparation to a depth of 300–
400 μm” [165]. This means that the hard tissues treated 8.14 The Cooling
with this wavelength achieve an important cariogenic
microorganism count reduction in the irradiated layers, It is also equally important to use a cooling spray with a
which is statistically significant when compared to the water amount and an air volume sufficient to remove the
conventional bur excavation. This is due to Er:YAG fragments created during irradiation and cool the treated
laser irradiation itself which causes structural changes surface quickly. The minimum amount of water which
in bacteria and the following cavitation effect can cause should be used is 8 mL/min, but it would be better if it
cellular wall disruption. Considering microbial growth could be doubled. Not all erbium lasers available on the
in permanent teeth affected by caries, it was found that market accurately show on the display the amount of
microbial reduction following Er:YAG treatments was used water. Often times the display only shows a per-
91%, while a microbial clearance rate of 80.6% was centage vis-à-vis the 100% capability that can hold in the
achieved following conventional preparation [166]. hand piece. However, the maximum value depends on
the pressure present in the local aqueduct water network
or in the building where the dental practice is, depending
8.13 Effect on Tissue Temperature on manufacturer’s settings, and also depending on the
setting of the individual laser entered by the installer. In
The energy generated by the erbium laser can be so pow- order not to run the risk of using an insufficient amount,
erful to breakdown the crystalline structure of hard tis- it is advisable that the operator personally measures how
sues of the human body; however, if the energy levels do much water per minute is delivered by the hand piece in
not excessively exceed ablation threshold limits, they can percentages of 10–20–50–100%. In this way, we can be
be much less aggressive than the diamond bur used on a aware of how much water is used, obviating overheating
high-speed drill. The vibration and pressure developed tissues and avoiding thermal damages; these in turn
by using a traditional technique can very easily create could cause tooth pulp necrosis, a phenomenon of den-
micro fractures that branch out on the prepared decayed tal hypersensitivity, or alter the tooth surface with sub-
cavity walls. These will give rise to sensitivity, pain to sequent worsening of composite adhesion.
heat/cold stimulation, risk of pulp infiltration damages,
and secondary decay, causing reconstruction failure. If
the erbium laser is used with the adequate selected 8.15 The Welding Effect
parameters (i.e., low energy and frequency), sufficient
enough to obtain decay ablation without creating any It is also possible to select a cooling spray containing a
trauma inside the tissues, cracking will not occur. The reduced amount of water when more thermal interac-
very high water absorption coefficient for the two erbium tion is required. This type of use, which can modify the
laser wavelengths allows to limit the penetration of the tooth surface, is called “welding” and it may reduce den-
beam by just a few microns (7 μm in the enamel and tinal sensitivity and can transform the outer tooth wall,
5 μm in the dentin for Er:YAG 2940 nm, 21 μm in the especially at tooth neck level or in case of preparation of
enamel, and 15 μm in the dentin for the Er,Cr:YSGG a fixed prosthesis, in order to be more resistant to acids
2780 nm) [7–11]. This limited penetration, especially if produced by decay-inducing bacteria and less perme-
combined to a very short pulse width, allows a very lim- able. The micro-structural effect is represented by the
ited transfer of heat into tissues. With optimal cooling obliteration of dentinal tubules by the melting of the
made by an integrated air/water spray, temperature dentin outer layer and coagulation of collagen fibers.
increase at pulp level will be below 5 °C [103, 167–169]. This procedure must be performed with low energy lev-
On average, there is a temperature increase by 1–2 °C in els and for very short treatment periods, otherwise it is
the pulp chamber, while the use of a high-speed bur possible to cause severe pulp damage due to temperature
entails a more frequent potential heat damage, espe- increase.
264 R. Poli et al.
8.18.4 Influence on Na+–K+ Pump remains unclear. According to Chow et al. [218], a pos-
and Bio-Resonance sible explanation on how lasers reduce pain by produc-
ing an alteration in the conduction of action potentials
Apart from the gate control pathway, it is possible that in peripheral nerves is the generation of varicosities
infrared lasers influence the Na+–K+ pump action. This along the axons more than in cell bodies. These enlarge-
pump is located on the surface of the neuron axon, in a ments could reduce the speed of fast axonal flow and the
transmembrane position with an external part, one in mitochondrial membrane potentials, resulting in neuro-
cytoplasmic position and a controlling beta domain and transmission failure in A delta and C nociceptors fibers
a “nose” in the internal side of the membrane [208]. The [219, 220]. In these experiments, after the end of irradia-
pump is a hollow tubular protein which spans the cell tion, the neurons were able to return to original function
membrane of nerves and establishes the gradients in because were not irrevocably damaged and the varicosi-
Na+ and K+ which are essential for propagating an ties resolved after 24 h.
impulse down a nerve through membrane depolariza-
tion and repolarization. During each enzymatic cycle,
the pump transports three Na+ ions outside the cell and 8.18.6 Which Energy Dose to Use?
two K+ ions into it, while hydrolyzing one molecule of
ATP. This pump allows the generation of Na+ and K+ The settings necessary to induce laser analgesia have
been already investigated through several studies [48,
8 gradients across the plasma membrane in virtually all
171], but further research is needed in order to deter-
animal cells and is particularly important in nerves for
re-establishing membrane polarity of impulses [209, mine the exact amount of medium infrared energy and
210]. Partial spatial dissociation of the beta domain of the correct parametry necessary to produce a more pre-
this ion channel protein, which controls the function of dictable protocol and a reliable level of laser analgesia.
the pump, closes the lumen of the “pipe” and thus pre- Different to medium infrared irradiation, near infrared
vents the repolarization for a short period of time. energy dose has been extensively studied and determined
Vibrational effects of laser energy are thought to act at to obtain an analgesic effect. It is known that there is an
the interface of the beta domain and the cytoplasmic irradiance threshold required to exert maximal suppres-
“nose,” closing the pump’s inner channel and thereby sion of nerve activity and control acute and/or chronic
blocking membrane repolarization. FRP lasers at pain. According to Bjordal et al. [221], the optimal dose
10–30 Hz seem able to provoke this spatial change on acute pain in the first 72 h after the injury should be
thanks to their vibrational energy. This phenomenon 7.5 J/cm2. The majority of authors proposed greater lev-
has been termed “bio-resonance.” els of energy, such as Lizarelli (cited by Angelieri et al. in
2011) [222] who indicated a dose included in the range
5–20 J/cm2 for severe pain. Other authors suggested a
8.18.5 Direct Inhibition of Nerves fluence of 35 J/cm2 to reduce orthodontic pain, because
5 J/cm2 were not effective [222]. In current literature,
Another plausible mechanism that has been identified as similar protocols reported conflicting results [223].
a possible explanation in analgesia onset is the direct
inhibition of neural activity. Transcutaneous visible and
infrared lasers, with continuous wave or complimentary 8.18.7 ffects of Laser Energy
E
gated emission, applied at several points along the on Biochemistry
course of peripheral nerves, can cause conduction veloc-
ity slowing and decreased amplitudes potentials of A A final further possible explanation of the laser action
delta and C fibers [211–215]. In animals, studies have on pain is represented by the biochemical action of low
been proven a specific laser inhibition of these fibers level laser therapy through the production and/or the
which transmit nociceptive stimuli. This means that a inhibition of endogenous substances that create neuro-
laser beam is able to reduce the nociceptors response to pharmacological effects locally and systemically [221,
a variety noxious stimuli, including pro-inflammatory 224, 225]. It is well known that the wavelengths included
substances [216, 217]. The exact mechanism by which in the so-called optical window (approximately between
photons can inhibit or at least slow or partially block the range 600 and 1300 nm) are able to promote the syn-
nerve conduction causing a functional impairment thesis, the modification, the release and to influence the
metabolism or the inhibition of numerous biochemical
Laser Use in Dental Caries Management
267 8
substances. As an example, near infrared irradiation can tin, the tip is again placed farther away, the laser irra-
increase beta endorphin, endogenous opioids, sustain diation becomes defocused (thus reducing the energy
the peripheral release of histamine and prostaglandins, density), and cavity preparation is complete.
facilitate central release of serotonin and acetylcholine, 55 Turtle Technique (also called Tortoise T.): The tip is
and allow cellular oxidation and the production of ATP immediately placed at 1 mm from the tooth and kept
[226–229]. Similarly, the possible inhibitory effects are at this distance for the preparation procedure. Low
represented by the reduction of several interleukins power is then set in order to obtain pulp analgesia
secretion (IL-1b, IL-6, IL-10) and other factors involved and has a lower risk of discomfort for the patient.
in inflammation process or nociception (COX2, nitric Then, the energy is gradually increased up to a suffi-
oxide, PGE2, TNFɑ, bradykinin) [230–232]. cient level able to obtain tissue ablation and this is
Additionally, in general there is a direct effect of laser carried on till enamel ablation is completed. When
energy on the increase of local hemodynamics with the dentin is reached, the power is reduced, and cav-
higher removal of pain stimulating substances [191, 220, ity preparation is completed. This latter technique is
233]. Until now there is no incontestable demonstration considered the most reliable to avoid patient’s dental
that erbium family lasers have a similar biochemical sensitivity during the restorative treatment. It is
range of effects. Laser-induced analgesia can be consid- regarded as the most satisfactory, delicate, and effec-
ered a possibly effective alternative treatment in affect- tive to obtain dental analgesia [48].
ing pain perception. Non-standardized study design,
lack of consistent laser operating parameters, and lack It has been scientifically demonstrated that permanent
of statistical analysis do not allow firm conclusions as to teeth are more sensitive to pain than deciduous ones,
which laser wavelength is superior or what parameters and that laser analgesia is easier for the latter [186].
might be employed to achieve predictability, and have According to Moritz (2006) [164], the laser analgesic
failed to underline a strong protocol of how the mid-IR effect on the tooth should last approximately 15 min and
wavelengths may be applied in achieving laser analgesia after its disappearance no histological alteration of the
[234]. In conclusion, to obtain successful analgesia it is pulp occurs. On the contrary, according to Whitters
highly plausible that it is necessary to apply low level et al. [192], the pain threshold after laser analgesia
energy (and power) or, more precisely, it is indispensable obtained by the means of a Nd:YAG laser returned to
low energy density and low power density. Furthermore, baseline approximately after 60 min.
initially it is useful to use low levels of air and water
spray which can induce dental sensitivity due to the
cooling effect of air and/or water. 8.20 rotocol for Tooth Analgesia
P
with the Erbium Laser
8.19 echniques for Laser Analgesia
T In order to study erbium laser analgesia, we recently
on Teeth [171] studied a protocol in order to propose a systematic
painless restorative treatment of the teeth. We used the
Two different techniques have been proposed in order to Er,Cr:YSGG (2780 nm) laser applying a combination
obtain the laser analgesia: between Rabbit and modified Turtle technique. Before
55 Rabbit Technique (also called Hare Technique): The starting cavity preparation, a laser-induced analgesia
laser is immediately set on high power levels, able to phase was always performed by initially using very low
perform hard tissues ablation and this is maintained levels of energy, and then by gradually increasing them,
during the whole treatment. At the beginning, how- without using any air/water spray. In this way, the dental
ever the beam is kept defocused at 6–10 mm from the pulp had the possibility to adapt to laser irradiation
tooth. So, the energy density is low and it takes without triggering a mechanism of annoying sensitivity,
advantage of the low level laser therapy. The tip is but gradually performing analgesia. Then, it was possi-
moved all around the tooth, at its neck level. Then, ble to obtain a gradual painless ablation of tooth hard
the tip is gradually brought closer up to 1 mm from tissues. The analgesia phase was therefore started with
the dental surface and so the ablation effect can start. power values of 0.1 W (consequently the energy had val-
At this point, if the patient feels some discomfort, it ues of only 10 mJ) at a pulse repetition rate of 10 Hertz
is possible to move aside the tip again. As soon as the and afterwards these levels were gradually increased to
beam gets through the enamel and reaches the den- 0.2 W, then to 0.5 W with a repetition rate of 15 Hz, and
268 R. Poli et al.
then, finally to 1 W and to 2 W with the same pulse rep- To correctly perform laser-induced analgesia in our
etition rate. Overall, this stage always lasted 3′30″ (210 s). protocol, we suggest to maintain the tip at a distance of
The study of laser-induced dental analgesia with 10 mm from the tooth from the start. In this way, it is
regard to cavity preparation was performed by adopting possible to obtain a very low energy density from the
the following sequence: initial stage (only 6 J/cm2 with movement) and average
A. Preliminary pulp test using the electric pulp tester to power density (1 W/cm2), thus allowing the pulp to pro-
evaluate dental vitality and to establish the baseline gressively adapt to laser irradiation and achieve analge-
threshold of dental sensitivity. sia without risking painful or annoying sensations. With
B. Beginning of the dental analgesia induction phase regard to discomfort felt by patients, the factors that
by using power settings of 0.1 and then 0.2 W seem to have a higher tendency to promote the shift to
(energy per pulse of 10 and 20 mJ) at a pulse repeti- greater discomfort categories are as follows: posterior
tion rate of 10 Hz, for 30 s each (without using any teeth compared to a superficial one, the time needed for
air/water cooling spray), keeping the tip at 10 mm ablation of hard tissues, and the use of laser at high
from the tooth using a spacer. Subsequently, the power levels. One of the most important factors that
power was increased to 0.5 and then to 1 W (energy influenced pain perception was age. In this study, all
per pulse of 33 and 67 mJ) for 60 s each, with a spray patients that felt greater discomfort or pain were in age
composed by 15% of water (for our laser this means brackets 20–29, 30–39, and 40–49. We think that younger
approximately 10 mL/min) and 20% of air, at a pulse patients could obtain analgesia more easily and quickly
8 repetition rate of 15 Hz, keeping the tip at the same as their dental hard tissues are richer in water and they
distance from the tooth neck. have wider dentinal tubules. This could facilitate abla-
C. Preconditioning of hard tissues with 2 W of Power tion and progression of laser beam effect on pulp nerves.
for 30 s with a cooling spray of 50% water (approxi- With regard to older patients, they could be less sensitive
mately 20 mL/min) and 80% air, at 15 Hz of pulse to irradiation for the opposite reasons: their dental tis-
repetition rate, with the tip at approximately 1 mm sues are more sclerotic and calcified, they have narrow
from the tooth. The laser beam was kept in focus or, dentinal tubules, and even if they are more difficult to
if the patient felt discomfort, it was defocused ablate, they protect the pulp more and they are less influ-
according to sensitivity. enced by stimuli. When a restorative treatment with
D. Pulp test (EPT) performed again to evaluate the erbium laser is planned, without resorting to any local
presence of analgesia and establish how the thresh- injected anesthesia, it should be considered that cuspids
old value of dental sensitivity had changed. and incisors may be more sensitive, especially if the
E. Preconditioning and beginning of enamel ablation decay is deep. For these teeth, the energy can rapidly
with a 3 W Power for 30 s (same previous settings as affect nerve fibers of the pulp because of the limited
for pulse repetition rate, distance, and cooling thickness and cause pain. Actually, in our research we
spray). saw that the opposite was true: premolars and molars
F. Enamel ablation with 4 W of power (same previous were more sensitive than front teeth. By using our proto-
settings). col, initially applying very low energy levels and gradual
G. Possible enamel ablation with 5–6 W of power (same irradiation, we obtained a better and quicker laser anal-
previous settings). gesia for anterior teeth. The possible explanation of this
H. Possible dentin ablation with 3–3.5 W of power is connected to the greater thickness of hard tissues for
(same previous settings). posterior teeth compared to incisors and cuspids. It is
I. Preparation completion and smear layer removal also our opinion that the depth of the decay is impor-
with a power of 2 W (same previous settings). tant sensitivity-wise, but the time of preparation is more
J. Pulp test at the end of the preparation. To assess if relevant in affecting it. This is due to the effect of erbium
the threshold value of dental sensitivity had further on the dentin. This kind of laser, combined with water,
changed after ablative laser irradiation. opens the dentinal tubules. The more the laser is used,
K. Pulp test after 15′–20′ from the end of cavity prepa- the more the tubules will be opened, and the higher the
ration to assess if analgesia was over. patient’s sensitivity will be. Besides, if dental hard tissues
are not easily laser ablated (for example, if they include
The entire period of laser analgesia induction had an a lower water percentage) and if, for this reason, it is
overall duration of 3′30″ (210 s), and it was performed necessary to extend its use for a longer period of time or
on all patients. to increase the energy levels in order to facilitate abla-
At the end, as specified, cavity preparation pro- tion, then the risk of pain further raises. One additional
ceeded. element to consider is the fact that laser analgesia could
Laser Use in Dental Caries Management
269 8
not be completely effective to also achieve periodontal between anxiety and discomfort? We believe it is possi-
tissues analgesia. During this research, even if the tooth ble to affirm that groups of patients reporting higher
was completely insensitive to carious hard tissue abla- levels of anxiety before attending a dental session are
tion, we have quite frequently noticed that the patient the same who felt greater discomfort during therapy. So,
could feel the discomfort provoked by the positioning of it is likely that the anxiety factor contributes to generate
the dental dam clamp, the matrix, or the wedge. Thanks a higher subjective evaluation of discomfort. In adult
to the proposed protocol it was possible to perform a patients, we noticed that the level of anxiety felt during
restorative treatment by using the Er,Cr:YSGG a dental session had more influence on the possibility to
(2780 nm) in 24 patients out of 30 (80% of the sample) obtain complete leaser analgesia; this is probably due to
without resorting to any kind of local anesthesia and the patient’s individual difficulties related to dental care
without the traditional hand piece and bur. These past experiences. On the other hand, with regard to
patients didn’t feel any pain (in 57% of cases) or they felt pediatric patients, if they never had dental experiences
only a very light sensitivity (in 23% of patients). The in the past, if they were not very anxious by nature, but
equipment we used was very likely to produce laser- rather calm and happy, and if they did not have a nega-
induced analgesia, which allowed us to remove all the tive influence from parents and/or relatives, they may be
carious tissues and to complete the composite recon- more incline to accept the dental treatment. This will
struction without any pain for the patient. In relevant mostly and more easily occur if the dentist adopts a psy-
literature, the comparison between traditional hand chological, positive, delicate, and serene approach. All
piece with bur and erbium laser showed that with the of this will be facilitated by adopting the erbium laser; if
former the dentist can obtain painless treatment in only neither needles nor local anesthetics are used, especially
20–50% of patients [235]. The use of Er,Cr:YSGG laser if the operator avoids noises and vibrations which are
precludes the administration of local anesthesia by typical of the traditional handpiece combined with the
injection and avoids the use of the traditional handpiece bur. This approach will reinforce and maintain the
and bur. Thus, we can obtain reduced anxiety in patients, patient trust toward the dentist.
something that is frequently associated to dental thera- . Figure 8.6a–f shows a cervical carious lesion
pies. Following these considerations, is it possible to involving enamel and dentin on tooth #4. Enamel decay
draw some firm conclusions on the strong correlation removal using erbium:YAG laser.
270 R. Poli et al.
a b
c d
e f
.. Fig. 8.6 a Buccal view with cervical carious lesion involving average power density 490 W/cm2, peak power density 153.199 W/
enamel and dentin on tooth #4. Enamel decay removal using cm2, total energy 810 J, pulse width 160 μs, 1 mm tip-to-tissue dis-
erbium:YAG laser. b Detail of cavity on tooth #4. c Preparation with tance, 100% water, 70% air, total treatment time 180 s. Dentin and
Er:YAG laser (Pulsar with wavelength of 2940 nm by LAMBDA Dr. smear layer settings: sapphire tip diameter 800 μm, length 12 mm,
Smile, Italy). Gingivectomy: angulated handpiece, sapphire tip diam- 3.3 W, 20 Hz, 165 mJ, peak power 1031 W, average power density
eter 400 μm, length 12 mm, 2.4 W, 20 Hz, 120 mJ E/pulse, peak 360 W/cm2, peak power density 112.346 W/cm2, total energy 594 J,
power 750 W, average power density 659 W/cm2, peak power density pulse width 160 μs, 1 mm tip-to-tissue distance, 100% water (18 mL/
205.860 W/cm2, total energy 432 J, pulse width 160 μs, 1 mm tip-to- min), 70% air, total treatment time 120 s. d Detail of cavity on tooth
tissue distance, 50% water, 50% air, total treatment time 180 s. #4 after gingivectomy. e Detail of completed cavity after dentin
Enamel settings: angulated handpiece, sapphire tip diameter 800 μm, preparation. f Completed composite restoration. (Procedure by Dr.
length 12 mm, 4.5 W, 20 Hz, 225 mJ E/pulse, peak power 1406 W, Francesco Buoncristiani)
Laser Use in Dental Caries Management
271 8
8.21 The Laser Handpiece and Tips there are truncated-cone shaped tips, with rectangular
section and chisel-shaped. Each one of them creates a
Most modern erbium lasers are provided with two types different beam emission which in its turn provides an
of handpiece. One uses interchangeable tips of various ablation zone and produces a different cavity shape. The
lengths, diameter, and materials. On the market, there second type of handpiece is also called tipless because it
are tips with lengths ranging between 3 and 28 mm. does not have the previously described tips, but a lens
With the shorter tips, it is possible to access small areas which can also be interchangeable, and it focuses the
within the teeth arch or in difficult spots (i.e., the upper beam at a distance of about 5–10 mm from the surface.
second and third molars, buccal areas of posterior Operators work at a greater distance compared to the
teeth) or perform treatments when the patient has lim- previous hand piece. At times in the scientific literature,
ited mouth opening (i.e., pedodontic patients). With this type of use is defined as “defocused,” but this is not
longer tips and with a small diameter of 200–300 μm, it the correct term. In reality, the beam is focused at a few
is possible to perform endodontic and periodontal millimeters (usually 5–7 mm) away from the surface of
laser-assisted treatments. They are made of quartz or the hand piece from which the beam is delivered. Such
sapphire. Often it is possible to differentiate them from use is defined as “contactless.” This greater distance
one another because of their color, yellow for the for- from the target improves visibility, but it provides a less
mer and white for the latter. Usually, the tips most used favorable and uncomfortable perspective in poorly
in restorative dentistry are the ones measuring 4–10 mm. accessible areas such as the upper molars. The reason is
The tip-to-tissue working distance should constantly be that it is more difficult to position at that distance and
kept at 0.5–1 mm in order to obtain optimal energy den- keep accuracy at 5–10 mm from target. Furthermore, it
sity. In some scientific articles, this operational modal- is very difficult to accurately irradiate a small target
ity is wrongly defined as “in contact” since the operator since the beam is wider. The target area (spot size) cov-
is working at close proximity with the tooth. ered by the beam tends to be larger than when the oper-
Nevertheless, there should never be contact, and the ator works almost in contact; thus, it is very difficult to
tooth surface should never be touched in order to avoid prepare very small cavities and, if the hand piece is not
the creation of enamel-dentinal microfractures and to kept steady on the ablation target zone, the effect is
avoid damage to the delicate laser tips. This working often dispersed on a wider area, resulting in an unin-
modality is also called “focused,” even if in reality the tended widening of the cavity and elimination of
laser beam is not convergent, i.e., it is not focused on the healthy tissue. This hand piece, however, is more effi-
target. The laser energy delivered by the tip is in fact cient since it allows the removal of a larger amount of
immediately divergent with approximately an 8° diver- decayed tissue in less time.
gence angle per side. The reason to keep the tip at
0.5–1 mm is due to the fact that at that distance, energy
density (fluence) is optimal, and it is the one that allows 8.22 The “Erbium Noise”
a more efficient ablation. By increasing the distance, flu-
ence will drop dramatically, preventing adequate exci- All types of hand piece produce a similar and character-
sional interaction with tissues. On the other hand, if the istic noise. It is often defined as a “popcorn” type of
working distance is below 0.5 mm, the operator may noise, as it reminds corn popping in the pan. It is com-
run the risk of causing dental damage following con- pletely different from the noise produced by a traditional
tact, tip deterioration after accidental crash against the turbine and by the bur, thus patients tend not to associ-
cavity surface may occur, reduced effectiveness of the ate it to the fear for the dentist. Noise intensity is directly
air/water spray to cool and eliminate residues, and a proportional to the employed energy, which creates
very limited visibility on the working area. The diame- micro-explosions in the water present in tissues and in
ter of tips used for hard tissue ablation usually ranges the one used for cooling. Also, irradiation frequency
between 400 and 1000 μm. The smaller the diameter, the impacts noise. The higher the number of pulses, the
smaller the cavity the operator can prepare and save lower the number of “explosions” heard as they will
healthy tissues. Tips with larger diameter produce a “merge” with one another, and they will sound as one
spot size which will inevitably create a bigger size cavity; noise. At about 30–40 Hz, the noise is continuous, with-
thus, it is not possible to do small or very conservative out interruptions between pops.
preparations. For minimally invasive dentistry includ-
ing only occlusal grooves, it is preferable to use a tip
with the smallest diameter possible. By doing so, prepa- 8.23 pproach According to Cavity
A
ration will be quicker because there will be more energy Classification
density since all the energy will be focused on a smaller
surface. Usually, tips used for this type of therapy are Depending on the place where the decay lesion is, the
cylindrical with a circular cross-section. Additionally, removal approach will be different.
272 R. Poli et al.
8.23.1 Class I normally require short times and reduced laser energy,
compared to those to be used for posterior teeth. Laser
Occlusal decay on posterior teeth (Class I) is obviously preparations can also be more conservative than the
easier to treat, but the enamel is quite thick. Thus, it may ones obtained with traditional techniques. In order to
be necessary additional time to fully remove this type of protect nearby teeth and avoid damage to their surfaces,
lesion, especially in the case they extend under the occlu- it is advisable to place a cellulose strip inter-proximally
sal plane and when the decay opening is limited, and a to prevent the laser beam to affect the healthy walls of
lot of healthy tissue covers the entire lesion. In order to nearby teeth. It would be better instead not to use metal
avoid extended laser ablation, and to reduce operating matrixes for the same purpose as they could reflect the
times, the operator can also open the decayed enamel laser beam and thus become a source of potential risk
grooves by using a small diamond bur, and only use laser for operator’s eye safety.
irradiation later on. Small size cavities are more difficult
to treat because they are less accessible. The combination
of small high-speed diamond bur and lasers with mini- 8.23.4 Class V
mum diameter tips is certainly advantageous.
Usually, ablation starts by placing the tip perpendic- Cervical cavities (Black’s class V) can be prepared easily
ular to the tooth surface, by making small, very slow and rapidly, due to the limited thickness of the enamel
and to the presence of root cement nearby. For anterior
8 continuous movements and by keeping that position
from the beginning of the creation of a small cavity. teeth, it is also possible to use a straight hand piece
Later on, the beam should be gradually oriented toward instead of the angled one to facilitate access to cervical
the cavity walls outwardly (up to a maximum of 45° per tooth decay. With the cervical area of posterior teeth, it
side) to complete preparation [48]. For larger cavities is usually easier to use an angled hand piece and 3–4 mm
inside the dentin and with large geometries, it is very dif- length tips which facilitate access to vestibular or lingual
ficult to reach each side of the walls. In this case, it could areas, despite the interference of cheek and/or tongue.
be necessary to eliminate much healthy tissue in order to
be able to complete the full decay removal. The use of
low-speed burs and manual excavators may allow to 8.24 Interaction with Dental Materials
remove the residual decayed tissue and avoid the elimi-
nation of healthy tissue. It is always important to pay attention to dental materi-
als present in adjacent teeth. The erbium laser beam can
very easily interact with amalgam, composites, and den-
8.23.2 Class II tal metal alloys. Irradiated silver-based amalgam can
rapidly absorb energy, increase temperature, and create
Cavities concerning premolar and moral interproximal thermal problems to pulp and periodontium. Should the
areas (Black’s class II), when they need preparation temperature further increase, amalgam melting may
from the occlusal surface, they normally require more occur with subsequent damage to reconstruction and
execution time by using the laser rather than the bur release of mercury vapor. In case of secondary decay or
because the volume of tissue to be removed is consider- reoccurring decay under the amalgam filling, it is always
able and the enamel wall can be large. Visibility is often necessary to remove the metal reconstruction through
reduced, as well as accessibility. To be able to reach any traditional methods (by high-speed bur) and only after
area concerned with the carious lesion, it is key that the this operation, carious tissue can be removed by laser.
tip is placed inside the cavity that is being created, in Interaction with composite occurs very easily when irra-
order to keep the correct tip-to-distance constant. The diated [236]. Their ablation is very easy thanks to the
most difficult aspect is represented by the difficulty of water content. However, the composite matrix under-
sufficiently inclining the tip toward the walls to be pre- goes explosive fragmentation as a result of the interac-
pared. It should be borne in mind that the angle formed tion with the laser energy; it re-solidifies and quickly
by the tip vis-à-vis the decayed cavity wall should not aggregates around the tip and jeopardizes the integrity
exceed 45° otherwise ablation becomes ineffective. of the laser fiber. Tips altered by resin fragments must be
cleaned and polished rapidly to avoid this risk. Tip
inspection can be done by wearing amplifying glasses or
8.23.3 Class III and IV by using a jeweler’s lens with 30 magnifications. Polishing
can be done by using rotating discs to polish composites
In the case of class III and class IV cavities, accessibility mounted on a low-speed hand piece. It is then possible
is much better, thus no major difficulties are noted. to gradually move on to rougher discs to the smoother
Enamel thickness is limited and, as such preparations one, and this allows to remove residues, burn marks,
Laser Use in Dental Caries Management
273 8
correct possible nicks and polish tips. Such procedure is and teeth treated with root canal therapy, it is advis-
much easier for quartz tips than for sapphire tips because able to use the Etch and Rinse adhesive system. In the
the latter are harder. However, polishing may be more other cases, it would be preferable to use a Self-Etch
complex when there are composite fragments attached system, in particular if the cavity is deep and if the
to the tip end. These materials, in fact, are difficult to patient is very young (the same applies to permanent
remove when melted by laser energy and then they re- teeth).
solidify on it, thus is advisable to avoid resin-based 55 For deep cavities, it may be advisable to use glass
materials ablation during conservative therapy. In case ionomer cement or a flowable composite as liner on
composite reconstructions need to be redone, it is pref- the cavity floor, in close proximity of the pulp, in
erable to remove the old material by diamond bur; only order to obtain good protection of the pulp and of
later should the laser beam be used to ablate decayed deep dentin, and to position in such area a low elas-
tissue and to extend enamel preparation laterally, to ticity material and limited polymerization shrinkage;
complete dentin excision and condition the final surface these characteristics facilitate optimal reconstruction
before adhesive techniques are performed. If the tooth adaptation to the cavity internal surface.
near the decayed element has a metal alloy crown, irra- 55 Use a photo-polymerization lamp with controlled
diation of the latter can involve thermal interaction light irradiation (i.e., soft start or pulse delay tech-
quickly leading to temperature increase with potential nique) to limit polymerization shrinkage of compos-
risks of trauma to the tooth pulp and to the periodon- ites and evenly reach all stratified areas.
tium. Ceramic crowns, as well as temporary resin crowns, 55 Always use an incremental technique to stratify the
may sustain damage by erbium laser energy, the former composite, in order to have max 1–2 mm layers of
can be fractured following rapid thermal expansion. If material and compensate for and minimize its polym-
interaction is limited, damage may be limited to scratches erization shrinkage.
or nicks. Temporary/provisional crowns may suffer 55 Use low polymerization shrinkage composite resins
damage similar to that seen with composite resin. for reconstruction (i.e., silane-based composites,
Nonprecious metal alloys used for removable prostheses even if their clinical use should still be further stud-
are easily damaged through temperature increase, while ied and validated).
pink resins and artificial teeth can be similarly damaged.
For all of these reasons, it is advisable to pay special
attention to all surrounding dental materials during the
entire conservative therapy. 8.26 rbium Laser in Reconstruction
E
with Post in Endodontically Treated
Teeth
8.25 Clinical Considerations
Teeth subjected to endodontic treatments can benefit
Clinical considerations for laser-assisted conservative from the erbium laser use during composite reconstruc-
dentistry are as follows: tion performed in combination with a post. Thanks to
55 At the end of carious cavity preparation, eliminate irradiation, both canal walls following endodontic treat-
unsupported enamel prisms by using manual instru- ment, and the post can be optimized for the adhesive
ments (enamel cutters, excavators) and/or high or process. Most modern posts are made up of carbon,
low-speed hand piece fitted with diamond fine burs quartz, silica, or glass fibers, embedded in an epoxy
or rubber tips to bevel cavity margins. Alternative to matrix or in a methacrylic resin. They have an elasticity
this process, it is possible to use the erbium laser to modulus similar to that of dentin, so that under masti-
bevel cavity margins. It is advisable to set limited cation the material behaves similarly to tooth tissues and
energy values (40–80 mJ) and frequency of about forces are discharged in an equivalent way. By combin-
25–50 Hz. ing this property to the possibility of obtaining an adhe-
55 Perform acid etching by using orthophosphoric acid sive bond among the various materials (root and crown
at 34–38% (maximum timing 30 s on enamel, 15 s on dentin, adhesive system, fiber post and core material in
dentin) to optimize and make the treated surface uni- composite for cementing and reconstruction), it is pos-
form to regularize the areas affected by the erbium sible to reduce the risk of fracture [237, 238]. These
laser beam. posts have high biocompatibility, they are easy to use,
55 Use an adequate adhesive system that takes patient’s they have high mechanical resistance, good corrosion
characteristics into account, such as age, teeth condi- resistance, they are easy to be removed, and they have a
tions (deciduous or permanent), decay depth, if the very high appearance value (for quartz and glass posts).
tooth has been subjected or not to the endodontic Post retention by the root depends on the chemical
therapy. For superficial cavities, permanent teeth, interaction and micromechanical strength among post,
274 R. Poli et al.
dentin, and resin-based cement. Should there be insuffi- face and a micro-rough texture which can facilitate
cient bonds between resin and dentin or at interface level retention. Following post space preparation, canal walls
between composite and post, restorative rehabilitation cleaning is a critical procedure, however indispensable,
will fail, in association with the partial or total detach- because there is a lot of smear layer inside the canal, as
ment of the reconstruction and of the post embedded in well as gutta-percha residues and endodontic cement on
it. The bond strength is influenced by the degree of dentinal walls. All of this represents a contamination
hydration/dehydration of the inter-canal dentin wall. If that may negatively affect adhesive procedures. Intra-
the inside of the canal is dehydrated, hydrophile mono- tubular moisture and residues of irrigation liquids inside
mers of the adhesive system will not be able to penetrate the tubules can furthermore complicate or impair
dentinal tubules resulting in a lack of hybrid layer. On adhesion process steps.
the contrary, if the water content is excessive, monomers The erbium laser used to provide thorough cleaning
will be excessively diluted, and they will not perform. and decontamination of the endodontic space allows an
Other factors that contribute to determine a higher or extremely accurate cleaning of the dentinal surface and
lower retention strength between post and root are rep- the elimination of the smear layer, but, on the other
resented by physical property of the composite cement, hand, it is advisable to avoid its excessive use since it may
unfavorable canal configuration (accentuated curvature, induce dentin dehydration. It is very important to use
root with very thin walls not allowing a wider prepara- limited energy values (from 100 to 125 mJ) and fre-
tion) or due to insufficient canal length which does not quency of 10–20 Hz in order not to negatively impact
8 allow the positioning of a sufficiently long retaining the dental surface and not to create micro-structural
post, from adverse effects of canal sealing cements damages to the dentin and to its hybrid layer [243]. The
which, by containing eugenol they combat resin polym- main difficulty in obtaining efficient laser conditioning
erization used for cementing, and due to anatomic or on canal walls is represented by the fact that the tips
histological characteristics of dental tissues (i.e., num- inside the canal irradiate toward the apex with a diver-
ber of tubules at the different levels inside the canal) gence of 8° per side, thus the beam reaches dentinal
[239]. The post fiber polymeric matrix is highly cross- walls with a very marked inclination and that, thus, does
linked, thus bonding phenomena with composite mono- not interact much with the surface. For this reason, it is
mers do not easily occur. The bond between the advisable to avoid excessive irradiation and excessively
reconstruction composite and the post occurs only par- high parameters since they could damage hard dentinal
tially, and the resin acts as a bond with glass or quartz tissues and their organic portion. The same parameters
fibers. To improve the odds of obtaining such link, dif- mentioned above can be used on the post surface to
ferent types of posts and canal walls pre-treatments have facilitate the formation of micro-roughness which may
been proposed. For example, several authors frequently have a retention effect on the resin core material and
proposed the roughening of post surfaces in view of increase post resistance and reconstruction.
increasing retention. However, this exposes glass or
quartz fibers, and it may give rise to their weakening.
Sand blasting with A2O3 powders in 50 μm particles or 8.27 The Use of the Dental Rubber Dam
the use of hydrofluoric acid must be performed with
extreme attention to avoid too aggressive alteration of As with all conservative dental treatment, laser-assisted
fibers. For quartz posts, it has been underlined [240, 241] procedures must be completed with dental dam in place,
that it would be useful to use the HF acid at a concentra- in order to avoid contamination in the operating area.
tion below 9%. In such a way, higher tensile strength is Placement can be achieved before the preparation of
obtained. However, the same treatment can be risky for decayed cavities, but after the step in which laser analge-
glass fiber posts because it would induce corrosion. sia is attempted. Absence of the dental dam allows bet-
Some solvents could increase the adhesion strength ter irradiation in the tooth cervical area and of the gum
between quartz or glass fiber posts and the resin core surrounding the tooth. After formal analgesia, it will be
material. In particular, they have been tested with hydro- possible to place the dam in place and proceed with cav-
gen peroxide (H2O2) at 24% for 1 min [242, 243] and di- ity preparation by removing carious tissue. In this way,
chloromethane (CH2Cl2) for 1 min [244]. Both solutions mild analgesia will be achieved in soft periodontal tis-
showed promising results, but they should still be tested sues as well, allowing the positioning of the dam clamp,
on larger samples. Apart from its decontaminating the matrix, and the wedge, that will be perceived by the
effect, the erbium laser produces a smear layer free sur- patient with minimal discomfort.
Laser Use in Dental Caries Management
275 8
8.28 he Use of the CO2 Laser with Hard
T in the range of 100–500 mJ. CO2 lasers can be operated
Dental Tissues with very low single-pulse energies (in the order of μJ up
to mJ) and fluence, while frequency can be increased for
The carbon dioxide laser (CO2 10.6 μm) has been exten- higher cutting rates [250]. The laser beam can also be
sively used in the last 40 years for oral surgery. The con- scanned to minimize heat accumulation in the treatment
tinuous wave (CW) emission mode and complementary area [245]. The wavelength of 9300–9600 nm is coinci-
gated mode allow an efficient and quick vaporization dent with the strongest absorption of dental hard tissues
and ablation of soft tissues, also obtaining a very good due to phosphate ions in hydroxyapatite. Therefore, the
hemostasis. Early studies using a CW 10.600 nm CO2 energy necessary for ablation of tooth hard tissues is
reported extensive cracking and charring of enamel, lower at these wavelengths versus others and this allows
dentin, and bone [245, 246]. During the last 10 years, a reduced accumulation of heat in the tooth. Moreover,
researchers have modified the native 10.6 μm CO2 laser due to this very high absorption, the penetration is lim-
to emit at 9.3–9.6 μm wavelength, which is the peak of ited to under 1–2 μm. With erbium lasers, the shortest
absorption for the molecule of phosphate in hydroxy- pulse width is 50–60 μs, while the CO2 allows efficient
apatite, by replacing the normal 12C16O2 molecule with ablation of enamel and dentin with laser pulses of
an isotopic 12C18O2 [247]. The absorption is particularly 10–15 μs [247, 249], so it is possible to obtain high peak
important because in this case enamel, which is mainly power values with lower energy levels, and this can be
composed of calcium and phosphate, absorption is 5–6 less aggressive and has a lower possibility of collateral
times higher at 9.3–9.6 μm than at the more commonly damage of healthy dental structure [248, 251]. According
used 10.6 μm wavelength and it allows more efficient to Staninec et al. [245], the thermal relaxation time of
heating and ablation of dental hard tissue [248]. the energy deposited in enamel at these wavelengths is
Transversely excited atmospheric-pressure (TEA) CO2 on the order of 1–2 μs for enamel and 5.5 μs for dentin
lasers and other radio frequency excited (RF) pulsed [250], so the use of a laser with pulses of 10–20 μs width
lasers combined with 3D computer controlled program- reduces the threshold for plasma shielding in the plume
mable scanning systems are now available on the market of ablated material, which would shield the surface and
from several manufacturers and seem even more versa- reduce the efficiency of irradiation, allowing the abla-
tile and efficient when compared to erbium family lasers tion of enamel and dentin at rates of 10–20 and
[245, 246]. Using such lasers it is possible to perform a 20–40 μm/pulse, respectively [245, 247]. The use of lon-
wide range of procedures. Such as modification of the ger CO2 laser pulses has the advantage of raising the
pulse duration of new carbon dioxide laser in order to plasma-shielding threshold allowing higher ablation
obtain an efficient removal of dental hard tissues (cari- rates per pulse, however the longer pulses are more likely
ous lesion ablation, caries prevention, removal of com- to produce a larger zone of peripheral thermal damage.
posite restorations) and bone, as well as retaining the The practitioner should remember that, although abla-
surgical effect on soft tissue [249]. The most important tion rates are higher for longer pulses, the peripheral
feature regarding modern carbon dioxide devices is that thermal damage caused by these longer pulses may be
they can be operated at high pulse repetition rates—in too extensive for practical use. Such thermal damage
the order of kHz—and this allows a very practical may result in thermal stress cracking, accumulation of
removal rate of hard tissues and an incomparable ability non-apatitic calcium phosphate (CaP) phases on the
of gingival and mucosal ablation [248]. The erbium surface and excessive damage to the collagen matrix
lasers presently used for hard tissue ablation operate [245, 252], so it is advisable to limit the length of laser
most efficiently at very low repetition rates (10–25 Hz). pulses.
Therefore, in order to achieve higher cutting rate erbium . Figure 8.7a–f shows carious tissue removal in
lasers must deliver a larger amount of energy per pulse, tooth #3 MO using the CO2 9.3 μm laser:
276 R. Poli et al.
a b
c d
e f
e f
.. Fig. 8.7 a–f Carious tissue removal in tooth #3 MO using Solea with a 1.0 mm spot size at 20–40% cutting speed. d Photo of the
CO2 9.3 μm laser (Convergent Dental, Natick, MA, USA). Image completed preparation. e Immediate postoperative view of the resto-
key: a Preoperative occlusal view of the upper right molar with a ration in place. f Postoperative radiograph showing the competed
carious lesion on the mesial surface. b Preoperative radiograph. c A restoration. The entire procedure was performed without injected
photo of the partially completed carious lesion excavation. The anesthesia using the “hard and soft tissue setting” and 100% mist.
9300 nm laser with a 1.25 mm spot size was used with a cutting speed Caries indicator was used once more before restoring the tooth. The
between 20% and 60%. Caries indicating solution was used to verify total laser time was 12 min. (Procedure by Dr. Joshua Weintraub)
the progress of the preparation. Subsequently the laser was used
Laser Use in Dental Caries Management
277 8
8.29 Resistance to Acid the use of 9.3 μm CO2 short-pulsed laser increases the
caries resistance of occlusal pit and fissure surfaces in
Another important advantage of CO2 laser, in particular patients in addition to fluoride therapy. A total of 22%
9.3 μm CO2, is the chemical and structural modification of of the participants in the control group developed car-
enamel surface obtainable during irradiation [248]. This ies, while 0% of the participants in the test group (treated
laser irradiation vaporizes water and carbonate and with Solea) developed caries [259].
changes the chemical composition of the remaining min- One possible therapeutical approach is to irradiate
eral content of enamel, thus decreasing the solubility to the grooves of occlusal surfaces with this laser prior to
acids with an enhanced resistance to secondary caries [253]. placing sealants to further enhance the resistance to
This allows to increase the acid resistance and conse- decay. Should the practitioner need to remove a sealant
quently to reduce the incidence of carious lesions [254– due to its failure, the same laser can be used for this pur-
258]. The occlusal pits and fissures are the areas of the pose [258]. It is also important to underline that irradia-
tooth in which dental caries is most frequent. Thermal tion with this wavelength reduces the sensibility of
modifications of these surfaces with the 9.3 μm CO2 dental tissues to acid etching.
laser have been shown to obtain a greater resistance to . Figure 8.8a–e demonstrates a gingivectomy and
acid dissolution. In a clinical study, Rechmann et al. Class V restoration, tooth #20, using the 9300 nm CO2
demonstrated over 12 months with 60 participants that laser.
278 R. Poli et al.
a b
c d
.. Fig. 8.8 a Gingivectomy and restoration, deep Class V decay of speed of ablation was achieved by varying the working distance,
tooth #20 B (Solea laser (Convergent Dental) 9300 nm CO2. Pre-op. hand speed, and rheostatically controlled cutting speed. Note, clean
b Only topical anesthetic (TAC 20 alternative) was used. First, gingi- exposure of apical margin for best restoration. This is an advantage
vectomy was performed to expose the apical extent of the deep sub- due to CO2 ablating soft tissue more precisely than other wave-
gingival decay, utilizing the 1.00 mm spot size, 1% mist, and cutting lengths. d The tooth was then restored with Scotchbond Universal
speed of ~30–40%. The procedure was performed utilizing the tipless (3M) and TPH Spectra ST (Dentsply). e At 3 days post-op, note
contra angle handpiece. c Decay was then removed using the same remarkably fast healing and excellent tissue appearance. (Procedure
settings except mist was increased from 1% to 80%. Precise control by Dr. Joshua Weintraub)
Laser Use in Dental Caries Management
279 8
8.30 Pulpal Temperature Considerations that are produced without a proper cooling due to exces-
sive overheating of the mineral phase [245]. One disad-
Enamel, dentin, and bone can be rapidly removed with vantage related to the use of this powerful laser is the
the 9.3 μm CO2 laser without peripheral thermal dam- formation of highly conical and deep ablation craters cre-
age by mechanically scanning the laser beam and also ated when the irradiation is performed in the same spot
with the aid of cooling water spray [248]. by repeated laser pulses. This is also at the base of stalling
If compared to a high-speed traditional handpiece, phenomenon (cessation of ablation after penetration of
this laser allows to avoid excessive peripheral thermal or 2–3 mm) and of excessive heat accumulation. To avoid
mechanical damage [251], provided the use of enough this and obtain a more efficient ablation, it is necessary to
water cooling is guaranteed, otherwise some desiccation use small spot sizes (<0.3 mm) and the laser should be
of tissues might occur. Thermocouple measurements scanned in two dimensions to expose a new area for each
showed an increase in temperature of 3.3 ± 1.4 °C with- pulse [245, 251]. Scanning and positioning of the beam
out water cooling versus 1.7 ± 1.6 °C with water cooling are now feasible due to recent advances in compact high-
[245, 247]. Even though the tooth temperature rise was speed scanning technology such as the miniature galva-
less than 5 °C without water cooling during an irradia- nometer “galvo” based scanners [251, 260].
tion at 50 Hz, it is still necessary to use a water spray to . Figure 8.9a–g shows a gingivectomy and restora-
produce the desired effect. This is advisable for the pos- tion, fractured and decayed tooth #8, using the CO2
sible formation of non-apatitic calcium phosphate phases 9.3 μm laser.
280 R. Poli et al.
a b
8 c d
e f
.. Fig. 8.9 a Preoperative appearance tooth #8 (Solea laser (Con- then removed utilizing the 1.00 mm spot size, 1% mist, and cutting
vergent Dental) 9300 nm CO2). b Pre-op radiograph. c Only topical speed of ~30–40%. Note, clean exposure of apical margin for best
anesthetic (TAC 20 alternative) was used. First, gingivectomy was restoration. This is an advantage due to CO2 ablating soft tissue and
performed to expose the apical extent of the fracture and decay, uti- bone more precisely than other wavelengths. e The tooth was then
lizing the (Solea laser (Convergent Dental) 9300 nm CO2) 1.00 mm restored temporarily (as the tooth was to be crowned) with Scotch-
spot size, 1% mist and cutting speed of ~30–40%. The procedure was bond Universal (3M) and TPH Spectra ST (Dentsply). f Post op
performed utilizing the tipless contra angle handpiece. d Next, bone radiograph. g At 1 week post-op, tissue has rapidly healed with
was precisely ablated utilizing the same handpiece, the 0.5 mm spot excellent tissue tone. (Procedure by Dr. Joshua Weintraub)
size, 80% mist, and cutting speed between ~60 and 80%. Decay was
Laser Use in Dental Caries Management
281 8
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8 8.33 Conclusion
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291 9
Laser-Assisted Endodontics
Roy George and Laurence J. Walsh
Contents
References – 312
Core Message
. Table 9.1 Classification of uses of lasers in endodontics
Endodontics is a technically demanding aspect of den-
tistry because of the limited ability to see and instrument Primary Examples
the root canals of teeth. Conventional endodontic treat- application
ment is painstakingly slow, and traditional hand and pow-
ered endodontic instruments do not contact all the walls of Diagnosis Detection of pulp vitality
• Doppler flowmetry
the root canal. The use of lasers can assist in providing
• Low-level laser therapy (LLLT)
enhanced detection of bacteria and microbial biofilms in • Laser fluorescence
the root canal to guide debridement approaches and help • Detection of bacteria
define endpoints for instrumentation. Fluorescence feed-
Pulp therapy Pulp capping
back can indicate where microbial deposits remain and Pulpotomy
where further treatment is needed. There are a range of
Canal prepara- Biomechanical preparation
ways that lasers can enhance biomechanical preparation of
tion Removal of smear layer
the root canal system, particularly through fluid agitation Sterilization of the root canal
and inducing cavitation in water-based fluids, to remove • High-level lasers—photothermal
debris and smear layers. Such actions can be optimized disinfection
using modified fibers to deliver the laser energy in various •
Low-level lasers—photodynamic
disinfection
side-firing patterns. Lasers can achieve disinfection of the
root canal through both photothermal and photodynamic Periapical surgery Ablation of granulation tissue
processes, reaching with laser energy areas that are difficult Bone cutting and root resection
9 to access using instruments, to inactivate microbial patho- Laser photobio- Laser-induced analgesia
gens. Additional applications of lasers in endodontics modulation Accelerated healing after pulpotomy or
include the assessment of pulp vitality through laser periapical surgery
Doppler flowmetry, photothermal and photodynamic Other Removal of root canal filling materials
bleaching of discolored sclerosed vital or stained non-vital and fractured instrument
teeth, pulp capping and pulpotomy, photobiomodulation Softening gutta-percha
Removal of moisture/drying of canal
and laser-induced analgesia, and endodontic surgical
applications including periapical surgery and treatment of
invasive cervical resorption. In each of these areas, the use
of lasers can simplify treatment protocols and optimize hand or rotary endodontic files, laser effects reach across
clinical outcomes. the entire root canal system and penetrate to some extent
into dentine tubules. It is well known that with conven-
tional instrumentation, large parts of the root canal sys-
9.1 Introduction tem are untouched. The use of lasers, in many cases
combined with appropriate fluids, can assist in achieving
The primary goal of root canal treatment is to eliminate the goals of three-dimensional cleaning and profound
microorganisms from the root canal system and the disinfection of the canal.
radicular dentin. Laser technology can assist in the diag- Supporting these primary goals of endodontics are
nosis of microbial deposits to guide biomechanical other laser applications in the diagnostic and therapeu-
treatments and can help to inactive organisms through a tic categories, as shown in . Table 9.1. The uses of var-
range of thermal, photodynamic, and photomechanical ious lasers used in endodontics and some of their more
processes. Unlike mechanical instrumentation such as popular applications are listed in . Table 9.2.
Laser-Assisted Endodontics
293 9
In laser Doppler flowmetry (LDF), laser light is
. Table 9.2 Selected applications of lasers
transmitted through tooth structure to the dental pulp by
Laser Wavelength Reported uses in endodontics means of a fiber-optic probe held in a reproducible posi-
tion on the tooth surface. If the pulp is vital, there will be
Short a445 nm–514.5 nm Endodontic disinfection blood flow within the tissue. With movement of erythro-
wave cytes, the scattered light is frequency-shifted, while light
KTP 532 nm Soft tissue surgery in
length
endodontics, endodontic reflected from static tissue is unshifted. The reflected light
disinfection is analyzed for its frequency shift to give a noninvasive,
aHe–Ne 633 nm Doppler flowmetry, objective, painless, semi-quantitative assessment of
Diode 635 nm photoactivated disinfection pulpal blood flow. LDF has been used to estimating
of root canals pulpal vitality in both adults and children, particularly in
Diode 810–980 nm Soft tissue surgery in teeth which have been affected by dental trauma, exces-
endodontics, endodontic sive occlusal forces, or orthodontic movement.
disinfection, laser-induced LDF can also assist in the recognition of non-vital
analgesia, laser photobio- teeth. For this application, LDF has been found to be
modulation
particularly valuable for assessing the blood flow in lux-
Nd:YAG 1064 nm Soft tissue surgery in ated teeth, as the pattern of results over time can guide
endodontics, endodontic decisions around “at-risk” teeth so that loss of vitality
disinfection, biomechanical
can be recognized and can then trigger endodontic inter-
preparation
vention [2, 3].
Long Er,Cr:YSGG Tooth preparation, soft and While LDF is regarded as a highly accurate method
wave 2780 nm hard tissue surgery in for diagnosing the state of pulpal health and indeed
length endodontics, endodontic
comes closest to serving as a “gold standard,” it must be
disinfection, biomechanical
preparation recognized that LDF readings are prone to interferences
from environmental- and technique-related factors,
Er:YAG 2940 nm Tooth preparation, soft and
including superimposed signals arising from blood flow
hard tissue surgery in
endodontics, endodontic in the periodontal tissues rather than in the pulp, the
disinfection, biomechanical posture of the patient, and their heart rate. If the laser
preparation light reaches the periodontium, then the reflected signal
Carbon dioxide Pulp capping; soft tissue will not be entirely of pulpal origin [4–7]. One technique
10,600 nm surgery in endodontics to overcome this is to place the probe on dentine in the
floor of a cavity in the tooth, rather than on the enamel
a Commercial availability for use in dentistry is limited due to surface, since this is closer to the dental pulp and
the replacement with 635-nm diode lasers, so its inclusion here improves the signal-to-noise ratio [8].
is purely for historical reasons
There has also been work to explore the applications
of transmitted laser light, rather than reflected laser
light as in LDF. It has been suggested that transmitted
light would be useful for the assessment of tooth pulp
vitality both because the blood flow signals do not
9.2 Diagnostic Laser Applications include flow of non-pulpal (e.g., periodontal) origin and
because the response to blood flow changes is more
9.2.1 Laser Doppler Flowmetry obvious [9].
With both LDF and the transmitted light approach,
During dental pulp sensibility testing, a pain response it must be borne in mind that transmission of laser light
elicited to a hot or cold stimulus or to an electric pulp may be influenced to some extent by tooth shade as well
tester provides information about the dental pulpal sen- as by the presence of dental caries and restorations.
sory supply, but not about its blood supply. Although Light can however be conducted within irregular sec-
the sensitivity of these commonly used tests is high, false ondary dentine, so the presence of carious lesions or
results can lead to unnecessary endodontic treatment. tooth-colored restorations in molar teeth does not
This is a particular problem when teeth have experienced always prevent laser light reaching the pulp space. Light
dental trauma or are undergoing orthodontic tooth will not, however, pass through amalgam restorations or
movement [1]. gold crowns [10, 11].
294 R. George and L. J. Walsh
a b c d
e f
.. Fig. 9.1 Optical fibers and their applications in laser endodon- based fluid (500 mJ/pulse at 4 Hz). The point of greatest thermal
tics. a Conventional plain-ended fiber placed into an epoxy resin rep- change is the blue color change, followed by green and then by red. d
lica of the root canal showing forward emission of visible red laser The same tooth 5 s after lasing has stopped, showing dissipation of
energy. Using plain ended tips requires the fiber to be moved to thermal changes at the root surface (for details, see Ref. [17]). e
achieve irradiation of the canal walls. b Honeycomb fiber placed into Smear layer present on the root canal walls when rotary instruments
the root canal showing lateral emission of visible red laser energy. To are used with water as the lubricant fluid. SEM magnification 2000×.
enhance visibility, the canal was filled with ink prior to inserting the f The same location after using a conical tip fiber to deliver 940-nm
fiber. c Thermochromic (heat-sensitive) dye applied to the root sur- diode laser energy to activate EDTA irrigant. The laser was applied
face showing subtle thermal changes during lasing of less than half for ten cycles of 10-s duration using 80 mJ/pulse at 50 Hz (for details,
a degree Celsius when the honeycomb tip is used to activate water- see [18])
method [13, 16] (. Fig. 9.3). There is also the possibil- example, by quenching fluorescence emissions (such as
ity of using long wavelength ultraviolet light (380– hydrogen peroxide or ozone).
400 nm) or violet light (405 nm) to elicit fluorescence A false-negative signal could affect the diagnostic
emissions from bacterial deposits. In this instance, the value of fluorescence-assisted assessment of endpoint to
emissions are in the visible red region [28–30]. chemo-mechanical preparation of the root canal system
For the successful use of fluorescence to guide laser- disinfection. In endodontic treatment, irrigating solu-
based treatment methods, it is important to recognize tions such as sodium hypochlorite and hydrogen perox-
factors which could impair the fluorescence process, for ide are used because of their chemical actions which
296 R. George and L. J. Walsh
a b
.. Fig. 9.3 Panels a and b show labual and palatal (mirror) views of the fiber entering the canal. Use of real-time fiber-optic detection of
bacteria. A flexible fiber with a specially treated surface is inserted into the canal. The typical fiber diameter is 150–200 μm. The fiber is then
linked to a fluorescence diagnostic system
Laser-Assisted Endodontics
297 9
Calmix™ calcium hydroxide paste, Odontopaste™ cal- diode laser could be an adjunctive tool for early detec-
cium hydroxide paste, 2% lignocaine with 1:80,000 tion and management of symptomatic cracks, facilitat-
adrenaline, and eucalyptus oil had no effect on dentine ing early interventions with the aim of improving
fluorescence readings [35]. long-term survival of the teeth [42].
Key Points for Laser Fluorescence Assessment 9.3 Laser-Assisted Widening of the
55 False-positive fluorescence can occur with certain Root Canal
endodontic medicaments (e.g., tetracyclines).
55 Oxidants can quench fluorescence signals. One of the earliest explorations of the possible use of
55 Fiber optics with lateral light collection properties lasers to enlarge the root canal was the study of Levy
are required. [43], in which an Nd:YAG laser with water spray was
55 Low laser powers are used so there are no deleteri- used to widen root canals in the apical zone from ISO
ous thermal effects. #20 to ISO #35, based on the fit of K files. The tech-
55 Suitable wavelengths include ultraviolet, visible, nique employed was a painting and sweeping action cir-
and near-infrared laser light. cumferentially, with lateral pressure on the canal walls
during withdrawal of the fiber. The procedure took 60 s,
using of 300 mJ and 1 Hz. Consistent with this,
Matsuoka et al. [44] required approximately 2 min to
9.2.3 iagnosis of Symptomatic Cracks
D enlarge root canals from 0.285 to 0.470 mm. Both Ali
in Vital Teeth et al. [45] and Jahan et al. [46] took only 60 s of lasing
time to prepare the root canal using a crown-down tech-
Cracked tooth also known as cracked tooth syndrome nique. This excludes the time required to change fiber-
(CTS) can be a difficult disorder to diagnose and man- optic tips. It would be predicted that canals with larger
age [37, 38]. Failure to diagnose the condition early tapers would be easier to prepare than those with nar-
could result in crack progression and potential tooth rower tapers.
loss, while early diagnosis may result in treatment with a With regard to the Ho:YAG laser, Cohen et al. [47]
conservative restoration. When cracks progress to com- used a 245-μm-diameter optical fiber to enlarge canals.
municate with the pulp, root canal treatment and a cus- The fiber was inserted to the apex, energized, and then
pal coverage restoration are often necessary [39, 40]. withdrawn slowly at 4 mm/s. Using this technique,
Lasers are of interest in the assessment of cracks canals with internal dimensions of ISO #25 were wid-
because current diagnostic techniques (bite tests, transil- ened to an apical size of ISO #40. Using the same laser,
lumination, etc.) are limited in their ability to consis- Cohen et al. [48] employed a step-back technique with
tently determine the offending teeth and cusps, with four different optical fiber tips (with diameters of 140,
most clinicians relying on the patient’s reported symp- 245, 355, and 410 μm) to enlarge canals progressively,
toms in making a diagnosis. It is difficult to establish the while Deutsch et al. [49] used six different sized optical
location and direction of the crack responsible for fiber tips for enlarging the root canal with the Ho:YAG
symptoms. Moreover, a range of other pathologies can laser.
mimic the symptoms of CTS, making differential diag- With regard to the Er,Cr:YSGG laser, Ali et al. [45]
nosis challenging. reported the use of fibers of various diameters to prepare
Sapra et al. in 2021 showed in an in vitro study that root canals using a crown-down technique. While noting
significantly more laser energy passes through teeth with that this laser wavelength was useful for removal of
cracks, compared to teeth without cracks [41]. In further smear layer and debris, the risk of ledging, zipping, per-
work, they suggested that near-infrared lasers could be foration, or over-instrumentation of canals was noted.
used as an adjunct for identifying cracked teeth in a clin- Matsuoka et al. [50] reported that the Er,Cr:YSGG laser
ical setting [42]. They used an 810-nm diode laser at a could be used successfully to prepare root canals with
power of 1 W in a continuous wave mode, delivered curvatures up to 10°, using a step-back technique, with
through a 200-μm-diameter tip, for screening for cracks an average energy of 2 W, a pulse rate of 20 Hz, and an
in vital teeth [42]. The surfaces of the suspect tooth were air and water spray. In contrast, Jahan et al. [46] reported
lased in a scanning motion across the surface. A crack that preparation of canals with a curvature above 5°
was identified from the patient experiencing a transient could lead to zipping, ledge formation, or perforations.
sharp pain, which disappeared immediately as the scan There is more limited information regarding the use of
moved past the crack [42]. This study provides a plat- the Er:YAG laser for enlarging the canal. Matsuoka et al.
form for further work to explore how a near-infrared [44] reported using the Er:YAG lasers to enlarge the root
298 R. George and L. J. Walsh
canal using three different size conventional optical fiber Diode lasers are cost-effective, compact, and porta-
tips used sequentially, in line with the step-back approach. ble devices. The near-infrared laser emissions from these
Although several studies have shown the potential devices (810–980 nm) have penetrating disinfecting
for lasers to widen the root canal, it is difficult to attain actions, which are an additional advantage to being able
all the mechanical objectives of root canal preparation to remove smear layer. Wang [66] used a 980-nm wave-
when laser energy is delivered with conventional optical length diode laser at 5 W for 7 s to remove smear layer;
fibers. This relates to their inability to deliver laser however, concerns remain in terms of generation and
energy directly onto the walls of the root canal, as well conduction of heat to the supporting apparatus if high
as the operator challenge of maintaining a constant irradiances are used [67].
withdrawal rate. In 2006, Altundasar et al. [51] showed Nd:YAG lasers are more effective for disinfecting the
that delivery of laser energy onto the walls of the root root canal, and relatively less effective for removing
canal using a conventional (plain) optical fiber to remove smear layer, compared to the erbium lasers [68]. Goya
smear layer gives inconsistent ablation. From the stand- [69], who investigated the effect of the Nd:YAG laser on
point of optics, a beam delivered from a plain fiber (and smear layer, found that black ink increases the removal
thus largely parallel to the walls of the root canal sur- of smear layer by enhancing absorption of laser energy.
face to be ablated) has low efficiency, and this has been However, Wilder-Smith et al. [70] identified that thermal
demonstrated in the laboratory setting, by comparing damage was a concern when using the Nd:YAG laser to
the effects of parallel and perpendicular beams directed remove smear layer.
onto root canal dentine slices. The water-absorbing properties of the Er:YAG and
In an attempt to overcome some of these problems, Er,Cr:YSGG lasers make these useful both for disinfec-
9 fiber tips with sculpted polished ends and greater lateral tion of the root canal and for removal of smear layer [61,
emissions have been developed [49, 52–56]. Shoji et al. 64, 71]. Takeda et al. [61] undertook a comparative study
[52] employed a cone-shaped irradiation tip which could of the argon ion laser (1 W, 50 mJ, 5 Hz), Nd:YAG laser
disperse laser energy in an annular pattern. This alumi- (2 W, 200 mJ, 20 Hz), and Er:YAG laser (1 W, 100 mJ,
num reinforced silicate tip was used to deliver Er:YAG 10 Hz) in terms of removal of smear layer from prepared
laser energy to enlarge root canals. This tip design pro- root canal walls, compared to EDTA. All lasers achieved
duced maximal enlargement when the laser was used at better smear layer removal than EDTA, and the Er:YAG
30 mJ and 10 Hz. laser was the most effective of the three lasers used. In a
later study, Takeda et al. [65] reported that Er:YAG
lasers were better than CO2 lasers and three different
Key Points for Laser-Assisted Widening of the acids in removal of smear layer. Ali et al. [45] reported
Root Canal less smear layer or debris when using an Er,Cr:YSGG
55 Laser wavelengths should ablate hard tissue for laser, compared to the conventional root canal tech-
maximum effectiveness. niques; however, the mechanical quality of the canal
55 Thermal side effects need to be controlled. preparation (smoothness, taper, etc.) was worse with the
55 Special tip designs improve safety and effective- laser method. Biedma [72] also reported similar results
ness. of that of Ali et al. [45] but using the Er:YAG laser.
55 Suitable wavelengths are in the middle infrared. As already noted, several studies have reported
55 Laser energy must be pulsed to ensure thermal inconsistent or inefficient removal of smear layer when
stresses are reduced. using erbium lasers delivered using conventional optical
55 Concurrent irrigation assists cooling. fibers. Altundasar et al. [73] reported inconsistent smear
layer removal of the walls of the root canal when the
Er,Cr:YSGG laser (operated at 3 W and 20 Hz) was
delivered using a conventional tip, while Anic et al. [51]
9.4 emoval of Smear Layer from Root
R reported greater efficiency of a perpendicular beam for
Canal Walls ablation when compared to a parallel beam. Kimura
et al. [74] stated that it was difficult to evenly irradiate
Many laser types have been reported to be useful in the root canal walls using a conventional fiber tip and advo-
removal of smear layer from root canal walls, including cated an improvement in the fiber tip design or method
the argon fluoride (ArF) and other excimer lasers [57], of irradiation to avoid obtaining an uneven surface.
argon ion lasers [58], KTP laser (532 nm) [59], diode To overcome such problems, several authors have
lasers, Nd:YAG lasers [60, 61], HoYAG lasers [62], employed sculptured fiber tips that have greater lateral
Er:YAG lasers [17, 63], Er,Cr:YSGG lasers [46, 64], and delivery of laser energy [52–54]. Alves et al. [55] used the
CO2 lasers [65]. Er:YAG with forward-emitting sapphire tips and hollow
Laser-Assisted Endodontics
299 9
fibers and compared these to modified tips which gave
lateral emissions. Shoji et al. [52] used an Er:YAG laser 55 Water-based irrigant fluids should be used; the pro-
delivered into a cone-shaped tip to enlarge artificial root cedure should never be done dry.
canals in a block of bovine dentine using Er:YAG laser 55 Laser activation enhances the action of EDTA in
energy. The cone-shaped tip was faster for cavity prepa- smear layer removal.
ration and smear layer removal, compared with conven- 55 Lasers can enhance the actions of other water-
tional instruments. Likewise, Takeda et al. [65] used a based fluids such as sodium hypochlorite through
conical tip with the CO2 to remove smear layer from the agitation and warming of the fluid.
root canal. 55 Thermal side effects need to be controlled.
Stabholz et al. [75] designed an endodontic side- 55 Special tip designs improve safety and effective-
firing spiral tip (RCLase; Lumenis, OpusDent, Israel), ness.
which comprised a hollow waveguide with spiral slits 55 Tips degrade readily during use and this alters their
along the length of the tube. The end of the tip was emission characteristics.
sealed to prevent the forward transmission of laser 55 Laser energy must be pulsed to ensure thermal
energy. The Er:YAG laser was used at 500 mJ and 12 Hz stresses are reduced.
through this tip to remove smear layer successfully. 55 Concurrent irrigation assists cooling.
However, such tips are too large and rigid to be used in
narrow, curved root canals. Moreover, if the tip were to
bend, more energy would be emitted across those slits
that are in a straight line with the beam. To overcome 9.5 Disinfection
such concerns, flexible fiber optics with various thick-
nesses have been used to gain better access to the full 9.5.1 Photothermal Disinfection
length of the root canal. Furthermore, fibers have been
modified to allow for better delivery of laser energy that Laser light can penetrate areas of canals where irrigat-
is directed onto the walls of the root canal [19, 21, 76]. ing and disinfecting solutions cannot reach, such as fins,
For enhanced removal of smear layer from the root deltas, and lateral canals [85]. Selective photothermoly-
canal walls, water-absorbing middle-infrared laser wave- sis occurs when laser energy is applied into the root
lengths (e.g., Erbium:YAG) can be used. The laser canal system. For water-absorbing laser wavelengths,
energy that reaches the canal walls can directly ablate rapid expansion of water contained within microorgan-
the dentine of the root canal walls and remove smear isms leads to their rupture, while for the visible and
layer, especially when used with EDTA [77]. It is how- near-infrared wavelengths, primary absorption of laser
ever important to note that the optimum energy settings energy into porphyrins, melanin, and other pigments
need to be considered when using lasers for the removal occurs. The increase in temperature then denatures pro-
of smear layer [78–81]. Operators need to also consider teins, and this renders the organisms unviable [86–88].
the suitability of the laser wavelength, the diameter and When such methods are used, it is important to
flexibility of the fiber-optic delivery system, the design employ pulsed modes and rest periods to allow for cool-
of its tip, the dimensions of the root canal system, and ing of the root structure so that there is no collateral
the type of endodontic procedures being undertaken injury to the periodontal ligament from thermal stress.
[19, 21, 76]. Understanding such factors ensures correct Assessments of safety undertaken in laboratory condi-
techniques are used, and this helps prevent carboniza- tions are based on threshold values around 5.5–7 °C as
tion, ledge formation, and apical extrusion of fluids [21, the limit of acceptable temperature increases on the root
76, 82–84]. surface [89, 90].
Directing laser energy onto the walls of the root
canal is essential for effective disinfection. To maximize
this effect, different fiber modifications have been devel-
Key Points for Removal of Smear Layer oped to increase lateral emission of laser energy, includ-
55 Laser wavelengths should absorb strongly in water ing designs with safe tips to reduce irradiation directed
to generate cavitation. toward the root apex. Examples include conical tips,
55 The use of pulsed modes is essential. side-firing honeycomb tips, and honeycomb tips with
55 Laser pulse energy must be limited to prevent fluid silver-coated ends (safe-ended fibers) [76].
extrusion from the apex and excessive projection of Photothermal laser disinfection is a useful supple-
fluid from the root canal system. ment to existing protocols for canal disinfection as the
55 Most suitable laser wavelengths are in the middle properties of laser light may allow a bactericidal effect
infrared. beyond 1 mm of dentine. It must be remembered that
endodontic pathogens can be present not only in the
300 R. George and L. J. Walsh
canal but also extending into the dentine tubules for sev- laser light of the appropriate wavelength, reactive oxy-
eral hundred microns. This emphasizes the value of gen species are generated, which then damage the micro-
actions such as laser fluid agitation to enhance the effi- bial cell membrane, leading to leakage of contents
cacy of current irrigating protocols, which can increase through it and denaturation of microbial proteins and
the distance of the laser effect [91]. DNA [88, 93].
At the present time, the lasers used most commonly Since LLP relies on the chromophore becoming elec-
for photothermal disinfection are the Nd:YAG, KTP, tronically activated, it is essential to match the laser
and near-infrared diode lasers. All of these have been wavelength used with the chromophore, in exactly the
shown to have excellent antibacterial efficacy, with same manner as is done for laser photodynamic therapy
greater penetration of the disinfecting action than of oral lesions, where the laser energy activates other-
middle-infrared wavelengths [92]. wise nontoxic dyes producing reactive oxygen species
that cause injury and death of tumor cells [94, 95].
PAD is a specific interaction, in that treatment with
Key Points for Photothermal Disinfection the laser alone (i.e., in the absence of the enhancing
55 Laser energy must absorb into major chromo- dye), or with the dye alone, produces much less micro-
phores (water, porphyrins, melanin, and other pig- bial killing than the combination of dye with laser. For
ments) for bacterial inactivation to occur. example, using visible red laser light, bactericidal effects
55 This can be done with almost any laser system, but can be achieved using a range of blue, purple, and green
preferred lasers are Nd:YAG, KTP and near- dyes within the phenylmethane family, all of which are
infrared diode lasers. Middle-infrared lasers will strong absorbers of red light [96, 97]. Other photosensi-
9 show the lowest penetration (~0.5 mm). tizers of interest include indocyanine green (ICG) and
55 Lateral emitting/side-firing tips are preferred to curcumin, which are activated at 808 and 470 nm,
ensure even irradiation is achieved. respectively [98, 99]. PAD can be undertaken with LEDs
55 Disinfection can be achieved for microbial deposits as well as with lasers, since either will activate the photo-
deep within dentin which would not be reached by sensitizers [100].
most medicaments placed into the canal. Both in vitro and clinical studies of PAD have dem-
55 Penetration depths vary according to the laser onstrated its ability to kill photosensitized oral bacteria
wavelength used. Maximum penetration occurs (such as Enterococcus faecalis). To date, 12 studies have
with near-infrared laser energy. reported PAD as being effective in eliminating
55 Pulsed modes must be used to lower thermal stress Enterococcus faecalis from infected root canals [101].
to the root and periodontium. While PAD can be undertaken as part of the routine
55 Total dosimetry must be monitored so that the irra- disinfection of the root canal system, it also has a poten-
diation remains within safe limits. tial use for eradicating persistent endodontic infections
55 Movement of the fiber enhances coverage of the for which conventional methods have been unsuccessful
walls of the root canal. [102–104]. It does not cause significant thermal stress to
55 The fiber is moved from the apex in a coronal direc- the roots of teeth or the adjacent periodontal tissues [105].
tion, tilting and rotating the fiber to help gain bet- There are many possible dyes which could be used
ter exposure of the canal walls. for PAD. In its simplest form, the dye should undergo
55 The fiber must be kept in constant motion. photodynamic activation and produce reactive oxygen
55 Several passes one after the other are required to species (ROS), which are the means by which microor-
ensure that all parts of the root canal receive suffi- ganisms are inactivated. Dyes such as tolonium chloride
cient laser energy to inactivate microorganisms. and methylene blue are excellent producers of ROS in
that regard. Using colored dyes which are activated by
shorter wavelengths of light enhances effectiveness,
since shorter wavelength light has a higher photon
9.5.2 Photodynamic Disinfection energy than longer wavelength light (such as in the near-
infrared region of the spectrum).
Photoactivated disinfection (PAD), also known as pho- There has been some confusion as to the mechanisms
toactivated chemotherapy (PACT), is based on the inter- involved when green dyes such as indocyanine green
action of laser light with photosensitizers. These may be (ICG) are exposed to near-infrared laser energy around
endogenous (such as porphyrins found in Gram-negative 800–830 nm, which absorbs strongly in this material. The
bacteria) or exogenous in the form of dyes such as tolo- effect of the laser energy being absorbed is to heat the dye
nium chloride or methylene blue applied into the root and therefore indirectly heat what the dye has become
canal, which then bind to microbial outer membranes attached to. This is a type of photothermal disinfection
(. Fig. 9.4). When the photosensitizer is exposed to process and is not a photodynamic process since the
Laser-Assisted Endodontics
301 9
a b c d
e f g
.. Fig. 9.4 Root canal photodynamic disinfection. This case pre- treatment showing delivered power 95-mW continuous wave mode.
sented with a large periapical lesion on the lateral incisor and apical Typical irradiation is 60–90 s. f, g Transmission of visible red laser
root resorption. a Diagnostic file. b Isolated tooth. c Tolonium chlo- light through the coronal and radicular tooth structure. This acti-
ride dye solution. d Injection of dye solution into the root canal sys- vates the dye and provides biostimulation effects
tem. e Laser control panel for 635-nm diode laser midway during
action is mediated through heat rather than through the dye is in contact with all the parts of root canal, even
generation of ROS. This underpins the applications of when its shape is complex. Agitation of dyes can enhance
ICG dye in laser-based tumor therapies. ICG dye can the contact of dyes with the root canal walls, giving bet-
absorb between 600 nm in the visible red region all the ter penetration into dentine tubules [106]. Some photo-
way through to 900 nm, and it can emit fluorescence sensitizer dyes are smaller molecules and so will have an
between 750 and 950 nm. ICG when exposed to 810-nm inherently better penetration by diffusion than others
laser light will fluoresce, which is a major way ICG is with larger molecular sizes, and in any event, penetra-
used in medical diagnostics. Nevertheless, it is a simple tion of the dye can be enhanced further by agitation,
fluorescence dye and is not a photosensitizer. such as by using LAI [106]. The dye photosensitizer
There has also been a level of confusion used in the solution must be in contact with the target for a short
terminology surrounding photodynamic disinfection, period of time, prior to its activation by light, to allow
with terms such as photoactivated chemotherapy sufficient time for binding to microorganisms. PAD pro-
(PACT), photo-disinfection, and lethal laser photosensi- cedures should only be initiated after ensuring that the
tization (LLP) all having been used to describe the effect root canal system is cleared of all fluids that could dilute
with blue dyes; however, some studies using ICG also or inactivate the dye, such as saliva or blood or soft tis-
use these terms, which is incorrect. sues. These may contain scavenging systems for reactive
For the use of photoactivated disinfection (PAD) for oxygen species which could impede the photosensitiza-
root canal disinfection, it is important to ensure that the tion process [107].
302 R. George and L. J. Walsh
of the root canal, while with conventional irrigation it is peroxide to a final concentration of 3%. Any thermal
important to place the tip of the irrigation needle to within stresses at the cementum are reduced when irrigation
1 mm of the working length to ensure adequate fluid fluids are replaced, which enhances cooling of the root
exchange [122, 123]. The laser-generated agitation causes structure [84, 136].
fluid motion, which overcomes the bubble entrapment In a recent study which evaluated the efficiency of
effect. Fluid streaming, which is caused by the collapse of EDTAC activation for smear layer removal using a 940-
the laser-induced bubbles, is a major aspect of how laser- nm diode laser operated in pulsed mode and delivered
activated fluids clean the walls of the root canal [124, 125]. by plain fiber tips into 15% EDTAC or 3% hydrogen
Cavitation and agitation generated by lasers in fluid- peroxide, lasing EDTAC was found to considerably
filled root canals create fluid movement and shear improve smear layer removal to a greater extent than
stresses along the root canal walls, enhancing removal lasing into peroxide. Of interest, the diode laser protocol
of the smear layer and biofilm. Rapid fluid motion is for smear layer removal was more effective than the clin-
caused by expansion and subsequent implosion of laser- ical “gold standard” protocol using EDTAC with
induced bubbles [126, 127]. sodium hypochlorite (NaOCl). In addition, when using
When used with sodium hypochlorite and EDTA, diode lasers, there are additional benefits gained through
laser activation of aqueous fluids can increase the effi- photothermal disinfection and biostimulation [18].
ciency of debridement and disinfection of root canals When using a diode laser versus an erbium laser, it
[128–130]. Moreover, there is now direct evidence that must be remembered that the fluid agitation effects are
pressure changes and shock waves which accompany less for a diode laser than for an erbium laser; however,
cavitation may enhance the susceptibility of bacteria in both are a great improvement on irrigants which are
9 biofilms to antimicrobial agents. The problem of bio- simply held static in the root canal [137].
films in root canals has direct parallels to the tubing of
medical catheters, where such shock wave approaches
are now attracting interest [131, 132]. Key Points for Laser-Induced Cavitation
An obvious problem which arises is whether fluid 55 Laser energy must absorb into water for cavitation
movement in the root canal leads to greater extrusion of to occur in a water-based fluid.
fluids beyond the root apex. Conventional needles used for 55 A small volume of water will show greater cavita-
irrigation create apical pressure and extrude some fluid tion than a large volume for the same laser pulse
[133]. Studies of fluid extrusion beyond the apical con- energy; this has relevance to the effects seen in
striction using Er:YAG and Er,Cr:YSGG lasers with bare small versus large diameter canals.
or conical fiber tips positioned at distances of 5 or 10 mm 55 Middle-infrared lasers (Er:YAG and Er,Cr:YSGG)
from the apex have shown that the extent of microdroplets will show the fastest cavitation (microseconds) ver-
of fluid displaced past the apex was no greater than that sus 940–980-nm diode lasers (seconds) and will
seen when conventional 25-gauge non-side-venting irriga- cause the fastest fluid motion in the canal.
tion needles were used [82]. The PIPS technique aims to 55 Lateral emitting/side-firing tips are preferred as
ensure fluid motion is along the root canal walls, rather this changes the direction of cavitation bubble for-
than entirely toward the apical foramen, in order to reduce mation and collapse.
the volume that could be extruded. Several studies have 55 Pulsed modes must be used; shorter pulse dura-
shown that small volumes of fluid are extruded during tions will cause greater cavitation to occur for the
PIPS and during other methods of LAI [134, 135]. same pulse energy but will increase the risk of fluid
When fibers with laterally emitting honeycomb pat- extrusion through the apex.
ters are used, these generate agitation with fluid move- 55 More fluid extrusion occurs when the apical fora-
ment directed onto the walls of the canal, while both men is larger.
conventional plain fibers and tips with conical ends gen-
erate fluid movement largely in a forward direction.
Having the laser energy directed laterally lowers the risk
of fluid extrusion beyond the apex [79, 130]. 9.7 Laser-Enhanced Bleaching
Diode lasers in the 940–980-nm wavelength range
can be used to generate cavitation, relying on their water Sclerosis following dental trauma and the severe forms
absorption. Such lasers are used in pulsed modes, both of intrinsic staining due to the loss of vitality or end-
to optimize the cavitation dynamics and to reduce col- odontic treatment are challenging to manage. Some of
lateral thermal effects on the roots (. Fig. 9.1c, d). these conditions are resistant to conventional bleaching
Such lasers can then be used with water-based fluids to treatments based on carbamide or hydrogen peroxide.
remove debris and smear layers from the walls of the Common factors in intrinsic staining include
root canal. For diode lasers, the cavitation effects can be demeclocycline- containing tetracycline medicaments
enhanced by supplementing the water with hydrogen and bismuth oxide, an agent used to achieve radiopacity
Laser-Assisted Endodontics
305 9
in some epoxy resin sealers and in mineral trioxide reaction), photocatalytic actions, and photodynamic
aggregate (MTA) [138–141]. actions, where the laser energy activates a suitable pho-
The underlying chemistry which explains the pat- tosensitizer. There is also photooxidation, an effect
terns of discoloration with these different types of mate- which is essential for breaking up tetracyclines and
rials is quite complex. In the case of MTA, it is the AODTC [148].
formation of bismuth sulfide, which is black in color Sclerosed discolored traumatized teeth, which have
and therefore causes the tooth to appear gray. Iron remained vital, can be treated using the KTP laser with
released from hemoglobin following trauma can also photodynamic bleaching, employing rhodamine as the
form iron sulfide. Such sulfide compounds are very sta- photosensitizer. The same technique can also be used suc-
ble and not readily oxidized [142]. cessfully to treat using external bleaching applied in the
Removal of tetracycline medicaments from the root office setting non-vital teeth with stains from endodontic
canal does not prevent later discoloration. In fact, stud- treatment and teeth with tetracycline staining [149].
ies have shown that current irrigation methods using We undertook a clinical study of photodynamic
plain needles, open-ended notched irrigation needles, or bleaching for treating confirmed cases of tetracycline
side-vented needles do not completely remove all traces discoloration as a single-appointment procedure used
of such medicaments [143]. Laser-activated irrigation is the KTP (frequency-doubled Nd:YAG) laser (wave-
however significantly more effective for removing end- length 532 nm) combined with a rhodamine-B photo-
odontic medicaments than any protocols based on nee- sensitizer gel (Smartbleach) applied to the teeth and
dle irrigation [144]. activated for 30 s. Each tooth underwent four cycles of
Tetracyclines bind readily to tooth structure and 30 s of laser exposure. Digital image analysis was under-
then form a red-purple degradation tetracycline taken in a blinded manner, and this showed a significant
product (4 alpha, 12 alpha-anhydro-4-oxo-4-
lightening effect was achieved in 78% of the teeth
dedimethylaminotetracycline, known as AODTC) when treated. An in-office KTP laser photodynamic bleaching
moisture is present. AODTC is resistant to oxidation treatment provides a useful option for improving tooth
but can undergo photolysis when exposed to visible shade in teeth with tetracycline discoloration [150].
green light (530–535 nm), opening possibilities for laser In later work, we showed that KTP laser photody-
therapy using a KTP laser (. Fig. 9.6) [145–147]. namic bleaching for tetracycline staining was more
There are numerous ways that lasers can be used to effective than using arrays of LEDs in the visible green
enhance bleaching. These include photothermal effects range (535 nm) with the same photosensitizer or photo-
(warming the gel to make hydrogen peroxide more active Fenton bleaching using LED arrays in the visible blue
chemically), photochemical actions (such as the Fenton (460 nm) [151, 152].
a b c
.. Fig. 9.6 KTP laser photodynamic bleaching of a discolored non- photosensitizer in repeated cycles to treat all the anterior teeth. c Post-
vital maxillary central incisor tooth (#11) from an external approach. operative view at the end of the same appointment. There has been a
a Preoperative view of the discolored tooth. All the teeth have tetracy- useful improvement in the shade of the root filled #11 tooth as well as
cline staining of developmental origin. Tooth #11 has undergone end- the adjacent teeth from the laser treatment. A tooth-colored restora-
odontic treatment. b Application of KTP laser onto a rhodamine tion was subsequently placed 2 weeks later to restore the #11 tooth
306 R. George and L. J. Walsh
a b
.. Fig. 9.7 Vital pulp capping. a Bleeding pulp at the base of the radiation to seal the area and control bleeding. The cavity was then
cavity preparation following an iatrogenic exposure of vital pulp tis- lined with glass ionomer cement and the tooth restored with amal-
sue. b Immediately after firing several pulses of carbon dioxide laser gam. There was no loss of vitality over time
308 R. George and L. J. Walsh
a b
c d
.. Fig. 9.8 Laser treatment of invasive cervical resorption. Tooth the granulation tissue filling the resorption defects on the root sur-
#21 (left maxillary central incisor) distal developed invasive resorp- face can be seen. c Pulses from a carbon dioxide laser were used to
tion after internal “walking” bleaching with hydrogen peroxide. The ablate the resorbing granulation tissue. After this, the root surface
bleaching occurred prior to PFM crowns being placed on both max- was conditioned and a glass ionomer cement restoration placed. d
illary central incisor teeth. a Preoperative view. b With a flap raised, 12-month follow-up showing a stable situation
Laser-Assisted Endodontics
309 9
water mist spray. Appropriate flow of water spray pre- appropriately disinfected. Disposable tips have become
vents desiccation of the bone, ensures cooling of the site available for some laser systems; however, many fiber-
to maintain bone viability, and irrigates the site to optic systems are used where the fibers are cleaved after
remove debris. These middle-infrared lasers give deep each use [195]. Appropriate disinfection and steriliza-
cuts with sharp edges which are free of charring. Similar tion must be carried out for laser accessories and com-
benefits are found when these lasers are used for root ponents that come into direct contact with oral soft and
resection procedures [190, 191]. hard tissues. Other relevant recommendations include
Lasers have been used successfully for root end resec- the following:
tion and root end cavity preparation during apical sur- 1. Fluid fed through a sleeve around the laser to cool it
gery [192]. The use of an Er:YAG or Er,Cr:YSGG laser during surgery must be sterile.
with an operating microscope for periapical surgery has 2. Deposits of carbonized tissue residue can reduce the
been shown to give significantly better results in terms quantity and quality of the light emission. Therefore,
of postoperative healing, in comparison with using con- it is necessary to wipe the tip after use. It may be nec-
ventional surgical approaches for apicoectomy. Such essary to calibrate the tip during the procedure.
lasers can be used safely for root resections provided 3. Sapphire tips that come into contact with sterile tis-
short-pulse duration is used and the water spray flow sue must be sterile and need to be cleaned and then
rate is sufficient [193, 194]. sterilized after each use.
with the Er:YAG laser, a temperature reduction occurs body, which is uniformly in all directions. However,
after a few seconds from 37 to 25 °C, because of the canals that are irrigated with fluids will benefit from
cooling effect of the air/water spray. transfer of heat into that fluid.
a d
b e
c f
.. Fig. 9.9 An overview of the published literature on lasers in end- been consistent across from 2000 to 2023. Panel c (left bottom): this
odontics. Panel a (left top): this pie diagram shows the distribution bar graph shows the total number of publications identified in a
of research topics on lasers in endodontics for the period from 2000 PubMed search for English language journals from 1965 to late Jan-
to 2023, based on search results from PUBMED for English lan- uary 2023, for topics within the three major themes of lasers in end-
guage journals. The topics are arranged in descending order clock- odontics—diagnosis, canal preparation, and pulp therapy. Panels d–f
wise, for the nine top topics within lasers in endodontics. Panel b (left show the cumulative number of publications growing over time for
middle): this diagram shows that the relative distribution of publica- key topics within the three broad areas of diagnosis, root canal prep-
tions on lasers in endodontics across the 12 most common topics has aration, and vital pulp therapy and other treatments
312 R. George and L. J. Walsh
relating to using laser technologies both to detect bacte- An area which is still at a relatively early stage is the
ria and other pathogens and also to assist in determin- use of lasers for analgesia, including the reduction of
ing the vitality of the dental pulp. This indicates there is discomfort following traditional endodontic treatment
a strong ongoing interest in being able to use these vari- visits, as well as reducing the pain of dental injections.
ous laser technologies to augment existing clinical diag- Treating painful conditions using photobiomodulation
nostic tools, to help in forming a diagnosis, and to assess is a well-established clinical approach in many areas of
the progress of treatment. Over time, it is likely that medicine and allied health, and it is likely that over the
progress in the area of pathogen detection may lead to coming decade, much greater interest will be placed on
devices that can be employed widely both in general using lasers to improve the patient experience during
dental practice and in specialist endodontic practice for endodontics and restorative dentistry.
real-time assessment of the load of pathogens in the
root canal system. If and when this occurs, it will be
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Contents
References – 335
ment. However, there are additional biologic benefits surgical sites or on the surface of implants [14, 15]. It is
that accrue to the use of soft tissue lasers: essential that the correct power densities be utilized, or
1. The Hematologic Response: selective photothermol- the surface of the implant can be damaged or melted at
ysis, in the context of blood vessel coagulation, sug- power densities as low as 50 mJ/pulse at 20 Hz [16]. There
gests that pulses of light with a wavelength targeted can be deleterious effects on the soft tissue with burning,
for absorption by hemoglobin with appropriate pulse charring, or denaturation of the soft tissue complex,
duration and fluence can heat blood vessels to leading to tissue necrosis or a tissue dehiscence around
achieve coagulation and hemostasis without causing the neck of the implant.
nonspecific damage to surrounding tissues [8].
2. The Neurogenic Response: C-fibers are small- The 10,600 nm Carbon Dioxide (CO2) Laser
diameter fibers acting as nociceptors from the periph- The 10,600 nm Carbon Dioxide (CO2) laser can also be
ery to the central nervous system. The diameter of used for decontamination of soft tissue tags and granu-
these axons ranges from 0.2 to 1.2 μm and can reach lation tissue as well as hard tissue surgery. Studies using
up to 3 μm in some cases. The thermal effect of lasers the carbon dioxide laser report a very high reduction of
will block depolarization of these afferent C-fibers, S. sanguinis and P. gingivalis bacteria using that wave-
particularly in low velocity neural pathways such as length [17, 18].
non-myelinated afferent axons from nociceptors, pre-
venting pain impulses from being transmitted [9].
3. The Lymphatic Response: lymphedema refers to tis- 10.2.2 All Tissue Lasers
sue swelling caused by an accumulation of protein-
rich fluid that is drained through the body’s lymphatic All tissue lasers are used to cut and shape hydroxyapa-
system, most often caused by bacterial infection or tite (HA) containing tissues, including tooth structure
10 tissue trauma. Laser decontamination, as well as and bone. They are optimized for absorption in water
thermolysis, can prevent lymphatic fluid buildup containing tissue and HA, resulting in precise cutting
with concomitant soft tissue edema [10]. trajectories within a short period of time. However, they
may also be employed to cut soft tissue with a much
Diode lasers should be used with caution near osseous lower thermal coefficient. This combination effect makes
tissue since the photonic energy can scatter in soft tissue. all tissue lasers an excellent choice for dental implant
However, when used judiciously with lower average procedures. These types of procedures can be catego-
power (approximately 1 W), they can aid in disinfecting rized into two groups:
the soft tissue site prior to grafting or implant placement. 1. Ablation: considered to be refined removal of layers
The reduction of bacterial pathogens in periodontal of tissue; it can be described as including gingivo-
pockets after irradiation with a diode laser has been plasty or osteoplasty.
studied. A comparison between the initial and the final 2. Resection: considered to be removal of large seg-
bacterial counts reveals that irradiation with the diode ments of tissue en masse; it can be described as
laser facilitates considerable bacterial reduction, espe- including gingivectomy or ostectomy.
cially of Actinobacillus actinomycetemcomitans, from
periodontal pockets [11]. It follows that diode lasers can
be used with the same result on soft tissue flaps around rbium-Based Lasers: Er,Cr:YSGG, 2780 nm;
E
dental implants prior to implant placement. and Er:YAG, 2940 nm
A low average power output must be used for sec- The Erbium-based lasers are useful for implant proce-
ondary implant recovery. If not, the cover screw could dures because they have the lowest thermal coefficient.
potentially become fused to the implant body, making it This is particularly important in preventing overheating
impossible to remove. of bone where implants are to be placed, whether in
shaping of the osteotomy, debridement, or decontami-
The Nd:YAG Laser nation of the extraction site.
The Nd:YAG laser at 1064 nm is commonly used in peri- Erbium lasers are antibacterial and can be used to
odontal therapy to incise and excise soft tissues as well as remove both calculus and biofilm around tooth struc-
for curettage and disinfection of periodontal pockets ture and implant surfaces [19, 20]. Er:YAG lasers pos-
[12]. The high peak power produced by a free-running sess suitable characteristics for both oral soft and hard
pulsed mode laser can cause deep tissue penetration. This tissue ablation [21]. Contouring and cutting of bone
possible thermal effect of this laser on tissues lying below can be achieved with minimal damage and faster heal-
the irradiated area is a matter of concern during peri- ing. In addition, irradiation with the Er:YAG laser has
odontal treatment [13]. Hence, caution must be exercised a bactericidal effect with reduction of lipopolysaccha-
before using the Nd:YAG laser for decontamination of rides [22]. This is a major component of the outer
Lasers in Oral Implantology
323 10
membrane of Gram-negative bacteria and plays an tion down to periosteum with ideal hemostasis and no
active role in the pathogenesis of periodontal and peri- visible change in color of the soft or hard tissue
implant tissue breakdown. The properties of the pho- (. Fig. 10.2). The choice of tip is important when used
tonic energy from the Er,Cr:YSGG laser also verifies its for flap design. A wide diameter end-firing tip will ablate
effectiveness for decontamination of hard and soft tis- a larger margin of tissue with lower accuracy, resulting in
sue. One advantage of the Er,Cr:YSGG laser is the more challenging closure and potential scarring from sec-
deeper penetration of laser energy in water containing ond intention healing. Narrow end-cutting tips at angle to
tissue, making this wavelength more effective for decon- the tissue will be more precise with a more precise depth
tamination and osseous ablation in a shorter period of control.
time. If the patient is on anticoagulant medication or sup-
Clinical studies have concluded that even at low plements that mimic anticoagulants, an Nd:YAG or any
energy densities, the Er:YAG laser has a high bacteri- wavelength diode laser can be employed to create an
cidal potential on implant surfaces. Additionally, no incision with slightly less precise margins and a more
excessive temperature elevations or morphological pronounced thermalized zone. Deeper thermolytic
implant surface alterations were detected [23]. Other zones can be more effective at sealing blood vessels for
authors have found that Er,Cr:YSGG laser irradiation hemostasis in critical cases. Alternatively, a sapphire
can be equally effective at decontaminating the surface laser scalpel tip can be used to mimic the precision of an
of titanium implants [24]. all-tissue laser. In . Figs. 10.3 and 10.4, an InGaAsP
The osteotomy within bony structures can be chal- diode with an emission wavelength of 1064 nm is shown
lenging since thin and fragile bony walls of the maxilla utilizing that tip. An advantage to the sapphire scalpel is
and mandible are prone to fracture from contact pressure that it has an incision width similar to a conventional
and vibration caused by mechanical instruments. A laser
osteotomy offers a viable and non-destructive alternative.
10
.. Fig. 10.7 Removal of the periodontal ligament and apical .. Fig. 10.8 Decortication of the dense lamina dura prior to
pathology with Er,Cr:YSGG laser with 17 mm Z6 tip at 3.5 W, implant and graft placement with Er,Cr:YSGG laser with 17 mm Z6
25 Hz, 30% water, 30% air tip at 3.5 W, 15 Hz, 30% water, 30% air
10.5 Lateral Wall Sinus Lifts appropriate power settings to minimize the potential for
overheating the bone and to prevent perforation of the
Two serious limiting factors in the placement of implants Schneiderian membrane.
in the posterior maxilla are the anatomical shape and
location of the maxillary sinus and quantity of bone. To
ensure successful implant placement in the posterior 10.5.1 Lateral Sinus Graft Procedure
region, a minimum of 8–10 mm of sound bone structure
is necessary. A full-thickness flap must be raised, and the outline of
Additionally, bone density in the posterior maxilla is the bony window must be predetermined. As shown in
often poor, which could lead to complications during . Fig. 10.10, after tracing the outline of the corticot-
implant placement such as lack of initial stability. To omy, a bony window is created by placement of the
improve placement outcomes, maxillary sinus lift sur- Er,Cr:YSGG laser’s beam at 30–45° to the cortical sur-
gery was developed as a method to increase the amount face in a non-contact mode (with 1–3 mm distance from
of bone available for the implant initial stability. This the target tissue). Lasing should be performed with slow
has now become a routine procedure to address deficient movements until the darkness of the underlying
maxillary posterior bone. Schneiderian sinus cavity is visualized. Ablation should
The lateral window sinus lift is a direct sinus lift pro- be stopped after completing the predetermined window
cedure which allows for visualization of the sinus space border decortication and the window can be rotated
and to facilitate graft placement. Also, tearing of the superiorly or removed. The remaining part of the surgi-
membrane can be more easily treated, minimizing con- cal procedure is completed using conventional surgical
tamination or extravasation of the graft during healing. instruments.
The lateral approach involves a modified Caldwell- The Schneiderian membrane must be kept intact so
10 Luc operation to gain access to the sinus cavity. A bony it can help to contain the graft material as well as to
window is created in the lateral maxillary wall, the prevent migration of the graft particles in the sinus cav-
Schneiderian membrane is elevated, and bone grafting ity. If the membrane is perforated or torn, the graft
material which may consist of autogenous bone, material may become infected leading to a failed sinus
allograft, alloplast, or xenograft is placed between the graft procedure. . Figure 10.11 shows the completed
membrane and sinus cavity. A resorbable collagen membrane reflection and the graft material placed. The
membrane may be placed between the bony window radiographic information in . Fig. 10.12 confirms the
and flap to prevent graft migration or soft tissue invag- completed graft filling in that part of the sinus.
ination.
The surgical instruments traditionally used to per-
form sinus grafting are rotary handpieces with carbide
round burs or diamonds [30]. More recently, piezoelec-
tric ultrasonic devices have replaced rotary instruments
because of the reduced risk of membrane perforation
[31, 32].
The development of hard tissue wavelengths has
enabled bone ablation to be carried out with minimal
adjacent damage. The use of Erbium-based lasers in
dentoalveolar surgery represents a less traumatic experi-
ence for the patient when compared to the intense vibra-
tion of the slow-speed surgical bur. However, to prevent
overheating of the bone, it is important to maintain a
sufficient coaxial water spray. The water spray will con-
tribute to lifting of the Schneiderian membrane off of
the inner wall of the sinus cavity, thereby reducing the
potential for membrane perforation.
In the maxilla, the speed of the laser ablation is com- .. Fig. 10.10 Preparation of lateral wall window with an
parable with that of the bur due to the cancellous struc- Er,Cr:YSGG laser without damage to Schneiderian membrane.
ture of the osseous tissue. However, it is important to set Laser settings are 6 mm Z6 tip, 3.5 W, 20 Hz, 30% water, 30% air
Lasers in Oral Implantology
327 10
10
.. Fig. 10.14 A photomicrograph of a minor thermalized zone of 8–15 μm adjacent to an erbium-based laser osseous incision, depicted
approximately between the two blue arrows, above. (Courtesy Dr. Harold Passow)
.. Fig. 10.17 Locating the center of the implant cover screw and
implant recovery is initiated. A 14–17 mm Z6 zirconia tip of the .. Fig. 10.20 Placement of a flared healing about to create the
Er,Cr:YSGG laser is used at 2.5 W, 25 Hz, 30% water, 30% air emergence profile
330 R. J. Miller
a b
c d
.. Fig. 10.22 The upper right central and lateral incisors are 100 Hz, H mode, air 10%, and water 10%, delivered with an MZ5 tip
extracted and replaced with immediately loaded implants and final to trough the gingiva around the abutment and the prepared teeth. d,
abutments. a Is the pre-operative view of the healed, bulky tissue. b, e Depict the immediate post-operative view with excellent tissue con-
c Show an Er,Cr:YSGG laser, used at an average power of 2 W, tours, which are ready for final impressions or digital scan
a b
.. Fig. 10.25 Comparison of citric acid a and Erbium laser ablation b of hydroxyapatite on an implant surface [52]
334 R. J. Miller
10.10.4 Laser-Assisted Surgical Treatment Once the implant body has been debrided circumfer-
of Peri-implantitis entially to the bone level, a graft is replaced to the con-
tours of the original bone volume (. Fig. 10.28). The
The treatment protocol for peri-implantitis involves sur- choice of graft material should be designed to regener-
gery to ensure proper visualization and access. ate host bone and not become fibrous encapsulated.
. Figure 10.26 depicts a full-thickness flap being raised . Figure 10.29 shows a failure of peri-implantitis
to expose diseased tissue and the implant defect. The treatment, with remnants of a non-resorbable graft
complete defect must be exposed to the margins of extravasating from the bone defect. A full-thickness flap
healthy bone. This will allow visualization of the extent was raised, and the Er,Cr:YSGG laser, with the param-
of the defect and allow access for complete debridement eters employed in . Fig. 10.27, removed all granulation
of all pathology. Curettes are then employed to remove tissue and bone graft remnants. A new resorbable graft
the gross volume of tissue followed by the Er,Cr:YSGG was placed, primary closure around the transmucosal
laser’s ablation of remaining pathologic tissue as shown abutment was achieved and a post-op radiograph was
in . Fig. 10.27. taken. The graft material appears as red on a colorized
digital radiograph (. Fig. 10.30). The 6-month post-
operative colored radiograph of . Fig. 10.31 shows
autogenous bone fill in the previous defect with stable
periodontium.
10
12. Romanos GE. Clinical applications of the Nd:YAG laser in 31. Delilbasi C, Gurler G. Comparison of piezosurgery and con-
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laser for intraoral soft tissue surgery. Lasers Surg Med. foration rate in lateral maxillary sinus floor augmentation using
1991;11(5):455–361. conventional rotating instruments and piezoelectric device-a
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339 11
Laser-Assisted Pediatric
Dentistry
Konstantinos Arapostathis, Dimitrios Velonis, and Marianna Chala
Contents
References – 374
a b
c d e
.. Fig. 11.1 Resin-modified glass ionomer (RMGI) restorations on and cavity preparation (see . Table 11.2 for energy parameters) by
the primary second molars, without the use of local anesthesia, of a Er,Cr:YSGG (2780-nm gold handpiece, 0.6-mm MZ tip, H tissue
3-year-old uncooperative girl with primary molar hypomineraliza- mode). c After laser preparation. The cavity was well extended into
tion (PMH). a Preoperative intraoral view. According to the transi- dentin. The child revealed no pain and no complain and cooperation
tional treatment recommendations, stainless steel crowns (SSC) was relatively good. d Final RMGI restoration. e Intraoral view
should be placed on teeth #75 and #85 under local anesthesia. b 24 months after treatment. Restorations are still in place and there
Laser analgesia (starting with 50 mJ, 10 Hz, 82% water (16 mL/min), are no caries lesions. The patient is now 5 years old and cooperative,
70% air, distance 6–10 mm from the tooth, for 40–60 s and continu- and it is the practitioner’s decision if and when will provide a more
ing with 80–100 mJ for 60 more seconds before tooth preparation) permanent rehabilitation
trust of the child, and perform needle-free and also no metal music,” etc. The special glasses are going to make
painful procedures. Through this, oral laser applications you look like “a ninja,” “a princess,” etc. In conjunction
may also offer an alternative strategy in behavior man- with the technique “tell, show, do,” positive reinforce-
agement. A positive experience during dental treatment ment (e.g., use of phrases like “great job” or a reward at
is of paramount significance for a lifelong confiding the end of the session) and distraction techniques (e.g.,
relationship between the child and the dentist, which television, movies, music) should be adopted. Children
may also lead to better oral health in the adulthood. who do not cooperate or the mental status does not
Either way, for its successfulness and the child’s allow them to comply cannot be candidates for laser
acceptance, a well-prepared presentation, training, and therapy.
education on that have to be proceeded before use. The
pediatric dentist may use some of the basic behavior
techniques to introduce laser to the child. One of the 11.3 ocal Anesthesia and Laser
L
most powerful techniques is “tell, show, do” in which the Application
practitioner explains verbally the consecutive stages of
the dental treatment (tell), demonstrates the equipment Local anesthesia is the basis in controlling pain during
and shows the different tools/instruments on the hand/ dental treatment but, at the same time, one of the most
finger (show), and executes the procedure (do) [3]. Laser common and major fears for the patient. Traditionally,
technology can be presented using friendly, familiar, most of the dental treatment procedures need to be per-
easy-for-the-child-to-understand words like “special formed under local anesthesia. Laser analgesia provides
flashlight,” “magic light,” “colored light,” etc. The sound an extra tool for the dentist to avoid or reduce the use of
of the laser could be like “making popcorn,” “playing local anesthesia in some cases. It should be stated that
342 K. Arapostathis et al.
analgesia is not really anesthesia but a way to reduce distance 6–10 mm from the tooth for 40–60 s and con-
sensitivity, needing a more intensive stimulus for the tinuing with 80–100 mJ for 60 more seconds before
patient to feel pain. Studies using infrared wavelengths tooth preparation (gold handpiece, 0.6-mm MZ tip, H
(diode, Nd:YAG) conclude that low-level laser therapy tissue mode) (. Figs. 11.1a–e, 11.2a–g, and 11.3a–d).
(LLLT) can suppress the excitation of unmediated There are no studies reporting any analgesic effect of
C-fiber afferents of the pulp. Also, there are studies CO2 wavelength. Theoretically, the ideal laser wave-
regarding the potential analgesic effect of erbium family length choice would be the one that has an analgesic
laser irradiation and the mechanism resulting in this effect and that can be used in all of those treatment pro-
effect. Many clinicians report that they have been suc- cedures at the same time.
cessful in performing a variety of dental procedures, in The performance of laser analgesia using erbium
pediatric dentistry too [4, 5]. family lasers could be a useful tool to overcome behav-
In all clinical cases presented in this section, laser ioral problems, especially for needle-phobic children
analgesia was applied using the Er,Cr:YSGG (2780 nm) seeking dental treatment (. Fig. 11.2a–g). Also, only
laser with the following parameters: starting with 50 mJ, the application of topical anesthetic gel on dry gingi-
10 Hz, (0.5 W), 82% water (16 mL/min), 70% air, and val or mucosa for 3–5 min (e.g., EMLA cream (lido-
11 a b
c d
.. Fig. 11.2 Behavior shaping using laser for the completion of No local anesthesia but laser analgesia (see text and . Fig. 11.1b for
dental treatment of a referred 7.5-year-old needle-phobic girl with laser parameters) and preparation by Er,Cr:YSGG (2780 nm, gold
low cooperation at the dental office. Laser treatment used to intro- handpiece, 0.6-mm MZ tip, H tissue mode). d After laser preparation
duce dentistry, gain the trust of the child, perform needle-free and of #65. The child revealed no pain and no complaint and coopera-
also no painful procedures, and “desensitize” the patient through tion was good. e After RMGI placement on #65. f Intraoral view of
gradual exposure to dental treatment: perform first sealants, needle- the upper arch after 2 months. The patient presented for extraction
free restorations (laser analgesia and preparation), and finally of tooth #64 with the administration of local anesthesia (4% artic-
extraction. a Initial intraoral view of the upper arch. b Left bitewing aine, 1:200,000 epinephrine). Cooperation was excellent. g After
radiograph. Tooth #64 had to be extracted due to abscess and root 20 months. The permanent successor is erupting and space mainte-
resorption. Note that caries was well extended into dentin on #65. c nance has to be removed. Restoration on #65 remains intact
Cavity preparation on #65 (see . Table 11.2 for energy parameters).
Laser-Assisted Pediatric Dentistry
343 11
e f
caine 2.5% and prilocaine 2.5%); each gram of EMLA to remain cooperative, but children are frightened, lose
cream contains 25-mg lidocaine and 25-mg prilocaine), trust to the dentist when their teeth ache, and then do not
without the administration of injected local anesthe- cooperate. It is the dentist’s responsibility, after evaluat-
sia, is efficient in performing minimal gingival inter- ing the child’s maturity and providing adequate psycho-
ventions in several clinical cases by erbium family logical preparation to reach a high degree of cooperation,
lasers (. Figs. 11.3a–d and 11.4a–f). to decide if local anesthesia should be administered
It should be noticed that a prerequisite for achieving before laser-assisted dental treatment. In general, if there
cooperation with the child and complete dental treat- is a possibility of pain, it is preferable to deliver local
ment is the minimization of disturbance and the absence anesthesia before the start rather than during the dental
of pain. Completion of dental treatment with children is treatment in children with low cooperation. Examples of
directly related to the absence of pain. There is always a such cases are shown at . Figs. 11.5a–e and 11.7a–g.
possibility of pain during dental treatment after laser These patients were not cooperative (one had extremely
analgesia, and in this case, laser energy parameters high gagging reflex which is very often associated with
should be altered, or local anesthesia should be deliv- “hidden” dental anxiety) [6, 7]. Laser analgesia could be
ered. Adult patients can communicate their feelings with used, but it was decided that block anesthesia was more
the dentist and may tolerate the pain to some extent and appropriate for these patients.
344 K. Arapostathis et al.
.. Fig. 11.3 Minimal gingivoplasty and subgingival composite min), 70% air, tip distance 1 mm (close contact), tip parallel to the
resin restoration, in a single visit and without administration of local long axis of the tooth (gold handpiece, 0.6-mm MZ tip, H tissue
anesthesia, on tooth #83 of a 7-year-old boy. a Initial clinical view. mode). c After gingivoplasty and cavity preparation by Er,Cr:YSGG
Placement for 3 min only EMLA cream (lidocaine 2.5% and prilo- (2780 nm) (see . Table 11.2 for energy parameters). d Final compos-
11 caine 2.5%) on dry gingiva. b Minimal gingivoplasty using
Er,Cr:YSGG (2780 nm) at 50 mJ, 20 Hz, (1.0 W), 30% water (6 mL/
ite resin restoration
c
b
.. Fig. 11.4 Minimal gingivoplasty using Er,Cr:YSGG and reat- (2780 nm) (see laser energy parameters on . Fig. 11.3b). b Initial
tachment of tooth fragment, in a single visit and without local anes- radiographic image (no complete root formation). c After minimal
thesia, following enamel-dentine subgingival (no pulp involvement) gingivoplasty and before tooth fragment reattachment using com-
crown fracture on a permanent incisor of a 7.5-year-old boy. a Rub- posite resin. There is no gingival bleeding and tooth structures have
ber dam placement, EMLA cream (lidocaine 2.5% and prilocaine been exposed. d Final restoration. e, f Clinical and radiographic
2.5%) for 3 min. Minimal gingivoplasty using Er,Cr:YSGG views 30 months after treatment showing root formation
Laser-Assisted Pediatric Dentistry
345 11
d e
a
b
c d
.. Fig. 11.5 Minimal gingivoplasty and treatment of subgingival restoration and sealant) and (2) minimal gingivoplasty on teeth #83,
caries, in a single visit, on teeth #83, #84, and #85 after preparation #84, and #85 (see laser energy parameters on . Fig. 11.3b). c Caries
by Er,Cr:YSGG (2780 nm) of a 7.5-year-old girl. Also treatment of removal from teeth #83, #84, and #85 (see . Table 11.2 for energy
occlusal caries on #46. a Intraoral initial clinical view. b Block anes- parameters for primary teeth). d Clinical view after 26 months. The
thesia (4% articaine, 1:200,000 epinephrine) and placement of rub- girl is almost 10 years old, #83 is movable, and #84 has been nor-
ber dam. Using Er,Cr:YSGG (2780 nm): (1) remove caries from #46 mally exfoliated. Restoration on #83 is intact. e Placement of SSC
(enamel: 4 W, 20 Hz, 200 mJ, 82% (16 mL/min) H2O, 70% air), (RC on #84 and #85 and buccal RMGI restoration on #83
346 K. Arapostathis et al.
11
a b
c d
.. Fig. 11.6 Mimi, 12-year-old girl, clear medical history, caries on Intraoral initial clinical view. b After gingivectomy 1 W, continuous
#37, under eruption, composite restoration, block anesthesia, gingi- mode, 300-μm initiated fiber. c After cavity preparation. d Final
vectomy with diode laser, Biolase, Epic X, 940-nm wavelength. a intraoral view
Laser-Assisted Pediatric Dentistry
347 11
a b
c d
e f
.. Fig. 11.7 Konstantinos, 11-year-old male, clear medical history, with diode laser, Biolase, Epic X, 940-nm wavelength 1 W, continu-
under orthodontic treatment, delay eruption of canines (#43, 33). a, ous mode, 300-μm initiated fiber (tooth #43). g Postoperative intra-
b Intraoral initial clinical view and X-ray. c, d Crown exposure with oral view. Hemostasis was better and easier with diode laser
Er,Cr:YSGG, 2.780-nm, Biolase (tooth #33). e, f Crown exposure
348 K. Arapostathis et al.
wavelength and high absorption in water, is the less pen- the surgical procedures by minimizing the use of flaps,
etrative of all) [8, 9]. Regarding caries prevention CO2, provide excellent bleeding control without suturing,
erbium family lasers and Nd:YAG (due to their high and result in a fast and less eventful healing
power values emitted and ability to photo-thermally (. Fig. 11.9a–e)
melt enamel) have been tested alone or in combination Apart from tooth decay, tooth injuries represent the
with fluoride, especially through in vitro studies. Infrared most frequent pathology encountered in pediatric den-
irradiation (diode lasers), due to its high penetration tistry. Around 20% of children suffer a traumatic injury
(and low absorption on hard tissue), is used widely in to their primary teeth and over 15% to their permanent
detecting caries. teeth [10]. Dental trauma is a stressful and challenging
Periodontal diseases in children usually include min- emergency situation for the child, the parents, and the
imal severity gingivitis infections, usually due to poor dentist. Accurate diagnosis in combination with imme-
everyday oral hygiene and hyperplastic gingivitis with diate intervention is required, so that any risk of sequel
the formation of pseudo-pockets (not completely problems or healing complications is minimized. Mid-
erupted teeth). In addition, gingival and periodontal infrared wavelength lasers could be used to reduce acute
changes may be seen during or following orthodontic pain, to improve and speed up tissue healing (photobio-
treatment, due to difficulties in maintaining good oral stimulation effect), to provide decontamination and
hygiene and/or the periodontal tissues following the inflammation control, and to help control bleeding.
teeth movement during the orthodontic treatment Among other advantages, the use of lasers can often
(. Fig. 11.8a–h). All laser wavelengths can be used in make it easier for the dentist to perform several proce-
these instances for laser decontamination and if needed dures in the same appointment (. Figs. 11.3a–d, 11.4a–
removal of hyperplastic gingival tissue. They simplify f, and 11.5a–e).
11 b
d
c
.. Fig. 11.8 Gingivectomy due to hyperplastic gingiva after orth- guide the soft tissue removal. e Measuring and comparing the size
odontic treatment and aesthetic reasons [canines replacing the miss- between the same teeth of the opposite sides, using a 1064-nm diode
ing second incisors] of a 16-year-old girl. a Initial situation, b–d laser [1 W, continuous mode, 300-μm initiated fiber speed of move-
measuring and comparing the size between the same teeth of the ment 1 mm/s] to create dots and guide the soft tissue removal. f
opposite sides, using a 1064-nm diode laser [1 W, continuous mode, Immediate postoperative, g–h healing at 1 and 3 months postopera-
300-μm initiated fiber speed of movement 1 mm/s] to create dots and tive
Laser-Assisted Pediatric Dentistry
349 11
e f
g h
a b
c d
.. Fig. 11.9 Bracket recovery and re-bonding, 12-year-old boy. a Ini- extended thermal trauma [water cooling every 10 s, for 10 s] since the
tial situation: the bracket is located under the alveolar mucosa and is no tissue is very thin and the metallic surface of the bracket accumulates
longer bonded on the canine. b Surgical procedure and bracket recov- heat rapidly. c, d Excellent hemostasis and bracket bonding. e Intraoral
ery using a 1064-nm diode [0.8 W, continuous mode, 300-μm initiated view after the end of the orthodontic treatment
fiber, speed of movement 2 mm/s]. Extra caution and care to avoid
350 K. Arapostathis et al.
a b
c d
11
e f
g h
.. Fig. 11.10 Nine-year-and-5-month-old female (dental age ~ 11) direction of the fiber parallel to the roots to minimize absorption of
with a short labial frenum and midline diastema prior to orthodontic energy in the dental pulp and bone. d Step 3. e Final postop result. f
treatment. Frenectomy performed under local anesthesia. Laser One week F/U. g One month F/U. h Nine months F/U. Note no
parameters: pulsed Nd:YAG initiated fiber 320 um, average power excellent coagulation, no carbonization, and no need for suturing.
3.2 W, pulse 40 mJ, repetition rate 80 Hz, pulse duration 100 μs. Instructions include rinsing with mild antiseptic solution during the
Treatment duration: total < 20 min, 30 s ON/30 s OFF. Mode: con- first week of healing with chamomile or active oxygen solutions or
tact, parallel to teeth, stretched fibers, by manually pulling the upper drops (Unisept). Also, note excellent healing without scarring
lip. Progressive steps are shown. a Preop. b Step 1. c Step 2. Note the
Laser-Assisted Pediatric Dentistry
353 11
a b c
d e
.. Fig. 11.11 Nd:YAG spontaneous diastema closing after laser 3.2 W, pulse 40 mJ, repetition rate 80 Hz, pulse duration 100 μs. Peak
frenectomy performed at the stage of upper lateral incisors’ eruption power 400 W, fiber diameter. Treatment duration: total < 20 min,
in the mid-mixed dentition. No orthodontic movements were made. 30 s ON/30 s OFF. Mode: contact, parallel to teeth, stretched fibers,
a Six months preop, b 2 weeks preop, c immediate postop, d 1-year by manually pulling the upper lip
F/U, e 3-year F/U. Laser parameters: pulsed Nd:YAG, average power
a b c
d e f
.. Fig. 11.12 Nd:YAG extreme case of upper labial frenum. Nine- best prevented at the time of the frenectomy by smoothening the end
year-old male with excessively thick and short frenum, combined of the attachment of the frenum in the lip mucosa with the laser.
with partial orthodontic treatment. a Ten months prior to laser fre- Laser parameters for frenectomy: pulsed Nd:Yag, average power
nectomy. b, c Preop. d Immediate postop. e One week F/U. f Four 4.0 W, pulse 40 mJ, repetition rate 100 Hz, pulse duration 100 μs.
months F/U diastema closing spontaneously. g Sixteen months with Fiber diameter 320 um. Treatment duration: total < 20 min, 30 s
partial orthodontic treatment of the lower anteriors and tongue ON/30 s OFF. Mode: contact, parallel to teeth, stretched fibers, by
thrust. h 22 months F/U with orthodontic treatment. i Four years manually pulling the upper lip. Laser parameters for the residual
F/U. Note good healing despite extensive modification. j Residual mucosal tag: repetition rate reduced to 80 Hz
mucosal tag. k Laser aesthetic removal of the mucosal tag. This is
354 K. Arapostathis et al.
g h
i j k
11
a b
c d e
.. Fig. 11.13 Panagiotis, 12 years old, clear medical history, does rine). c Er,Cr:YSGG (2780 nm) was applied at 1.00–1.50 W, 20 Hz,
not like bleeding (taste) and sutures. Er,Cr:YSGG (2780 nm), gold 30% H2O, 70% air, 6 mL/min H2O. d Complete coagulation after
handpiece, 0.6-mm MZ tip. Distance: 1 mm, close contact, hard tis- laser application. e After 3 days
sue mode. a, b Local anesthesia (4% articaine, 1:200,000 epineph-
Laser-Assisted Pediatric Dentistry
355 11
a b
c d
f
e
.. Fig. 11.14 Aggelos, 7.5 years old. a, b Clear medical history, rine). c Er,Cr:YSGG (2780 nm) was applied at 1.00–1.50 W, 20 Hz,
space between #11 and #21 and no space for #22, not cooperative, 30% H2O, 70% air, 6 mL/min H2O. d Complete coagulation after
does not like bleeding and sutures Er,Cr:YSGG (2780 nm), gold laser application. e After 2 days. f After 1 year. Tooth #22 is in place
handpiece, 0.6-mm-MZ tip. Distance: 1 mm, close contact, hard tis- without any orthodontic treatment
sue mode. a, b Local anesthesia (4% articaine, 1:200,000 epineph-
356 K. Arapostathis et al.
a b
c d
.. Fig. 11.15 Frenectomy and pseudo-pocket removal, 12-year-old ous mode, 300-μm initiated fiber, speed of movement 1-mm/s water
11 girl. a Initial intraoral view. Hyperplastic tissue entirely covering the cooling every 10 s for 5 s for thermal relaxation] for both surgical
interdental spaces and in contact with the brackets and the orth- procedures. c Immediately postop. No carbonization can be
odontic wire, compromising dental hygiene. Frenum attached too observed. d Follow-up after 6 months. The distance between the fre-
close to the attached gingiva [less than 2 mm], buccal position of the num and the attached gingiva in more than 3 mm, stable result, no
incisor roots and thin biotype, indicating frenectomy to prevent scar formation
future gingival recession. b Using a 1064-nm diode [0.8 W, continu-
a b
.. Fig. 11.16 Frenectomy and laser decontamination for gingivitis, thermal relaxation] for decontamination and a CO2 laser [2 W, con-
12-year-old girl. a Initial intraoral view: gingivitis due to pure tinuous mode, 200-μm spot area at focus, cooling with water every
hygiene and frenum attached too close to the attached gingiva [less 5 s for 2 s and charring removal with gauze] for the frenectomy. No
than 2 mm], buccal position of the incisor roots, and thin biotype, carbonization and no bleeding can be observed. d Follow-up after
indicating frenectomy to prevent future gingival recession. b, c Using 1 year. The distance between the frenum and the attached gingiva is
a 1064-nm diode [0.5 W, continuous mode, 300-μm fiber, no initia- more than 3 mm, stable result, no scar formation
tion, speed of movement 1-mm/s water cooling every 10 s for 5 s for
Laser-Assisted Pediatric Dentistry
357 11
c d
a b c
d e
.. Fig. 11.17 Lingual frenectomy on a 9-year-old male. a Tongue postop. e “Tongue-tie” instrument, or Sklar Director, or Groove
mobility restrained to vermillion border. b Intraoral view of the lin- director 5.5″ probe, to hold and stretch the lingual frenum while pro-
gual frenum. c Immediately postop. No suturing needed, no bleed- tecting adjacent structures. Laser parameters: pulsed Nd:YAG, aver-
ing. Care must be taken to avoid and preserve the sublingual fold and age power 3.2 W, pulse 40 mJ, repetition rate 80 Hz, pulse duration
carunculae. d Increase in outward tongue mobility immediately 100 μs. Peak power 400 W, fiber diameter 300 μm
Lingual Frenectomy (. Fig. 11.17a–e) There is no general consensus both on its diagnostic
Ankyloglossia, or high lingual frenum attachment, or criteria and in the treatment protocols among practitio-
“tongue-tie” is a congenital variation or anomaly in ners of various specialties that examine or treat such
which the tongue has restricted mobility secondary to a patients, including pediatric dentists, oral and maxillofa-
short lingual frenum, and cannot be protruded beyond cial surgeons, ENT specialists, plastic surgeons, pediatric
the lower incisors, or the vermillion border of the lips. surgeons, pediatricians, speech therapists, and so on.
The restricted mobility of the tongue may also lead to The most widely accepted and used clinical assess-
difficulty in swallowing and pronouncing certain conso- ment tools are the Hazelbaker Assessment Tool for
nants that require the tip of the tongue to reach the hard Lingual Frenulum Function (HATLFF) [33] and the
palate [32]. Bristol Tongue Assessment Tool (BTAT) [34].
358 K. Arapostathis et al.
a b c
11
d e
f g
.. Fig. 11.18 Mesiodens a, b extracted at age 5 years and 10 etition rate (5 Hz), 150 mJ, VLP (1000 μs) pulse de-focussed
months, causing delayed eruption of UL1, which has not erupted non-contact, spot size 600 um diameter d. A linear opening at the
1.5 years after extraction of the mesiodens c. The exposure was per- incisal ridge of the crown is sufficient e. One week f and 1 month F/U
formed under no local anesthesia with an Er:YAG laser, at low rep- g
Laser-Assisted Pediatric Dentistry
359 11
a b c
.. Fig. 11.19 Er:YAG exposure of upper lateral permanent incisors very long pulse de-focussed non-contact, spot size 600 um diameter.
was requested by the orthodontist to accelerate orthodontic treat- Following a minimal incision that runs the length of the incisal edge
ment a. With minimal amount of local anesthesia which can be of the crown b, within 3 weeks, the orthodontist was able to bond
applied either at the mucobuccal fold or only around the incision orthodontic brackets c
site, a higher repetition rate can be used, such as 20 Ηz, 150 mJ, and
a b
c d e
g
f
.. Fig. 11.20 Initial OPG before extraction of the upper right pri- the minimally invasive surgical access and the dry field with good
mary canine a. One year later, the upper right permanent canine is coagulation c. A bracket was bonded to the distal aspect of the
still impacted b. Using a simple SLOB (same lingual opposite buc- crown with a pre-attached elastic chain d. In minimal access cases
cal) method, it was determined that the distal aspect of the crown without a surgical flap, it is advisable that a chemically cured resin is
lies below the alveolar crest (not shown). All access was performed used, as limited access does not always allow adequate light curing
by an Er:YAG laser. Soft tissues were removed at 150 mJ, 20 Hz, and of the resin material under the orthodontic bracket or button. Note
VLP (1000 μs), with and RO7 handpiece with a sapphire tip, in con- optimal healing in less than 2 weeks e; no analgesics were used. One
tact mode without water irrigation. Bone was removed with the same year later f, the tooth emerges and is re-bracketed and brought to the
handpiece and tip, but at 200 mJ, 20 Hz, and VSP (100 μs) c. Note arch in 1.5 years after the initial surgery g
360 K. Arapostathis et al.
a b
11
c d
.. Fig. 11.21 Pyogenic granuloma—fibroma. Exophytic lesion of ment and bothersome to this 2-year-and-10-month-old boy a, b. Ten
normal mucosal color on the gingivae between lower central and lat- months later, the lesion is causing further displacement of the teeth,
eral. Using a pulsed Nd: YAG laser with a 300-μm fiber at 3.2 W, 80 and parents agreed to have the lesion removed by laser in the dental
Hz, 40 mJ in contact mode. Primary incisors, causing tooth displace- office setting c, d
a b
c d
.. Fig. 11.22 Irritation fibroma removal with Nd:YAG laser in an the lesion by its base with forceps and placing the tip parallel to the
18-year-old male. Lesion a was excised using a pulsed Nd:YAG laser tissue base. b Immediately postop. c Two weeks f/u. d One year f/u.
with a 300-μm fiber at 3.2 W, 80 Hz, 40 mJ in a contact mode holding Note the quality of healing and the absence of scar tissue
Dentin Hypersensitivity Its mode of action has been attributed to the follow-
Dentin hypersensitivity (DHS) is a common condition, ing:
described as pain or unpleasant sensation upon intake 1. Surface modification and sealing of dentinal tubules
of cold food or liquids, even with breathing cold air. It to some extent (5–25%)
occurs as the cervical dentin, and the root may be 2. Blocking Αβ and C nerve fibers
exposed to external stimuli secondary to periodontal
inflammation, gingival recession, iatrogenic (scaling and
root planning) causes, abfraction, aggressive tooth- Note The same protocol may be used for pulpal analgesia
brushing, and/or consumption of soft, erosive drinks. It and for alleviating hypersensitivity in teeth with molar inci-
is a rather uncomfortable or debilitating condition that sor hypomineralization (MIH) both for minimizing discom-
may influence chewing, drinking, and performing oral fort between dental appointments and for making dental
hygiene and may also have emotional consequences. Its work better tolerated by the young patient [39]. Teeth with
management includes the use of desensitizing agents for MIH, owing to their porous structure, have been shown to
office or home use (GLUMA desensitizer, fluoride var- be in a state of continuous mild pulpal inflammation [40].
nish, HA paste, bioglass) and desensitizing toothpastes
(Sensodyne, Emoform KNO3, Colgate Sensitive Pro- An 8-year-old patient with MIH shares his experi-
Relief). ence: “I am Triantafyllos and I am 8 years old. My teeth
The use of Nd:YAG for DHS has more than 20 years hurt. I could not eat anything or drink water; neither
of research. Er:YAG was also studied with some suc- could I wash my teeth. When I drank cold water, it hurts
cess, but Nd:YAG remains the laser of choice for DHS a lot; when I drank hot water, it hurts a little less, and
[36–38]. when I ate food, it hurts even less. When I brushed my
362 K. Arapostathis et al.
11
.. Fig. 11.23 (Published in LAHA (7 www.laserandhealthacademy. with forceps and removed with an Nd:YAG laser (Fotona) at a set-
com) 2017 as is). Oral warts: a 10-year-old girl noticed a “peculiar ting of 4 W, 100 Hz, 40 mJ, VSP (100 μs), and 300-μm fiber from its
growth on her gums” that was growing during the last month and base. Fluence was 56.6 J/cm2; peak power was 400 W. There was no
was not bleeding upon brushing. On intraoral examination, a 1-cm bleeding and no need for suturing, and no antibiotics or analgesics
exophytic band-like lesion following the attached gingiva contour of were prescribed. Healing was excellent without scarring, no pain or
the left upper primary canine. The lesion was of irregular surface, swelling was reported, and no recurrence was noted after 6 months
pedunculated on its base, and differential diagnosis consisted of oral F/U. The biopsy report confirmed the diagnosis of oral papilloma.
papilloma (oral wart) and pyogenic granuloma. The lesion was Figure. Preoperative (Pre-op) and immediately postoperative
removed under local anesthesia with 20-mg lidocaine and 0.11-μg (Post-op) views of the surgical site. Excellent healing at 7 months
epinephrine infiltration at the mucobuccal fold. The lesion was held without scarring or recurrence
teeth though, I was crying because it hurts a lot when was negative on the upper molars but positive on all lower
the toothbrush touched my teeth. incisors. After running the following laser protocol, the
Dr. Dimitris did something to my teeth, and they air test was negative immediately after, and scaling was
immediately stopped hurting, and I am happy.” performed without any significant discomfort. The proto-
It is strongly discouraged to increase the power to col used was with a pulsed Nd:YAG laser, at 100 mJ,
1.5 W or the time of application >1 min as this poses 10 Hz, 1 W, 300-μm fiber, and 100-μs pulse duration, for
significant risk for thermal damage, microcracking, and 1 min in a scanning motion around the cervical area of
carbonization [36]. the tooth, noncontact. It is very important to always move
the fiber tip during laser emission, as there is evidence that
Case A 15-year-and-8-month male complained of sensi- keeping the probe still may result in irreversible damage to
tivity only in the front lower teeth. On clinical examina- the pulp and ultimately necrosis. The sensitivity did not
tion, he showed calculus deposits (grade 1 scale) on upper recur after 5 months follow-up. Because of the nature of
first permanent molars and lower incisors with mild local- such cases, the only evidence that can be provided is the
ized gingival inflammation. Air syringe test for sensitivity patient’s testimony, which is hereafter quoted in exact
Laser-Assisted Pediatric Dentistry
363 11
a b
.. Fig. 11.24 a Seventeen-year-old girl presented with an exophytic the specimen was sent for histopathologic diagnosis, which con-
lesion on the soft palate mucosa. The lesion was pedunculated and firmed the viral origin of the lesion. Postoperative instructions
whitish, and the clinical impression was oral wart. b The lesion was included rinses with mild antiseptic solutions, such as chamomile
removed under local anesthesia and an Nd:YAG laser at 3.5 W, and Unisept (activated oxygen-based solution). c Healing after
100 Hz, 300 μm fiber, and 100 μs pulse duration from its base. No 9 days
minor salivary gland was detected at the vicinity of the lesion, and
.. Fig. 11.25 Traumatic fibroma attached to the left sublingual traumatizing the duct or causing postsurgical edema, which may
duct removal, 11-year-old boy. a Initial intraoral view. b Surgical result in blocking the sublingual duct. No carbonization and no
excision using a CO2 laser [3 W, continuous mode, 200-μm spot area bleeding can be observed. Thus, suturing can be avoided, which is an
at focus, speed of movement 1.5 mm/s, cooling with water every 10 s advantage, since sutures on this area may, too, block the duct. c Fol-
for 5 s, and charring removal with gauze]. Extra caution to avoid low-up after 1 week. Uneventful healing and free sublingual duct
364 K. Arapostathis et al.
a b
11 c
.. Fig. 11.26 Marsupialization of two mucoceles on the mucosa of excessive postsurgical edema [may increase the traumatic effect of
the vestibular region of the left lip, 12-year-old boy. a Initial situa- the brackets and result in relapse]. b Marsupialization of the two
tion. Traumatic injury due to orthodontic brackets resulting in saliva submucosal cysts using the CO2 laser 10,600 nm with minimal
superficial blocking of the salivary glands (normal texture under pal- surgical trauma [2 W, CW, speed of movement 1.5 mm/s, at focus,
pation). Major concerns which exclude surgical excision: (a) the 200 μm, total working time 1 min]. c Follow-up after 1 week.
number of mucoceles [extended surgical area], (b) the use of sutures Uneventful healing and normal function of the small salivary glands
[can cause blocking on the surrounding small saliva glands], (c) an
translation. “For a long period of time, I had big difficulty Incision and Drainage of Abscess and Fistula
drinking cold beverages, because of my tooth sensitivity. Drainage of an abscess of dental/periodontal origin can
However, with the use of lasers, Dr. Velonis made that be performed by a laser with minimal topical or local
sensitivity a distant memory” (EM, 15-year-old). anesthesia and minimally invasive access.
With an Er:YAG laser, the opening can be performed
Dry Socket with 80–120 mJ, 10–15 Hz, and 50–1000-μs pulse dura-
In cases where a dry socket develops after a difficult tion. If the abscess is under the periosteum, adequate
tooth extraction, the Er:YAG can offer immediate relief local anesthesia is required, and the Er:YAG is the laser
from the pain by removing the necrotic tissue from the of choice to proceed with 150–200 mJ, 10–20 Hz, and
socket. The settings used are similar to those of dentin 100-μs pulse duration with a contact or noncontact
removal, i.e., 150–200 mJ, 10–15 Hz, and 100-μs pulse handpiece.
duration, with water irrigation and a contact handpiece. When using near-infrared laser, local anesthesia is
It does not need local anesthesia. Light bleeding occur- required. With an Nd:YAG, laser settings range from 4
ring after removal of the necrotic tissue is beneficial for to 5 W, 70 to 100 Hz, and 100 μs to 300 μm fiber. With
the healing process. Usually, a single application is ade- a diode 810/980-nm laser, use 4–6-W in continuous
quate to manage a dry socket. wave.
Laser-Assisted Pediatric Dentistry
365 11
a b c
e f
d
i j
k l
.. Fig. 11.27 Excision of one traumatic medium-size mucocele mucocele. Every 20 s of irradiation, 40 s water cooling. k Coagula-
located superficially on the oral mucosa of the lower lip, 16-year-old tion for bleeding control using the CO2 laser [same as above only on
boy. a–d Intraoral view. e Drawing the line of the incision. f–j Step- bleeding spots] and immediate postop view. l–t Day-by-day healing
by-step surgical procedure: laser excision using a CO2 laser 10,600 nm up to 3 months: 12 h l, 24 h m, 2 days n, 5 days o, 7 days p, 10 days q,
[2 W, CW, 200-μm spot area at focus, speed of movement 1.5 mm/s, 2 weeks r, 3 weeks s, and 3 months t. No scar formation
total irradiation time 4 min], avoiding the direct irradiation of the
366 K. Arapostathis et al.
n o p
m
q r s
11
a b
.. Fig. 11.28 Nd:YAG, before a and 1 day F/U b. Note beginning of fibrin formation to heal the ulceration
a b
.. Fig. 11.29 Seven-year-old girl collided with schoolmate and sus- handpiece and fiber, Fotona). The settings were 75 mJ, 20 Hz, and
tained only a soft tissue injury. She was asked to not take any anti- 100-μs pulse duration. Average power was 1.5 W and peak power
inflammatories, or other topical ailments, to see the effect of was 750 W, but energy density (fluence) was 0.27 J/cm2 because of
photobiomodulation (PBM) treatment over the course of 3 days. A the large spot size of 6 mm. a Day 0, b day 1, c day 3
pulsed Nd:YAG laser was used with a fiber of 6-mm-diameter (R24
368 K. Arapostathis et al.
a b
.. Fig. 11.30 a, b Five-year-old sustained intraoral lacerations at pulsed Nd:YAG laser, at 2 W, 20 Hz, with a 300-μm fiber, following
the swimming pool. Settings for aphthous ulcers were used, high- the aphthous ulcer protocol described earlier in this chapter. Note
intensity laser treatment (HILT) to accelerate wound healing with a the healing of the lacerations after 4 days
a b c
d e
.. Fig. 11.31 Case #1. Four-year-and-2-month-old female pre- ulcerate in the labial mucosa, dorsum of the tongue, and swelling and
sented to my private practice on September 6, 2011, with her mother. bleeding of the gums. Mother had recently had an episode of recur-
Chief complaint (CC) and HCC: her mouth and gums hurt for rent herpes labialis. Treatment plan: laser (Nd: YAG) irradiation of
2 days; she has fever 38.5 °C and does not want to eat or drink or oral lesions. No use of antibiotics or antifungals or antivirals. a, b
brush her teeth. Her gums bleed easily and there is halitosis. Patient Day 3 of primary herpetic gingivostomatitis, initial exam. c, d Day 8
was referred from her pediatrician who had prescribed topical anti- of primary herpetic gingivostomatitis, 5 days post-laser irradiation. e
fungals and antibiotics, which she did not yet take. PMHx and Day 8 of primary herpetic gingivostomatitis, 5 days post-laser irra-
PDHx: no significant medical history. Diagnosis: clinically (not diation—only mild difficulty swallowing secondary to lesion in the
microbiologically or serologically) documented primary herpetic gin- palatal pillar which was not seen at the first visit. Irradiated this
givostomatitis with appearance of painful vesicles and bullae that lesion at this appointment, and the patient felt immediate relief
a b c
d e f
.. Fig. 11.32 Case #2. Primary herpetic gingivostomatitis treat- July 10, 2011: second laser treatment for few new blisters. Improving,
ment with Nd:YAG laser (DEKA). a, b Seven-month-old male pre- parents reporting that he finally smiled on the night of the first treat-
sented on ca. Day 9 of infection. He does not drink water or milk ment and slept well and started talking again. Difficult with water on
and cries most of the time; parents and child do not sleep well; still that same day but drank water the next day. e, f December 10, 2011,
fever >38 °C and was prescribed Daktarin gel. May 10, 2011: first F/U
laser treatment. Pre-cooperative (Frankl 1). Peak power 1500 W. c, d
370 K. Arapostathis et al.
a c
b
11
d
e
g
.. Fig. 11.33 Laser-assisted pulpotomy on a first primary molar of defocus for 5–10 s (gold handpiece, 0.6-mm MZ tip, S tissue mode)
a 5.5-year-old girl. Block anesthesia (4% articaine, 1:200,000 epi- over the canal orifices d. Complete coagulation after laser applica-
nephrine) and placement of rubber dam. a Pulp exposure during car- tion. e The cavity was filled up with IRM (fast-setting zinc oxide
ies removal. b Removal of the coronal pulp tissue (diamond bur and eugenol paste). Clinical view after 15 days. The placement of RMGI
spoon excavator). Hemorrhage was controlled. c Er,Cr:YSGG restoration was followed. f, g Radiographic and clinical pictures
(2780 nm) was applied at 50 mJ, 10 Hz, (0.5 W), no water, 40% air, 16 months after treatment
11.7.4 Pulpectomy (erbium family, diode, Nd:YAG,) with great results for
better decontamination of the main and the lateral
It is the endodontic treatment for primary teeth and is canals on permanent teeth [58–62] (see 7 Chap. 9).
indicated for teeth without or minimal pathological These same protocols for permanent teeth, using the
(internal or external) root resorption due to irreversible same parameters, are also recommended for primary
pulpitis or necrotic pulp. The traditional technique teeth, but there are only four studies (one in vivo, one
involves removing of all coronal and root pulp tissue, in vitro, and two case reports) for deciduous teeth, all
limited mechanical instrumentation, root canal disin- using photodynamic therapy, leading to satisfactory
fection using the appropriate irrigants, and filling the results [63–66]. In addition to the traditional technique,
root canals with resorbable material (pure zinc oxide a laser-assisted disinfection method could be per-
eugenol paste or iodoform-calcium hydroxide paste). formed before the final conclusion of the endodontic
Several protocols have been developed using lasers treatment (. Fig. 11.34a–i). Laser-assisted disinfec-
Laser-Assisted Pediatric Dentistry
373 11
a b c
d e
f
g h i
.. Fig. 11.34 Laser-assisted pulpectomy and gingivoplasty on a tissue mode). d Obstruction of the root canals with pure zinc oxide
first primary molar of a 6.5-year-old boy. Endodontic therapy of and eugenol paste and filling the tooth chamber with fast-setting
#84 due abscess. The patient returned 10 days after the initiation of zinc oxide and eugenol paste (IRM). Gingivoplasty (see laser energy
treatment with a subgingival crown fracture. a Intraoral view of parameters on . Fig. 11.3b) and cavity preparation followed (see
lower teeth. b Block anesthesia (4% articaine, 1:200,000 epinephrine) . Table 11.2 for energy parameters). e After gingivoplasty and cav-
and placement of rubber dam. Occlusal view of #84. c Laser- ity preparation and decontamination. f Final restoration with
activated irrigation (Er,Cr:YSGG 2780 nm) was applied at 33 mJ, RMGI. g Pulpectomy and restoration after 3 months. SSC was
30 Hz, (1.0 W), no water, no air, tip inside the tooth chamber, saline placed on #84 at that visit. h, i Periapical radiograph and clinical
solution for 5 s each root canal (gold handpiece, 0.6-mm MZ tip, H views 16 months after treatment
tion could have better results on primary teeth where should be avoided, especially when the laser-activated
there are more complex, with variable morphology, irrigation protocol is used, because if extruded from
root canals making instrumentation and disinfection the open or resorbed root apex it could be irritant to
complicated. Irrigation with sodium hypochlorite the surrounding tissues.
374 K. Arapostathis et al.
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11
377 III
Contents
References – 395
.. Fig. 12.1 Diagram showing the simultaneous work of high-level ously, a low level of energy penetrates or scatters into the surround-
laser therapy (HLLT) and low-level laser therapy (PBM). HLLT ini- ing tissues during high-level laser treatment, which stimulates tissues
tiates various thermal effects on tissues, such as carbonization, and cells without producing irreversible thermal changes in the tis-
vaporization, coagulation, and ablation of soft tissue, as well as sues, resulting in modulation of wound healing in the surrounding
sometimes removal of the hard tissue (erbium lasers). Simultane- tissues. (Partially adopted from Aoki et al. [2])
treatment time, when there is a need for soft tissue pro- Nd:YAG laser is effective for ablation of potentially
cedures that otherwise need referral to other specialties hemorrhagic soft tissue. Diode lasers represent a shal-
such as periodontist or oral surgeon, in particular for lower penetration depth compared to Nd:YAG lasers
fee-paying patients who demand optimal results with and are less likely to cause pulpal damage after use [55].
minimal effort as quickly as possible [55]. The diode lasers can be used in a continuous-wave or
. Table 12.1 outlines the progressive stages of gated-CW mode [7] and are the ideal choice for the use
wound stabilization and healing of the many cellular in orthodontic setup because of the smaller size (“foot-
and biochemical pathways as potential recipients of print”) of the laser device and relatively lower cost
sub-ablative (low-level) laser photonic energy between involved [57].
approximately 600 and 1400 nm wavelength. Outside The second category highlights the superficially
this range, similar induced effects may be attributable to absorbed lasers (CO2, Er:YAG and Er,Cr:YSGG
low thermal rise and consequent tissue stimulation. lasers), in which the laser beam is absorbed in the
superficial layer and does not penetrate or scatter
deeply [2, 58–60]. These lasers have higher absorption
12.2 Overview of Lasers Used for Soft coefficient in water, and due to the high-water content
Tissue Procedures of oral mucosa (>90%), they are very effective soft tis-
sue lasers [55]. The CO2 laser beam is absorbed at the
Various laser systems have been used for soft tissue pro- tissue surface with very little scatter or penetration [2]
cedures, which work by ablating, incising, and excising and is associated with relatively thin layer of coagula-
the soft tissue, as well as providing the much-needed tion around the ablated site. The ablation for CO2
coagulating effect. The frequently used soft tissue lasers laser is basically caused by heat generation (photo-
include the carbon dioxide laser (10,600 nm), erbium thermolysis) [2]. Erbium lasers have the highest
lasers [erbium-doped yttrium-aluminum-garnet absorption into water and target molecular water or
(Er:YAG) laser (2940 nm) and erbium chromium-doped the hydroxide ion as primary targets and mineral as a
yttrium-scandium-gallium-garnet (Er,Cr:YSGG) laser secondary target and therefore are used for ablation of
(2780 nm)], neodymium-doped yttrium-aluminum- both hard and soft tissues [56]. Erbium lasers provide
garnet (Nd:YAG) laser (1064 nm), the diode group of the most rapid, favorable, and uneventful wound heal-
12 lasers (800–980 nm), and the potassium, titanyl phos- ing due to their precise ablation with minimal thermal
phate (KTiOPO4, KTP-“green”) laser (532 nm), together effects as well as low inflammatory response [60].
with the InGaN (“blue”) 445 nm laser [2, 3]. However, hemostasis is less effective with the erbium
lasers because of the minimal tissue denaturation,
accentuated by the coaxial water spray which guaran-
12.2.1 The Shallow or Deeply Penetrating tees subsequent sufficient bleeding and blood clot for-
mation in the ablated defects and thereby induces
Lasers and Hemostasis
favorable wound healing [6]. Overall, erbium lasers
The soft tissue lasers can be categorized into two provide the highest absorption into water, minimizing
broadly acting types: the deeply penetrating-type lasers the thermal effects on the surrounding tissues during
(visible and near-infrared spectrum, 532–1100 nm) that irradiation.
are essentially transmitted through water, showing a
lower absorption coefficient in water [56] such as KTP
green laser. This explains their deep penetration into 12.2.2 issue Ablation: Non-contact or
T
healthy soft tissue, such as Nd:YAG and diode lasers, Contact Cutting Mode
in which the laser light penetrates and scatters deeply
into tissue [56]. However, they are selectively absorbed As has been seen elsewhere (7 Chap. 3), laser-tissue
in areas of inflammation by blood components and tis- interaction is the result of electromagnetic (photonic)
sue pigment [56], which makes them suitable for soft energy being absorbed and converted into other (pre-
tissue procedures [56]. The Nd:YAG laser is often used dominately thermal) energy. Three forms of energy
in free-running pulsed mode, with very-short-duration transfer can be observed:
pulses and an emission cycle (ratio of “on” time to (a) Radiation—where the photon stream is delivered
total treatment time) of <1% and very high peak power through a short airspace with no contact between
per pulse (100–1000 W) [56]. The Nd:YAG laser is a delivery tip and target tissue. This may be commonly
deeply penetrating type of laser and produces a rela- referred to a “non-contact mode.”
tively thick coagulation layer on the lased soft tissue (b) Conduction—where enhancement of the energy
surface, exhibiting strong hemostasis. Therefore, the conversion can be achieved through direct contact
Laser Use in Muco-Gingival Surgical Orthodontics
383 12
between the delivery tip and the tissue. This may be 12.3 Soft Tissue Diode Lasers
commonly referred to a “contact mode.”
(c) Convection—transfer of energy within the body of Since their introduction in 1962 [63, 64], the diode laser
the tissue through fluid movement or circulation. family has grown considerably and diode lasers with
This may occur regardless of either contact or non- wavelengths in the range of 445–2200 nm have been
contact modes. used for treatment of various medical conditions [55, 57,
65–67]. However, reports on the use of the 810–830, 940,
Most surgical lasers produce a photothermal effect on 980, and 1064 nm wavelengths are more frequent in the
soft tissue, evaporating soft tissues through rapid ther- literature [55, 57, 69]. They have high absorption coeffi-
mal rise. The non-contact lasers such as CO2 or erbium cients in water and hemoglobin and particularly in oxy-
lasers (Er:YAG and Er,Cr:YSGG) directly and easily hemoglobin, therefore rendering different soft tissue
evaporate soft tissues by photothermal effects that effects. However, diode laser light is poorly absorbed by
vaporize interstitial water. However, the non-contact the hydroxyapatite and enamel [54, 55]; however, it is an
mode is associated with less precise cut and lack of pro- excellent soft tissue surgical laser for incising, excising,
prioceptive feedback compared to contact mode lasers. and coagulating gingiva and mucosa. The active media
When lasers are used in contact mode to make an of semiconductor (diode) lasers are varied and can
incision or excise soft tissue, they often need “initiation” include aluminum (Al), gallium arsenide (GaAs), and
of the laser tip end. In this process, part of the emitting occasionally, indium (In) [55, 68, 69]. Examples are gal-
light in the Nd:YAG and diode lasers is attenuated and lium-aluminum-arsenic (Ga-Al-As), arsenic-gallium
converted into heat; the laser tip end gets initiated, creat- (As-Ga), and indium-gallium-aluminum-phosphorus
ing a condition called “hot tip.” This initiation produces (In-Ga-Al-P) lasers. The diode lasers are portable
secondary thermal effects at the heated tip end that can (<5 kg), small, relatively simple to use [68]. There is also
cut or incise soft tissue as well as offer coagulation of the a stable power output, long lifetime, and low installation
tissue as a result of contact with the over-heated tip and maintenance costs [68].
rather than by the laser energy itself [2, 3]. . Figure 12.2
shows an initiated fiber-optic tip prior to laser exposure
of an ectopic lower left canine. Diode and Nd:YAG 12.3.1 iber-Optic Tip Size, Power Output,
F
lasers produce a relatively thicker coagulation layer on and Continuous/Gated-CW Mode
the treated surface than superficially absorbed lasers [4].
for Diode Lasers
Diode lasers are considered to be suitable for daily prac-
tice of orthodontic soft tissue procedures owing to suf-
The soft tissue diode lasers usually work in a “contact
ficient hemostasis and precise incision margins [61, 62].
mode,” and the laser beam is delivered by a fine glass
For the purpose of this chapter, the use of diode lasers
optic fiber, with a fiber system tip that can be angled, so
for soft tissue procedures will be discussed in more detail
that the dentist holds it in a pencil-like holder for accu-
due to their ease of use in orthodontics.
rate manipulation of the areas that are difficult to handle
[68]. For surgical incisions and excision, a 400-μm diam-
eter fiber-optic tip is recommended, as smaller diameter
fibers tend to be more friable and liable to fracture [69].
The fiber-optic tip needs initiation prior to performing
surgical excision, often by tapping the initiated tip on a
blue articulating paper, the use of black ink, a solid color
in a magazine page or a piece of cork have been met with
varying degrees of success [55, 70]. Diode lasers with
power outputs of <500 mW are used in low-level laser
therapy to provide photobiomodulation (PBM) and
associated wound repair and pain relief [55]. However,
for excision there is often a need for a continuous power
output of 1.0–1.5 W [70], depending on the fibrotic
nature of the tissue. In order to decrease the carboniza-
tion and thermal damage and allow for thermal recovery
of the tissue, a gated-CW mode (with repetitive “on–off”
cycles of varying length and frequency depending on the
make of the laser) has been suggested and implemented
.. Fig. 12.2 A typical initiated fiber-optic laser tip will be used for in many contemporary diode laser units [69, 71].
laser excision
384 A. Borzabadi-Farahani
.. Fig. 12.3 a A pre-operative intra-oral frontal view of a patient continuous wave 940 nm diode (InGaAsP) laser (Epic 10, Biolase,
with gingival hyperplasia of the maxillary anterior teeth, in particu- Irvine, CA), with a 400-μm diameter fiber-optic tip, in a contact
lar in the maxillary right lateral incisor (UR2) region. b Post-opera- mode after initiation (power output = 1 W)
tive appearance at 1 week. Laser operating parameters used were the
a b
.. Fig. 12.4 a A pre-operative intra-oral frontal view of a patient hypertrophic gingival tissue. Laser operating parameters used were
with gingival hyperplasia of the maxillary and mandibular front the continuous wave 940 nm diode (InGaAsP) laser (Epic 10, Bio-
teeth immediately after removal of fixed braces. This amount of gin- lase, Irvine, CA), with a 400-μm diameter fiber-optic tip, in a contact
gival hyperplastic makes the provision of orthodontic retainers very mode after initiation (power output = 1 W). Some carbonization is
challenging. b Immediate post-operative appearance following sul- evident at the laser gingivectomy sites. c Close-up view at 1-week
cular local infiltration (2% lidocaine) and removal and debulking of post-operative follow-up after laser gingivectomy.
aesthetic crown lengthening or papilla flattening can be less bleeding and a clear dry field during surgery, offer-
technically demanding tasks in that the gingival margins ing an alternative to the scalpel for the aesthetic gingival
sometimes need very minor recontouring that needs a recontouring [85–87]. . Figure 12.4a–c show a patient,
higher degree of precision than that achieved with a following removal of fixed braces, who has undergone
scalpel blade, regardless of the operator’s skill level [84]. gingival recontouring of the maxillary and mandibular
Diode lasers offer the precise incision control because of front teeth.
386 A. Borzabadi-Farahani
a b
12
.. Fig. 12.5 a A male patient with a buccally impacted maxillary contact mode (gated-CW mode, average power output = 1 W, pulse
right canine. b Immediate post-operative view of laser-assisted expo- duration = 1 ms, time on/time off = 50%). Time spent for the laser
sure through soft tissue ablation. The bloodless field facilitates the exposure was approximately 10 min. c Appearance at 24 h follow-up.
bonding process and placement of orthodontic brackets. Laser oper- Note that the amount of inflammation is minimal. The patient
ating parameters were the 940 nm diode laser (Epic 10, Biolase, reported very minimal pain and discomfort during the first 24 h
Irvine, CA), with an initiated 400-μm diameter fiber-optic tip, in a
Laser Use in Muco-Gingival Surgical Orthodontics
387 12
a b
c d
.. Fig. 12.6 a A female patient with an impacted maxillary right preserve the keratinised tissue, the starting exposure point should be
canine. The maxillary right lateral incisor was extracted due to severe the tip of the crown in buccal exposures. c After bonding a small size
root resorption caused by the impacted canine. b Immediately after bracket, please note that the bloodless exposure site facilitates imme-
laser-assisted exposure. A 940 nm diode laser (Epic 10, Biolase, diate placement of orthodontic bracket. Orthodontic force was
Irvine, CA) with an initiated 400-μm diameter fiber-optic tip, in a applied with 014 niti wire immediately after exposure that reduces
contact mode, was used (gated-CW mode, average power out- the treatment time. d At 6-month follow-up after canine substitution
put = 1 W, pulse duration = 1 ms, time on/time off = 50%). Time and at the time brace removal, note the healthy keratinised tissue at
spent for the laser exposure was approximately 10 min. In order to the maxillary right canine labial aspects
undergone laser exposure right after exposure and at minimum post-operative discomfort and excellent heal-
24 h follow-up. Note that the amount of post-operative ing at subsequent follow-ups. The diode laser in this case
inflammation is minimal. clearly provided bloodless site that allowed immediate
. Figure 12.6a shows a female patient with an orthodontic bonding of the maxillary canines and
impacted maxillary right canine that caused severe root reducing the treatment time.
resorption of upper right lateral incisor (which was Compared to laser tooth exposure, a patient with a
extracted due to poor prognosis), right after laser expo- similar superficially palatally impacted canine is usually
sure (. Fig. 12.6b), bonding and applying orthodontic referred for full-thickness mucoperiosteal flap, which
force (. Fig. 12.6c) as well as at 6 months follow-up can be very aggressive and often needs placement of a
(. Fig. 12.6d). protective dressing (pack) over the surgical site while it
. Figures 12.7a–d illustrate the remarkable healing heals [92]. The use of scalpel usually involves suturing
process in a male patient with a palatally impacted max- with stitches during surgical procedure that need to be
illary right canine, after palatal laser exposure. removed 1–2 weeks post-operatively [93]. All demon-
. Figures 12.8a–j show another patient with a buc- strated cases were performed using the 940 nm diode
cally impacted maxillary right canine and a partially (InGaAsP) laser (maximum power output = 10 W, Epic
erupted maxillary left canine. The gated-CW mode and 10, Biolase, Irvine, CA), using a 400-μm diameter fiber-
pulse duration of 1 m second was used, which led to optic tip, in a contact mode and after initiation.
388 A. Borzabadi-Farahani
a b
c d
a b
.Fig.
. 12.8 a, b A male patient with a buccally impacted maxillary right optic tip, in a contact mode (gated-CW mode, average power output = 1 W,
canine and a partially erupted maxillary left canine, immediate post-oper- pulse duration = 1 ms, time on/time off = 50%). Time spent for the laser
ative view. c, d Laser operating parameters were the 940 nm diode laser exposure was approximately 15 min. e, f Following placement of orthodon-
(Epic 10, Biolase, Irvine, CA), with an initiated 400-μm diameter fiber- tic wire. g, h Appearance at 1 week. i, j Appearance at 4-month follow-up
Laser Use in Muco-Gingival Surgical Orthodontics
389 12
c d
e f
g h
i j
12
a b
.. Fig. 12.9 a A female patient presenting with a labial frenum. b Following laser frenectomy with a 940 nm diode laser (Epic 10, Biolase,
Irvine, CA). c At 1-week follow-up
Diode lasers have been used to uncover temporary Traditionally ablative non-contact lasers (CO2 and erbium
anchorage devices (TADs), in frenectomy where highly lasers) have been used in the field of oral and maxillofacial
attached frenum impedes tooth movement in diastema surgery and aesthetic medicine [100–102]. Unfractionated
cases (. Fig. 12.9a–c), circumferential supracrestal CO2 laser (10,600 nm) can’t be delivered with a quartz fiber
fiberotomy to prevent relapse of rotated teeth, removal as it is absorbed by the quartz and instead is delivered
of operculum on mandibular second molars that pre- using a system of mirrors and waveguides [102]. CO2 laser
vents banding, or to improve healing of minor aphthous has been used to treat wrinkles, skin scars tissues, prema-
ulceration following placement of fixed orthodontic lignant lesions (oral leukoplakia), 7 warts, and benign
braces [7, 55, 70, 99]. neoplasms [102, 103]. CO2 and erbium lasers both target
392 A. Borzabadi-Farahani
water, however the water absorption coefficient of Er:YAG sue [56]. As mentioned earlier, erbium lasers target molec-
(2940 nm) is about ten times that of a CO2 laser, limiting ular water or the hydroxide ion as primary targets and
its tissue penetration providing more precise ablation with mineral as a secondary target and can be used for both
minimal thermal damage of surrounding tissue [100–103]. hard and soft tissue procedures [56]. However, erbium
Soft tissue penetration depth for CO2 laser is approxi- lasers are limited by their lack of 7 hemostasis, which
mately 0.2 mm [56, 60] and for erbium lasers (Er:YAG and makes them unattractive for exposure and bonding of
Er,Cr:YSGG lasers) can be as shallow as 5 μm [56, 58]. impacted teeth and limited oral surgery setup available in
CO2 lasers have the highest absorption in hydroxyapatite orthodontic practices.
and calcium phosphate and must be used with care during Selected uses of CO2 (. Figs. 12.10a–e and 12.11a–
soft tissue procedures to avoid direct contact with hard tis- i) and erbium (. Fig. 12.12a–g) lasers in three patients
a b
c d
12
.. Fig. 12.10 a A 10-year-old patient with impacted upper right to avoid any damage on periosteum and leave enough tissue thick-
central incisor (UR1) and labial frenum. b Following the application ness, irradiation time: 20 s, cooling with water for 40 s), charring was
of local anesthesia, simultaneous crown exposure of UR1 (apically removed with gauze. c Immediate post-operative appearance. d Post-
positioned flap) and frenectomy carried out using a 10,600 nm CO2 operative appearance at 2 weeks. e At 3-month follow-up. Case cour-
laser (average power: 2 W, 50% on, spot diameter: 200 μm, total irra- tesy Dr M. Chala
diation time: 3 mm, Beam direction: parallel to the attached gingiva
Laser Use in Muco-Gingival Surgical Orthodontics
393 12
a b
c d
e f
g h
.. Fig. 12.11 a A 16-year-old patient with impacted upper left cen- 10,600 nm CO2 laser to remove the hyperplastic inflamed tissues and
tral incisor (UL1), remnant of URA, and labial frenum; the patient further exposure of UL1 crown. e The surgical site after removal of
wore a provisional restoration in UL1 area for almost 8 years. b carbonized tissue. f Diode 1064 nm laser used for decontamination
Appearance pre-operatively, demonstrating lack of attached gingiva of the UL1 region to improve the gingival health. g The appearance
in UL1 region. c Periapical radiograph showing rotated UL1 and at 1-month follow-up. h The appearance during orthodontic treat-
fragment of dental origin, believed to be ULA. d Following extrac- ment. i Appearance after finishing orthodontic treatment at 18 years
tion of URA remnant, frenectomy and vestibuloplasty with of age. Case courtesy Dr M. Chala
394 A. Borzabadi-Farahani
a b c
d e f
12
g
.. Fig. 12.12 a Intra-oral view showing delayed eruption of UR1. b appearance. f Appearance at 1 month. g Appearance at 2 months
Periapical X-Ray view. c Follow-up at 2 years. d Laser exposure of follow-up. Case courtesy Dr M. Chala
UR1 with a 2780 nm Er,Cr:YSGG laser. e Immediate post-operative
for frenectomy and exposure of impacted incisors are and rotated, with an associated fragment of dental ori-
shown. gin. Treatment included extraction of URA remnant,
The case represented by . Fig. 12.11a–i, is of a frenectomy, and vestibuloplasty with 10,600 nm CO2
16-year-old patient with impacted upper left central laser to remove the hyperplastic inflamed tissues and
incisor (UL1); the patient wore an upper anterior acrylic further exposure of UL1 crown. The use of the diode
removable prosthesis for almost 8 years. Lack of 1064 nm laser was employed for decontamination of the
attached gingiva in UL1 region, traumatic fitting of the UL1 region and to improve the gingival health. On-
prosthesis, excessive plaque accumulation, are evident. going orthodontic treatment and follow-up provided a
The radiographic examination reveals UL1, impacted finished result at 18 years of age.
Laser Use in Muco-Gingival Surgical Orthodontics
395 12
In case images . Fig. 12.12a–g, demonstration of Acknowledgment The author acknowledges the contri-
a further laser-assisted soft tissue exposure of an bution of Dr. Marianna Chala (Private Practice, Athens,
unerupted upper central incisor (UR1). Intra-oral view Greece) for illustrated patients in . Figs. 12.10 and
of a 9-year-old boy presenting with delayed eruption 12.11, as well as Dr. Konstantinos Arapostathis
of UR1 (a), X-Ray view (b) and follow-up at 2 years (Associate Professor, Paediatric Dentistry, School of
(c). Application of local anesthesia followed by laser Dentistry, Faculty of Health Sciences, Aristotle
exposure of UR1 with a 2780 nm Er,Cr:YSGG laser University of Thessaloniki) for illustrated patient in
(d, e) (Biolase, Gold hand piece, tip: 0.6 mm MZ tip, . Fig. 12.12.
Distance: 1 mm, Hard tissue close contact mode,
power: 1–1.50 W, 20 Hz, 30% H2O, 70% Air, 6 mL/min
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399 13
Contents
References – 438
a b c d
e f g h
.. Fig. 13.1 a An immediate postoperative view of an excision of An Er:YAG laser was used with an 600 μm glass tip in contact with
an irritation fibroma on the lower lip. An 810 nm diode was used the tissue at an average power of 2.4 W (80 mJ, 30 Hz, without water
with a 400 μm glass fiber in contact with the tissue at 1.2 W continu- spray.) Fluence 263 J/cm2. f Two-week postoperative view of the
ous wave. Fluence 149 J/cm2. b A 3-week postoperative view of the healed area. g An immediate postoperative view of an excision of an
healed area. c An immediate postoperative view of an excision of an irritation fibroma on the buccal mucosa. A 10,600 nm Carbon Diox-
irritation fibroma on the buccal mucosa. An Nd:YAG laser was used ide laser was used with a 0.8 mm diameter hollow tubular tip that
with an 320 μm glass fiber in contact with the tissue at an average was focused on the lesion at 5 W continuous wave. Fluence 146 J/
power of 3 W (100 mJ, 30 Hz) Fluence 915 J/cm2. d A 3-week post- cm2. h Three-week postoperative view of the healed area. (Courtesy
operative view of the healed area. e An immediate postoperative of Dr. Donald Coluzzi)
view of an excision of an irritation fibroma on the inner lip mucosa.
Hemostasis is one of the most sought-after advantages 13.2 enign Lesions and Tumors
B
that the laser provides. Depending on the target tissue, of the Oral Cavity
the laser wavelength and emission mode selected, an
almost totally dry operation field is produced. This can
also be achieved in patients with hemorrhagic diatheses
[14]. The use of sufficiently matched energy for cutting 13.2.1 Leukoplakia
will produce little carbonization leaving the wound
unchanged in color and structure. This makes orienta- A color change from normally pale pink oral mucosa to
tion during the procedures easier, even for the surgically white is one of the most often discovered abnormalities
inexperienced dentist. When using the laser not only is in the oral cavity. Failure to identify and recognize the
the wavelength important, but also parameters such as cause of this alteration can be an omission with serious
temporal emission mode (continuous wave or pulsed), consequences since early squamous cell carcinomas may
pulse duration, emission cycle, exposure time, and the appear in early stages as a white lesion.
speed of the incision [15, 16]. All this in the right pro- Clinically, the term leukoplakia has been used differ-
portions will lead to a clean cut with little carboniza- ently by many authors that it now presents a “white
tion and contraction of proteins resulting in scarring patch that cannot be rubbed away” [21]. As defined by
[17–20]. the World Health Organization, leukoplakia is “a white
As mentioned, all of the dental wavelengths cur- patch or plaque that cannot be characterized clinically
rently available can be used for soft tissue oral surgery. or pathologically as any other disease” [22, 23]. As such,
As mentioned in 7 Chap. 3, the laser-tissue interaction leukoplakia should be used only as a clinical term; it has
can vary because of the different absorption characteris- no specific histopathological connotation and should
tics of the applied incident photonic energy. However, never be used as a microscopic diagnosis. Subsequently,
with careful technique and prudent choice of operating the World Health Organization WHO (2005) changed
parameters, healing from laser surgery should be the definition of leukoplakia to “A predominantly white
uneventful. . Figure 13.1a–h depicts examples of an plaque of questionable risk having excluded (other)
excisional procedure performed with four different known diseases or disorders that carry no increased risk
wavelengths. for cancer” [24].
402 O. Hamadah
In clinical practice, the Malmö protocol of 1983 [25, tection against ignition in comparison to conventional
26] has been helpful in differentiating between poten- PVC endotracheal tubes [33]. Saline moistened gauze
tially precancerous and benign lesions. The distinction also should be used to protect the pharynx, endotra-
of these is purely clinical, based on surface color and cheal tube, and facial skin. Preferably, no metal instru-
morphological (thickness) characteristics, and does ments should be used during CO2 lasing for safety
have some bearing on the outcome or prognosis. Since measure. Instead, wooden or plastic spatulas can be
leukoplakia has been and still is an exclusion diagnosis, used to manipulate the oral tissues when irradiated with
it is mandatory to perform a biopsy to verify the diag- CO2 laser.
nosis. Clinically, there are two types of leukoplakia: All staff within the operating theater must wear
homogenous and nonhomogeneous. Homogeneous safety glasses for this laser wavelength. An evacuation
lesions are uniformly flat, thin, and exhibit shallow system must be used to remove smoke and debris from
cracks of the surface keratin. The risk of malignant the surgical site.
transformation in the homogenous type lesion is similar Oral potentially premalignant lesions can be man-
to any other normal mucosa tissue, whereas nonhomo- aged under local or general anesthetic according to
geneous lesions exhibit oral cancer transformation rates lesion size, location, and health status of the patient.
ranging between 2.2% and 35%, especially when its Oral leukoplakia without dysplastic histopathologi-
biopsy reveled dysplastic entities [27–30]. In the thera- cal features can be removed utilizing an ablation tech-
peutic treatment protocol of leukoplakia, it is manda- nique. The peripheral margins of the lesion are outlined
tory to excise all areas of the lesion that showed surface with single mode pulse and vaporized with CO2 laser in
morphology that could warrant dysplasia. In conven- continuous mode at 4–6 W average power, with scanning
tional surgery, a flap procedure is usually employed, and mode covering the extension of the lesion. A second
the result can be scarring and prolonged and painful pass may be required to achieve a complete vaporization
healing. Several treatment modalities have been sug- with adequate depth [34].
gested to manage this lesion including scalpel excision, A complete resection of oral leukoplakia becomes
electrosurgery, cryosurgery, laser surgery, and chemo- mandatory when incisional biopsy of such lesion
prevention medications. A particularly difficult group revealed dysplastic changes [34].
of patients to manage are those with multiple oral, For lesion resection, the power levels vary between 5
potentially premalignant lesions in whom extensive and 15 W in continuous mode according to the thick-
areas of mucosa may show signs of dysplastic change. ness and extension of the lesion. For devices offering
13 Widespread leukoplakias have been shown to have
higher rates of malignant transformation than more
pulsed mode, the following parameters were suggested
to facilitate resection of hyperkeratotic lesions: a power
localized lesions [31]. The introduction of laser technol- of 4.5 W on PW, 80 Hz, fluence of 44.78 J/cm2, and a
ogy, for example, using the CO2 laser, offers the option spot diameter of 400 μm [35].
of vaporizing the lesion and leaving it to heal with no- Initially, a single pulse mode is used to outline the
to-minimal scar formation [32, 33]. However, the ability resection margins, situated at least 5–10 mm beyond the
to analyze the submitted laser-excised specimen for apparent clinical margin of the target lesion.
pathology was soon questioned. Conventional excision Subsequently, the laser is adjusted to continuous mode
produces a serial section of the whole specimen, and and the peripheral marks are connected at the submuco-
spot biopsies were criticized as insufficient. In the eyes sal level. The whole specimen is then excised by under-
of traditional surgeons, the pathologic evidence was cutting at approximate 5 mm constant depth [34, 36].
being (literally) vaporized. Therefore, the standard of However, when resecting mucosa overlying alveolar
care before ablation of an oral potentially premalignant bone, the undercutting depth should be shallower.
lesion is still to obtain an incisional biopsy for histo- It is recommended that the resected area and all
pathological assessment. peripheral margins should be vaporized using a defo-
The CO2 laser manifests strong absorption ability in cused beam to eliminate residual disease and to facilitate
soft tissues, causing a superficial evaporation with mini- hemostasis. The wound is left to heal by secondary
mal thermal damage to the surrounding tissue and intention, with no need for sutures, dressing, or grafting.
maximum selectivity to remove targeted lesion. It works Several studies demonstrated that the CO2 laser offers
with a non-contact mode, using a handpiece attached to precise cutting ability of the oral mucosa with less bleed-
an articulating arm delivering the laser beam to the tar- ing and scar formation in the surgery field.
get tissue. All excised specimens should be preserved and fixed
For procedures performed under general anesthesia, in 10% formalin and sent for histopathology examina-
an endotracheal intubation with a cuffed ETT tube is tion. Large biopsies must be orientated by sited sutures
recommended to be used as it provides significantly pro- to define the involved margin with the disease.
Laser Use in Minor Oral Surgery
403 13
a b
.. Fig. 13.2 Surgical and dental CO2 laser handpieces used in the tal CO2 laser handpiece with multiple tips facilitating treatment of
oral cavity. a Straight handpieces with different focal lenses small mucosal and gingival lesions within the oral cavity
(50/100 mm) used for resection of extended and bulk lesions. b Den-
As the wound will heal by secondary intention, post- (. Fig. 13.4). An incisional biopsy was performed
operative instructions include using a mouth rinse such which revealed the presence of severe dysplasia. Lesion
as chlorhexidine 0.12% and avoiding spicy and coarse resection was performed using the CO2 laser. Exposed
food. Tranexamic acid 5% can be used as mouthwash if alveolar bone was covered by a platelet-rich fibrin PRF
oozing happens. Augmentin antibiotic is prescribed as membrane which was stitched to resection margins. The
1000 mg twice a day and paracetamol or ibuprofen for healing was uneventful, and no recurrence was detected
pain relief as required. Complete healing and mucosal at 6 months postoperatively.
re-epithelialization of the resected area is usually
achieved within 4–6 weeks. Follow-up sessions usually
are organized at 1, 3, and 6-month intervals thereafter. 13.2.2 Lichen Planus
Finally, although the CO2 laser has been proven to be
the treatment of choice of oral potential premalignant Lichen planus is a chronic inflammatory mucocutane-
lesions, recurrence or malignant transformation is still ous disorder; it generally affects middle aged to elderly
unavoidable [31, 35]. females and the lesions mostly appear in the buccal
Recurrence of a white lesion is a serious develop- mucosa, tongue, gingiva, and vermillion border of the
ment. Studies show that the use of laser treatment has at lower lip [45]. It is a T-cell mediated autoimmune disease
least a similar if not better outcome than the conven- in which the cytotoxic CD8+ T cells trigger apoptosis of
tional therapy [37–39]. In functionally sensitive regions the basal cells of the oral epithelium. Several antigen-
as the lips, a laser excision demonstrated significant specific and nonspecific inflammatory mechanisms have
improvement in outcome [40]. been proposed to explain the accumulation and homing
Most of the studies regarding laser treatment of oral of CD8+ T cells subepithelially, and the subsequent
leukoplakia were performed with the 10,600 nm carbon keratinocyte apoptosis [46].
dioxide wavelength. However, it is also possible in some Clinically, oral lichen planus (OLP) may appear in six
small lesions, especially those located in the anterior forms: Reticular (Wickham striae), erosive, atrophic,
part of the oral cavity to use a fiber-based delivery sys- plaque-like, papular, and bullous. The reticular shape is
tem of an Nd:YAG laser or a diode laser, depending on the most common type which is usually asymptomatic
the accessibility of the lesion [41–44]. exhibiting localized or generalized extension with no need
Two different types of handpieces used with CO2 for treatment [47]. However, other clinical patterns such
laser device in the oral cavity (. Fig. 13.2). as erosive or atrophic forms may cause variable amounts
. Figure 13.3 shows a case of leukoplakia on the of pain or discomfort, especially when the patient is con-
lateral border of the tongue. A 50-year-old female pre- suming spicy or hot foods. Additionally, oral function
sented with an inconspicuous medical history except for and patient’s quality of life may be affected [48].
smoking. An Nd:YAG was used to vaporize the lesion. The clinical diagnosis of OLP should be associated
Six months later, a small area has recurred. with a histopathological examination to rule out the
Verrucous leukoplakia extending from the interior presence of any associated sinister elements such as dys-
aspect of the upper left mucosa to the tuberosity plasia or neoplasia [49]. The microscopic features of
404 O. Hamadah
a b
c d
13 e f
.. Fig. 13.3 a A 48-year-old male with severe dysplasia located on specimen was then resected by undercutting at approximate 5 mm
ventral tongue. b This procedure was performed under general anes- constant depth. g The surgical bed and all peripheral margins were
thesia; however, local anesthesia was also provided to aid hemostasis vaporized using a defocused beam to eliminate residual disease and
during the resection. The CO2 laser was used with power levels vary- to facilitate hemostasis. The wound surface was left, without closure
ing from 10 to 15 W c. d, e The outlined margins were first deter- or dressing, to heal by secondary intention. h The excisional speci-
mined using single pulse mode which served as surgical boundaries, men was oriented by placing multilength sutures at the margins and
extending 0.5 cm beyond the apparent clinical margins of the lesion. fixed in 10% formalin and transferred for histopathology evaluation.
Subsequently, the laser was set to continuous mode, and the periph- i Healing and resection field re-epithelialization was achieved within
eral marks were connected at the submucosal level. f The whole 4–6 weeks
Laser Use in Minor Oral Surgery
405 13
g h
OLP usually include plasma cells, subepithelial band- their randomized controlled trail the superiority of
like infiltration of lymphocytes and acanthosis [46, 50]. Er:YAG and Nd:YAG on scalpel surgery in ablation of
Bearing in mind that the risk of malignant transfor- erosive lichen planus [52]. The Er:YAG laser was applied
mation is higher in erosive and atrophic lesions, treatment in a contact mode using reciprocal movements of 15 s per
of these types should be considered mandatory. Several cm2 with the following parameters: average power: 2 W,
treatment methods are available and topical corticoste- frequency: 10 Hz, pulse duration: 230 μs, spot size:
roids are mostly considered the treatment of choice; in 0.9 mm, water/air: on. The Nd:YAG laser was also applied
the light of side effects such as thinning of the oral mucosa in a contact mode using reciprocal movements of 15 s per
and secondary candidiasis, it has been preferable to find cm2 with the following parameters: average power: 1.5 W,
alternative pharmacological treatments, including reti- frequency: 40 Hz, pulse duration: 350 μs, spot size:
noids and immunosuppressive agents, especially cyclo- 300 μm. Coagulation was achieved by applying the two
sporine and tacrolimus. Low level laser therapy lasers with a non-contact mode using an average power
(photobiomodulation) and high-power (surgical) laser of 3 W with circular movements of unfocused beam
may be considered as alternative tools for OPL treatment, 1–3 mm far away from the treated area. The findings of
especially for those unresponsive lesions to traditional this research showed that high-level laser intervention
pharmacological regimes [51, 52]. Surgical removal of exhibits a superior clinical outcome compared to the scal-
affected mucosa may be performed either by a scalpel or pel excision for the surgical treatment of oral erosive
high-power laser. Elimination of OLP with a laser offers lichen planus. Taking into consideration that the Er:YAG
complete resection of the lesion usually in one session causes less thermal damage to the oral mucosal tissue, it
with minimal postoperative complications such as pain, has been considered as the most effective laser type in this
bleeding, or scar formation. Tarasenko et al. reported in study at the end of the first postoperative month [45].
406 O. Hamadah
a b
c d
13
e f
.. Fig. 13.4 a, b A 39-year-old male presented with a recurrent ver- alveolar maxillary bone was covered by a PRF membrane which was
rucous leukoplakia. The lesion extends clinically from the interior stitched to resection margins. A partial pressure denture was placed
aspect of the upper left mucosa to the tuberosity. c–f Lesion periph- to support the membrane and to aid hemostasis control. The healing
eral outlining and resection were performed by applying CO2 laser was uneventful, and no recurrence was detected 6 months post inter-
using both dental and straight handpieces. A periosteum elevator vention
was used to facilitate the lesion dissecting. g, h The exposed upper
Laser Use in Minor Oral Surgery
407 13
g h
The CO2 laser (10,600 nm) manifests a high absorp- approximately 3 mm/s, and the power density was
tion in the water component of oral mucosa which 1527.8 W/cm2. The procedure was conducted under
facilities a precise resection of oral mucosal lesions local anesthesia.
with post-surgery coagulation. It also can be used in a The same patient presented with reticular and
defocused mode enabling evaporation of superficial tis- atrophic-shape lichen planus on the left buccal mucosa
sues even when the lesion exhibits a large extension (. Fig. 13.6). The lesion was vaporized using the CO2
thus the evaporated area will heal by secondary inten- laser defocused beam with scanning mode covering the
tion [53]. extension of the lesion. Similar laser parameters were
Treating of lichen planus using the CO2 laser was used as in the abovementioned case.
reported in several studies with an advantage of reduc-
ing the lesion size and pain severity. The operation is
performed after administration of local anesthesia using 13.2.3 Fibroma
defocused continuous CO2 laser (10,600 nm) with power
range reported from 2 to 20 W. The lesion is irradiated The lesion most commonly found in the oral cavity is the
to achieve superficial vaporization with a slow gliding fibroma. It occurs as a discrete, superficial, pedunculated
motion, until the lesion is completely removed. The mass commonly found on the buccal mucosa. It is usually
ablation should not reach the connective tissue level. of non-neoplastic nature and arises as a response to persis-
Although a study suggested using CO2 laser with defo- tent mechanical irritation such as calculi, foreign bodies,
cused continuous mode, others recommended super chronic lip or check biting, overhanging margins restora-
pulsed mode [54–56]. tion, sharp spicules of bones, and overextended borders of
OLP recurrence rate differs according to follow-up appliances [57, 58]. The irritation fibroma is also termed a
period, lesion extension, type of OLP, and technique of traumatic fibroma, peripheral fibroma, fibrous nodule,
laser application and parameters used [54]. fibroepithelial polyp, focal fibrous hyperplasia, and inflam-
A 27-year-old male presented with pan-oral lichen matory fibrous hyperplasia [59]. It is composed of collag-
planus (. Fig. 13.5). Multiple incisional biopsies were enous, fibrous connective tissue covered with keratinized
performed, and the histopathological report confirmed or parakeratinized squamous epithelium. In the lesion,
the clinical entity of the lesions. A surgical CO2 laser there can be myxomatous degeneration or pathological
(λ = 10,600 nm) was used applying a continuous defo- weakening of the connective tissue along with bone for-
cused mode with an output power of 3 W. The spot mation and in growth of fatty tissue. Affected patients
diameter was 0.5 mm, the speed of movement was often notice the lesion only after masticating on the area
408 O. Hamadah
a b c
.. Fig. 13.5 a A 27-year-old male presented with a symptomatic lichenoid lesion on ventral tongue. b Immediately after CO2 laser vaporiza-
tion. c Four weeks postoperative view showing complete healing with no sign of recurrence
a b c
13
.. Fig. 13.6 a The same abovementioned patient exhibiting reticular and atrophic shape lichen planus lesions on the left buccal mucosa. b
Lesion ablation using CO2 laser with continuous mode. c Uneventful healing of the oral mucosa 3 weeks postoperatively
and then experiencing post traumatic pain and swelling. [60]. Depending on the lesion size and location, it is out-
At this point, the fibroma will have grown to at least lined about 2 mm outside its border using an initiated
2–3 mm in size depending on the region and would be vis- 320–400 μm quartz optic fiber. As the tip contacts the
ible in a mirror. The lesion will generally continue to grow, base of the lesion, activate the laser to make an incision
becoming a nuisance, and should be removed. When a circumscribing the lesion, then move the tip in quick
scalpel is used, postoperative bleeding often makes the gentle 2–3 mm strokes to achieve complete resection of
procedure difficult, especially if the lesion is inflamed with the lesion. It is important while performing the cutting to
increased vascularization. Moreover, suturing is often nec- direct the tip at the base of the resected specimen and not
essary. Laser surgery allows both excision and hemostasis toward the oral mucosa. This allows a precise resection
simultaneously [20, 57]. without damaging underlying tissues. The area is left to
Treatment protocol includes injection of local anes- heal in secondary intention with no need for dressing.
thesia peripherally and underneath the lesion. A tissue . Figure 13.7 is a case of an asymptomatic fibroma
forceps or a suture is used to grasp the lesion away from present on a 45-year-old female patient, nonsmoker,
its base. Employing a contact mode, laser choice of with an inconspicuous medical history. A diode laser
Nd:YAG or diode laser with wavelength of 450, 810, performed the excisional biopsy and the tissue healed
940, and 980 nm can be used to perform the resection without any scarring or residual lesion.
Laser Use in Minor Oral Surgery
409 13
a b c
.. Fig. 13.7 a Pre-operative view of a fibroma in the buccal vesti- tissue at 30 W, 12,500 Hz, and a 9 μs pulse duration, 200 μm glass
bule. b Immediate postoperative view of the excision. An 810 nm fiber, contact mode. Average power 3.38 W. Fluence 554 J/cm2. c A
diode laser was used with a 200 μm glass fiber in contact with the 4-week postoperative photo shows complete healing
a b
c d
.. Fig. 13.8 Traumatic fibroma left buccal mucosa in a 50-year-old CW 800 μm beam diameter × 30 s. Incisional hemostasis achieved. d
female. a Lesion secured with suture to stabilize the tissue and facili- Postoperative uneventful early healing at 10 days. (Clinical case
tate accurate estimation of the level of incision. b, c Using a CO2 courtesy of Prof. Steven Parker)
10,600 nm laser with non-contact, fixed focal length delivery: 1.0 W
. Figure 13.8 depicts an irritation fibroma present medical history included hypertension and cardiac dys-
inner mucosal lining of the lip of a (50-year-old female rhythmia, which are drug controlled. She has a bruxism
patient with a non-contributory medical history?) A habit which could contribute to the presence of the
superpulsed 10,600 nm carbon dioxide laser performed lesions.
the excision, while a suture kept tension on the lesion. . Figure 13.10 depicts a fibroepithelial polyp local-
Clinical case courtesy of Prof. Steven Parker. ized on the left buccal mucosa as a result of chronic irri-
. Figure 13.9 is that of a 38-year-old female, non- tation. The lesion was excised using the diode laser and
smoker, presented with multiple areas of fibromas. Her complete re-epithelization was achieved after 3 weeks.
410 O. Hamadah
a b
c d
.. Fig. 13.9 a Pre-operative view of multiple fibroma lesions on the a 320 μm glass fiber in contact with the tissue at an average power of
lower right lip. b A similar view showing that the lesions are con- 4 W (100 mJ, 40 Hz). Fluence 637 J/cm2. d A 4-week postoperative
tained in the keratinized portion of the tissue. c An immediate post- photo showing complete healing with no residual lesion present
13 operative view of the excision areas. An Nd:YAG laser was used with
a b
c d
.. Fig. 13.10 a Fibroepithelial polyp seen on the left buccal mucosa Three weeks postoperative view showing complete healing. d The
caused by regular biting of the check. b The 980 diode laser with 3 W polyp after excision was fixed in 10% formalin and sent for histopa-
peak power and duty cycle 50% was used to excise the lesion. Com- thology examination
plete hemostasis was achieved with no need for dressing or sutures. c
. Figure 13.11 is a clinical case of an oral papil- Heck’s disease was confirmed depending on clinical
loma. The patient is a 36-year-old male, smoker with an characteristics, histopathological examination, and
inconspicuous medical history. A diode laser performed immunohistochemical staining. Depending on the exten-
the excision and excellent healing is anticipated. sive clinical situation, the decision was made to treat the
A 14-year-old female presented with extensively dis- patient using CO2 laser at wavelength: 10,600 nm, con-
tributed nodules and papules, which appeared when she tinuous mode and power of 6 W. It showed good func-
was 6 years old (. Figs. 13.12 and 13.13). The size of tion and aesthetic results. Five treatment sessions were
the lesions ranges from 2 to 30 mm. The diagnosis of required to manage all regions in the oral cavity.
412 O. Hamadah
a b
.. Fig. 13.11 a Pre-operative photo of a small oral papilloma on glass fiber in contact with the tissue at 30 W, 12,500 Hz, and a 9 μs
the buccal mucosa. b An immediate postoperative view of the exci- pulse duration. Average power 3.38 W. Fluence 554 J/cm2. Complete
sion of the lesion. An 810 nm diode laser was used with a 200 μm healing is expected
a b c
13
d
.. Fig. 13.12 a A 14-year-old female presented with an extensive with 6 W continues mode, which minimized the time of resection and
case of pan-oral focal epithelial hyperplasia covering most of her reduced the thermal damage of the oral mucosa. d The labial aspect
lining oral mucosa. b, c Immediate postoperative view of the labial of the upper lip 1 month following CO2 laser intervention with no
aspect of the upper lip after resection of lesions using the CO2 laser sign of relapse or new primary lesions
a b c
.. Fig. 13.13 a The same patient exhibiting multiple papillomatous aspect of the lower lip after ablation of lesions using the CO2 laser
lesions on the lining mucosa of the lower lip extending to the com- with continuous mode. c Uneventful healing of the oral mucosa
missure in both sides. b Immediate postoperative view of the labial 10 days postoperatively
mandibular, and vestibular region. The development of patient presented because of his concern with the grow-
a lipoma is not necessarily hereditary although heredi- ing size of the tumor although it has not yet caused any
tary conditions, such as familial lipomatosis can stimu- functional impairment. His hypertension and diabetes
late its growth [69]. Genetic studies support prior are controlled with medication. A diode laser was used
epidemiologic data in humans showing a correlation for the excision. A 15-year postoperative photo shows
between high mobility group proteins (HMG I-C) and excellent healing and no recurrence.
mesenchymal tumors [70]. When the patient’s complaint
is the size of the lesion, or to verify the diagnosis, the
treatment is excision. The laser’s ability to achieve 13.2.6 Pyogenic Granuloma
instant hemostasis offers a good view of the site, which
is important in some areas of the mouth, for example, in Pyogenic granuloma is a vascular lesion of skin and oro-
direct proximity to the mental nerve [71]. While any pharyngeal mucosa. It appears as reddish overgrowth
laser wavelength will perform the surgery, a fiber deliv- due to mechanical, physical, chemical, or hormonal
ered laser that has better maneuverability could be an trauma [51]. It is generally located in the anterior of the
advantage in the depth of the wound [72]. Depending on maxilla and can be painful if it is constantly irritated.
the dimension of the lesion, sutures would be placed to The lesion can grow rapidly and will often bleed pro-
avoid food impaction. For bigger and subdermal lesions, fusely after little or no trauma, and it has the appear-
irradiation with the Nd:YAG laser is performed by ance of a highly vascular granulation tissue with
inserting a 600 μm optical fiber within a cannula through inflammation on histologic examination. Special vari-
a 1 mm incision after applying local anesthesia under- ants of the pyogenic granuloma are the epulis granulo-
neath the tumor. The fiber is passed through the proxi- matosum and the granuloma gravidarum. Treatment is
mal end of the clamp, in order for the fiber to be a little not necessary except in cases of excessive bleeding or
longer than the cannula. The fiber is pouched no more pain and ulceration. After pregnancy, the lesion nor-
than 2–3 mm beyond the end of the cannula while laser mally regresses. [1, 52]. As expected, any surgical laser
emission is activated. The recommended parameters to that achieves good control of bleeding may be used [45,
be used to treat subjects in a single session using Nd:YAG 53]. A biopsy must be taken for histological verification
include average power 6 W, pulse repetition rate 30 Hz, of the lesion.
energy per pulse 200 mJ, and pulse width 100 μs [73, 74]. Pyogenic granuloma (PG) is one of the common
. Figure 13.14 is that of a 48-year-old male patient, inflammatory nonneoplastic vascular hyperplasias seen
nonsmoker with a non-contributory medical history in the oral cavity. It occurs in response to many factors,
presented with a slow growing mass in the mandibular for example, long-term irritation, traumas, or hormonal
vestibule. It was beginning to annoy the patient. A diode factors. It often arises in the second decade of life in
laser was used for an excisional biopsy and a diagnosis young females, probably due to the effects of female
of lipoma was confirmed. Sutures were placed because hormones [75].
of the large size of the excised tissue and the depth of Clinically, oral PG is a smooth or lobulated pedun-
the wound. Healing proceeded uneventfully. culated or sessile exophytic lesion which enlarge rapidly
. Figure 13.15 is a clinical case of a lipoma on the and easily bleeds. It is recognized as small pink to red to
lateral border of the tongue. The 58-year-old male purple papules depending of the persistence of the
414 O. Hamadah
a b
c d
.. Fig. 13.14 a Pre-operative photo of a lipoma lesion in mandibu- 2.93 W. Fluence 967 J/cm2. b The excised specimen has an irregular
lar vestibule. It is soft and elastic, but firmly attached to the underly- lobular surface, and the histologic diagnosis was that of a common
13 ing and covering tissue. There is no sign of any inflammatory process.
An 810 nm diode laser was used with a 300 μm glass fiber in contact
lipoma. c Immediate postoperative view showing closure of the deep
wound with sutures. d One-week postoperative view depicts good
at 30 W, 13,000 Hz, and a 9 μs pulse duration. Average power healing
lesion. It is most likely to appear in the gingiva and less eign bodies, calculus, and sharp restorations should be
common in the palate, oral mucosa, tongue, and lips eliminated [78].
[76]. Complete surgical resection of PG is considered the
Histologically, PG comprises a highly vascular pro- treatment of choice. This could be performed using a
liferation that resembles granulation tissue with a dense scalpel as a conventional treatment or preferably using
inflammatory infiltrate of neutrophils, plasma cells, and laser with indicated wavelengths [79]. The Nd:YAG,
lymphocytes. The surface of chronic lesions becomes CO2, Er:YAG, and high-power diode laser have been
ulcerated and replaced by a thick fibrinopurulent mem- reported in several studies as a suitable tool for surgical
brane showing more fibrous entities. Long-standing removal of PG offering a precise excision with minimal
PGs may progress to gingival fibromas as a result of bleeding [80, 81]. The wavelengths of diode 980 nm and
fibrous maturation [77]. Nd:YAG 1064 nm laser are well absorbed by oral lesions
Differential diagnosis of PG includes peripheral which exhibit a high amount of melanin and hemoglo-
giant cell granuloma, a peripheral odontogenic or ossi- bin such PG. Therefore, they consider the ideal lasers for
fying fibroma, and less commonly Kaposi’s sarcoma, PG management [82].
bacillary angiomatosis, and non-Hodgkin’s lymphoma. The procedure is performed after infiltration of
Thus, biopsy is the most decisive way to confirm the local anesthesia usually with a fiber lasing in a contact
diagnosis. Radiographic findings are absent in most mode with average power ranging between 2 and
cases [77]. 3.75 W. According to specifications of available laser
Scaling and curettage usually are the initial treat- device, continuous/interrupted or pulse mode can be
ment, and the patient is instructed to improve his/her used. The fiber tip (320–400 μm diameter) is pointed at
oral hygiene. In addition, all expected irritants like for- an acute angle of about 15°, moving it circumferen-
Laser Use in Minor Oral Surgery
415 13
a b c
d e f
.. Fig. 13.15 a A pre-operative view of the swelling in the left por- bonization because of the emission mode, but the hemostasis is
tion of tongue. b The tissue overlying the area is excised and the mass excellent. d A photo of the large sized lesion. e Three-week postop-
can be seen. It is adhered deeply in the underlying tissue. c An imme- erative photo shows healing with a substantial tissue defect. f Fif-
diate postoperative view of the excision area. An 810 nm diode laser teen-year postoperative view of the completely healed area with no
was used with a 400 μm glass fiber in contact with the tissue at 1.6 W sign of recurrence or a functional defect
continuous wave. Fluence 199 J/cm2. The lesion does show some car-
a b c
.. Fig. 13.16 a A discrete nodular, erythematous, sessile over- clinical diagnosis was a pyogenic granuloma which was confirmed
growth covering the cervical third of the crowns #11 and #12. b histopathologically. c Three weeks postoperative view showed
Complete removal of the lesion using 2 W super pulse CO2 laser. The uneventful healing
tially around the base of the lesion. Whenever the Er:YAG laser 2940 nm with average power: 3 W, energy
lesion starts to detach from its adjacent tissues, the per pulse: 300 mJ, frequency: 10 Hz, short pulse, with
fiber tip is directed toward the base of lesion itself to contact headpiece, with 50% water and 50% air, Tip
avoid cutting deeply within the tissues underneath Ø = 1 mm) [84].
resected lesion. For PG located on gingiva and for aes- To avoid recurrence, the excision should extend down
thetic and functional request, the proper gingival con- to the periosteum. Nonetheless, recurrence rate was
tour is better to be achieved during laser resection and reported in 8% of PGs resected with lasers in compari-
interdental papilla should be preserved when it is pos- son to 15% for those undergoing conventional treat-
sible. ments [85].
If PG is around an implant, then Er:YAG/ . Figure 13.16 is a healthy 48-year-old female com-
Er,Cr:YSGG lasers have the advantage of removing the plaining of a recurrent gingival overgrowth associated
lesion with minimal thermal effects to the implant sur- with the area of teeth 12/11. The patient manifested bad
face and surrounding bone [83]. The following parame- oral hygiene with interproximal open margin restora-
ters may apply safely in the field of intervention: tions. The lesion was about 1 cm in diameter with a ses-
416 O. Hamadah
sile base. The clinical diagnosis displayed a pyogenic Application Firstly, a gentle tension should be applied to
granuloma. It was asymptomatic and bled easily with technique pull the lesion away from its base and get
light contact. The CO2 laser was used to excise the lesion clean cut with clear borders, then the
offering a precise cutting with good hemostasis. clinician starts cutting the lesion with the
focused mode and finally the mode is
defocused to achieve the tissue vaporization
with keeping the tip away from the tissue for
13.3 Pre-prosthetic Surgery about 6 mm during the operation, and finally
the wound will stay exposed to heal in the
second intention in the site, the excised mass
should be sent to the pathological examina-
13.3.1 pulis Fissurata and Pre-prosthetic
E tion to confirm the diagnosis [93]
Vestibuloplasty of the Edentulous
Patient
Laser Diode
The epulis fissuratum or denture-induced fibrous hyper- Wavelength 810 nm
plasia is a trauma or inflammation caused lesion in
Average 2W
patients with partial or full dentures [86]. Ill-fitting and
power
overextended dentures can irritate the mucosal tissue
and create a hyperplastic tissue flap that can develop Emission Pulsed
mode
signs of secondary inflammation [87, 88]. Due to con-
stant irritation, the lesions can progressively grow, com- Local As needed
promising the support for the denture, which in turn anesthesia
causes more irritation. Often these epulis are combined Application Firstly, the lesion is grasped with Adson
with alveolar ridge atrophy and diminished or missing technique forceps or any other helpful toothless forceps
vestibular depth [89]. During conventional surgery, to fix the lesion and keep it under tension
then the excision starts at the base of the
hemostasis is difficult to achieve, especially for patients
mass in order not to over cut the tissues in
with bleeding dyscrasias. Furthermore, in most cases, the site with continuous removing and until
suturing the incision can result in a diminished vestibu- the lesion is detached and until we reach a
lar depth. Since laser surgical wounds show a reduced healthy connective tissue then the removed
number of myofibroblasts, there will be a diminished mass should be fixed in 10% formalin and
13 contraction the tissue when healing by secondary inten- sent to the histopathologist, neither sutures
nor dressings are needed in the site [94]
sion [90, 91]. Secondary wound healing is ordinarily
uneventful and significantly less painful than with a con-
ventional surgical protocol. Therefore, excision of the
. Figure 13.17 is that of a 68-year-old female patient,
epulis fissurata should be performed with a laser to
nonsmoker, presents with an ill-fitting denture and a
achieve adequate hemostasis even in patients with bleed-
very painful epulis fissuratum lesion in the midline lin-
ing disorder. If there are very large tissue flaps, a fiber-
gual vestibule. Her medical history is significant for
delivered laser can easily undercut them for excision [92].
hypertension, cardiac dysrhythmia, and Coumarin anti-
Several dental lasers have been used with the follow-
coagulant medication. A diode laser excised and con-
ing recommended protocols and parameters in the treat-
toured the tissue. Two weeks later, the area had healed,
ment of epulis fissuratum:
facilitating a new lower full denture, correctly extended.
Vestibular depth can be very challenging with elderly
Laser CO2 patients, and a vestibuloplasty can be planned. After los-
Wavelength 10,600 nm
ing their teeth at a young age, many of these patients
show a profound progressive atrophy of the skeletal bone.
Power 5–6 W This atrophy has anatomical limitations in the mandible
Emission Pulsed due to the structure of the self-supporting bone; thus, the
mode patient seldom presents with less than 8 mm of residual
Frequency 50 Hz bone height. In the maxilla, the limitations are the nasal
cavity with an apertura piriformis and the floor of the
Spot size 0.9 mm
maxillary sinus. If the alveolar ridge is lost, the bony con-
Local As needed figuration of the maxillary sinus takes over to function as
anesthesia the ridge. In the anterior segment, the alveolar ridge can
recede and disappear. Considering these anatomical situ-
Laser Use in Minor Oral Surgery
417 13
a b c
d e f
.. Fig. 13.17 a Pre-operative photo of an epulis fissuratum lesion tissue is carefully dissected from the underlying tissue bed, with the
in the midline lingual vestibule. The slight bleeding is due to admin- advantage of incisional hemostasis. d Immediate postoperative view.
istration of local anesthesia. A 980 nm diode laser was used with a e Excised tissue and histological confirmation of provisional diagno-
320 μm quartz fiber in contact at 1.5 W, CW. b, c The hypertrophic sis. f Healing at 2 weeks. (Case courtesy Prof. Steven Parker)
ations, experience has shown that, in a mandible with a Gingival recession is normally located in the anterior
residual height of approximately 10 mm, it is impossible mandible, due to a high insertion point of the mandibu-
to expect a satisfactory prosthodontic outcome. In the lar frenulum and a mis-aligned mental muscle with
maxilla a vestibular extension in the premolar and molar mobility of the periodontal soft tissue under function.
region is possible. However, the vestibule can only extend Treatment of this recession accompanied by a malalign-
to a certain height without compressing the residual soft ment of the mental muscles should be carefully planned
tissue, so relapse can occur. It is possible to stabilize the ahead of time so that patient can care for the healing
wound healing by inserting a free gingival graft [95]. edentulous area. The objective of the surgery is to divert
. Figure 13.18 is that of a 68-year-old male with a the muscle movement away from the periodontium and
medical history of cardiac insufficiency, hypertension, establish a neutral zone in the affected anterior vestibule
and nephrolithiasis, presents with insufficient vestibular [96]. One option is called the Kazanjian technique. An
depth. A diode laser was used for a vestibular excision incision line is made on the mucosa in the lip from canine
and a free gingival graft was inserted. The border of the to canine; or, it can be extended to the premolar region,
existing denture was extended apically to aid the graft in depending on the patient’s muscle activity zone [97]. A
healing. Six months postoperatively, the vestibular thin mucosal flap is prepared to the periosteum at the
depth is now adequate. mucogingival border by using a laser with a 200 μm fiber.
Atrophy of the alveolar ridge leads to the appear- Then the mental muscle is excised away from the perios-
ance of pre-existing frenula that can subsequently inter- teum into the vestibule. When sufficient vestibular depth
fere with the denture flange or the periodontal tissue. is achieved, the mucosal flap is placed back onto the peri-
Laser surgery offers benefits for frenum revision and osteum, and fixed there with two or three resorbable
vestibuloplasty and suturing, such as for conventional sutures to spread out the flap. The muscle and wound in
Z- or VY-plasty procedures, which are not necessary. the lip are prone to secondary granulation. The postop-
418 O. Hamadah
a b c
d e
.. Fig. 13.18 a Pre-operative view of the very short maxillary ante- covering the periosteum. d An extension was placed on the denture
rior vestibule extension, which is inadequate for a stable denture. b border for a scaffold enabling the graft material to adapt and heal. e
An incision was made to the periosteum with 810 nm diode laser A 6-month postoperative view shows the new vestibular depth with
employing a 400 μm glass fiber in contact with the tissue at 1.6 W healed tissue
continuous wave. Fluence 199 J/cm2. c A free gingival graft is placed,
a b c
13
.. Fig. 13.19 a Pre-operative view of a maxillary anterior frenum 135 J/cm2. The incision’s extension was well into the gingival tissue
whose attachment is embedded in the gingiva. b Immediate postop- to eliminate the muscle pull. No sutures were placed. c Postoperative
erative photo of the completed frenum revision. A 10,600 nm Car- view of the revised frenum, showing completely healed tissue
bon Dioxide laser was used in the SP mode at an average power of (Clinical case courtesy of Dr. Charles Hoopingarner)
1.5 W with an 800 μm beam diameter in non-contact mode. Fluence
erative outcome is generally uneventful, and patients revised frenum would also allow an adequate extension
report minimal bleeding with tolerable discomfort which of the denture flange. A carbon dioxide laser in super-
is eased with mild oral pain medication. Some swelling pulsed mode was used for the surgery. A 2-month post-
could occur. Over time, a relapse of recession can occur; operative photo shows total healing and a stable position
however, good oral hygiene measures can produce some of the frenum’s attachment.
stable reattachment. If the recession persists, a connective A prosthetic treatment in an edentulous patient can
tissue graft can be placed to re-establish an adequate zone be a real challenge to the dentist especially when the ves-
of attached gingiva. tibular depth is shallow, also epulis fissuratum which is a
. Figure 13.19 shows the revision of the maxillary soft tissue overgrowth related with a long-term irritation
frenum of a 65-year-old male with no significant medi- in the site or poorly adapted or over extended denture
cal history. The maxillary anterior frenum attachment can make the case more complicated [98, 99].
must be revised to allow improved periodontal health Vestibuloplasty and removing the fibrous hyperplasia
and further treatment planning for tooth restoration, are mainly performed by conventional scalpel but recently,
which may involve a maxillary denture. Clearly, the many lasers such as CO2, Er:YAG, Nd:YAG, and diode
Laser Use in Minor Oral Surgery
419 13
lasers are considered as appropriate alternative tools
Laser Diode
because of their advantages in reducing the postoperative
complications and acceleration the healing [98, 99]. Wavelength 940 nm
Achieving adequate vestibular depth has an essential Average 3W
role to improve the retention of the complete denture power
and leads to a good oral hygiene; alternatively, inade- Emission Pulsed
quate vestibular depth will produce poor plaque control, mode
gingival resection, and poor aesthetics, so that vestibulo-
Local As needed
plasty can be a necessary procedure in order to deepen anesthesia
the oral vestibule and increase the keratinized gingiva
Application Incising the tissues using an initiated 400 μm
[100]. However, this may be achieved using a range of
technique fiber tip extending all over the mucogingival
dental lasers following the instructions based on previ- junction with a horizontal stroke parallel to the
ous research as follows: bone relieving the muscle fibers from the
periosteum until we reach the desired depth [103]
Laser CO2
Wavelength 10,600 nm
Average 3W 13.4 renulae Revision for Children
F
power and Adults
Emission Pulsed
mode A frenulum attachment positioned within the attached
Focal spot 0.25 mm gingiva can lead to gingival recession and accompanying
size periodontal problems. The revision of this attachment
can be easily performed with a laser. The wound is usu-
Local As needed
anesthesia ally not sutured and the secondary intention healing
generally proceeds uneventfully [104]. This same treat-
Application The incision is horizontal across the muscle
ment method can be performed on children at any age
technique attachment by moving the hand parallel to the
mucogingival junction line with pulling the lip with no negative influence on the development of the
outward to keep it under tension, the mucogingival complex.
procedure is performed with an angled tipless Similarly, lingual frenulum the so-called Tongue-Tie
handpiece which is 1–3 mm away from the can be easily released using any available diode laser
tissue during the cutting procedure removing
wavelength, CO2 laser, or Er:YAG/Er,Cr:YSSG laser.
layer by layer in sweeping motions, moving it
at the “hand-speed” for a few seconds until we Early recognition and management of an abnormal
reach the periosteum [101] tongue frenulum attachment, especially Type III and IV
frenula can help prevent, breast feeding difficulty, air-
way and sleep disturbance, snoring, speech, and orth-
odontic problems [105].
Laser Er:YAG Midline diastema caused by a hypertrophic maxil-
Wavelength 2940 nm lary frenulum may interfere with orthodontic therapy
Pulse energy 200 mJ
and increase the possibility of post-orthodontic relapse.
If the space between the upper 7 central incisors is
Frequency 2 Hz more than 2–3 mm, frenectomy will become essential to
Local As needed facilitate its closure, as it is less likely to close spontane-
anesthesia ously [106].
Application Ablating the strong attached tissues starting Using laser to remove a prominent frenum is a sim-
technique from the mucogingival junction and 2 mm ple, quick, and efficient method in both contact and
from the bottom of the vestibule, removing non-contact laser application modes. A small amount of
the tissue by moving the laser tip until we local anesthesia is infiltrated then the frenum is incised
reach the ideal depth and after finishing the
procedure we can coagulate the surface with a
using a focused beam to lyse the fibrous band. This is
very long pulse defocused mode, finally the accomplished by grasping the tissue with a fine 7 hemo-
wound will remain exposed to heal in the stat or forceps at its inferior and superior attachment.
second intention without any sutures [98, 102] The frenum is then excised by directing the laser along
the hemostat outer levels. No sutures are need, and to
420 O. Hamadah
a b
c d
ensure hemostasis the bed of resected area is scanned by bands, where the underlying periosteum remains contig-
defocusing the beam [107]. uous to the alveolar osseous tissue. Where indicated, the
. Figure 13.20 depicts a mandibular anterior fre- use of either scalpel or suitable laser wavelength to score
num of a 35-year-old female patient with no significant the periosteum dissuades such complication and “finger-
medical history. The frenum inserts at the base of the like” multiple frond reinsertion.
gingiva and is causing a developing loss of clinical . Figure 13.22 shows a clinical case of a 15-year-old
attachment to the anterior teeth. One-month postopera- female patient undergoing orthodontic treatment pre-
tively, the frenum’s attachment has been repositioned on sented with the anterior impinging mandibular frenu-
the mucosa to eliminate the muscle pull on the gingival lum causing gingival recession. An incision for a mucosal
tissues. flap procedure was performed with a diode laser and tis-
. Figure 13.21 demonstrates the advantage of laser sue was repositioned. One-year postoperatively, the
soft tissue surgical management in the revision of a failed attached tissue has regenerated, and periodontal health
earlier upper labial frenectomy. Anecdotal evidence pro- is restored.
vides a potential for re-insertion of resected fibrous
Laser Use in Minor Oral Surgery
421 13
a b
c d
.. Fig. 13.21 a The case of a 33-year-old female patient who was banding, using parameters: 1.5 W Average Power/150 mJ
referred by her general dentist for a developing periodontal problem pp/10 Hz + water spray and air. Time taken 30 s. c Immediate post-
with her frenum. Her history involved a previous scalpel frenectomy operative appearance—a final pass with no water spray allows a
during teen years, that shows signs of fibrous reinsertion in the tenacious plasma coagulum to protect the wound. No sutures
attached gingiva. Anecdotal reasons are offered that omission to required. d Early healing at 2 weeks. (Case courtesy Prof. Steven
score the periosteum during the surgical procedure may predispose Parker)
to re-insertion. b Er:YAG 2940 laser was used to dissect all fibrous
422 O. Hamadah
a b c
d e f
.. Fig. 13.22 a A pre-operative view of gingival recession of the lower vestibular depth is created as shown in d. e A 1-week postoperative view
central incisor caused by the mandibular anterior frenum’s attachment. shows fibrin covering the wound as it heals by secondary intention
b An 810 diode laser was used with a 400 μm glass fiber in contact with granulation. f A 3-week postoperative photo depicts good healing. g
the tissue at 1.6 W continuous wave for an incision in the mucosa for a One-year postoperative view shows complete healing with a healthy fre-
13 flap procedure. Fluence 199 J/cm2. c The flap is completed and adequate nal attachment revision and resolution of the gingival recession
[108]. Their growth is attributed to endothelial cell common among Caucasians, who have a prevalence of
hyperplasia, they are classified as “children” or “con- 10–12% [114].
genital.” Several treatment modalities were suggested for
Another subclassification for hemangiomas is focal management of hemangiomas and vascular malforma-
and segmental. Focal hemangiomas are localized and tions. This will differ depending on the lesion’s type, size,
unilocular. Multifocal hemangiomatosis also exists, and depth, and location [115]. Surgery has been the main
newborns with more than five lesions should undergo a form of treatment for these lesions although total
study to rule out visceral involvement [109]. Segmental removal is sometimes not possible due to the extent of
hemangiomas are more diffuse in the form of a plaque the lesion, which may involve vital structures, significant
and can lead to dysfunction and cosmetic alterations. deformity, prolonged pain, skin necrosis, nerve damage,
The extremities and face are common places of appear- systemic toxicity, and hemorrhagic phenomena [116].
ance. Other possibilities include embolization, steroid
The current classification of vascular lesions can be therapy, cryosurgery, electrodessication, and laser ther-
consulted on the website of the International Society for apy. High-power density laser treatment is an alterna-
the Study of Vascular Anomalies (ISSVA) [110–113]. As tive, becoming one of the main treatment options for
a summary, we can classify the vascular anomalies as vascular lesions [117].
seen in . Fig. 13.23. The mechanism of laser therapies in treating heman-
The presentation of hemangiomas is variable in giomas is achieved by targeting intravascular oxyhemo-
terms of size, extent, and morphology. When there is globin, resulting in vascular injury. In general, laser
superficial dermal involvement, the skin takes on a irradiation is indictable for the treatment of early super-
raised, firm appearance with a vivid crimson color. If ficial hemangiomas or the superficial portion of a com-
the hemangioma is confined to the deeper dermis, sub- pound hemangioma, due to the limited penetration
cutaneous tissue, or muscle, the overlying skin may be depth which is less than 5 mm [115]. However, Nd:YAG
slightly raised and appear bluish in color. Hemangioma laser is more suitable for larger hemangiomas measuring
may present with a macular, telangiectatic appear- up to 2 cm in depth. Percutaneous interstitial irradiation
ance. is another treatment modality that can be used for deep
However, spontaneous involution may be incom- hemangiomas to avoid skin damage and to diminish
plete, and ~15–20% of the residual lesion may remain. lesions effectively. It is very frequent that vascular lesions
In cases of complete involution, scarring, replacement are included between different planes, which makes it
with fibrofatty tissue, tissue discoloration, and telangi- impossible to completely remove them due to the risk of
ectasia are generally observed. A total of 65.3% of injuring other structures. For this reason, when it is sus-
affected patients are children. These lesions are more pected that their anatomical relationship may pose
424 O. Hamadah
problems, a detailed study of their location must be car- will facilitate a homogeneous delivery of laser to the
ried out. Nuclear magnetic resonance and selective whole lesion.
arteriography, among others, are tests that can help us
make the most appropriate therapeutic decision. Excisional Biopsy
The use of different lasers for treatment of vascular In the case of excisional biopsies, any surgical laser that
lesions has been recommended in the literature. Any can emit a sufficient power density can be used. The
high-power density laser can be used, but it is conve- most widely used lasers for this purpose are the CO2
nient to know the effect the wavelength used will have, as laser, Er:YAG, Er,Cr:YSGG and diode lasers. It is essen-
well as the parameters applied on irradiated tissues. The tial to consider that the fiber in infrared diode lasers
most commonly used lasers are Nd:YAG and infrared must be activated to obtain the cutting effect. The emis-
diode lasers. sion parameters will vary depending on the laser which
In the oral cavity, it is common to see isolated lesions will be used. The lesion is removed by cutting through
that can be easily removed, but on some occasions their the healthy tissue that surrounds the visible lesion.
proximity to bone structures can hide a vascular shunt Unlike the other techniques—which will be discussed
that could complicate the intervention and even jeopar- later, histological information can be obtained from an
dize the patient’s life. excisional biopsy.
Once the topographic scope of the lesion has been
established, we can opt for different techniques; exci- Transmucosal Photothermal Coagulation
sional biopsy, transmucosal thermocoagulation, or Another therapeutic option is transmucosal photother-
intralesional photocoagulation. However, before utiliz- mal coagulation. This technique takes advantage of the
ing any interventional technique to manage a vascular mucosa’s poor absorption of the applied laser wave-
lesion, a precise diagnosis should be obtained to deter- length, so that the energy accumulates in the hemoglo-
mine the extent and flow pattern of the lesion. This will bin contained in the vascular lesion.
include having a thorough history of the present com- This technique can be considered the least invasive
plaint and an accurate clinical examination. The extent of the three techniques proposed with the use of laser.
and flow patterns of vascular malformations are usually It is of high value to know the optimum wavelength
confirmed depending on the findings of color Doppler absorbed by target tissue since this will be the basis of
ultrasound, MRI, or angiography. the success of the treatment. . Figure 13.24 shows
For transmucosal thermocoagulation and intrale- wavelength absorption peaks of different biological
13 sional photocoagulation techniques, it is recommended
to infiltrate the bed of target lesions with local anesthe-
chromophores. It is important to note that it is a loga-
rithmic graph and having a good understanding is para-
sia without adrenalin to avoid vessel contraction. This mount to anticipate the behavior of laser used.
a b c
d e
.. Fig. 13.25 a, b Two pre-operative views of a vascular malforma- 128 J/cm2. The laser was activated until the tissue appeared blanched,
tion on the upper right lip. c Immediate postoperative view. An and then the laser was turned off. d A 1-week postoperative view
810 nm diode laser was used with a non-initiated 600 μm glass fiber shows granulation is proceeding. e Four-week postoperatively, the
out of contact with the tissue at 2.5 W continuous wave. Fluence area is healed and the lesion disappeared
a b c
13
.. Fig. 13.26 a Pre-operative view of a large vascular malformation duration. Average power 3.75 W. Fluence 928 J/cm2. c A 5-day post-
lesion on the lower lip. b An 810 nm diode laser was used with a operative photo shows normal wound healing
400 μm glass fiber in contact with 30 W, 12,500 Hz, and a 10 μs pulse
a b c
.. Fig. 13.27 a Pre-operative view of the hemangioma on the cen- average power of 2 W in SP mode with a 400 μm non-contact tip.
tral area of the lower lip. b Immediate postoperative view of the Fluence 289 J/cm2. c A 6-week postoperative photo showing com-
lesion ablation. A 10,600 nm Carbon Dioxide laser was used with an plete resolution of the vascular lesion
gioma and promote its regression. The Nd:YAG laser mode through a glass slide placed with added compres-
was used in the transmucosal photothermal coagulation sion over the lesion. This will prevent the laser from pen-
technique, in which the laser was applied in non-contact etrating the lining mucosa above the lesion and help in
Laser Use in Minor Oral Surgery
427 13
a b c
d e
.. Fig. 13.28 a Pre-operative view of a hemangioma on the lower motion, covering the extent of the lesion. No anesthesia was used,
lip from the extraoral view. b The intraoral view showing the extent and the patient was comfortable. d The immediate postoperative
of the lesion to the inner mucosa. c An 808 nm diode laser was used view after 1 min shows the tissue is light gray color. Ice was applied
with a 400 μm non-initiated fiber in non-contact, approximately for 2 min to reduce edema of the surrounding tissues. e Three-month
2 mm from the tissue surface. Average power 3.0 W CW. Fluence postoperative view shows complete tissue healing. (Clinical case
154 J/cm2. The handpiece was in constant movement with a circular courtesy of Dr. Giuseppe Iaria)
a b
c d
.. Fig. 13.29 a The initial clinical appearance of a hemangioma achieved by delivering the laser in non-contact mode through a glass
affecting the upper lip and philtrum. The lesion gradually increased slide placed with added compression over the lesion. c, d A complete
in size since birth. b An irradiation session, in which the transmuco- resolution of the vascular lip lesion after five irradiation sessions.
sal photothermal coagulation technique was applied, used Nd:YAG The patient is set to undergo a surgical intervention to correct the lip
laser with pulse mode to facilitate vessels shrinkage inside the lesion asymmetry after puberty
without damaging the superficial surface of the lesion. This was
428 O. Hamadah
lasing the lump homogenously. Obviously, the Nd:YAG was used: 2 W (100 mJ per pulse), 20 Hz, pulse duration
laser was applied in pulse mode with following operat- 140 μs with a fiber tip of 800 μm, 12% water, and 12% air
ing parameters: 3 W, 60 Hz, and 50 mJ. Five sessions for irrigation. No anesthesia was used in this procedure.
were required. The case requires cosmetic correction All lesions were resected in the same session and left to
after puberty and complete development of the lip. heal by secondary intention. Complete re-epithelization
The clinical appearance of multiple vascular lesions was achieved after 3 weeks.
noticed on the right buccal mucosa which were treated A 32-year-old woman who presented with a defor-
previously without complete resolving (. Fig. 13.30). mity in the lip/nose area on the right side of her face
An Er,Cr:YSGG laser with the following parameters (. Fig. 13.31). It was a congenital lesion that increased
a b
c d
13
e f
.. Fig. 13.30 a Multiple vascular lesions appearing on the buccal penetration and incidental bleeding. d Immediate postoperative. e
mucosa. b, c Lesions removal using Er:Cr:YSGG. Cutting was per- Healing process after 1 week of treatment. f Three weeks post laser
formed about 1–2 mm outward of the lesion margin to avoid lesion application view showing uneventful healing
Laser Use in Minor Oral Surgery
429 13
a b
c d
e f
g h
.. Fig. 13.31 a, b A vascular lesion affecting the right upper lip pro- end of the cannula, while laser emission is activated. The 980 nm
ducing facial asymmetry. c, d Intraoral view of the lesion which mea- diode laser, 1 W in continuous mode was used in this case. h Three
sures about 2 cm in diameter. e–g The intralesional lasing technique weeks post laser application showing significant reduction in lesion
was used by inserting a 320 μm optical fiber within a cannula through size with no sign of scaring or discoloration
the lesion wall to the center of the lump, passing 2–3 mm beyond the
430 O. Hamadah
slowly in size over time, which was prominent over the through the proximal end of the clamp no more than
last year. The pre-operative study showed a vascular 2–3 mm beyond the end of the cannula while laser emis-
lesion that extended from the cutaneous plane to the sion was activated. Clinical case courtesy of Prof Antoni
mucosa, crossing the levator labii superioris muscle, the J. España.
zygomaticus minor muscle, the risorius muscle and, par- A 14-year-old female was diagnosed with an upper
tially, the orbicularis oris muscle. In her previous consul- lip congenital hemangioma, exhibiting consistent
tation visits, she had been advised against carrying out enlargement overtime (. Fig. 13.32). The patient pre-
any treatment due to the high risk of a worse unsightly sented complaining of her lip asymmetry. Surgical resec-
result. As there being a possibility to reduce the volume tion of the lesion was excluded as it would cause
of the lesion, the intralesional technique was performed unfavorable deformity of the lip. The transmucosal pho-
with the help of a 980 nm laser, 1 W in a CW. One car- tothermal coagulation technique was used to reduce the
tridge of 0.5% articaine anesthetic solution with volume of the vascular lesion using the Nd:YAG laser
1:200,000 epinephrine was infiltrated, half the amount with a wavelength of 1064 nm, offering a penetration
near the infraorbital nerve and the other half on the depth of 4–6 mm by non-contact mode. The following
anterior superior alveolar nerve. The procedure was per- parameters was applied: 3 W, 50 Hz, and 60 mJ. The
formed by inserting a 320 μm optical fiber within a can- laser beam was delivered using a 320 μm fiber tip and
nula, through the lesion wall. The fiber was passed laser irradiation was applied 2 mm away from the visible
a b
13
c d
.. Fig. 13.32 a, b Initial clinical appearance of a hemangioma radiation, the treated area turned off-white, with a surrounding ery-
affecting the right upper lip. The lesion showed a persistent increase thematous flare with a slight swelling. e, f A 2 weeks view post laser
in size especially over the last year. MRI was organized to determine irradiation showing a good recovery with fibrin residues. g, h A com-
the extent and the flow pattern of the lesion. c, d First irradiation plete resolution of the lip vascular lesion after seven irradiation ses-
session. For aesthetic and function purposes, transmucosal photo- sions. i, j The patient underwent a surgical intervention to correct the
thermal coagulation technique using Nd:YAG laser with pulse mode lip asymmetry. k, l Six weeks post-surgery, whereby the final result
was applied to facilitate vessels shrinkage inside the lesion without was remarkable with no sign of scaring or discoloration
damaging the superficial surface of the lesion. Immediately after
Laser Use in Minor Oral Surgery
431 13
e f
g h
margins of the lesion toward its center in a spiral mode. Extravasation mucoceles are considered pseudo-cysts as
Treatment was repeated at an interval of 4 weeks for no epithelial lining is detected histopathologically. In
seven treatment sessions. Subsequently, the patient contrast, retention mucoceles are true cysts with cubic
underwent a surgical correction to re-contour the resid- or squamous cell epithelial linings [77]. They are less
ual deformity and hypertrophied tissues in the lip, in common but more frequent among major salivary gland
order to improve cosmetics and competency. ducts as a result of ductal obstruction by a calculus or
scar that interferes with the normal salivary flow causing
mucosal lump and ductal dilatation.
13 13.5.2 Mucocele In some cases, extravasation mucoceles can regress
spontaneously with no sign of recurrence. Treatment is
A mucocele is considered the most common minor sali- only necessary when the patient’s function is impaired.
vary gland disorder with a high incidence rate among Several treatment modalities of mucoceles have been
older children or young adults in both genders, nonethe- described in the literature including: cryosurgery, intra-
less, mucoceles have been reported in patients of all ages lesion injection of corticosteroid, micro-
[139]. It is caused by accumulation of mucus following marsupialization, conventional surgical removal, and
rupture of a salivary gland or a traumatic injury to its laser ablation [142, 143].
duct in which the saliva spills into the oral cavity’s subepi- Excision can be performed by scalpel which can be
thelial tissue [77]. Clinically, it appears as a round, well- challenging since there is no true cystic capsule. Similarly,
circumscribed, asymptomatic dome-like swelling that a laser can also lacerate the lesion; but, with a fiber
ranges from a few millimeters to several centimeters in delivery, it is possible to weld the injured and now over-
size. Depending on the persistency and the amount of lapping wound edges together. This can conserve some
mucosa accumulated inside the lesion, the outer surface of the form of the cyst and gland without blindly dis-
may exhibit deep blue to pinky-pale color [140]. Mucoceles secting too much tissue. In deep excisions, two or three
are usually painless, however, in some persistent long- sutures are placed to avoid food impaction and allow
standing cases, the size of mucoceles can cause discomfort healing to occur. Patients report very little pain or loss
and interfere with speech, chewing and swallowing and of function. Wound healing is by secondary intention.
even causes a concern to the patients from being sinister Ramkumar et al. suggested using diode laser in
lesion [141]. Although the lower lip is the most common wavelength of 940 nm, with fiber tip 400 μm at 1.5 W in
site for a mucocele, it is also present on the ventral tongue, continuous mode. The initial incision was performed on
the floor of the mouth, and check mucosa [142]. the uppermost site of the swelling and then the lesion
According to its cause, mucoceles are classified as was resected completely down to the muscular layer
retention cysts and extravasation accumulations. [144].
Laser Use in Minor Oral Surgery
433 13
Choi et al. depending on available data of 164 ful healing, attributable in part to wavelength-associated
patients found that oral mucocele recurrence is signifi- PBM.
cantly higher on the ventral tongue (50%) than on the . Figure 13.34 is a 22-year-old patient who had a
labial/buccal mucosa. In addition, patients aged under sublingual retention cyst for more than 2 months. The
30 years old exhibited a higher recurrence rate (16.0%), swelling appeared after a traumatic injury to the floor
compared with older individuals (aged >30 years, 4.4%). of the mouth, causing a scar in the salivary gland duct
With respect to intervention method, both surgical pro- which obstructed saliva flow. The occlusal view was
cedures using scalpels and those using laser showed sim- negative with no sign of calcified stones. The outer sur-
ilar recurrence rate [145]. face of the swelling was removed by a diode laser with
. Figure 13.33 is a 16-year-old female who has a a wavelength of 810 nm and power of 2.5 W. The
recent history of biting her lower lip. A rounded swelling patient showed a good recovery after 1 month postop-
with semi-translucent appearance suggested the devel- eratively.
opment of a mucocele. Under local anesthesia, the . Figure 13.35 is a healthy, non-smoking 26-year-
lesion was surgically dissected, taking advantage of laser old female, was concerned about a lump on her lower lip
hemostasis and using a diode 980 nm laser. The lesion that had been growing for 3 months, measuring about
was removed intact, to facilitate histological examina- 5 mm in diameter. It was soft on palpation with a bluish
tion. Early (5 days) and later (1 month) indicate unevent- color, nonetheless, blanching test was negative. The
a b c
d e f
.. Fig. 13.33 a Pre-operative appearance of rounded translucent was possible to dissect the lesion. d Immediate postoperative appear-
swelling lower lip in a 16-year-old female. History of recent biting ance. No sutures required. e, f Early (5 days) and later (1 month)
trauma. b, c Using a 980 nm diode laser and 320 μm quartz fiber uneventful healing and complete resolution of the surgical site.
1.2 W CW power parameters, together with incisional hemostasis, it (Case courtesy Prof. Steven Parker)
a b c
.. Fig. 13.34 a A well-defined retention cyst on the on the floor of the mouth expanding for more than a month. b The cyst was excised
using the 810 nm diode laser. c No relapse was seen after 1 month and the operation bed showed good recovery
434 O. Hamadah
a b c
d e f
.. Fig. 13.35 a Mucocele of the right lower lip was recognized at muscular layer and the surgery bed was left to heal with secondary
3 months. b The 810 nm diode laser with initiated 300 mic tip was intension. e Ten days postoperatively. f One-month post laser surgery
used to remove the lesion. c, d Excision area extended down to the with no sign of recurrence or scaring
810 nm diode laser was used to excise the lesion, which imaging, and endoscopic evaluation. Other symptoms
was identified as a retention cyst. The excision area was can be due to an obstruction such as one in Wharton’s
left to heal with secondary intention with no need for duct in the floor of the mouth resulting in an infection
dressing or closure sutures. of the gland. Chronic inflammation may lead over time
to an atrophic replacement of the acinar cells by scar
and fatty tissue [149]. An acute inflammation is often the
13.5.3 Sialolithiasis first sign of a sialolithiasis even in the presence of an
13 extensive calculus formation. Instead of extirpating the
Sialolithasis is the occurrence of a salivary stone or gland, a different therapeutic concept has been devel-
calculus and is a frequent cause of inflammatory oped nowadays which analyzes the location and size of
changes within the large salivary glands. Statistics the stones [150]. In cases of normally small size parotid
show that over 78% of salivary stone formation affect stones, a basket extraction shows promising results. Also
the submandibular gland and 81% appear in the extracorporeal sonographically controlled lithotripsy
parotid gland; but is a rare occurrence in the sublingual plays a major role in therapy. Endoscopic techniques
gland, though not totally unknown [146]. Clinical can more precisely locate the stones. Although extra-
practice detects signs of stone formation in 1 out of and intracorporal lithotripsy show excellent results, that
10,000 patients. The incidence in male patients is 2–3 method is not often used due to accessibility and cost of
times higher than in females. The greatest presence can the apparatus.
be found in the age range of 50–70 years, but sialiths A trans oral approach has been established as an
have been reported in children. Some reports assume a alternative; as a result, more than 90% of all subman-
correlation between sialolithiasis and other stone dis- dibular stones can be removed preserving the gland.
eases as urinary or biliary stones, but large multicenter After sounding the duct to locate the stone, it is easy to
studies show no correlation at all [146, 147]. Major incise the tissue and locate the stone which can be mobi-
salivary gland stones are usually measured between 5 lized and removed. Following the incision using a 320–
and 10 mm in size. Giant sialoliths is a term used to 400 μm surgical fiber, a dissecting scissors is used to
describe those stones exceeding 15 mm in any one dilate the incision wound and expose the sialolith. After
dimension [148]. the exposure, the sialolith is grasped with the mosquito
The typical symptoms include a painful swelling of hemostat or forceps and removed from the duct. Once
the affected salivary gland which is intensified by chew- the stone is retrieved, the duct is marsupialized into the
ing and at mealtimes. The diagnosis is based on the clin- floor of the mouth with 5/0 vicryl sutures [151]. Checking
ical symptoms, ultrasound examination, radiographic duct patency is an essential step after sialolithotomy, in
Laser Use in Minor Oral Surgery
435 13
a b c
.. Fig. 13.36 a A radiograph of the area showing a large sialolith in tissue at 30 W, 12,500 Hz, and a 9 μs pulse duration. Average power
the Warton’s duct. X-ray shows a large sialolith in the Wharton’s 3.38 Watts. Fluence 554 J/cm2. c Immediate postoperative view
duct. b A photo of the excised sialolith. An 810 nm diode laser was shows good hemostasis. No sutures were placed and healing is
used for the incision with a 200 μm glass fiber in contact with the expected to be normal
some cases, a micro-drainage may be placed in the duct 13.5.4 xcessive Gingival Display (Gummy
E
to avoid scar formation and blockage of the duct. Smile)
Conventional instrumentation offers no control of
bleeding and with the flow of saliva, visibility can be A smile is the most essential expression on a person’s
extremely difficult during the surgery. A laser insures face. It has a vital role in facial attractiveness, and it can
good hemostasis and therefore a good overview of the positively affect the patient’s social interactions.
operation site. Sutures are not usually placed, and the However, an ideal smile comes from a balance between
healing is uneventful healing with little scaring [152– three mutually related main factors: teeth, gingiva, and
154]. Accordingly, several laser wavelengths have been lips [155]. Increased interest has been shown to rectify
employed to treat sialolithiasis, including carbon diox- excessive gingival display in growing numbers of indi-
ide, diode, Ho:YAG, and Nd:YAG lasers. viduals. Reports demonstrate a prevalence of 7% in
7 Angiero et al. reported the efficacy of 810 nm males and 14% in females. Several factors may take part
diode laser as an alternative surgical tool to remove in producing this aesthetic issue. For instance, delayed
stones from the submandibular duct even those over tooth eruption, a short or hypermobile upper lip, gingi-
4.5 cm in size. The laser was used in continuous mode at val hyperplasia, and skeletal reasons [156]. Nevertheless,
2.5 W power, and the beam was delivered using a 320- lip repositioning surgery had seen the light for the first
μm flexible fiber [152]. time by Rubinstein and Kostianovsky in 1973, and it
. Figure 13.36 shows a clinical case of a 48-year-old was considered as an effectual, safe, and predictable
male smoker presented with a painful swelling subman- approach to manage gummy smiles with an average of
dibular which intensifies during chewing and eating. His 2.71 mm of exposed gingiva [157]. However, gummy
medical history includes hypertension and hyperlipid- smiles can be managed using several treatment
emia. A radiograph was taken and the diagnosis was approaches. For example, orthognathic surgery, orth-
made as sialolithiasis. A diode laser performed the inci- odontic intrusion, crown lengthening, botulinum toxin,
sion, and the stone was removed. No sutures were placed and lip repositioning. Thus, the underlying causing fac-
and the healing is expected to be normal. tor should be identified decisively in order to determine
. Figure 13.37 is a 56-year-old female complained the appropriate treatment plan accurately [158]. The
of firm painful swelling in the right floor of the mouth. concept includes the removal of a partial-thickness
The clinical and radiological examination confirmed the mucosal strip from the vestibular alveolar mucosa of the
presence of a 1 cm stone in the submandibular gland. internal upper lip, then suturing the apical edge of the
The 980 nm diode laser was used to create an incision exposed wound to the mucogingival margin aiming to
over the stone. A dissecting scissor was used to dilate the shorten the vestibule and reduce lip movements. Whereas
incision wound to facilitate the stone’s removal. A various modifications were dissimilar to the original
micro-drainage was placed in the duct for 3 days after technique, some of them described a full-thickness flap
stone retrieval to avoid scar formation and blockage of excluding the frenum by creating a V-shape in the middle
the duct. The patient was seen in 1 month time with no of the flap [156].
sign of swelling or salivary flow disturbance.
436 O. Hamadah
a b
c d
13
.. Fig. 13.37 a Painful swelling associated with the right subman- flow and prevent scar formation. c 1 cm sialolith was removed from
dibular gland duct. The location of the stone was confirmed radio- the duct. d One-month view of the floor of the mouth showed
graphically. b Incision was performed using the 980 nm diode laser uneventful healing with normal saliva flow from the salivary gland
which helped in stone removal. Then a micro-drainage was placed orifices
inside the duct and sutured to adjacent mucosa to enhance saliva
Laser surgery is considered as a proper alternative extraordinary visual surgical field during the procedure
tool in soft tissue oral surgeries due to its recorded even in the extremely vascularized tissues [159, 160].
advantages in decreasing the postoperative complica- Lip repositioning using laser surgery is an effective,
tions and in accelerating the healing process. Putting in safe, and predictable approach to manage excessive gingi-
mind the fact that the CO2 laser is the laser of choice in val display caused by soft tissue disorders (short upper lip
the majority of soft tissue oral surgeries, consequential or hyperactive elevator muscles). The procedure is
to its efficient role in providing coagulation and an explained step by step in the related photos in . Fig. 13.38.
Laser Use in Minor Oral Surgery
437 13
a b
c d
e f
.. Fig. 13.38 a A 24-year-old female presented complaining of an ing. d A strip of mucosa removed by CO2 laser demonstrates a par-
excessive gingival display while smiling. b The tissue was dried prior tial-thickness flap removed without bleeding. e, f A 15 blade was
to marking of the incision outlines using a sterile surgical marking used in peeling movements to encourage a slight bleeding which
pen, the margins were made 1 mm coronal to the mucogingival line helps in accelerating the wound recovery, also the margins were dis-
in order to achieve accurate suturing from the distal line of the sec- sected about 2 mm around to minimize tension during wound sutur-
ond premolar in both of the right and the left sides, in addition, a ing. g Subsequently, the wound’s borders were sutured with
V-shape was made in the area of the upper lip frenum. Thus, the lip interrupted technique using 4/0 silk sutures. The first one was per-
midline was punctually determined and the symmetry was well formed in the midline in order to ensure the symmetry of the lip. h A
achieved. Then the second incision was made in the labial mucosa couple of indicative sutures in the midpoint of the canines areas in
parallel to the first incision and 10–12 mm apical to it, the two inci- each side, so that two windows were made in order to compare the
sions were connected. c A partial thickness epithelial strip was care- symmetry of the lip. Additional sutures were used in the rest of the
fully removed utilizing 10,600 nm CO2 laser with 4 W in continuous two regions. i Follow-up appointment illustrates the punctual mid-
mode, this facilitated complete resection of the strip without bleed- line and crystal-clear lip symmetry
438 O. Hamadah
g h
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pho.2017.4410. 154. Martellucci S, Pagliuca G, de Vincentiis M, Greco A, Fusconi
138. Álvarez-Camino JC, España-Tost AJ, Gay-Escoda M, De Virgilio A, Gallipoli C, Gallo A. Ho:YAG laser for
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oral.18528. 155. Younespour S, Yaghobee S, Aslroosta H, Moslemi N,
139. Khandelwal S, Patil S. Oral mucoceles—review of the litera- Pourheydar E, Ghafary ES. Effectiveness of different modali-
ture. Minerva Stomatol. 2012;61(3):91–9. PMID: 22402300. ties of lip repositioning surgery for management of patients
140. More CB, Bhavsar K, Varma S, Tailor M. Oral mucocele: a complaining of excessive gingival display: a systematic review
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2014;18(Suppl 1):S72–7. https://doi.org/10.4103/0973- https://doi.org/10.1155/2021/9476013. PMID: 34660802;
029X.141370. PMID: 25364184. PMCID: PMC8516537.
141. Nagar SR, Fernandes G, Sinha A, Rajpari KN. Mucocele of 156. Tatakis DN. Lip repositioning techniques and modifications.
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org/10.4103/jomfp.jomfp_396_20. PMID: 34083968. 157. Ardakani MT, Moscowchi A, Valian NK, Zakerzadeh E. Lip
142. Bagher SM, Sulimany AM, Kaplan M, Loo CY. Treating repositioning with or without myotomy: a systematic review. J
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445 IV
Laser-Assisted Oral
Multi-tissue
Management
Contents
Contents
References – 473
Laser Treatment of Periodontal and Peri-implant Disease
449 14
Core Message be a daunting task: there can be several species of patho-
Therapy for periodontal and peri-implant disease contin- gens in any one site; some can be more opportunistic
ues to evolve with new methodologies, medications, and than others and may proliferate after the initial inflam-
instrumentation added to the conventional armamentar- mation rather than cause it; and the patient’s immune
ium. Dental lasers have been used both adjunctively and response can vary.
alone in the protocol. Clinical studies and basic investiga- Peri-implant disease shares the same etiology—
tions have shown that laser photonic energy has been a microorganisms causing a plaque-associated pathologic
useful addition to increase the effectiveness and outcomes condition—and the literature is beginning to report sig-
of treatment of the disease. nificant statistics that indicate many implant sites will
develop the disease [3]. All of the abovementioned con-
ditions and factors will contribute to the severity as well
14.1 Introduction as to the success of any therapy. For clarity, soft tissue
inflammation—bleeding on gentle probing—is termed
The periodontium is essential for optimal oral function peri-implant mucositis, whereas inflammation of the
and health. Any inflammation will affect both soft and peri-implant mucosa and subsequent implant bone loss
hard tissues and could lead to loss of those structures. is termed peri-implantitis.
Periodontal disease is an infection whose primary etio- The recent periodontal and peri-implant disease
logic factor is the oral pathogens existing in the plaque classification scheme describes both the staging of the
biofilm. Initially, the gingiva will become inflamed with- severity and complexity of the disease and the grading
out attachment loss, and the disease is thus termed gin- which can help assess the outcome and progression of
givitis. With increasing pathogen invasion, there will be the disease [4, 5]. Once the diagnosis is reached, a treat-
loss of connective tissue attachment as well as apical ment plan can be developed.
migration of the epithelial tissue with subsequent infec- The general understanding is that the gold standard
tion and resorption of the alveolar bone. Periodontal for successful treatment of these diseases is gained in
disease is a worldwide public health burden. Indeed, clinical attachment level. The root/implant surface
studies show that various stages of periodontitis are one should be restored to biocompatibility to re-establish
of the most commonly occurring diseases in middle- that attachment without the presence of inflammation
aged adults [1]. Moreover, periodontal disease has been [6, 7]. There are however other clinical creditable end-
linked with other systemic diseases. Oral pathogens can points such as lack of bleeding on probing, complete
migrate through the inflamed and ulcerated gingival epi- removal of accretions, and measurable regeneration of
thelium into the rest of the body. There are suggested bone, periodontal ligament, and cementum. Of course,
clinically important associations between periodontal the patient’s oral hygiene improvement and reduction of
bacteria and conditions ranging from peripheral artery other risk factors can also be considered and are crucial
disease, liver cirrhosis, and chronic kidney disease to for maintenance of a stable periodontium.
other systemic disorders including cardiovascular, respi- This chapter will be divided into three modalities of
ratory, and osteoarticular problems. These connections treatment utilizing lasers in nonsurgical, surgical, and
highlight the importance of treating this disease because antimicrobial photodynamic modalities. These methods
of its implication on general medical health. Interestingly, are separate therapies but may be combined to produce
the reverse association is also important: the patient’s the best result. A nonsurgical protocol is the first
age, smoking habits, and the presence of diabetes can approach, but surgery may follow to help unresolved
worsen chronic periodontal inflammation. Other risk problems. Photoactivated medications can be a useful
factors include genetics and lifestyle, and, clearly, this addition for either procedure. Since periodontal or peri-
disease is multifactorial. implant disease can have episodic progression, one or
Putative periodontal pathogens, such as Aggregati- more of these treatments may be employed for the cur-
bacter actinomycetemcomitans and Porphyromonas gin- rent stage of the disease.
givalis, have long been considered the primary
contributors to the disease. However, the red complex
especially three species—Porphyromonas gingivalis, Tan- 14.2 Nonsurgical Periodontal
nerella forsythia, and Treponema denticola—are now and Peri-implant Disease Laser
regarded as the most pathogenic and are prevalent in Therapy
biofilm. Moreover, these pathogens can reinfect the
patient, diminishing the effect of therapy, especially with The term “nonsurgical therapy” is defined as a protocol
sporadic supportive maintenance care [2]. Unfortu- to remove as much calculus as possible, to disrupt or
nately, determining which organisms are important can eliminate the biofilm and accompanying microbes, and
450 D. J. Coluzzi et al.
to reduce inflammation contributing to periodontal and regimen. Several appointments may be necessary to com-
peri-implant disease as initial therapy. After this phase plete the initial nonsurgical protocol, and adequate eval-
of treatment, the patient’s periodontal condition will be uation periods will determine how successful the patient
evaluated. Two possibilities then exist: one, the patient compliance and the practitioner’s efforts have been.
will receive nonsurgical periodontal maintenance; two, a
surgical procedure must be performed as a next step.
During initial nonsurgical therapy, it is essential that 14.2.1 urrently Available Laser
C
root/implant accretions be thoroughly removed [8]. Wavelengths
Conventional periodontal treatment begins with calcu-
lus and biofilm removal, using scaling instruments on Dental lasers are generally used adjunctively for the
the tooth surfaces while using carbon fiber or plastic above-described initial nonsurgical therapy [14, 15]. For
curettes on the implant fixture. For the patient with gin- purposes of this section, the laser instrument described
givitis or beginning peri-implant mucositis, that proce- will have a minimum output of approximately 0.5 W of
dure is very straightforward with ease of access. As the average power. This is to distinguish it from other lasers
severity of the disease increases, root/implant debride- used for photobiomodulation or for antimicrobial pho-
ment becomes more difficult. Some erbium lasers fea- todynamic therapy.
ture a separate laser feedback system that indicates a Any of the commercially available dental lasers can
calculus deposit. This is an adaptation of a new modal- be utilized for nonsurgical periodontal or peri-implant
ity of a visible light diode laser to detect subgingival disease therapy. At this date, the generic types and nom-
accretions [9]. Studies have shown that some calculus inal emission wavelengths include diode (445, 532, 810,
remains, despite careful root planing or implant debrid- 940, 980, and 1064 nm), Nd:YAG (1064 nm),
ing, and treatment outcomes may not always be success- Er,Cr:YSGG (2780 nm), Er:YAG (2940 nm), and CO2
ful with deeper pockets [10–12]. Thus, surgery would be (9300 and 10,600 nm). For treatment of periodontal and
necessary to access those areas, along with placing peri-implant diseases, all of the above wavelengths can
regenerative materials. be used for debridement of the soft tissue side of the
Another consideration is that conventional ultra- periodontal pocket; both erbium wavelengths are also
sonic and sonic scalers used for subgingival debridement currently indicated for calculus removal on the tooth
may not be effective to produce a bactericidal effect [13]. structure. With the exception of Nd:YAG, there are no
This initial therapy is usually performed in the general general contraindications for use of these wavelengths
dentist’s clinic if immediate referral to a periodontist is around implant fixtures. Studies have shown that the
not indicated. Within that office setting, a dental hygien- high-peak-power emission of the Nd:YAG laser with
ist may deliver all or part of the treatment in accordance microsecond pulses caused melting on sandblasted,
14 with the scope of practice and other regulations govern- acid-etched, and titanium plasma-sprayed surfaces of
ing his/her license. During any therapeutic session, the titanium implants [16]. The details are described in
patient must be instructed in an effective oral hygiene . Table 14.1.
Laser type Nominal Periodontal tissue target for laser photonic Precautions
wavelength in nm energy used in nonsurgical therapy
Diode 445, 532, 810, 940, Debridement and detoxification of 1. For periodontitis, prolonged contact with
980, 1064 nm inflammatory tissue due to selective dark colored calculus, root surface, and
absorption in areas of inflammation by soft osseous tissue should be avoided
tissue pigments and blood components, 2. For peri-implant mucositis, no implant
including pigmented bacteria. Very good surface damage has been reported
hemostasis of blood in the sulcus
Nd:YAG 1064 Same as diode 1. For periodontitis, prolonged contact with
dark colored calculus, root surface, and
osseous tissue should be avoided
2. For peri-implant mucositis, the beam should
be placed parallel to the long axis of the
implant fixture so that any interaction will
be minimized
Laser Treatment of Periodontal and Peri-implant Disease
451 14
Laser type Nominal Periodontal tissue target for laser photonic Precautions
wavelength in nm energy used in nonsurgical therapy
Er, Cr:YSGG 2780 Debridement of inflammatory soft tissue 1. For periodontitis, care should be used to
Er:YAG 2940 due to the absorption in water of sulcular avoid excessive removal of cementum
fluid and organic components of soft tissue during calculus removal. Water spray must
inflammation along with the cellular water be used
of pathogens 2. For peri-implant mucositis, low average
Removal of root accretions due to the power should be used
primary absorption in the water component
of dental calculus and secondary absorp-
tion in the mineral component. Good
hemostasis of blood in the sulcus
CO2 9300 Debridement and detoxification of 1. For periodontitis, prolonged contact with
10,600 inflammatory soft tissue due to the tooth surface should be avoideda
absorption of water and organic compo- 2. For peri-implant mucositis, low average
nents of sulcular fluid and soft tissue power should be used
inflammation along with the cellular water
of pathogens.
Very good hemostasis of blood in the
sulcus
a Note:the potential exists for 9300-nm CO2 lasers to be used for calculus removal. Currently, there is no indication for use in this
procedure
14.2.2 Adjunctive Laser Use Considering the microbial component, it follows that
laser irradiation would have significant potential as an
The general principle of adjunctive laser use for peri- adjunct to traditional scaling instrumentation used on
odontal and peri-implant disease therapy is to supple- teeth and implants. All of the lasers listed in . Table 14.1
ment conventional instrumentation in removing or use the photothermal effect capable of strong bacteri-
disrupting the biofilm and calcified deposits. cidal and detoxification effects [21]. As an example, a
Conventional mechanical therapy of periodontal pock- recent study confirmed a significant decrease in several
ets does not necessarily achieve complete removal of pathogens 6 months posttreatment with the adjunctive
bacterial deposits and toxins. Employing a laser has the use of a 980-nm diode [22]. In addition, the infected soft
potential to improve therapeutic results [17, 18]. tissue in the pocket can be debrided; the lymphatic and
All dental lasers produce a temperature rise in the blood vessels can also be coagulated to enable healing.
target tissue, which would affect the pathogens and the
resulting inflammation. In general, most non-sporulating
bacteria, including periodontopathic anaerobes, are 14.2.3 General Protocol [23]
readily deactivated at temperatures of 50 °C [19]. Both
coagulation of the inflamed soft tissue wall of a peri- Following the examination and diagnosis, the clinician
odontal pocket and hemostasis are achieved at a tem- should refer to the periodontal charting and perform
perature of 60 °C [20]. It should be noted that surgical initial nonsurgical therapy. A suggested protocol is as
excision of soft tissue occurs at 100 °C; thus, using a follows:
laser at these lower temperatures defines a nonsurgical 1. Prior to any other instrumentation, laser irradiation
therapy. When erbium lasers are used for calculus at low average power is used to reduce the microbial
removal, the primary interaction occurs when the pho- population in the sulcus [24]. This will lower the risk
tonic energy vaporizes the interstitial water of the min- of bacteremia and reduce the aerosolized contami-
eralized matrix at a minimum temperature of nants during conventional instrumentation. When
100 °C. However, the rapid pulsing of those lasers used using the diode, Nd:YAG, and CO2 wavelengths, care
with water spray minimizes any significant temperature should be taken to avoid prolonged laser contact
rise in the surrounding tissues. with subgingival calculus and root surfaces. For
452 D. J. Coluzzi et al.
implant surfaces, care should be exercised with the mined during the periodontal exam, charting, and
Nd:YAG beam placement. When using erbium diagnosis. When planning treatment, several points
lasers, calculus removal is occasionally performed at should be considered:
the same time with the initial laser irradiation. 55 The patient’s physical limitations such as posture or
2. Appropriate conventional instrumentation is used to temporomandibular joint disease
perform calculus removal of the tooth or implant 55 The patient’s pain sensitivity during the procedure
surface. Erbium lasers can be used primarily or and medications necessary to control it, ranging
adjunctively. Better clinical results have been reported from topic and local anesthetics to sedation
on laser decontamination of implants compared to 55 The patient’s systemic health along with any risk fac-
mechanical treatment [25]. tors that would affect the treatment outcome
3. Decontamination of the pocket epithelium is per- 55 The number of pockets to be treated and the anat-
formed with laser irradiation. The photonic energy omy of each
interacts with different components of the inflamed 55 The amount and tenacity of debris and biofilm to be
soft tissue to disrupt the biofilm and microbial com- disrupted/removed
ponents. The parameters employed produce an aver- 55 Any restorations or occlusal problems that need
age power below that is used for excisional surgery, attention and could compromise access or success of
and the clinician should refer to the laser’s operating the therapy
manual to verify the average power settings. The 55 The patient’s ability to continue adequate oral
treatment objective is to aim the laser beam toward hygiene techniques
the soft tissue with overlapping strokes to ensure that
the entire area of the pocket is irradiated. The time
The severity of the disease will determine the appoint-
needed for this portion of the protocol depends on ment schedule both for therapy and for the patient’s tol-
the pocket anatomy—its shape, depth, and width. erance for treatment. Most importantly, the treatment
Visible debris will accumulate on the contact tip ofplan must be customized for each patient. Some cases of
some lasers or will be flushed out of the pocket with
gingivitis may only require full-mouth debridement and
others. Decontamination is complete when fresh disinfection and can be accomplished in two appoint-
bleeding emanates from the pocket. ments, including polishing. Other advanced conditions
4. To ensure coagulation and sealing of the blood capil-
with excessive deposits and biofilm may necessitate that
laries and lymphatic vessels, laser energy is used. only a few teeth are to be treated in each visit.
Generally, this occurs in a short time, and the last The length of each appointment can also vary. For
beam placement will be at the entrance to the pocket.
example, moderate generalized disease would be treated
In more shallow pockets, the decontamination pro- with hourly visits in each area of the disease. Some clini-
14 cedure may produce the desired hemostasis without cians divide the mouth into quadrants for therapy; oth-
any additional irradiation. After the laser is turned
ers choose to treat all the deeper pockets first. The latter
off, digital pressure will help re-adaptation of the tis-
approach has an advantage in that those pockets with
sue to the tooth, especially in deeper pockets. In more disease can be retreated with steps 3 and 4 on sub-
more shallow pockets, the decontamination proce- sequent appointments, especially if some inflammation
dure may help the initial healing. remains after the first session. To ensure those pockets
5. The patient is given postoperative and oral hygiene receive maximum debridement, the laser can be used
instructions. There should be minimal tissue manip- again during the other therapy visits.
ulation of the treated area so that the fibrin clot is Locally delivered chemotherapeutic agents, such as
not disrupted. Very gentle brushing and flossing minocycline hydrochloride, doxycycline hyclate, and
should be performed for 2 days. Spicy and crunchy chlorhexidine gluconate may be placed in pockets to
foods should be avoided for at least 1 day. Gentle help biofilm suppression. They are most effective after
rinsing with warm salt water three times a day should
the biofilm has been disrupted by the debridement pro-
soothe the tissues in a short period of time, and only
cedure. As such, those additions should be performed
mild discomfort should be expected. Subgingival after the last laser treatment. Antimicrobial photody-
irrigation must be avoided. namic therapy should also be considered, as discussed in
the next section of this chapter.
The patient’s oral care skills must be continually
14.2.4 Treatment Planning assessed and reinforced in this protocol. If the presence
of biofilm is not minimized, the intended healing will
The above protocol of initial therapy should be followed not progress. An assessment appointment should be
for every patient manifesting periodontal or peri- scheduled approximately 4 weeks after the completion
implant disease. The extent of the disease will be deter- of the initial therapy.
Laser Treatment of Periodontal and Peri-implant Disease
453 14
Following the initial nonsurgical therapy, the next . Figure 14.4 demonstrates the use of a diode laser for
appointment 3 months later will assess both the patient’s adjunctive treatment of peri-implant mucositis.
home care and the periodontal status. Expected out-
comes are inflammation reduction or absence, healthier
tissue tone, and reduced pocket depths without bleed- 14.2.6 onsiderations About Laser Use
C
ing. Minimum force should be used during probing in in Initial Nonsurgical Therapy
this period, since the attachment apparatus is easily dis-
rupted. Normal detailed probing can be performed at In any laser-tissue interaction, the absorption of the
the 6-month post-therapy appointment. Reevaluation photonic energy depends on many factors, as discussed
can continue at 3-month intervals, with careful assess- in 7 Chap. 3. For periodontal and peri-implant therapy,
ment of how the disease is resolving. Supportive ther- those same factors are at work in a very limited space—
apy to preserve the improved clinical attachment and the periodontal pocket and surrounding structures. The
minimum inflammation can continue. This will proba- clinician should be mindful of the periodontal anatomy
bly include additional debridement and laser decontam- of each site so that both conventional and adjunctive
ination, along with the patient’s daily oral hygiene laser therapies can proceed with as much precision and
regimen. effectiveness as possible while minimizing trauma to the
surrounding tissue. Therefore, the following points are
important:
14.2.5 Clinical Case Examples 55 Each wavelength will have different interaction on
the various periodontal tissues and implant fixtures.
. Figure 14.1 shows a diode laser used in a shallow For example, the near-infrared wavelengths are easily
inflamed periodontal pocket on a patient with Stage I scattered and are only absorbed by inflammation.
grade A periodontitis (gingivitis). . Figure 14.2 depicts Their depth of penetration in sulcular fluid can be
the adjunctive use of an Nd:YAG laser during therapy significant, which means that the energy could travel
of Stage III grade B periodontitis. . Figure 14.3 shows beyond the intended target tissue [26]. On the other
the adjunctive use of an Er,Cr:YSGG laser for initial hand, erbium lasers can be used efficiently to remove
treatment of Stage IV grade B periodontitis. subgingival calculus, although it is possible to remove
a b c
.. Fig. 14.1 a Preoperative view of an inflamed shallow gingival side of the sulcus. c Six-month postoperative view showing no
sulcus of the upper left cuspid. b An 810-nm diode laser with a 300- inflammation
μm bare fiber and 0.4-W CW emission directed toward the soft tissue
454 D. J. Coluzzi et al.
a b c
d e f
g h
14
.. Fig. 14.2 a Preoperative view of a 5-mm pocket on the lower left 400-μm fiber and an average power of 1.8 W (30 mJ/pulse and 60 Hz)
central incisor. b Preoperative view of a 6-mm pocket on the lower and directed toward the soft tissue side of the pocket. f, g Six-month
right second molar. c Preoperative periodontal probe chart. d, e postoperative view showing pocket depth reduction and lack of
After hand and ultrasonic scaling, an Nd:YAG laser is used with a inflammation. h Six-month postoperative periodontal probe chart
a b c d
.. Fig. 14.3 a Preoperative view of an 8-mm pocket with bleeding Seven-month postoperative probing shows significant pocket depth
on probing. b Preoperative radiograph of the pockets. After ultra- reduction without bleeding on probing. d Seven-month postopera-
sonic removal of the calculus, an Er,Cr:YSGG laser was used with a tive radiograph depicts a more stable periodontium. (Clinical case
500-μm-diameter radial firing tip at an average power of 1.5 W courtesy of Dr. Rana Al-Falaki)
(50 mJ, 30 Hz) with a pulse duration of 60 μs for debridement. c
Laser Treatment of Periodontal and Peri-implant Disease
455 14
a b c
d e
.. Fig. 14.4 a Preoperative view of a 7-mm pocket with bleeding on sion directed toward the soft tissue and away from the implant fix-
probing around an implant. b Preoperative radiograph. c After care- ture. d Six-month postoperative view showing pocket depth reduction
ful conventional debridement of any calculus, an 810-nm diode laser and lack of inflammation. e Six-month postoperative radiograph
with a 400-μm tip was used with an average power of 0.4 CW emis-
some cementum on the root surface [27]. Interest- will be readily absorbed by dark calculus causing a
ingly, a recent systematic review indicated that significant temperature rise; so, the tip should be
adjunctive use of erbium lasers with conventional angled toward the soft tissue. Likewise, when using
instrumentation can be appropriate to remove an erbium laser for calculus debridement, the tip
residual debris from root surfaces [28]. should be as parallel to the tooth axis to avoid exces-
55 The current literature indicates that lasers are gener- sive cementum removal.
ally safe for treatment of peri-implant mucositis, but 55 As granulation tissue is removed, it may accumulate
some precaution should be exercised [29, 30]. As around the laser tip or tube. Those should be checked
mentioned previously, Nd:YAG lasers’ usual emis- and cleaned often to avoid concentration of the
sion mode produces very short pulse durations and a energy in the debris.
very high peak power per pulse. Those high powers 55 Proper case selection is important and continuing
have been known to damage titanium surfaces. evaluation must be performed. If areas of disease do
Erbium lasers have the same pulse durations but pro- not respond to the nonsurgical approach, then sub-
duced no surface alterations with low energy density sequent surgical therapy will be necessary.
use. Understanding of those differences is necessary
for the clinician to choose the appropriate wave-
length for beneficial treatment.
55 The laser parameters must produce low average 14.2.7 cronyms for Nonsurgical Initial
A
power to minimize ablation of healthy tissue. Each Periodontal and Peri-implant
laser instrument has specific operating instructions Therapy
for this procedure with suggested settings, and these
should be used as a guide to begin the therapy. Clinicians may find various acronyms in the operating
55 Each laser has a specific handpiece and emission manuals of different laser instruments or in scientific lit-
device—for example, an optical fiber tip or a small erature. The intent of these terms is the same—to pro-
tube. The clinician should ensure that the laser beam vide the first phase of treatment. Such terms as LAD/
is aimed as precisely as possible toward the intended LABR (laser-assisted decontamination/laser-assisted
target tissue. For example, diode photonic energy bacterial reduction), LAPT (laser-assisted periodontal
456 D. J. Coluzzi et al.
Diode 445, 532, 810, Incision and excision of gingival 1. For gingival surgery or debridement of granulation
940, 980, 1064 tissue along with hemostasis. Good tissue, prolonged contact with dark colored calculus,
absorption in pigmented tissue and root surface, and osseous tissue should be avoided
hemoglobin, likewise in areas of 2. For peri-implantitis, no implant surface damage has
acute inflammation been reported when low average power irradiation is
used
Nd:YAG 1064 Same as diode 1. For gingival surgery and granulation tissue debride-
ment, prolonged contact with dark colored calculus,
root surface, and osseous tissue should be avoided
2. For peri-implantitis, the beam should be placed
parallel to the long axis of the implant fixture so that
any interaction will be minimized
Er, Cr:YSGG 2780 Excellent incision and excision of 1. For osseous surgery and calculus removal, water
Er:YAG 2940 soft tissue with minimal depth of spray must be used
cut due to the very high absorption 2. For peri-implantitis, low average power should be
in the water content of that tissue. used near the implant fixture
Good hemostasis
Excellent cutting and shaving of
osseous tissue
CO2 9300 Excellent incision and excision of 1. For osseous surgery with 9300 nm, water spray must
10,600 soft tissue due to the high absorp- be used
tion in the water content of that 2. For peri-implantitis, low average power should be
tissue. Very good hemostasis used near the implant fixture. Care should be taken to
Excellent cutting and shaving of minimize reflection from the metal implant toward
osseous tissue (9300-nm wavelength surrounding tissue
only)
14.3.1 Flapless Periodontal conventional scaling instruments, and then blunt dissec-
and Peri-implant Surgery tion is performed at the osseous crest. The laser is then
used to obtain hemostasis and to form a fibrin clot so
Description of Flapless Surgery: There are two current that the loose gingival tissue can be approximated back
flapless techniques that are considered to be surgical but to the tooth. Occlusal adjustments are performed and
without employing any open-flap technique for debride- postoperative instructions given. This procedure has
ment. These fulfill the concept of a minimally invasive generated case report studies that offer histologic evi-
procedure but could have limitations because of limited dence of new connective tissue attachment, new cemen-
access to the entire diseased area of the periodontium tum, and new alveolar bone [41, 42]. The Nd:YAG
around the root or the implant. One, termed LANAP®, is wavelength (1064 nm) is usually safe when using appro-
an acronym for laser-assisted new attachment procedure priate parameters for pocket irradiation. However, the
and uses a proprietary Nd:YAG instrument. The other is photonic energy has a potential of deep tissue penetra-
termed laser-assisted comprehensive pocket treatment bility, so care must be taken to avoid thermal damage to
(LCPT) [39, 40] where any erbium laser can be employed. the underlying tissues.
The LANAP® protocol entails a specific step, single- . Figure 14.6 shows a clinical case of Stage III
session treatment, shown in . Fig. 14.5. After verifying grade B periodontitis in the maxillary anterior sextant.
The LANAP ® protocol is used for successful treatment
the pocket depth, the laser selectively removes the pock-
et’s epithelial lining. The root surfaces are debrided with (clinical case courtesy of Dr. Raymond Yukna).
458 D. J. Coluzzi et al.
a b c d e f g h
.. Fig. 14.5 Graphic depiction of LANAP® using the pulsed laser energy performs hemostasis; establishes a thick, stable fibrin
Nd:YAG laser. a Bone sounding to determine pocket depth. b Under clot; activates growth factors; and upregulates gene expression. f The
local anesthesia, typically a 360-μm optic fiber delivers 3.6–4.0 W gingival tissue is pressed toward the tooth to secure it without
average power at a pulse duration of 100–150 μs to selectively remove sutures. g Occlusal adjustments are performed to eliminate improper
the diseased epithelial lining of the pocket, denature pathologic pro- contacts and to allow for passive eruption. h Showing anticipated
teins, and create bacterial antisepsis. c The root surface accretions healing in an environment conducive to true regeneration of new
are removed with piezo ultrasonics and conventional instruments. d cementum, new periodontal ligament, and new alveolar bone.
Blunt dissection with a conventional dental instrument is used to (LANAP® is a patented and registered trademark of Millennium
modify the osseous contour at the alveolar crest and perform intra- Dental Technologies, Inc., Cerritos, Calif., USA.). (Graphic repro-
marrow penetration to gain access to stem cells and growth factors. e duced with permission from Millennium Dental Technologies)
Using the same fiber but with a pulse duration of 550–650 μs, the
The same company has an identical procedure for enchymal stem cells. The parameters used will not affect
treatment of peri-implant disease, termed LAPIP™ hemostasis in the bone; on the contrary, the procedure
(Laser-Assisted Peri-Implantitis Protocol.) The laser should enhance bleeding which would be advantageous
emission is reduced so that much less average power is for tissue regeneration. There may also be some bios-
applied around the implant structure. The fiber is aimed timulatory effects in the surrounding tissues. The next
as parallel as possible to the long axis of the fixture to step is laser ablation of the external gingival tissue at the
14 avoid the metal absorbing the energy and thus overheat- pocket entrance. The epithelium and occasionally a
ing as well as to minimize any reflected photons off the layer of connective tissue are removed. The pocket
surface. depth is automatically reduced with this small dimen-
LCPT (laser-assisted comprehensive pocket therapy) sion gingivectomy, and the exposure of the connective
uses erbium lasers with wavelength emissions of 2870 or tissue will delay the migration of the epithelium into the
2940 nm [39, 40]. As noted previously, these lasers can pocket while the attachment is being re-established.
be used for soft tissue and calculus removal. In addition, That procedure will cause some gingival recession, but
they are indicated for use in contouring osseous tissue. the primary benefit of pocket healing will be realized.
Thus, they can be useful for debridement of both granu- The last step is to ensure adequate coagulation for a
lation tissue and bone defects in moderate to deep peri- stable blood clot to seal the pocket entrance. The erbium
odontal pockets, depending on the accessibility. The laser is used in a noncontact mode without water spray
procedural steps are shown in . Fig. 14.7. After assess- to achieve this.
ing the pocket, the laser and hand instrumentation is This procedure can also be used for the treatment of
used for root surface debridement. That is followed by peri-implant mucositis or the initial stages of peri-
removal of the epithelial and diseased connective tissue implantitis.
of the lining of the gingival pocket as well as diseased . Figure 14.8 is a clinical case of Er:YAG (2940 nm)
osseous tissue. The treatment objective is thorough laser-assisted LCPT for treatment of Stage III grade B
decontamination of the whole pocket as well as enhance- periodontitis. There is a radiographic evidence of osse-
ment of bleeding from bone surface, including bone ous healing and new attachment at 1 year postopera-
marrow-derived cells which are a major source of mes- tively.
Laser Treatment of Periodontal and Peri-implant Disease
459 14
a c
d f
.. Fig. 14.6 a Clinical view of the anterior facial region. b Clinical was treated with the LANAP® protocol as described in . Fig. 14.4.
view of the lingual anterior region. c Pre-treatment periodontal d Three-year facial postoperative view. e Three-year lingual postop-
probe chart showing pockets and mobility on all the anterior teeth. erative view. Note the reduction in inflammation. f Three-year post-
Each horizontal line represents a 2-mm increment, and the red mark- operative periodontal probe chart shows significant pocket depth
ings indicate bleeding on probing. Mobility is indicated with Roman and mobility decrease. (Clinical case courtesy Dr. Raymond Yukna)
numerals on the incisal view icon at the top of the chart. The patient
460 D. J. Coluzzi et al.
a b c d e f g h
.. Fig. 14.7 A graphic depiction of LCPT (laser-assisted compre- The outer epithelium and some connective tissue are removed to
hensive pocket therapy) using an Er:YAG laser. a The pocket depth delay epithelial migration into the healing pocket. This gingivectomy
is assessed. b Subgingival calculus is removed with both the laser does produce some gingival recession. g The laser is used in a non-
(utilizing a water spray) and the conventional instrumentation so contact mode without a water spray to ensure hemostasis and to pro-
that the diseased root surface is decontaminated and detoxified. c duce a stable blood clot to protect the entrance to the pocket, as well
The laser is used to remove the diseased epithelial and connective as to stimulate the outer surface of the periodontium. h Showing the
tissue lining of the pocket. d The osseous tissue is also debrided by new attachment and pocket depth reduction. (Graphic modified
the laser using a water spray to promote bleeding from the bone, and from Aoki et al. [39] with permission © copyright 2015 John Wiley
the resulting healthy tissue is shown. e Some of the laser irradiation and Sons A/S)
can offer biostimulation to the surrounding intrasulcular tissue. f
a b c
14
d e
.. Fig. 14.8 a Deep pockets are present on the lateral incisor. The debrided. The outer epithelium was recontoured to delay gingival
one measures 8 mm with bleeding on probing. b The radiograph downgrowth, and a stable clot was formed. The latter procedure was
shows the vertical bony defect (black arrow). c Immediate postopera- performed without a water spray. d One-year postoperative view
tive view showing a stable blood clot. The Er:YAG laser was used shows good healing with a slight loss of the gingival papilla. e The
with a 600-μm curved tip at 1.0-W average power (50 mJ/pulse at radiograph confirms the osseous defect has filled in (black arrow).
20 Hz) with a water spray to remove the inflamed soft tissue in the (Clinical case and details courtesy of Dr. Koji Mizutani and modi-
pocket and adjunctively with a curette to debride the root surface. fied from citation [9] with permission © copyright 2016 John Wiley
Then the inner epithelial wall and the osseous defect were also and Sons A/S)
Laser Treatment of Periodontal and Peri-implant Disease
461 14
14.3.2 sseous Periodontal Surgery
O gical instruments usually need a wider area of access
Employing a Flap compared to the laser with its irradiation confined to the
end of the tip. Thus, more precision is possible.
Osseous surgery, during which bone is removed, recon- Bone grafting procedures with appropriate mem-
toured, and/or reshaped, is one of the major periodontal branes may be used in areas where the defect cannot be
surgical procedures. Optimum bone anatomy will help properly contoured. A laser produces minimal thermal
establish and maintain clinical attachment, shallow pock- damage resulting in a new osseous surface with good
ets, and physiologic gingival architecture—all of which vascularity and a lack of smear layer, which should aid
are critical for long-term stability of periodontal tissue. in successful bone augmentation [43, 44].
At the time of writing, no studies are available for the . Figure 14.9 shows the use of an Er:YAG laser for
9300-nm wavelength, but there are manuscripts showing open-flap surgery for Stage III grade C periodontitis on
that both Er, Cr:YSGG (2780) and Er:YAG (2940 nm) a 9-mm deep pocket on the distal of the mandibular
[30, 31] wavelengths are effective in ablation of bone tis- right cuspid. This pocket remained after initial therapy.
sue with minimal thermal damage. In addition, the heal- The flap was elevated, and the laser was used to remove
ing assessment of those lasers performing an osteotomy the granulation tissue and debride the root surface. The
is at least comparable to conventional instrumentation osseous defect was also debrided, and no grafting mate-
[45] and may be advantageous for faster and improved rial was placed. The inner surface of the flap was irradi-
outcomes [46, 47]. ated for debridement, and sutures were carefully placed.
The correct laser wavelength delivered through a Eight years postoperatively, there were significant pocket
small diameter tip can offer more precision and better depth reduction and clinical attachment gain (clinical
access than mechanical instruments. Conventional sur- case courtesy of Dr. Akira Aoki).
a b c d
e f g
h i j k
.. Fig. 14.9 a, b After initial therapy, a 9-mm pocket with bleeding tion material was placed. h The laser is used with the same parame-
on probing remains on the distal of the mandibular right cuspid ters to decontaminate and stimulate the gingival flap tissue. i The flap
shown clinically and radiographically. c, d A flap is elevated, and is sutured in place. j Eight-year postoperative view showing healthy
granulation tissue fills the pocket when viewed from the buccal and gingival tissue with some recession. In fact, there was 7 mm of
lingual aspects. e An Er:YAG laser is used with an 80° 400-μm tip at pocket depth reduction and 5 mm of clinical attachment gain. k
1.2 W average power (40 mJ per pulse at 30 Hz) with a saline water Eight-year postoperative radiograph. (Case photos and details mod-
spray for debridement. f, g Showing the clean vertical bone defect ified from Aoki et al. [39] with permission © copyright 2015 John
with no thermal damage from the laser energy. No bone augmenta- Wiley and Sons A/S)
462 D. J. Coluzzi et al.
a b c d
e f
.. Fig. 14.10 a Radiograph showing 11-mm pocket on the mesial of with 50% air and 40% water spray in the short pulse mode. Subse-
the maxillary first premolar that remained after initial therapy. b quently, the smear layer was removed from the root surface and osse-
After the subgingival calculus was removed with ultrasonic instru- ous tissue with an average power of 0.75 W (15 mJ, 50 Hz) with 50%
mentation, a flap is raised, and the osseous defect is explored with the water and 40% air spray. d View of the sutured flap. e Eight-month
periodontal probe. c Immediate postoperative view of the debrided postoperative photo with periodontal probe, demonstrating good
infrabony pocket. An Er,Cr:YSGG laser was used with a 600-μm reattachment with slight gingival recession. f Eight-month postoper-
diameter contact tip. To remove the granulation tissue from the soft ative radiograph showing a more stable periodontal condition with
and hard tissue, an average power of 1.5 W (50 mJ, 30 Hz) was used bone regeneration. (Clinical case courtesy of Dr. Rana Al-Falaki)
14
. Figure 14.10 demonstrates a similar open-flap ments generally do not cause any surface damage to
procedure for treatment of Stage IV grade B periodonti- implants [48–51]. The precaution is that high average
tis, where the Er,Cr:YSGG laser was used on an 11-mm power settings can generate heat on the peri-implant tis-
pocket on the mesial of the maxillary right first premo- sues and/or directly affect the titanium fixture. Thus,
lar that did not respond to initial therapy. After raising appropriate parameters and techniques must be
a flap, the laser was used to debride the root surface, the employed during the surgical session.
pocket epithelium, and the osseous defect. No bone Several recent studies report the benefits of laser-
graft material was placed, and the flap was sutured after assisted surgery [52, 53].
confirming that the defect was filled with bone marrow- After debridement of the surrounding tissues and
derived blood. An 8-month analysis showed pocket decontamination of the implant itself, bone augmenta-
depth reduction and attachment gain with slight gingi- tion materials and appropriate membranes can be placed
val recession. in the defect to enhance regeneration. Clearly, good
bone vascularity is important to achieve, and proper
Surgical Therapy for Peri-implantitis laser parameters can accomplish this. As mentioned,
Debridement and detoxification of the implant surfaces lasers should allow for beneficial bone healing following
as well as the diseased tissues surrounding implant fix- surgery along with a biocompatible implant fixture.
tures are the primary objectives for the treatment of . Figure 14.11 demonstrates how an Er,Cr:YSGG
peri-implantitis. Many laser wavelengths have been laser for severe peri-implantitis therapy. After reflecting
studied for their ability to efficiently debride implant a flap, the osseous defect was filled with granulation tis-
surfaces. The diode, carbon dioxide, and erbium instru- sue, and the laser debrided soft and hard tissues in the
Laser Treatment of Periodontal and Peri-implant Disease
463 14
a b c
d e f
.. Fig. 14.11 a Preoperative view of peri-implantitis around a max- implant was debrided at an average power of 1.25 W (25 mJ, 50 Hz)
illary posterior implant with an 8-mm pocket. b After the flap is with 70% water and 50% air. Lastly, the internal surface of the flap
reflected, the extent of the defect, filled with granulation tissue, can was decontaminated at any average power of 0.75 W (15 mJ, 50 Hz)
be seen. c Immediate postoperative view of the debridement therapy. with 50% water and 40% air. Note the good vascularity of the osse-
An Er,Cr:YSGG laser was used with a 600-μm-diameter contact tip. ous tissue. d Bone grafting material is placed immediately to fill the
The granulation tissue was removed from the soft and hard tissue area. e The flap is sutured in place. f Six-month postoperative view of
with an average power of 2.0 W (66 mJ, 30 Hz) with 70% water and the healed periodontium with no inflammation. (Clinical case cour-
50% air, angling the tip away from the implant surface. Then the tesy of Dr. Rana Al-Falaki)
area. A bone graft and membrane were placed, and the 1, 2, and 3 years confirm that the original osseous defect
flap was sutured in place. Six months later, the periodon- was successfully repaired (clinical case courtesy of Dr.
tal health was restored (clinical case courtesy of Dr. Taichen Lin).
Rana Al-Falaki). In summary, dental lasers can be used in a surgical
. Figure 14.12 shows the use of an Er:YAG laser approach for treatment of periodontal and peri-implant
for the treatment of severe peri-implantitis. In this case, diseases with benefits such as precision and enhanced
there is a large per-implant defect present in the maxil- visibility during debridement. In addition, osseous tis-
lary left cuspid and bicuspid with recorded pocket sue can be predictably ablated and contoured. Future
depths of 8–12 mm with bleeding and suppuration. A research should emphasize proper power settings and
surgical flap was raised conventionally, after which the describe the details of the protocol. Laser application
area was debrided with the laser. Bone graft material for bone ablation is becoming a very useful modality for
was placed, hemostasis was achieved with the laser, and developing the various usages on periodontal and
the flap was sutured. The 1-year clinical follow-up shows implant therapy. Preventing thermal damage following
healthy periodontium, and subsequent radiographs of laser treatment is critical for optimal wound healing.
464 D. J. Coluzzi et al.
a b c
d e f
g h
i j k
14
.. Fig. 14.12 a, b Preoperative view of 8–12-mm pocket depths contact mode to produce a clot, and the flap was sutured back into
around the maxillary left cuspid, part of a three-unit implant- position. h One-year postoperative view shows some gingival reces-
supported fixed prosthesis. c Preoperative radiograph of the area sion but otherwise healthy tissue. i One-year postoperative radio-
shows a significant infrabony defect. d The Er:YAG laser was used at graph shows the complete repair of the previous osseous defects. j
20 Hz and 50 mJ/pulse with a water spray in near contact mode to Two-year postoperative radiograph. k Three-year postoperative
remove granulation tissue and debride the implant surface. e No radiograph. ((Clinical case courtesy of Dr. Taichen Lin.) Graphic
thermal damage was observed on the implant surface or the osseous modified from Lin et al. [54] with permission © copyright 2019 Else-
structures. f Bovine bone graft material (InterOss) was grafted into vier A/S)
the bony defects. g The laser was used without water spray in a non-
Laser Treatment of Periodontal and Peri-implant Disease
465 14
14.4 Antimicrobial Photodynamic Therapy 14.5 Photosensitizer
in Management of Periodontal
and Peri-implant Disease A photosensitizer is a chemical compound, which when
activated by an appropriate wavelength forms a highly
reactive oxygen species which results in cell death.
The photosensitizers should have some characteris-
14.4.1 Photodynamic Therapy
tics including the following:
55 Exist as nontoxic and chemically pure compound
Photodynamic therapy (PDT) is a new approach in kill-
55 Have the ability to stain the target
ing or eliminating pathogens and uses light of a specific
55 Be economical and easily available
wavelength to activate a nontoxic photoactive dye (pho-
55 Possess a short interval between administration of
tosensitizer) in the presence of oxygen to produce cyto-
the drug and peak accumulation in the tissue
toxic products [55, 56]. Various terms are used for PDT
55 Have a short half-life
such as photoactivated chemotherapy (PACT), photo-
55 Be rapidly eliminated from normal tissue
dynamic disinfection (PDD), light-activated disinfec-
55 Have activation at specific wavelength
tion (LAD), photodynamic inactivation (PDI),
55 Possess the ability to produce the huge amount of
photoactivated disinfection (PAD) and antimicrobial
cytotoxic products
photodynamic therapy (aPDT) in different studies and
55 Have the ability to act on wide range of microorgan-
literature. Among these terms, aPDT is the most
ism [60]
accepted one for antimicrobial purposes [57–59].
The successful outcome of PDT critically depends
The most applicable photosensitizers which used in den-
on three elements: photosensitizer, light source, and oxy-
tistry for antimicrobial procedures are described below.
gen (. Fig. 14.13).
charge. This photosensitizer can be applied for both with antioxidant, immunomodulation, and antimicrobial
gram-positive and gram-negative bacteria. It can pene- effects, which makes it a potential photosensitizer in
trate through the porin channels in the outer membrane aPDT procedures. Under irradiation by an appropriate
of gram-negative bacteria and interacts with the anionic wavelength (red range), it can produce singlet oxygen [71].
macromolecule lipopolysaccharide creating MB dim-
mers which have a role in the photosensitization pro-
cess. It has a peak absorption at wavelength of 660 nm 14.5.7 Chlorophyll
[64, 65].
Chlorophyll is a green pigment that is found in green
plants activated by the range of blue and red wave-
14.5.3 Indocyanine Green lengths. The high potency of ROS production and struc-
ture modification by replanting metal ion complex make
Indocyanine green (ICG), a green-coloring agent, has it suitable as a photosensitizer in aPDT procedures [72].
recently been introduced as photosensitizer. The mecha-
nism of this photosensitizer is somehow different from
other ones. The effect of ICG is mainly that of photo- 14.5.8 Riboflavin
thermal therapy (PTT) rather than photochemical reac-
tion. This anionic photosensitizer can be activated by Riboflavin (vitamin B2) is an efficient photosensitizer
810 nm, but its absorption critically depends on the dis- inducing oxidative damage when activated with visible
solving medium, the chemical bonds of plasma proteins, light, especially blue light and LED lamps make it suit-
and its concentration [60, 66]. able for aPDT procedure [73].
Curcumin is a yellow-orange pigment isolated from In photodynamic therapy procedure, the light source
Curcuma longa L. which is mostly used as a spice. It has coincides with maximum absorption of the photosensi-
some therapeutic effects on liver diseases, wounds, and tizer used. The light source for aPDT can be classified
inflamed joints, as well as for blood purification and into three types:
microbial effects. Curcumin has shown no toxic effects 1. Broad spectrum lamps
on a number of cell cultures and animal studies. It has a 2. Light-emitting diode lamps (LED)
broad absorption peak in the 300–500-nm range (maxi- 3. Lasers
14 mum 430 nm) and produces strong phototoxic effects.
Therefore, curcumin has the capability to be used as a Among the different sources, lasers have some charac-
photosensitizer. Easy handling, low cost, and efficacy teristics that make them superior compared to other
make this photosensitizer more popular [67–69]. sources. Monochromaticity which allows the laser to
interact with photosensitizer due to matching with its
peak absorption results in elimination of unnecessary
14.5.5 Chlorella tissue heating by bandwidths not effective in PDT reac-
tion [74, 75].
Chlorella is a green natural microalga which contains In dentistry, most of the photosensitizers are acti-
proteins, vitamins, and minerals and is used as a dietary vated by wavelengths between 630 and 700 nm.
compound. It has antimicrobial, anticancer, anti- Currently, with the introduction of new photosensitizer
inflammatory, and antioxidant wound-healing charac- such as ICG, infrared wavelength like 810 nm is also
teristics. It can be activated by red wavelength [70]. used which has more penetration depths. On the other
hand, blue light LED (400–500 nm) which coincidences
with curcumin can be a suitable option due to its avail-
14.5.6 Phycocyanin ability in all dental offices for curing of dental resin
composites and capability in creating free radicals more
Phycocyanin is a blue-green pigment used as a coloring efficiently compared to red light. LEDs are more cost-
agent in the food industry. It is extracted from spirulina effective and compact in comparison to lasers [76, 77].
Laser Treatment of Periodontal and Peri-implant Disease
467 14
14.7 Mechanism of Photodynamic Therapy action (0.02 μm) that make its action localized without
affecting distant cells [82, 83].
When a photosensitizer is activated by an appropriate One of the main concerns during photodynamic
wavelength, electrons are transferred from a lower level of therapy is the photosensitivity of bacteria which seems
energy to a higher one which is called the triplet state. mainly related to the charge of the photosensitizer used.
Then, the energy is transferred to a biomolecule or to oxy- The neutral or anionic sensitizer binds effectively to
gen which leads to the production of cytotoxic species. gram-positive bacteria. It also binds to some degree to
These products damage the cellular plasma membrane or the outer membrane of gram-negative bacteria [84]. The
DNA. Both consequences lead to cell death [78, 79]. porous layer of peptidoglycan and lipoteichoic acid out-
The transfer of electrons in activated photosensitizer side the cytoplasmic membrane of gram-positive species
can be done in two pathways including transfer to the allows the photosensitizer to cross into the cell. On the
neighboring molecule (type 1 reaction) or to oxygen other hand, gram-negative bacteria have an inner cyto-
(type 2 reaction) to produce reactive oxygen species plasmic membrane and an outer membrane separated
(ROS) like singlet oxygen and other radicals like hydroxyl by the peptidoglycan-containing periplasm which acts
radical. Although the two pathways can have a role on as a physical barrier between cells and its environment
bacterial killing, type 2 by producing highly reactive sin- [85]. The binding of negatively charged photosensitizer
glet oxygen is detected as the main pathway in killing to gram-negative bacteria may be improved by linking
bacteria (. Figs. 14.14 and 14.15). This mechanism is the photosensitizer to a cationic molecule [86].
totally different from that of antibiotics; hence, the The success rate of photodynamic therapies depends
resistance of bacterial strain is not likely, due to acting on the type, dose, incubation time, and localization of
on multiple targets inside the bacteria [80, 81]. the photosensitizer, the availability of oxygen, the wave-
It’s important to note that antioxidant enzymes pro- length of light (nm), the light power density, and the
duced by bacteria may protect against some oxygen rad- light energy fluency. Limitations of this treatment which
icals but not singlet oxygen which makes aPDT a more should be considered are the low-oxygenated environ-
effective procedure. Singlet oxygen has a short lifetime ment and the diffusion ability of the photosensitizer and
in biological system (≤0.04 μs) and a short radius of light to be used [87].
Phosphorescence
Bacterial or fungal
cell death
.. Fig. 14.14 The mechanism of PDT. The photosensitizer is raised or a singlet oxygen. The latter is thought to be the main toxic agent
to an excited state by absorbing photonic energy, and a triplet state for pathogens
is created. Its energy is transferred to create either a hydroxyl radical
468 D. J. Coluzzi et al.
Activated
photosensitizer
Radicals and 1O
2
radical ions
Substrate Substrate
1O
Oxidative
2 injury to cell
Cell death
a b
.. Fig. 14.16 a Application of TBO inside the pocket. b Irradiation of papilla by blunt tip of LED. c Irradiation of the pocket by intra-
pocket tip of LED. (Clinical case courtesy of Dr. Chen Ying Wang)
a b
14
c d
.. Fig. 14.17 a Clinical aspect of treatment site. b ICG was applied inside the pockets. c The view of treatment site after ICG application.
d Irradiation of pockets by diode laser at wavelength of 808 nm
Laser Treatment of Periodontal and Peri-implant Disease
471 14
a b c d
.. Fig. 14.18 a Facial view of the periodontitis condition of the sitizer. c Immediate posttreatment view of the site. d A 1-month
lower anterior area. b After scaling of the pockets, the methylene posttreatment photo showing tissue health with no inflammation.
blue solution is applied. A visible diode laser activates the photosen- (Clinical case courtesy of Dr. Steven Parker)
a b c
d e f
.. Fig. 14.19 a Facial view of peri-implantitis of the lower right Lingual view 31 months later of the healed area. g Radiograph of the
cuspid. b The lingual view of the implant area with a discharge of treated implant, 31 months later. (Clinical case courtesy of Dr.
exudates. c Preoperative radiograph showing the peri-implant defect. Chen-Yeng Wang, modified from citation [14] with permission ©
d The application of phenothiazine chloride inside the pocket. e copyright 2016 John Wiley and Sons A/S)
Facial view 31 months later showing excellent peri-implant health. f
472 D. J. Coluzzi et al.
a b
c d
.. Fig. 14.20 a Clinical examination of treatment site. b Methylene blue was applied inside the pockets. c Irradiation of pockets by diode
14 laser at wavelength of 660 nm. d Clinical examination after 6 months
each pocket moving apico-coronally both buccal and that MB in concentrations below 100 μg/mL, activated
lingual parts of the tooth. The patient was followed by 660-nm diode laser for 60 s, reduces the chance of
after 6 weeks and 3 and 6 months. tooth discoloration [103]. Pourhajibagher et al. in evalu-
ation of antimicrobial photodynamic therapy with
indocyanine green and curcumin on human gingival
14.9 Considerations During aPDT Therapy fibroblast cells came to this conclusion that to avoid
cytotoxicity the concentration of the sensitizers and
The effective treatment of periodontal problems must laser irradiation time are essential for aPDT. They also
include proper oral hygiene instructions, which consist observed that the optimum concentration of ICG as
of a combination of daily tooth brushing, interdental photosensitizer for aPDT should be at least 1000 μg/mL
cleaning, and, when necessary, use of chemotherapeutic with 30- or 60-s irradiation time by 810-nm diode laser
agents [e.g., mouthwash]. Thus, the patient’s compliance [104].
with those instructions is fundamental for the success of In a review for assessing the efficacy of aPDT for the
the treatment of periodontal and peri-implant disease. treatment of periodontitis and peri-implantitis,
A low-oxygenated environment and the diffusion Chambrone et al. [105] stated that aPDT provided simi-
ability of the photosensitizer and light to be used are lar clinical improvements as conventional therapy in
limitations of photodynamic therapy, which should be periodontal and peri-implant patients. In one random-
taken into consideration. ized controlled clinical trial, Martins et al. found signifi-
Moreover, the application of some photosynthesiz- cant improvement in clinical parameters with aPDT’s
ers like methylene blue (MB) can stain the teeth if the adjunctive use in open-flap debridement of periodonti-
appropriate concentration is not used. It was suggested tis [106]. In another clinical trial, Segarra-Vidal et al.
Laser Treatment of Periodontal and Peri-implant Disease
473 14
found that adjunctive aPDT use with SRP produced a 4. Papapanou P, Sanz M, Buduneli N, Dietrich T, Feres M, Fine
significant reduction of Aa pathogens [107]. As a fourth DH, Flemmig TF, Garcia R, Giannobile WV, Graziani F,
Greenwell H, Herrera D, Kao RT, Kebschull M, Kinane DF,
example, Xue showed evidence of additional clinical Kirkwood KL, Kocher T, Kornman KS, Kumar PS, Loos BG,
improvement in the maintenance of residual pockets Machtei E, Meng H, Mombelli A, Needleman I, Offenbacher
with aPDT [108]. Other studies reviewing both clinical S, Seymour GJ, Teles R, Tonetti MS. Periodontitis: consensus
and experimental protocols demonstrate some positive report of workgroup 2 of the 2017 world workshop on the
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Carvalho P, Serra AJ. Photodynamic antimicrobial chemo-
479 15
Laser-Assisted Multi-tissue
Management During Aesthetic
or Restorative Procedures
Donald J. Coluzzi, Mark Cronshaw, and Joshua Weintraub
Contents
References – 504
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
481 15
Core Message Nd:YAG instruments operate in a free-running pulsed
Whether treating new carious lesions or planning extensive mode, producing very high peak powers; some diode
prosthodontics, the dental clinician must consider how the lasers also can operate with relatively short pulse dura-
restoration will harmonize with the periodontium so that tions and moderate peak power output. This pulsing
the result will be both healthy and maintainable. Likewise, modality can help to control collateral thermal damage.
recontouring gingiva and the underlying supporting bone
for improved aesthetics must entail the same deliberation.
An important additional consideration is the patient’s per- 15.2.2 Erbium Lasers
ception of the desired aesthetic result. Clearly, this can
have a significant influence on the success of the planned The two wavelengths of these mid-infrared instruments
treatment. Dental lasers can be used for modification of have the highest absorption by water compared to any
soft or hard supporting tissue. The appropriate wavelength other available lasers, with a smaller secondary interac-
and operating parameters must be chosen for the specific tion with the mineral components of hard tissue. These
tissue, but the result can be very predictable and biologi- lasers employ a free-running pulsed emission, and their
cally compatible with the restoration. high peak power is primarily and rapidly absorbed into
water. In soft tissue, this produces a shallow area of
ablation. In hard tissue, there is superheating of the
15.1 Introduction water content of the tooth or bone, resulting in an explo-
sive expansion. This disrupts and ejects whole fragments
This chapter will describe the use of multiple laser wave- of the calcified structure, resulting in a “cavity.” The
lengths to alter and improve hard and soft dental tissues mineral remains unchanged. The term “all tissue laser”
for improved aesthetics and successful restoration place- implies that an erbium instrument can perform soft tis-
ment. While this chapter’s intention is to not exhaus- sue excisions, tooth preparation, and osseous proce-
tively review all aspects of periodontal surgery, dures.
fundamental concepts of soft tissue anatomy such as
biotype and biologic width will be discussed. The basic
principle is that after any alteration to soft or hard tis- 15.2.3 Carbon Dioxide Lasers
sue, good physiologic contour must be restored.
Predictable tissue management primarily relies on the There are also two far-infrared wavelengths in this cate-
clinician’s choice of the proper wavelength to interact gory. Both are highly absorbed by hard tissue and sec-
with the target tissue while using appropriate parame- ondarily by water. Current developments in technology
ters and techniques to maximize the efficiency of tissue allow the 9300-nm machine to remove carious lesions
removal, establish proper contour, and minimize any and prepare teeth, contour the bone, and perform soft
collateral damage. 7 Chapters 3 and 4 discuss these tissue surgery. The 10,600-nm device can only be used
concepts in great detail. for soft tissue procedures in its present form.
15.2 Review of Laser Wavelengths 15.2.4 ith Any of the Above Wavelengths
W
and Tissue Interaction Employed for Soft Tissue Surgery,
There Are Several Considerations
15.2.1 Diode and Nd:YAG Lasers 55 Very fibrous gingival tissue surrounding chronic
inflammation due to a margin discrepancy of a
These near-infrared wavelengths produce photonic crown will be much more difficult to incise with the
energy that is generally scattered in soft tissue and is near-infrared wavelengths because of their photonic
transmissive through water but will be absorbed by pig- energy’s preference for melanin or hemoglobin in the
mented and/or inflamed areas. These lasers are for soft tissue. Moreover, these wavelengths can cause some
tissue only; they have virtually no interaction with conductive heat buildup in tissue distant to the surgi-
healthy tooth structure and should not be used on the cal area with possible peripheral edema. Lasers with
bone. They work well in well-vascularized tissue and longer wavelengths, such as carbon dioxide, would
provide excellent hemostasis. As noted previously, be much better instruments for that type of tissue.
482 D. J. Coluzzi et al.
55 Alternatively, acutely inflamed gingiva with its well- 55 When performing osseous crown lengthening, an
vascularized structure would be easily ablated by the open-flap or closed-flap technique may be used. With
same near-infrared lasers. the absence of visualization during a closed-flap pro-
55 A water spray can be used to control the tissue tem- cedure, the clinician must use maximum tactile sense
perature during ablation. This irrigation can be emit- while excising and contouring the bone and while
ted either from the laser (erbium and 9300-nm simultaneously avoiding alterations to the healthy
carbon dioxide instruments) or from other sources root surface.
such as the operatory triplex syringe. The near- 55 Whether an open or closed flap is chosen, it is recom-
infrared wavelengths are generally transmitted mended that the soft tissue modification proceeds
through water, but the mid- and far-infrared pho- first. It is much more difficult to excise and reshape
tonic energy is highly interactive. While the water the gingival tissue after the new bone form is estab-
will cool the tissue, it would reduce the average power lished.
at the target tissue when using erbium or carbon 55 Similar to soft tissue surgery, the laser beam’s place-
dioxide wavelengths, since some of the laser energy ment should be as precise as possible. The bony tis-
will be actively absorbed. sue must be properly contoured so that there are no
55 When using all tissue lasers, care must be exercised remaining defects, troughs, or unusual anatomy. The
while removing soft tissue to avoid unintentional underlying bone will determine the ultimate contour
removal of tooth structure. The laser beam must be of the soft tissue covering it.
aimed as precisely as possible, and a suitable physical
barrier (such as a matrix band or plastic instrument)
could greatly aid in only ablating the target tissue.
This precaution is especially important with some 15.3 Gingival Biotype
noncontact laser delivery systems.
55 While performing a gingivectomy, the clinician must Gingival anatomy has been generally described and cat-
strive to match the healthy physiologic contour of egorized as either thin or thick [1, 2]. Variations of those
the adjacent gingiva. The desired goal is that the terms sometimes appear in print as “thin-scalloped” or
healed site not only will be harmonious with the “thick-flat,” and current terminology is phrased thick or
patient’s periodontium but also will retain its shape thin biotype. Although somewhat difficult to determine
with a healthy attachment. One benefit of using a visually, the disappearance of the tip of the periodontal
laser for the procedure is that small areas of tissue probe into the sulcus usually indicates a thick tissue bio-
can be treated in steps until the desired contour is type. Other characteristics can aid in the classification:
achieved. This precision is easier to accomplish com- 55 The thin biotype is generally less than 1.5 mm in
pared to tissue removed with a surgical blade. thickness with a width of 3.5–5 mm and is character-
ized by a narrow zone of keratinized tissue with thin
15 marginal bone surrounding teeth with triangular
anatomic crowns. An example is shown in
15.2.5 or Procedures Involving Alveolar
F . Fig. 15.1a.
Bone, the Important Points 55 The thick biotype is at least 2 mm in thickness with a
to Remember Are Presented Below width of 5–6 mm and features a large amount of
keratinized tissue, thick marginal bone, and bony
55 During osseous surgery, care must be taken to avoid plates surrounding square anatomic crowns. An
overheating the bone and compromising its vascular- example is shown in . Fig. 15.1b.
ity. The appropriate lasers for this procedure use a
water spray, and the clinician should ensure that the The alveolar crest position and labial cortical plate
irrigation is properly directed toward the target tis- thickness have a significant correlation with the gingival
sue. biotype [3]. It has been shown that patients with thin
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
483 15
a b
.. Fig. 15.1 a An example of thin biotype tissue in the mandibular incisor area. Note the narrow zone of keratinized tissue. b An example
of thick biotype tissue with a large area of attached gingiva
tions such as creating adequate resistance and retention periodontal health and aesthetics. The emergence pro-
form or to make significant alterations to the shape of file must be scrutinized on each axial surface depending
the restoration will dictate the apical extension of the on various clinical situations ranging from a diastema
preparation. However, placement of the apical margin closure and height of contours of partial denture abut-
of the restoration within the biologic width can produce ments to placement of interproximal contact areas and
inflammatory periodontal disease [10]. This subgingival all subgingival margins. In all situations, the final resto-
margin location can create the greatest biologic risk, and ration on an implant abutment or a pontic in a fixed
the best practice is to place that margin a maximum of bridge must harmonize with the rest of the patient’s
0.5 mm into the sulcus. This distance will minimize any dentition.
chronic inflammation by not impinging on the biologic The re-establishment of a normal embrasure with a
width. From another perspective, this would mean that restoration is particularly challenging when there is no
the margin should be a minimum of 2 mm away from papilla, as in pontic or implant spaces and some dia-
the alveolar crest. stema areas [12]. Adding width to close a space generally
For aesthetic procedures where only the periodon- necessitates a deeper subgingival margin of the restora-
tium is altered without placing any restorations, the new tion [13]. Of course, the final result must achieve peri-
soft tissue must still retain an optimum biologic width so odontal health. Various techniques are necessary such
that there will be long-term stability. as troughing the gingiva to add additional restorative
Thus, any restorative or aesthetic procedure that material, contouring the edentulous ridge, and trough-
alters hard or soft tissue must establish a new healthy ing around the implant fixture. All of these are ideal
biologic width and dentogingival complex. procedures that can be performed with a laser.
15
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
485 15
a b c
d e f
g h i
.. Fig. 15.3 a Preoperative view of a crown restoration with a produce an ovate pontic concavity on the soft tissue. f Four-week
recurrent carious lesion at the gingival margin. b A 2-week postop- postoperative view with new restoration in place. Note the much-
erative view showing the healed tissue after crown lengthening and improved gingival embrasures and papillae due to the improved
troughing with an Nd:YAG laser using a 320-μm fiber and an aver- emergence profile. g An 810-nm diode laser used with a 400-μm tip at
age power of 2.0 W (100 mJ at 20 Hz). c Four-week postoperative 1.0-W continuous wave begins to uncover an implant fixture. h A
view showing the crown delivery. Note the emergence profile. d Pre- 2-week postoperative view of the healed gingival contour. i A 6-week
operative view of a bonded pontic replacing the maxillary lateral postoperative view of the restored implant. Note the healthy gingival
incisor. e An Er:YAG laser used with a 400-μm tip and an average tissue. (Implant case courtesy Dr. Steven Parker)
power of 2.0 W (40 mJ per pulse at 50 Hz) without water spray to
486 D. J. Coluzzi et al.
15.6 Crown Lengthening than a thicker anatomic form. After ensuring that bio-
logic width is adequate, it is essential to restore the phys-
This term is used to describe the intentional surgical iologic contours after soft tissue crown lengthening.
removal of periodontal tissues for both aesthetic This combination of removal and sculpting should pro-
improvements and proper and predictable placement of duce a harmonious gingival outline segment and will
a restoration. Many clinical conditions can be indica- also minimize any “rebound” or undesired tissue
tions for crown lengthening, such as subgingival carious regrowth. . Figure 15.4 demonstrates how a laser is
lesion, subgingival fracture of tooth structure, inade- used for both procedures.
quate axial height of a preparation, unequal gingival Any available dental laser can be used, keeping in
levels, altered passive eruption, and short clinical crowns mind how it interacts with the target tissue and adjust-
due to wear. ing the parameters for optimum ablation. When using
The primary goal is to attain a healthy biologic width erbium or carbon dioxide wavelengths, caution should
around the total circumference of the tooth [14–16]. be taken to avoid any tooth interaction until needed. In
There are other important objectives such as achieving . Fig. 15.2a, the diode laser can be aimed directly at the
the proper aesthetic tooth form or providing sufficient enamel, since that wavelength has minimal interaction
tooth structure for a successful restoration. For aesthetic with healthy tooth structure. However, the beam of
procedures, the clinician can achieve the desired result erbium and carbon dioxide wavelengths should be
of a more pleasing smile by applying the principles of placed parallel to the enamel to avoid unintended
maintaining a healthy dentogingival complex. Crown removal of the enamel, as shown in . Fig. 15.2b. As
lengthening can be limited to soft tissue only, or both noted, biologic width must be considered both when
soft and hard tissue can be contoured. planning this surgery and after it is completed. After
soft tissue crown lengthening, the clinician should deter-
mine if adequate biologic width remains; if not, then
15.7 Soft Tissue Crown Lengthening osseous crown lengthening must be performed.
15 a b
.. Fig. 15.4 a The diode laser is used for a gingivectomy and subse- already performed on both central incisors. Since this wavelength
quent gingivoplasty on a maxillary central incisor. Note that the can also be used for tooth preparation, the tip should not be aimed
beam can be directed toward the tooth with minimum interaction or directly at the tooth surface during the soft tissue crown lengthening
damage potential. b An Er:YAG laser is performing the gingivo-
plasty on the maxillary right central incisor. The gingivectomy was
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
487 15
sider the overall design of the smile that exists and how 15.7.3 linical Cases of Soft Tissue Crown
C
the practitioner can change that form [17, 18]. Clearly, Lengthening
there are personal interpretations of aesthetics, and
those can have a wide variance among patients both . Figure 15.5 shows the use of an erbium laser to
individually and culturally [19]. Moreover, the clinician improve gingival aesthetics. Excessive gingiva results in
may have specific opinions. In the end, the treatment the appearance of short clinical crowns. After biologic
objective is to produce a pleasing and healthy result for width is measured, it was determined that soft tissue
the patient [20]. crown lengthening could proceed. A tissue marker pro-
The starting point for any smile design is the clinical vided a “layout” to guide the clinician for the proce-
crown profile of the maxillary central incisors and the dure. Note that the laser is used parallel to the labial
corresponding gingival shape surrounding them [21]. If surface to avoid any interaction with the enamel. The
the patient desires some alteration, for example, a immediate postoperative view shows good tissue con-
“gummy smile,” then the biologic width must be located. tour.
After that, the surgical plan would be to create good . Figure 15.6 illustrates a case of porcelain veneers
symmetry on both sides of the midline. The zenith or placed to improve aesthetics and to close the diastema
apical most point of the gingival outline should ideally of the maxillary incisors. The patient opted out of orth-
be the same height on the central and cuspid, while the odontic treatment as a first step. A harmonious gingival
lateral incisor’s height can be 1–2-mm shorter [22]. architecture to produce a pleasing smile along with a
The ideal gingival contour has a scalloped shape, good emergence profile for the restorations was meticu-
and all of the interdental papillae fully occupy the inter- lously planned. A diode laser was used.
proximal embrasures. During gingival surgery, care . Figure 15.7 illustrates another case of aesthetic
should be taken to not produce a less scalloped, flatter crown lengthening utilizing an Nd:YAG laser. Adequate
gingival margin, since that could result in shorter inter- biologic width was measured, and the laser performed a
dental papilla and the opening of the embrasure spaces. gingivectomy and gingivoplasty. The Nd:YAG wave-
The latter condition is sometimes referred to as “black length produces a similar tissue interaction result to a
triangles,” and that would be a compromised aesthetic diode laser, although the free-running pulse emission
outcome. The most predictable gingival response will mode produces very short-duration pulses with a low
occur when the new postoperative outline follows the emission cycle. The relatively long intervals of non-
smile design principles as well as providing optimum emission are periods of thermal relaxation for the tissue
periodontal health [23]. during the surgery, which is an advantage for thinner tis-
sue biotype.
. Figure 15.8 shows the use of a diode laser to
15.7.2 oft Tissue Crown Lengthening for
S remove gingiva at an abfraction lesion in order to finish
Restorative Dentistry the apical extent of the preparation. The laser can easily
recontour the tissue and maintain a dry field for place-
The traditional restorative requirements of adequate ment of the restoration. As noted above, the diode wave-
and sound tooth structure can be problematic when a length has no interaction with the tooth structure. In
carious lesion extends subgingivally. The clinician must addition, the new gingival level will facilitate the patient’s
be able to visualize and remove the diseased tooth struc- oral hygiene in that area.
ture while analyzing the periodontal condition. In addi- . Figure 15.9 depicts a recurrent carious lesion
tion, an acceptable emergence profile must be produced. around an existing restoration on bicuspid. The inflamed
Retraction or removal of gingiva impinging on a marginal gingiva prevents total access to the lesion. A
lesion is essential for thorough caries removal. If bio- carbon dioxide laser was used to remove the tissue, repo-
logic width is adequate after the preparation is complete, sitioning it more apically so that a new composite could
then the clinician must decide if the margin placement be placed. The 9300-nm instrument also removed the
will aid or hinder the patient’s ability to maintain oral carious lesion, and that discussion can be found in
hygiene to try to prevent another lesion [24]. In both 7 Chap. 8 (clinical case courtesy of Dr. Joshua
cases, a laser can be used. Weintraub).
488 D. J. Coluzzi et al.
a b
c d
.. Fig. 15.5 a Preoperative view showing uneven gingival contour, with an average power of 2.0 W (40 mJ per pulse at 50 Hz) without a
with pronounced differences in the zeniths of the maxillary central water spray to perform the gingivectomy and gingivoplasty on all six
incisors. b A periodontal probe is used for the determination of bio- maxillary anterior teeth. d Immediate postoperative view showing
logic width and the overall dimensions of the dentogingival complex. excellent hemostasis and tissue contour. (Clinical case courtesy of
c After tissue is marked, an Er:YAG laser with a 600-μm tip is used Dr. David Hornbrook)
15
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
489 15
a b
c d
.. Fig. 15.6 a Preoperative view of the maxillary anterior segment to 0.8-W continuous wave and another dot was placed. That area
with a large diastema between the central incisors and uneven gingi- showed normal ablation and that parameter was chosen to utilize for
val height of all incisors. b Biologic width determination and analy- the surgery. d The immediate postoperative view shows the com-
sis of the dentogingival complex are performed with a periodontal pleted crown lengthening and finished preparations. Note that the
probe. c After verifying the periodontal condition, soft tissue crown central incisors were reduced on their mesial aspect and a subgingi-
lengthening was performed with an 810-nm diode laser using a 400- val trough was placed. Both of those procedures will enable new por-
μm bare fiber. In order to lay out the intended new gingival form, a celain contours so that the diastema can be closed. e Six-month
400-μm-diameter “dot” was placed at the new gingival zenith using a postoperative view demonstrates how the laser adjunctively fulfilled
power of 1.0-W continuous wave. Careful inspection of that small the principles of smile design and emergence profile while creating a
area of ablation revealed slight carbonization, which indicates the healthy periodontal condition
tissue temperature was excessive. The laser parameter was adjusted
490 D. J. Coluzzi et al.
a b
.. Fig. 15.7 a Preoperative view of the anterior maxillary sextant postoperative view. The laser’s free-running pulse mode emission
with asymmetrical gingival scalloping. Biologic width measurements allows for thermal relaxation of the tissue, particularly on the lateral
revealed adequate tissue available for soft tissue crown lengthening. incisors’ thinner biotype. Note the areas of gingivoplasty for new
Note the thinner biotype on the later incisors compared to the cen- tissue form and outline. c Three-week postoperative view showing
tral incisors. An Nd:YAG laser was used with a 320-μm fiber at an improved aesthetics with a more harmonious gingival scallop and
average power of 1.8 W (60 mJ per pulse at 30 Hz). b Immediate embrasures
15
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
491 15
a b
.. Fig. 15.8 a Preoperative view showing abfraction lesion on a pared and restored. c Immediate postoperative view of the final res-
maxillary molar. The gingival tissue has proliferated over the apical toration. The laser created a dry field with lack of any bleeding from
aspect of the lesion. b An 810-nm diode laser with a 400-μm bare the tissue to aid in the placement of the restorative material. The
fiber is used with an average power of 1.0 W to remove the gingival final margin placement should allow easy patient access for mainte-
tissue and re-establish proper contour. The lesion can then be pre- nance
492 D. J. Coluzzi et al.
a b
.. Fig. 15.9 a Preoperative view showing a recurrent carious lesion diate postoperative view showing the new tissue contour with the
with inflamed gingival tissue. The carious lesion extends subgingi- margin of the new composite restoration placed at the free gingival
vally. b The gingiva was recontoured with a 9300-nm carbon dioxide margin. Note how the laser achieved good control of tissue fluids to
laser using a 0.25-mm spot size, a 65-μs pulse duration, and a cutting aid in the composite placement
speed between 10% and 30% with minimal water spray. c The imme-
15
15.8 Osseous Crown Lengthening to guide the clinician in the procedure; however, laser
energy does not easily distinguish between bone and
If the intended crown lengthening will compromise the root surface cementum and/or dentin. Conventional flap
biologic width, an osseous procedure will be required. reflection may be necessary to both visualize and prop-
The desired goal is to shape the osseous crest to match erly contour bone, especially in large areas of missing
the gingival scallop outline form, and both should par- tooth structure or in multiple adjacent sites. In a local-
allel the restorative margin. As implied above, in g eneral, ized area, for example, with a subgingivally fractured
soft tissue crown lengthening is performed first before cusp, a closed-flap osteotomy and osteoplasty can be
the osseous procedure. The clinician must consider performed [26]. In either case, the bone must be con-
whether to proceed by raising a flap in an “open-flap” toured as close to an ideal physiologic form as possi-
surgical approach or operate without elevating any soft ble—without ledges, craters, or other deviations.
tissue—the so-called closed-flap or flapless technique Meticulous attention to creating proper anatomical
[25]. A contact laser tip can transmit tactile information form is much more challenging without flap access [27].
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
493 15
The overlying principle of biologic width dictates the 15.8.3 sseous Crown Lengthening for
O
amount of hard tissue removal along with the mainte- Restorative Dentistry
nance of adequate periodontal support.
The typical surgery begins with designing the new As a tooth preparation extends deeply into the gingival
gingival outline and determining the initial biologic sulcus, the clinician must evaluate how and where the
width. In this case, it is assumed that both soft and osse- bone will be repositioned. The restoration’s margin and
ous crown lengthening will be performed. Next, the gin- the surrounding periodontium will correspond to each
gival tissue is excised and contoured to achieve that new other; therefore, the immediate postoperative tissue
sculpture. That may result in destruction of all or part position, form, and contour will dictate the ultimate
of the soft tissue attachments. If possible, the existing result.
osseous crest should be sounded. Then the clinician
makes the decision about raising a flap. Removal of
2–3 mm of osseous resection is generally required to re- 15.8.4 linical Cases of Osseous Crown
C
establish new biologic width [8]. Similar to soft tissue
Lengthening
crown lengthening, an osteotomy and osteoplasty
should be performed, resulting in a stable anatomic scaf-
. Figure 15.10 shows an existing restoration of the
fold for the overlying gingiva. If an open-flap procedure
upper left lateral incisor whose clinical crown’s length
was used, the soft tissue flap is usually apically reposi-
was not harmonious with the other anterior teeth.
tioned and sutured. In a flapless technique, the clinician
Additionally, there was gingival pigmentation in the
should ensure that the soft tissue is well approximated
area (7 Chap. 16 provides a detailed discussion of
on the tooth surface [28].
laser-assisted removal of gingival pigmentation). After
depigmentation with the Nd:YAG laser, the Er:YAG
laser performed both soft tissue crown lengthening
15.8.1 Lasers for Osseous Crown
and closed-flap osseous crown lengthening. A new res-
Lengthening toration was placed (case courtesy of Dr. Shigeyuki
Nagai).
As mentioned above, only the erbium family and the . Figure 15.11 depicts a typical clinical dilemma
9300-nm carbon dioxide lasers are currently indicated where an existing crown restoration has fractured off
for bone procedures. The Er,Cr:YSGG (2780 nm) and with an inadequate amount of clinical crown remaining.
the Er:YAG (2940 nm) instruments primarily target the Osseous crown lengthening was performed in an open-
water component in osseous tissue, whereas the 9300- flap procedure using an Er:YAG laser. The successful
nm carbon dioxide energy interacts the hydroxyapatite. procedure resulted in sufficient tooth structure for a new
All three wavelengths utilize free-running pulse emission crown to be constructed.
with very short pulse durations. Each features a water . Figure 15.12 demonstrates an open-flap osseous
spray to help minimize any overheated areas of ablation. crown lengthening procedure to restore a fractured
To guide the beam, some instruments have contact tips, lower right second bicuspid. The 9300-nm carbon diox-
and others have small cylindrical guides used out of ide laser was used, and a 5-month postoperative photo
contact. shows good healing with the re-establishment of bio-
logic width (clinical case courtesy of Dr. Joshua
Weintraub).
15.8.2 Osseous Crown Lengthening for . Figure 15.13 depicts a fractured clinical crown on
Aesthetics the upper left central incisor. The patient chose the
option of endodontic treatment, crown lengthening,
All of the concepts of smile design must be considered core buildup, and new restoration. The 9300-nm carbon
before any surgery begins. If any restorations will be dioxide laser completed the soft tissue and closed-flap
placed, their gingival margin position should also be osseous crown lengthening. The final restoration was
planned. Typically, multiple teeth are involved in aes- delivered 3 weeks postoperatively, and the 1-year post-
thetic dentistry, and harmony among them must be operative photo shows a healthy periodontium with a
achieved. A diagnostic wax up can certainly aid in visu- new restoration (clinical case courtesy of Dr. Joshua
alization of the desired treatment outcome. In addition, Weintraub).
approximate areas of laser excision and contouring can . Figure 15.14 shows a case of varied gingival
be simulated. heights and contour of some maxillary teeth. Closed-
494 D. J. Coluzzi et al.
a b c
d e f
g h i
j k
15
.. Fig. 15.10 a Patient presented with gingival pigmentation and laser was then used with a 400-μm curved quartz tip for closed-flap
uneven gingival architecture on the upper left maxillary lateral inci- osseous reduction. The average power of 1.75–3.0 W (70 mJ,
sor, with a provisional restoration in place. b The radiograph shows 25 Hz–120 mJ, 25 Hz) was used to remove and contour the osseous
the restoration margin very close to the osseous crest. The treatment crest with water spray. f Continuous periodontal probing determined
plan is to remove the pigmentation and perform closed-flap gingival the bone reduction and final contour. g The immediate postoperative
and osseous crown lengthening so that the new restoration could result depicting additional tooth structure. h The healed tissue
restore the aesthetics. c An Nd:YAG laser, delivered through a 320- 2 weeks later. i The final restoration was placed 2 weeks later, which
μm quartz fiber, was used at 2.4 W, 80 mJ, 30 Hz, for 5 min to remove was 4 weeks after the two laser wavelength soft and hard tissue pro-
the epithelial pigmentation on the maxillary anterior tissue. The cedures. j A 14-month post procedure radiograph shows good peri-
immediate postoperative result is depicted. d Immediately following, odontal health. k The 4-year postoperative view with excellent
an Er:YAG laser with a pointed soft tissue tip (. Fig. 15.4) was used gingival architecture and tooth aesthetics with a slight recurrence of
at 1.5 W, 50 mJ, 30 Hz, without water for 12 s to remove the gingival pigmentation
tissue and to apically reposition the gingival margin. e The Er:YAG
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
495 15
a b c
d e f
.. Fig. 15.11 a Preoperative view. The patient presented with a por- ments, the same laser parameters were used to remove and reposition
celain fused to metal crown that had become dislodged. The incisal the osseous crest. Note that the tip is aimed at the bone, avoiding
one-third of the preparation had also fractured. The crown was rece- contact with the root. d The immediate postoperative view of the
mented, and it was determined that osseous crown lengthening flap repositioned with new tooth form revealed. e One-month post-
would be necessary because of the inadequate biologic width. b An operative view shows the healed attachment and new gingival height.
Er:YAG laser was used with a 400-μm tip with an average power of A new crown preparation can proceed with adequate ferule for good
2.4 W (80 mJ at 30 Hz) with a copious water spray to apically reposi- retention form. f Two weeks later, the crown is delivered, and the tis-
tion the gingival margin, achieving the soft tissue portion of the sue should continue to heal for a successful restorative result
crown lengthening. c After raising a flap with conventional instru-
flap gingival and osseous crown lengthening were osseous crown lengthening to provide adequate tooth
accomplished with an Er:YAG laser, and then porcelain structure for new restorations. . (Clinical case courtesy
veneers were placed. The clinical photos show a portion of Dr. Mark Cronshaw).
of that procedure on the cuspid. A 4-year postoperative . Figure 15.16 shows a patient who presented with
view shows healthy periodontium and excellent aesthet- worn and unaesthetic maxillary and mandibular ante-
ics (clinical case courtesy of Dr. David Hornbrook). rior teeth. A treatment plan was developed that included
. Figure 15.15 shows a patient who presented with increasing the vertical dimension, osseous crown length-
a desire to improve the aesthetics of the upper anterior ening for the upper right and left central incisors, a max-
teeth. The Er,Cr:YSGG laser with a 600 μm 9mm long illary frenectomy, and restorations, and the Er,Cr:YSGG
tip assisting with flap surgery and removal of the apical laser was utilized (clinical case courtesy of Dr. Mark
portion of the root, and then performed gingival and Cronshaw).
496 D. J. Coluzzi et al.
a b c
d e
.. Fig. 15.12 a Preoperative view of a large fractured buccal cusp fractured to the osseous crest. d The laser was then set at a 1.0-mm
of the lower right second bicuspid. The patient considered all treat- spot size, 40–50% cutting speed, and a 80% water mist spray for the
ment options and chose crown lengthening, endodontic therapy, and alveolar bone ablation. Note the good vascularity of the ablated
a final restoration. b The 9300-nm carbon dioxide laser was used at a osseous structure. e A 5-month postoperative view shows the final
1.0-mm spot size, 20–30% cutting speed, and 1% water mist spray to restoration. (Clinical case courtesy of Dr. Joshua Weintraub)
perform the soft tissue incision. c The buccal flap extended to the
proximal surfaces of both adjacent teeth, showing that the cusp had
15
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
497 15
a b c
d e f
.. Fig. 15.13 a Preoperative view of a fractured clinical crown. b the bone to determine the osseous crest, the same handpiece was
After endodontic treatment was completed, the soft tissue removed used with a 0.5-mm spot size, 80% water mist, and a cutting speed
to expose the apical extent of the fracture. The 9300-nm carbon between 60% and 80%. The result was to expose at least 2 mm of
dioxide laser was used with a tipless contra angle handpiece and a tooth structure coronal to the osseous crest. d Depicting the provi-
1.00-mm spot size, 1% water mist, a cutting speed between 20% and sional crown in place. e Showing the 3-week postoperative view when
30%. Control of the tissue removal was achieved by varying the the final restoration was delivered. f One-year postoperative view
working distance, hand speed, and cutting speed. c Showing the with healthy periodontium. (Clinical case courtesy of Dr. Joshua
completed crown lengthening and core buildup. After sounding to Weintraub)
a b
c d
.. Fig. 15.14 a Preoperative view of varied gingival architecture of the restoration. Osseous crown lengthening is necessary on the
around existing porcelain crowns. b An Er:YAG laser was used with labial surface, and a closed-flap technique was used. The Er:YAG
a 400-μm tip with an average power of 2.0 W (40 mJ at 50 Hz) with- was used with the same parameters—2.0 W (40 mJ 50 Hz) but with a
out water spray for the soft tissue removal. This photo shows that water spray. c The crown lengthening is completed on all of the teeth.
procedure in progress on the cuspid, and perio probing on that tooth d Four-year postoperative view shows excellent periodontal health
shows that there will be a violation of biologic width in order to along with good smile design. (Clinical case courtesy of Dr. David
establish the intended new gingival outline and to place the margin Hornbrook)
498 D. J. Coluzzi et al.
a b c
d e f
g h i
15
.. Fig. 15.15 a Showing the preoperative view of the patient who proposed contour for a closed-flap crown lengthening procedure.
desired improved aesthetics. b Depicting the radiograph of continu- The Er,Cr:YSGG laser with a 600-μm 9-mm-long tip was used at
ing periapical pathology on the upper right lateral incisor with previ- 2.5 W, 40% water, and 20% air for the gingivectomy. The osseous
ous endodontic treatment. The Er,Cr:YSGG laser was used at 2.5 W, architecture was adjusted to a distance of 3 mm apical to the newly
25 Hz, 40% water, and 20% air to perform a semilunar soft tissue established gingival margins. The same tip was used at 3.0 W, 30 Hz,
incision. c Depicting the osseous exposure, contouring, and apical 60% water, and 60% air. A photobiomodulation dose of 50 J/cm2 for
resection performed at 3–3.5 W, 25 Hz, 85% water, and 20% air with 100 s was then applied to the surgical sites. The teeth were then pre-
the same tip. The granuloma removal and debridement utilized the pared for restoration and the provisionals were placed. Two weeks
soft tissue parameters, and the finished surgery is shown in d. Then a later, the tissue is healing well h. The final restorations were delivered
retrograde MTA apical filling and platelet-rich fibrin were placed. e 4 weeks later i, and the 4-year postoperative result is shown in j, with
Showing the postoperative radiographic result. The healed apical a healthy periodontium and excellent aesthetics. (Clinical case cour-
surgery site is shown in f. g Depicting the initial incision and the tesy Dr. Mark Cronshaw)
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
499 15
a b c
d e f
g h i
j k l
.. Fig. 15.16 a Preoperative view of patient presenting with worn Depicting closed-flap crown lengthening. The Er,Cr:YSGG laser uti-
and unaesthetic maxillary and mandibular anterior teeth. After lized a 600-μm 9-mm long tip and 3 W, 30 Hz, 60% water, and 60%
studying all the findings, the treatment plan is to include increasing air. The tip enters the sulcus parallel to the root with a slow sweeping
the vertical dimension of occlusion by 2 mm, lowering the incisal motion. The clinician should ensure good water flow in and out of
plane by 2 mm, osseous crown lengthening on UR and UL 1, frenec- the sulcus. To refine the osseous architecture, Wedelstaedt bone chis-
tomy, and restorations. The diagnostic wax up is shown in b. Soft els are used g, and a blunt piezo ultrasonic tip removes any minor
tissue crown lengthening was performed. The Er,Cr:YSGG laser was bony irregularities h. The frenectomy was next performed using the
used with an MZ6 9-mm tip. The proposed gingival architecture was previous soft tissue parameters: MZ6 9 mm at 2.5 W, 25 Hz, 40%
laid out with small dots on the tissue surface using 0.5 W without air water, 20% air i. It is important to score the periosteum j to produce
or water. A probe measurement from the wax up verifies gingival a scar which prevents frenal proliferation incisally. k Showing the
margin placement, as shown in c. d Depicting the completed soft tis- completed soft and hard tissue surgery. All teeth were prepared and
sue crown lengthening. The same tip was used at 2.5 W, 25 Hz, 40% provisional restorations were placed 1 month postsurgery. l Showing
water, and 20% air to remove the soft tissue. The osseous crest was the final restorations delivered, approximately 5 weeks later. (Clini-
located with probing, as shown in e. The bone reduction must result cal case courtesy Dr. Mark Cronshaw)
in the crestal bone location 3 mm apical to the gingival margin. f
500 D. J. Coluzzi et al.
15.9 Soft Tissue Management hemostasis. Moreover, the laser can achieve excellent
for Placement of Direct or Indirect restorative results [29].
. Figure 15.17 depicts a recurrent carious lesion on
Restorations
the upper right central incisor that extends into the gin-
gival sulcus. The 9300-nm carbon dioxide laser recon-
Manipulation of soft tissue with various wavelengths
toured the impinging gingival tissue, removed the
and subgingival margin placement has been discussed
carious lesion, and re-prepared the tooth for a new res-
earlier in this chapter. The restorative dentist must con-
toration. (Further discussion about lasers caries removal
sider and apply all of those principles while preparing
can be found in 7 Chap. 8.)
the tooth. Modern dental direct restorative materials
. Figure 15.18 shows how an Nd:YAG laser is used
generally require meticulous control of moisture and
for troughing around two preparations during the con-
bleeding to ensure a good bonding environment.
struction of new crowns. The laser is gently placed in the
Successful fabrication of indirect restorations involves
sulcus and aimed toward the gingival soft tissue. It offers
many factors. One important one is to duplicate the fin-
excellent tissue management which facilitates any
ished preparation with as much accuracy as possible.
impression technique.
Whether for direct fillings, impressions, or optical scan-
. Figure 15.19 depicts an Er,Cr:YSGG laser used
ning, any available dental laser can accomplish soft tis-
for troughing around a molar. The rigid tip was aimed at
sue management, moisture control, debridement, and
a b
c d
15
.. Fig. 15.17 a Preoperative view showing a carious lesion that of the speed of ablation was achieved by varying the working dis-
extends subgingivally. b The gingiva was recontoured with a 9300- tance, the hand speed, and the cutting speed. c The immediate post-
nm carbon dioxide laser using 1.00-mm spot size, 1% water mist operative view shows the new restoration with good soft tissue
spray, and a cutting speed of 20–30%. The existing composite was contour. Note the good moisture control to aid in the composite
removed, and the tooth was prepared with the same settings except placement. d A 6-day postoperative view showing the healed gingival
for increasing the water spray mist from 1% to 80%. Precise control tissue. (Clinical case courtesy of Dr. Josh Weintraub)
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
501 15
a b
c d
.. Fig. 15.18 a Preoperative view of the maxillary left central and bleeding so that the impression material can accurately capture the
lateral incisors which will be prepared for porcelain crowns. b Imme- subgingival margins. The interdental papilla was also slightly con-
diate postoperative view of the laser troughing. An Nd:YAG laser toured. This average power is less than the parameters generally used
was used with a 320-μm bare fiber at an average power of 1.2 W for incisions since there is no need for any tissue removal. c The
(40 mJ at 30 Hz) in the sulcus, aimed at the soft tissue side of the resulting impression shows accurate marginal detail. d Three-week
pocket with gentle pressure. The fiber is used in short arcs of a circle, postoperative and 1-week postdelivery view of the completed resto-
interacting with small segments of the tissue at a time. The goal was rations showing an excellent tissue response
to gently retract and debride the tissue space along with controlling
a b
c d
.. Fig. 15.19 a Preoperative mirror view of a maxillary molar tooth in short arcs of a circle to debride and widen the sulcular tissue
defective crown restoration. A new crown will be constructed. b so that the subgingival margins were revealed. (c) A photo of the
Immediate postoperative mirror view of the laser troughing. After final impression. Note the clear margin definition. d The final crown
the tooth was prepared, an Er,Cr:YSGG laser was used with an MZ was delivered with excellent results including gingival health. (Clini-
5 tip at an average power of 2.25 W (75 mJ per pulse at 30 Hz) in the cal case courtesy of Dr. Glenn van As)
sulcus with minimal water spray. The tip was moved around the
502 D. J. Coluzzi et al.
a b c
d e f
.. Fig. 15.20 a The mirror view of two maxillary premolar teeth excellent control of bleeding and tissue retraction on the first premo-
that will receive full porcelain crown restorations. b A diode laser lar’s gingiva after the laser use. e View of the final impression show-
with a 400-μm bare fiber and an average power of 0.8 W is used par- ing excellent capture of both preparations. f Two-week postoperative
allel to the long axis of the preparation of the first premolar to view of the preparations, after the provisional restorations are
expose the margins and debride the sulcus. The fiber is used in short removed, showing adequate gingival health. g Three-week postop-
arcs of a circle. c Retraction cord is placed in the sulcus of the second erative view of the final restorations showing an excellent result.
15 premolar. d The preparations are ready for the impression. Note the (Clinical case courtesy of Dr. Glenn van As)
the soft tissue in the sulcus, being careful to avoid con- ters, the laser easily reveals the subgingival margins with
tact with the preparation margins. The impression pre- excellent bleeding control (clinical case courtesy of Dr.
cisely captured all the marginal detail (clinical case Glenn van As).
courtesy of Dr. Glenn van As). . Figure 15.21 shows how a carbon dioxide laser is
. Figure 15.20 shows a comparison between diode used to retract the tissue around a central incisor. The
laser tissue retraction and conventional cord technique 10,600-nm wavelength is very effective in soft tissue
during full-crown preparations on adjacent maxillary removal while achieving excellent hemostasis (clinical
premolars. Using careful technique and proper parame- case courtesy of Dr. Steven Parker).
Laser-Assisted Multi-tissue Management During Aesthetic or Restorative Procedures
503 15
a b c
d e
.. Fig. 15.21 a Preoperative view of a crown preparation in prog- tissue removal that appears carbonized will be rinsed away; however,
ress while determining the dentogingival complex measurement. b A the hemostasis is excellent. d Two-week postoperative view shows the
10,600-nm carbon dioxide laser used with a 600-μm beam diameter healed tissue contour which will facilitate the good emergence profile
in noncontact at a power of 1.0-W continuous wave. The beam was of the restoration. e View with crown delivered. (Clinical Case cour-
aimed precisely at the soft tissue while avoiding interaction with any tesy of Dr. Steven Parker)
tooth structure. c Immediate postoperative view. The small area of
a b
c d
.. Fig. 15.22 a Preoperative view of edentulous ridge after removal concavity where the convex pontic will be positioned. The laser shap-
of a bonded bridge. Note the chronic inflammation of the tissue due ing can proceed with small amounts of tissue removal, but the clini-
to the ridge lap design of the previous pontic, which prevented the cian must be careful to leave at least 1.0 mm of tissue covering the
patient from adequately cleaning the area. b A periodontal probe is bone. d A 15-year postoperative view showing excellent periodontal
used to measure the tissue thickness. There is sufficient tissue to health with the new bridge restoration with its ovate pontic. The
allow removal for an ovate pontic design. c A diode laser is used with patient can easily maintain the pontic space and adjacent tissue.
a bare 400-μm fiber at 1.0 W continuous wave emission to sculpt the (Clinical case courtesy of Dr. David Hornbrook)
Contents
References – 530
Impact of Laser Dentistry in Management of Color in Aesthetic Zone
509 16
Core Message anti-depressant, and minocycline [7, 8] and hormonal
A pleasingly attractive smile is composed of a harmonious disorder [9, 10]. Recent studies have also reported the
balance of a well-aligned set of teeth with healthy ana- correlation between passive smoking in women and chil-
tomic contour of the gingiva and lips. Patients’ demand for dren with hyperpigmentation [10–12]. Amalgam tattoo
aesthetic dentistry can be met with the practitioner’s choice is a condition that is commonly observed in the gingiva
of procedures and materials. Dental lasers can certainly be [13]. Post-inflammatory hyperpigmentation (PIH) is a
integrated into the treatment plan, and this chapter will sequela of cutaneous disorder described in dermatology.
provide details about modifying the color of the dental PIH on the lip is a common cause by trauma (e.g., burns,
soft and hard tissues to help attain the desired outcome. lip biting, and trauma by pen and pencil).
The first section will describe on treatment for pigmenta-
tion of nonneoplastic origin. The second section will pro- Classification of Pigmentation
vide details about whitening. Pigmentation can be classified by Dummett index [14]
and Takashi index [11].
The Dummett oral pigmentation index (DOPI)
16.1 ingival and Lip Pigmentation
G describes the color intensity of pigmentation into four
Management scores:
1. No clinical pigmentation (pink-colored gingiva)
Kenneth Luk 2. Mild clinical pigmentation (mild light brown color)
3. Moderate clinical pigmentation (medium brown or
mixed pink and brown color)
16.1.1 Introduction 4. Heavy clinical pigmentation (deep brown or bluish
black color)
A well-aligned set of teeth not only improves function
and oral hygiene maintenance but also most importantly Takashi index describes the extension of melanin pig-
produces a confident and attractive smile. Gingival con- mentation into three scores:
tour, emergence profile, and teeth proportion all con- 1. Score 0: No pigmentation
tribute to the smile profile [1]. However, dark 2. Score 1: Solitary unit(s) of pigmentation in papillary
pigmentation (. Fig. 16.1) of the gingiva and lip may gingiva without extension between neighboring soli-
deflect the attention of a perfect smile [2]. Melanin pig- tary units
mentation of the gingiva and lip is most commonly 3. Score 2: Formation of continuous ribbon extending
noticed in ethnic groups [2–4], smokers [3, 5, 6], patients from neighboring solitary units
under medication such as anti-malarial agents, tricyclic
Various Treatments for Depigmentation signal that the depth of ablation is beyond the basal
The use of chemical peel and cryosurgery has been used layer. Water spray is not used with 10600nm CO2 irra-
for melanin depigmentation. Treatment with scalpel and diation, but carbonization effect can be reduced with the
diamond bur [16] has also been used and compared with short pulse durations that those CO2 lasers offer.
lasers [17–21]. In a split mouth clinical trial, the use of 9300nm CO2 laser is the most recently developed
lasers has been shown with less relapse 3 months postop CO2 laser for both hard and soft tissue treatments.
when compared with electrosurgery [22]. This laser delivers high output power and short pulse
duration with the water spray. Precise control of abla-
tion differs from accustomed laser parameters by
16.1.2 Laser Ablation selection of percentage of power and rheostatically
controlled cutting speed. The powers and pulse dura-
For over 10 years, CO2, Er:YAG, Er,Cr:YSGG, Nd:YAG, tions were measured and converted to parameters gen-
and diode lasers (. Fig. 16.2) have been reported with erally discussed and illustrated by the author in
good results in melanin depigmentation [23–28]. The . Fig. 16.3 [29].
procedure requires ablation (vaporization) of the sur- Visible light, near-infrared diode, and Nd:YAG
face gingiva or mucosa to the basal layer where the (445–1064 nm) wavelengths are poorly absorbed in
melanocytes are located. water but well absorbed in pigment. Initiated 320-μm
Erbium and CO2 wavelengths (. Fig. 16.2) are well fibers and similar-sized quartz tips are commonly used
absorbed in water and thus will remove shallow layers of to ablate the layers in contact mode. Apart from direct
soft tissue and eventually reach the layer of melanin. surface absorption, the laser photons can also penetrate
Sapphire tips or focusing window are used in noncon- to the basal layer and capillaries to be absorbed
tact mode. The use of erbium lasers has the advantage (. Fig. 16.4). The tissue tag on the treatment site should
of using water spray not only to keep the ablation front be removed regularly to view the color improvement.
from dehydration but also to irrigate the debris to give a For diode lasers, it has been demonstrated that water
clear view during the procedure. Although this reduces irrigation during ablation can be used to reduce the col-
the hemostatic effect, bleeding would be a good warning lateral thermal damage [30, 31].
16
Impact of Laser Dentistry in Management of Color in Aesthetic Zone
511 16
.. Fig. 16.3 Pulse duration
and fluence in relation to the
power percentage of 9300nm
CO2 laser in soft tissue mode
with a repetition rate of
187 Hz. Peak power measured:
150 W at 10%, 260 W at
20–100% [29]
a b c
.. Fig. 16.5 a Showing the preoperative view. b Immediate postop- The procedure was performed utilizing the tipless contra-angle
erative view. Gingivectomy on tooth #8 by 9300nm CO2 laser was handpiece. The total procedure time was approximately 20 min. c
performed utilizing 1 mm spot size, 1% mist and cutting speed of Showing the 2-week postoperative view. (Clinical case courtesy of Dr
~30–40%. For the depigmentation, the same laser employed a 1.25- Joshua P. Weintraub)
mm spot size, 1% mist, and cutting speed between ~20% and 30%.
a b c
.. Fig. 16.6 a Preoperative view of melanin pigmentation. b On the an average power of 4 W (MSP mode and 20 Hz) on the left quad-
right quadrant, the Er:YAG laser was used with 800-μm sapphire tip rant. Treatment time for each side was 10 min. c Six-month postop-
at an average power of 1.8 W (120 mJ, 15 Hz) and a 1000-μs pulse erative view shows stable tissue color and good tissue tone performed
duration. The Nd:YAG laser was used with a 320-μm bare fiber and by both lasers.
a b c
16
.. Fig. 16.7 a Preoperative view of melanin pigmentation. b Imme- Although some areas still showed pigmentation [11, 12], the overall
diate postoperative view of upper and lower anterior segments. c aesthetic appearance was very pleasing. (Clinical case courtesy of
One week postoperative view showed mucosa with good maturation. Dr. Mudasser Iqbal)
was calculated. The treatment time took 12 min to com- evaluated. Treatment was significantly faster with
plete the upper and lower anterior segments (clinical Er,Cr:YSGG laser and required no anesthesia, with
case courtesy of Dr. Mudasser Iqbal). faster healing and less postoperative discomfort after
A recent study by Altayeb et al. [32] compared 1 week of treatment, compared to the diode laser
ablative gingival depigmentation on 60 patients using treatment. It was concluded that both lasers effi-
diode laser (940 nm) and Er,Cr:YSGG (2780 nm) ciently removed gingival pigments with comparable
lasers. A 2-year follow-up in efficiency of depigmen- in clinical outcomes and overall positive patient expe-
tation, patient perceptions, and recurrence rates was rience.
Impact of Laser Dentistry in Management of Color in Aesthetic Zone
513 16
16.2.1 Non-ablative Laser Procedures length is well absorbed by melanin and hemoglobin, the
use of a high-power laser can concentrate the thermal
The word non-ablative is frequently used in dermatology energy on the surface with a very short pulse (. Fig. 16.8).
on skin resurfacing techniques. Unlike an ablative laser A continuous sweeping motion should be used, and re-
procedure which vaporizes the skin surface, a non- irradiation of the already coagulated area should be
ablative procedure penetrates the surface and coagulates avoided. This technique resulted in a treatment time of
the subsurface layer of the skin while keeping the surface 2 min for single arch between first premolars. Using a
layer in place. In depigmentation, the author uses the low-power diode laser with long pulse to continuous
description of “non-ablative” to describe this effect using wave usually allows thermal conduction deeper into the
near-infrared and visible light diode lasers. The surface tissue [30, 31]. A similar principle called laser-patterned
mucosa will peel off at day 1 or 2 after treatment. microcoagulation using 20-W 980-nm diode laser was
reported on depigmentation of one papilla [35].
he Fundamental Interaction Is
T
Photocoagulation
Photocoagulation, in this case laser coagulation, 16.2.2 linical Cases of Non-ablative
C
describes a laser-tissue interaction where the target tis- Technique with an Infrared Diode
sue component is well absorbed by the laser wavelength
and there is a coagulation effect when the temperature . Figure 16.9 shows a case of melanin depigmentation
reaches 60 °C. Hemoglobin is very well absorbed in using an 810-nm very short pulsed high peak power
Nd:YAG, visible light, and near infra-diode lasers. Thus, diode laser.
photocoagulation is most commonly applied for hemo- . Figure 16.10 shows a case of lip depigmentation
stasis of a surgical wound such as extraction socket or a using an 810-nm very short pulsed high peak power
periodontal pocket. Treatment of vascular lesions such diode laser. The patient, a young lady, had tried to
as varix and hemangioma can also benefit by photoco- mask the pigment with dark colored lipstick but was
agulation. unable.
. Figure 16.11 shows a case of photocoagulation
Near-Infrared Diode Lasers of a lip hemangioma using an 810-nm diode. Three
A non-ablative technique using a high-power 810-nm laser treatments were performed at a monthly interval.
diode laser (30 W, 20 kHz, 16-μs pulse duration) was The patient wanted the lesion removed for her wedding
reported by the author [33, 34]. Since the 810-nm wave- photos.
a b c
.. Fig. 16.9 a Preoperative photo of gingival melanin pigmenta- anesthesia, the treatment time was 80 s on the maxillary arch only. b
tion. An 810-nm diode laser was used with a 600-μm bare fiber with Immediate postop showing non-ablative mucosa. c The 6-week post-
30 W of peak power, a 16-μs pulse duration, at 20 kHz. Under local operative photo is shown and the pigment is not present
a b c
.. Fig. 16.10 a The preoperative view of a pigmented area on the peak power, 16-μs pulse duration, at 20,000 Hz for an exposure time
lower lip. b The immediate postoperative view. Under local anesthe- of 8 s with non-ablative technique. c Two days postoperative view. d
sia, an 810-nm diode laser was used with a 600-μm fiber with 30 W of A 5.5-year postoperative view showing no relapse of pigmentation
a b
16
.. Fig. 16.11 a The preoperative view of a hemangioma on the in second visit, and 10 s in third visit) without anesthesia. b Three
lower right lip. An 810-nm diode laser was used for photocoagula- months postoperative view showing normal lip tissue
tion with 30 W, 20,000 Hz, 16-μs pulse duration (3 s in first visit, 3 s
a b
.. Fig. 16.12 a Preoperative view of a varix (venous blood vessel) Hz, 16-μs pulse duration for two visits. (Two seconds on labial in first
on the interproximal papilla of the maxillary central incisors. An visit, 2 s labial and 2 s palatal in second visit). b Eight months post-
810-nm diode laser was used for photocoagulation with 30 W, 20,000 operative view
445 1 W, continuous 88 W/cm2 40 s Absorption in melanin ten times higher than 810 nm
wave, 2 mm Absorption in hemoglobin 100 times higher than
average defocused from 810 nm
power = 1.0 W tissue Novel wavelength with no complications yet
reported; however, the absorption and significantly
lower power density should produce fewer
complications
810 30-W peak power 1697 W/cm2 40 s to 3 min for a Complications can be gingival recession and bone
Pulse duration 16 2 mm comparable area necrosis
μs, defocused from
20,000 pulses per tissue
second
Average power
9.9 W
pared with other dental laser wavelengths. In ablative 16.2.5 Pigmentation of Exogenous Origin
technique, Taher Agha and Polenik [36] evaluated 30
patients using 445-, 940-, 2780-nm wavelengths. It was Metal tattoo such as amalgam is not uncommon in pig-
concluded that all three wavelengths were fast, effec- mentation of the gingiva. Pigmentation lip is regularly
tive in pigmentation removal, and well tolerated by caused by pencil (lead) and pen.
patients.
Visible blue diode laser (445 nm) can also be used Clinical Cases of Metal Tattoo
with non-ablative technique. The author showed 1-W . Figure 16.14 shows a patient presented with amalgam
continuous wave being comparable in achieving the tattoo at the gingival margin and papilla on the upper
same result and speed as 30-W 810-nm diode laser [37]. central incisors [38]. Under microscope and local anes-
This much lower-power density produces the same effect thesia, the Er:YAG laser (40 mJ at 30 Hz) with water
and can minimize any unwanted thermal damage to the spray was used. The metal debris embedded in the con-
tissue. . Table 16.1 shows some further details in com- nective tissue was effectively removed, without producing
paring the two wavelengths. major thermal damage such as carbonization and coagu-
lation (b). At one week of postoperative view (c) and one
year of post treatment (d), favorable wound healing was
16.2.4 linical Case of Visible Light Diode
C achieved without any gingival tissue defects or recession.
for Non-ablative Depigmentation The gingival color recovered a natural aesthetic appear-
ance. (Ishikawa I et al. Potential applications of
. Figure 16.13 shows a depigmentation case by 445-nm Erbium:YAG laser in periodontics. J Periodont Res;
wavelength. 2004; 275–285.; with permission. Journal of Periodontal
516 K. Luk and E. Anagnostaki
a b c
.. Fig. 16.13 a The preoperative view of the lower anterior gingiva technique. (Gingiva between the lower left central and lateral inci-
with melanin pigmentation. b The 445-nm diode laser with a 320-μm sors shows an ablated site indicating over-irradiation beyond coagu-
bare fiber, defocused 2 mm from the tissue, was used at 1-W CW for lation temperature. c The 5-month postoperative view shows normal
40 s under local anesthesia. Immediate postop with non-ablative tissue color and contour
a b c d
.. Fig. 16.14 A 73-year-old female presented with an amalgam tat- restoration. The 9300nm CO laser and topical anesthetic were used.
too on the attached gingiva on the distal buccal of the implant site. The laser does not selectively ablate pigment but removes the affected
The previously extracted #4 had an existing large DO amalgam with tissue and pigment (. Fig. 16.15 ). (Clinical case courtesy of Dr
radiographic evidence of the tattoo apical to the gingival floor of the Joshua P. Weintraub)
a b c
16 .. Fig. 16.15 a Preoperative photo. b The amalgam tattoo was removed in layers until the tattoo was gone. The total procedure time
ablated utilizing a 9300nm CO2 laser with a 1.00-mm spot size, 1% was approximately 3 min. c A 6-week postoperative view, showing
mist, and cutting speed between ~20% and 30%. Tissue was carefully excellent healing
c d
a b c
.. Fig. 16.17 a Preoperative view. b Immediate postoperative view after an 810-nm laser exposure of 1 s with 30 W, 20,000 Hz, 16-μs pulse
duration using a non-ablative technique with anesthesia. c One-year postoperative view
16.2.6 Postoperative Care recurrence after 1 year [40] and at 2 years [42] after treat-
ment. Recently, evaluation of 940-nm and 2780-nm
The patient should be advised to avoid smoking, alco- depigmentation by Altayeb et al. [32] reported long-
hol, and acidic and spicy food. Sashimi is best avoided term stability of gingival color over the 2 years was bet-
for the first few days. Gentle tooth brushing around the ter with diode laser. The re-pigmentation intensity and
gingival margin and warm salt mouth rinse is recom- extensity were higher significantly in the Er,Cr:YSGG
mended. In general, no analgesic is required. However, group than in the diode group at 1 year and 2 years.
there has been report from mild discomfort to pain with Patients should be aware of the recurrence of pigmenta-
hot food 1 day after treatment [39, 40]. tion, but this can be retreated readily. Cessation of med-
ication and giving up on smoking habit reduce the
likelihood of relapse.
16.2.7 Recurrence of Melanin Pigmentation
Recurrence of pigmentation
Author Wavelength Re-evaluation No. of Location No. of Recurrence
period (months) cases
trast, when using the non-ablative procedure, the author There have not been reports of any major clinical
reported a treatment time of 1–2 min to complete one complications; however, there is a possibility of gingival
dental arch [33, 34]. recession and bone necrosis which can be caused due to
excessive ablation, over-irradiation, and deep tissue heat
16 conduction. Prophylaxis and good oral hygiene are
16.2.9 Ablative vs. Non-ablative Technique essential to stabilize gingival tissue prior to depigmenta-
tion. This can avoid any dispute with gingival recession
The ablative technique can be performed by all Class after depigmentation. The clinician should carry out the
IV surgical lasers and is most commonly used. The procedure with good understanding of the optical prop-
operator is able the observe color change layer by layer erty of the laser he/she is using and the laser-tissue inter-
during ablation. Carbonization during treatment action involved. On the other hand, a clinician is
should be avoided, and any tissue tags should be accustomed to completing many procedures in one
removed during the procedure to have a clear view of appointment. The thought of “touching up” a pig-
the ablation front. mented area should not be construed as poor operative
The non-ablative technique relies on the optical technique; rather, it should be viewed as an opportunity
properties, biophysical properties (laser-tissue inter- to further improve the aesthetic result.
action), and laser parameters described above.
Therefore, not all Class IV lasers can use this tech-
nique. Although the non-ablative technique can be 16.2.10 Summary
completed much faster, the operator should have a
clear understanding of the principles before perform- In the author’s experience, many patients are troubled by
ing this technique. the pigmentation, even one spot of pigment on the lip,
Impact of Laser Dentistry in Management of Color in Aesthetic Zone
519 16
for example, but not aware of possible treatment. Pigment formed will not harm the enamel, the dentin, the pulp of
on the lip is more of concern than gingiva. Furthermore, the teeth, and the surrounding tissues.
ethnic communities in the Middle Eastern countries are
more concerned with gingival pigmentation.
For those who are made aware of their pigmentation, 16.3.2 Tooth Structure
acceptance of treatment is high. They are usually more
appreciative of our examination skills and will have con- Enamel
fidence in our techniques. In addition, treatment accep- Enamel is the outer layer of the tooth and the hardest
tance is good for both men and women at any age group. tissue in the body.
When discussing the procedure, the patients must be Mature dental enamel has a complex organized
made aware of possibilities of relapse, depending on the structure, mainly containing inorganic minerals
cause of pigmentation. One example is shown in (96%) and a small amount of organic material and
. Fig. 16.5c, and the patient should be informed that a water (4%), but no cells or collagen [52]. The basic
second procedure will be necessary. As an aside, this is inorganic structural blocks are hydroxyapatite crys-
an opportune time to discuss smoking cessation. After tals. Ionic exchange can occur, resulting in ionic sub-
the laser treatment of the pigmentation, the shade of the stitutions, which have key effects on the hydroxyapatite
teeth may look darker as their gingiva returns to a pinker physical and chemical properties. As an example, the
color, since there will be less contrast between the enamel fluoride incorporation in enamel was shown to
and the soft tissue. increase its resistance to demineralization [53].
Mineral gain and loss are a dynamic physicochemical
process on the tooth surface. Light scattering by the
16.3 Laser-Assisted Dental Bleaching mineral crystals plays a considerable role in light scat-
tering processes.
Eugenia Anagnostaki The organic component contains non-collagenous
proteins (60%) and lipids (40%) and can function simi-
larly to a semipermeable membrane, allowing small mol-
ecules to penetrate through [54]. According to a study of
16.3.1 Introduction Eimar et al. [55], this is a possible explanation for the
mechanism of bleaching.
A smile creates an immediate visual first impression. A
bright tooth shade is the most important factor for mak- Dentin
ing a smile attractive, according to Dunn [48]. Dentin contains about 48% of mineral, 28% of
During recent years, aesthetic dentistry has become a organic material, and 24% of water. Dentinal tubules
very important field of dentistry. But it is also among extend from the dentin-enamel junction up to the
the achievements of preventive dentistry, that people are edge of the pulp. The tubules are where the majority
taking more care of their teeth in recent times. The most of scattering occurs, whereas collagen fibrils play a
popular and the least invasive procedure within aes- minor role; scattering by the mineral crystals in den-
thetic dentistry is dental bleaching. tin is negligible [56].
Dental bleaching was known and performed from
ancient years, but in the scientific literature, bleaching as
a procedure was first described in 1951 by Pearson [49], 16.3.3 Natural Tooth Color
night guard vital bleaching in 1989 by Haywood and
Heymann [50], and laser-assisted tooth bleaching in The main determinant for the tooth shade is dentin with
1998 by Reyto [51]. its yellow to brown shades. At the same time, enamel
It is important to clarify the often interchangeable properties, like thickness, chemical and physical compo-
terms “bleaching” and “whitening”: According to the sition, as well as the hydroxyapatite crystal size, affect
FDA, the difference between bleaching and whitening is the scattering of the light. Smaller crystals scatter more
that the term “bleaching” should only be used when the light and the tooth appears brighter [56]. The enamel
teeth can be whitened beyond their natural color and can have blue, green, and pink tints.
when the products used contain bleach. “Whitening” The color perception depends on the observer, the
refers to restoring a tooth’s surface color by removing object, and the light source. It is a complex procedure
superficial staining and debris. resulting from reflection, absorption, and scattering of
In order to keep bleaching noninvasive, we have to the light to the object and returning to the eye of the
ensure that the materials applied and the methods per- observer [57].
520 K. Luk and E. Anagnostaki
As visual examination is a subjective method, there Carbamide peroxide Two parts One part
are instruments available in dentistry—colorimeters and
CH4N2O • H2O2 NH3 + CO2 and H2O2
spectrophotometers—which provide unbiased informa-
tion on the tooth color.
a H2O2 O* + H2O
16.3.4 Discoloration
pH>7 LIGHT/HEAT
Extrinsic Staining b H2O2 H + HO2*
The exposed surface of the teeth is covered by a
protein-polysaccharide coating, the pellicle. The pelli- .. Fig. 16.18 Chemical reaction mechanisms of carbamide perox-
cle is easily stained by exogenous colorants from food, ide and hydrogen peroxide. The first phase is the reduction of carb-
drinks, mouth rinses, or oral medications but also amide peroxide into two parts of ammonia and carbon dioxide and
one part hydrogen peroxide. Hydrogen peroxide can be further
from chromogenic bacteria, dental materials, or indus- reduced (A) into an oxygen radical and water or (B) under certain
trial exposure to metal dust. Chromogens either bind conditions into a perhydroxyl radical and a hydrogen ion
and directly stain the teeth or bind and then stain and
darken with time, or pre-chromogens bind and subse- Chemically, a carbamide peroxide concentration of
quently undergo a chemical reaction to cause staining 16% is equivalent to 5.76% of hydrogen peroxide, since
[58]. carbamide peroxide is being reduced to approximately
The extrinsic staining either may stain the pellicle, two parts of ammonia and carbon dioxide and one part
and can easily be removed by means of a thorough of hydrogen peroxide.
cleaning, or may be retained on the tooth surface form- For in-office use, available bleaching gels contain from
ing a stain-enamel complex through ion interaction. 25% up to 40% hydrogen peroxide. The action of the gel
Accumulation of extrinsic stains is affected by the oral can be accelerated chemically or by means of a light
hygiene habits, saliva composition and flow, and enamel source such as plasma, LED, halogen lamps, or lasers.
surface roughness. The chemical reaction is a reduction of hydrogen
peroxide into oxygen and water and preferably into per-
Intrinsic Staining hydroxyl and hydrogen. The perhydroxyl (HO2•) free
This staining is distributed throughout the internal radical belongs to the most reactive species in tooth
structure of the teeth and may either develop preerup- bleaching, the formation of which is favored by high
tive during odontogenesis or appear at any time after (alkaline) pH, but this is rarely the situation as the prod-
eruption. The staining can be localized to few teeth or uct shelf life is adversely affected under these conditions
be present on all of them depending on the period of [61]. . Figure 16.18 shows a graphic representation of
development when it took effect. It can be caused by the reduction and subsequent reaction of carbamide
changes in the structure of the hard tissue itself or by peroxide and hydrogen peroxide during activation.
incorporation of chromogenic molecules inside the hard
16 tissue [59].
Conditions such as alkaptonuria, congenital eryth- 16.3.6 Mechanisms of Bleaching
ropoietic porphyria, congenital hyperbilirubinemia,
amelogenesis imperfecta, dentinogenesis imperfecta, The mechanism of the action of either carbamide perox-
tetracycline intake, fluorosis, and enamel hypoplasia ide or hydrogen peroxide is not completely investigated.
contribute to preeruptive intrinsic staining. Until now, studies have shown that the unstable oxygen
Hemorrhagic products in the pulp, root resorption, or perhydroxyl radicals are diffusing through the organic
and aging may cause posteruptive staining. matrix of the enamel and dentine and are causing a
breakdown of ring structures of stain molecules fol-
lowed by a breakdown of long molecular chains in the
16.3.5 Chemistry of Bleaching Materials organic tooth matrix into shorter ones, which absorb less
and therefore reflect more light. It is important to know
The bleaching gel applied for home bleaching may that there is a saturation point during the bleaching pro-
contain carbamide peroxide as an active substance, in cess, where there are only hydrophilic pigment-free struc-
concentrations from 5% up to 20%, or hydrogen per- tures and the lightening of the teeth stops dramatically.
oxide, in concentrations of maximal 10%. Some At this point, bleaching should be stopped immediately,
countries have specific regulations for the active or the next step would be a rapid loss of enamel [62].
ingredients. An example is the 2011/84/EU European However, this “breakdown of stain molecules”
Directive [60]. hypothesis might be weak since (1) the organic chromo-
Impact of Laser Dentistry in Management of Color in Aesthetic Zone
521 16
phore concentration, if they exist, in tooth enamel is –– Pregnancy/lactation
extremely low (below the detection limit of many spec- –– Severe surface damage due to attrition, abrasion,
troscopy techniques) and (2) several studies have shown and erosion
that following tooth bleaching the translucency of tooth –– Untreated dentinal hypersensitivity
enamel decreased significantly, making it more opaque. –– Lack of compliance
Studies have shown that the tooth enamel organic In the case of home bleaching, the outcome depends on
matrix is mainly composed of amide groups that repre- a good supervision and motivation by the dentist, which
sent enamel proteins. Eimar et al. [55] found that hydro- will lead to a good compliance from the side of the
gen peroxide does modify neither the organic nor the patient.
inorganic relative contents of dental enamel but oxidizes
their enamel organic matrix. The conclusion states that In-Office Bleaching or Power Bleaching
oxidation of enamel protein and the increase in enamel The procedure is performed chairside, and highly con-
opacity following peroxide treatment seem to indicate centrated bleaching gels are applied on the buccal tooth
that the peroxide whitens teeth by oxidizing its transpar- surface. The appointment time can be lengthy, but the
ent organic matrix into an opaque whiter material. This result is immediately visible and is even enhanced within
is a more comprehensive theory of the mechanism by the next 1–2 days. There are disadvantages: the costs for
which peroxide might whiten teeth. such treatment are higher, the postop sensitivity might
be more intense, and there can be some reversible but
moderately painful alteration to the soft tissue sur-
16.3.7 Bleaching Methods rounding the teeth.
According to Walsh [64], the indications for bleach-
There are two main approaches to vital tooth bleaching: ing are:
home bleaching (night guard bleaching) and in-office 55 Discoloration related to genetic disorders (dentino-
bleaching. The two techniques may be combined in genesis imperfecta)
order to enhance the result. According to Auschill [63], 55 Permanent acquired discoloration: fluorosis stain-
7 days of home bleaching result to a similar effect of one ing, tetracycline staining, lead poisoning
session of in-office bleaching. 55 Posttraumatic discoloration (vital tooth with scle-
rotic dentin)
Night/Day Guard Vital Bleaching or Home 55 Moderate tooth discoloration
Bleaching 55 Discoloration related to the physiological aging of
As first described by Haywood and Heymann [50], this teeth
is the most popular bleaching method. Customized 55 Improvement of the teeth’s natural color before the
trays, occasionally referred to as “night guards,” have to placement of a prosthetic restoration in the adjacent
be used for several hours a day or overnight, depending area
on the concentration of the material used.
The material mainly used is carbamide peroxide in Furthermore, bleaching is contraindicated in cases of:
concentrations up to 20%. Several companies also offer 55 Severe untreated tooth sensitivity due to exposed
prefabricated-preloaded trays for home bleaching: cervical dentine from dental erosion, gingival reces-
55 Indications for home bleaching (according to So- sion, or gingival pathology. In this case, the sensitiv-
Ran Kwon [62]): ity problem should be resolved first.
–– Generalized yellow, orange, or light brown discol- 55 Unrealistic expectations of the treatment result.
oration 55 Inability of the patient to sit still in the dental chair
–– Age-related yellow discoloration during the procedure and tolerate the required soft
–– Mild tetracycline staining tissue isolation devices.
–– Superficial brown fluorosis stains 55 Inability of the patient to follow (at least for a while)
–– Discoloration due to smoking or chromogenic changes needed to prevent reformation of extrinsic
foods or drinks stains (smokers).
–– Genetically yellow or gray teeth 55 Inability to have the restorations in the teeth to be
–– Patient wishing shade improvement with mini- bleached changed, after a necessary delay of 2 weeks
mally invasive treatment after the whitening treatment [64].
–– Yellow discoloration of single vital teeth
55 Contraindications for home bleaching (according to
So-Ran Kwon [62]): Procedure
–– Amelogenesis or dentinogenesis imperfecta After a thorough cleaning with oil- and glycerine-free
–– Severe tetracycline staining pumice, hydrogen peroxide gels in concentrations
–– Discoloration due to restorative materials between 25% and 40% are applied on the teeth to be
522 K. Luk and E. Anagnostaki
whitened. The soft tissue must be protected from the Argon and KTP lasers. Understanding these differences
caustic action of the bleaching gel. Depending on the will allow for the most effective bleaching outcome by
material used, activation is achieved chemically (by producing the maximum number of powerful free radi-
thorough mixing of the gel components usually con- cals from the bleaching gel.
tained in syringes) and/or by non-coherent light, heat, The application of KTP, argon, and diode lasers is
or a laser. The different light sources are used to enhance widely supported by the literature [66, 68, 70]. Nd:YAG
the chemical decomposition of hydrogen peroxide and lasers possibly cause overheating due to their high peak
with this to enhance the whitening efficacy. When heat is power and are under investigation for their safety in
applied, a temperature elevation in the gel of 10 °C is bleaching [67, 71, 72]. Newly introduced diode lasers
reported to double the speed of hydrogen peroxide operating at a wavelength of 445 nm have gained
decomposition [65]. For a laser-activated application, approval for dental applications. However, their clinical
the gel should contain a proper photocatalyst, which is safety in dental bleaching remains an area that requires
an absorber that matches the spectrum of the light used further investigation.
to activate or accelerate the gel action. In addition, spe- CO2 lasers were the first lasers indicated for use dur-
cial filtering substances are used in order to keep the ing bleaching procedures, but their application is no
energy inside the gel, and not allow a temperature rise longer supported, since Luk et al. [73] showed overheat-
inside the pulp [66]. ing on tooth surface and pulp. Additionally, there have
Studies have shown that the hydrogen peroxide pen- not been any controlled clinical studies for that wave-
etrates deeper if activated by laser or other light sources length.
[61, 67]. Furthermore, Kwon [68] found that light- CO2 and erbium lasers show a photo-thermal action
activated bleaching is not more dangerous to the pulp by since they are absorbed in water contained in the bleach-
the stronger oxidizing action. ing gel. Caution must be given due to the absorption of
The difference between activation by ordinary light these lasers in hydroxyapatite and due to the high peak
or by laser is that ordinary light sources emit a broad power of erbium lasers [74]. It is essential to stay far
spectrum of photonic energy with increased possibility below the ablation threshold for enamel and always keep
of thermal damage [69]. Using an appropriate laser, it is the teeth covered by bleaching gel. As explained in
possible to shorten the interaction time of the material 7 Chap. 3, these wavelengths are immediately absorbed
on the tooth surface, thus avoiding possible superficial in the water within the gel, causing it to rapidly dehy-
damages. drate. Thus, attention is necessary so as not to activate
the laser on a dry layer of gel.
Laser-Assisted In-Office Bleaching The application of erbium lasers (Er:YAG and
During an in-office bleaching procedure, it is possible to Er,Cr:YSGG) in dental bleaching is still under investiga-
activate the bleaching material by a laser. . Figure 16.19 tion. In a study, Nguyen et al. [75] showed that laser-
shows the laser wavelengths and their basic mechanism assisted bleaching (KTP and Er:YAG) gives similar
of action, which is photo-thermal catalysis in cases of results in a shorter time compared to nonactivated
diodes and Nd:YAG and photochemical in the case of bleaching, but they concluded that data on mechanisms
of action of the Er:YAG laser on bleaching gel and den-
16 tal tissues are still limited and additional studies are
needed to assess the contribution of the Er:YAG laser in
tooth bleaching.
In the only available randomized controlled study
comparing color outcome and sensitivity among con-
ventional in-office bleaching, diode laser-activated and
Er,Cr:YSGG laser-activated bleaching, the authors con-
cluded that there were no significant intergroup differ-
ences in color outcome and that no significant
hypersensitivity was observed in the Er,Cr:YSGG-laser-
activated group [76].
The risks of damaging the underlying tissue are
depending on the wavelength of the laser to be used:
Erbium family and CO2 lasers are well absorbed in water
and may be absorbed in the tooth surface, but shorter
.. Fig. 16.19 A listing of generically named dental lasers with their wavelengths in the red to near-infrared, as well as in the
corresponding wavelengths and the two mechanisms of action in visible spectrum, are more likely to penetrate into the
laser-assisted bleaching pulp.
Impact of Laser Dentistry in Management of Color in Aesthetic Zone
523 16
Therefore, it is essential to always use the appropriate lus and is possibly related with a direct activation of
bleaching gel with a particular laser wavelength, to have neuronal receptors by the hydrogen peroxide and its
a high absorption of the energy inside the gel, and to products [81]. In a study by Schulte [82], the sensitiv-
minimize any increase of the temperature in the pulpal ity was severe enough to cause 14% of the patients to
tissues. To achieve this high absorption, bleaching gels discontinue the bleaching treatment.
for the blue and green wavelengths contain orange-red For sensitivity treatment, potassium nitrate gels or
dyes like rhodamine, and bleaching gels for red to infra- casein phosphopeptide-amorphous calcium phos-
red wavelengths contain bluish-purple dyes. Titanium- phate (CPP-ACP) pastes are used immediately after
dioxide particles also act as a broadband absorber in a the bleaching session with an effective reduction of
gel offered by many laser manufacturers [74]. sensitivity. Agents such as potassium salts, which
The action of the argon and KTP wavelength is not depress nerve excitability, are claimed to be more
only photo-thermal and photochemical but photolytic effective than tubule-occluding agents in reducing
as well. This relies upon specific absorption of a narrow sensitivity according to Markowitz [81], but accord-
spectral range of green light (510–540 nm) not only in ing to a newer randomized controlled clinical trial,
rhodamine but also into chelate compounds formed there is no significant difference between the above-
between apatite, porphyrin, and tetracycline. Through mentioned agents [112].
this, argon and KTP lasers are capable to achieve a good In a study by Moosavi et al. [83], photobiomodulation
bleaching result even in teeth not responding to other therapy with an infrared diode laser could be recom-
techniques (tetracycline-stained teeth) [77]. mended as a suitable strategy to reduce the intensity
In addition, the KTP laser induces a photochemical of tooth sensitivity after in-office bleaching. The
reaction in the special formulated bleaching gel, provid- parameters applied with an 810-nm diode laser were
ing a higher free radical outcome than during a photo- 3 J of energy, energy density of 12 J/cm2, and power
thermal action [75]. Through buffering to an alkaline density of 800 mW/cm2 on the cervical area of the
pH of 9 and high energy, the produced free radicals were tooth.
shown to be more reactive [64]. 4. Penetration of the bleaching material into the pulp
has been shown in several in vitro studies to take
place. However, penetration is relatively low due to a
16.3.8 Safety Concerns positive pulpal pressure and the presence of dentinal
fluid. The affected pulp tissue can protect itself from
Studies show varying results concerning the safety of damage by hydrogen peroxide through the enzymatic
the bleaching methods. One main point is the toxicity of breakdown of the molecule by peroxidase and cata-
hydrogen peroxide as a strong oxidative; another is the lase [84]. These cellular enzymatic systems eliminate
possible corrosiveness of the gels used. Additionally, the excess oxygen, but still it is not known how much
activation by any light source might overheat the target hydrogen peroxide can be tolerated by the pulp tissue
and underlying tissues: [85]. Additionally, an in vivo study demonstrated that
1. The exposure of the organism to the hydrogen perox- bleaching with or without light activation did not
ide, according to Li and Greenwall [78], is minimal cause damage on pulp tissue of young sound premo-
when used properly, either in-office or at home. lar teeth [86]. Another in vivo study showed that there
Enzymes in the saliva are capable to neutralize up to was no increase in the levels of cell damage biomark-
eight times the amount of hydrogen peroxide used in ers in serum and saliva among the groups tested but
a home bleaching session. During in-office bleach- found a significant increase in biomarkers in gingival
ing, with a good isolation of the soft tissue, the level crevicular fluid immediately after treatment [87].
of chemical is not detected systemically. 5. Overheating of the pulp in the case of in-office
2. Local soft tissue effects usually manifest as chemical bleaching needs to be avoided, through the choice of
burns. These can appear due to either poor isolation a material which needs only a short time activation
or extended contact time with the material and poor and contains the proper filtering absorber to block
fitting trays, in the case of home bleaching. Vitamin the heat inside the gel. According to Zach and Cohen
E used locally on the defects is supported by the lit- [66], the pulp can only tolerate a temperature rise up
erature [79]. to 5.5 °C. Eriksson and Alberktsson [88] found that
3. Tooth sensitivity is another side effect and might be 42 °C might be a critical temperature to the pulp
an indication of a pulp response to the oxygen and when sustained for 1 min. On the other hand,
perhydroxyl free radicals [80] (produced from the Baldissara et al. [89] reported that an intrapulpal
breakdown of hydrogen peroxide; see . Fig. 16.18). temperature rise of 8.9–14.7 °C in humans does not
It usually appears for the first 24 h to 3 days, and this induce pulpal pathology. The values of temperature
has to be differentiated from the post-bleaching sen- rise obtained in this study were not critical for pulp
sitivity which appears like a sudden shooting stimu- health; however, this was a preliminary study.
524 K. Luk and E. Anagnostaki
6. Enamel surface morphology. The effect of bleaching without light activation are used according to a study of
materials (either home or in-office) on the enamel Sulieman [94].
surface is controversially documented in the litera- Unfortunately, only short-term results on bleaching
ture. efficacy have been reported by most studies [68], while
only a few of them report results over the long term [63,
The studies that have been performed on the adverse 95]. It has been shown that although higher peroxide
effects of bleaching on chemical and physical character- concentrations produce a quicker shift than lower con-
istics of the enamel use several different methods: SEM centrations, the result on whitening is the same for all
(direct or indirect), profilometry, microhardness, cal- concentrations at the end of the whitening process.
cium loss, and infrared spectroscopy. Out of these, the However, the differences in effectiveness of tooth whit-
microhardness seems to be the preferred choice of the ening appear to be significant when results are evaluated
researchers [90]. However, those methods are destruc- over a longer period.
tive, which means that it is impossible to follow up the In a retrospective case series study, Leonard [96] had
same samples during a period of time. But the processes shown that long-term shade retention was reported by
in the mouth are dynamic, so there is the need of exam- 82% of the participants 4 years post-bleaching. Later,
ining what is happening in vivo, over time. Out of the the group of Boushell and Leonard [97] showed that sat-
numerous studies investigating the impact of bleaching isfactory retention of the shade change without re-
procedures on enamel, only a few are performed in vivo treatment can be expected in at least 43% at 10 years
conditions. posttreatment.
Clinical studies found no statistically significant Two long-term studies done by Grobler et al. [95]
loss of surface enamel hardness or loss of calcium and assessing the effectiveness of 10% carbamide peroxide
phosphorus as minerals out of the enamel [91]. In con- showed that the majority of patients maintained whiten-
trary, many in vitro studies show microhardness reduc- ing improvement for up to 6 months. From an initial
tion after bleaching. Attin et al. [92] reviewed the shade change of 5, there was between 18% and 26%
published literature on the effect of bleaching on relapse. However, significant relapse was noticed when
enamel microhardness. They conclude that if in the dif- the patients were evaluated 14 months after tooth whit-
ferent (in vitro) studies the intraoral conditions are ening, mostly for the whiteness/brightness parameter. It
simulated as close as possible (e.g., with the use of arti- is suggested that re-whitening should be done at about 14
ficial or human saliva as a storage medium or re-fluori- months post-whitening in the case of home bleaching.
dation after bleaching), then the study outcome shows Clinical studies evaluating the outcome of laser-
a lower risk of enamel microhardness reduction due to assisted bleaching are controversial: Strobl et al. [71]
the bleaching treatment, compared to the remaining concluded after a split mouth study in 20 patients that
studies. the Nd:YAG laser did not enhance the bleaching suc-
The most severe alterations in enamel in vitro have cess; furthermore, the laser-activated sites have been
been described when acidic bleaching gels were used more sensitive after treatment than the nonactivated
[93]. The hydrogen peroxide per se is acidic, and the sites. Gurgan et al. [70] could show that the use of a
gels are usually kept in acidic pH in order to increase diode laser results in spectrophotometric measured bet-
16 shelf life. Gels produced for use with the KTP laser ter outcome, with less gingival and tooth sensitivity, and
contain a special buffering system and set the pH to it might be preferred among in-office bleaching systems.
around 9.5 [66]. Surmelioglou et al. [76, 98] concluded that application
of lasers to induce the bleaching reaction does not pro-
vide better aesthetic or long-term color stability.
16.3.9 Long-Term Effectiveness Nevertheless, the treatment time was significantly less
and Stability of Tooth Whitening for the laser-activated groups.
Concerning tetracycline-discolored teeth,
A number of authors have investigated the effectiveness Kuzekanani and Walsh [98] found in vivo, through a
of tooth whitening by comparing different techniques quantitative analysis of digital pre- and post-bleaching
and different peroxide concentrations. The evidence on digital images, that KTP laser photodynamic bleaching
effectiveness suggests that all of them are effective and provides a clinically useful improvement in tooth shade.
reach similar results when their respective protocols are Regarding the relapse in the color after tooth whiten-
followed. ing, it is known that the oxygen within the tooth from
The stability of outcome of various whitening prod- the oxidative process initially alters the optical proper-
ucts has been widely evaluated, and significant shade ties of the tooth. Then oxygen dissipates over the follow-
improvement can be predicted when products such as ing week(s), and the tooth takes on the actual lightened
carbamide peroxide gel, or hydrogen peroxide, with or shade [99].
Impact of Laser Dentistry in Management of Color in Aesthetic Zone
525 16
Is it the protein molecules re-bonding the double
bonds, is it aging or the oxidized organic matrix which is
turning less opaque and more transparent again with
time, or finally is it the enamel changes caused by the
bleaching materials, guiding the teeth to a new discolor-
ation by leakage from extrinsic stains? Investigations
will continue, especially in comparing color relapse after
laser-activated bleaching, with the traditional methods.
Unfortunately, the available studies concerning laser-
assisted bleaching do not provide clear conclusions. The
details of the protocols, laser wavelengths, and gels used
are often not fully described. Long-term outcome stud-
ies are absolutely necessary in order to evaluate the
advantages of this method.
.. Fig. 16.23 JW power bleaching gel applied with the gingival bar- .. Fig. 16.24 Gingival barrier in place and the Smartbleach Gel
rier in place applied to the teeth
528 K. Luk and E. Anagnostaki
tooth which was activated first, second, third, etc., and 16.3.14 Clinical Cases
rinsed off carefully to avoid damage the gingival and
soft tissue barriers. In this way, the resting and contact Two clinical cases of laser-assisted bleaching are shown.
time of the gel on each tooth is approximately the same. Case 1 was performed with the 532-nm KTP laser and
Then a new layer of gel is applied on the teeth, and Smartbleach, and case 2 was performed with a 1064-nm
the procedure outlined above is repeated twice. After the diode laser using JW Power Bleaching Gel.
third cycle, the bleaching gel is removed tooth by tooth . Figure 16.25 is a clinical case of laser-assisted
again, with the high-speed suction, and rinsed off, and with the KTP 532-nm device and Smartbleach. The
then the protective barriers are removed. The final color 6-month post-bleaching photo shows good color sta-
is documented. bility.
If any bleaching gel leakage affected the soft tissue, . Figure 16.26 depicts bleaching using a 1064-nm
vitamin E oil should be applied to the area. diode with JW Power Bleaching Gel.
In case of hypersensitivity or pain, a non-staining
desensitizing gel can be applied.
The total contact time of the gel on the teeth is there- 16.3.15 Summary
fore approximately 30 min, and the laser exposure time
is 90 s per tooth. In summary, the use of lasers is a safe and effective way
A typical appointment for laser-assisted bleaching to enhance in-office bleaching procedures.
includes the following steps: Thorough knowledge of laser-tissue interaction
1. Obtain the patient’s informed consent. and laser safety is indispensable. In such a way, a well-
2. Obtain the initial shade using shade tabs and/or trained clinician can perform a laser-assisted bleaching
spectrophotometer, and document it with a clinical with no side effects. Precise evidence-based clinical
photograph. protocols need to be established and followed to stan-
3. Apply cheek retractors. dardize the procedures and expect predictable out-
4. Polish the teeth with pumice or glycerine-/oil-free comes.
paste, and avoid any contact with saliva.
5. Remove bleaching gel from refrigerated storage and
mix, following manufacturer’s instructions. 16.4 Conclusion
6. Air-dry teeth to be bleached and apply gingival pro-
tection barrier. The clinician’s first goal for a dental patient is to help
7. Apply bleaching gel in an appropriate thickness. maintain a healthy dentition. Many patients also desire
8. Irradiate tooth by tooth or per quadrant following a smile that fits their own aesthetic criteria. Of course,
appropriate laser protocols. the interpretation of those concepts will vary widely
9. Adhere to laser safety principles. based on an individual’s culture, philosophy, and per-
10. After recommended interaction time, remove gel, sonality, to name just a few. Thus, practitioners should
and rinse teeth with water. be aware of techniques to help fulfill the patient’s aes-
11. Air-dry teeth, check gingival barriers, reapply gel if
16 required, and repeat steps 8 and 9.
thetic demands. This chapter has demonstrated how
dental lasers are one instrument that can be used for
12. If necessary, apply desensitizing gel or other similar hard and soft tissue enhancement.
materials.
13. Give post-bleaching instructions—for example,
avoid dark colored food and liquids, and continue
good oral hygiene.
14. Evaluate shade change.
Impact of Laser Dentistry in Management of Color in Aesthetic Zone
529 16
a b c
d e f
g h
.. Fig. 16.26 a Pre-bleaching view. b Pre-bleaching shade match of after the first bleaching session, the canines are matched to A-3 and
the canines is A 3.5. c Pre-bleaching shade match of the central inci- the centrals are A-1. f Immediately after the second session, the
sors is C-1. d After retractors and tissue protection are in place, the canines are now A-2 and the centrals are B-1. g One month after
bleaching gel is placed on the teeth. The laser is placed approxi- bleaching, treatment of the color is stable. h Six years after treat-
mately 2 cm from the teeth, and the gel is activated. e Immediately ment, the color is very stable and remains bright
a b c
d e f
g h
.. Fig. 16.25 a Pre-bleaching shade selection—A 2. b Retractors leakage of the gel. f Five days after bleaching. Papilla has a normal
and gingival protection in place. c Bleaching gel applied. d Activa- appearance. Shade B1 has been achieved. g Six months after bleach-
tion with the KTP (532 nm) laser. e Immediately after bleaching. ing. h Two years after bleaching
Note some blanching on papilla between the central incisors due to
530 K. Luk and E. Anagnostaki
87. Sürmelioğlu D, Gündoğar H, Taysi S, Bağiş YH. Effect of dif- 101. Paravina R, Johnston W, Powers J. New shade guide for evalu-
ferent bleaching techniques on DNA damage biomarkers in ation of tooth whitening—colorimetric study. J Esthet Restor
serum, saliva, and GCF. Hum Exp Toxicol. 2021;40(8): Dent. 2007;19(5):276–83.
1332–41. 102. Hadis MA, Zainal SA, Holder MJ, Carroll JD, Cooper PR,
88. Eriksson AR, Albrektsson T. Temperature threshold levels for Milward MR, Palin W. The dark art of light measurement:
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evaluation of thermal injury thresholds in human teeth: a pre- Grootveld M. Photobiomodulation dose parameters in den-
liminary study. J Oral Rehabil. 1997;24(11):791–801. tistry: a systematic review and meta-analysis. Dent J.
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Quintessence Int. 1993;24(1):39–44. Lynch E, Grootveld M. A spectrophotometric study on light
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533 V
Contents
17.5 avity Preparation and Soft Tissue Cutting with the CO2
C
9.3 μm Short-Pulsed Laser – 549
References – 555
Core Message phosphate ions [2–4]. The mineral of enamel and dentin
While all commercially available dental lasers can be clini- can be described by the formula of carbonated hydroxy-
cally used for soft tissue procedures, the quest continues apatite [Ca10−x(Na)x(PO4)6−y(CO3)z(OH)2−u(F)u].
for the ideal instrument to safely and efficiently interact Numerous laboratory studies in the past have shown
with dental hard tissue. This chapter describes several that increasing resistance to enamel demineralization
years of research that has resulted in the second generation may be achieved by microsecond-pulsed CO2 laser irra-
of hard tissue lasers. The interaction of carbon dioxide diation [5, 6]. The most strongly absorbed wavelengths
laser photonic energy with tooth enamel and dentin has in dental enamel are the 9.3 and 9.6 μm CO2 laser wave-
been studied for several decades, with first publications in lengths [7, 8] (. Fig. 17.1).
the 1960s. Carbon dioxide lasers at 9.3 and 9.6 μm wave- At 9.3 and 9.6 μm wavelengths, the enamel absorp-
length show the highest absorption of all dental lasers in tion coefficient is ten times higher compared to the
dental hard tissues. Laboratory studies have shown that 10.6 μm CO2 laser wavelength [7, 8]. This is demon-
these short-pulsed CO2 lasers can efficiently be used to ren- strated in . Table 17.1.
der enamel caries resistant by transforming the originally Due to the irradiation heat, the carbonate phase loss
carbonated apatite into the much acid less soluble hydroxy- from the enamel crystals is responsible for the reduced
apatite. Adding fluoride after the laser treatment addition- dissolution of enamel in acid [10] due to transformation
ally reduces the acid solubility of enamel and creates the of the carbonated hydroxyapatite into the more acid-
desired least acid-soluble fluorapatite. Irradiation with the resistant hydroxyapatite. If at this point in time fluoride
9.3 μm laser wavelength can reduce mineral loss by 55% is added, fluorapatite is created, which is even less acid
over untreated enamel. Safety studies have shown that soluble than hydroxyapatite [11].
without harmful effects to the pulpal tissue, these lasers Fluoride works predominantly via topical mecha-
can efficiently and safely be used on vital teeth. The first nisms, including (1) demineralization inhibition at the
in vivo clinical study engaging an orthodontic bracket crystal surfaces inside the enamel, (2) remineralization
model showed over 4 weeks a 46% and over 12 weeks a enhancement at the surfaces of the crystal (the newly cre-
87% reduction in mineral loss. The first in vivo occlusal ated remineralized layer is very resistant to acid attack),
caries prevention by pulsed CO2 laser and additional fluo- and (3) finally inhibition of bacterial enzymes [12].
ride varnish application proof-of-concept pilot study dem- Topical fluoride in solution in the oral cavity boosts
onstrated that a microsecond pulsed 9.6 μm CO2 laser with remineralization by accelerating the growth of a new
additional fluoride varnish applications significantly inhib- surface on top of the partially demineralized subsurface
ited the formation of carious lesions in fissures of molars crystals in the carious tooth structure. The newly formed
in vivo in comparison to a non-irradiated control tooth in veneer-like surface layer on top of the crystal is like flu-
the same arch over a 1-year observation interval. These
positive results were confirmed in a main clinical study
with 60 subjects similarly designed as the pilot study. Using 100
2.78 µm Er,Cr:YSGG 9-11 μm CO2
ICDAS and SOPROLIFE daylight and fluorescence
assessment tools proved the reduction in caries. Moreover, PO43-
2.94 µm Er:YAG
the 9.3 and 9.6 μm CO2 μs-short-pulsed lasers are very effi-
Absorption (%)
a b
c d
.. Fig. 17.2 SEM pictures of unpolished enamel after irradiation at 10.3 μm, 9.6 μm, and 9.3 μm but not at 10.6 μm. (Photos from Ref.
with CO2 laser wavelength: a 10.6 μm, b 10.3 μm, c 9.6 μm, and d [16]. Used with permission)
9.3 μm, all 50 μs pulse duration; melting of the enamel prisms occurs
2000
Enamel
Vaporization
λ = 9.6 µm
100 ms pulse
1500
(5 – 9 mm band)
17
Temperature (°C)
10 J/cm2 Melting
1000
8 J/cm2
500 6 J/cm2
4 J/cm2
2 J/cm2
0
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Time (ms) x10–3
.. Fig. 17.3 Plot of temperature at the surface of dental enamel versus time following irradiation by a carbon dioxide laser at 9.6 μm, over
a range of fluences, and with a pulse duration of 100 μs. (Adapted from Ref. [17])
Current Research and Future Dreams for Dental Lasers
539 17
2.0
( = 9.6 m, 1–6 J/cm2, 25 pulses)
Normal (Unirradiated)
1.5 1 J/cm2
2 J/cm2
Reflectance (a.u.)
3 J/cm2
1.0
6 J/cm2
5 J/cm2
0.5 4 J/cm2
0.0
1600 1550 1500 1450 1400 1350 1300 1250 1200 1150 1100
Wavenumber (cm-1)
.. Fig. 17.4 Fourier transform infrared reflectance (FTIR) spectrum showing the carbonate bands following surface treatment of dental
enamel after applying a range of fluences with a 9.6 μm CO2 laser. (Adapted from Ref. [18]. Used with permission: SPIE, Bellingham, WA)
a 2000 b 2000
1500 1500
Z, vol% x m
Z, vol% x m
1000 1000
500 500
0 0
s
5
l7
F
th
th
th
th
ith
th
th
th
l
l
ro
ro
ro
r5
r6
r7
wi
wi
wi
wi
wi
wi
wi
sw
nt
nt
nt
se
se
se
Co
Co
Co
l3
l4
l5
l6
s
s
La
La
La
ro
ro
ro
ro
r3
r4
r5
r6
nt
nt
nt
nt
se
se
se
se
Co
Co
Co
Co
La
La
La
La
.. Fig. 17.5 a Mean relative mineral loss DZ for the laser-treated the laser-treated and control groups, four different laser energies,
enamel and for the control groups, three different laser energies, after after 9 days of pH cycling with additional fluoride, showing on aver-
9 days of pH cycling with no additional fluoride use resulting on age 55% reduced mineral loss for the laser-treated teeth (statistically
average in 53% reduced mineral loss for the laser-treated teeth (sta- significant reduced mineral loss with P < 0.0001; error bars represent
tistically significant reduced mineral loss with P < 0.0001; error bars standard deviations). (Adapted from Ref. [19])
represent standard deviations). b Mean relative mineral loss DZ for
540 P. Rechmann
a b
c d
.. Fig. 17.6 SEM pictures of enamel after 3 μs pulse duration irra- higher magnification, with (a) being the lowest magnification at
diation; only minor or no changes are visible with a few molten areas x=44, (b) at higher magnification with x=100, (c) at x=200, and (d)
at the highest magnification (lines are drawn between irradiated and showing the highest magnification with x=600)). (Adapted from Ref.
nonirradiated surfaces; arrows indicate area showed at the next [19])
17 melting is not necessary in driving out carbonate as resistance of the remaining enamel was also enhanced.
reported above and achievement of enhanced caries A 65% reduction in mineral loss in comparison to the
resistance [19]. nonirradiated surfaces was shown (. Fig. 17.5a, b).
It had been established that ablation of enamel This effect is an advantage when cavities are drilled with
occurs at temperatures above 1200 °C [17]. In the labora- a 9.3 μm CO2 short-pulsed laser and a restoration is then
tory study presented here [19], when 9.3 μm CO2 laser placed. The restoration margins will be better protected
short-pulsed laser energies were applied, causing abla- against recurrent caries. A failure of the restoration will
tion of enamel for cutting teeth (. Fig. 17.7), caries be more unlikely.
Current Research and Future Dreams for Dental Lasers
541 17
a b
c d
.. Fig. 17.7 SEM pictures of enamel after 6 and 7 μs pulse duration at the next higher magnification, with (a) being the lowest magnifica-
irradiation; rough surface morphology with slight ablation of the tion at x=27, (b) at higher magnification with x=150, (c) at x=300,
enamel occurs at 6 μs pulses; 7 μs pulses (in a, between triangles) and (d) showing the highest magnification with x=600). (Adapted
result in noticeable ablation of the enamel (lines are drawn between from Refs. [19, 22])
irradiated and nonirradiated surfaces; arrows indicate area showed
17.2 Pulpal Safety Study be safely used to alter enamel surfaces to render them
more resistant to caries without permanently damaging
Before proving that both short-pulsed CO2 9.6 and the dental pulp. Histological examination of all teeth
9.3 μm laser irradiation clinically render enamel more disclosed no indication of an inflammatory response in
caries resistant, a pulpal safety study had to be per- the pulp tissue at any time point. All histological sec-
formed. The intention of such a study was to show that tions appeared normal with no changes seen in the nor-
the laser treatment would not harm the dental pulp. A mal pulpal morphology. Permanent or serious damaging
clinical study using third molars was completed per- of the dental pulp was not observed [23]. Lately, a sec-
forming pulp histology after laser treatment and sham ond pulpal safety study performed with a 9.3 μm, 15 μs
dental procedures, respectively. The conclusion was that pulsed CO2 laser confirmed that this laser can ablate
the 9.6 μm CO2 laser, pulsed with 5–8 μs pulse width, can enamel safely without harming the pulp [24].
542 P. Rechmann
17.3 I nhibition of Caries in Vital Teeth by shiny. Nevertheless, after 1 week of home care, typically
CO2 Laser Treatment: First In Vivo the shiny aspect faded off.
The laser employed was a CO2 laser, Pulse System,
Study Using the Orthodontic Bracket
Inc. (PSI) (Model #LPS-500, Los Alamos, NM), which
Model had been designed for dermatology indications (9.6 μm
wavelength, 20 μs pulse duration, 20 Hz pulse repetition
To test the caries preventive potential of specific CO2 rate, 1100 μm beam diameter). To achieve caries preven-
laser irradiation for the first time in vivo, an orthodontic tive changes, each irradiated spot had to receive 20 laser
model was used [25]. Typically, orthodontic treatment is pulses; the laser fluence per pulse averaged 4.1 ± 0.3 J/
associated with rapidly enhanced demineralization of the cm2 (for more details, see [33]). An area cervical to the
enamel due to the increased plaque accumulation around bracket (. Fig. 17.8) on one side of the bracket was
the brackets [26]. This also includes a change to a more irradiated, while the opposite site on the same tooth
cariogenic bacterial milieu [27, 28]. After bracket bond- served as the control side later on.
ing in orthodontic patients, demineralization takes place The patients were instructed to brush for 1 timed
at the gingival and middle thirds of the facial surfaces minute twice daily with a provided over-the-counter
[29]. Demineralization switches from typically the inter- (OTC) toothpaste (1100 ppm fluoride as NaF).
proximal areas to the facial as well as from posterior to The study teeth were extracted 4 or 12 weeks after
anterior areas of the mouth [30, 31]. This well-established irradiation, respectively. In the laboratory, they were cut
caries pattern was used as a model system [25, 32] to into halves through the bracket so that the laser-treated
determine whether the laser treatment prevents deminer- area was on one half and the non-laser control area on
alization and/or even enhances remineralization in vital the other half. Afterwards, they were embedded in
human teeth at those more caries-prone regions. acrylic and prepared for the cross-section microhardness
Twenty-four orthodontic patients with a need for testing. . Figure 17.10 shows a microscopic picture of
extraction of bicuspids within the planned orthodontic a typical cross section with enamel, dentin, and orth-
treatment gave their consent and were enrolled into the odontic bracket with the composite and the micro-
study. Brackets were bonded with a conventional light- indents. During the cross-section microhardness testing
cured composite resin (Transbond XT, 3M ESPE, St. procedure, a pyramid-shaped diamond tip is pushed
Paul, MN) [25] onto the buccal surface of the bicuspid into the enamel with a defined weight. The softer the
scheduled for extraction. An enamel area directly next enamel is due to the occurred demineralization, the
to the bracket at the cervical area of the tooth wider the indent will be. The width of the indent is mea-
(. Fig. 17.8) was treated according to the laser treat- sured and the actual mineral loss can be calculated.
ment protocol. The two pictures in . Fig. 17.9 demon- In . Fig. 17.11, the mineral loss of enamel (volume
strate the clinical aspect of the laser-treated surfaces; percentage) is plotted versus the depth into the tooth
due to the biofilm removal, the irradiated enamel is very presenting a mineral loss profile for the 4-week study
arm teeth. The green line with the triangle symbols rep-
resents the average mean volume % mineral at each
depth for the laser-treated teeth and the blue line with
the square symbols for the non-laser-treated controls. At
15 μm depth, the control teeth (square symbols) show a
17 very high loss of mineral with a remaining only 40%
average volume % mineral, increasing to an average of
82% at a depth of 45 μm. In contrast, the CO2 9.6 μm
Laser test
Control side side laser-irradiated enamel (triangle symbols) shows 62%
volume % mineral at the 15 μm depth. Further into the
tooth, the volume % mineral increases at 45 μm depth to
85%, which represents the typical volume % mineral
content of sound enamel.
To compare the “mineral loss” between groups, the
mean relative mineral loss, ∆Z (vol% × μm), can be cal-
culated. After the 4-week observation, the mean relative
mineral loss ∆Z for the laser-treated enamel was
402 ± 85 (mean ± standard error [SE]), while the con-
.. Fig. 17.8 Orthodontic bracket placed on a study bicuspid using
an abundant amount of composite to create a microbial plaque trap; trols showed an almost doubled mineral loss ∆Z of
the irradiated area cervical to the bracket is marked red in this pic- 737 ± 131. The laser treatment resulted in a significant
ture, and the other side served as control 46% reduction of demineralization around the orth-
Current Research and Future Dreams for Dental Lasers
543 17
.. Fig. 17.9 Orthodontic bracket placed on a lower right (left pic- by the laser irradiation, and the area appears white and shiny, but
ture) and on an upper left (right picture) study bicuspid showing an after a period of a week of home care, the colors matched again
irradiated area beyond the bracket. Obviously, the biofilm is removed
100
Orthodontic
Enamel bracket 90
80
Vol% mineral
Composite 70
60
Laser 4 weeks n = 12
50
Dentin Control 4 weeks n = 12
Micro
40
indentations
30
.. Fig. 17.10 Microscopical picture demonstrating the cross sec- 0 10 20 30 40 50 60 70 80 90 100
tion microhardness testing; the bicuspid histological cross section Depth / µm
shows dentin, enamel, and composite, used to bond the orthodontic
bracket onto the enamel; the micro-indentations were placed right
below the enamel surface following an elaborated distribution pat- .. Fig. 17.11 A depth profile of volume % mineral loss for the
tern; the indents are located right below the area where the orth- laser-irradiated areas (green line with triangle symbols) and for the
odontic bracket was bonded to the enamel; this area represents the controls (blue line with square symbols) for the bicuspids at the
microbial plaque challenge, and consequently demineralization 4-week time point (mean ± standard error). (Adapted from Ref. [33])
occurs here. (Adapted from Ref. [33])
ents a high caries demineralization challenge to the
odontic brackets in comparison to the controls enamel. In addition, this demineralization challenge
(. Fig. 17.12) (significance level P = 0.04). cannot simply be overcome by using an OTC 1100 ppm
The reduction in mineral loss was even more impres- fluoride toothpaste [25]. Gorton et al. in 2003 reported
sive after 12 weeks (. Fig. 17.12). The control areas using the orthodontic bracket model that the mean min-
showed a fairly high relative mineral loss ΔZ of eral loss value ∆Z in their control group was 805 ± 78
1067 ± 254. In contrast, for the CO2 laser-treated area, (mean ± SE) vol% × μm. This establishes a considerable,
the mean relative mineral loss was much lower (ΔZ measurable, demineralization in only 1 month even
135 ± 98) and even lower than for the 4-week mineral when fluoride toothpaste is used. In this CO2 laser orth-
loss. The difference in mineral loss between laser and odontic bracket model study, the participants in the
control for the 12-week observation was significant (sig- control regions around the brackets had a high mineral
nificance level P = 0.002). For the 12-week group, the loss of ∆Z of 737 ± 131 vol% × μm at the 4-week and
laser treatment produced a noticeable 87% inhibition of even higher one of 1067 ± 254 vol% × μm at the 12-week
enamel demineralization. arm, similar to the mineral loss Gorton et al. stated [25].
Previous studies had demonstrated that the orth- However, the application of the CO2 9.6 μm short-
odontic bracket model employed in this study here pres- pulsed laser irradiation significantly reduced the mineral
544 P. Rechmann
900 1750
800 1500
700
1250
600
z, vol% x m
z, vol% x m
500 1000
400 750
300
500
200
100 250
0 0
Control (4 weeks) Laser (4 weeks) Control 12 weeks Laser 12 weeks
.. Fig. 17.12 Relative mineral loss ∆Z (vol% × μm) for the laser- laser-treated and control groups are statistically significant with a
treated enamel and for the non-laser-treated controls (n = 12 for significance level of P = 0.04 for the 4-week and P = 0.002 for the
both groups, mean ± SE) (4 weeks left and 12 weeks right graphs) 12-week observations. (Adapted from Ref. [33])
after treatment. The differences in relative mineral loss between
loss in the 4-week and in the 12-week arm of the study oral cavity were irradiated. The change in demineraliza-
by 46% and 87%, respectively. While the mineral loss for tion and remineralization was assessed by three visual
the 12-week group controls was higher than for the methods: (1) ICDAS—the International Caries
4-week group controls, the additional reduced mineral Detection and Assessment System; (2) SOPROLIFE in
loss for the treatment group after 12 weeks in compari- daylight and in blue fluorescence mode; and (3)
son to the 4 weeks might be explained by enhanced rem- DIAGNOdent fluorescence tool. The study’s intention
ineralization over a longer observation time period. was to show caries inhibition in fissures of molars [38].
This study showed that caries inhibition demon- The significant challenge was to reach normal configu-
strated in numerous models and experiments in the labo- rated as well as deep pits and fissures with the laser irra-
ratory [34–37] can also be achieved in humans in vital diation. In order to facilitate adequate laser interaction
teeth using short-pulsed 9.6 μm CO2 laser irradiation with the walls of deep fissures, we designed and used a
[33]. Moreover, this study showed that the orthodontic custom contra-angle laser handpiece especially made for
bracket model could be considered to explore any caries this study.
inhibition agents or tools in living teeth in humans. Twenty subjects were recruited and consented for the
study. Their age ranged between 10 and 15 years; they
were at high caries risk according to CAMBRA rules
17.4 I n Vivo Occlusal Caries Prevention by [39–41] and presented at least two fully erupted second
Pulsed CO2 Laser and Fluoride Varnish molars in the same arch (contralateral) with untreated,
non-carious (non-cavitated) occlusal surfaces. One
Treatment: A Proof-of-Concept Pilot
17 Study
molar was randomly selected for the laser irradiation,
and the tooth on the opposite site in the same jaw func-
tioned as control.
In the orthodontic bracket model study, the test teeth At baseline, right after laser treatment and at the 6-
were extracted to perform the cross-sectional micro- and 12-month recall visit, the occlusal surfaces of the
hardness testing. A subsequent in vivo pilot study was study molars were visually judged for decalcification
designed with the goal to determine the caries preven- applying the ICDAS II criteria (International Caries
tion effects of a short-pulsed CO2 laser without the need Detection and Assessment System) and the SOPROLIFE
to extract the study teeth for analytical assessments [38]. Light Induced Fluorescence Evaluator system (SOPRO,
In this proof-of-concept study, for the first time, ACTEON Group, La Ciotat, France).
in vivo occlusal pits and fissures of second molars in the
Current Research and Future Dreams for Dental Lasers
545 17
17.4.1 aries Assessment Methods Applied
C
in the In Vivo Occlusal Caries
Prevention by Pulsed CO2 Laser
Studies
.. Fig. 17.14 The left picture of the occlusal surface of a molar is tion). The tooth shows an ICDAS 3 code, already exhibiting physical
taken with SOPROLIFE in daylight mode (white LED illumination) enamel breakdown in the central grove. The enamel breakdown
and the right taken in blue fluorescence mode (blue LED illumina- became clearly visible
1.5 P = 0.03
0.4 P = 0.02
Mean difference ICDAS score
P < 0.0001
0.3
1.0 P = 0.001
0.2
Sopro daylight score
Mean difference
0.1
1.5 –0.0
–0.1
1.0 –0.2
–0.3
–0.4
–0.5
–0.5
th
th
th
th
th
th
th
th
th
th
th
th
on
on
on
on
on
on
on
on
on
on
on
on
-m
-m
m
-m
m
m
-m
-m
m
-m
-m
m
2-
2-
6-
r3
r6
l3
2-
2-
r3
r6
r1
l3
l6
l1
l
r1
se
se
tro
ro
l1
se
se
se
tro
tro
ro
La
nt
La
se
ro
n
La
La
nt
La
n
Co
Co
nt
La
Co
Co
Co
Co
.. Fig. 17.15 Average change of ICDAS scores between baseline .. Fig. 17.16 Average changes of SOPROLIFE daylight scores for
17 and 3-month, baseline and 6-month, and baseline and 12-month laser-treated and control teeth between baseline and the 3-, 6-, and
recall (mean ± SE) for laser-treated and control teeth; statistically 12-month recall (mean ± SE) showing statistically significant differ-
significant differences between laser and control at 6- and 12-month ences at the 6- and 12-month interval (significance level P = 0.02 and
recalls (P = 0.001 and P < 0.0001, respectively) P = 0.03, respectively). (Graph adapted from Ref. [38])
In addition to the ICDAS scoring, the study teeth (. Fig. 17.16) revealed an increasing daylight score for
were also evaluated with the SOPROLIFE system. They the controls and a decreasing score for the laser-treated
were scored with a recently presented scoring system, fissures similar to the ICDAS scoring. The differences
which was developed for the SOPROLIFE Light between the average changes were again like the ICDAS
Induced Fluorescence Evaluator for daylight and for the scores statistically significant between baseline and
blue fluorescence mode [51, 52]. For the control as well 6-month and baseline and 12-month recall.
as the laser-treated teeth, the SOPROLIFE scores . Figures 17.17 and . 17.18 show the occlusal sur-
ranged between 0 and 3 at baseline with no statistically face of a control and a laser-treated tooth, respectively,
significant differences between study and control group. with the pictures taken with the SOPROLIFE camera in
Calculating the changes in SOPROLIFE daylight daylight mode and in the blue fluorescence mode. The
scores between baseline and each recall time point pictures demonstrate the obvious differences over time
Current Research and Future Dreams for Dental Lasers
547 17
Subject 11 CA
SOPROLIFE daylight
Baseline 6 months
.. Fig. 17.17 Control tooth of a subject at baseline and at the lower row blue fluorescence mode; baseline left 6-month recall right).
6-month recall, pictures taken in daylight and fluorescence mode, (Photos from Ref. [38]. Used with permission: John Wiley & Sons)
respectively. The area of demineralization appears wider in daylight
mode and in fluorescence mode after 6 months (upper row daylight,
Subject 11 CA
SOPROLIFE daylight
Baseline 6 months
.. Fig. 17.18 Laser-irradiated tooth of a subject at baseline and at tively, is not visible anymore (upper row daylight, lower row blue
the 6-month recall, pictures taken in daylight and fluorescence mode, fluorescence mode; baseline left 6-month recall right). (Photos from
respectively. The area of demineralization in the distal fossa of the Ref. [38]. Used with permission: John Wiley & Sons)
laser-treated tooth in daylight mode and fluorescence mode, respec-
between the baseline and the 6-month recall. Both mode, after 6 months, the demineralization zone and the
molars show noticeable changes in the fissure system, red fluorescence width and intensity, respectively, disap-
being very distinct in the distal groove. While the area of peared on the laser-irradiated tooth.
demineralization in the control tooth appears to become Similar to the SOPROLIFE daylight scores, the
more extended in both daylight mode and fluorescence SOPROLIFE blue fluorescence average scores for base-
548 P. Rechmann
th
th
th
th
th
on
on
on
on
on
-m
m
-m
-m
m
-m
2-
2-
r6
l6
l3
r1
l1
se
se
ro
ro
se
ro
nt
La
La
nt
La
Co
Co
Co
a b
.. Fig. 17.20 First Solea cavity preparations: a Upper left jaw with the green pilot laser visible; b lower right jaw after the clean laser prepa-
ration was finished. (Clinical photos courtesy of Dr. Mark Mizner)
.. Fig. 17.23 Solea cavity preparation—left picture after laser high hemostatic effect when cutting soft tissue with a CO2 laser.
preparation with overgrown gingiva; right picture after gingivectomy (Clinical photos courtesy of Dr. Joshua Weintraub)
was performed without anesthesia, no bleeding occurs due to the
Dentin Bonding
Overall, the shear bond strength to ablated dentin
ranged material depended widely from 19.15 ± 3.49 MPa
for OptiBondTE as lowest bond strength value and up
to 43.94 ± 6.47 MPa for Peak SE as the highest observed
bond strength value.
. Figures 17.25 and 17.26 represent the shear bond
strength test results for laser-ablated dentin after apply-
ing total etch bonding systems. The Peak TE control
sample achieved the highest bond strength value for
dentin bonding (63.02 ± 7.56 MPa (mean ± SD)) of all
in this study tested systems. OptiBond Solo Plus showed
roughly half the bond strength (31.58 ± 6.02 MPa). For
both bonding systems, Peak TE and OptiBond Solo
Plus TE, the bond strength values of the irradiated den- .. Fig. 17.26 Human dentin—hand irradiation shear bond strength
OptiBond Solo Plus TE, (mean ± SD); statistically significant differ-
tin significantly decreased compared to the controls ences to the controls are marked (****P ≤ 0.0001)
.. Fig. 17.25 Human dentin—hand irradiation shear bond strength .. Fig. 17.27 Human dentin—hand irradiation shear bond strength
Peak TE (mean ± SD); statistically significant differences to the con- Peak SE (mean ± SD); statistically significant differences to the con-
trols are marked (****P ≤ 0.0001) trols are marked (***P ≤ 0.001; ****P ≤ 0.0001)
554 P. Rechmann
17.7 Conclusion
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557 18
Contents
References – 570
amounted to a 1-h demonstration, once the laser was and high output laser power was chosen to ablate this
purchased and delivered. Frustration at the total lack of tissue. Unfortunately, the power levels—with the benefit
understanding as to what was exactly happening (the of hindsight, far too high for such delicate tissue,
laser operating beam was invisible, adding to the “magi- together with an incorrect angle of approach with the
cal” effects on tissue) was compounded by the fact that delivery fiber, led to thermal damage to the soft tissue,
this first laser—a near-infrared Nd:YAG—was ideally the underlying periosteum and necrosis of the underly-
suited—indeed originally developed—for soft tissue ing bone. As a result, the early post-operative period was
ablation; indeed, any possible use on tooth tissue was very painful with a delayed period of sloughing of tissue
limited to a slow and erratic ablation of accessible pig- and a resulting gingival fenestration. The patient was
mented caries. Hardly an instrument that would deliver later referred to a periodontist for corrective gingival
pain-free cavity preparation which was what the pur- surgery.
chase was expected to provide. There was no pride associated with such failure and
Undeterred and within a belief that the interaction the combination of personal shame and litigation fuelled
of this laser wavelength with soft tissue would deliver an anger to overcome the lack of knowledge as to what
predictable outcomes, it rapidly emerged that something was exactly happening and how the effects of laser use
was drastically wrong and mostly it was the lack of on oral tissue might be better controlled. Much of the
operator understanding (. Fig. 18.1). In this clinical early personal learning about laser use was through
case, the fibrous nature of the frenum was recognized overcoming mishaps in wavelength choice and dose.
D E
F G
18
.. Fig. 18.1 The use of the Nd:YAG 1064 nm laser in a case of fiber in contact mode. 250 mJ per pulse/15 Hz. Average power
lower labial frenectomy a. b Initial laser surgery at excessive power 3.74 W. Fluence 1162 J/cm2. Time taken 30 s. Total energy delivered
and lack of consideration of anatomical structures, leading to deeper 113 J. Pulse width 100 μs. Peak power density 3,108,495 W/cm2
tissue damage. c Appearance at 4 weeks and d 8 months, necessitat-
ing onward specialist referral. Laser operating parameters: 320 μm
Lasers in General Dental Practice: Is There a Place for Laser Science in Everyday Dental Practice…
561 18
During the following 4 years, a great deal of work was wavelengths, those within the blue visible and near-
made available with several laser manufacturers together infrared wavelength regions of the electromagnetic
with extensive travel; in addition, other laser wave- spectrum enjoy positive absorption by pigmented pro-
lengths such as the carbon dioxide and some early tein and hemoglobin. Longer wavelengths (mid to far
“diode” wavelengths were experienced through com- infrared) are absorbed by water and hard tissue min-
pany affiliation. A fundamental example of lack of eral. The phenomenon of absorption leads to a conver-
understanding of a new laser wavelength—the carbon sion of incident photonic energy into thermal energy
dioxide 10,600 nm—was highlighted through the belief within the target tissue element, and this can be predict-
that the examples of relationship between laser wave- ably configured to deliver a desired change in the tissue.
length and absorptive target tissue elements (essentially, With high-powered surgical lasers, the rise in tempera-
tissue pigments, proteins, water and hard tissue mineral) ture will lead to structural change, which will cause
would alone provide a safe guide as to the choice of laser ablation.
(. Fig. 18.2). The supposed high absorption in hydroxyapatite led
The oral cavity is a complex mixture of tissue ele- to the belief that here was an answer to the quest to own
ments and each element—protein, melanin, water, a laser suitable for tooth cavity preparation. As shown in
hemoglobin, and carbonated hydroxyapatite—exhibits . Fig. 18.2, the result of using incorrect and inappro-
differing levels of absorption with any of the laser wave- priate laser operating parameters continued to expose a
lengths available in dentistry. Essentially, shorter laser personal lack of understanding of the relevant funda-
D E
F G
.. Fig. 18.2 The use of the CO2 10,600 nm laser in an attempted the tissue. c Following attempts to remove the carbonized dentine
Class V cavity preparation, having provided assurance to the patient and residual caries, the restoration was completed d. Fortunately, no
that no rotary instruments would be used a. Relatively low average pulpal damage followed. Average power 1.0 W. Continuous wave
power delivered (1.0 W) was not the prime issue in the complications emission. Non-contact delivery/beam size 600 μm. Fluence 111 J/
incurred b—carbon deposits after initial laser irradiance), but the cm2. Time taken 5 s. Power density 164 W/cm2
emission mode (CW) and lack of water, leading to over-heating of
562 S. P. A. Parker
a b
.. Fig. 18.3 The use of the 810 nm diode laser to treat pericoronitis “loose” retromolar anatomical structures and spaces. c Sixteen days
at lower left wisdom tooth. a Shows inflamed operculum associated post-operative presentation. The patient had experienced severe
with functional wisdom tooth. b Immediately post-laser resection of pain, discharge, halitosis and trismus. Healing eventually achieved.
soft tissue. Care must always be given to the equal irradiation of Laser operating parameters: Average power 2.0 W. Continuous wave
keratinised and non-keratinised epithelium and in the case of exces- emission. Contact delivery/beam size 320 μm. Fluence 310 J/cm2.
sive power, the possibility exists for deeper edema to spread within Time taken 25 s. Total energy 50 J
mentals of laser science and biophysics. Once again, a dures or areas of treatment that can be carried out with
lack of control of rapid over-heating led to damaging the help of lasers—either those delivering tissue ablation
effects and furthermore, as in . Fig. 18.3, this led to as well as those associated with non-ablative photobio-
painful after-effects and delayed healing. modulation.
If there is a consequence to this self-imposed and What is of fundamental importance is that no matter
dangerous learning curve that formed the early part of what the level of adjunctive use a given laser may bring,
the author’s association with dental lasers, it was that the clinician is first and foremost a dentist and it remains
18 clinical experience should be complemented by a a duty to the patient that treatment offered should be
grounding in relevant science, applied clinical training based on evidence and within the capability or regula-
and development of prescriptive analytical skill in case tion of the dentist to provide it. Evidence demands sci-
of selection and laser choice. ence and furthermore enforces the belief that like all
The rapid expansion in recent years in laser wave- other aspects of clinical procedures and techniques, the
lengths available to the dental clinician, together with a presence of a laser must be justified and all parameters
rationalization toward machine size, sophistication and of its use for a given procedure defined through evidence-
in many instances, cost has allowed a full range of clini- base.
cal treatment areas to be further explored and managed This philosophy and approach can be simply demon-
with the help of laser photonic energy. . Figure 18.4 strated through the adoption of the “MIMO” concept—
provides a (non-exhaustive) list of those clinical proce- Minimum Input …… Maximum Outcome.
Lasers in General Dental Practice: Is There a Place for Laser Science in Everyday Dental Practice…
563 18
.. Fig. 18.4 Specific areas of therapy and clinical procedures where laser-assisted treatment may be carried out. Each procedure has received
peer-reviewed publication as listed in PubMed (7 www.ncbi.nlm.nih.gov/pubmed)
18.3 “MIMO”
.. Fig. 18.6 Hierarchical relationships of publication media, study design and distorting factors as they relate to the sustainability of sci-
ence and evidence in laser dentistry
566 S. P. A. Parker
knowledge but also position within a spectrum of truth. their own chosen agenda. Certainly, “super-objective”
Anyone can upload anything and claim intellectual filters such as the Cochrane Database of Systematic
property rights; whether a statement is true or not or Reviews represent the leading resource for systematic
even if the material is original or not, it is possible to reviews in health care. The following is taken from their
both host a dubious source of knowledge and manipulate website (7 www.cochrane.org):
its truthfulness. Of course, such a viewpoint is offensive
to those who post honest and scientifically strong mate- »» The Cochrane editorial process follows a consistent and
structured path. It is unique in two ways: (1) to monitor
rial (clinical and non-clinical) relating to laser action
the process of review development throughout the edito-
within dentistry. Nonetheless, the internet as a generic
rial life cycle, beginning with registration of a title,
source may be seen as least robust or dependable.
through preparation and publication of the protocol and
From there, online newsletters, blogs together with
completed review; (2) Cochrane Reviews are updated to
corporation-led “advertorial” and “infomercial” (yes—
take account of emerging evidence, to provide the best
there is a difference!) publicity of a clinical team, com-
and most current evidence to guide decision-making.
pany, technique, or laser instrument, while striving to
uphold the corporate or personal ethics of those However, sometimes the restrictive nature of literature
involved may be seen as being open to claims of subjec- review might result in (for instance) several hundred
tivity and massaging of truth to some extent. published papers being considered, but with application
The so-called reference texts, of which this book is of inclusion criteria only a handful are further exam-
an example, are often seen as totally credible but lacking ined. Certainly, the reader is encouraged to look at the
in peer-review; hence, there is only the reputation of exact nature of review and if this is a personal enquiry
individual authors and overall publisher’s approach to into a given laser technique or study, care, and caution
scrutiny that provides reinforcement of truth and ethics. should be exercised in total reliance on article abstract
Within the hierarchy of publication, only high-impact- material, as often a brief overview of a paper belies the
factor independent journals may get close to a perfect complete impact of the publication.
source of objective knowledge, science, and applied clin- Further upwards and to the peak of excellence; the
ical laser therapy. Public university degree theses will “double-blind” study has been described earlier and the
enjoy a degree of peer-review, and instrument or tech- component compartmentalization of study design
nique patents (but not exclusively, registered trade- (cohort/group/sample size, inclusion and exclusion crite-
marks) must prove originality and pass the severe ria), materials and method, data collection and interpre-
scrutiny of approval boards. tation, statistical analysis and audit through successive
Having explored the medium of knowledge dissemi- studies, not only confers a gold standard in all aspects of
nation, the other hierarchy relates to the type of article, dentistry research but must provide the way forward in
study or investigation in our quest for originality and defining the extent and strict methodology of laser
objectivity within laser dentistry. application in clinical dentistry.
Certainly, in the early days of laser use in dentistry, Such studies are complex and expensive; often they
the common currency of technique and application of are collaborative efforts within a group, university or
lasers in dentistry was the anecdote. Individual presenta- professional clinician cohort. An example of audit
tion of results through case presentation led the way and (among others) of prevalence of such refined studies
provided pathways of clinical therapy. Of course, the within laser dentistry was published by Cobb [7]. This
great drawback was whether results—so proudly dem- “snap-shot” of the types of papers relating to specific
onstrated—represented definitive protocols of tech- application of laser therapy within periodontology
18 nique, laser wavelength, and operating parameters, or involved a review of 278 articles. Applying consideration
maybe just luck! If laser dentistry was to receive accep- that has been explored above, only 12.6% of papers were
tance among professional colleagues, groups or those classified as “objective, controlled,” amounting to 35
entrusted with teaching, the reliance on anecdote repre- papers. If this points to a possible 87% being “subjec-
sented too fragile a base in sustainability and (possibly) tive” and possibly unreliable, it would provide ample
truth. ammunition to those non-laser users (possibly hypocrit-
From . Fig. 18.6, it is possible to view the ascending ically immersed in their own non-objective field of den-
levels of study types, in terms of objectivity, scientific tistry) to brand lasers as of no sustainable benefit to
rigor, reproducibility and ultimately, clinical relevance. dentistry.
Literature reviews are sometimes suspect—what control The author prefers to draw upon his own experience
exists to mandate the selection of published material? during the past 15 years, not only as a clinician but
The risk would lie with individual reviews that declare within university teaching and research, journal edito-
Lasers in General Dental Practice: Is There a Place for Laser Science in Everyday Dental Practice…
567 18
rial duties and personal publication, to bear witness that implies. Course X given by organization Y may have
the general standard of objective research and clinical integrity and convey accurate contemporary opinion,
application of laser use in dentistry has progressed enor- presented by an accredited experienced practitioner.
mously and with it the quality and sustainability of Taking such credit to a higher level, such as post-
objective publication. graduate degree application may suffer from non-
compliance with the entry criteria of that university. In
consequence, so much of education in laser use in den-
18.6 ducation and Qualification Pathways
E tistry has suffered because of lack of structure and pro-
in Laser Dentistry gressive pathway.
This is not a new phenomenon; in 2005 when
So why is laser use in dentistry so sporadic? There may installed as President of one laser organization, the
be several reasons: financial, lack of awareness among author was invited to join the editorial board of another
dentists or knowledge of what lasers can perform, but laser organization, located in a different continent.
perhaps the greater one is the lack of grounding and Despite best efforts to effect change, neither organiza-
integrated teaching of laser therapy at undergraduate tion would forego their own exclusivity and allow recip-
level. If a student is introduced to tooth cavity prepara- rocation of (otherwise complementary) education
tion using a rotary drill, such treatment modality forms achievement levels in laser use. What frustration! Those
the basis of the concept of restorative dentistry; equally, having progressed through one organization and wish-
a soft tissue incision performed with a scalpel defines an ing to join another, would need to begin once more at
approach to surgery that will be carried into one’s pro- the bottom. Examples of such perceived selfishness and
fessional career. The early learning in undergraduate life blinkered ambition continue to the present time in dis-
forms a bed-rock foundation to clinical opinion and suading dental professionals from joining and benefit-
techniques and this, together with the bonds established ting from the forum of like-minded colleagues in laser
between student and professor is part of the excellence use.
and integrity of clinical dentistry seen all over the world. In many regions of the world, public university-
Early adopters of laser dentistry were not able to based education has supplanted some historically
access structured educational pathways; rather, those popular laser organization-centered course pathways
who wished to consider laser use would attend an intro- with their own. Accredited diploma and post-gradu-
ductory course, often provided by the company selling ate MSc and PhD degree opportunities are now com-
the machine. Such courses would prove invaluable in mon—certainly in Europe, with the benefit to the busy
providing the novice with basics. Many such courses had clinician that many are part-time and distance-learn-
a drawback in that they would often limit presentation ing modular courses. Of particular benefit is the
material to the extent of the particular laser and what International recognition of such education and grad-
could be achieved with it. Notwithstanding, introduc- uates of such courses are becoming the opinion-mak-
tory experiences continue to provide initiation into the ers within an emerging generation of specialists and
world of lasers. experts. In turn, those universities that have developed
Awareness of different laser wavelengths and clinical degree opportunities have themselves witnessed
opportunities will drive the clinician to explore wider expansion in accredited personnel, over and comple-
education avenues. Courses at varying levels of intensity, mentary to existing faculty staff—ambassadors who
subject matter and complexity are now frequently pro- in turn develop the outreach of evidence-based educa-
moted—often as break-out sessions at a laser scientific tion. The appeal of these courses is high and in the
conference. author’s experience as a university faculty member,
With both these types of courses, verifiable continu- students have traveled thousands of miles across con-
ing education credits underline the significance of learn- tinents to take advantage of accredited learning path-
ing and awareness to benefit clinician, patient and ways.
professional licencing body. As such they will be quanti- At the beginning of this chapter, I wrote “to know is
fiable in terms of course content and expectation. Many to use; to understand is to empower.” The fundamental
of such courses draw upon accepted core curriculum elements to support such a statement must be the
structures an example of which is set out in a paper by acknowledgment of a scientific base to all laser–tissue
White et al. on curriculum guidelines for dental laser interaction, together with an accredited grasp of bio-
education [8]. physical principles that govern the degree of laser–tissue
Often, however the value of such courses is thwarted interaction, by laser type, laser wavelength, and target
through the non-linear pathway that such attendance tissue composition.
568 S. P. A. Parker
to an acceptance not only of the suitability of lasers in 4. Rosen H. Cracked tooth syndrome. J Prosthet Dent. 1982;47:36–
dentistry but also the evidence-based protocols for 43.
5. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson
their supportive role in treatment. WS. Evidence based medicine: what it is and what it isn’t. BMJ.
1996;312(7023):71–2.
6. Parker S, Cronshaw M, Grootveld M, Anagnostaki E, Mylona
References V, Chala M, George R, Walsh L. The influence of delivery power
losses and full operating parametry on the effectiveness of diode
visible–near-infrared (445–1064nm) laser therapy in dentistry—
1. Lenters M. Iatrogenic damage to the adjacent surfaces of pri-
a multi-center investigation. Lasers Med Sci. 2022;37(4):2249–
mary molars, in three different ways of cavity preparation. Eur
57. https://doi.org/10.1007/s10103-021-03491-y.
Arch Paediatr Dent. 2006;7(1):6–10.
7. Cobb CM. Lasers in periodontics: a review of the literature. J
2. Baldissara P, Catapano S. Clinical and histological evaluation of
Periodontol. 2006;77:545–64.
thermal injury thresholds in human teeth: a preliminary study. J
8. White JM, et al. Curriculum guidelines and standards for dental
Oral Rehabil. 1997;24(11):791–801.
laser education. Lasers in dentistry V. SPIE Int Soc Opt Eng.
3. Turp C, Gobetti J. The cracked tooth syndrome: an elusive diag-
1999;3593:110–22.
nosis. J Am Dent Assoc. 1996;127:1502–7.
18
571
Supplementary
Information
Glossary –572
Index –577
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG
2023
D. J. Coluzzi, S. P. A. Parker (eds.), Lasers in Dentistry—Current Concepts, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-031-43338-2
Glossary
Ablation Removal of a segment of tissue or (dental nitrogen, and small amounts of hydrogen and helium.
restorative) material using photothermal energy. When The laser is pumped with an electrical discharge, and the
applied to laser-tissue interaction, it describes the irre- emission is due to the population inversion of the car-
versible disruption of the physical structure of the tar- bon dioxide molecules. Current available wavelengths
get. It is sometimes termed vaporization, although that range from 9300 to 10,600 nm and are in the far-infrared
is not technically correct. thermal portion of the electromagnetic spectrum.
Absorption The transfer of electromagnetic radiation Chopped pulse See gated pulse mode.
into the target tissue resulting in a change in that tissue.
For available dental lasers, that transfer is primarily light Chromium A transition metal element used as a dopant
into heat. The true opposite of absorption is transmis- for laser active medium crystals, such as yttrium, scan-
sion. dium, gallium, and garnet (see YSGG).
Absorption coefficient The change in energy as the wave Chromophore A compound or molecule normally
passes through a layer is a constant of the material for a occurring in tissues that is an absorber of specific wave-
given wavelength and is called its absorption coefficient. lengths of visible light.
Active medium The material within the optical cavity Cladding A thin coating that surrounds the core of glass
that, when stimulated and amplified into a population in a fiber-optic delivery system. The cladding maintains
inversion, will emit laser energy. This medium may be an the propagation of the laser beam along the glass. The
ion, molecule, crystal, semiconductor wafer, or a combi- cladding is surrounded by a thicker jacket to aid in flex-
nation of gases. A synonymous term is lasant. ibility.
Amplification A process that occurs within the optical Coagulation For thermal tissue interaction, an observed
resonator of the laser whereby stimulated emission pro- denaturation of soft tissue proteins that occurs at
duces a population inversion. The amount of amplifica- approximately 60 °C. The term is usually applied to
tion is known as gain. blood when it changes from a fluid to semisolid con-
gealed mass.
Articulated arm One type of laser delivery system that
uses segments of a hollow tube that are coupled with Coherency A term that describes radiant waves travel-
right angle mirrors that allow propagation of the laser ing in phase both temporally and spatially.
beam along its length. Commonly found as part of the
delivery system in mid- and far-infra red wavelength Collimation The state in which all electromagnetic rays
dental lasers. are parallel with virtually no divergence.
Attenuation The observed decline in energy as a beam Contact mode The direct touching of the laser delivery
passes through an absorbing or scattering medium. system to the target tissue.
Average power An expression of the amount of laser Continuous wave mode A manner of applying laser
photonic energy delivered over a unit of time. In contin- energy in which beam power density remains constant
uous wave emission, it is the total power delivered; with over time; also abbreviated CW. This mode is commonly
free-running or gated pulse emission, it is an expression used clinically.
of the product of the peak power multiplied by the emis-
sion cycle. Delivery system The manner in which laser energy is
transferred to the target tissue. For dental lasers, there
Beam A directional stream of photons; any collection are fiber-optic, hollow waveguide, and articulated arm
of radiant electromagnetic rays that may be divergent, systems. The distal end can employ additional tips, and
convergent, or collimated. the beam may be used in a contact or noncontact mode.
Carbon dioxide laser A laser whose active medium is Diffraction The bending of a light ray as the light passes
composed primarily of helium, with carbon dioxide, through a medium, also known as refraction.
573
Glossary
Diode laser A laser whose active medium consists of an Fiber optics A laser delivery system composed of a glass
array of semiconductor wafers in a double-heterostructure fiber, which can contain multiple strands and is used to
arrangement. These lasers are pumped with electrical cur- propagate the laser beam along its length. The glass is
rent, and the resulting light is collected and focused into surrounded by cladding and a jacket or layers of jackets.
a beam. Various elements, such as aluminum, arsenide, The bare fiber can be used for laser procedures, or addi-
gallium, indium, nitrogen, and phosphorous, are part of tional quartz or sapphire tips can be added to the distal
the composition of the wafer. The emission wavelengths end of the fiber optics.
can range from the visible into the near-infrared thermal
portion of the electromagnetic spectrum. Fluence See energy density.
Divergence An observed amount of the spread of the Focal length The distance between the focusing lens and
laser beam as it increases its distance from the emission the focal point, which is the place where the laser beam’s
aperture or focal point; the opposite of collimation. It is power and energy are delivered at maximum density. It
measured in degrees of an angle. is usually measured in millimeters. In bare fiber-optically
delivered lasers, there is no focusing lens so focal length
Doping The addition of an element to the laser active does not exist. The greatest emission is at the end of the
medium crystal, resulting in a specific emission of fiber. In other delivery systems, such as an articulated
energy. Those elements are known as dopants and in arm, the focal point is usually several millimeters from
most cases; they are either rare earth ions or transition the end of the delivery system.
metal ions. An example is doping an yttrium aluminum
garnet crystal with the element of erbium. Free-running pulse mode A primary (inherent) laser
operating mode where the emission is truly pulsed and
Electromagnetic radiation Flow of energy consisting of not gated. The pumping process only sustains lasing
oscillating electric and magnetic fields lying transverse conditions for a very short time. Flashlamps, radio fre-
to the direction of the wave’s propagation. quency electron signals, and diode lasers are examples
of the pumping mechanism used. The resulting laser
Electromagnetic spectrum The entire range of all forms emission consists of very short pulse durations in the
of radiant energy from gamma rays to radio waves and microsecond range, and peak powers of thousands of
is usually depicted with increasing wavelength and/or Watts are possible. A laser operating in this mode can-
decreasing frequency. not be operated in continuous wave. This mode is com-
monly used clinically for dental hard tissue procedures.
Emission cycle A ratio of the emission on time to the on
plus off time, expressed as a percentage. An alternative Frequency The number of oscillations or cycles of a
term is duty cycle, although that term usually refers to wave of electromagnetic radiation per second, usually
the limit of operation of a machine. expressed as Hertz and abbreviated Hz. Frequency is the
inverse of wavelength.
Energy The ability to perform work, measured in a
unit known as a Joule, abbreviated J. For dental lasers, Gated pulse mode A laser operating mode where the
a common value is a millijoule (mJ) which is one-one emission is a repetitive on and off cycle. The laser beam
thousandth of a Joule. is actually emitted continuously, but a mechanical shut-
ter or electronic controls “chop” the laser beam into
Energy density The measurement of energy per unit pulses. This term is synonymous with chopped pulse
area, usually expressed as Joules/square centimeter, also mode, and this mode is commonly used clinically. When
known as fluence/radiant exposure. to “on time” and the “off time” can be controlled sepa-
rately, it is termed variable gated continuous wave mode.
Erbium A rare earth element that is used to dope a crys-
tal of yttrium, aluminum, garnet or yttrium, scandium, Gaussian curve A graphic depiction of normal distribu-
gallium, and garnet (see YAG or YSGG). tion of an entity. For lasers, it illustrates the cross section
of the power density during a certain time period, usu-
Excited state An atom or molecule with electron orbit(s) ally a pulse.
in an energized or higher level than the resting state.
Handpiece An instrument attached to the distal portion
Extinction length The distance into a material where the of the delivery system that contains the focusing lens
power density has dropped to 37% of its original value. system. In some cases, an additional tip is attached to
A synonymous term is attenuation length. the handpiece to complete the assembly.
574 Glossary
Hertz A term of frequency of an electromagnetic wave. lation inversion occurs. At each end of the resonator,
The term is sometimes used for the number of pulses per there are reflective surfaces or mirrors which produce
second or repetition rate of a pulsed dental laser, with amplification and coherency. The distal mirror is par-
some confusion. tially transmissive; when there is sufficient energy, the
beam can exit through that mirror.
Hollow wave guide A laser delivery system that uses a
flexible hollow tube with a mirrored inner surface to Peak power The measurement of the maximum power
propagate the laser beam along its length. in each pulse. It is the result of dividing the energy per
pulse by the pulse duration.
Infrared spectrum That portion of the invisible, nonion-
izing electromagnetic spectrum radiation whose wave- Photon A unit or quantum of radiant energy.
lengths range from the red border of the visible spectrum
at 700 nm up to 10,000 nm (0.07–1.0 μm). Commonly Plume Essentially the smoke produced from aerosoliza-
understood, but not universally agreed to, subdivisions tion of by-products due to the laser-tissue interaction.
are (1) near-infrared wavelengths from 700 to 1400 nm, It is composed of particulate matter, cellular debris,
(2) mid-infrared 1400–3000 nm, and (3) long infrared carbonaceous and inorganic materials, and potentially
3000–10,000 nm. biohazardous products.
Intensity See power density. Population inversion A state within the laser cavity
in which the quantity of excited species of the active
Irradiance See power density. medium exceeds that of the unexcited species (those at
the resting, stable state).
Joule A unit of expression of energy.
Power The amount of work performed per unit time,
Lasant See active medium. expressed in Watts (W) or thousandth of a Watt (mW).
A Watt is one Joule per second.
Laser An acronym of light amplification by stimulated
emission of radiation. The basic components of the Power density The measurement of power per unit
device are the active medium, external energy source or area, usually expressed as Watts/square centimeter, also
pumping mechanism, optical resonator, and the focus- known as intensity, irradiance, and radiance.
ing and delivery systems.
Pulse duration A measurement of the total amount of
Meter A unit of measurement and, for electromag- time that the pulse is emitted, also known as pulse width.
netic waves, used to describe the wavelength. For dental
lasers, it is divided by a million and termed a micron Pulse rate The number of pulses per second produced
symbolized by μm or divided by a billion and termed a by the laser, sometimes known as “hertz,” although that
nanometer, abbreviated nm. is technically incorrect.
Mode-locked laser This laser uses a group of techniques Pulse width See pulse duration
of modulation or absorption in the resonator to pro-
duce ultrashort pulses in the picosecond or femtosecond Pumping The process of energy transfer from an exter-
range. These lasers are currently used experimentally. nal energy source into the gain medium of the laser. This
pumping provides for the excitation and stimulation of
Monochromatic The characteristic of a laser beam the active medium. Some examples of pumping mech-
where only one wavelength is present. anisms are electricity, electrical fields, radio frequency
signals, or a flashlamp.
Neodymium A rare earth element used to dope an active
medium laser crystal, such as yttrium aluminum garnet Q-switched laser This laser uses Q switching to produce
(see YAG). pulse durations in the nanosecond range. The Q (qual-
ity) factor of resonator losses is modulated, and the
Noncontact mode The delivery system is used without result is that the power can build up quickly. These lasers
touching the target tissue. are currently used in the laboratory.
Optical resonator (optical cavity) The component of a Radiant energy Energy transferred by an electromag-
laser containing the active medium in which the popu- netic wave, also called radiation.
575
Glossary
Reflection The returning of electromagnetic radiation Thermal relaxation time The amount of time required
by surfaces upon which it is incident. The two general for temperature of the tissue that was raised by absorbed
types are specular, which is created from a smooth pol- laser radiation to cool down to 37% of that value imme-
ished surface, and diffuse, which emanates from a rough diately after the laser pulse.
surface.
Transmission The passage of electromagnetic radiation
Refraction See diffraction. through any medium, the opposite of absorption.
Repetition rate See hertz. Vaporization The physical process of converting a solid
or liquid into a gas; for dental procedures, it describes
Selective photothermolysis A precise laser-tissue inter- conversion of liquid water in the target into steam.
action in which the radiation is well absorbed and the
pulse duration is shorter than the thermal relaxation Watt A unit of power.
time which minimizes tissue damage.
Wavelength The distance between any two similar
Spontaneous emission The release of energy (a photon) points on a wave; for example, from peak to peak, mea-
as the previously excited particle level returns to its rest- sured in meters.
ing, stable state.
YAG An acronym describing a solid crystal of yttrium,
Stimulated emission The release of energy (a photon) aluminum, and garnet that can be doped with various
from an already excited particle by interaction with a rare earth elements and is used as an active medium for
particle of identical energy, producing two coherent par- some lasers.
ticles. This process was theorized by Albert Einstein in
1916 and is the basis for laser operation. YAP An acronym describing a solid crystal of yttrium,
aluminum, and perovskite (a calcium titanium oxide
Superpulse A variation of gated pulsed mode in which mineral) that can be doped with various rare earth ele-
the pulse durations are very short, often producing high ments and is used as an active medium for some lasers.
peak power, also termed very short pulse.
YSGG An acronym describing a sold crystal of yttrium,
Thermal effect For lasers, the absorption of the radi- scandium, gallium, and garnet that can be doped with
ant energy by tissue producing an increase in tempera- various rare earth elements and is used as an active
ture. medium for some lasers.
577 A
Index
Dentogingival complex (DGC) 325, 330, 332, 483, 484, 486, 488, –– photodynamic disinfection 301, 312, 465
489, 503, 504 –– photothermal disinfection 304, 307
Depigmentation 10 –– root canal system 300, 303, 312
Digital imaging fibre-optic transillumination (DIFOTI) 143 –– safety issues 309
Diode lasers 424 –– smear layer removal, root canal 268, 298, 299, 304
–– advantages 340, 374, 419 –– temperature effects 309–310
–– analgesic effects 185, 307 Energy density 17, 31, 55, 67, 70, 72, 77, 81, 83, 87, 90–91, 94, 95,
–– applications 391 242, 244, 245, 249, 250, 258, 267, 268, 271, 281, 351, 367, 523,
–– average power 90 526
–– cavitation effects 304 Epulis fissurata 416
–– collimation 22, 24, 25, 36, 37, 71, 105, 161 Erbium energy 247
–– continuous/gated-CW mode 383 Erbium lasers
–– crown lengthening 499 –– ablation mechanism, hard dental tissues 244, 281
–– direct energy conversion 68 –– adjunctive use of 455
–– emission modes 53, 195 –– advantages 351, 374, 554
–– fiber-optic tip size 383, 385–387 –– analgesia 224, 264, 267, 306, 342, 559
–– GaAlAs laser 306 –– autogenous augmentation procedure 327
–– implant dentistry 320, 330, 335 –– average power 74, 91, 94
–– infrared 27, 136, 424, 510, 513, 523 –– cavity preparation, parameters for 341, 342, 344
–– laser ablation 510 –– contact/non-contact mode 383, 400
–– laser wavelengths and tissue interaction 481–482 –– endodontically treated teeth 273–274
–– lip pigmentation management 509 –– Er
–– mechanical components 25 –– YAG laser 74, 244, 259, 281, 297–299, 303, 306, 310, 322, 382,
–– and Nd 383, 392, 522
–– YAG laser 28, 90, 400, 435, 481, 511 –– Er,Cr
–– oral medicine, LLLT 210, 213 –– YSGG laser 74, 82, 85, 259, 260, 269, 281, 298, 303, 304, 308,
–– oral surgery 395 323–327, 329–331, 334, 335, 382, 383, 392, 394, 395
–– orthodontics, soft tissue procedures 382–384, 391 –– implant dentistry 320, 330
–– peak power 74, 90, 481, 513 –– laser incision 14, 17, 323, 327, 380
–– pericoronitis 207, 562 –– laser wavelengths and tissue interaction 481–482
–– peri-implant mucositis, adjunctive treatment of 333, 450, 451 –– laser-assisted LCPT 457, 458, 460
–– photobiomodulation 292, 293, 306, 331 –– minimal gingivoplasty 344, 345
–– power output 24, 27, 43, 99, 383, 387 –– in-office bleaching 522
–– semiconductor laser 25, 28, 68, 425 –– open flap surgery 461
–– shallow-inflamed periodontal pocket 322, 453 –– osseous crown lengthening 493, 497
–– smear layer removal 298, 299, 304, 370 –– peri-implantitis 334, 458, 462, 463
–– TAD 391 –– soft dental tissue 481
–– wavelengths 41, 50, 85, 157, 220, 515 –– soft tissue management 9, 500
Direct pulp capping 307, 308, 346, 370, 371, 374 –– soft tissue oral surgery 7, 395, 401
Discoloration, teeth 251, 281, 472, 520, 521, 525 –– thermal exchange 45
Dye lasers 67 –– titanium implant, decontamination of 323, 450
–– water absorable 298, 299, 302, 304, 392
Eye protection 99, 105, 109, 112, 113, 116, 117
E
Educational pathways 567 F
Elastic (Rayleigh) scattering 138, 139, 148
Electrochemical impedance spectroscopy (EIS) 143 Facial pain 206, 208
Electroconductivity measurement (ECM) 143 Fiber-optic 387
Electron transfer reactions 39 Fiber-optic transillumination (FOTI) 143
Electrosurgery 14, 307, 330, 380, 402, 410, 510 Fibroma 8, 16, 22, 48, 49, 361, 363, 401, 408–410, 414
Emission cycle 31, 32, 89, 91, 94, 382, 401, 487, 511 Flapless surgery
Emission mode 27 –– LCPT 456–458, 460
Emitting device 71, 76–77 Fluid agitation, laser 300, 302–304, 312
Enamel caries resistance Fluorescence lifetime imaging microscopy (FLIM) 134
–– carbon dioxide laser 552 Fluorescence resonance energy transfer (FRET) 134
–– carbonated apatite 537, 554 Focus-to-tissue distance 77–79
–– fluoride 247–249, 254, 277 Fourier transform infrared reflectance (FTIR) spectrum 537, 539
–– mean relative mineral loss DZ 539 Free-running pulse laser 68, 511
–– short-pulsed carbon dioxide laser 537, 549 Full-mouth bleeding score (FMBS) 468, 469
Endodontics, laser-assisted
–– analgesia 293
–– classification 292
G
–– dental pulp 293, 309–310 Gag reflex 9
–– invasive cervical resorption lesions 308 Gas lasers 23, 27, 67, 110
–– laser-enhanced bleaching 304 Gate theory 60, 265
–– periodontal tissues 300, 310 Gated pulsed mode 30–31
579 D-L
Index
H I
Hand speed 32–33, 278, 419, 497, 500
Implantology, dental 7
Hard dental tissues
–– autogenous augmentation, bone removal for 326
–– advantages 241
–– carbon dioxide lasers 322
–– applications 56, 143
–– decontamination of 320
–– carbonated apatite 536
–– definition 320
–– carbon dioxide lasers 275
–– diagnosis of
–– continuous wave and complimentary gated mode 30, 142
–– diode lasers 321–322
–– enamel caries resistance 536
–– direct sinus lifts, window creation in 326
–– erbium lasers 82, 275
–– early peri-implantitis 332
–– femtosecond lasers 56
–– erbium lasers 322
–– hydrokinetic theory 82
–– gingiva, increase width of 324
–– hydroxyapatite, role 83
–– handpiece selection
–– laser fluorescence 56
–– laser applications 320
–– laser-induced breakdown spectroscopy 139
–– laser incision 323
–– laser-induced cavitation phenomenon 55
–– laser troughing 330
–– mean relative mineral loss 539
–– late peri-implantitis 329
–– mid-IR laser beam interaction, enamel 151
–– Nd
–– mode
–– YAG laser 323
–– effect on 242
–– osteotomy 323, 325
–– enamel caries resistance 247
–– PBM 331
–– erbium lasers 244, 258
–– peri-implant disease 332
–– morphological damage 55
–– postsurgical laser utilization 324
–– non-biological materials, oral cavity 83
–– presurgical procedures 320
–– OCT in 152
–– second-stage implant surgery 322
–– optical properties, of enamel 537
–– surgical applications 335
–– pulpal safety study 541
–– surgical site preparation 324–326
–– QLF 145–146, 152
–– treatment of 333
–– Raman spectroscopy 140–143, 146
In-office bleaching 225
–– shear-bond strength testing 551–554
Indirect pulp capping 370
–– short-pulsed carbon dioxide laser 277, 554
Inelastic scattering of light 129, 139
–– structural components 106
Infrared diode lasers 136, 297, 300, 308, 309, 523
–– thermal energy 38
InGaAlAs laser
–– ultrashort-pulsed irradiance 103
International Caries Detection and Assessment System
–– in vivo occlusal caries prevention 56
(ICDAS) 544
–– water and carbonated hydroxyapatite 10
–– water augmentation 54
Hare technique 267
Hazards of laser beams
K
–– adverse surgical outcome 104 Kazanjian technique 417
–– chemical and fire hazards 110
–– hollow metal delivery, care 107
–– inhalation and laser plume risks 107–109 L
–– irradiation power 104 Lambert-Beer law
–– laser wavelength 104 Laser abrasion 350, 374
–– mechanical hazards and safety mechanisms 110 Laser assisted new attachment procedure (LANAP) 457–459
580 Index
–– quantitative fluorescence 38 N
–– red light 27
–– singlet oxygen 38 Nd
–– sources 23 –– YAG laser
–– theories on 21 –– adjunctive use of 451, 453
–– tissue scattering 59 –– analgesic effects 185, 456
–– visible green light 305 –– articulated arm 28, 71
–– visible light diode 450 –– crown lengthening 9
–– waves 21 –– deep penetration 322
–– white light 21 –– free-running pulse emission 30, 44, 306
Lip pigmentation management –– laser ablation 510
–– ablative technique 511–519 –– lower labial frenectomy 560
–– dark pigmentation 509 –– management 10, 368
–– depigmentation, treatments for 510 –– multi-tissue management 481–484, 486, 487, 489, 490,
–– exogenous origin 515–517 493–499, 501–504
–– infrared diode 513–514 –– orthodontics 222, 391
–– near-infrared diode 510 –– peak power 31–32, 43, 69, 74–75
–– non-ablative technique 513–514 –– periodontal therapy 322
–– PIH 509 –– photothermal disinfection 299, 300
–– postoperative care 517 –– pocket irradiation 457
–– treatment duration 517 –– pulpal analgesia 59–60
–– visible light diode 514–515 –– pulpotomy techniques 307
Lipoma 413, 414 –– root canals widening 281
Liquid lasers 67 –– soft tissue 85
Low-level laser therapy (LLLT) 9, 265, 292, 306, 307 –– solid-state crystals 23
Low-power laser therapy (LPLT) Near-infrared diode lasers 425
Nominal ocular hazard zone (NOHZ) 111
Non-ablative 517
M Non-ablative technique
–– depigmentation procedure 513, 518
Marketing process 12–14
–– gingival pigmentation management 519
Mature dental enamel 519
–– infrared diode 513
Medical vacuum systems 119
–– lip pigmentation management 509
Metal tattoo 515–516
–– near infrared diode 513
Micro-abrasion 340
–– photocoagulation 513, 514
Microfluidic technique 141
–– treatment duration 517
Microleakage 242, 251, 252, 255, 257, 258, 260, 261, 351
–– vs. ablative 513
Mid infrared wavelength lasers 348
–– with anesthesia 514, 516
Minimal gingivoplasty 344, 345
Non-contact laser waves 42
Minimum input maximum outcome (MIMO) algorithm 562
Non-steroidal anti-inflammatory drugs (NSAIDS) 222
Movement speed 81
Non-surgical initial periodontal 455–456
Mucogingival surgery 380
Mucosal chronic inflammatory and autoimmune diseases 212–213
Mucositis O
–– chemo- and radio-induced 215
–– development of 219 Optical biopsy 136, 138
–– LLLT 9 Optical cavity/resonator 24, 25
–– peri-implant 332 Optical coherence tomography (OCT) 136, 137, 152, 155, 159
–– treatment 205 Optical fibers 6, 22, 70, 71, 87, 90, 298, 410
Multi-tissue management Oral cavity
–– alveolar bone 482 –– biostimulating effects 203
–– biologic width 481 –– keratinized gingiva, width of 419
–– carbon dioxide lasers 481 –– OCT 136
–– crown lengthening 486 –– optical fiber delivery system 85
–– dentogingival complex 483–484 –– soft tissue oral surgery
–– diode laser 481, 485, 486 –– fibroma 407, 408
–– emergence profile 484–486 –– leukoplakia 401, 402
–– erbium lasers 481 –– lichen ruber planus 403
–– gingival biotype 482–483 –– lipomas 412
–– laser wavelengths and tissue interaction 481–482 –– papilloma 410
–– Nd –– pyogenic granuloma 413
–– YAG laser 481 Oral hygiene maintenance 9, 509
–– osseous 481 Oral medicine, LLLT
–– soft tissue 486–492 –– bisphosphonate-induced osteonecrosis
–– soft tissue management 500 –– BMS
–– soft tissue surgery procedures 481 –– chemo- and radio-induced mucositis 215
–– tissue preparation 503, 504 –– drug therapy, oral mucosa 218, 414
582 Index
V W
Variable gated continuous wave lasers 69 Water affinity 244
Vascular malformation 422–426 Welding effect 263
Visible spectrum dental lasers 27 Whitening, tooth 190, 226, 524
Wickham’s striae 403