laser dentistry · 2020-05-15 · Erbium lasers in pediatric dentistry. Tel: +49 341 48474 302 /...

laserinternational magazine of laser dentistry1

2014

i s sn 2193-4665 Vol. 6 • Issue 1/2014

| researchUse of lasers in periodontal bone defects

| case reportEr:YAG laser and composite resin ablation

| industry reportErbium lasers in pediatric dentistry

Tel: +49 341 48474 302 / email: [email protected]

Bio_Emulation_A4_allgemein_2014.pdf 1Bio_Emulation_A4_allgemein_2014.pdf 1 03.03.14 13:5003.03.14 13:50

editorial I

I 03laser1_2014

Dear reader,

First of all, I would like to wish all our friends and DGL members a happy, healthy and suc-cessful 2014! I am sure many of you already have fixed dates and venues on their schedules,which are hopefully both obligatory and relaxing. I assume that you, being an active reader oflaser international magazine of laser dentistry, are not only interested in new technologies and applica-tion concepts, but you also wish to participate in direct discussions with speakers and users atour WFLD (World Federation for Laser Dentistry) Congress on 2–4July in Paris.

Scientists, practitioners and postgraduate students from all parts of the world will meet inParis to exchange their latest findings and opinions as well as controversial problems. It will beyour decision whether you let yourselves be charmed by either the various wavelengths or Paris’irresistible flair.

It is my special pleasure to welcome you all in the name of the WFLD board and the Paris or-ganizational team to this year’s most exclusive laser event.

Looking forward to meeting you in Paris

You’re sincerely,

Prof. Dr Norbert Gutknecht

Welcome toParis 2014

Prof. Dr Norbert Gutknecht

Editor-in-Chief

I content

page 40 page 46

page 18 page 24 page 30

I editorial

03 Welcome to Paris 2014

| Prof. Dr Norbert Gutknecht

I research

06 Use of lasers in periodontal bone defects

| Prof. Dr Aslan Yaşar Gokbuget et al.

10 Mucocele of the lip treated by using 980 nm diode laser

| Dr Merita Bardhoshi et al.

18 Diclofenac, dexamethasone or laser phototherapy?

| Jan Tunér

I case report

14 Pain reduction of recurrent aphthous stomatitis

| Dr Maziar Mir et al.

24 Er:YAG laser and composite resin ablation

| Carlo Fornaini

I industry report

30 Erbium lasers in pediatric dentistry

| Giovanni Olivi et al.

I economy

34 Gain power at your laser clinics!

| Dr Anna Maria Yiannikos

I meetings

37 International events 2014

I science

38 ISMI:A new Society for Implantology

I interview

40 LaserCUSING: Laser melting with metals

44 “Technology has allowed my work to evolve

enormously”

| An interview with Dr Carlo Fornaini, president-elect of the

World Federation for Laser Dentistry

I news

46 News

I about the publisher

50 | imprint

Cover image courtesy of Fotona,

www.fotona.com

04 I laser1_2014

page 38

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Fotona_A4_laser_Int114.pdf 1Fotona_A4_laser_Int114.pdf 1 03.03.14 16:0903.03.14 16:09

I research

Fig. 1_Bone defect.

Fig. 2_First radiographic

examination.

Fig. 3_Probing.

_Introduction

The use of lasers in periodontal treatment hasbeen well documented over the past ten years.Lasers can be used for initial periodontal therapyand surgical procedures. When used in deep peri-odontal pockets with associated bone defects, notonly does laser remove the diseased granulation tis-sue and associated bacteria, but it also promotes os-teoclast and osteoblast activity, often resulting inbone regrowth. This usage becomes more compli-cated because the periodontium consists of bothhard and soft tissues. The many lasers available,such as CO2, Nd:YAG and diode lasers, can be used inperiodontics because of their excellent ablation andhaemostatic characteristics.

Chronic periodontitis is initiated by microbialplaque, which accumulates on the tooth surface atthe gingival margin and induces an inflammatoryreaction. The inflammatory response in patientswith chronic periodontitis results in destruction ofthe periodontal tissues. With a constant bacterialchallenge, the periodontal tissues are continuouslyexposed to specific bacterial components that have

the ability to alter many local cell functions. Thefunction of the inflammatory process is to protectthe host and limit the effect of the biofilm. Some tis-sue destruction occurs as part of this process. Extentand severity of damage vary among individuals andover time, and may involve attachment loss. Thisvariation in disease expression is the result of the in-teraction of host genetics and environmental andmicrobial factors.

A major goal of periodontal therapy is to achievea biocompatible root surface through the removalof bacterial biofilms and smear layer. Ultrasonicscalers and hand instrumentation are the mostcommonly used procedures for root debridement inperiodontal therapy. To achieve more efficient sub-gingival instrumentation at deeper probing depths(PDs), the tips of scalers have evolved to smaller di-ameters and longer working lengths. Clinical stud-ies reported similar results when comparing ultra-sonic scalers and manual instrumentation for rootdebridement, even though manual instrumentationrequires more time and physical effort. Mechanicalroot debridement results in a smear layer contain-ing bacteria, bacterial endotoxins, and contami-

Use of lasers inperiodontal bone defectsA case report with six years follow-up

Authors_Prof. Dr Aslan Yaşar Gokbuget & Necla Aslı Kocak, Turkey

06 I laser1_2014

Fig. 1 Fig. 3Fig. 2

research I

Fig. 4_Surgery.

Fig. 5_Augmentation.

I 07laser1_2014

nated root cementum. Furthermore, it does not re-move plaque and calculus completely from inter-radicular septa or root concavities. Individually orcollectively, these factors are likely to hamper theperiodontal healing process. A significant disadvan-tage of ultrasonic scalers, for the patient and the cli-nician, is the formation of a contaminated aerosol.Dentistry has changed tremendously over the pastdecade to the benefit of both the clinician and thepatient. One technology that has become increas-ingly utilized in clinical dentistry is that of the laser.Laser is an acronym for Light Amplification by Stim-ulated Emission of Radiation. Laser is a device thatutilizes the natural oscillations of atoms or mole-cules between energy levels for generating coherentelectromagnetic radiation usually in the ultraviolet,visible, or infrared regions of the spectrum. It is a de-vice that produces high intensity of a single wave-length and can be focused into a small spot. Initiallyintroduced as an alternative to the traditional halo-gen curing light, the laser now has become the in-strument of choice, in many applications, for bothperiodontal and restorative care. Because of theirmany advantages, lasers are indicated for a wide va-riety of procedures.

Presently, various laser systems have been usedand in recent years, laser radiation has been sug-gested as an alternative instrumentation modalityfor the treatment of chronic periodontitis. In vitro

studies reported effective results for Nd:YAG laserroot debridement. When used at low-energy densi-ties with a water-spray surface coolant, the Nd:YAGlaser provides a homogeneous and smooth root sur-face topography. In addition, laser is effective at re-moving dental calculus and smear layer and exhibitsbactericidal effects without inflicting any signifi-cant thermal damage to the root surface. Severalclinical studies compared traditional instrumenta-tion to the Nd:YAG laser for treatment of periodon-tal disease. However, laser usage for such purposesremains controversial, probably because of insuffi-cient evidence that any specific wavelength of laseris superior to traditional instrumentation. The lack

of evidence supporting laser usage results frompoorly designed studies and the lack of continuity ofdesign between studies, e.g., wide variations in laserparameters, energy densities, experimental designs,and the lack of proper controls in many studies.

_Advantages and disadvantages

Advantages of laser treatment are greaterhaemostasis, bactericidal effect, and minimalwound contraction. Compared with the use of aconventional scalpel, lasers can cut, ablate and re-shape the oral soft tissue more easily, with no orminimal bleeding and little pain as well as no or onlya few sutures. The use of lasers also has disadvan-tages that require precautions to be taken duringclinical application. Laser irradiation can interactwith tissues even in the noncontact mode, whichmeans that laser beams may reach the patients eyesand other tissues surrounding the target in the oralcavity. Clinicians should be careful to prevent inad-vertent irradiation to these tissues, especially to theeyes. Protective eyewear specific for the wavelengthof the laser in use must be worn by the patient, op-erator, and assistant. Laser beams can be reflectedby shiny surfaces of metal dental instruments, caus-ing irradiation to other tissues, which should beavoided by using wet gauze packs over the area sur-rounding the target. However, previous laser sys-tems have strong thermal side effects, leading tomelting, cracking, and carbonization of hard tissues.

_Clinical presentation and case management

A 44-year-old female patient presented at ourprivate clinic PGG for treatment of the periodontalproblems at the right maxillar molar site (Fig. 1).Upon review of her medical history she was other-wise healthy. She had previously been treated forchronic periodontitis with a non-surgical approach.Then radiographic examination was made (Fig. 2). Itrevealed a combined marginal and vertical radiolu-cency. On clinical examination, deep probing depths

Fig. 4 Fig. 5

I research

Fig. 6_Suturing.

Fig. 7_ Six years after radiation.

Fig. 8_Radiograph six years after

radiation.

were isolated (Fig. 3). No clinically detectable mobil-ity of the teeth was present. One day prior to surgery,the patient was given 2,000 mg of amoxicillin andfollowing surgery put on a regimen of amoxicillin(1,000 mg tid) for five days post-op. A crestal inci-sion is scalloped around the teeth necks to eliminatethe internal epithelium and granulation tissue fromthe pocket (Fig. 4). A mucoperiostal flap is rised toexpose the teeth, and bone tissue and granulationtissue are eliminated from the bone defect withNd:YAG laser with 300 µm tip, VSP, 1.5 Hz, 10 Wpower setting was used and Er:YAG laser with powersettings of VSP, 120 mJ, 10 Hz with water and airflushing was used for teeth surface detoxification.Due to defect morphology we used a combinedtechnique with enamel matrix derivative (Emdo-gain). Then, xenogenous bone grafts (Bio-Oss®)were compacted into the defect (Fig. 5). A Bio-Gide®barrier was placed over the defect and was extendedboth buccally and lingually.

The buccal and lingual flaps were released andtension-free primary closure was achieved with 4-0silk sutures (Fig. 6). The patient was instructed tocontinue antibiotics as prescribed and to rinse withthe 0.12 % chlorhexidine gluconate bid for 30 sectwice a day. Finally, a strict maintenance and oral hy-giene protocol were established. The area healeduneventfully after six months. Periapical radi-ographs were taken throughout the healing processto evaluate the mineralization of the graft over time,bone formation within the bony defect was evident.Radiographically it appeared that there was in-creased mineralization of the bone surrounding theteeth.The patient was again examined every year. Six years after treatment (Fig. 7), a new radiograph(Fig. 8) was taken which demonstrated completeresolution of the bony defect surrounding the teeth.

_Discussion

As technology advances into dentistry, whetherit is laser or another exciting venue, the optionsavailable to clinicians will continue to increase. Al-

though the use of lasers in dentistry is relatively new,the future looks very bright. In summary, laser treat-ment is expected to serve as an alternative or ad-junctive to conventional mechanical periodontaltreatment. Currently, among the different types oflasers available, Nd:YAG, Er:YAG and Er,Cr:YSGGlaser possess characteristics suitable for dentaltreatment, due to their dual ability to ablate soft andhard tissues with minimal damage. In addition, thebactericidal effect of laser with elimination oflipopolysaccharide, its ability to remove bacterialplaque and calculus, an irradiation effect limited toan ultra-thin layer of tissue, faster bone and soft tis-sue repair make it a promising tool for periodontaltreatment including scaling and root surface de-bridement. The decision to use a laser should bebased on the proven benefits of haemostasis, a dryfield, reduced surgical time and the general experi-ence of less postoperative swelling.

_Conclusion

Although no definitive conclusion can be drawnfrom a single case report, the guided bone regener-ation combined laser technique described in thiscase report effectively eliminated teeth associatedthree-wall bony defect and deep pocket. Under theconditions of the present case, it may be concludedthat the Nd:YAG and Er:YAG laser combination canbe safely and effectively utilized for degranulationand implant surface debridement in the surgicaltreatment of periodontal infection._

08 I laser1_2014

Fig. 6 Fig. 8Fig. 7

Prof. Dr Aslan Y. Gokbuget

PGG Dental Clinic

Tesvikiye Casddesi Kismet Apt. 133 d.8

34365 Nisantasi

Istanbul, Turkey

Tel.: +90 212 2480317

Fax: +90 212 2475118

_contact laser

PROFESSIONAL EDUCATION PROGRAMMES

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Batch: EN2014 - Fulltime (new) or Module based

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• Create new economic potential for your practice

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Next Start: 15 September 2014 Aachen, Germany

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AALZ_DGL_A4_laser114.pdf 1AALZ_DGL_A4_laser114.pdf 1 06.03.14 15:5406.03.14 15:54

I research

Fig. 1_Clinical diagnosis.

Fig. 2_Laser treatment.

_Introduction

Mucoceles are defined as mucus-filled cavitiesthat can appear in the oral cavity, paranasal sinusesor lacrimal sac. They are characterised by the accu-mulation of liquid or mucoidmaterial, giving rise toa rounded, well circumscribed transparent andbluish-colored lesion of variable size.1,3,5,7 The con-sistency is tipically soft and fluctuant in response topalpation. Mucoceles are painless and tend to re-lapse. Etiologically, most mucoceles are consideredto be secondary to traumatic or obstructive disor-ders of the mainly minor salivary glands—the pref-erential location being the humid mucosa of thelower lip. Mucoceles are usually asymptomatic, al-though in some patients they can cause discomfortby interfering with speech, chewing or swallowing.They can be different in size, small and large. How-

ever, in most cases these lesions rupture sponta-neously or traumatically a few hours after beingformed, with the release of a characteristic viscousmucoidfluid. This may give the mistaken impressionof healing, since the lesion decreases in size or dis-appears. However, once the small perforation al-lowing release of the mucocele contents has healed,the secretions accumulate again and the lesion re-lapses.5,9,15 In case of repeated trauma, the lesionmay become nodular and firmer in response to pal-pation with rupture being more difficult in this sit-uation. Treatment may be performed by conven-tional surgery, cryotherapy and more recently lasersurgery. Carbon dioxide laser and high-intensitydiode laser both have provided satisfactory results.8

The purpose of this study was to evaluate the effec-tiveness of 980 nm diode laser in the treatment ofmucocele of the lower lip and also to compare theresults obtained after mucocele resection withscalpel versus 980 nm diode laser.

_Patients and method

A total of 10 patients (six males and four females)aged 15 to 40 were treated for mucocele of the lip bya 980 nm diode laser. An initial clinical examinationconsisting of the past medical and dental history aswell as thorough extra- and intraoral examinationwere performed on all patients. Complementaryblood test, complete blood count and erythrocytesedimentation rate made it possible to exclude in-fectious diseases. The collected data were evaluatedand a clinical diagnosis for the type of lesion was es-tablished (Figs. 1). All patients were given a writtenand verbal information on the nature of laser treat-ment and signed informed consent forms were ob-tained prior to treatment. Treatments were con-

Mucocele of the lip treated by using 980 nm diode laserAuthors_Dr Merita Bardhoshi, Prof. Dr Norbert Gutknecht, Dr Esat Bardhoshi, Dr Alketa Qafmolla, Dr Edit Xhajanka &

Dr Neada Hysenaj, Albania & Germany

10 I laser1_2014

Fig. 1 Fig. 2

research I

I 11laser1_2014

ducted from January 2007 to January 2011 at theDepartment of Oral Surgery (Dental Clinic of theUniversity of Tirana, Albania). For all treatments, adiode laser was used (Sirona, 980 nm, cw, optical fi-bre 300 micrometer, 4 W). Treatments were con-ducted with infiltration anaesthesia of 2 % lido-caine, 1 cc and excision was performed by surgicaltechnique. The treatment area was cooled by the ap-plication of ice 2 to 5 minutes after treatment. Sur-gical fields were bloodless, no sutures were requiredand time of surgery was 2–4 minutes (Fig. 2). Thespecimens obtained were fixed in 10 % formalin so-lution for posterior histological study to establishthe definitive diagnosis. The resulting surgicalwounds were allowed to heal by second intention(Fig. 3). After treatment, analgesic medication wasprescribed to be used if necessary, but no antibioticswere prescribed. Ten clinical cases of mucoceleswere treated by scalpel. An elliptic incision wasmade to fully enucleate the lesion along with theoverlying mucosa and the affected glands. The op-eration proved more complicated when the lesionruptured, since the loss of references made it moredifficult to ensure complete elimination of the le-sion. The wounds were finally sutured. The follow-up visits were scheduled ten days, one month, sixmonths, one year and three years after surgery. Alllesions were photographically documented at allstages of treatment and healing.

_Results

The study comprised 20 patients (twelve males &eight females ), six cases presented between ten and20 years of age, nine cases between 20 and 30 yearsof age, three cases between 30 and 40 years of age

and two cases between 40 and 50 years of age. Inmost of the cases, there was no evident etiologicalfactor. Mucoceles ranged from 1–3 cm in diameter,no pain was reported by all patients, and only sevenpatients referred discomfort associated with nib-bling of the lesion. Immediately after the excision, allsurgical fields were bloodles (Fig. 4). Histopatholog-ical examination confirmed the initial diagnosis. Allpatients were followed up seven days postopera-tively for pain and swelling .

After four weeks, the wound healing character-istics of all clinical cases were evaluated. Patientstreated with diode laser reported good, comfortablehealing without complications (Fig. 4) or functionaldisturbances, versus ten scar formations and fourrelapses with scalpel. After six months to one year,no recurrence was observed in patients treated withlaser versus three cases treated with scalpel. No lipparesthesias were recorded after the treatment ofboth of the two groups of patients.

_Statistical analysis

We have presented some of the cross tabulationsusing SPSS16 (Statical Package for Social Sciences).Data for patient characteristics are given as meanand standard deviation in order to obtain informa-tion and to observe the difference between thescalpel and laser procedure. For each step we haverecorded pain, functional disturbance, swelling andrecurrence on a standard visual analogue scale from0 to 4. The maximum value for pain is one, showingthat the response is mild pain. We recorded just onecase with such kind of pain in the laser procedure.The mean is 0.625 and the standard deviation is 0.25.

Please contact Claudia Jahn

[email protected]

AD

[PIC

TUR

E: ©

SU

KIY

AKI]

I research

Fig. 3_Healing by second intention.

Fig. 4_ Immediately after the

excision, all surgical fields were

bloodless.

We have also checked for any relationship betweenpain and age. A cross tabulation is presented in thecase processing summary as well as a Pearson cor-relation for both of the two procedures. The Pearsoncorrelation in this case shows that the correlationbetween pain caused in laser procedure and age iscorrelated negatively with the coefficient of -0.02,which is however not sufficient statistically at 5 %and 1 % (p-value is 0.943).1 This correlation betweenthese two variables is not genuinely significant atthe rate of significance as chosen above. While thePearson correlation between pain and age for thescalpel is also negative, suggesting that these twovariables are correlated negatively and still not suf-ficiently statistically significant at the rate of 5 and1 % level of significance.

_Discussion

In our study 52 % of the lesions were found inmales. In all our clinical cases, mucocele growth wasgenerally found to be slow. In the course of theanamnesis, some patients reported accidental trau-matism and suction habits. Lesions vary in diameterbetween 0.2 mm and 2 cm without symptoms. Us-ing the scalpel, some authors1,3,5,8,9 propose the re-moval of both the affected and neighboring glandsin order to prevent relapse. Special care is requiredto avoid damaging other glands or ducts with thesuture needle, as this may become a cause of recur-rence. The total treatment time with laser was 3 to 5 minutes, the same as authors state in the literaturereports.2,7,12 This was lower than the treatment timeby scalpel which required sutures after the full enu-cleation of lesion by an elliptic incision, whereaswounds treated by laser surgery healed by second-ary intention regardless of their depth. However, thesize of the surgical wound is increased compared tothe size of the lesion.

Laser surgery is an option of choice for pediatricand geriartric patients who have difficulties tolerat-ing long surgical procedures. Authors recorded nopostoperative bleeding or healing complicationswith laser surgery.15,17,20 This was reflected in ourstudy’s postoperative period as the patients recov-ered without complications. We recorded no recur-rence, no lip paraesthesias, no relapses after treat-ment of mucocele with 980 nm diode laser. Further-more, we observed complications in the healingprocess of the patients treated with scalpel. Thesecomplications ranged from recurrence, scarringand relapse attributable to damage to the neighbor-ing minor salivary glands cause by scalpel or needleupon suturing. Other advantages of the laser versuscold surgery include bloodlessness and a highly de-contaminated surgical bed which allow for lessswelling and pain during the postoperative period.Moreover, as is reported in literature,14,16,17,18,19,20

these advantages also allow for the appearance of fewer myofibrobasts resulting in comparativelylesser wound contraction.12,13 Our postoperative re-sults of minimal pain and no or minimal swelling co-incides with the observations of other authors.1,3,5,7

No analgesics or antibiotics were needed in any ofthe patients treated with laser, other than all pa-tients treated with cold scalpel.

_Conclusion

Laser surgery is a modality for the treatment ofmucocele with beneficial effects and advantages.Intraoperative advantages were a good coagula-tion, a good visualization of the operative field andthe short operating time, which made it possible tominimise fear and anxiety in the patients during theprocedure. The advantages of laser surgery also in-clude a reduction of relapses and scar formation, of-fering the best aesthetic outcome in comparison tothe scalpel. Laser surgery is therefore an asset notonly for the patient but also for the surgeon._

Editorial note: A list of references is available from the

publisher.

12 I laser1_2014

Fig. 3 Fig. 4

Dr Merita Bardhoshi

University of Medicine

Department of Oral Surgery

Dibra Street 63

Tirana, Albania

Tel.: +335 5672042658

Fax: +335 542253675

[email protected]

_contact laser

PARIS, July 2nd, 3th & 4th, 2014

14th World Congress forLASER DENTISTRY

www.dental-laser-academy.com

WFLD-paris2014.com

WFLD_A4_2014.pdf 1WFLD_A4_2014.pdf 1 21.02.14 12:1121.02.14 12:11

I case report

Fig. 1_Low Level Laser

Aphthous Pen.

Fig. 2_Minor aphthous ulcer.

_Introduction

Recurrent aphthous stomatitis (RAS) is a commoncondition, restricted to the mouth, and typically startsin childhood or adolescence as recurrent small, roundor ovoid ulcers with circumscribed margins, erythe-matous haloes, and yellow or gray floors. RAS hasthree clinical types: minor, major and herpetiform ul-cers. Ulcers with similar clinical features (aphthous-like ulcers) may be associated with systemic condi-tions such as Behçet syndrome, auto-inflammatorysyndromes, gastrointestinal disease or immune de-fects such as HIV/AIDS.The etiology of recurrent aph-thous stomatitis (RAS) is not entirely clear. A geneticbasis exists for some RAS.

This is shown by a positive family history in aboutone third of patients with RAS, an increased fre-quency of HLA types A2, A11, B12, and DR2, and sus-ceptibility to RAS which segregates in families in as-sociation with HLA haplotypes. RAS probably involvescell-mediated mechanisms but the precise im-munopathogenesis remains unclear. Phagocytic andcytotoxic T cells probably aid in destruction of oral ep-ithelium that is directed and sustained by local cy-tokine release. Patients with active RAS have an in-creased proportion of gamma-delta T cells compared

with control subjects and patients with inactive RAS.Gamma-delta T cells may be involved in antibody-de-pendent cell-mediated cytotoxicity (ADCC). Com-pared with control subjects, individuals with RAShave raised serum levels of cytokines such as inter-leukin (IL)–6 and IL-2R, soluble intercellular adhesionmodules (ICAM), vascular cell adhesion modules(VCAM), and E-selectin. However, some of these donot correlate with disease activity.1-4

LLLT has been reported as a useful treatment forseveral conditions, such as reduction of the destruc-tive interleukins and TNF-production, improvementof the immune system function, reduction of pain andthe healing time period.5-12

Lasers (high power and low power) have been usedin some case reports and studies for pain reductionand shortening healing time of RAS.13-32 Most of thesereports focussed on office treatment, but many pa-tients have recurrent lesions and there were noknown home care devices for laser treatment of RAS.Therefore, to assist patients in using lasers at home bythemselves, a class 2M low level laser was inserted ina pen-like device. This laser is called LLLAP (Low LevelLaser Aphthous Pen) and it seems that it was the firsttime that such a device is introduced to dental pro-fessionals. Therefore, the aim of this pilot study wasto evaluate the pain reduction efficiency of this par-ticular instrument.

_Material and method

A prospective randomised trial was conductedwith 30 patients. Inclusion criteria were: having atleast one minor aphthous ulcer smaller than 5 mm,satisfaction and ability to take part in the study, ful-filment of the patient consent form according to theCode of Ethics and having new lesions in the first two

Pain reduction of recurrentaphthous stomatitis Evaluation of class 2M diode laser as a home care device

Authors_Dr Maziar Mir, MSc, Dr Masoud Mojahedi, MSc, Dr Jan Tunér DDS, Dr Hassan Adalatkhah, MSc, Dr Amir Mansour Shirani, MSc & Dr Masoud Shabani, Germany & Iran

14 I laser1_2014

Fig. 1 Fig. 2

case report I

days. Exclusion criteria were: pregnancy, carcinoma,taking steroids or anticoagulant and anti-inflamma-tory agents, eye problems or mental retardation orimpairment and patients with aphthous-like ulcerswith signs and symptoms of systemic diseases like Behçet syndrome, auto-inflammatory syndromes,gastrointestinal disease, or immune defects such asHIV/AIDS and severe anaemia. Ethically, all these patients were treated as well but were not counted asstudy cases.

The samples were allocated into three groups:Group 1 received laser therapy (low-level laser aphthous pen, registration number in Iran: 72619).The device was prepared by insertion of the diode laserin the tooth brush, then it was calibrated and tested(Fig.1). Group 2 received topical triamcinolone ace-tonide 0.1 % in orabase (gelatin, pectin, and carb -oxymethyl cellulose sodium in Plastibase® (Plasti-cized Hydrocarbon Gel), a polyethylene and mineraloil gel base, Adcortyl in orabase, Bristol-Myers SquibbCompany). Group 3 received placebo (red LED light).

Laser parameters were: InGaAlP diode class 2Mlaser, wavelength 660 nm, continuous, 40 mW, irradi-ation diameter 3 mm, spot size 0.19625 cm2, 30 sec-onds, 1.2 J, 6 J/cm2 twice per day for five consecutivedays, near non-contact mode and near at a perpendi-cular angle (Figs. 2-4). Class 2 laser was used becausethis laser was used at home and it is necessary to usea relatively safe laser. For this kind of laser, natural re-action of a person like shutting of the eyelid is suffi-cient for eye protection. But patients were educatedin the application of the laser, not to stare into thebeam or view it directly with optical instruments andto put it in a place which is not reachable by children.The Research Ethical Committee approval wasadopted with number 01391023 for this researchfrom Ardebil University of Medical Sciences.

The VAS scale was used for the evaluation of pain,in the range of 0 to 10 so that 0 is no pain and 10 is verysevere pain. Evaluations were performed beforetreatment, immediately after irradiation and everyday during the first five days. The data were analysedby one way ANOVA and PostHoc tests.

_Results

Thirty patients took part in the study, 16 were menand 14 were women. The location of minor RAS was theupper lip in 20 patients and the lower lip in 10 patients.

In ANOVA data analysing, there was no significantVAS difference between the groups before treatment(p=0.500). After treatment, there was significant dif-ference between the LLLT/Adcortyl groups and theplacebo group immediately after the first session and

during the first five days (p = 0.001).The data forMean, Standard deviation and PostHoc test resultsare presented in table 1. There was no significant dif-ference between laser and Adcortyl groups but bothwere significantly better than the red light pen. Chart1 shows the pain reduction during five consecutivedays among the groups.

_Discussion

Many different treatments are considered for RAS.Relief of pain and reduction of ulcer duration are themain goals of therapy. Topical corticosteroids remainthe mainstays of treatment.4 Thus, in this study, onegroup received topical Adcortyl™ in Orabase™ for bet-ter comparison.

Different kinds of laser were successfully used instudies for treatment of RAS. The GaAlAs diode laser,15

He-Ne laser,16,17 argon laser,20 InGaAlP laser,14,21

Nd:YAG laser,22,29 diode 830 nm,29 GaAs (904 nm),24

CO2,26,30,31 diode lase32 were used in case reports andstudies. For cases with aphthous-like lesion in Behçetsyndrome, CO2 laser23 and GaAs (904 nm)25 have beenapplied successfully. For cases with aphthous-like ul-cer in AIDS (Acquired Immune Deficiency Syndrome)cases, diode 660 nm laser has been used with good re-sult.27

Fig. 3_Laser irradiation with

aphthous laser pen.

Fig. 4_Four days after treatment.

Fig. 5_ Pain reduction during five

consecutive days among intervention

groups.

I 15laser1_2014

Fig. 3 Fig. 4

VAS

8

7

6

5

4

3

2

1

0VAS before VAS immediate VAS first day VAS second day VAS third day VAS fourth day VAS fifth day

laser

placebo

ointment

Fig. 5

I case report

Table 1_Result of PostHoc test for

multiple comparisons between

groups.

As the low level laser can modulate inflammatorymediators such as TNF-alpha, IL-6 and others, reduc-tion of pain can be achived. The healing of the aph -thous ulcer can be attributed to increase of the cellu-lar activity, especially fibroblasts, keratinocytes andimmune cells. Therefore, wound healing and boostingof the natural function can be achieved.

Most studies focus on in-office treatment. The lowlevel laser therapy often requires additional treat-ment sessions and there is no known home care de-vice for laser treatment of RAS. Patients with RAShave recurrent ulcers and in-office treatment foreach recurrent lesion requires several visits to thedental office and consequent economic problems.Therefore, a class 2M low level laser was inserted in apen-like device in order to assist patients to use lasersat home.

In this study, laser pen was statistically better thanlaser placebo in pain reduction. This was simillar toanother study.21 The laser pen statistically had an ef-ficiency similar to topical corticosteroids (as a routinetreatment) in pain reduction. This finding was consis-tent with other studies.24,29 In the present study, onlypain reduction was evaluated but in the Salmanstudy24: the laser treatment group had a shorter heal-ing time in comparison to Adcortyl™. Laser therapy

reduced healing time in recurrent aphthous stomati-tis in comparison to the control group (topical lido-caine) in some studies.33

As corticosteroids have several side effects, lasertreatment may have some advantages for the treat-ment of recurrent aphthous stomatitis.

_Conclusion

In this clinical pilot study, the laser pen seems to beuseful for the treatment of RAS as a home care device.

Editorial note: A list of references is available from the pub-lisher.

16 I laser1_2014

Variable N Mean Std.D Groups Sig CI95%

VAS before treatment LaserPlaceboOintment

101010

7.46.86.8

1.071.391.39

Laser-OintmentLaser-PlaceboOintment-Placebo

0.560.56

1

(-0.8)-(2.04)(-0.8)-(2.04)(-1.44)-(1.44)

VAS imm. after treatment LaserPlaceboOintment

101010

1.86.42.4

0.425.80.51


0.300

(-1.6)-(0.41)(-5.61)-(-3.95)(-5.01)-(-2.9)

VAS 1st day after treatment LaserPlaceboOintment

101010

1.65.82.2

0.511.30.78


0.300

(-1.6)-(0.47)(-5.2)-(-3.1)(-4.6)-(-2.5)

VAS 2nd day after treatment LaserPlaceboOintment

101010

15.21.8

0.61.30.78


0.1900

(-1.91)-(0.31)(-5.3)-(-3.08)(2.28)-(4.51)

VAS 3rd day after treatment LaserPlaceboOintment

101010

14.41.4

0.61.71.07


0.7400

(-1.7)-(0.96)(-4.7)-(-2.03)(-4.3)-(-1.63)

VAS 4th day after treatment LaserPlaceboOintment

101010

0.83.60.6

0.421.710.51


0.900

(-0.97)-(1.37)(-3.9)-(-1.6)(1.82)-(4.17)

VAS 5th day after treatment LaserPlaceboOintment

101010

0.62.80.6

0.511.390.51


100

(-1.01)-(1.01)(-3.2)-(-1.1)(-3.2)-(-1.1)

Dr Masoud Shabani

Oral Health Department, Official Complex of Ardebil University of Medical Sciences, Daneshgah Street 5618985991 Ardebil, Iran

Tel.: +98 451 5521417 Fax: +98 451 5522196

[email protected]

_contact laser

Buldental_A4_2014.pdf 1Buldental_A4_2014.pdf 1 10.03.14 17:2810.03.14 17:28

_Introduction

In the May 2013 edition of Photomedicine andLaser Surgery, the editorial written by Prof. Tina Karuis titled “Is it time to consider photobiomodulation asa drug equivalent?” Well, is it? Let us have a look andsee what the literature has to say about two very pop-ular drugs:

NSAIDs (non-steroidal anti-inflammatory drugs)are the best sold pharmaceuticals ever. The short-term effects on pain and inflammation are obviousand valuable. The long-term effects, however, havebeen questioned and this is especially valid consider-ing the many side effects of NSAIDs. Millions of pa-tients are on long-term medication with NSAIDs, andeven lifelong. Indeed, many persons die from theirmedication. So an alternative option is required. I be-lieve it is already available: laser phototherapy! First,let us have a look at the strength of the scientific evi-dence for NSAIDs as such, and long term use of thesein particular:

The meta-analysis by Bjordal1 on the effect ofNSAIDs on knee osteoarthritis pain appears to be-come important for the recognition and future devel-opment of LPT. Let us read the abstract: The researchgroup summarises that non-steroidal anti-inflam-

matory drugs (NSAIDs), including cyclo-oxygenase-2inhibitors (coxibs), reduce short-term pain associatedwith knee osteoarthritis only slightly better thanplacebo, and long-term use of these agents should beavoided. Up for analysis were 23 placebo-controlledtrials involving 10,845 patients, 7,767 of whom re-ceived NSAID therapy and 3,078 placebo therapy. Allin all 21 of the NSAID-studies were funded by thepharmaceutical industry, and the results of 13 ofthese studies were inflated by patient selection bias asprevious NSAID-users were excluded if they had notpreviously responded favourably to NSAID. Such anexclusion criterion for non-responders has neverbeen seen in any controlled trial of LPT or other non-pharmacological therapies of osteoarthritis. In the re-maining ten unbiased NSAID-trials, the differencefrom placebo was only 5.9 mm on a 100 mm painscale.

This is far less than established data on differencesthat are considered minimally perceptible (9 mm) orclinically relevant (12 mm) for knee osteoarthritis pa-tients. In addition, none of the trials found any effectsbeyond 13 weeks. This bleak support for long term useof NSAIDs is an excellent support for non-pharma-ceutical methods, such as LPT. Diclofenac is one of thebest-selling NSAIDs. Several investigators have com-pared the effect of LPT and diclofenac.

I research

18 I laser1_2014

Diclofenac, dexamethasoneor laser phototherapy?Part I

Author_Jan Tunér, Sweden

[PICTURE: ©ROBERT KNESCHKE]

The aim of a study by Marcos2 was to evaluate theshort-term effects of LPT or sodium diclofenactreatments on biochemical markers and biome-chanical properties of inflamed Achilles tendons.Wistar rats Achilles tendons (n = 6/group) were in-jected with saline (control) or collagenase at peri-tendinous area of Achilles tendons. After one houranimals were treated with two different doses of LPT(810 nm, 1 and 3 J) at the sites of the injections, orwith intramuscular sodium diclofenac. Regardingbiochemical analyses, LPT significantly decreasedCOX-2, TNF-alpha, MMP-3, MMP-9, and MMP-13gene expression, as well as PGE2 production whencompared to collagenase group. Interestingly, di-clofenac treatment only decreased PGE2 levels. Bio-mechanical properties were preserved in the laser-treated groups when compared to collagenase anddiclofenac groups.

Ramos3 investigated the effects of LPT (810 nm) inrat-induced skeletal muscle strain. Male rats wereanaesthetised with halothane prior to the inductionof muscle strain. Previous studies have determinedthat a force equal to 130 % of the body weight corre-sponds to approximately 80 % of the ultimate ruptureforce of the muscle tendon unit. In all animals, theright leg received a controlled strain injury while theleft leg served as control. A small weight correspon-ding to 150 % of the total body weight was attachedto the right leg in an appropriate apparatus and left toinduce muscle strain twice for 20 minutes with three-minute intervals. Walking index, C-reactive protein,creatine kinase, vascular extravasation and histolog-ical analysis of the tibial muscle were performed aftersix, twelve and 24 hours of lesion induction. LPT in anenergy-dependent manner markedly or even com-pletely reduced the Walking Index, leading to a betterquality of movement. C-reactive protein production

was completely inhibited by laser treatment, evenmore than observed with Sodium diclofenac inhibi-tion (positive control). Creative Kinase activity wasalso significantly reduced by laser irradiations. In con-clusion, LPT operating in 810 nm markedly reduced in-flammation and muscle damage after experimentalmuscle strain, leading to a highly significant en-hancement of walking activity.

The aim of the study by de Almeida4 was to analysethe effects of sodium diclofenac (topical application),cryotherapy, and LPT on pro-inflammatory cytokinelevels after a controlled model of muscle injury. For such, we performed a single trauma in the tibialisanterior muscle of rats. After one hour, animals were treated with sodium diclofenac (11.6 mg/g of solution), cryotherapy (20 min), or LPT (904 nm; superpulsed; 700 Hz; 60 mW mean output power;

research I

I 19laser1_2014

[PICTURE: ©INESBAZDAR]

I research

1.67 W/cm2; 1, 3, 6 or 9 J; 17, 50, 100 or 150 s). As-sessment of interleukin-1 and interleukin-6 (IL-1 andIL-6) and tumour necrosis factor-alpha levels wasperformed at six hours after trauma employing en-zyme-linked immunosorbent assay method. LPT with1 J dose significantly decreased IL-1, IL-6, and TNF-al-pha levels compared to non-treated injured group aswell as diclofenac and cryotherapy groups. On theother hand, treatment with diclofenac and cryother-apy does not decrease pro-inflammatory cytokinelevels compared to the non-treated injured group.Therefore, the authors conclude that 904 nm LPT with1 J dose has better effects than topical application ofdiclofenac or cryotherapy in acute inflammatoryphase after muscle trauma.

The purpose of a study by Albertini5 was to inves-tigate the effect of LPT on the acute inflammatoryprocess. Male rats were used. Paw oedema was in-duced by a sub-plantar injection of carrageenan, thepaw volume was measured before and one, two, threeand four hours after the injection, using a hy-droplethysmometer. To investigate the action mech-anism of the GaAlAs laser on inflammatory oedema,parallel studies were performed using adrenalec-tomised rats or rats treated with sodium diclofenac.Different laser irradiation protocols were employedfor specific energy densities (EDs), exposure times andrepetition rates. The rats were irradiated with laser for80 s each hour. The EDs that produced an anti-in-flammatory effect were 1 and 2.5 J/cm2, reducing theoedema by 27 % and 45.4 %, respectively. The ED of2.5 J/cm2 produced anti-inflammatory effects similarto those produced by the cyclooxigenase inhibitorsodium diclofenac at a dose of 1 mg/kg. In adrenalec-tomised animals, the laser irradiation failed to inhibitthe oedema. These results suggest that LPT possiblyexerts its anti-inflammatory effects by stimulatingthe release of adrenal corticosteroid hormones.

The aim of a work by Meneguzzo6 was to investi-gate the effects of infrared 810 nm on the acute in-flammatory process by the irradiation of lymphnodes, using the classical model of carrageenan-in-duced rat paw oedema. Thirty mice were randomly di-vided into five groups. The inflammatory inductionwas performed in all groups by a sub-plantar injectionof carrageenan (1 mg/paw). The paw volume wasmeasured before and 1, 2, 3, 4 and 6 hours after theinjection using a plethysmometer. Myeloperoxidase(MPO) activity was analysed as a specific marker ofneutrophil accumulation at the inflammatory site.The control group did not receive any treatment (GC);GD group received sodium diclofenac (1mg/kg) 30minutes before the carrageenan injection; GP groupreceived laser irradiation directly on the paw (1 Joule,100 mW, 10 sec) one and two hours after the car-rageenan injection; GLY group received laser irradia-

tion (1 Joule, 100 mW, 10 sec) on the inguinal lymphnodes; GP+LY group received laser irradiation on bothpaw and lymph nodes one and two hours after thecarrageenan injection. MPO activity was similar in thesodium diclofenac as well as in the GP and GLY groups,but significantly lower than the GC and GP + LYgroups. Paw oedema was significantly inhibited in GPand GD groups when compared to the other groups.Interestingly, the GP+LY groups presented the biggestoedema, even bigger than in the control group. LPTshowed an anti-inflammatory effect when the irradi-ation was performed on the site of lesion or at the cor-related lymph nodes, but showed a pro-inflammatoryeffect when both paw and lymph nodes were irradi-ated during the acute inflammatory process.

The aim of a study by Barretto23 was to investigatethe analgesic and anti-inflammatory activity of LPTon the nociceptive behavioural as well as histomor-phological aspects induced by injection of formalinand carrageenan into the rat temporomandibularjoint. The 2.5 % formalin injection (FRG group) in-duced behavioural responses characterized by rub-bing the orofacial region and flinching the headquickly, which were quantified for 45 min. The pre-treatment with systemic administration of diclofenacsodium-DFN group (10 mg/kg i.p.) or irradiation withinfrared LPT (LST group, 780 nm, 70 mW, 30 s, 2.1 J,52.5 J/cm2), significantly reduced the formalin- induced nociceptive responses. The 1 % carrageenaninjection (CRG group) induced inflammatory re-sponses over the time-course of the study (24 h, threeand seven days) characterised by the presence of intense inflammatory infiltrate rich in neutrophils,scanty areas of liquefactive necrosis and intense in-terstitial oedema, extensive haemorrhagic areas, andenlargement of the joint space on the region. The DFNand LST groups showed an intensity of inflammatoryresponse that was significantly lower than in CRGgroup over the time-course of the study, especially inthe LST group, which showed exuberant granulationtissue with intense vascularization, and deposition ofnewly formed collagen fibres (three and seven days).

The aim of a study by de Almeida7 was to analysethe effects of sodium diclofenac (topical application)and LPT on morphological aspects and gene expres-sion of biochemical inflammatory markers. The re-searchers performed a single trauma in the tibialis an-terior muscle of rats. After one hour, animals weretreated with sodium diclofenac (11.6 mg/g of solu-tion) or LPT (810 nm; continuous mode; 100 mW; 1, 3or 9 J; 10, 30 or 90 s). Histological analysis and quan-tification of gene expression (real-time polymerasechain reaction-RT-PCR) of cyclooxygenase 1 and 2(COX-1 and COX-2) and tumour necrosis factor-alpha(TNF-alpha) were performed at six, twelve and 24 h af-ter trauma. LPT with all doses improved morphologi-

20 I laser1_2014

A billion smiles welcome the world of dentistry

FDI 2014 · New Delhi · IndiaGreater Noida (UP)

Annual World Dental Congress11-14 September 2014

www.fdi2014.org.inwww.fdiworldental.org

Deadline forearly bird registration

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FDI_EarlyBird_A4.pdf 1FDI_EarlyBird_A4.pdf 1 06.01.14 10:5106.01.14 10:51

I research

22 I laser1_2014

cal aspects of muscle tissue, showing better resultsthan injury and diclofenac groups. All LPT doses alsodecreased COX-2 compared to injury group and to di-clofenac group at 24 h after trauma. In addition, LPTdecreased TNF-alpha compared both to injury and di-clofenac groups. LPT mainly with dose of 9 J is betterthan topical application of diclofenac in acute in-flammation after muscle trauma.

Yet another study by Marcos8 investigated if asafer treatment such as LPT could reduce tendinitisinflammation, and whether a possible pathway couldbe through inhibition of either of the two-cyclooxy-genase (COX) isoforms in inflammation. Wistar rats(six animals per group) were injected with saline (con-trol) or collagenase in their Achilles tendons. Thenthey were treated with three different doses of IR LPT(810 nm; 100 mW; 10 s, 30 s and 60 s; 3.57 W/cm2; 1 J,3 J, 6 J) at the sites of the injections, or intramusculardiclofenac, a nonselective COX inhibitor/NSAID. Itwas found that LPT dose of 3 J significantly reducedinflammation through less COX-2-derived gene ex-pression and PGE2 production, and less oedema for-mation compared to non-irradiated controls. Di-clofenac controls exhibited significantly lower PGE2cytokine levels at 6 h than collagenase control, butCOX isoform 1-derived gene expression and cytokinePGE2 levels were not affected by treatments. As LPTseems to act on inflammation through a selective in-hibition of the COX-2 isoform in collagenase-inducedtendinitis, LPT may have the potential to become anew and safer non-drug alternative to coxibs.

The aim of the study by de Paiva Carvalho9 was toevaluate the effect of single and combined therapies(LPT, topical application of diclofenac and intramus-cular diclofenac) on functional and biochemical as-pects in an experimental model of controlled musclestrain in rats. Muscle strain was induced by overload-

ing tibialis anterior muscle of rats. Injured groups re-ceived either no treatment, or a single treatment withtopical or intramuscular diclofenac (TD and ID), or LPT(3 J, 810 nm, 100 mW) 1 h after injury. Walking trackanalysis was the functional outcome and biochemi-cal analyses included mRNA expression of COX-1 andCOX-2 and blood levels of prostaglandin E2 (PGE2). Alltreatments significantly decreased COX-1 and COX-2gene expression compared to the injury group. How-ever, LPT showed better effects than TD and ID re-garding PGE2 levels and walking track analysis. Theauthor concludes that LPT has more efficacy thantopical and intramuscular diclofenac in treatment ofmuscle strain injury in acute stage.

Crystalopathies are inflammatory pathologiescaused by cellular reactions to the deposition of crys-tals in the joints. The anti-inflammatory effect of He-Ne laser and that of the non-steroidal anti-inflam-matory drugs (NSAIDs) diclofenac, meloxicam, cele-coxib, and rofecoxib was studied in acute and chronicarthritis produced by hydroxyapatite and calcium py-rophosphate in rats. The presence of the markers fib-rinogen, L-citrulline, nitric oxide, and nitrotyrosinewas determined. In the study by Rubio10, crystals wereinjected into the posterior limb joints of the rats. Adose of 8 J/cm2 of energy from a HeNe laser was ap-plied for three days in some groups and for five daysin other groups. The levels of some of the biomarkerswere determined by spectrophotometry, and that ofnitrotyrosine was determined by ELISA. In arthriticrats, the fibrinogen, L-citrulline, nitric oxide, and ni-trotyrosine levels increased in comparison to controlsand to the laser-treated arthritic groups. When com-paring fibrinogen from arthritic rats with disease in-duced by hydroxyapatite to healthy and arthritic ratstreated with NSAIDs, the He-Ne laser decreased lev-els to values similar to those seen in controls. Inflam-matory and oxidative stress markers in experimentalcrystalopathy are positively modified by photobios-timulation._

Editorial note: To be continued with further studies on the

effectiveness of diclofenac and LPT and conclusion in laser

2/2014. An list of references is available from the author.

Jan Tunér

Spjutvagen 11

772 32 Grängesberg

Sweden

[email protected]

_contact laser

[PICTURE: ©RACORN]

Dental Tribune InternationalThe World’s Largest News and Educational Network in Dentistrywww.dental-tribune.com

DTMediamix_A4_engl_2014.pdf 1DTMediamix_A4_engl_2014.pdf 1 22.01.14 11:2422.01.14 11:24

I case report

_Introduction

In 1954, Buonocore1 initiated a real revolution indentistry by proposing the possibility of obtainingstronger adhesion between composite resin andenamel through an etching process using or-thophosphoric acid. The practical application of histheory completely changed the rules of conserva-tive dentistry, shifting from the concept of “exten-sion for prevention”2 to that of “minimally invasivedentistry”3 and, subsequently it was applied, withseveral advantages, also in orthodontics4 and pedi-atric dentistry.5 Although such adhesive systems arelargely employed in dentistry today, there are stillsome unsolved problems.

In fact, the etch depth is variable and not pre-dictable6, as well as the type of acid-etching patternaccording to the Silverstone classification7, 8; more-over, rinsing does not necessarily completely arrestthe acid etching process in the depth of the exposed

enamel9 and, last but not least, there is a clinicalchallenge in controlling the geometry and extent ofthe etched enamel area.10

With the aim to eliminate these disadvantages,several methods were proposed over the years as analternative to orthophosphoric acid, such air abra-sion and maleic acid11-13, but the results were not en-couraging. In 1990 Hibst and Keller14 described thepossibility of using the Er:YAG laser for cavity prepa-ration in conservative dentistry.

This wavelength (2,940 nm), being very close tothe absorption peaks of water (3,000 nm) and hy-droxyapatite (2,800 nm), which are largely presentin enamel and dentine, causes the explosion of theintracellular water and thus the destruction of thedental tissues (15).

In recent years many advantages of using lasertechnology, as compared to the traditional rotating

24 I laser1_2014

Er:YAG laserand compositeresin ablationAuthor_Carlo Fornaini, Italy

[PICTURE: ©STASIQUE]

case report I

Fig. 1_Case 1, initial situation.

Fig. 2_Extensive resorption

of the root.

Fig. 3_After laser application.

Fig. 4_Application of orthophos-

phoric acid.

Figs. 5 & 6_Application of composite

resin, polymerisation and polish.


Fig. 8_Bleaching.

Fig. 9_Post-treatment results.

Fig. 10_Laser application.

I 25laser1_2014

Fig. 1 Fig. 2

Fig. 3 Fig. 4

Fig. 5 Fig. 6

Fig. 7 Fig. 8

Fig. 9 Fig. 10

I case report

Fig. 11_Application of

orthophosphoric acid.

Fig. 12_Application of composite

resin, polymerisation and polish.


Fig. 14_Removal of amalgams,

preparation of the cavities.

instruments, have been described and demon-strated by in vitro, ex vivo and in vivo tests.16-19

An interesting study, based on a questionnairegiven to 100 patients, recorded the patients’ satis-faction after receiving conservative dental treat-ments by Er:YAG laser: all the patients reported thatthey wished to be treated only by laser in the future,and they also wanted to suggest this opportunity totheir friends.20

One controversial aspect regards the need to useorthophosphoric acid also after Er:YAG laser prepa-ration. The most validated theory is that to obtainthe maximum bond strength and the minimum ofmicroleakage, it is necessary to also perform a con-ventional etching after laser conditioning.21

Recently, a great deal of importance has beengiven to the mode of the irradiation, in particular tothe pulse duration: an interesting in vitro study22

based on strength analysis by traction test and mor-phological analysis by SEM and Atomic Force Mi-croscope, showed the same effects with Er:YAG ir-radiation alone as with acid etching. This was ob-tained by using the so-called “QSP” mode (Fotona,Ljubljana, Slovenia) in which each pulse is split intoseveral shorter pulses that follow each other at anoptimally fast rate. In this way, a specific surfaceroughness is achieved, representing a real alterna-tive to acid etching. Water and hydroxyapatite arenot the only elements with which the Er:YAG laserhas a high affinity—its interactions with PMMA andSilicon Dioxide are also very interesting due to the

fact that these two molecules are present in greatconcentrations in composite resin.

This, from a clinical point of view, makes theEr:YAG laser very effective in the removal of oldcomposite restorations, with the result of obtaininga rough surface, able to be bonded to a new coat ofresin, which is not possible to achieve with conven-tional rotating instruments.23-24

_Clinical cases

Case 1

Patient DK, a 24-year-old woman, came to ourclinic to improve the aesthetic aspect of her upperleft central incisor, which had been treated manyyears earlier with an extensive re-construction us-ing composite resin (Fig. 1).

The patient reported that during a road accidenttwelve years earlier, she experienced a traumaticself-extraction of the tooth, which was re-im-planted after a root-canal therapy. At the X-ray ex-amination, extensive resorption of the root was no-ticed, which did not allow the preparation of a crown(Fig. 2).

The superficial coats of resin of tooth 21, and alsoof 11 in its distal portion, were removed by Er:YAGlaser (LightWalker AT, Fotona, Slovenia) with theseparameters: 250 mJ, 10 Hz, SSP mode, non-contacthandpiece, air-water spray. The duration of the op-eration was around seven minutes. No anestheticswere used and the patient reported no pain or dis-

26 I laser1_2014

Fig. 11 Fig. 12

Fig. 13 Fig. 14

case report I


Figs. 16 & 17_Same procedure on

the internal surfaces of the bridge.

Figs. 18-22_Results of laser

application.

Fig. 23_Application of

orthophosphoric acid.


resin, positioning of the bridge,

polymerisation.

I 27laser1_2014

Fig. 15 Fig. 16

Fig. 17 Fig. 18

Fig. 19 Fig. 20

Fig. 21 Fig. 22

Fig. 23 Fig. 24

comfort (Fig. 3). A gel of 37 % orthophosphoric acidwas subsequently applied on the treated surface for15 minutes (Fig. 4).

The area was rinsed, dried and a coat of bondingwas applied and polymerized by LED lamp. Subse-quently, a coat of composite resin was applied, poly-merized and polished (Figs. 5–6).

Case 2

Patient PG, a 21-year-old female, came to ourclinic for a bleaching treatment in the dental arches(Fig. 7). A bleaching gel containing 35 % hydrogenperoxide and a red coloring agent was used for thetreatment (Fig. 8). The bleaching reaction was ac-celerated by Nd:YAG laser (Fidelis Plus III, Fotona,Slovenia). The patient had been previously in-formed that due to the fact that the bleachingagent is active only in the enamel and not in thecomposite, the post-treatment results would leavea chromatic difference between the two parts ofthe crown (Fig. 9).

To solve this problem, the superficial coat on thedistal part of the upper right central incisor was ab-lated by Er:YAG laser (Fidelis Plus III, Fotona, Slove-nia) with the following parameters: 250 mJ, 10 Hz,SSP mode, non-contact handpiece, air-water spray(Fig. 10).

The duration of the operation was around 140sec. No anaesthetic was used and the patient re-ported no pain or discomfort. A gel of 37 % or-

thophosphoric acid was then applied to the treatedsurface for 15 minutes (Fig. 11).

The area was rinsed, dried and a coat of bondingwas then applied and polymerized by LED lamp. Sub-sequently, a coat of composite resin was applied,polymerized and polished (Fig. 12).

Case 3

Patient LC, a 37-year old male, came to our clinicbecause of a missing first lower molar. Due to thepresence of large, old amalgam restorations in thenearby teeth (45 and 47) it was decided to removethese old fillings and to apply a “California bridge”bonded with composite resin (Fig. 13).

The removal of the amalgams and the prepara-tion of the cavities was performed by conventionalrotating instruments and carbide burs (Fig. 14); thenthe impression was taken to construct the bridge.Before cementation, in order to enhance the adhe-sion, an Er:YAG laser (Fidelis Plus III, Fotona, Slove-nia) was used for the enamel conditioning with thefollowing parameters: 150 mJ, 10 Hz, SSP mode,non-contact handpiece, air-water spray (Fig. 15).

The duration of the operation was around 70 sec-onds. No anaesthetic was used and the patient re-ported no pain or discomfort. The same treatment,with the same parameters, was performed on the in-ternal surfaces of the bridge, completed in compos-ite resins reinforced with glass fibers (Targis-Vectris,Ivoclar Italia, Italy, Figs. 16 & 17).

I case report


resin, positioning of the bridge,

polymerisation.


Fig. 27_Planning of a composite

“Maryland bridge”.


28 I laser1_2014

Fig. 25 Fig. 26

Fig. 27 Fig. 28

case report I

Optical microscope observation showed that, inaddition to the creation of a rough surface in thecomposite, the action of the laser also removed theresin around the fibers, thus allowing for penetra-tion of the bonding agent, with a resulting strongeradhesion (Figs. 18–22). Subsequently, a 37 % or-thophosphoric acid gel was applied on the treatedsurfaces of the teeth for 15 minutes (Fig. 23). Thesurfaces were rinsed, dried and a coat of bondingwas applied and polymerized by LED lamp. Subse-quently, a coat of composite resin was applied andthe bridge positioned and polymerized (Figs. 24–25).

Case 4

Patient MP, a 42-year-old female, came to ourclinic for a rehabilitation of the left upper arch,where the first premolar was missing (Fig. 26). Dueto financial considerations, it was decided to applya composite “Maryland bridge” bonded to thenearby teeth (teeth 13 and 15, Fig. 27).

Before cementation, to enhance the adhesion,the surfaces of the teeth and the bridge were irradi-ated by Er:YAG laser (LightWalker AT, Fotona, Slove-nia) with the following parameters: 150 mJ, 10 Hz,SSP mode, non-contact handpiece, air-water spray(Figs. 28–29).

The surfaces were rinsed, dried and a coat of bonding was applied and polymerized by LEDlamp. Subsequently, a coat of composite resin wasapplied, the bridge positioned and polymerized(Figs. 30–31).

_Conclusion

Since its introduction in dentistry, the Er:YAGlaser has demonstrated its ability to treat an everwider range of clinical situations with significantadvantages in term of results, patient satisfactionand comfort.

Today, thanks to its efficacy in composite resinablation, it is also possible to apply this technologyto re-make old composite restorations with soundaesthetics results, and to enhance the adhesion ofnon-metallic prosthetics with good results in termof bond strength._

Editorial note: A list of references is available from the pub-

lisher.


Figs. 30 & 31_Application of

composite resin, positioning of the

bridge, polymerisation.

I 29laser1_2014

Prof. Dr Carlo Fornaini

MD, DDS, MSc

Dental School, Faculty of Medicine,

University of Parma,

Via Gramsci 14

43126 Parma, Italy

Tel.: +39 0521 292759

Fax: +39 0523 986722

[email protected]

www.fornainident.it

_contact laser

Fig. 29 Fig. 30

Fig. 31

I industry report

Fig. 1_Upper labial frenum with deep

papillary insertion at the palatal site,

in a 9-year-old child.

Fig. 2_Er:YAG laser labial

frenectomy.

_Introduction

Taking care of a pediatric patient’s oral health is achallenging task, but one that can be exceptionally re-warding. Providing a positive experience to childrenenables them to have a trusting, long-term relation-ship with a dental professional. Combining skill,knowledge and cutting-edge diagnostic and opera-tive technologies help to guide children toward a life-time of good oral health. Among the many motiva-tional, diagnostic and operative innovations to con-sider, one must include lasers. Laser technology in pe-diatric dentistry today is a new treatment modality forchildren and teens; it represents an alternative in-strument that sometimes complements, and at othertimes substitutes for traditional techniques. Lasertreatment of hard and soft tissues allows for a more

comfortable and minimally invasive intervention. Inaddition to the use of high technology, the psycho-logical effect on the child represents an importantbenefit which may positively influence the accept-ance of subsequent dental treatments.

Several of the factors that make laser therapy anelective procedure in pediatric dentistry are:– Its minimally invasive nature, with more affinity for

carious tissue (higher water content); – Higher safety, because it does not use rotating in-

struments or blades in a small mouth (which canmove unpredictably);

– It is more comfortable for the patient due to the lackof direct contact and vibration on the tissue surface;

– It is more acceptable because in many cases the useof local anaesthetics can be avoided;

Erbium lasers in pediatric dentistryAuthors_Giovanni Olivi, Matteo Olivi & Maria Daniela Genovese, Italy

30 I laser1_2014

Fig. 1 Fig. 2

industry report I

– It allows for easier and faster minor gingival andmucogingival surgery without scalpel or suture,and with good control of bleeding;

– Secondary intention healing and the postsurgicalperiod are predictable and usually asymptomatic;

– The use of an innovative technology such as thelaser is also well accepted by parents, who appreci-ate being able to offer their children the advantagesof laser care. It also provides a favourable psycho-logical impact on the child, who with his or herimagination, may see the laser as a magical tool thatuses "light and water to clean teeth".

All these advantages allow laser therapy to im-prove patient compliance by positively influencingboth the objective factors that affect the perceptionof pain (see the operative advantages of laser tech-nology in Tables 1 & 2) and the subjective factors of

pain, by raising the threshold of pain (analgesic effect)and the threshold of suffering (reducing the inci-dence of the anxiety or fear related to a negative per-sonal or family experience when "needles, drills,scalpels, sutures, etc." are used, thus influencing thecognitive and emotional state of the patient).1

For these reasons the use of the laser with pediatricpatients has proved to be a valid method of interven-tion, as noted by a number of authors who have re-ported good levels of patient acceptance during hardand soft tissue therapy. 1,3,4,5,6,7,8,9,10,11,12,13

_Clinical laser applications

Various applications are possible on both hard andsoft tissues using different laser wavelengths. Eachwavelength has its own applications due to the spe-

Table 1_Operative and clinical

advantages of lasers in restorative

treatments.

Table 2_Operative and clinical

advantages of lasers in soft-tissue

treatments.

Fig. 3_Typical secondary intention

healing after one week.

Fig. 4_Complete and stable healing

of the labial frenum, with new

attachment on the mucogingival

junction, after one year.

I 31laser1_2014

Operative Advantages:

Comfort: non-contact—no vibration/noiseSafety: no rotating or cutting instruments

used in the mouthPainless: reduced need for local anaesthesia

or no anaesthesiaApproach: improved patient compliance

Clinical Advantages:

Minimally invasive: selective for carious tissue Decontaminating effect for deep cariesMicro-retentive surface:a cleaned and debrided surfaceLess rise in temperature in pulp and periodontalsurface during irradiationDirect pulp capping: coagulation/bactericidal effectSoft-tissue application: exposure of subgingival tooth margins during cavitypreparation

Table 1

Operative Advantages:

Comfort: non-contact modeSafety: no cutting instruments used in the

mouth Painless: reduced need for local anaesthesia

or no anaesthesiaApproach: improved patient complianceEasy use: intuitive, knowledge of the science

more important than skill

Clinical Advantages:

Minimally invasive:selective for fibrous and/or inflamed tissuesDecontaminating effect of the surgical siteCoagulating effect of near-infrared lasersNo rise in temperature in tissue for medium- infrared lasersSoft-tissue healing:comfortable post-operative period

Table 2

Fig. 3 Fig. 4

I industry report

Table 3_Common applications of

lasers in pediatric dentistry.

Fig. 5_Proximal caries in lower

primary molars in a 6-year-old

patient. LightWalker Er:YAG laser,

treating both carious tissue and

marginal gingiva for healthy tissue

exposure.

Fig. 6_Cavity preparation and

gingivectomy performed:

note absence of bleeding and

thermal damage to the soft tissue.

Fig. 7_Restoration completed.

cific type of biological absorption of each tissue thatis targeted: visible, near, medium and far infraredlasers interact differently with different chro-mophores (melanin, haemoglobin, water and hydrox-yapatite) contained in different target tissues (mu-cosa, gingiva, dental tissues) and therefore the laserchoice is regulated by the optical affinity and coeffi-cient of absorption of the tissues for each particularwavelength.

Lasers in the visible and near-infrared electro-magnetic spectrum are specifically absorbed by

haemoglobin and melanin and are used in the treat-ment of soft-tissues pathologies. On the other side,the Erbium lasers, in the medium infrared spectrum,are absorbed by water in gum and mucosa and by water surrounding the hydroxyapatite, and are there-fore used on both soft and hard tissues. Among all thewavelengths used in dentistry, the Er:YAG laser (2,940 nm) is the most highly absorbed in water andhas proven to be the most flexible, all-purpose laser indentistry. In the far-infrared spectrum, the CO2 lasers(9,300 and 10,600 nm) are also primarily absorbed bywater in gum and mucosa and are used in oral surgeryfor the incision and vaporization of soft tissues. It isimportant to underline that with healthy gum andmucosa, the water chromophore is prevalent—whilehaemoglobin (blood) is prevalent in inflamed and invascular tissue.

If a dentist has multiple lasers, the wavelengthchoice must be taken according to the type of healthyor pathologic tissue: mucosa, keratinized and non-keratinized gingival, fibrous tissue. Additional differ-ences are dependent on location, health condition,pigmentation, vascularization, hydration and can besummarized as biotype variances.14,15 All wavelengthsabsorbed by either water or haemoglobin are alsoused for the coagulation, vaporization or removal ofthe pulp tissue (vital and non-vital pulp therapy). Forthe application of laser energy in pediatric dentistry,the Erbium:YAG laser is considered as the most usable,all-tissue laser.

_Laser analgesia: an advantage in pediatric dentistry

Among the several advantages of lasers in dentalapplications, laser-induced analgesia represents aunique way to treat an infantile patient with minimalor no discomfort. Laser irradiation of the operatory sitewith low energy prior to any surgical or non-surgicalprocedure generates disruption of the NA+/K+ pumpof the cell membrane of the nervous fibers, causing atemporary loss of conductance of the nervous impulseand a consequent analgesic effect in the irradiatedarea. Naturally, operating below the threshold of pain(by using the minimum effective energy and power)helps to avoid betraying the child’s trust.14

_Hard and soft tissue laser

The high affinity for water, the main chromophorein carious and soft tissues, makes this laser the safestand easily used in many procedures on healthy, dem-ineralised and carious dental tissues (enamel anddentin) as well on gingival and mucogingival tissues.

When approaching the panel setting, it is impor-tant to consider the different water content of the dif-

32 I laser1_2014

Hard-Tissue Laser Applications

Preventive Dentistry: laser-assisted fissure sealing,MIHRestorative Dentistry: carious removal and cavitypreparationEndodontics: laser-assisted pulp capping, pulpo-tomy and pulpectomy; root canal debriding and decontamination

Soft-Tissue Laser Applications

Oral Pathology: gingival hyperplasia, fibrous hyper-plasia, fibroma, epulis, mucocele, eruption cyst,dentigerous cyst, foreign bodiesOrthodontics: exposure of impacted teeth, distalmolar operculectomy, gingival contouring, intraoral attachment welding,ceramic bracket debondingPeriodontics: gingival contouring, labialfrenotomy/frenectomy, lingual frenum release

Laser Applications for Dental Trauma

Trauma to hard tissue and pulpTrauma to periodontal tissue

Low Level Laser Therapy

TMJ pain, orthodontic pain; Muscular trismus and contracture; For accelerating orthodontic movements; Herpes, aphthous or orthodontic ulcers; Dental trauma

Table 3

Fig. 5 Fig. 7Fig. 6

industry report I

Fig. 8_Uncomplicated

enamel-dentin fracture in a

10-year-old patient.

Fig. 9_LightWalker Er:YAG laser is

used for cleaning, decontamination

and roughening of dental structure.

Fig. 10a & b_Fractured upper

central incisor cleaned and

prepared with erbium laser: before

(a) and after (b).

I 33laser1_2014

Fig. 8 Fig. 9

Fig. 10a Fig. 10b

ferent tissues, such as enamel and dentin, and the dif-ferent composition of the primary tooth compared tothe permanent tooth (newly erupted versus aged) andadjust the parameters accordingly.16,19 As previouslyreported, the pulp tissue is high in water content andis readily vaporized with the Erbium:YAG laser, andtherefore care must be taken with deep cavities thatare very close to pulp chamber (Figs. 8–10).20,21 Vapor-ization and coagulation of the pulp is very well per-formed by the latest technology of the Er:YAG laser,with a very low rise in temperature in the remainingtissue, which is important for the pulp vitality duringpulp coagulation or pulpotomy. The LightWalker(2,940 nm; Fotona, Ljubljana, Slovenia) at 5 or 10 mJ,15 Hz, at 300 microseconds pulse duration, 5 to 10seconds defocused exposure, is very effective for pulpcoagulation during a pulp-capping procedure. Soft-tissue procedures are easily performed and the Er-bium:YAG laser never produces tissue carbonisationeven at high energy (Figs. 1–7).

The use of water spray and the possibility to mod-ulate the duration of the pulse allows for greater orlesser thermal interaction for different procedures(the interaction is more thermal with a low ratio of wa-ter spray and less thermal when a higher water sprayratio is used). A gingivectomy or a frenectomy will beperformed with a longer pulse duration (300–600 mi-croseconds) than a cavity preparation (50–100 mi-cros) and with different energy. When treating multi-ple tissues in the same intervention, for example boneand gingiva/mucosa in a labial frenectomy or im-pacted tooth exposure, care must be taken in varyingthe settings according to the different tissues.

_Conclusion

Lasers have demonstrated their effectiveness andsafety for pediatric dental care. The Erbium:YAG laser,in particular, allows the clinician to perform an inno-vative, minimally invasive form of dentistry that isvery well accepted by children.

Before starting to use a laser, it is important to un-derstand the physical characteristics of the differentlaser wavelengths and their interaction with biologi-cal tissues to assure that they are used in a safe way,in order to provide the benefits of this technology toyoung patients. It is therefore highly recommended toinvest in the appropriate training and education be-fore applying this technology on pediatric patients._

Dr Giovanni Olivi

Prof.a.c.of Laser Paediatric Dentistry — University of GenoaSIOI — Italian Society of Paediatric Dentistry SIE — Italian Society of EndodonticsAIOM — Italian Academy of Microscope Dentistryprivate practice: InLaser RomeAdvanced Center for Esthetic and Laser Dentistry

Piazza F. Cucchi,3 00152Tel.: +39 065815190

[email protected] www.inlaser.it

_contact laser

I economy

34 I laser1_2014

Gain power at your laser clinics!Author_Dr Anna Maria Yiannikos, Germany & Cyprus

_During the last two issues we have discussedthe importance of marketing in our clinics startingwith the first element of marketing mix-service.Let’s move on now to the second P of the marketingmix-Price!

First we should decide upon our pricing method.Our possible options are the following:

– Competition-Oriented Pricing: We set up the pricebased on ours key competitors’ prices.

– Cost-Oriented Pricing: First we calculate our costsand then we add in a suitable profit margin.

– Demand-Oriented Pricing: Different prices for theservice according to the type ofa) Patients (for example, we give discounted

prices to an insurance) b) Service version (We might charge less if we

have our own CAD/CAM machine in our prac-tice)

c) Place (different prices for patients in a villagethan in a town)

d) Time (20 years ago, an implant was very ex-pensive in relation to others applied in recentyears)

The pricing method that we choose is based uponour:

– Competitive advantage (how our patients per-ceive us when they compare us to our colleagues)

– Patient reaction – based on their demand– Competitive reaction (how our colleagues react)

A very sensitive and very important issue thatneeds our attention is to avoid Price wars – Why?

a) Our patients’ expectations are distortedb) Price advantage is short-livedc) Patients will become sensitive to price at the ex-

pense of value and benefits

Price is what we are going to charge for our treat-ments and actually represents the value of our serv-ice. Value is expressed as equal to benefits received(= tangible or emotional) over expectations (=price).

Benefits can be tangible or emotional. Tangiblebenefits for our patients are the larger amount offillings that we can finish in one session due to ourlasers. Emotional benefits are when they feel thatthey belong in an exclusive or expensive clinic.

Value = benefits/price

There are two ways that we can change the value of

our services:

1. The “boring” way: We increase the benefits with-out changing the price or reduce the price with-out changing the benefits

Death

Relocation

New Relationships

Lower Price

Product Dissatisfaction

Company Indifference

68%14%

9%

5%

3%1%

economy I

2. The creative way: By being different! This is theway that we will be able to gain the desirable com-petitive advantage!

What is a competitive advantage? It is our abilityto perform better than our colleagues and to main-tain being different (superior longevity = remain inthe market longer in superiority).

Since we are talking about performance we canachieve the highest in two ways: differentiation andcost. Being a cost leader requires offering the low-est prices in the market. This business level strategyhas two main disadvantages: Firstly, a colleague willimitate us sooner or later by offering lower pricesthan we do. Secondly our patients will not perceiveus as professionals in the long run since will not up-grade our services by investing in new technologiesor in further education due to the low cost. Let us re-member that research has proven that the reasonthat companies/clinics loose customers/patientsare divided into many aspects (Fig. 1).

Clearly, the most profound cause of loosing pa-tients is our company’s lack of difference towardsour colleagues. It is so obvious that the most creativestrategy to attract more patients, to create value and

to gain the desirable competitive advantages, is bybeing different, by being unique. It is by being fasterthan other offices (easily achieved with our lasers)or also by being more exclusive or expensive.

Why do people queue for hours and pay hun-dreds of Euros to buy a Louis Vuitton or a JimmyChoo handbag? Why do you think? The real answeris: because of its emotional benefits! For these brandnames and many more, people are willing to paymore than for the functional benefits in order togain a feeling of belonging to a higher social class, afeeling of uniqueness, of their position, an item or aservice that makes them feel exceptional.

How can we create those feelings and competi-tive advantages for our services?

1. By promoting care and compassion. This of coursecannot be achieved by words – we cannot only sayto our patients that we care. People have to walkout of our office and be absolutely shocked byhow much we care about them.

2. By our competitive advantage based on the num-ber of services we offer.

3. By our level of customer service. Is our team com-posed by incredible people, so that when patientswalk in our clinic, they are overwhelmed by the

Y education everywhere and anytime

Y live and interactive webinars

Y more than 500 archived courses

Y a focused discussion forum

Y free membership

Y no travel costs

Y no time away from the practice

Y interaction with colleagues and experts across the globe

Y a growing database of scientific articles and case reports

Y ADA CERP-recognized credit administration

www.DTStudyClub.com

Register for

FREE!

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

AD

I economy

hospitability and our team? Will our team go theextra mile for our patients and let them know howmuch they care?

4. Another potential competitive advantage couldbe our location. We need to have a location that isvibrant, growing; populated with people who canafford the dentistry we want to offer.

5. Convenience can also be considered a possiblecompetitive advantage. Many people cannot af-ford to take time off and they want to come in theevening or on a weekend.

6. It is our choice of course if we want to meettheir demand.

We are professionals, therefore we canincrease our profits in this competitive erathat we are working in and be different in acreative way by applying the following sim-ple formula: laser equipment + continuous

education

This will lead to our specializa-tion in the field of lasers, resultingin our uniqueness. To continue, letus also refer to the moments that wedo not feel comfortable of telling theprice—when we might be afraid that the patientmight react negatively. We have high-tech clinics,we offer exclusive treatments, therefore premiumservices. Let us not forget to charge for them!

Now, more practically: For example, we have thepatient on the chair how do we present the price? Itwould be better to tell the price dividing it in units—let the patient do the calculations for the whole costof the treatment. We could also use the sandwichtechnique to present the price.

_The sandwich technique

This technique sandwiches the price betweenpositive statements. For example if we are dealingwith laser treatments, we say one benefit at the be-ginning, for example “Using a laser is a very relaxedexperience since we avoid drilling” and then we addthe second benefit, “You will be very satisfied be-cause we perform the treatments without anaes-thesia”— and then we add the price in the middle—“The cost of the treatment will be 400 €”. Then, with-out a break, we insert the last benefit on top— “Youwill also feel very comfortable since the procedurewill be without the need of sutures”.

Finally, remember never to argue about the price— do not forget that there is no objective price — forone patient the price can be perceived cheap and foranother one extremely expensive.

Studies have shown that:a) Consumer behavior is often based on the individ-

ual’s perception and other psychological charac-teristics.

b) The more unique a product/service offering is per-ceived by the consumer, the greater is a company’sfreedom to set prices above those of competitors’.

Therefore, the value is affected by what the pa-tient perceives— If our patients perceive us as acredible office, offering services based on highquality and technology, derived from our

knowledge from our premium studies, thenthey will have a good reason to pay the re-quested amount for the treatments.

_The patient says Yes!

Never forget to praise them—saying for ex-ample—“Mr Smith, your decision is the best for thehealth of your mouth and your wellbeing”. Psycho-

logical experiments have shown that whateverwe say the next 25 sec. will be registered in thepatient’s long-term memory, meaning thatthey will never forget it. And when Mr Smithgoes home and tries to recall what happened

previously in our clinic, he will remember imme-diately that he made the best possible choice!

All the above topics and proposals can be elabo-rated further and new conclusions and ideas can becreated from them. Our medical studies leave a gapwhere the business department of our clinics is con-cerned. That is why we have created DBA. DBA is thenew innovative Dental Business Administration Mas-tership Course by AALZ. It is created exclusively fromdentists for dentists, dental managers/administratorsand will be launched in Aachen, Germany, on the 5 May 2014. It is all about preparing dentists to un-dertake their business as entrepreneurs, presenting allthe business-oriented material they will need in orderto be managers and directors of their own clinic andhave full control and maximum utilization of re-sources and team. The course will be launched at 5 May 2014, immediately after the completion of the2nd WALED Congress at AALZ — RWTH Aachen Univer-sity Campus._

36 I laser1_2014

Dr Anna Maria Yiannikos

Adjunct Faculty Member ofAALZ at RWTH Aachen Uni-versity Campus, GermanyDDS, LSO, MSc, MBA

[email protected] www.dba-aalz.com

_contact laser

[PICTURE:

©EV

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International events

meetings I

I 37laser1_2014

201430th AACD 2014—Annual Scientific

Session American Academy of Cosmetic

Dentistry

Orlando, FL, USA

30 April–3 May 2014

www.aacd.com

SIDEX 2014

Seoul, Korea

10–11 May 2014

www.sidex.or.kr

28th EAED Annual Meeting

Athens, Greece

29–31 May 2014

www.eaed2014.com

SINO-DENTAL 2014

Beijing, China

9–12 June 2014

www.sinodent.com.cn

APDC 2014—The 36th Asia Pacific Dental

Congress

Dubai, UAE

17–19 June 2014

apdentalcongress.org

WFLD—5th Congress

Paris, France

3–4 July 2014

www.wfld.info

Oral Implantology World Congress

Paris, France

2–4 July 2014

www.oiwc-paris2014.com

23rd Annual DGL Congress

LASER START UP

Düsseldorf, Germany

26–27 September 2014

www.oemus.com

I science

_The International Society of Metal Free Implan-tology (ISMI) was established in January 2014 in Con-stance (Germany). Founding president of the new soci-ety is Dr Karl Ulrich Volz from Constance, a resident im-plantologist and pioneer in the field of ceramic im-plants. Members of the founding group are renowneddental implantologists from Germany and abroad.

Aim of the new society is promoting metal-free im-plant dentistry as an innovative and particularly future-oriented direction within the field of implantology. Inthis context, ISMI supports its members with trainingand education opportunities as well as with regular ex-pert and market information. In addition, ISMI cam-paigns in their public relations, i.e. in circles of experts aswell as in patient communication, for a comprehensiveestablishment of metal-free implant treatment con-cepts.

In addition to patient advertising and public rela-tions, ISMI offers its members a range of benefits, suchas an individual homepage for every member, a special-ist online archive and a chat on „Metal Free Implantol-ogy“, training opportunities and a monthly newsletter.

_Metal-free implantology

For more than 40 years, titanium implants haveproven to be excellent dental implants. Although theroots of implantology were metal free, the then avail-able aluminium oxide ceramic has not worked for rea-sons of stability. The developer of these implants, Prof.Dr Willi Schulte, told Dr Volz shortly before his death ina personal letter that he was still convinced that the fu-ture belongs to zirconia implants.

Dr Rudelt from Hamburg has worked very success-fully with zirconia implants for over 30 years. He handedon human histologies to Dr Volz, documenting a 20-year span of results. Unfortunately, his promising workcould not be continued due to the economic crisis inJapan and the thus affiliated end of financial support by

the main sponsor KODAK. Dr Ulrich Volz then took up theissue again in the year 2000 because the patients of hisenvironmental medical clinic, as well as the residentdoctors Dr Joachim Mutter and Dr Johannes Naumann(formerly Environmental Medicine, University ofFreiburg/Breisgau) persisted on the use of metal-freeimplants. Over the past 13 years, Dr Volz successfully in-serted more than 8,000 zirconia implants and charac-terised the trend towards metal free implantology.

Today, zirconia is an established material for dentalimplants. Stability, osseointegration and prosthetic op-tions more and more achieve the level of conventionaltitanium implants. The broad use of titanium dioxide incosmetics and medicines causes an growing number ofincompatibilities. The patients’ demand for highly aes-thetic, tissue-friendly, anti-allergic and metal-free zir-conia increases year by year. Market experts estimatethat the proportion of zirconia implants is to reach atleast 10 per cent, more likely 25 per cent in the next years.

For more information on metal-free implantology,visit www.ismi.me._

ISMI: A new Society forImplantology

38 I laser1_2014

ISMI—International Society of

Metal Free Implantology

Lohnerhofstr. 2

78467 Konstanz, Germany

Tel.: +49 7531 991603

Fax: +49 7531 991604

[email protected]

www.ismi.me

_contact laser

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P R O F E S S I O N A L M E D I C A L C O U T U R E

E X P E R I E N C E O U R E N T I R E C O L L E C T I O N O N L I N E

WWW.CROIXTURE.COM

A3-wbleeds.pdf 1A3-wbleeds.pdf 1 11.09.13 17:1711.09.13 17:17

I interview

_You recently opened a new development center. It

sounds like the industry is rapidly expanding?

That's true. The industrial applications are cur-rently exploding, literally. Laser melting with metalsexerts a strong fascination when it comes to the com-ponents of the future. As the technology leader, wemust support this market process by introducing in-novations. When it comes to complex systems, wemust ensure a wide-ranging interplay between op-tics, design, control technology, software and powdermaterial. At our new development center, my col-leagues and I are hard at work on “discrete innova-tions” not intended for disclosure to the general pub-lic. Certain industries are quite sensitive…

_Which applications do you mean? Probably those

in the automotive industry…?

Yes, but not only there. Sectors that are definingand driving the process forward include the automo-tive and medical technology sectors, as well as aero-space. These technology drivers not only demandhigh standards in terms of quality and choice of ma-terials, but also with regard to quantitative aspects,such as increasing productivity. These customers re-quire shorter construction times and more parts in asingle-build chamber. We developed the X line 1000R,which currently has the largest build chamber, for theautomotive industry. The transition from a 400 Wlaser to a 1,000 W laser is an important milestone forthe process. It was developed in close cooperationwith laser specialists from the Fraunhofer Institute.The goal was to develop quicker processes that arealso more affordable. One of the applications we hadin mind was time-saving development of engines formodern vehicles.

_You mentioned the aerospace sector. How does

this industry use the process?

The aerospace sector is driving forward innova-tions. High quality solutions are in demand here, in-cluding the use of reactive materials such as titaniumor aluminum-based alloys that can only be producedreliably to a high quality in a closed system. In general,users such as the following are convinced that theprocess will become increasingly well-established:NASA, the German Aerospace Center, Honeywell,Snecma, Aerojet/Rocketdyne and Astrium SpaceTransportation from the EADS Group. NASA engi-neers are even considering using additive manufac-turing to produce components on the ISS—in orbit.The advantage of this is the ability to produce parts in

LaserCUSING: Laser meltingwith metals

40 I laser1_2014

If there’s one thing currently generating excitementin terms of production methods, it’s 3-D printers. Atall the trade fairs, 3-D printers are the big attractionin the industry. Does this signal a departure from aform-based way of thinking in favor of the geomet-rical freedom of components produced using addi-tive methods? Interested parties are already findingout whether it’s possible to print Lego blocks, or—more ambitiously—food items. With so much cre-ativity out there, we wanted to explore what can beaccomplished realistically using laser melting withmetals in an industrial context. We spoke with Dr Florian Bechmann, Head of Development at Concept Laser, about the current state of technol-ogy, trends and options for the near future.

interview I

space using CAD data, provided there is a sufficientstock of powder.

_Are the USA playing a leading role?

In terms of the USA, it can be said that a lot of cap-ital and staff resources are in use. The engineers andstudents at universities there are fascinated by thepossibilities presented by laser melting. Americansare considered to be creative and believers in progress,and to have the necessary drive. Unfortunately, westill have little contact with the aerospace industry inChina. At present, we're outside that market. But thatdoesn't mean it has to stay that way. We Europeanscan contribute our research and mechanical engi-neering capabilities mainly in the USA and Europe. In Europe, the EU promotes this process through projects like AMAZE due to a strong belief in theprocess’s sustainability and high level of innovation.

_Are other sectors getting on board as well?

Of course. After all, the options are attractive. Theapproach is currently revolutionizing medical tech-nology, for example: traditional process chains arebeing completely reconceptualised. LaserCUSINGparts are in demand as implants since their poroussurfaces incorporate well into the body, yet also pro-vide the necessary elasticity. One rising application isthe affordable and rapid production of dental pros-thetics from biocompatible materials. These arehighly adaptable, long-lasting dental solutions in-stead of dental prosthetics that have to be craftedmanually with much effort. The process is even ad-vantageous for retrofitting: worn-out turbine partscan be quickly and affordably regenerated. This kindof application is relevant in power plant engineeringand aircraft construction. In this hybrid technique,

layers of the exact same material can be applied addi-tively to the existing part. In addition to regeneration,new whole parts are also produced for turbine tech-nology applications. LaserCUSING also allows func-tionalities such as cooling channels to be integrated,which improve the performance of components. Theoffshore industry is considering installing laser-melt-ing systems on drilling platforms, which would allowfor independent, on-site production of certain com-ponents. The technology is not fixed to a specific lo-cation and can be operated locally.

_Environmental friendliness is one of the major is-

sues of our time. What is the situation from an envi-

ronmental perspective?

The Laser melting process is highly sustainable: onthe one hand, due to the localized production options,

I 41laser1_2014

Fig. 1_”We are constantly improving

our patented Quality Management

Module (‘QM Module’) in order to set

the standard in terms of prediction

quality and operability, as well as in-

fluencing the ongoing construction

process.”

Fig. 2_ “3-D mapping can be ex-

pected in the future: this capability

would increase the transparency of

the process and captures the compo-

nent in its structural entirety.”

Fig. 1

Fig. 2

I interview

Figs. 3a & b_Sector components

(application examples).

Fig. 4_Discrete innovations:

the largest build envelope yet for

large parts in the automotive and

aerospace sectors.

which reduce logistic complexity, and on the other,because the process reduces the quantity of materialrequired. There aren't any oil or coolant emissions ei-ther, as is often still the case in mechanical engineer-ing processes. Even the residual heat can be used. A1,000 W laser produces approximately 4 kW of heat,which can be used by building systems if channeledinto a cooling water circuit. There are good reasonswhy laser melting is considered a green technology.

_Will 3-D printers soon become a fixture on our

desks, like laser printers are today?

The additive process encompasses this option. Butto remain serious: we should distinguish betweenconsumer and industrial applications. ProducingLEGO blocks oneself from plastic, using 3-D printingwill soon be realistic. The range of materials andscope of applications for ordinary people will remainvery limited, however. Producing replacement partsfor vintage cars, or cars in general, is certainly alsoconceivable—but these are industrial applications,once again. We always focus on purely industrialsolutions with particular quality standards andmaterial requirements, through to certification ofthe materials and process. Industrial solutionswould be too heavy for a desk (laughs); here,we focus on current metal-process-ing methods in a production envi-ronment.

_If you wanted to describe what makes your sys-

tem technology special, what would you mention?

Our Quality Management Modules are definitelyan important distinguishing feature for us and ourcustomers. I would also mention the separation of thebuild chamber and handling area, which is character-istic of our products; this offers maximum occupa-tional safety and ergonomics. Our automated pow-der transport in containers is also practical. Handlingmaterials in a closed system has many advantages.It's important for safety, but also to prevent contam-ination, such as by oxygen. Safety is very important tous. We comply with the ATEX Directive of the EU veryconscientiously. I would also mention interfaces withthe production environment, e.g., crane accessibilityfor building boards weighing up to 80 kg. This is con-venient for the operator. Some details are interestingas well: such as filter replacement in processes usingreactive materials, such as titanium. The contami-nated filter is flushed with water and its contents arethen safely disposed of in an environmentally-friendly manner.

_Which other impulses do you see in the future for

industrial laser melting?

The scope of applications is growing, which meansthe range of materials is expanding as well. This re-quires strong consulting services, which we must pro-vide to the market. The system must also be repeat-edly adjusted to accommodate these new materials.At the same time, design requirements for compo-nents are also becoming more demanding. Thisranges from lightweight construction and largelyfoam structures to functional integration, such ascooling technology in components. This is very excit-ing for us since certain developments become possi-ble beyond the confines of one sector thanks to mul-tiplication effects. Another aspect is the growing im-portance of quality among users. Customers expectactive process monitoring and series production ca-pability, i.e., reproducibility at an industrial level.

42 I laser1_2014

Fig. 3a

Fig. 3b

Fig. 4

interview I

_What's going on in terms of quality require-

ments?

From the customer's perspective, this is currentlythe most important area. Customers are interested ingeometry, density, productivity and, above all—qual-ity. Two approaches are expedient here: activeprocess monitoring using machine technology anddevelopments in materials. This includes the certifi-cation of materials, such as in medical technology, ormanufacturer-specific instructions, which must becomplied with in the automotive and aerospace sec-tors.

_What does quality mean in concrete terms for

mechanical engineering?

First of all, it's the interplay in the system amongoptics, mechanics, control technology and softwarethat I mentioned at the outset. The key factors, how-ever, are situated in comprehensive quality monitor-ing. Active QA means checking, comparing, analyzingand evaluating process data in real time. We are con-stantly improving our patented Quality ManagementModule (“QM Module”) in order to set the standard interms of prediction quality and operability, as well asinfluencing the ongoing construction process.

_Could you describe this QM Module more specifi-

cally?

It involves two approaches: 1. QMmeltpool and 2.QMcoating. QMmeltpool means that the system usesa camera and photo diode to record signals during thelaser process. This data can then be compared to ref-erence values. The optical system is designed coaxi-ally. It allows the camera to record a very small area ofthe melting pool approx. 1x1 mm². In other words, ittakes a very detailed picture. It can detect impairedlaser performance due to contamination of the F-theta lens or caused by natural aging of the laser, aswell as deviations in the dosing factor. The second ap-proach is the QMcoating QM module, which ensuresthat the optimal powder quantity is used. Becauseonly what's needed is used, it saves powder material—up to 25 per cent—while also reducing set-up times.QMcoating monitors the layer surface while powderis being applied. If too little or too much powder isdosed, the dosing factor is adjusted accordingly, i.e.,actively counteracted. The two QM modules monitorand document the process, thereby ensuring repro-ducible quality.

_What developments can be expected in the fu-

ture?

In the area of process signal analysis in general,also known as the “component map.” 2-D maps aregenerated during the construction process and mustultimately be represented in 3-D models. This is com-parable to the images from CT measurement, which iscomputer tomography, like that familiar from med-

ical technology. This mode of imaging and capabilitywould increase the transparency of the process andcaptures the component in its structural entirety.Transparency is a highly dynamic, rapid process,which operators can only master with special aids.Another point is the speed of component construc-tion. This figures high on customers' wish lists. Thereare two methods: on one hand, higher laser output,such as in the X line 1000R (i.e., the jump from a 400 W to a 1,000 W laser) and on the other, using mul-tiple lasers. Multiple laser sources will be able to sig-nificantly increase the build rate in the future, thoughthe advantage of employing familiar process param-eters has to be weighed against the increasing com-plexity of the optical arrangement. These concepts in-volve multiplication not only of the lasers themselves,but also of most of the other optical components aswell._

Thank you for this conversation.

Fig. 5_Active quality assurance using

QMmeltpool: although the human eye

is incapable of detecting defects,

QMmeltpool nevertheless identifies

deviations in component quality.

Fig. 6_QMcoating: without

QMcoating, the layer may be

insufficiently coated (the red areas

indicate a lack of powder material);

with the QMcoating approach,

however, the powder dosing factor is

adjusted within the tolerance range.

I 43laser1_2014

Concept Laser GmbH

An der Zeil 896215 Lichtenfels, Germany

Tel.: +49 9571 949238Fax: +49 9571 949249

www.concept-laser.de

_contact laser

Fig. 5

Fig. 6

I interview

_Dr Fornaini, congratulations on your election asthe next president of WFLD. I understand you will as-sume your post during the next congress in Paris, in July2014. Are you already able to discuss your goals for yourtwo-year tenure?

First of all, I would like to say that the governance ofour federation entails teamwork and results areachieved with the contributions of all the executivecommittee members. This is the reason for the nomi-nation of the president-elect two years before his or hereffective start as president: in this way, he or she has theopportunity to work with the other members of the ex-ecutive committee, including the past president. That

said, it is normal that each president will have his or herown way of leading the federation, and I too have myown vision, which is concentrated on three main re-lated points.

I think it is now necessary for a renewal of the fed-eration’s leadership including the divisions, there areseveral colleagues who served since many years the Association and are now able to actively participate toits leadership. This is related to the second point of myvision, the need to promote young members by encouraging them to participate in the association’sactivities and in congresses.

Then, my goal is to expand the federation to newcountries and thereby disseminate information on theuse of laser technology to people who are still not us-ing lasers, through the organisation of courses andevents in these countries.

But I must say that the organising and scientificcommittees for the Paris congress pre-empted me bychoosing to invite many new young speakers, and thismakes me very happy.

_Could you tell us more about the European MasterDegree in Oral Laser Applications (EMDOLA)? What doyou think makes it stand out from other programmes?It seems to be an important part of WFLD congresses. Do all students have to defend a master’s thesis in frontof the international jury during the congress?

The EMDOLA is one of the most important post-graduate opportunities for comprehensive educationon the use of laser in dentistry and it is unique in thatall five universities involved in it (the University ofParma and Sapienza University of Rome in Italy, NiceSophia Antipolis University in France, University ofLiège in Belgium and University of Barcelona in Spain)

“Technology has allowed mywork to evolve enormously” An interview with Dr Carlo Fornaini, president-elect of the World Federation for Laser Dentistry

Author_Nathalie Schüller

44 I laser1_2014

Pr. Carlo Fornaini is teacher at the University ofParma(Italy) and Researcher at the university ofNice (France). He is also Coordinator of EMDOLAMaster in these two Universities. He publishedmore than 100 papers , mainly on the use of laser indentistry. He is President-elect of the World Feder-ation for Laser Dentistry (WFLD).

Dr Carlo Fornaini

interview I

offer the same programme in eight modules. A studentmay thus choose to attend a module at any one of theseuniversities.

I think it is important to distinguish between uni-versities and scientific societies and, while in somecases EMDOLA graduation ceremonies have been heldduring WFLD congresses, the difference between thesetwo entities must be pointed out: the EMDOLA is of-fered at the universities and all the academic activities,including the master’s thesis defence, take place at theuniversities.

That said, I think that EMDOLA is a great resource forWFLD and in recent years I have seen many of its grad-uates start participating in WFLD congresses, givinglectures and publishing in journals.

So, EMDOLA can be considered to bring new bloodto WFLD to avoid its ageing, and WFLD can be consid-ered to represent the new ground where little plants ofthe EMDOLA may grow into large trees.

_You had a lecture on laser welding at the IMAGINADental congress in February in Monaco. Would you tellour readers why this topic is important? Since you co-authored the book Laser Welding, published three yearsago, has much changed in this area?

IMAGINA Dental is a very interesting event on newtechnologies in dentistry and this was the second edi-tion to which I have been invited. I am very eager to beparticipating for two main reasons. The first is that thelaser session will be combined with the congress of theEMDOLA ACADEMY, of which I am president. The sec-ond is that laser welding is a topic about which I am pas-sionate: I spent several years of my life discovering away to weld intra-orally and, once I had achieved thisand published my papers, many people from differentcountries congratulated me.

The invitation to contribute a chapter to the bookLaser Welding was most satisfying for me, giving methe opportunity to collaborate with engineers andphysicists, each of us describing in our chapter ourstudy.

I think intra-oral laser welding is still today a field ofdentistry full of potential applications in orthodontics,prosthetics and implantology.

_The use of laser treatment in the dental practiceappears to be very limited still. What are the reasons inyour opinion, and do you feel this will change in the fu-ture?

Even if the percentage of laser users among dentistsis still not high, in recent years, there has been a dra-matic increase in publications, courses and the estab-lishment of scientific societies concerned with this

topic. The course I give on laser to the undergraduatestudents at the dental school at my university serves asan example of the extent to which laser is given con-sideration today at university.

In any case, the number of laser users in dentistry isgrowing and this is probably due to the reduced pricesof the devices and the increased number of treatmentspossible today. If I think back to the first appliance Iused, with their great dimensions, high costs and poorergonomics, I think I was really a pioneer!

Fortunately, technological expertise is increasingrapidly and I am often surprised when visiting countrieswhere, some years ago, I had helped my colleagues tostart using laser in their practice to find that they havebecome expert laser dentists.

_As with any medical field, the industry is constantlychanging. The integration of CAD/CAM dentistry is con-stantly being promoted and it will become increasinglyeasier to integrate it into a dental practice. Is the situa-tion the same for lasers, and how has this affected yourcurriculum or the way you teach your students?

When I recall when I started to work as a dentist(around the Middle Ages!), it is evident that technol-ogy has allowed my work to evolve enormously. I amhappy to have had the opportunity to live in a time ofsuch great technological progress. I think that laser isable to integrate with every dental technology device,in particular CAD/CAM devices. When I began my laststudy on a laser scanning handpiece, which led to therealisation of X-Runner (Fotona), I had in mind thepossibility of fully assisted prosthetics: the inlaypreparation programmed in advance and performedwith a laser scanning handpiece, optical impressiontaking and fabrication with a CAD/CAM device. The result? Perfection!

_What are the advantages and/or limitations of using laser in dental practice?

I think that the main aspect that in the past dam-aged the image of laser in dentistry was that it was pre-sented as being something almost magical that wasable to produce the best results possible in the hands ofanybody. Evidently, it is not so and we must be honestand realise its limits and the importance of knowledgeof all aspects of this technology, physics and laser–tis-sue interactions included.

Only with comprehensive theoretical and practicaltraining is it possible to use laser in every clinical situa-tion to advantage and without risk to patients.

I always say to my students, “Laser is not the magicwand that transforms the worst of dentists into stars!”.

Thank you very much for the interview.

I 45laser1_2014

NEWS

A U.S. research project has shown that Pichia, a bene-ficial fungal yeast, inhibits growth of the harmful fungalyeast Candida, which also causes oral thrush. The re-searchers hope that the findings will contribute to thedevelopment of a therapeutic agent to fight the painfulmouth infection, as well as other fungal infections.

The study involved testing the mouths of twelve healthyindividuals and twelve patients diagnosed with HIV forthe presence of fungi and bacteria. HIV-infected partic-ipants were selected for comparison because oral can-didiasis is the most common oral complication in thesepatients, the researchers explained. Using DNA analy-sis, the researchers observed no differences with re-gard to bacteria between the two study groups. “How-ever, what changed significantly was the compositionof the fungal community,” said senior author Dr Mah-moud A. Ghannoum. “We found that when Candida ispresent, Pichia is not, and when Pichia is present, Can-

dida is not, indicating Pichia plays an important role intreating thrush.”

In the second phase of the study, the researchers con-ducted laboratory experiments on the fungi. When theygrew Candida in test tubes in the presence of Pichia,there was a striking reduction in Candida growth.

“One day, not only could this lead to topical treatmentfor thrush, but it could also lead to a formulation of ther-apeutics for systemic fungal infections in all immune-comprised patients,” Ghannoum said. “In addition topatients with HIV, this would benefit very young pa-tients and patients with cancer or diabetes.”

The study, titled “Oral Mycobiome Analysis of HIV-In-fected Patients: Identification of Pichia as an Antago-nist of Opportunistic Fungi,” was published online onMarch 13 in the PLOS Pathogens journal. It was con-ducted by Case Western Reserve University and theUniversity Hospitals Case Medical Center.

Scientists discover that

Microorganism prevents mouth infectionThe figures are stark: the average density of den-

tists to head of population in Africa is 1 to 150,000;in industrialized countries, the average is 1 to5,000. In Ethiopia, the lack of ac-cess is even more dra-matic with a density ofonly 1 dentist per 1 million people. Thisinformation derivesfrom the Oral HealthAtlas developed by FDIWorld Dental Federation, whichprovides a clear picture of dental health aroundthe world.1 Even in countries with fast growingpopulations of dentists, unequal access to dentalcare is a major obstacle to optimal oral health.

“Developing countries face great challenges intheir quest for optimal oral care”, stated Dr TinChun Wong, FDI President. “Oral health is integralto general health and a basic human right, and wemust ensure cost-effective solutions becomeavailable to all. Promoting better research and ob-taining valid data will help us achieve this objec-tive.”

The damage to oral health due to poor access to careis exacerbated by the fact that many developingcountries are disproportionally affected by a num-ber of oral diseases. The combination of high risk oforal disease and low access to care, results in manypatients not getting adequate treatment in time.

World Oral HealthDay is celebratedevery year on 20th

March. The theme ofWorld Oral HealthDay 2014 was ‘Cel -ebrating Healthy

Smiles’. It reflects the major contribution oralhealth makes to our lives. Around the world, FDImember dental associations, schools, companiesand other groups will celebrate the day with eventsorganized under this single, unifying and simplemessage. For more information, visit: www.world -oralhealthday.org

1 Beaglehole, R., Benzian, H., Crail, J., and Mackay, J. (2009) The

Oral Health Atlas. Mapping a neglected global health issue. FDI

World Dental Federation. Cointrin, Switzerland.

World Oral Health Day

Calls attention to high risk of oral diseases

Sirona reports on the wide range of applications ofdiode lasers in a special edition of the English-lan-guage laser international magazine of laser dentistry. The"SIROLaser Factbook—Clinical articles about SIRO-Laser Advance and Xtend applications" includes re-search by well-known experts as well as informativefield reports from experiencedusers of laser technology.

Compact and informative: Sixtypages full of solid expertise andpractical applications await thereaders of English texts col-lected by Sirona in “SIROLaserFactbook—Clinical articlesabout SIROLaser Advance andXtend applications.” Academicarticles and real-life user reportsby well-known experts provideinformation on the many uses

and treatment options of diode lasers with a wave-length of 970 nm. Interesting facts and figures, studyresults, documented case studies with descriptivepictures, and recommendations for further readingcomplete the compendium.

“Anyone with an interest in laserdentistry should read the SIROLaserFactbook,” says Ingo Höver, productmanager at Sirona. The book is es-pecially meant for beginners, saysthe laser specialist. “However, ex-perienced users will also find itworth reading. I am sure that theywill be surprised to learn the manypossibilities of diode lasers and the range of applications that areopen to them with models like theSIROLaser Advance or SIROLaserXtend.”

SIROLaser Factbook

Comprehensive information on diode lasers

46 I laser1_2014

[PICTURE: ©JEZPER]

WFLD will hold

14th World Congress for Laser Dentistry in Paris

In order to establish an association be-tween breastfeeding and severe earlychildhood caries, researchers exam-ined the oral health status of 715 in-fants from low-income families inPorto Alegre.

They found that the prevalence ofcaries was highest in children whowere breastfed at 24 months or be-yond compared with babies who hadbeen breastfed until twelve months oryounger. In addition, they observedthat high-frequency breastfeeding increased the as-sociation between long-duration breastfeeding andcaries.

Exclusive breastfeeding up to six months of age is rec-ommended by the World Health Organization. How-ever, the organization also recommends continuingbreastfeeding along with appropriate complementaryfoods up to two years of age, even though several casestudies have linked prolonged on-demand and noctur-nal breastfeeding to early childhood caries, primarily

because breast milk is considered a critical source ofenergy and nutrients.

The study, titled “Association of Long-Duration Breast-feeding and Dental Caries Estimated With MarginalStructural Models”, was published online on Feb. 19 inthe Annals of Epidemiology. It was conducted by sci-entists at the University of California, San Francisco, incollaboration with the Universidade Luterana do Brasiland Universidade Federal de Ciências da Saúde dePorto Alegre.

Prolonged breastfeeding may increase

Risk of cavities in primary teeth

Bisphenol A (BPA) is a widely used chemical in plastics,such as food containers, and is also found in dentalcomposites and sealants. Now, two recently publishedstudies have suggested that BPA may play a crucial rolein cellular transformation and disease progression inprostate cancer patients, and may promote breast can-cer growth.

The first study, titled “Exposure to Bisphenol A Corre-lates with Early-Onset Prostate Cancer and PromotesCentrosome Amplification and Anchorage-Independ-ent Growth In Vitro,” was conducted at the Cincinnati

Cancer Center and included 60 urology patients. Over-all, they found higher levels of BPA in prostate cancerpatients compared with study participants without thedisease. The difference was even more significant inpatients under the age of 65, the researchers reported.In addition, they observed that exposure to low dosesof BPA increased the percentage of cells with centro-some amplification two- to eightfold, said Dr. Shuk-meiHo, principle investigator and director of the cancercenter. The study was published online on March 3 inthe PLOS ONE journal.

In the second study, researchers at the University ofTexas at Arlington found abnormal amounts of HOTAIRexpression in breast cancer cells and mammary glandcells exposed to BPA. HOTAIR is a molecule that cansuppress genes that would normally slow tumorgrowth or cause cancer-cell death. The findings sug-gest that BPA disrupts the normal function in such mol-ecules and is linked to tumor growth in breast cancerpatients. The study, titled “Bisphenol-A and Diethyl-stilbestrol Exposure Induces the Expression of BreastCancer Associated Long Noncoding RNA HOTAIR InVitro and In Vivo,” will be published in the May issue ofthe Journal of Steroid Biochemistry and Molecular Bi-ology.

New studies link BPA to

Breast and prostatecancer

I 47laser1_2014

This event will gather dental specialists for all aroundthe world and the scientific program has been de-signed with different speakers trying to cover all the dif-ferent fields regarding laser use in dentistry and the ap-pliance if laser in implantology. The combination of sci-entific studies, substantiating the scientific evidence oftreatments performed with laser, as well as the clinicalexperiences of recognized professionals are a huge at-traction and a not-to-miss congress.

Nowadays WFLD is present on five continents, in al-most 50 countries with the mission of propagating sci-ence with no economic interest. The WFLD World Con-gress and Paris, as a city, come together to make a greatscientific event. Do not miss what may be one of thebest congress in laser dentistry from 2 to 4 July in Paris.Submit your abstract and register already on the con-gress website www.wfld-paris2014.com.

Congress President : Ass. Prof. Dr Frederick GaultierChairman of the scientific committee : Prof. Dr Jean-Paul RoccaChairman European Divison of WFLD : Prof. Josep ArnabatWFLD Chairman of International and legal affairs : Prof. S. Nammour

[PICTURE: ©SAMOT]

[PICTURE: ©VIETROV DMYTRO]

Although dental caries rates among children havedeclined in several high-income countries over thelast decades, the opposite trend has been noted forlow-income countries. A survey conducted at theUniversity of Copenhagen has shown, however,that school programmes can contribute signifi-cantly to a gradual reduction of inequalities in den-tal health.

Through analysis of data from the World Health Or-ganization’s Global School Health Initiative, a pro-gramme that was launched in 1995 in 61 countriesto improve the health of students and other mem-

bers of the community through schools, the re-searchers observed that about 60 per cent of thecountries give formalised instruction on how tobush teeth. However, not all countries have accessto clean water and the necessary sanitary condi-tions, which constitutes a major challenge for thehealth and school authorities in Asia, Latin Amer-ica and Africa in particular. Dental health inequali-ties may also arise in high-income countries.

Overall, the survey showed that schools have acentral role in promoting health and preventingdiseases because healthy school environmentsthat offer children education on dental health aregenerally well placed to set children on a path to ahealthy lifestyle throughout their lives, Petersenexplained. The study, titled “Promoting oral healthof children through schools—Results from a WHOglobal survey 2012”, was published in the De-cember issue of the Community Dental Healthjournal.

Crucial role of schools in

Promoting oralhealth

In their study, researchers at the University of Califor-nia collected dental and salivary bacterial samples atthree- to six-month intervals from low-income His-panic mothers and their children from pregnancythrough 36 months postpartum to calculate the childcaries incidence. In total, the study included 243mother–child dyads.

Over the course of the study, the researchers found thatsalivary levels of mutans streptococci and lactobacilliwere greater among mothers of caries-affected chil-dren compared with caries-free children. Overall, theyobserved that the incidence of caries was twice as highin children with mothers who had higher levels of bac-teria.

According to the American Dental Association, cario-genic bacteria, and mutans streptococci in particular,are transmitted soon after the first teeth erupt. The as-

sociation thus recommends that parents, including expectant parents, visit a dentist to decrease themother's mutans levels to decrease the child's risk ofdeveloping early childhood caries.

The study, titled “Maternal Oral Bacterial Levels PredictEarly Childhood Caries Development”, was publishedonline in Dec. 19, 2013, in the Journal of Dental Re-search ahead of print.

Mothers' oral bacteria may predict

Likelihood of early childhood caries

48 I laser1_2014

About 6 to 15 per cent of patients suffer from peri-implantitis, inflammation that destroys soft and hardtissue surrounding the implant after placement. It isknown that the concentration of matrix metallopro-teinase-8, an enzyme that is also responsible for pe-riodontitis, increases significantly when inflamma-tion around the dental implant arises. Prof. LorenzMeinel from the Institute of Pharmacy and Food

Chemistry at the University of Würzburg ex-plained that this increase could be identi-fied through a special chewing gum using asmall peptide chain that is bound to a bitter-tasting compound. Once enzyme concen-trations in a patient’s saliva exceed a certainlevel owing to complications with the im-plant, the peptide chain will snap, releasingthe bitter compound. In the future, specialchewing gum could be part of post-opera-tive care in addition to routine check-ups.Patients would have to contact their dentistupon recognising the bitter taste.

In addition to the development of the chew-ing gum, the researchers are consideringdeveloping a coating that uses the peptidechain system and can be applied to the im-

plant directly.

The project will be carried out in collaboration withSwiss dental implant manufacturer Thommen Med-ical and various other European companies and sci-entific institutions. The research has received fund-ing of € 1 million for two years from the EuropeanUnion.

Could chewing gum prevent

Implant failure in the future?

[PICTURE: ©OLLYY] [PICTURE: ©AN NGUYEN]

[PICTURE: ©BOTAZSOLTI]

Saliva may indicate

Susceptibility to depression in boys

Neutrophils are a vital part of the body’s immunesystem. Recognized as the most abundanttype of white blood cell present in humanblood, neutrophils function primarily asthe body’s first line of defenceagainst infection and inflamma-tion. Within minutes ofstimulation, neutrophilsmigrate from the blood totissue where they accumu-late at sites of infection. Oneof the most common labtests ordered on a regularbasis is the counting of neu-trophils in the blood (ab-solute neutrophil count).

“However, simply counting theneutrophils may not be enough inmany cases. If neutrophils do notmigrate well and cannot reach in-

side the tissues, this situation could have the sameconsequences as a low neutrophil count,” says DrDaniel Irimia, Assistant Professor at the BioMEMS

Resource Center at Massachusetts General Hos-pital. The team recently designed miniaturizedsilicon-based devices that can be used tomeasure neutrophils’ migration patternsfrom just a finger prick of blood in a few min-utes. He also says, “The device was designedsuch that probing neutrophil mobility be-comes extremely easy to perform.”

By being able to measure the risk for in-fections that a particular patient has at aparticular time from just a droplet of bloodin a matter of minutes is a significant im-provement and one that will improve cur-

rent treatment. For more information onthis research, refer to: www.worldscien-t i f i c . c o m / d o i / p d f / 1 0 . 1 1 4 2 /S2339547813500040.

Calculating risk of infection

In mere minutes from a droplet of blood

I 49laser1_2014

Cluster headache is one of the most severe forms ofheadache. It is usually unilateral and occurs mostlyaround the eye or in the temple. Attacks last up to sev-eral hours. In many people, cluster headache leads to asignificant loss of quality of life. A new type of clusterheadache treatment is the stimulation of thesphenopalatine ganglion (SPG). The ATI Neurostimula-tion System stimulates the SPG in order to break thepain cycle. The neurostimulator, which is the size of analmond, is inserted through a small incision in the gin-giva and programmed by the physician. As clusterheadache occurs unilaterally, the implant is inserted onthe relevant side. The surgery is performed under gen-eral anaesthetic and takes about an hour.

The patient can control his or her therapy independ-ently via a remote control. When a cluster attack occurs,he or she holds the device against the cheek to activatethe implant. This stimulates the SPG and abates the at-tack. In many patients, the frequency of attacks de-creases permanently.

The effectiveness of the ATI Neurostimulation Systemhas been clinically proven in the most comprehensivemedical study on cluster headache. With the ATI neu-rostimulator, 82 per cent of all attacks—even mediumto severe—can be treated effectively, the manufac-turer, Autonomic Technologies, stated. In 46 per cent ofpatients, the attack frequency was reduced signifi-cantly—from an average of 14 down to two attacks per week. The ATI Neurostimulation System has beenintroduced at nine clinics in Germany and is in use inBelgium.

Gingival implant supports

Reduction of clusterheadache

[PICTURE: ©OLLYY]

For the first time, researchers at the University ofCambridge have identified a biomarker for major orclinical depression in human saliva. An examinationof saliva samples of hundreds of teenagers revealedthat boys especially may be at the greatest risk of depression.

Following a group of boys and girls over 12 to 36months by measuring levels of cortisol in their saliva,as well as collecting self-reported information onsymptoms of depression, the researchers found thatboys with depressive symptoms and elevated morn-ing cortisol were 14 times more likely to develop clin-ical depression compared to boys with neither.

However, the connection was not as distinctive in fe-male participants. Girls with high cortisol and de-pressive symptoms were four times more likely todevelop depression, suggesting differences be-tween the sexes in how depression develops.

The study, titled “Elevated morning cortisol is a strat-ified population-level biomarker for major depres-sion in boys only with high depressive symptoms”,was published on 18 February in the Proceedings ofthe National Academy of Sciences of the UnitedStates of America journal.

[PICTURE: ©SUZANNE TUCKER]

[PICTURE: ©DMITRY LOBANOV]

I about the publisher

50 I laser1_2014

Copyright Regulations _laser international magazine of laser dentistry is published by OEMUS MEDIA AG and will appear in 2014 with one issue every quarter. The

magazine and all articles and illustrations therein are protected by copyright. Any utilization without the prior consent of editor and publisher is inad-mi ssible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.

Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to theeditorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right tocheck all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicitedbooks and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, representthe opinion of the afore-mentioned, and do not have to comply with the views of OEMUS MEDIA AG. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall beassumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate orfaulty representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.

PublisherTorsten R. Oemus [email protected]

CEOIngolf Dö[email protected]

Members of the BoardJürgen [email protected]

Lutz V. [email protected]

Editor in ChiefNorbert [email protected]

Coeditors in ChiefSamir NammourJean Paul Rocca

Managing EditorsGeorg BachLeon Vanweersch

Division EditorsMatthias FrentzenEuropean Division

George RomanosNorth America Division

Carlos de Paula EduardoSouth America Division

Toni ZeinounMiddle East & Africa Division

Loh Hong SaiAsia & Pacific Division

Senior EditorsAldo Brugneira JuniorYoshimitsu AbikoLynn PowellJohn FeatherstoneAdam StabholzJan TunerAnton Sculean

Editorial BoardMarcia Martins Marques, Leonardo Silberman,Emina Ibrahimi, Igor Cernavin, Daniel Heysselaer,Roeland de Moor, Julia Kamenova, T. Dostalova,Christliebe Pasini, Peter Steen Hansen, Aisha Sul-tan, Ahmed A Hassan, Marita Luomanen, PatrickMaher, Marie France Bertrand, Frederic Gaultier,Antonis Kallis, Dimitris Strakas, Kenneth Luk, Mukul Jain, Reza Fekrazad, Sharonit Sahar-Helft,Lajos Gaspar, Paolo Vescovi, Marina Vitale, CarloFornaini, Kenji Yoshida, Hideaki Suda, Ki-Suk Kim,Liang Ling Seow, Shaymant Singh Makhan, Enri-que Trevino, Ahmed Kabir, Blanca de Grande, JoséCorreia de Campos, Carmen Todea, Saleh GhabbanStephen Hsu, Antoni Espana Tost, Josep Arnabat,Ahmed Abdullah, Boris Gaspirc, Peter Fahlstedt,Claes Larsson, Michel Vock, Hsin-Cheng Liu, SajeeSattayut, Ferda Tasar, Sevil Gurgan, Cem Sener,Christopher Mercer, Valentin Preve, Ali Obeidi,Anna-Maria Yannikou, Suchetan Pradhan, RyanSeto, Joyce Fong, Ingmar Ingenegeren, Peter Kleemann, Iris Brader, Masoud Mojahedi, Gerd Volland, Gabriele Schindler, Ralf Borchers, StefanGrümer, Joachim Schiffer, Detlef Klotz, HerbertDeppe, Friedrich Lampert, Jörg Meister, ReneFranzen, Andreas Braun, Sabine Sennhenn- Kirchner, Siegfried Jänicke, Olaf Oberhofer, Thorsten Kleinert

Editorial OfficeGeorg [email protected]

Claudia [email protected]

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Transcript of laser dentistry · 2020-05-15 · Erbium lasers in pediatric dentistry. Tel: +49 341 48474 302 /...