Laser Therapy

Clinical applications of dental lasers

Mitchell A. Lomke, DDS
Dental lasers currently have 24 clinical indications for use that are recognized by the FDA. This article explores the scientic basis for these clinical indications in patient diagnosis and treatment. Multiple examples of relevant clinical applications for these wavelengths are explored in detail and illustrated via clinical photographs. Received: April 1, 2008 Accepted: June 20, 2008

ll dental lasers exert their desired clinical eect on a patients target tissue by a process called absorption.1 This target may consist of hard tissue, including natural tooth structure, carious enamel and dentin, dental calculus, bone, or even an existing defective composite restoration within the tooth. Many dierent types of intraoral soft tissue targets commonly are observed upon routine examination, such as redundant gingival tissue, aberrant frenum, operculum, epulus, or benign lesions in the form of a broma or a papilloma. Dental lasers function by producing waves of photons (quanta of light) that are specic to each laser wavelength.2 This photonic absorption within the target tissue results in an intracellular and/or intercellular change to produce the desired result. Dental lasers may be separated into three basic groups: soft tissue lasers, hard tissue lasers, and nonsurgical devices such as diagnostic/ composite and photodisinfection lasers. This article will provide details on each of these laser classication groups; however, it also is important to be familiar with the common terms related to dental lasers. Chromophore refers to the substance or quality within a

specic target tissue that serves as an attractant for a laser photon.3 This photonic absorption within a target tissues chromophore is the basis for a dental lasers functional dynamic process, referred to as a laser/tissue interaction.1 Nearly all surgical dental lasers function via this wavelength-specic photonic absorption, which causes the temperature within the target tissue cells to increase very rapidly to an evaporative state. These dental lasers cut tissue by a functional process known as a photothermal interaction or photothermal ablation.2 A typical example is the clinical use of a diode, a laser that is utilized in dentistry to treat soft tissue only.3 The chromophore of diode lasers is pigmented (or colored) tissues, specically melanin, hemoglobin (Hb), and oxyhemoglobin.3 The diode is ecient for treating a patients soft tissues because gingival tissues have a concentration of these chromophores; as a result, a diode photon has a high anity for gingival tissues. Diode lasers are used in contact with a patients soft tissue to perform common dental procedures such as gingivectomies or soft tissue lesion (broma) removal.4 Dental lasers oer a number of clinical advantages (especially for soft tissues), including hemostasis (the sealing of local vasculature), the ability to seal nerve endings and
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lymphatic vessels, reduced postoperative pain and swelling (thus reducing the need for postoperative analgesics/narcotics), reduced bacterial counts, and a minimized need for sutures in most surgical procedures.5 Although clinicians can control some of the factors that aect laser/ tissue interactions, two factors remain independent of the operator: the unique characteristics of the laser wavelengths emissions and the qualities inherent within the specic target tissue. Among the factors that clinicians can control are the power setting of the laser (power density), the total power delivered over a given surface area (energy density or uence), the rate and duration of exposure (continuous versus pulsed, and pulse duration and repetition), and the method by which energy is delivered to the target tissue (contact versus non-contact).6 In fact, clinicians will have precise control over the laser to achieve the desired tissue eect by adjusting any of four variables (power, spot size, total treatment time, and repetition rate).2 For example, when an area of inammatory tissue and an equivalent volumetric area of brotic tissue are treated with a diode laser at the same power setting, two very dierent interactions will occur. The laser will cut the brotic tissue at a far
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Laser Therapy Clinical applications of dental lasers

slower rate, as there is more collagen in the thicker dermal layer, which scatters the diodes energy and prevents that energy from reaching the underlying blood vessels. Conversely, the laser will cut the inammatory tissue much faster because of the higher concentration of Hb-rich red blood cells (RBCs). Using the same laser power setting and decreasing the diameter of the laser tip used (spot size) by 50% (for example, from 1.0 mm to 0.5 mm) will cause the power density exerted on the target to quadruple, due to the inverse square rule.2 Clinicians should understand that by using a smaller diameter laser tip (and increasing the power density to the target as a result), the rate of ablation will increase dramatically. The clinical technique will need to be adjusted accordingly by either defocusing the beam (moving the tip farther away from the target) or decreasing the lasers power setting. The dental laser wavelengths used most commonly are located within the near, mid, and far infrared portions of the electromagnetic spectrum (EMS).2 Within these specic areas of the EMS, the photons emitted by these lasers are an invisible, non-ionizing, non-mutagenic type of radiation.6 These laser wavelengths are clinically eective when they are used at proper power settings by trained hands. Dentists should always use the lowest possible power setting to achieve the intended treatment objective.2 Merely increasing a lasers power settings will not necessarily cut tissue faster or more eciently; in fact, it can cause an adverse result or even lead to treatment failure. Using too much power unnecessarily will increase the target tissues temperature too rapidly and by too much, resulting in collateral thermal damage.1 This eect can manifest
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as tissue necrosis and/or sloughing of tissue due to the wide zone of edema that has been created. These complications defeat the clinical advantage for using a dental laser: to achieve treatment goals in a more eective and conservative manner (due to the laser's specic ablative capacity) than conventional instrumentation would allow. Lasers are named according to the chemical elements or molecules that make up their core (also known as the active medium).2 The active medium serves to retain a specic lasers dopant ions and may consist of a man-made crystal rod, a gas, or a semi-conductor.2 When reading a free-running pulsed laser wavelengths specic name, the elements to the left of the colon refer to the dopant ions; the elements to the right of the colon are its active medium.2 For example, an Er:YAG laser includes a crystal rod active medium consisting of yttrium, aluminum, and garnet (YAG), which is doped (or externally coated) with a layer of erbium ions. Examples of other dopant ions used in lasers include chromium (Cr), neodynium (Nd), and holmium (Ho). The dopant ion within a free-running pulsed laser produces a specic wavelength. Diode lasers use a semiconductor containing aluminum (or indium), gallium, and arsenide as its active medium.6 Currently, the only gas laser used in dentistry is carbon dioxide (CO2), whose active medium is a tube lled with a mixture of CO2, nitrogen (N), helium (He), and neon (Ne) gases. This laser uses a beam of energy that lases soft tissue in a non-contact mode.2 In the past, CO2 laser models were superpulsed or millipulsed machines that measured pulses by 10-3 seconds. By contrast, the newer micropulsed CO2 lasers pulses are measured
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in 10-6 seconds, which is 1,000 times faster. The newer ultrafast, micropulsed CO2 lasers are capable of ablating soft tissue without charring.7 (Charring is dened as the carbonization of a patients tissues, which happens when they are heated to temperatures above 200C.) The newer CO2 lasers can deliver more power to the intended target with shorter pulse intervals, making more ecient ablative eects with less potential for collateral thermal damage to adjacent tissues. The FDA has four dierent laser classes, based on the potential danger posed by the lasers within each class as a result of their inherent power. Most lasers used in dentistry are considered Class IV lasers.2 These lasers require eye protection (in the form of safety glasses) for the patient, the dentist, and the assisting stain short, anyone located with the Nominal Hazard Zone.2 These safety glasses must be wavelengthspecic and must have protective side shields and a specic optic density.2 Failure to use proper eye protection could cause severe and possibly irreversible eye damage.2

Clinical laser applications

Conventional dentistry involves using rigid metal or diamond instruments to drill, cut, or abrade hard and soft tissues. Traditional dental treatment is recognized as the process of removing infected or pathologic tissue by either drilling or cutting away the diseased component.2 Dental lasers can be used to cut, incise, and ablate hard and soft tissues. The inherent properties of laser lightsuch as selective absorption, coagulation, sterilization, and stimulatory eects on vital structuresmake lasers the treatment of choice in certain clinical scenarios.2

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Proper clinical technique is extremely important when lasing a patients oral tissues. It is strongly recommended that the operator use proper magnication and illumination to assess the treatments progress accurately and determine that photothermal ablation is occurring. A denitive color change will be observed at the initial moment of tissue ablation; at that point, the clinician should move the laser tip in a slow and deliberate paint brushing motion that corresponds to the patients specic tissues, always evaluating the laser/tissue interaction to obtain the optimal result. Many new laser users make the common error of using a fast and constant painting motion and moving the beam too quickly; this improper technique will not allow proper ablation to occur. Electrosurgery, or electrocautery, is not absorption-specic within a target tissue; as a result, extremely high temperatures are created within the tissue mass to produce a desired clinical eect known as fulguration. Electrosurgical techniques used at present for tissue ablation are unable to control the depth of necrosis in the tissue being treated. Most electrosurgical devices rely on the creation of an electric arc (between the treating electrode and the tissue that is being cut or ablated) to cause the desired localized heating. These high temperatures cause a depth of necrosis of more than 500 m (often more than 800 m and sometimes as high as 1,700 m); the inability to control such depth of necrosis is a signicant disadvantage to using electrosurgical techniques for tissue ablation.8 Lasers do not suer from electrical shorting in conductive environments and certain types of lasers allow for very controlled cutting with limited depth of necrosis, due to their inherent ability to absorb chromophores within a specic target tissue.

For the purpose of this article, clinical applications for lasers in dentistry are separated into three dierent groups: soft tissue treatment, hard tissue treatment, and non-surgical treatment.

Soft tissue lasers

Overall, dental lasers are relatively easy to use, as long as the clinician has been trained properly. It is important to understand that lasers function with an end cutting action (that is, laser energy is emitted from the end of the laser), while most other dental instruments are side cutting, with the cutting edges or abrasive surfaces located on the lateral surface. Although most laser soft tissue treatments heal by secondary intention, the postoperative course usually is uneventful.9 Most laser excisional or incisional procedures are accomplished at 100C, where vaporization of intraand extracellular water causes ablation or removes biological tissue. Clinicians must be wary of the heat generated within tissues during a procedure. If the tissue temperature exceeds 200C during a lasing procedure, carbonization and irreversible tissue necrosis will occur.6 This adverse consequence can be avoided completely by using the lowest power setting necessary to achieve the desired treatment goal. There are specic soft tissue indications for the clinical use of lasers, including anterior gingival esthetic recontouring, gingivectomy/gingivoplasty (for crown lengthening procedures), operculectomy, removal of epuli, incisions when laying a ap, incision and drainage procedures, frenectomy, vestibuloplasty, coagulation of extraction sites, treatment of herpetic and recurrent aphthous ulcer lesions, uncovering of an implant, pre-impression sulcular retraction, and ablation of an
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intraosseous dental pathology (such as a granuloma or an abscess). Other excisional laser procedures involve the removal of soft tissue targets that may appear as benign lesions (such as bromas or papillomas) on the lip, tongue, buccal mucosa, or palatal area; the removal of coronal pulp as an adjunct to root canal therapy; excisional biopsy; and sulcular debridement.4 Diode (810 nm, 940 nm, 980 nm, 1,064 nm), Nd:YAG (1,064 nm), CO2 (10,600 nm), Er:YAG (2,940 nm), Er,Cr:YSGG (2,780 nm), and potassium-titanyl-phosphate (KTP) (532 nm) lasers are the wavelengths used most commonly for soft tissue procedures.2 Diode and Nd:YAG lasers are alike in that these lasers are absorbed in pigmented tissues (melanin and Hb) and both wavelengths are transmitted to their targets in contact with a thin exible quartz ber. CO2 laser energy is absorbed in the target tissues water content and transmitted to the intended target using a hollow waveguide or an articulated arm. Erbium laser energy is transmitted to the intended target tissue by a clear sapphire or quartz tip, either in contact or approximately 0.5 mm from the target.2 Each wavelength has its own unique interactive qualities and a dierent clinical feel that operators must experience to attain a certain comfort level. A soft tissue crown lengthening procedure can be accomplished by using any of the laser wavelengths mentioned above. Figures 1 and 2 demonstrate the degree of accurate visibility on the preparations nish lines that can be achieved with this technique. Lasers also make it possible to combine two or more separate procedures into one appointment. It is not unusual to see the need for periodontal correction after a defective
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Laser Therapy Clinical applications of dental lasers

Fig. 1. An example of inamed, hypertrophied gingival tissues.

Fig. 2. The patient in Figure 1, after crown lengthening with a diode laser.

Fig. 3. A 45-year-old woman with an aberrant frenum pull.

Fig. 4. The patient in Figure 3, immediately following a diode laser frenectomy/vestibuloplasty.

Fig. 5. The patient in Figure 3, three weeks postsurgery.

Fig. 6. Marginal detail in an impression taken after Er:YAG treatment.

crown or other restoration has been removed. Lasers oer tremendous advantages in terms of precision cutting and hemostasis; as a result, tooth preparation, periodontal correction, and nal impressions can be combined into one appointment and the nal restoration can be inserted at the following appointment. Of course, the ability to accomplish all three steps in a single visit depends on the dentists level of expertise and the patients tolerance. A diode laser can be used for clinical scenarios in which an aberrant frenum pull causes recession and a loss of attached gingiva. In one case, a 45-year-old woman sought treatment for an aberrant frenum pull in the mandibular anterior region (Fig. 3). After proper debridement of the roots to remove any residual calculus, the diode laser was used
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to ablate the aberrant frenum. The laser incision was widened carefully by dissecting the underlying tissue bers to remove any tension (or pull) still on the remaining zone of keratinized tissue (Fig. 4). The tension from the aberrant frenum was released and the zone of attached gingiva increased. The concomitant increase in available vestibular depth improved the patients access to daily proper plaque control, improving the overall prognosis for long-term retention of her anterior mandibular teeth (Fig. 5). The author has used an Er:YAG laser to dessicate the marginal gingival tissues adjacent to vital nish lines prior to taking nal crown and bridge impressions. This technique is especially valuable for clinical scenarios in which laser periodontal correction has been completed and
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the gingival tissues are still moist with minor bleeding or sulcular uid that can ruin the nal impression. The lasers water spray must be turned o and the energy setting reduced to a very low range (1,000 sapphire tip, 100200 mJ with a repetition rate of 12 Hz). This technique takes advantage of erbiums photonic anity for water molecules. The water spray is turned o during this procedure, allowing the patient to absorb the erbium photons via the water in their tissues. The Er:YAGs sapphire tip is moved carefully (slightly out-of-contact) around the gingival sulcular areas in a circumferential motion. The uids around the tooth preparations nish lines evaporate, leaving these areas with a dry, opaque, whitish surface, which enhances the quality of the nal impression (Fig. 6).

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Fig. 7. A patient with redundant tissue under a loosened implant healing cap.

Fig. 8. The patient in Figure 7, following laser ablation.

Fig. 9. A preoperative view of a 15-year-old girl with excessive overgrowth of keratinized tissue.

Fig. 10. The patient in Figure 9, immediately following a CO2 laser frenectomy and diode laser recontouring.

Fig. 11. The patient in Figure 9, after healing was complete.

Soft tissue lasers make precision control possible, even when clinical access is very dicult. Figures 7 and 8 illustrate a case involving a 21-year-old woman with a healing cap that had come loose from an aberrantly placed implant in the maxillary anterior region, where there was little or no discernable vestibular depth. A millipulsed CO2 laser was used carefully to dissect the overgrowth of redundant gingival tissue and expose the underlying implant platform so that the nal impression could be taken. It is important to direct the laser tips emissions away from the implant platform to avoid possible negative thermal eects on the supporting bone. CO2 laser photons are not readily absorbed in the titanium composition of the implant. To

avoid possible thermal damage, always be careful to avoid contact with either the implant or the surrounding bone.10 In some clinical cases, the author has found that using dierent laser wavelengths in combination can achieve a more predictable level of care. In one case, a 15-year-old girl who had recently completed orthodontic treatment had both a high maxillary anterior midline frenum attachment and an excessive overgrowth of keratinized tissue, preventing proper exposure of the clinical crowns on teeth No. 8 and 9 (Fig. 9). A CO2 laser was used to perform the extensive frenectomy and a diode laser was used to perform the gingival esthetic recontouring. Outstanding hemostasis was attained and the
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lasers precise cutting ability made it possible to preserve the original peak of the interdental papilla (Fig. 10). One month later, the patient demonstrated outstanding healing and no appreciable wound contraction (Fig. 11). Many adolescent patients suer from ankyloglossia, in which the existing heavy lingual frenum attachment prevents normal functioning. These patients often are introverted because they have diculty with normal speech. Figures 1216 show a 13-year-old girl with excessive frena both superior and inferior to Whartons duct, which prevented a normal range of lingual protrusion. Micropulsed CO2 lasers have a unique ability to ablate soft tissues accurately with char-free power settings (30 Hz, 300 mJ), resulting in minimal collateral thermal damage.11 There was little or no bleeding during the procedure and suturing was contraindicated, as healing from this technique occurs via secondary intention. In the present case, healing was excellent and the patients range of motion was increased greatly. This patients speech improved so much that her parents reported a dramatic and positive change in her personality. The author has used diode lasers
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Fig. 12. A 13-year-old patient with ankyloglossia. Note excessive frena superior and inferior to Whartons duct.

Fig. 13. A preoperative view of the patient in Figure 12. Note the tongue protrusion.

Fig. 14. An immediate postoperative view of the patient in Figure 12.

Fig. 15. The patient in Figure 12, 5.5 weeks postoperatively.

Fig. 16. A posttreatment view of the patient in Figure 12 with enhanced tongue protrusion and mobility.

Fig. 17. The bleeding pulp chamber of a maxillary molar undergoing endodontic treatment.

Fig. 18. A diode laser is used to ablate the diseased intrapulpal tissue.

Fig. 19. The patient in Figure 17, after laser ablation.

as an adjunctive tool during the initial phase of endodontic therapy. During routine endodontic procedures, the 810 nm diode laser can be used to eliminate bleeding from the pulp chamber.12 This process takes advantage of the diode lasers inherent hemostatic action and bacteriocidal properties and aids with overall healing. This procedure should be done at a lower power setting (2 W, .1/.1 repeat pulse mode) in a wet eld with water only. The case can be completed with conventional endodontic instrumentation and obturation; Figures 1719 show this procedure used during routine endodontic therapy for a maxillary molar. The
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hemostatic advantage of the diode lasers photonic interaction with the inamed intrapulpal tissue results in a clean, dry eld. Lasers can be a useful treatment modality for excisional biopsies of benign soft tissue lesions in the oral cavity. After local anesthesia is administered, the lesion is outlined with the diode, Nd:YAG, Er:YAG, Er:YSGG, or CO2 laser to attain sound tissue margins. At that point, retraction pressure is applied, either by using a tissue forceps or by placing a single suture into the lesion and applying retraction to visualize the lesions base. The lasers ablative beam is directed at the lesions base rather than at
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the lesion itself. The lesion literally will peel away from the base tissue until it releases completely, with little or no bleeding. All specimens should be sent to a pathology laboratory for analysis; the pathologist should be informed when a laser has been used for a biopsy. Normal sensation returns to the treatment zone within the natural course of tissue healing. Figures 2023 illustrate how lasers were used to remove a traumatic broma from the midline of the tongue of a 52-year-old man. There was total hemostasis during the procedures and no scar formation. The author also has used lasers for operculectomies. A 12-year-old boy

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Fig. 20. A 52-year-old man with a traumatic broma located on the mid-dorsum of the tongue just to the right side of the midline.

Fig. 21. An example of the diode laser outlining technique.

Fig. 22. The excisional biopsy is completed with total hemostasis.

Fig. 23. The patient in Figure 20, four weeks after treatment. Note complete healing and no scarring.

Fig. 24. A 12-year-old boy with moderate to severe pericoronitis around the operculum of tooth No. 18.

Fig. 25. The patient in Figure 24, after a CO2 laser operculectomy.

Fig. 26. An intraoral view of the patient in Figure 24, six months postsurgery. Note that tooth No. 18 is fully erupted.

Fig. 27. The defective, ill-tting prosthetics of a 68-year-old woman.

Fig. 28. Diode laser-assisted soft tissue crown lengthening is performed.

had moderate pericoronitis around the operculum of unerupted tooth No. 18 (distal to orthodontically banded tooth No. 19) (Fig. 24). The redundant soft tissue ap was ablated with a CO2 laser, surgically exposing tooth No. 18 and faciliating its proper eruption (Fig. 25). In

addition, the lasers unique bacteriocidal ability reduced the resident pathogens within the infected pericoronal zone (Fig. 26). Lasers can be used when performing anterior gingival periodontal correction in conjunction with prosthetics in the esthetic zone.
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Many procedures can be done without laying a full-thickness ap, provided that an adequate zone of keratinized tissue exists and the biologic width of attachment is not violated. In one case (Fig. 2729), a 68-year-old woman had defective, ill-tting prosthetics that
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Fig. 29. A retracted postoperative view of the patient in Figure 27.

Fig. 30. A Class V abfractive defect with recurrent caries.

Fig. 31. Er:YAG laser ablation is used to remove decay and initially etch the tooth defect area.

Fig. 32. The nal composite restoration was cured into place.

she wished to replace. The anterior crowns on teeth No. 710 were removed, revealing recurrent caries, periodontal disease, and inadequate preparation height to support the replacement ceramic crowns. The remaining roots were scaled thoroughly to remove residual calculus. All remaining recurrent decay was eradicated and the supporting core buildups were redone. A diode laser was used to perform a crown lengthening procedure to increase the clinical crown height of the nal crown preparations and to predictably and precisely recontour the existing bulbous gingival tissue architecture. The result was excellent gingival healing that allowed for a dramatic improvement in the esthetic appearance of the nal prosthesis.
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Hard tissue lasers

At present, erbium lasers are the only hard tissue laser wavelengths available commercially. The main chromophore for erbium lasers is water, although they also are wellabsorbed in carbonated hydroxyapatite, a component of natural tooth structure and bone. These inherent absorption qualities allow erbium lasers to ablate tooth and bone. Erbium lasers are unique in that they are the only lasers that can cut both hard and soft tissues.2 The erbium lasers ability to remove composite restorations is due to their photonic absorption in the water that exists within all composite restorations. Hard tissue ablation results from microevaporative expansive events that occur within
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the target due to an extremely rapid buildup of heat and spontaneous evaporation of the available water content. This process also is referred to as a thermomechanical eect due to the pressure buildup involved.1 This type of laser/tissue interaction results in a characteristic popping sound. In the authors experience, most patients prefer this popping sound to the whirring of the dental drill. In certain clinical cases, an erbium laser can be used to remove a defective composite restoration, eradicate recurrent decay found underneath, and perform any soft/ hard tissue crown lengthening that may be necessary. Figures 3032 illustrate how an erbium laser was used to remove the decay from a

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Fig. 33. A patient with a defective composite on tooth No. 7.

Fig. 34. The patient in Figure 33, after the composite was removed with an Er:YAG laser.

Fig. 35. A lingual view of the patient after receiving a complete composite restoration.

Fig. 36. A radiograph of an 18-year-old woman with a defective composite restoration on tooth No. 30.

Fig. 37. An occlusal view of the defective restoration on tooth No. 30.

Fig. 38. The lasers sapphire tip is angled, allowing it to tunnel under the distal marginal ridge.

Fig. 39. A postoperative radiograph of the patient in Figure 36.

Class V abfractive lesion prior to placing the composite bonding restoration. In Figures 33 and 34, an Er:YAG laser was used conservatively to remove an existing composite from the distal aspect of

tooth No. 7. The tooth was restored (using composite bonding) to its proper contour (Fig. 35). An Er:YAG laser allows for conservation of sound tooth structure, even in cases where an existing composite restoration needs to be removed and extended interproximally. An 18-year-old woman had a defective composite restoration on tooth No. 30 (Fig. 36) and recurrent distal decay that was evident on the preoperative radiograph (Fig. 37). The Er:YAG laser was used to remove the defective composite restoration and ablate the distal carious lesion while a tunneling technique (in which the lasers sapphire tip was angled directly toward the distal carious lesion) was used to preserve the tooths distal marginal ridge (Fig. 38). A sectional matrix band was placed to protect the integrity
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of the adjacent tooths mesial surface and to help restore the tooths natural contour, both during condensation and while curing the nal composite with an LED device. A postoperative radiograph conrmed the proper condensation of the composite ll, as there was no evidence of voids and the distal marginal ridge of this tooth was preserved (Fig. 39). As a provisional service for patients in certain clinical scenarios, it is possible to use the erbium laser to remove recurrent decay around accessible defective margins and repair these areas with composite cured with an LED, rather than removing an extensive restoration completely. The LED curing light used in this case emits a blue light that is absorbed in camphorquinone, the photoactivator in most
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Fig. 40. A composite inlay with defective margins.

Fig. 41. The patient in Figure 40, after an Er:YAG laser was used to remove decay around the defective margins.

Fig. 42. The patient in Figure 40, after completion of the composite bonded restoration.

Fig. 43. A palatal abscess on a maxillary central incisor, with pocketing to 8 mm.

Fig. 44. The Er:YAG laser is used to make the initial incision to lay the full-thickness ap.

Fig. 45. The patient in Figure 43, after the Er:YAG laser was used to perform the osseous recontouring with a copious water spray.

Fig. 46. The patient in Figure 43, after the inner lining of the ap was debrided and the continuous sling suture technique was used for closure.

Fig. 47. A two-week postoperative view of the patient in Figure 43.

composite materials. Figures 4042 illustrate a case in which the Er:YAG laser was used to remove recurrent caries prior to repairing a composite. When performing a bony procedure (such as an osteoplasty or ostectomy), it is imperative to use less power (1,000 sapphire tip, 500550 mJ, 12 Hz) than would
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be used when cutting enamel; in addition, a copious amount of water spray must be used to avoid overexposing the bone to erbium irradiation and the resultant undesirable sequelae of bony necrosis, sloughing, and delayed healing.2 The Er:YAG laser can be eective for clinical cases that involve fullwww.agd.org

thickness aps and osseous recontouring. Figures 4347 illustrate a case in which the full-thickness ap was initiated by using the Er:YAG laser to make the initial sulcular incision and thus gain access to the underlying pathology. The internal aspect of the soft tissue ap was debrided thoroughly and the bony defect was ablated using the Er:YAG laser (with a 1,000 sapphire tip at 550 mJ, 12 Hz) and water spray. The bactericidal eects of the erbium photonic energy can be eective for this type of minimally invasive technique.13 After proper healing, the pocketing was reduced to 2 mm and the nal tissue contour showed signicant improvement.

Diagnostic/curing lasers
These types of devices can be used for caries and calculus detection.

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Argon lasers (488 nm) can be used for curing composites, while optical coherence tomography (OCT) can be used for imaging soft and hard tissue without using any ionizing type of radiation. Argon photonic wave energy is highly absorbed in camphorquinone, the photo-activator contained in light-activated composite materials.2 Argon curing lasers, while clinically eective, have fallen out of use with the advent of LED curing lights. An important distinction to be made is that an LED curing light is not a laser, as its light energy is inherently polychromatic.
Caries and calculus detection

Fig. 48. The normal intraoral uorescence of the VELscope. (From: http://www.velscope. com/velscope/images.php. Accessed August 2008. Reprinted with permission.)

Fig. 49. The loss of uorescence indicates possible pathology. (From: http://www. velscope.com/velscope/images.php. Accessed August 2008. Reprinted with permission.)

The DIAGNOdent (KaVo Dental Corporation, Lake Zurich, IL; 800.323.8029) is used for caries and calculus detection by emitting a non-ionizing laser beam at a wavelength of 655 nm (at a 90 degree angle) toward a specic darkened groove on the occlusal surface of a patients tooth where bacterial decay is suspected, or along the long axis of a root surface to detect the presence of bacteria-laden calculus.14 This diagnostic technology, in which the photons of this laser wavelength are absorbed into any existing bacteria in these areas of the patients tooth, is called laser-induced uorescence.15 The instruments digital display indicates the number of bacteria in this area of the tooth and may correspond to the extent of decay or existence of calculus.14 It is important to remember that a diagnosis of decay or periodontal disease should not depend solely on the instruments digital readout; the patients history, the clinical examination, the dentists experience, and radiograph evaluation all are factors necessary for a proper diagnosis.

While laser-induced uorescence enables a clinician to diagnose the presence of bacteria, it is the absence of uorescence that provides the diagnostic basis for the VELscope device (LED Dental Inc., White Rock, British Columbia, Canada; 888.541.4614). It should be noted that the VELscope is an LED device that produces a narrow range of wavelengths and technically is not a laser. The mortality rate for oral cancer has not improved signicantly within the last 50 years. The VELscope appears to be an important advance in the war against oral cancer. The VELscope makes it possible to scan the soft tissues of the mouth, allowing a trained eye to see an otherwise undetectable mass beneath the patients soft tissue epithelial surface. The device uses changes in the pattern of blue lightinduced uorescence that result from disease processes occurring in the oral mucosa, including underlying oral cancer.14 The inside of the oral cavity has an inherently normal degree of healthy uorescence when scanned with the VELscope (Fig. 48). When performing an oral
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examination through the VELscope, areas that have an absence of uorescence (and thus appear darkened) may indicate possible underlying pathology (Fig. 49).16 If there are any suspicious ndings, the dentist can oer the patient an expedient referral to an oral surgeon for a more extensive evaluation. In some cases, a patients life can be saved by detecting a previously undiagnosed neoplasm before it becomes more invasive.
Optical impressions

Computer-aided design/computeraided manufacture (CAD/CAM) technology uses computerized laser systems to assist with the fabrication of custom restorations, such as inlays, onlays, and crown and bridge prosthetics. CAD/CAM technology eliminates the need for conventional intraoral impression materials; instead, laser scanners take an optical impression of a prepared tooth and the opposing dentition and take a bite registration to produce an interactive three-dimensional image. The iTero system (Cadent, Carlstadt, NJ; 201.842.0800) uses
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Laser Therapy Clinical applications of dental lasers

is that it limits the user to ceramic restorations.

Current advances/research
Optical coherence tomography

Fig. 50. A photomicrograph of a cavity in enamel achieved with a Ti:Sapphire laser. (From: Niemz M. Laser tissue interactions, ed. 2. Berlin, Germany: Springer;2002:149. Reprinted with permission.)

this three-dimensional laser-based imaging technology and enables the dentist to take an optical impression and create a computer le with this data. The iTero unit transmits this le to the Cadent company, where a virtual model is created based on the transmitted data and a precise working master model is made. The physical master model is sent to the laboratory of the dentists choice, where a nal restoration is fabricated. When making the desired nal cast restoration, the laboratory uses whichever material is appropriate for the specic prosthetic application, be it gold, porcelain-fused-to-gold (PFG), or all-ceramic. This system eliminates the need to apply powders to the patients tooth preparation prior to the scan, as required by the CEREC system (Sirona, Charlotte, NC; 800.659.5977). The main advantage of the CEREC system is that the restoration is made in a milling machine within the dentists oce while the patient waits, eliminating the need for a temporary restoration. The chief disadvantage to this in-house milling technology system
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Optical coherence tomography (OCT) is a new type of dental diagnostic imaging of both hard and soft tissues that uses an intense, safe laser light beam that is backscattered from the tissue to capture twodimensional and three-dimensional images. It is noninvasive, with no x-rays or any other type of ionizing radiation required. OCT represents a major advancement in dental imaging due to its ability to provide detailed characterization of the dental microstructures, enabling dentists to make earlier and more accurate diagnosis of oral diseases (including decay and periodontal disease). OCT, with a resolution of up to 10 times that of radiography, is the rst modality to image both hard (teeth and bone) and soft (gingival tissue and mucosa) tissues.17 At present, OCT is not available commercially for dentistry.
Titanium:Sapphire laser

long-awaited alternative to the mechanical dental drill or current erbium lasers that leave microcracks and may cause collateral thermal and/or pulpal damage within a tooth. One drawback to the Ti:Sapphire laser is the acoustic damage (mechanical vibration) in underlying tissues; this damage manifests as fractures and cracks within the healthy parts of the tooth.1 At present, Ti:Sapphire lasers are not available commercially.
Photodynamic therapy

Titanium(Ti):Sapphire lasers are femtosecond lasers (10-15 second pulsed) that are ultrafast and extremely accurate; they perform hard tissue ablation without any thermal damage of natural tooth structure. Figure 50 is a scanning electron microscopy (SEM) image of a Ti:Sapphire laser cut in healthy enamel at a pulse duration of 770 femtoseconds and a pulse energy of 100 mJ. The cut achieved by the Ti:Sapphire laser is precise, clean, and superior in quality when compared to conventional diamond burs in high-speed dental handpieces, while generating far less heat.1 The fast and clean hard tissue ablative properties of the Ti:Sapphire laser may provide a
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Research is ongoing for the treatment of oral cancer using photodynamic therapy (PDT).18 The advantage of PDT for early carcinomas of the oral cavity is the ability to preserve normal tissues while eectively treating cancers up to 1 cm in depth. Clinical studies have demonstrated that PDT is an eective method for the treatment of dysplastic, microinvasive, and early forms of cancer. Mang et al used PDT successfully to treat maxillary gingival squamous cell carcinoma, avoiding the use of surgery or radiation therapy at this point in the management of the disease.19 This treatment regimen involves applying Photofrin dye (Axcan Pharma, Birmingham, AL; 800.472.2634) to a conrmed oral malignant lesion. The dye is attracted to the diseased area and is absorbed rapidly and selectively within the malignant cells. The tissue is exposed to a 630 nm laser with dye applications and subsequent laser exposures repeated at specic intervals. As a result, these early tumors are resolved with a minimum of side eects compared to conventional radical surgical resection (maxillectomy or mandibulectomy).18 While direct eects destroy the majority of tumor cells, there is accumulating evidence

General Dentistry

that PDT activates the host immune response and promotes anti-tumor immunity through the activation of macrophages and T lymphocytes.20,21 Photodisinfection lasers utilize low-intensity lasers and wavelengthspecic, light-activated photosensitive compounds to specically target and destroy microbial pathogens and reduce the symptoms of disease. These photosensitive compounds are applied topically to the intended target; at that point, the treatment site is disinfected with lasers at the appropriate wavelength and power settings.22

Directors for the Academy of Laser Dentistry. He is a clinical instructor as a member of the Deans Faculty at the University of Maryland Dental School in Baltimore.
1. Niemz M. Laser tissue interactions, ed. 2. Berlin, Germany: Springer;2002. 2. Miserendino LJ, Pick RM. Lasers in dentistry. Chicago: Quintessence Publishing Co.;1995. 3. Waynant RW, ed. Lasers in medicine. Boca Raton, Florida: CRC Press;2002. 4. Coluzzi D. Soft tissue surgery with lasers Learn the fundamentals. Available at: http:// www.contemporaryestheticsonline.com/issues/ articles/2007-03_01.asp. Accessed August 2008. 5. Coluzzi D. Types of lasers and what your practice needs: Laser dentistry made easy and profitable. Available at: http://www. dentaleconomics.com/articles/article_display. html?id=289751. Accessed September 2008. 6. A brief overview of dental lasers. Available at: http://www.laserdentistry.org/join/professionals. cfm. Accessed September 2008. 7. Stubinger S, Henke J, Donath K, Deppe H. Bone regeneration after peri-implant care with the CO2 laser: A uorescence microscopy study. Int J Oral Maxillofac Implants 2005;20(2):203-210. 8. Eggers P, Thapliyal HV, inventors; ArthroCare Corporation, assignee. Methods for electrosurgical tissue treatment in conductive uid. U.S. patent 6,224,592. July 27, 1998. 9. Pecaro BC, Garehime WJ. The CO2 laser in oral and maxillofacial surgery. J Oral Maxillofac Surg 1983;41(11):725-728. 10. Walsh LJ. The role of lasers in implant dentistry. Austral Dent Pract 2007;18(2):138-140. 11. Park CY, Kim SG, Kim MD, Eom TG, Yoon JH, Ahn SG. Surface properties of endosseous dental implants after Nd:YAG and CO2 laser treatment at various energies. J Oral Maxillofac Surg 2005; 63(10):1522-1527. 12. da Costa Ribeiro A, Nogueira GE, Antoniazzi JH, Moritz A, Zezell DM. Effects of diode laser (810 nm) irradiation on root canal walls: Thermographic and morphological studies. J Endod 2007;33(3):252-255. 13. Bornstein ES, Lomke MA. The safety and effectiveness of dental Er:YAG lasers. A literature

References

Summary
Lasers oer many useful clinical applications for general dentists in the diagnosis and treatment of patients, as long as the clinician receives the proper training to use this technology safely and eectively.

Acknowledgements
The author would like to thank Donald Coluzzi, DDS, for his editorial assistance with this article.

Disclaimer
The author has no nancial relationship with any of the manufacturers listed in this article.

review with specic reference to bone. Dent Today 2003;22(10):129-133. 14. Tobin AM. Oral cancer in a blue spotlight as more dentists buy screening devices. The Canadian Press;October 22, 2007. 15. Attrill DC, Ashley PF. Occlusal caries detection in primary teeth: A comparison of DIAGNOdent with conventional methods. Br Dent J 2001;190 (8):440-443. 16. Lane PM, Gilhuly T, Whitehead P, Zeng H, Poh CF, Ng S, Williams PM, Zhang L, Rosin MP, MacAulay CE. Simple device for the direct visualization of oral-cavity tissue uorescence. J Biomed Opt 2006;11(2):024006. 17. Otis LL, Everett MJ, Sathyam US, Colston BW Jr. Optical coherence tomography: A new imaging technology for dentistry. J Am Dent Assoc 2000; 131(4):511-514. 18. Photodynamic therapy with photofrin for treatment of dysplasia, carcinoma in situ and Stage I of the oral cavity and the larynx: A pilot study. Available at: http://www.roswellpark.org/ Patient_Care/What_Is_a_Clinical_Trial/ ClinicalTrialsOnlineSearch/ClinicalTrialsOnline SearchDisplay?trial=221&search_for=BodyPart &search_string=HeadNeck&search_for2= &Active=&program_search=false. Accessed September 2, 2008. 19. Mang TS, Sullivan M, Cooper M, Loree T, Rigual N. The use of photodynamic therapy using 630 nm laser light and pormer sodium for the treatment of oral squamous cell carcinoma. Photodiag Photodynam Ther 2006;3(4):272275. 20. Walsh LJ. Safety issues relating to the use of hydrogen peroxide in dentistry. Aust Dent J 2000;45(4):257-269. 21. Dougherty TJ. An update on photodynamic therapy applications. J Clin Laser Med Surg 2002; 20(1):3-7. 22. Anderson R, Loebe N, Hammond D, Wilson M. Treatment of periodontal disease by photodisinfection compared to scaling and root planing. J Clin Dent 2007;18(2):34-38. Published with permission by the Academy of General Dentistry. Copyright 2009 by the Academy of General Dentistry. All rights reserved.

Author information
Dr. Lomke is in private practice in Montgomery County, Maryland, and a member of the Board of

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