laserinternational magazine of laser dentistry42014

i s sn 2193-4665 Vol. 6 • Issue 4/2014

| researchInnovations with lasers could lead regenerative dentistry

| industry reportPrevention of deep periodontal diseases using Er:YAG laser

| technologyWireless digital sensors

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AALZ_DGL_A4_laser314.pdf 1AALZ_DGL_A4_laser314.pdf 1 26.08.14 12:0126.08.14 12:01

editorial I

I 03laser4_2014

Dear colleagues,

Laser users and laser researchers have never had so many opportunities to attend congressesnationally and internationally as they have had this year. At these numerous events, establishedknowledge and clinical applications have been confirmed, and new research findings and clini-cal treatment protocols have been introduced. The increase in high-quality scientific publica-tions has been exponential, demonstrating that the applications of laser technology in dentistryare being seriously explored.

For 2015, I would like to see similar developments in the area of evidence-based educationworldwide, so that this valuable technology can be increasingly placed into the hands of re-sponsible, well-trained colleagues.

I would like to thank our members and all other readers who have actively participated at con-gresses or attended conferences and training events in the field of laser for their commitment.I look forward to seeing you again at one of the various laser events in 2015.

Thus, it only remains for me to wish you a peaceful Christmas and a happy, prosperous andhealthy New Year.

Yours sincerely,

Prof. Dr Norbert GutknechtEditor and CEO WFLD

2014 Champion yearfor laser comes to an end

Prof. Dr Norbert Gutknecht

Editor-in-Chief

I content

page 40 page 42 page 46

page 22 page 26 page 34

I editorial

03 2014 Champion year for laser comes to an end

| Prof. Dr Norbert Gutknecht

I research

06 Innovations with lasers could lead regenerative dentistry

| Praveen R. Arany

10 Treatment of vascular lip lesions with laser

| Prof. Ass. Merita Bardhoshi et al.

I industry report

14 Prevention of deep periodontal diseases

using Er:YAG laser

| Dr Fabrice Baudot

22 Comparing the effects of manual, ultrasonic & Er:YAG

laser treatment

| Dr Zulala Tasneem et al.

I technology

26 Wireless digital sensors

| George Freedman

I economy

30 Staying ahead in dentistry

| Simon Beeston et al.

34 Gain power at your laser clinics!

| Dr Anna Maria Yiannikos

36 Regulatory system for medicines can

be used more effectively

| Escher

I education

40 Dental School of Aristotle University enters laser family

| Dr Dimitris Strakas

I meetings

42 Focus on laser: Annual Congress of the DGL and

LASER START UP 2014

| Katrin Maiterth

I news

38 Manufacturer News

46 News

I about the publisher

50 | imprint

Cover image courtesy of Fotona,

www.fotona.com

04 I laser4_2014

LI-PB77693EN_A4_for Laser Journal ADF 2014 print quality.pdf 1LI-PB77693EN_A4_for Laser Journal ADF 2014 print quality.pdf 1 03.11.14 11:0203.11.14 11:02

I research

Fig. 1_The use of various

wavelengths at different doses can

be used for various clinical

applications. The following acronyms

are used in this figure PBM—

Photobiomodulation;

enPDT—Photodynamic therapy with

endogenous chromophores and

exPDT—Photodynamic therapy with

exogenous chromophores (dyes).

_With the upcoming year, 2015, being desig-nated as the year of light, the acknowledgment forthe key role of light in multitude areas of our veryexistence and more specifically, in areas of humanhealth are being widely promulgated.1 Many refer-ences to the beneficial effects of light and specifi-cally sunlight are replete in the literature across an-cient civilisations.

Notably, the ability of concentrated light radia-tion in the management of lupus vulgaris by NielsRyberg Finsen received the Nobel Prize in Medicineand Physiology in 1903.2 The all-pervasive nature ofopto-photoelectronics in our current society isreadily evident such as the simplest supermarketlaser scanners and optical communications to pre-cision medical lasers and more recent laser weapon

systems. This is also perhaps best highlighted bythis year’s Nobel Prize in Physics to the inventors ofthe blue light emitting diodes (LEDs), a simple in-vention with profound impact on our current soci-ety.3

_Clinical laser application

Dentistry has historically been a leading clinicalspecialty in adoption of new technologies. Light hasbeen a central part of clinical dentistry from evolu-tions of operating lights and fibre optic illumina-tions to light cured restorations and more recently,optical imaging. Although lasers were commer-cially available since 1960’s, the first dental laser forhard tissue applications was approved by the USFDA in 1997. Adoption for high power soft tissueapplications has always been popular in manymedical fields such as surgery, oncology, dermatol-ogy and ophthalmology.

First discoveries

Following the invention of this exciting newtool, early biological concerns focused around thesafety of this new device with natural comparisonsbeing drawn to ionizing forms of electromagneticradiation. Among the early pioneering studies, An-dre Mester reported a peculiar phenomenon—highdoses destroyed tissue in a precise and predictablemanner but very low doses produced a startling im-provement in wound healing and promoted hairgrowth.4, 5 This was a surprising discovery on manyaccounts.

While high energy electromagnetic radiation,such as Gamma, X-rays and Ultraviolet, were able

Innovations with laserscould lead regenerativedentistryAuthor_Praveen R. Arany, USA

06 I laser4_2014

research I

to achieve significant linear energy transfer gener-ating biological damage (nucleic acid strandbreaks), the effects of visible (and later infra-red)lasers did not appear to fall within these routine bi-ological responses (Fig. 1). With much excitement,these initial observations spurred many investiga-tions for the use of low powered lasers and otherlight devices (including filter-based broad lightsources and LEDs) in many clinical and lab researchstudies.

Barriers in application

Unfortunately, a combination of the complexityof the early technology and a lack of understandingof its biological mechanisms has resulted in signif-icant discrepancies in their reported therapeuticbenefits. Hence, the lack of robust clinical efficacyhas largely relegated the field to being side-lined asa pseudo-scientific and alternative medicine field.Current problems in the field from its basic termi-nology that prevents accurate indexing of the liter-ature, to appropriate disease or biological re-sponse-specific clinical dose recommendationsappear to be major barriers. Nonetheless, develop-ment of low power applications has also shown significant progress specifically in the areas oftraumatic brain injury, post-traumatic stress disor-ders, reversal of methanol toxicity and wound heal-ing.6-15 In more recent years, mechanistic insightsinto light-biological tissue interactions have con-tributed to our better understanding for the thera-peutic applications of laser therapy.16-18

Defining photobiomodulation

Our operational definition for Photobiomodula-tion (PBM) is a form of phototherapy that utilisesnon-ionizing sources (including broad light, LEDsand Lasers) in the visible and infrared spectrum thatresult in therapeutic benefits such as alleviation ofpain or inflammation, immunomodulation andpromotion of wound healing and tissue regenera-tion. PBM is a non-thermal process involving pho-tophysical and photochemical events at variouslength scales resulting in beneficial photobiologi-cal responses. Its clinical applications could be ap-pended as PBM therapy.

_Study 1: Activating TGF-�1

Based on prior reports, we began studies in 1999to establish the parameters of the near infrared laserto effectively promote oral wound healing at lowdoses (3 J/cm2, 10 mW/cm2, 5 minutes). We per-formed a, thorough literature search to evaluatepossible biological pathways involved in promotingwound healing. There appeared to be distinct corre-lations with reported use of exogenous TGF-�1 andlaser treatments in wound healing.

Based on these observations, we assessed thelaser-treated healing response of oral tissues forTGF-�1 expression and noted increased expressionimmediately post treatment and at 14 days.19 Theincrease at 14 days correlated well with an in-creased in monocyte-macrophage influx, well-known cellular sources of TGF-�1. We next lookedinto the increased early expression of active TGF-�1 in these wounds.TGF-�1 is secreted as a latentgrowth factor complex when associated with a Latency Associated Peptide (LAP). The activationprocess involves dissociation of LAP from activeTGF-�1 dimer that is well-documented with a widerange of physio-chemical modalities such as pro-teases, extreme pH, heat, ionizing radiation and in-tegrin binding among others. The early wound hasabundant latent TGF-� from degranulatingplatelets present in the early wounds.

We observed low power laser treatments werecapable of activating the latent TGF-�1 complex. Tofurther pursue this observation mechanistically, wenoted that near infra-red laser was capable of gen-erating reactive oxygen species (ROS). This highlyreactive, transient chemical intermediate wassensed by a key methionine residue on the latentTGF-�1 complex that resulted in a change in itsconformation, resulting in its activation.20

Fig. 2_Therapeutic outline utilizing

laser-generated ROS activated

TGF-�1 to direct differentiation

of dental stem cells and

pre-odontoblasts to induce

dentin matrix and subsequent

mineralization.

I 07laser4_2014

I research

Fig. 3_Potential routes to move the

field of PBM towards mainstream

clinical dentistry. The wavy path from

lab research to clinics is meant to

reflect the multistep, tortuous basic

science explorations in a wide range

of topics that need to come together

to aid in clinical translation.

_Study 2: Dentin regeneration

Having noted the effects of low power lasers onpromoting oral mucosal wound healing in the priorstudy, we extended our clinical applications todentin regeneration where TGF-�1 has been shownto play a pivotal role in dentin physiology.21-25 Wenoted the ability of low power lasers to promotedentin regeneration using human dental stem cells.To validate these observations, rodent pre-odonto-blasts (MDPC-23) cells grown in a polymeric scaf-fold, simulating a 3-D niche were treated with lowpower lasers.

Laser treatments were able to induce dentin dif-ferentiation as evident by increased dentin-specificmatrix deposition and mineralisation. To confirmthe role of TGF-� in vivo, transgenic mice with lackof TGF-� receptor in all cells capable of inducingdentin (utilising a Dentin Sialophosphoproteinspecific transgene) were generated. Experiments inthese mice did not demonstrate any significantdentin induction following laser treatment validat-ing the critical role of TGF-� activation in mediat-ing its effects.

Previous studies have shown the therapeuticbenefits of supplementing exogenous (recombi-nant) TGF-� for reparative dentin, this study sug-gests the use of low power lasers can activate en-dogenous latent TGF-�1 present naturally in thepulp-dentin complex to drive differentiation of res-ident dental stem cells (Fig. 2). Thus, this therapycan utilise the inherent repair-regenerative re-sponses naturally present in native tissues.

_Clinical Applications of Laser-Dentin induction

These observations have potent clinical implica-tions where dentin would need to be therapeuti-cally generated. The two directly relevant clinical

scenarios are for pulp capping following deep car-ious lesions and for dentin desensitisation. In theformer case, removal of decayed or damaged toothstructure approximating the pulp (close to or clearexposure) that require the use of pulp cappingagents (such as Calcium hydroxide) could be po-tentially replaced with low power laser treatments.

In the second scenario,the use of low power lasertreatments on exposed dentinal tubules could po-tentially generate an intrinsic dentin barrier thatwould relieve tooth sensitivity. This would be moreeffective than our current approach to extrinsicallyocclude exposed tubules modes.

The two major limitations of the current studywere that we noted calcifications interspersedthroughout the pulp chamber, spatially distinctfrom the laser-biological tissue interface. We be-lieve this is perhaps a combination of the inherentnear-infrared laser wavelength that readily perme-ates throughout biological tissue as well as the sol-uble nature of the activated molecules. This couldbe potentially addressed by better optical focusingtechniques and use of specific reagents that absorbthe radiant energy and spatially restrict the biolog-ical interphase.

A second limitation in this study was the obser-vation that laser-generated dentin was a tertiary orreparative form that lacks pristine tubular struc-ture. It appears that additional cues both biophysi-cal (architecture) and biochemical (soluble, organi-zational), are likely necessary to promote morpho-differentiation of the newly induced dentin.

In attempts to further explore these molecularmechanisms, we have more recently extended de-veloped a polymeric scaffold system with precisemorphogen fields.26 Using this model, we were ableto extend our observations with dental stem cellsand laser-activated TGF-�1 mediated dentin dif-

08 I laser4_2014

ferentiation to mesenchymal stem cells suggestingthis approach could have significant potential withother stem cell types as well.

_Conclusion

Both ROS and TGF-� are central biological me-diators in a wide range of biological responses.27-29

The ability to selectively activate them in a spatio-temporally defined manner in vivo using low powerlasers provides a significant clinical tool for varioustherapeutic interventions.

Questions on precise wavelengths, clinical pro-tocol (delivery and dose ranges) and context of thepathophysiological response are all critical issuesthat need to be explored rigorously to enable fur-ther effective clinical translation of this therapy.30

Further, the ability to effectively move this therapyinto mainstream clinical dentistry will require morebasic research, development of robust clinical stan-dards and education at various levels (basic dentaltraining and continued education) (Fig. 3).

In the current era of personalised medicine andstrategies to utilise sophisticated technologies andpharmaceuticals to individualise health care, thesignificant promise of lasers in clinical dentistrymay indeed be the leading, pivotal technology thatushers in the new era of regenerative dentistry.

Acknowledgement

This work was supported by the intramural re-search program of the National Institute of Dentaland Craniofacial research, National Institutes ofthe Health._

Editorial note: A list of references is available from the

publisher.

Praveen R. Arany DDS, PhD

Cell Regulation and Control Unit,National Institute of Dental and Craniofacial Research, National Institutes of Health

30 Convent Drive Room 3A-301,Bethesda MD 20892, USA

Tel.: +1 301 496 3561praveenarany@gmail.com

_contact laser

www.DTStudyClub.com

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_In 1982, Mulliken and Glowacki introduced

a simple classification that was based on the clini-cal, histochemical and cellular criteria to distinguishbetween the various vascular anomalies (Genoveseet al., 2010). They described two distinct entities—hemangiomas and vascular malformations. Ac-quired lesions may be traumatic or idiopathic in ori-gin. Hemangiomas present with a variable mor-phology: Some are small and hardly noticeablewhereas others are large and disfiguring. Heman-giomas that are flat and appear reddish are consid-ered superficial. Those that are deep beneath theskin and appear bluish are called deep heman-giomas (Thurnherr et al., 2000). When a heman-gioma is superficial and deep it is called “compoundhemangioma”.

The correct diagnosis is critical for a proper treat-ment than. Vascular malformations are alwayspresent at birth though some may not be apparentuntil a later stage. Furthermore, they never prolifer-ate or involute. Instead they expand slowly and re-lentlessly throughout life, in pace with the growthof the patient. Thereby, trauma, puberty and preg-nancy can cause an accelerated growth. These le-sions are sub-classified according to the predomi-nant type of the vessel and the characteristics offlow like capillary malformation, venous malforma-tion and arteriovenous malformation. Initially, they

present as flat pink macules and are usually soft,compressible and enlarge in size when venous pres-sure is increased.

Some lesions such as venous lakes and varicosi-ties are part of the normal ageing process. The con-genital anomalies may be further subdivided ac-cording to the vessel type. They can be situated indifferent areas of the oromaxillofacial region:tongue, lips, palate, buccal mucosa or gingiva (Ro-manos, 2012). One option of managing these lesionsis the application of laser. Because of the aestheticimportance of the lips, the discrete anatomic bor-ders such as the vermilion border and their func-tional importance, laser treatment in this region hassome important benefits (Romanos, 2012). Severallaser systems have been developed using principlesof selective photothermolysis (DeBiase et al., 2006).The targeted chromophore in case of a vascular le-sion is oxyhemoglobin present in the red blood cor-puscles which circulate in the blood vessels. Lasertherapy is a good method to treat such a lesion.Among different laser systems, we choose the ap-plication of a 980 nm diode laser for the manage-ment of a vascular lip lesion since the wavelength of980 nm is well absorbed by haemoglobin. This char-acteristic makes it possible to achieve a very goodcoagulation and haemostasis that is very importantfor treating vascular lesions.

I research

10 I laser4_2014

Treatment of vascular lip lesions with laserAuthors_Prof. Ass. Merita Bardhoshi, Prof. Dr Norbert Gutknecht, Prof. Ass. Edit Xhajanka, Dr Esat Bardhoshi,

Dr Alketa Qafmolla, Dritan Gjini & Elda Gjini, Albania & Germany

[PICTURE: © VERYULISSA]

_Patients and methods

Patients

This study comprised 60 patients (32 males and28 females) aged 10 to 80 years treated for vascularlesions of the lip (Figs. 1–3). The research protocolwas performed in two groups: The first group with30 patients was treated with a 980 nm diode laserwhereas the second group, the control group with30 patients, was treated with a cold scalpel. Thetreatment was conducted from May 2007 to May2012 at the Department of Oral Surgery, DentalClinic of the University of Tirana, Albania. All pa-

tients were provided with clinical files. In the lasergroup, 20 patients were medically free and 10 werecompromised (each 3 patients with diabetic andcardiopathy and 4 patients under anticoagulanttherapy). In the control group, 18 patients weremedically free and 12 were compromised (each 4patients with diabetic, cardiopathy and under coag-ulant therapy).

In all patients, the lesions were considered to bevascular lesions based on their medical history, age,thorough extra- and intraoral examination andfindings of ultrasonography. All patients were givenwritten and verbal information on the nature oflaser treatment and were asked to sign informedconsent forms prior to the treatment. The follow-upperiods were defined one month, six months, oneyear and three years after treatment in order to eval-uate the characteristics of wound healing as earlyand long term results. All stages of treatment andfollow-ups are photographically documented for acomparative long-term evaluation.

Method

Treatments were performed on an outpatient basis under local anaesthesia. For the laser group a980 nm diode laser was used. The laser energy wasdelivered through a fibre optic with a gauge of 300 micrometre and an average power of 3 W in acontinuous mode from 10 to 60 seconds accordingto the size of the lesion in contact and non-contactmode. The laser tip was placed in a non-contactmode 2 mm away from the treated area.

The actual treatment started with workingaround the border of each lesion by circling aroundit several times all in one direction. Changes incolour and visible shrinkage were taken as signalsfor the end point of the treatment, until blanchingof the treated area and photocoagulation was com-pleted. In the contact mode, the fibre was in contactwith the mucosal surface of the lesion using gentle

research I

I 11laser4_2014

Figs. 1–3_Vascular lip lesions.

Fig. 1 Fig. 2

I research

Fig. 4_The treated surgical area was

bloodless and the intralesional

photocoagulation was completed.

Fig. 5_Immediately after the

treatment.

pressure. It was extended into the substance of vas-cular lesion to the periphery for such passes are re-quired.

The treated surgical area was bloodless and theintralesional photocoagulation was completed (Fig.4). The treated areas were iced for 3 to 5 minutes. Af-ter treatment (Fig. 5), an analgesic medication wasprescribed to be used if necessary—no antibioticswere given. Instructions for post-surgical behaviourtreatment consisted of an ice compress for 2 hours,abstention of warm food and drinks intake, place-ment of a vitamin E ointment on the lased area andavoidance of sun exposure for one month.

The patients of the control group were treatedwith conventional removal techniques by means ofblades. Excision as surgical technique was per-formed to fully enucleate the lesion and the woundswere sutured. Antibiotics were prescribed for all pa-tients—those patients who were under anticoagu-lant therapy had interrupted their therapy prior tothe surgery. The follow-up visits for the researchprotocol for both groups (laser and control group)were scheduled in intervals of 10 days, one month,six months, one year and three years after treat-ment. Hereby, pain, bleeding, swelling, scar forma-

tion, functional disturbance, aesthetic result, recur-rence as well as wound healing characteristics wereevaluated.

_Results

In this study, according to the research protocolthe results from two groups were compared. Thefirst one was a group of 30 patients with differentvascular lip lesions treated with 980 nm diode laser(Sirona Dental Lasers). A second group considered asthe control group was treated with conventionalsurgical blade techniques. The results were evalu-ated as early and long-term results. The patients ofthe laser group were treated in one session. In thisstudy, a case with a vascular lesion of the entirelower lip was included in which different sectionswere treated in five sessions.

Another special case within the laser group was apatient with a vascular lesion at the lower and upperlip which was treated in different sessions with a dis-tance of 2–3 weeks each. The surgery time for the laser group was very short — for the benefit of thepatients. Furthermore, no sutures were required andthe wounds healed in two or three weeks dependingon the lesion size. During the wound healing, none of the patients reported complications, which alsoincluded the compromised patients. In contrast, 3 to30 patients of the control group showed delay timesin the wound healing due to local problems particu-larly among the compromised patients. The param-eters evaluated are the following:

Bleeding

Bleeding during the surgical removal of vascularlesions can be considered a typical feature of suchtreatments. During the laser treatment, no bleedingwas observed in all patients. In the control group, after the excision with scalpel a prolonged packingwas needed and sutures were used to close the sur-gical wound.

12 I laser4_2014

Fig. 5

Fig. 3 Fig. 4

research I

Pain

The second parameter evaluated was the painpost-surgery. Out of 30 patients treated with laseronly one patient reported pain after the effect of lo-cal anaesthesia had stopped. The other patients hadan optimal post-surgical comfort and did not referpain at all. Among the patients treated with con-ventional blade surgery 22 out of 30 (70 per cent ofthe patients) referred pain which was solved withanalgesic drugs for some days.

Swelling

Another parameter evaluated in the follow-upvisits during the first week after treatment wasswelling. None of the patients treated with laser re-ported swelling. In contrast, 20 patients out of 30(66 per cent of the patients) from the control groupreferred swelling in the first week after the surgicalexcision.

Scarring

A common problem related to lip lesions is scarformation. Scar formation was evaluated within thecontrol visit one month after the treatment. In allpatients treated with a 980 nm diode laser scar for-mation was not observed (Figs. 6 & 7) whereas in allpatients treated with conventional blade surgeryscar formation was observed on the site of the per-formed excision.

Functional disturbance

The parameter functional disturbance was eval-uated six months after the treatment. For the lasergroup, no functional disturbance was recorded andthe lip looked normal in colour and consistence. In contrast, in the control group 6 cases out of 30 (20 per cent of the patients) reported a functionaldisturbance.

Recurrence

Recurrence was evaluated as long term result inthe follow-ups one year, two years and three years

after the treatment. According to the clinical datareported by patients treated with laser, no recur-rences were observed. In the control group only onecase reported recurrence of the lesion during thefirst year after the excision.

_Conclusion

The clinical application of a 980 nm diode laserfor the management of vascular lesions of the liphas some beneficial effects due to the good absorp-tion of haemoglobin. Laser treatment versus scalpelsurgery provides minimal invasive and minimal aes-thetic results. Compared to the patients treated withconventional methods, the laser treated patientsfelt more comfortable in the post-operative phasedue to less pain and swelling. Patients under antico-agulant therapy were treated without substitutionprior to laser surgery. During the treatment, therewas no bleeding in this patient group. The laser ap-plication was performed comparatively fast andwas also well-accepted in all age groups. The surgi-cally lased wounds healed within a short time with-out scar formation and functional disturbance._

Figs. 6 & 7_Four weeks after the

treatment with 980 diode laser.

Wound healing was completed

without scarring.

I 13laser4_2014

Fig. 7Fig. 6

Prof. Ass. Merita Bardhoshi

Medicine University

Department of Oral Surgery

Dibra Street 63, Tirana, Albania

Tel.: +355 674150102

Fax: +355 42253675

meritabardhoshi@yahoo.com

_contact laser

I industry report

Fig. 1_Clinical situation following

initial therapy. Some deep

pockets need long-term care.

_Periodontal maintenance is an integral partofsuccessful periodontal therapy (Axelsson & Lindhe,1981).The objective is to stabilise the microbial bal-ance restored after an initial periodontal therapy (Kornman, 1997). A systematic surgical approach following an initial therapy is no longer necessary asit is with standard treatment (Heitz-Mayfield, 2005).Over the past few years, periodontics has been shift-ing towards a non-invasive or non-surgical approachto access the deep cleaning of the periodontium, aspart of the development of all medical surgical tech-niques in general.

Non-surgical procedures, most respectful non-surgical periodontal tissue protocols have proven tobe efficient (Badersten & Egelberg, 1990, 1987, 1985,1984, 1981), but force us to leave risky sites that canbe difficult to manage in periodontal maintenance(Cobb, 2002; Becker et al.). Root furcation defects andresidual periodontal pockets deeper than 4 mm arethe daily reality faced by periodontists and hygienistsresponsible for their patients’ maintenances.

By means of a literature review of the physical andbiological properties of the Er:YAG laser, we wouldlike to demonstrate the relevance this device mayhave as a preventive tool in maintenance procedureson at-risk periodontal sites (Fig. 1).

_Aetiology and diagnosis of periodontaldisease

Periodontitis is an inflammatory disease affect-ing the periodontium. The inflammation arises as aresult of imbalance between the oral microbial floraand defence system of the host (Kornman, 1997). Microbial involvement is a major factor in the devel-opment of the disease, but other risk factors includ-ing but not limited to smoking, stress and geneticpredisposition contribute to the aetiology of peri-odontitis (Genco et al., 2013). For the sake of sim-plicity, we can distinguish between two variants ofperiodontitis (Page, 1997):1) Aggressive periodontitis (Figs. 2a & b), which oc-

curs before the age of 45.

Prevention of deep periodontal diseasesusing Er:YAG laserAuthor_Dr Fabrice Baudot, France

14 I laser4_2014

Fig. 1

industry report I

2) Chronic periodontitis (Figs. 3a & b), which devel-ops after the age of 45.

Major risk factors associated with chronic peri-odontitis include bacteria and tartar. General riskfactors such as diabetes, smoking or others also ag-gravate the disease. Local risk factors do not play amajor role regarding aggressive periodontitis; a pe-riodontal imbalance seems to be related primarily togeneral risk factors.

In both cases, the imbalance results in an inflam-matory reaction, rendering the periodontium porousto microbes. Subsequently, the polymicrobial florabecomes embedded in the biofilm and invades thedeep periodontium and even the inner tissue, leadingto the destruction of the periodontium. The origin ofperiodontal destruction seems to be more related tothe inflammatory reaction than to the microbial flora(Barthold, 2010).

The radiography of both clinical situations depictsan advanced stage of the disease, with similar skele-tal deterioration. These two cases differ primarily interms of the patient’s age, which is 25 in the case ofan aggressive periodontitis (Figs. 2a & b) and 68 yearsin that of a chronic periodontitis (Figs. 3a & b).

_Periodontitis treatment protocols

Treating periodontitis involves the restoration ofthe periodontal balance. The key instrument usedhere is infection-control through the reduction andmodification of the microbial mass. The eliminationof inflamed tissue helps to trigger the periodontalhealing process (Lindhe & Nyman, 1985). The treat-ment strategy consists in encouraging the immunesystem to fight the microbial flora by destabilising thesignificant protective biofilms in which they arehosted (Sanz & Van Winkelhoff, 2011, 7th EuropeanWorkshop).

Today, the widely accepted treatment protocolsfor periodontitis are centred on two phases (Dentino,2013):1) An initial treatment that serves to control the in-

fection, reduces inflammation and restores the pe-riodontal homoeostasis.

2) Periodontal maintenance treatment or supportivetherapy. This phase focuses on the maintenance ofthe periodontal balance achieved during the initialtherapy in the longer term.

Several initial treatment protocols have been de-scribed in the literature (Lindhe & Nyman, 1985):

– Surgical protocol: The use of “blind” scaling androot planning, which is aimed at controlling the in-

fection and reducing inflammation. This first step isfollowed by periodontal surgery for the purposes ofdecontaminating the four sites and eliminatingresidual periodontal pockets: the Widman Flap(Ramfjord & Nissle, 1974).

– Non-surgical protocol: This protocol preserves theperiodontal tissues more effectively. It consists ofonly one scaling and root planning without accessflap to decontaminate the periodontium. Residualpockets are numerous and are controlled as part ofa strict maintenance programme (Badersten &Egelberg, 1984).

– Minimally invasive periodontal regenerative sur-gery (Cortellini & Tonetti, 2007): Here, the peri-odontium is cleaned up to a surgical level but with-out an access flap. Special therapeutic means suchas optical aids and lasers can also improve thesenon-invasive procedures. A surgical technique in-spired by the Canadian University of Public Admin-istration ENAP published in 1976 by Yukna allowspatients to benefit from the surgical approach andnon-surgical techniques without suffering the dis-advantages.

Periodontics follows the preferred route taken inmedicine which is minimum intervention. This is one

Figs. 2a & b_Aggressive

periodontitis and pre-operative

radiography.

I 15laser4_2014

Fig. 2a

Fig. 2b

I industry report

of the reasons why non-surgical and minimally inva-sive techniques have been developed within the field.The surgical approach is long, highly invasive anddoes not shy away from a strict maintenance proto-col to prevent recurrence (Badersten, 1984; Teles,2012; Westfelt et al. 1983; Lindhe & Nyman, 1984;Harper & Robinson, 1987; van Winkelhoff et al., 1988;Renvert et al.,1990a; Shiloah & Patters, 1996).

Within cases of periodontitis, the heart of theproblem is related to microbial and immunologicalfactors. Periodontal maintenance is intended to sta-bilise the balance recovered through initial therapy,regardless of the initial protocol used (Ebersole,2013).

In view of the biological consequences, the risk-benefit ratio of performing invasive surgery does notseem favourable today (Heitz-Mayfield & Lang, 2013,Walsh & Waite, 1978; Badersten et al.,1984a, 1984b;Leon & Vogel, 1987, Oosterwaal et al., 1987; Cobb,1996). Our knowledge of microbiology and immunol-ogy has evolved, as have the technical platforms use.This also enables us to offer alternative therapies forthe treatment of periodontitis. The Er:YAG laser maybe central to this strategy (Figs. 4–6).

_Physical and biological properties ofthe Er:YAG laser

Er:YAG is a laser that emits radiation at a wave-length of 2,940 nm (Robertson, 1971). At this wave-length, one of the physical properties of the energyemitted is that it has double the peak absorption inwater and hydroxyapatite (Ishikawa, 2004). This is afundamental property that distinguishes Er:YAGfrom other lasers used in dentistry and singles-out asthe wavelength of choice in non-surgical periodon-tal debridement applications (Schwarz et al., 2008).

Photothermal properties

Due to very strong water absorption, the Er:YAGlaser has a therapeutic effect at low energy levels andlimits the thermal effects on tissue adjacent to thetargeted areas. Tissues subjected to Er:YAG radiationare vaporised by means of a huge increase in tem-perature upon impact, which is instantly reduced toa great extent by massive water absorption (Aoki,1994, Eberhard, 2003; Schwarz, 2003). Clinically, thiseffect is manifested in the form of a micro-tissue ab-lation on a few microns of material (Walsh, 1989).

Photomechanical properties

These properties are as follows:– Shockwave: the emission of laser radiation causes

a shock wave at each impact.– When radiation is emitted in a hydrated solution,

the energy released in the water molecules pro-duces multiple micro-explosions that allow for adeep agitation of the solution (Roca, ongoingstudy).

Biological effects of the Er:YAG laser

The physical properties of the Er:YAG laser haveanti-inflammatory and antiseptic effects, which arehighly useful in periodontal therapy. Periodontal tis-sues are not homogeneous in terms of water load.They can be characterised by a gradient of water load.The water load in the cement is higher than that in thebone, which is in turn lower than that in the ligamentand gum or inflamed tissue.

The photothermal properties of the Er:YAG laserallow the tissue to be vaporised in accordance with itswater load. The Er:YAG laser has proven to be a veryeffective and selective micro-surgical tool in situa-tions where there is a decreasing water load gradient(soft tissue vs. hard tissue), since the laser eliminatesthe most hydrated tissue while preserving the sur-rounding, less hydrated tissues.

Antiseptic effects

The photothermal and photomechanical proper-ties of the Er:YAG laser have antiseptic effects. Bacte-

16 I laser4_2014

Fig. 3a

Fig. 3b

Fig. 3a & b_Chronic periodontitis

and pre-operative radiography.

industry report I

rial biofilms are highly hydrated gels in which bacte-ria live and grow (Marsh & Bradshaw, 1995). Due totheir very nature, they perfectly absorb the energyemitted by the Er:YAG laser. Where they are directlyexposed to Er:YAG radiation, vaporisation will targetprimarily the biofilms and bacteria with the highestwater load in periodontal pockets.

Although no vaporisation occurs in deep layers orareas where radiation is attenuated, biofilms will bedestabilised in these areas. Bacteria will be renderedsoluble and therefore are accessible to the immunedefence system, which can then help to restore theperiodontal balance (Marsh, 2011).

The photomechanical properties also produce an-tiseptic effects by helping to destabilise microbialbiofilms within the periodontal pockets. Two photo-mechanical mechanisms produce this kind of effect:the shockwave generated by the radiation and themicro-explosions of the molecules. These two phe-nomena agitate the solutions and give the radiationantiseptic properties, as observed in clinical applica-tions of the Er:YAG laser in endodontics (Roca, ongo-ing study).

Agitation of irrigation solutions is more intenseand more rapid when using an Er:YAG laser than it iswhen using ultrasonic tools. The propagation of theshock wave is highly effective in the agitation of irri-gation solutions in hard-to-reach areas (side ducts,intra-ductal isthmus). In drawing a parallel with pe-riodontics, we see the potential relevance of theEr:YAG laser with regard to antiseptic action in areassuch as furcations or deep periodontal pockets,which cannot be accessed easily using conventionalmeans.

Anti-inflammatory effects

These effects are the result of a selective micro-tissue ablation associated with the direct irradiationof inflamed tissue using an Er:YAG laser. Here too, thedecreasing water load gradient between the in-flamed tissue and the adjacent and underlying struc-tures allows for selective vaporisation: The inflamedtissues are eliminated. The laser energy is highly re-duced upon reaching the healthy tissue, which helpsto preserve the latter. This mechanism allows theEr:YAG laser to have an instant, powerful anti-in-flammatory effect (Dominguez et al., 2010). In peri-odontal pockets, radiation acts as an ultra-preciseoptical curette.

_Therapeutic benefits of the Er:YAG laser in periodontics

As we have already seen, the therapeutic strategyfor periodontal treatment is aimed at restoring and

maintaining the balance between the immune sys-tem and the periodontal micro flora. By its antisepticand anti-inflammatory properties, the Er:YAG laserseems like an interesting tool that can be integratedwith the existing therapeutic arsenal. We can designits use in the initial periodontal therapy and peri-odontal maintenance. When compared to the me-chanical instrumentation in a non-surgical peri-odontal debridement, the Er: YAG laser achieves bet-ter results in the short and long term (24 months) ofchronic periodontitis (Schwarz, Aoki et al., 2008).

Er:YAG laser in initial periodontal treatment

The Er:YAG laser can be used to complement oreven replace conventional tools in surgical or non-surgical periodontal decontamination procedures.As we have already seen, its biological effects enableit to act as a highly selective and therefore highly ac-curate optical curette that meets non-invasive inter-vention criteria to remove inflamed tissue. Its anti-septic action is used to clean root and bone surfacesby direct exposure to laser radiation (Yoshino, 2009).

The ergonomic design of the optic-fibre makes ita very fine tool that can be used to deliver treatmentin areas that are often inaccessible to conventional

Figs. 4a & b_Clinical situation and

pre-operative radiography of an

aggressive periodontitis.

I 17laser4_2014

Fig. 4a

Fig. 4b

I industry report

Fig. 5_Micro-surgical intervention by

use of Er:YAG laser.

Fig. 6_Two-month postoperative

result. Note the stability of the

periodontal tissue.

tools (Sahar-Helft &Stabholtz 2013). Due to photo-mechanical phenomena processes (micro-explo-sions and agitation of solutions by shockwave) theantiseptic effect of the Er:YAG laser is shown and af-fect areas beyond those that are accessible by directradiation. The Er:YAG laser is a real surgical tool, butdue to its extreme precision it reaches its full poten-tial when used in minimally invasive or non-surgicalinterventions to promote healing (Schwarz, 2007).

Er:YAG laser in periodontal maintenance

Despite the interesting properties outlined above,in the literature the Er:YAG laser is not significantlydistinguished from conventional tools with regard totherapeutic effectiveness and intervention times inperiodontal maintenance procedures: The effects aresimilar (Tomassi, 2006; Derdilopoulou, 2007;Sculean, 2004). In contrast, Braun et al. (2010), whocompared the Er:YAG laser with sonic tools used inperiodontal maintenance, have clearly shown thatthe pain experienced by patients during maintenancesessions using the Er:YAG laser was less significantcompared to conventional sonic tools. The use of anEr:YAG laser in periodontal maintenance is morecomfortable for the patient than conventional tools,as already anticipated by Tomassi et al. in 2006.

In the literature currently available, the Er:YAGlaser has been tested on shallow pockets only (4–6 mm maximum) in periodontal maintenance. Itwould be interesting to test this laser in maintenanceprocedures that include periodontal pockets largerthan 6 mm and compare the laser with manual tools.The therapeutic properties of the Er:YAG laser offerminimally invasive surgical efficiency, particularly ininaccessible areas (Eberhard, 2003). In comparison,significant limitations are associated with the use ofmanual instrumentations in these hard-to-reach ar-eas to ensure periodontal maintenance (Matuliene &Lang, 2008).

The Er:YAG laser should allow a more effectivecontrol of biofilms in furcations and in periodontalpockets larger than 6 mm. The treatment of peri-odontal surfaces using the Er:YAG laser promotes pe-riodontal healing. Fibroblast attachment on root sur-faces that is treated by using an Er:YAG laser is higherthan those treated by using traditional sonic tools(Schwarz, 2003; Crespi et al., 2006).

Alternative to local antibiotics

The local application of antibiotic gels has gener-ated much interest since it allows significant localconcentrations of active ingredients to be achievedin periodontal pockets (Ciancio, 1995). However, theproblems of a possible resistance and side effectscaused by the repeated use of these products still re-main. Applying clinical doses of antibiotics to extra-periodontal sites such as the tongue or the tonsilsmay induce resistance in the bacterial flora (Roberts,2002).

The bactericidal effects of the Er:YAG laser arelikely to make it a beneficial alternative to these med-icines. In any case, even though the topical applica-tion of antiseptic or antibiotic molecules is a usefultherapeutic method (Quang et al., 2002), the destruc-tion of significant biofilms and solubilisation of micro-organisms made possible by the use of anEr:YAG laser can only be beneficial in potentiatingthis treatment strategy.

_Er:YAG laser in periodontal maintenance protocols

As we have already seen, the Er:YAG laser has asignificant and effective impact, identical to that ofconventional instrumentations, when used in theinitial periodontal decontamination therapy. Itsphotomechanical properties and the ergonomic de-sign allow for a minimally invasive treatment. There-fore, the Er:YAG laser can be integrated into peri-odontal maintenance treatments as a preventivetool for deep sites that are inaccessible to conven-tional tools.

18 I laser4_2014

Fig. 5

Fig. 6

Mousques et al. (1980), Magnusson et al. (1984)and Van Winkelhoff (1988) have demonstrated therecolonisation of cleaned sites 2–8 weeks after theinitial therapy. They highlight the need for a regularand deep cleansing to stabilise the periodontal bal-ance. Eccheveria et al. (gingival attachment loss,1983), Gantes et al. (tooth substance loss, 1992) andZappa et al. (pulp trauma, 1991) have demonstratedthe trauma related to repeated subgingival use ofmechanical tools.

Hemrev et al. (2006) point out the usefulness ofsolubilising biofilms during periodontal mainte-nance to expose bacteria that are isolated from theimmune system. To respond to these requirementsand overcome the disadvantages associated with re-peated subgingival intervention, the Er:YAG laser of-fers an alternative for periodontal maintenance of at-risk sites, thanks to its photothermal and photome-chanical properties. Therefore, we propose that thistool will be integrated into periodontal maintenanceprotocols, alongside conventional tools.

Such a maintenance session could be described asfollows:– Application of plaque-disclosing agent to identify

areas of dental plaque retention.– Supra-gingival and subgingival scaling (if neces-

sary) using sonic tools. Side remark: In theory, if themaintenance programme is well scheduled and re-spects the required frequency, there will be no sub-gingival tartar.

– Supra-gingival and subgingival polishing and airpolishing on areas deeper than 4 mm.

– Conventional tools using manual curettes on areasdeeper than 4 mm.

– Use of Er:YAG laser to irradiate furcation areas, ar-eas inaccessible to conventional tools and sites thatare higher than 4 mm.

Laser settings

It is the energy delivered by a laser beam whichproduces the therapeutic effect. To limit side effectsand particularly thermal effects, the energy applied inperiodontal maintenance should be low as long as the

industry report I

Fig. 7_LiteTouch Er:YAG,

“Laser-in-the-Handpiece”.

I 19laser4_2014

In the past 15 years, I have been focusing on periodontology in my work. But at the beginning of my career, I practised endo donticsexclusively and have also resumed the practice of implantology during the past seven years.

Endodontics allowed me to discover the surgical microscope, which in turn made it possible for me to develop a non-invasive periodontal decontamination technique which is an intermediate route between the surgical approach and non-surgical techniques. Optical aids are key elements of this surgical concept. However, I have already been using an integrated Er:YAG laserin my clinical protocol for five years. This technology has provided me with a tool that offers the level of precision required for decontamination microsurgery.

The ergonomic design and exceptional performance of the LiteTouch laser allows me to work in a highly efficient manner with optical aids, achieving tissue micro-ablation under a visual check and by destabilising the biofilms. Its anti-inflammatory and antiseptic effects are fundamentally important for periodontology.

The strong water absorption for which the Er:YAG laser is known means that it is suitable for multiple surgical applications particularly in the area of gingival microsurgery and in assisted pre-implant bone regeneration procedures. In my opinion, theEr:YAG laser has become an indispensable tool for non-invasive procedures.

Testimonial

Fig. 7

I industry report

Fig. 8_LiteTouch,

Er:YAG laser device.

Fig. 9_Dr Fabrice Baudot working in

his clinical practice.

treatment is not performed under direct visual con-trol like it is performed in surgery. As we have alreadyseen, the energy delivered by the Er:YAG laser at 2,940 nm has a very high water absorption rate. Thisphysical property makes the Er:YAG highly efficientat low energy levels and has allowed it to establish it-self as a standard in the field of periodontal mainte-nance among the various laser wavelengths used indentistry (Walsh et al.,1989).

The objective is not to eliminate tissue, but ratheronly to break down biofilms and solubilise micro-or-ganisms so as to make them accessible to the immunesystem. 1–2 watt of power will be sufficient toachieve these results with the Er:YAG.To avoid ther-

mal elevation by repeated applications, we recom-mend a frequency of approximately 20 Hz. Thus, theenergy delivered upon each impact may be between50 mJ and 100 mJ.

It is preferable to apply the laser beam in a contin-uous scanning motion inside and at the entrance of

the periodontal pockets, moving towards the bot-tom. This motion will have three advantages:– Limitation of possible thermal effects.– Agitation of the water delivered to the inside of

the periodontal pockets using the laser hand-piece.

– Maximisation of the treatment on all surfaces ofthe pocket by means of direct irradiation fromthe beam.

_Conclusions

Periodontal maintenance after initial (sur-gical or non-surgical) periodontal therapy isan integral part of the periodontitis-manage-ment strategy; indeed, it could even be

deemed to be essential. It consists of stabilising theperiodontal balance between the microbial flora andthe immune system established in the initial step. Thisobjective can be only achieved through gentle, effi-cient and repeated application at a frequency that isadapted to the patient’s needs. We have seen thatthere are a number of gaps in the range of conven-tional mechanical tools that are currently in use, al-though this is still somewhat efficient. Thanks to itsphysical and biological properties, the Er:YAG lasercan be integrated into the currently used mainte-nance protocols.

In addition to its effectiveness on inflamed tissuesand biofilms, the Er:YAG laser offers surgical comfortthat is fundamental for the observance of periodon-tal maintenance treatment as already suggested bySanz et al. in 2008 during the 6th European Workshopon Periodontology._

20 I laser4_2014

Dr Fabrice Baudot

Parodontologie et Implantologie

65, impasse des 3 pointes

34980 Saint Gély du Fesc

fabrice.baudot@me.com

_contact laser

Fig. 9

In addition to its effective-

ness on inflamed tissues

and biofilms, the Er:YAG

laser offers surgical com-

fort that is fundamental for

the observance of periodon-

tal maintenance treatment.

24. JAHRESTAGUNG DER DGL

LASER START UP 2015

27. und 28. November 2015in BerlinHotel Palace

LJ 8/14

Praxisstempel

Faxantwort0341 48474-290

Bitte senden Sie mir das Programm zum/zur

❏ LASER START UP 2015 ❏ 24. JAHRESTAGUNG DER DGL

am 27. und 28. November 2015 in Berlin zu.

Name/E-Mail

Programm anfordern!

Impressionen23. Jahrestagung der DGLLASER START UP 2014

I industry report

Fig. 1_Different shapes and lengths

of laser fiber tips.

_The elimination of calculus and bacterial mi-cro-flora has been a time-tested modality in treatingchronic periodontitis. To date, several approacheshave been introduced to achieve a complete elimina-tion of calculus, plaque and necrotic cementum. Handand ultrasonic instrumentation has long been con-sidered as the most effective and convenient methodof plaque and calculus removal. These conventionaltreatments, however, leave the root surface coveredwith a smear layer that contains germs and bacterialendotoxins. Also, with ultrasonic instrumentation,more damaged and rougher surfaces have beenseen.1, 2

Of late, research on the use of different lasers forcalculus removal such as CO2, Nd:YAG and Er:YAG has

been conducted. Of these, the Er:YAG laser is believedto be the most effective due to its absorption capac-ity by water. It induces root surface changes which aremore biocompatible for soft tissue attachment andthus improves the treatment outcome of periodontaldisease.3, 4 Thus the aim of the present study was toanalyse the effects of the Er:YAG laser as compared tohand and ultrasonic scaling on fibroblast attachmentto periodontal diseased root surfaces.

_Materials and Methods

Patients with chronic periodontitis reporting tothe M.A. Rangoonwala College of Dental Sciences andResearch Centre in Pune were selected for the study.The patients included in the study were non-smokers,systemically healthy and were of age ≥ 35 years. Pa-tients selected presented with at least one periodon-tal involved single-rooted teeth indicated for extrac-tion. 15 such teeth extracted from different selectedpatients were used in the study. Patients with a his-tory of antibiotic treatment in the past four monthswere excluded from the study.

Immediately after extraction, blood, saliva andsoft-tissue debris were removed by light scrubbingwith a sterile scrub and by rinsing with sterile salinesolution. Two specimens were obtained from eachtooth by cutting with a sterile diamond disk runningat low speed with sterile water coolant.

The coronal sectioning was done 1 mm below theCEJ and the apical sectioning was done 4 mm from theroot apex. Longitudinal buccolingual sectioning was

Comparing the effects of manual, ultrasonic & Er:YAGlaser treatmentAn in-vitro study on chronical periodontitis patients

Authors_Dr Zulala Tasneem, Dr Salika Sheikh, Dr. Rahul Kale, Dr Naresh Thukral & Dr Sangeeta Muglikar, India

22 I laser4_2014

Fig. 1

industry report I

done to expose the pulpal wall and to obtain two spec-imens from each root. To avoid contamination from thepulp, the pulpal wall was separated from the remainingouter portion of root dentin using a bur running at lowspeed. A total of 30 specimens thus obtained from allselected teeth were randomly assigned to threegroups:

Group A (n =10 treated with hand scaling)Group B (n = 10 treated with ultrasonic)Group C (n =10 treated with Er:YAG laser)

Specimens of Group A were hand scaled usingGracey curettes 1–2, 3–4, 5–6, 7–8 until all the visiblecalculus was removed. Specimens of Group B werescaled with ultrasonic for 60 sec until all the visiblecalculus was removed.

Specimens of Group C were treated with an Er:YAGlaser system (wavelength = 2.94 µm, Fotona, Slovenia)used at 160 mJ/pulse at 10 Hz, equivalent to the energydensities of 94 J/cm2 per pulse. The laser was used incontact mode under water irrigation. A laser sapphiretip was used in a parallel direction along the root sur-face with an angulation of 20 degree for 40 sec for eachsample. Root specimens were then placed in a petri dishcontaining anti-bacterial and anti-fungal solution toavoid contamination for 1 hour. Specimens were thenthoroughly rinsed in Dulbecco’s Phosphate BufferedSaline and covered with 2 ml fibroblast L929 suspen-sion. Cell culturing was done at 37 degrees in a humid-ified atmosphere of 95% air and 5% CO2 for 3 days.

5ml of cell suspension was seeded into the tissueculture containing root samples and incubated for 3days. At the end, the cells were rinsed with Dulbecco’sBuffered Saline (DPBS) and fixed by DPBS solutioncontaining 4 % glutaraldehyde. Fixed samples dehy-drated by passing through ethanol/water solutionwere immersed in hexamethyldisilazane for 30 min tocomplete the dehydration. Dehydrated cells werespluttered with gold and were observed by scanningelectron microscopy to view fibroblast attachment tothe root surfaces of the specimens.

_Results

Fibroblast morphology on all treated surfaces wasobserved and was found to be different following dif-ferent treatment modalities. In the Groups treatedwith hand scaling and ultrasonic scaling, scattered flatand healthy fibroblasts with a low number of lamel-lipodia and attachment extensions into the wavy sur-faces, covered with smear layer, were observed. In theEr:YAG laser group, the treated surfaces were ob-served to be covered by a confluent monolayer of flat,spindle-shaped fibroblasts, which were firmly at-tached to the root surface by means of many lamel-lipodia and attachment extensions.

_Discussion

In periodontal treatment, mechanical removal ofplaque and calculus is mandatory to control and pre-vent inflammatory processes. When ultrasonic andhand instrumentation were compared in clinicalstudies5, 6, results showed reductions in probingdepth and bleeding on probing. However, mechani-cal instrumentation leaves the root surfaces coveredwith smear layer that obliterates the orifices of thedentinal tubules and contains germs, bacterial endo-toxins and residual contaminated root cementumthat hampers good periodontal healing and regener-ation of connective tissue attachment.7

Er:YAG laser, however, is shown to induce a rootsurface that has better biocompatibility for soft-tis-sue attachment. It removes lipopolysaccharides, calcu-lus, smear layer and cementum, providing high bacte-ricidal potential at a low energy level on the root-in-fected dentin layer.8, 9 In the present study we found

Fig. 2_Dental X-ray picture.

Fig. 3_Close up of a dental calculus

removing.

I 23laser4_2014

Fig. 2

Fig. 3

[PICTURE: © PASHIN GEORGIY]

[PICTURE: © OCSKAY MARK]

I industry report

Fig. 4_Periodontal treatment

parameters, presaved in Fotona

laser.

Fig. 5_Ultrasonic scanner.

that the fibroblasts were tightly attached to speci-mens treated with Er:YAG laser as compared to spec-imens treated with hand and ultrasonic instruments.

Frentzen et al.10, in a histologic study compared theeffects of Er:YAG instrumentation of diseased rootsurfaces to mechanical removal of plaque and calcu-lus with ultrasonic instrumentation. The resultsshowed that ultrasonic debridement resulted in asmooth surface covered by a smear layer11 containingremnants of dental debris, contaminated root ce-mentum, bacterial endotoxin and subgingivalplaque12, 13 whereas Er:YAG laser irradiation induced aglazed microstructure presenting a rough aspect tothe root surface.

Babay14 evaluated fibroblast attachment to peri-odontal involved root surfaces, which were eitherroot planed with curette, ultrasonic scaler or acidchelated by different agents such as citric acid, tetra-cycline hydrochloride or EDTA to produce differentsurface textures. The results demonstrated that therewas a significantly greater number of fibroblasts at-tached to specimens treated with citric acid, tetracy-cline, and EDTA than those scaled only, which means

that fibroblasts were more likely to attach to rough-surfaced than to smooth-surfaced specimens.

Er:YAG laser induced a homogenous roughness tothe root surfaces15-17; this morphological roughnessof lased surfaces enhances the adhesion and prolifer-ation of fibroblasts, which are present in higher num-bers than those of the ultrasonically treated speci-mens. This surface transformation obtained by theEr:YAG laser probably exposes chemical root sub-stances that are highly selective for chemotaxis to fi-broblasts.18

It has been suggested that the biochemical modi-fications of the root surface induced by the use of anEr:YAG laser are responsible for an increase in fibro -blast attachment. These modifications could be eithera direct consequence of root conditioning by the ex-posure of some of the extracellular matrix con-stituents acting on the attachment mechanism of fi-broblasts or an indirect effect of biochemical factors,from increased fixation on the demineralised rootsurface. The results of the present study concurredwith the previous studies.19

Study results were similar to those obtained byFeist et al.20, who studied fibroblast adhesion andgrowth or cultured human gingival fibroblasts onroot surfaces treated by both Er:YAG laser and curette.He found that fibroblasts adhered to and grew on alltreated surfaces, but the group lased at 60 mJ/pulse,10 Hz, presented a significantly higher cell count thanthe other groups.

_Conclusion

Thus the present study suggests that laser treat-ment could be an important and useful tool to inducea modification of root surface morphology with acomplete elimination of the presence of the smearlayer, improving fibroblast attachment. Future exten-sive and well-controlled studies are needed to con-firm this hypothesis.

Editorial note: A list of references is available from the

publisher.

24 I laser4_2014

Dr Zulala Tasneem

M. A. Rangoonwala College Of Dental Science &

Research Centre

2390-B, K.B. Hidayatullah Road

Azam Campus

Camp Pune 411001

Maharashtra, India

_contact laser

Fig. 4

Fig. 5

[PICTURE: © GTFOUR]

_When digital dental radiography was firstintroduced in the late 1980s, conventional X-rayshad been in use for almost a century. The radi-ograph had, over the years, expanded the dentist’sinvestigative capacity in many ways; it was possi-ble to confirm health, or to detect disease, in manypreviously invisible areas of concern to the profes-sion, including coronally, pariapically, and peri-odontally. Visual access, complemented by radi-

ographic interpretation, provided a comprehen-sive environment for earlier and more accurate di-agnosis.

_Advantages of digital radiography

For the practitioner, the lost production of theconventional X-ray’s developing downtime (5 to 10minutes) has always been a very costly break in theproduction day. The virtually immediate computer-generated radiographic image eliminates this irri-tating issue. For the dental team, the elimination ofthe darkroom, its chemicals, solution replenishmentroutines, foul odours, and increasingly complicatedenvironmental liabilities are welcome changes.

Modern digital radiographic systems today pro-vide highly accurate and clinically relevant diagnos-tic information. Their many advantages include: virtually immediate results, clinical accuracy, ex-panded diagnostic options, decreased patient radi-ation, convenient data storage and communication,ease of clinical use by auxiliaries, decreased con-sumable costs, and a more environmentally friendlyprofile.

_Digital radiography options

Several categories of innovative dental radi-ographic imaging technologies have been intro-

I technology

Fig. 1_Wireless digital sensor

technology is the most popular digital

radiography process worldwide.

Fig. 2_Wired chip sensors with

bitewing images.

Fig. 3_The PSP sensor is quite

pliable and has a reasonable flex

upon insertion into the mouth.

Wireless digitalsensorsAuthor_George Freedman, Canada

26 I laser4_2014

Fig. 1

Fig. 2

Fig. 3

[PICTURE: © GONCHARUK MAKSIM]

technology I

duced into the dental marketplace. In general, theycan be used with existing X-ray units. As a majorbenefit to dental patients, a significant decrease inradiation emission is required. Practitioners look-ing to update and upgrade their traditional (silverhalide) radiographic systems have excellent clini-cal options. One of the most important selectioncriteria is the sensor-to-computer data transfermode. Some digital chip sensors, such as the CCD(Charge Coupled Device) and CMOS (Complemen-tary Metal Oxide Sensor), are hardwired to thecomputer through a USB or utilise a Bluetoothconnection. The digital PSP (Phosphor StoragePlate) sensors (ScanX, Air Techniques, Melville NY)are wireless, and are most similar in appearance,function and convenience to traditional radi-ographic film. Wireless digital sensor technology(Fig. 1) is the most popular digital radiographyprocess worldwide, with more than 50,000 den-tists having incorporated PSP into their practices.The three types of sensors, CMOS, CCD, and PSP areequivalent in terms of the data that they accumu-late per square millimetre during their very briefexposure to ionizing radiation, and then transfer toa digital image format.

Sensor diagnostic surface area

Sensor dimensions are crucial to diagnosticutility. The larger the active surface (or image) area,the greater the amount of information the sensorprovides to the practitioner. A traditional size 2 filmprovides about 1,100 mm2 of diagnostic area. Sim-ilarly, a size 2 ScanX wireless digital sensor offers1,080 mm2 of diagnostic area. Digital chip sensorstypically have a smaller active area, providing cor-respondingly less diagnostic information. There isa further complication for the wired chip sensorswith bitewing images (Fig. 2). The sensor wire mustbe placed between the posterior teeth, preventingtheir complete intercuspation. Unlike a thin card-board or plastic bitewing tab, the wire is 4–6 mm indiameter, leaving the teeth that distance apart. Theresulting empty interocclusal space is non-diag-nostic for dental structures, and in fact, preventsthe effective imaging of the gingival areas and the

crestal bone. This often necessitates a vertical re-orientation of the sensor and/or more radiographs,requiring a greater radiation exposure for the pa-tient (Fig. 3).

Sensor thickness

The thickness of the sensor can be a major bar-rier to patient comfort and proper positioning ofthe sensor. A traditional size 2 film, at approxi-mately 1.0 mm of thickness, can be rather uncom-fortable for some patients, particularly individualswith small mouths or conditions such as lingualtori. Wired digital sensors range from 5.5–8.3 mmin thickness. Their thickness makes them more dif-ficult position in the mouth and more difficult forthe patient to retain comfortably. The ScanX wire-less digital sensor is less than half as thick as a con-ventional X-ray film at 0.4 mm. Furthermore, un-like the rigid, wired sensors, the PSP sensor is quitepliable and has a reasonable flex upon insertioninto the mouth (Fig. 4), significantly increasing pa-tient comfort.

Fig. 4a & b_In some cases, effective

imaging requires a greater radiation

exposure for the patient.

Fig. 5_ScanX wireless digital sensors

are available in different sizes.

I 27laser4_2014

Fig. 4a Fig. 4b

Fig. 5

I technology

Fig. 6_ScanX wireless digital sensors

for standard bitewing.

Fig. 7_ScanX wireless digital sensors

periapical.

Fig. 8_ScanX wireless digital sensors

endodontic.

Fig. 9_ScanX wireless digital sensors

panoramic.

Fig. 10_ScanX wireless digital

sensors cephalometric.

Wireless sensor size range

ScanX wireless digital sensors are available in arange of sizes (Fig. 5): #0 and #1 for smaller and/orconstrained mouths, #2 for standard bitewing, (Fig.6) periapical, (Fig. 7) and endodontic (Fig. 8) images,#3 for long bite wings, #4 for occlusals, panoramic,(Fig. 9) cephalometric, (Fig. 10) and TMJ. Each sen-sor is a reusable plate that is inserted into a dispos-able protective barrier sleeve, positioned as re-quired, briefly exposed, scanned and the data is im-mediately transmitted to the computer for imagedisplay. During the scanning, the data is automati-cally erased from the sensor, preparing it for imme-diate re-use in a new protective barrier sleeve.

The intraoral sizes are fabricated of a flexiblysoft, reusable plastic that can be curved extensivelyto better fit the patient’s mouth. If the digital sen-sor is bent to the point where the surface cracks,the broken portion of the sensor surface can nolonger provide diagnostic information. With rea-sonable care, each sensor should last for thou-sands of images.

_Digital sensor replacement cost

Most breakdowns of chip sensors occur at thewire-sensor interface. While this should be easily(and inexpensively) repairable, there is a generalreluctance to refurbish this connection, and thedentist is placed in a position where new sensorsmust be acquired. Whether the problem is acrushed chip or a frayed lead cable, wired digitalsensors are very expensive to replace (often US$5,000–10,000 or more).

In fact, it is highly advisable to have a replace-ment (insurance) policy with the manufacturer ordealer to cover these eventualities. The replace-ment warrantee is typically more than US$1,000per year per sensor. Wireless sensors, on the otherhand, are far less costly; a size #2 replacement sen-sor costs about US$40. Moreover, there are nowires to break. Considering a lifespan of thousandsof exposures, the per-use cost of a PSP digital sen-sor is negligible.

_Developing/scanning time

Conventional X-rays were developed to imageviewability through chemical baths, water rinsesand air dryers. The process was long and frustrating,particularly if the results were needed quickly. Afterintraoral exposure, a single film might be ready in5–6 minutes, but a full mouth series took 10 min-utes or longer. Wired digital sensors transmit theionization data to the software immediately, andthe images are ready for viewing as soon as they areprocessed (typically a very minimal delay).

ScanX wireless digital sensors are placed in thesmall footprint scanning unit, ScanX Swift (Fig. 11)and the images are available for viewing momen-tarily. The first PSP image is ready within 11 seconds,and subsequent one take 4 seconds each. Thus, a 4-bitewing series is ready for viewing in less than 30 seconds, and a full mouth series within 2 min-utes. The unit automatically erases all the data oneach wireless sensor, readying it for the next radi-ograph.

28 I laser4_2014

Fig. 6 Fig. 8Fig. 7

Fig. 9

Fig. 10

technology I

_Image enhancement

Digital radiographs have higher resolution thanconventional film, and are thus clearer and moreaccurately diagnostic. The ScanX software hasadditional image enhancement tools that al-low dentist to manipulate the acquired raw im-ages (brightness, contrast, false colour, rever-sal) for additional analytic data without re-ex-posing the patient to additional radiation.These investigative tools are very valuable inpinpointing issues more specifically and farearlier than ever before. The software is intuitiveand easy to use.

Viewing digital images on a screen has signif-icantly improved both the way that practitionersdiagnose their patients and the means wherebythey develop simple and extensive treatmentplanning. The size of the monitor offers on-screenco-diagnosis and co-treatment planning that ac-tively involve the patient in the dental treatmentprocess.

_Data storage

The practice’s radiographic data is ideallystored in a single location on the office servercomputer from where it is readily accessible to allthe operatory. Since radiographic image files arerather large (and compression may cause the lossof important details), it is important to dedicateadequate storage space that can accumulate atleast 3 years’ worth of data. Cephalometric andpanorex images are particularly space consuming.Off-site and multiple location backups are goodsafe-computing practices that eliminate the un-likely, but potentially disastrous results of fire,flood, or a total irreversible failure of the storagedrive.

_Conclusion

Digital dental radiography is faster, cleaner,more effective and better than silver-based film.More than 99 per cent of dentists who use digitalradiography recognize that it was a good invest-ment. The obvious advantages include: immediacyof the images, decreased radiation exposure, imageenhancement, digital storage, and the eliminationof chemicals. The mainstream acceptance of digitalradiography has been slowed by high start-upcosts, however. Some of the earlier objections suchas rigidity and bulkiness of sensors, sensor corddamage, and ongoing maintenance and repair havebeen eliminated by the PSP wireless digital sensors.While the initial costs of conversion to digital radi-ography may be high at first, the long-and short-term clinical and financial benefits of digital radi-ography are well worth the investment._

Fig. 11_ScanX wireless digital

sensors are placed in the small

footprint scanning unit, ScanX Swift.

I 29laser4_2014

Dr George Freedman is a

founder and past president of the

American Academy of Cosmetic

Dentistry, a co-founder of the

Canadian Academy for Aesthetic

Dentistry and a Diplomate of the

American Board of Aesthetic

Dentistry. His most recent text-

book, “Contemporary Aesthetic Dentistry” is pub-

lished by Elsevier. Dr Freedman is the author or co-au-

thor of 12 textbooks, more than 700 dental articles,

and numerous webinars and CDs and is a Team Mem-

ber of REALITY. Dr Freedman was recently awarded

the Irwin Smigel Prize in Aesthetic Dentistry presented

by NYU College of Dentistry. He lectures internation-

ally on dental aesthetics, adhesion, desensitization,

composites, impression materials and porcelain ve-

neers. A graduate of McGill University in Montreal,

Dr Freedman is a Regent and Fellow of the Interna-

tional Academy for Dental Facial Aesthetics and main-

tains a private practice limited to Aesthetic Dentistry

in Toronto, Canada.

epdot@rogers.com

_about the author laser

Fig. 11

I economy

30 I laser4_2014

_Language competency can mean different

things to different people. A dentist and dentalnurse for example, will use a completely differentvocabulary to discuss the care of a patient to the onethey will use when explaining the treatment andprognosis to the patient and his or her family. A dif-ferent approach also needs to be adopted when giv-ing emotional and palliative support to the patientand his or her relatives.

Socio-economic change over the past 65 yearshas allowed international migration and led to mul-ticultural societies that would have been unthink-able two generations ago. Improvements in trans-port links, combined with changes in political andsocial attitudes towards professional and skilled mi-grant workers, have presented significant opportu-nities to those wanting to work abroad. There are anumber of professional qualifications that are ac-cepted globally, allowing dental practitioners towork without having to retrain before applying fornew overseas posts.

_What about language skills?

It is widely acknowledged that it is only a matterof time before all members of our profession, not

Staying ahead in dentistryPleading for language competency and communication skills

Authors_Simon Beeston & Dr Ross King, UK & Australia

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economy I

just those from outside the EU, will have to demon-strate that they are proficient in English if they wishto practise in the UK. A dentist needs to be able tocommunicate on social, palliative and clinical levelsusing appropriate language for all three. For exam-ple, good social English is not specific enough whenhaving to ask a patient appropriate questions dur-ing a consultation, and a dentist and dental nurseneed to use specific clinical vocabulary to commu-nicate effectively during a procedure.

Dentistry differs from other health professions inthat much of what a dentist does is procedural. Itdoes not just entail consultation: it also entails ex-plaining to every patient what is being done, why itis being done and what the experience is likely to be.Treatment plans and alternatives need to be clearlyexplained and understood. Records have to bemaintained accurately and be fully comprehensibleto another dentist if it is a group practice. Letters ofreferral must be comprehensive and unambiguous.

Another factor that is relevant to the UK, Australiaand New Zealand is that all three countries have alarge number of immigrants, so it is not at all uncom-mon to have the situation in which neither dentist norpatient has English as his or her first language. In thissituation, competency has to be at a high level.Workarounds such as telephone-based interpreterservices have been trialled but often dismissed as un-suitable, as they rely on the interpreter having pro-fession-specific vocabulary in multiple languages.

_Demonstrating English proficiencywith IELTS and ORE

In order to work in many English-speaking coun-tries, dental professionals whose first language isnot English and have not trained on a course taughtin English often need to demonstrate a level of com-petency by way of an International English Lan-guage Testing System (IELTS)* examination or simi-lar. However, the required IELTS score varies fromgoverning body to governing body and from coun-try to country. Overseas-qualified dentists fromoutside the European Economic Area whose quali-fications are not eligible for full registration with theGeneral Dental Council (GDC) in the UK are requiredto pass the Overseas Registration Examination(ORE). Successful completion of the ORE allowsthese dentists to register with the GDC and practiseunsupervised in the UK. Prior to taking the two-partexamination to demonstrate their clinical skills andknowledge, applicants must submit details of theirclinical experience and a single academic IELTS testreport form less than two years old with a minimumoverall band score of 7.0 and no score lower than 6.5in any section.

However, overseas-qualified dentists fromwithin the European Economic Area are currentlyexempt from submitting an IELTS test report form aspart of the ORE, although this might change withinthe next several years. The UK government is cur-rently consulting on changes to the Medical Act1983 that would introduce legislation to “seek tostop foreign healthcare professionals working inthe NHS unless they have passed robust languageand competence tests”. The proposed amendment ismore comprehensive and includes both EU nation-als and non-EU nationals. While the proposedamendment does not currently affect dentistry, it ishighly likely that the GDC would follow suit andtighten its English language competency require-ments further still.

The GDC should be applauded for setting the baron language assessment with UK dentistry and go-ing beyond what is currently required by the Med-ical Act1983. The very fact that candidates mustdemonstrate their language proficiency before sit-ting an examination demonstrates the importanceof good communication. Any change in legislationor desire to improve language practice would be anopportunity to make language proficiency require-ments at entry more industry-specific.

_Profession-specific examination with OET

With this in mind, it is instructive to review howtighter English language controls have already beenimplemented in Australia. The Australian DentalCouncil (ADC) requires overseas-trained dentalpractitioners to complete a three-part exam, onepart being proficiency in English. As well as IELTS, theADC recognises Cambridge English Language As-sessment’s Occupational English Test (OET)**, whichdiffers from IELTS in providing a profession-specific,

I 31laser4_2014

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I economy

fit for purpose assessment that uses typical clinicalscenarios to test knowledge and use of language. OETincludes four subtests (on listening, reading, writingand speaking) and, uniquely, all of these tests arerooted in the context of working as a dentist and us-ing specific language that is relevant to being effec-tive as a dentist. A typical example in the dentistryspeaking examination presents the candidate (whoplays the role of a dentist) with the scenario of a par-ent of a six-year-old boy who grinds his teeth atnight, asking for advice about this problem. The par-ent is on a limited income and is very concernedabout the extent of possible treatment. In this exam-ple, the candidate is required to explain the boy’sproblem, tell the parent ways of dealing with theproblem, and reassure the parent about his or herconcerns.

In the context of the clinical scenario, the candi-date must demonstrate that he or she not only un-derstands the vocabulary, but also can recognise thecontext and subtle variations of the conversationand respond accordingly. This particular scenario in-cludes language functions concerning asking for ad-vice, expressing concern, and looking for reassur-ance that would be common in a clinical communi-cation event. The candidate’s use of language mustdemonstrate that he or she understands that he orshe is not a friend putting an arm around the parent’sshoulder but a professional giving advice tailored tothe parent’s circumstances in a competent and au-thoritative manner.

_Lack of confidence is common causeof failure

Several years ago, the ADC identified that a lackof confidence in English was by far the most com-

mon cause of failure among candidates. As a result,the ADC raised the entry requirement from OETGrade C to Grade B in each of the OET subtests. Sub-sequently, the requirement has been raised furtherto grades of A or B. Personal experience also high-lights cases in which, despite demonstrating the re-quired language skills prior to entry, clinically excel-lent fifth-year dental students had English lan-guage skills that were inadequate and not fit forpurpose. Rather than indicating any failure inteaching, this simply reinforces the need to providespecific training in clinical communication skills.

By introducing enhanced language testing re-quirements, it is vitally important to ensure that ex-aminations are not only fit for purpose, but easilyadministered, fair and secure. Cambridge EnglishLanguage Assessment’s experience in runningglobal, high-stakes, secure examinations, such asIELTS and OET is the best and meets very high stan-dards in terms of authentication, security, reliabilityand validity. The organisation’s expertise and repu-tation can help provide regulators with a high levelof confidence.

One issue that we are very aware of in the UK isincreasing pressure on limited resources leading torestructuring within the National Health Service.With global issues of an ageing population, peopleliving longer and a greater need for health care,there is going to be more scrutiny on regulators torecruit internationally to meet the resourcing needs.Testing language competency and communicationskills is fundamental to this changing landscape inhealth care, and examinations such as OET are be-coming increasingly important in this, in terms ofnot just regulation, but also ensuring patient safetyand patient outcomes._

*IELTS is jointly managed by the British Council, IDP: IELTS Aus-

tralia and Cambridge English Language Assessment.

**OET is owned by Cambridge Boxhill Language Assessment Pty

Ltd. It is a joint venture between Cambridge English Language As-

sessment and Box Hill Institute.

32 I laser4_2014

Simon Beeston

Director of Admissions Testing Service

University of Cambridge in the UK

thenetwork@cambridgeassessment.org.uk.

Dr Ross King

Executive Secretary

Australian Dental Council

info@dentalcouncil.net.au.

_contact laser

[PICTURE: © ORLA]

Integration, Knowledge and Technology in the same place!

São Paulo - Brazil

São Paulo In te rna t iona lDental MeetingJanuary 22-25, 2015

Organizer

Support International Media

SÃO PAULO DENTAL ASSOCIATION

Exhibit Inquiry: SUVISON, a soleworld agent, sp2015@suvison.com

CIOSP_A4_2015.pdf 1CIOSP_A4_2015.pdf 1 22.10.14 11:5822.10.14 11:58

I economy

_In order to gain power at your laser clinics,a co-herent marketing strategy is of need. In the previous is-sues of laser, we already discussed components of the“Seven P Formula” which are product, price, promotion,place, packaging, positioning and people. The next P inmy list is “people”. This is the most important elementthat will ensure our clinic’s success or failure! Thereforelet’s stick to two maxims:

1. Hire for the attitude, knowing that we can train to de-velop the technical skills. Before we start the wholeprocess of selecting our candidates, we should makea list of the attributes of the ‘best’ employee. This listwill assist us in having a clear picture of what we arelooking for.

2. After the job posting, the resume screening processstarts in which we can select our star.

Let’s think of the whole process as a movie in fourscenes.

_How to find your perfect candidate

Scene 1

We get the resume, we screen them and in the mean-while we send thank-you letters to all interested candi-dates.

Scene 2

We continue with the second screening which is call-ing the candidates and asking each the same questionsto avoid biases. We can check their responses and be-haviour by means of their way of answering.

Scene 3

The selected candidates arrive on the day of the firstinterview. Here are some useful screening tips:

– We could give them an application form and ask themto fill in the required information. Some of the candi-dates cannot comply with this request or might evenmiss out some paragraphs or questions asked. Withthis, we can check how well they act, write and spell onspot.

– Do not permit any interruptions; show your respectand importance to the process.

– Mind the 30–70 % rule, which means letting the in-terviewee do 70 % of the talking and you as the inter-viewer do the remaining 30 %. We need to learn asmuch as possible about every individual.

– Ask ‘open questions’ to allow the candidate to sharehis thoughts and ideas. Additionally, we can use situ-ational interviews. Studies show that these are 50%more effective than the common ones and can bemore predictive of the candidate’s success to the post-

34 I laser4_2014

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

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ing. We can ask them, for example, to describe howthey would handle an angry patient when he shoutsat the reception area due to our 20 minute delay. In-stead of asking whether they are good in customerservice, let’s prefer the following question: “Give me anexample of a situation you remember that you gave a‘wow service experience’ to a client or the time thatyou received one.” These are the so-called behaviouralquestions and we can use them for a more effectiveinterview.

– What is the optimal duration of an interview? It shouldlast until we are satisfied with the whole procedure,until we do not have any doubts about our decision.

– We must be the master of the interview. This means,we must be well prepared and be the one who is rulingthe process.

Scene 4

After choosing the best candidates, we ask them fora testing period, which is paid. More specific, if there areabout three candidates, we can ask them for a work trialof 3–5 days each. This gives us the opportunity to seehow they act in our environment. By this, we can alsofind out more about their skills, or if their personalitiesdo not match with ours.

“Find the best employee not the best candidate”—What is the difference? There are some candidates thatare more experienced in an interview or better preparedand trained in answering interview questions than oth-ers. But this does not mean that they are also the bestemployees. We are not going to hire the best candidatethat applied for the job but we are going to select thebest – period! Remember to send thank-you letters tothose candidates that have not been selected.

Scene 5

After the testing period, we continue with the sec-ond interview. Here, we can explore fields that we hadn’t discussed before and can thus gain a completepicture of our candidate. In order to get a reliable pic-ture, just mind the following rules:

Remember to avoid mistakes! Therefore, mind the“14 seconds”-mistake: A study which was carried out atthe University of Chicago revealed that most interview-ers decide on a candidate within the first 14 seconds. Af-ter that, interviewers try to support this impression evensubconsciously. This means, in case of a candidate theinterviewer dislikes, he asks difficult questions, while inthe other case (interviewer likes candidate) he helpstheir candidate with the posed questions. Be prepared—ask clever questions to get clever answers! Know whatyou want from the start – for this, we have already pre-pared a short description for the best person for this job.Avoid copy/paste questions or you will get copy/pasteanswers! Instead of following the same old questions,be creative, be spontaneous. Listen to the candidate and

ask him questions that really reveal his character andpersonality. After all, at the end of the day we tend tospend more time with our colleagues and associatesthan with our own family and friends. Surprisingly, as aresult of this habit (copy/paste interviews) we tend tohire people for their skills and fire them for their char-acter. Therefore, hire a candidate for his personality andnot for his skills!

Always check references! The only way to avoid neg-ligent hiring processes and bad hiring decisions is to ver-ify the information the applicant gives you against everyreference. We can request a copy of the performanceappraisal or we can ask a co-worker or a friend of the ap-plicant to rank our candidate. An application form givesa clearer picture of a candidate than a CV. As a studyfound out, 40% of the information given in a resumemight be misleading (example one of my candidates hassend two different CVs). Thus, mind the sentence: “Application blanks tell you what you want to know—CV’s tell you what the applicant wants you to know”.

Finally, ask your candidates to tell their story from thebeginning – by starting with their first job instead of thecurrent one. This teaches us about their developmentand their way of thinking. The goal is to hire the best em-ployees, but often we end up with hiring the “best appli-cants”.

_If we still have hired the wrong person...

If you feel like having hired the wrong person, thenfire him as soon as possible before he disturbs your oryour team’s or the patient's peace. I remember once Ihired a receptionist who in two days earned two bigcomplaints from two very good patients of our clinic –because towards them she behaved in a childish and an-noying way! Thus, I propose the idea of using the word“trial” in the beginning: This makes us feel better if wewant to fire our newly hired employee since we preparehim for the “unexpected” without a big fuss. But what isnext? We could call our best alternative or we could gofor a new hiring process, which is of course time andmoney consuming. Thus, it is always better to focus onan efficient hiring process in the first run._

I 35laser4_2014

Dr Anna Maria Yiannikos

Adjunct Faculty Member of

AALZ at RWTH Aachen Uni-

versity Campus, Germany

DDS, LSO, MSc, MBA

dba@yianniksodental.com

www.dba-aalz.com

_contact laser

I economy

_A new report from Escher, the independent TIPharma platform for regulatory innovation, showsthat the current regulatory system for medicines inEurope can be used in a more efficient and effectivemanner. André Broekmans, chairman of Escher:“Overall, the EU regulatory system operates well,however important recent changes had not yet beenevaluated. One of our conclusions is that pathwaysthat were intended to bring important new medicinesfaster to the market are not used in the right way. Weare therefore missing opportunities to make medi-cines available to patients earlier.”

Escher collaborated with researchers from UtrechtUniversity to look into a number of areas that mightbe improved: pharmacovigilance, conditional ap-proval, paediatric investigation plans and decentral-ized authorisation procedures. The research showsthat some parts of the regulations are not yet fullyachieving the effects they were intended to have. Forexample, the conditional marketing authorisationpathway was intended to bring much-needed prod-ucts, for example for cancer treatment, to the marketfaster. The researchers found, however, that in prac-tice it has often been used as a back-up for the ‘nor-mal’ approval pathway, because requesting condi-tional approval had some perceived drawbacks (e.g.potential reimbursement issues and the level of post-marketing obligations). The researchers also identi-fied opportunities for making the regulatory systemmore efficient, without compromising public health,for example by adjusting the timing of the submissionand the level of detail of plans for the investigation ofmedicines in children.”

Broekmans states that these discrepancies betweenthe initial objectives of legislation and the effects ofregulatory instruments in real-world practice shouldbe better monitored. One of the main messages fromthe report is that the effectiveness of regulatory in-struments can be increased by reflecting on the inter-pretation and implementation of the primary legisla-tion. Companies and authorities need to learn togetherhow to better use the opportunities that the currentsystem provides.

Richard Bergström, Director General of the Euro-pean Federation of Pharmaceutical Industries and As-sociations (EFPIA), notes: “Our latest learning from ge-nomics and our improved understanding of human bi-ology have resulted in a record number of promisingbreak-through medicines in development. Entering anew era of personalised medicine, the current modelfor medicines development and approval may not beappropriate. Against this background EFPIA decided toprovide an unrestricted research grant to the Escherplatform to explore if the model is fit for purpose."_

36 I laser4_2014

Escher—The TI Pharma platform

for regulatory innovation

Galileiweg 8

2333 BD Leiden, Netherlands

Tel.: +31 71 332 2030

Fax: +31 71 332 2031

www.escher.tipharma.com

_contact implants

Regulatory system for medicinescan be used more effectivelySource_Escher, Netherlands

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AEEDC_A4_2015.pdf 1AEEDC_A4_2015.pdf 1 07.08.14 15:1907.08.14 15:19

Manufacturer News

I manufacturer news

38 I laser4_2014

It is not uncommon for dental practitioners to receive patients who suffer from snor-ing or sleep apnea. Snoring affects millions of people worldwide, more than half ofwhich may also experience sleep apnea. Fortunately, dentists are highly qualified todiagnose and even treat these problems, and thereby help their patients to improvetheir sleep as well as health, wellbeing and quality of life. Fotona’s NightLase ther-apy is easy for dental practitioners to perform and has a high success rate in pro-ducing a positive change in sleep patterns. Research has shown that this therapy re-duces the effects of sleep apnea and decreases the amplitude of snoring by meansof a gentle, laser-induced tightening effect caused by the contraction of collagen inthe oral mucosa tissue.

The company’s award-winning LightWalker laser systems enable the safe penetra-tion of heat into the oral mucosa tissue. It is gentle enough to be used on the sensi-tive tissue inside the mouth, but strong enough to provide clinically efficacious heat-ing. The heat generated by the Erbium laser allows collagen to re-form, resulting ina tightening of the soft palate and surrounding tissues. This causes a rise of the softpalate and tightening the tissues of the oropharynx, resulting in improved airflow. Afull course of NightLase consists of three separate treatment sessions over a sixweek period. The final results of the treatment have been shown to last up to a year,and the therapy can be repeated. Patients find this therapy to be a highly comfort-

able and satisfying solution. It requires no devices or appliances to be worn duringsleep and involves no chemical treatment. It’s a gentle and easy way for your patientsto regain a good night's sleep.

Fotona d.d.

Stegne 7

1000 Ljubljana, Slovenia

www.fotona.com

Fotona

Lasers treat snoring and apnea

Zolar Technology, a Canadian-based dental equipmentmanufacturer specialising in dental diode lasers, hasannounced that it is looking for new dealers worldwidein order to expand its international business. The com-pany's Photon laser series is certified by the Food andDrug Administration and according to European stan-dards. In addition, the products received market clear-ance in Canada only recently. Zolar's Photon and Pho-ton Plus soft-tissue dental diode lasers became avail-able in the US in July last year. Only a few months later,Zolar was granted a license from Health Canada'sMedical Devices Bureau to sell its Photon soft-tissuedental diode laser system with low-level laser therapy(LLLT) throughout Canada. The Photon series featuresa long-lasting battery pack for optimal portability, ad-vanced software with a large touch-screen display,password security and a wide range of built-in treat-ment procedures, backed up by a three-year warranty.

Zolar's executive officer, Paul Atkins, said: "With thePhoton diode laser now available with LLLT the dentistno longer has to purchase two separate devices to con-

duct soft tissue and dental pain therapy applications.The Photon now equipped with an LLLT option com-bines both applications in one device. This approval isan important milestone for Zolar, as the Photon remainsthe only soft tissue diode laser on the market equippedwith LLLT dental applications."

Although low-level lasers are being used successfullyin many dental clinics, the wide range of applicationsis still largely unknown to many practitioners, espe-cially dental specialists, according to the company.LLLT offers dental practitioners a noninvasive treat-ment option that can be used as an adjunct to tradi-tional therapies or as a therapeutic tool on its own. Ex-amples of clinical applications include dental analge-sia, treatment of dentin hypersensitivity, healing ofsoft-tissue lesions, reduction of pain and swelling aftersurgical procedures, better integration of implants intobone, and faster movement of teeth during orthodon-tic procedures. Zolar will be exhibiting its dental laserproduct portfolio at the Chicago Dental Society Mid-winter Meeting (Booth 619) from Feb. 26 to 28, 2015,and at the International Dental Show (Booth A060),which will take place from March 10 to 14, 2015.

Zolar Technology & Mfg Co. Inc

6315 Shawson Drive, Unit 7-8,

Mississauga, Ont.

Canada, L5T 1J2

Zolar Technology

Aspiring dental laser company seeks international distributors

[PICTURE: © YURI]

The 36th Australian Dental CongressBrisbane Convention and Exhibition Centre - an AEG 1EARTH venue Wednesday 25th to Sunday 29th March 2015

Invitation from the Congress ChairmanOn behalf of the Local Organising Committee of the 36th Australian Dental Congress, it is with great pleasure that I invite you to attend Congress and enjoy the river city of Brisbane.

Over three and a half days, highly acclaimed International and Australian speakers supported by contemporary research, will present a wide range of subjects relevant to practice. These presentations will be complimented by hands on workshops, Lunch and Learn sessions, specific programmes for members of the dental team. Social activities will be available for relaxation purposes.

The Brisbane Convention and Exhibition Centre is adjacent to the Southbank Precinct on the banks of the Brisbane River. Nearby is the Queensland Performing Arts Complex, the Queensland Museum and the Queensland Art Gallery and Gallery of Modern Art. A comprehensive industry exhibition will be held alongside the Congress enabling delegates access between scientific sessions to view the latest in equipment and materials.

Come and join us for the scientific programme, the opportunity to meet colleagues and the experience Brisbane has to offer.

Dr David H Thomson

Congress Chairman 36th Australian Dental Congress

Educating for Dental Excellence

facebook.com/adacongress twitter.com/adacongress youtube.com/adacongress adc2015.com

Titanium sponsor:

ADC_A4_2015.pdf 1ADC_A4_2015.pdf 1 07.08.14 10:4907.08.14 10:49

I education

_The Aristotle University of Thessaloniki is ahistorical university of Greece, located in Thessa-loniki. It was founded back in 1925. Today, the univer-sity hosts 12 faculties, 41 schools, and numerousother units, such as laboratories, study rooms, li-braries, clinics, research centres etc., covering a vastspectrum of scientific fields.

More than 95,000 students, of which 86,000 are inundergraduate programmes and 9,000 in postgradu-ate programmes, study at the Aristotle University. Theteaching and research staff consists of 2,248 peoplewith 716 professors, 506 associate professors, 576 as-sistant professors and 450 lecturers. The scientificteaching staff has 84 and the special laboratoryteaching staff 275 employees.

This staff is supported by 309 members of the spe-cial technical laboratory for teaching services and ad-ministrative personnel with 1,028 people. In terms ofnumber of staff, undergraduate and postgraduatestudents and the facilities offered, the University isthe largest university in Greece and South East Eu-rope. According to theAcademic Ranking ofWorld Universities, theUniversity is ranked inplaces 301 to 400amongst the 500 bestuniversities worldwidein 2010. In 2012, it wasranked as the best University in Greeceand in 2013 on the 194th place in the worldwhich is 62nd in Europe. The School ofDentistry, belonging to the Faculty ofHealth Sciences, is located in the north-western part of the University Campus.

It occupies two buildings, whereby the main buildinghosts the clinics, the laboratories and the administra-tive offices of the school and the second building,called Mandalidis Centre of Dental Research hosts thenewer clinics of the postgraduate students and re-search facilities.

_School of Dentistry

6,992 dentists have graduated from the school ofdentistry already, while today the number of studentskeeps on growing. The graduates graduates have beenworking not only in Greece but worldwide, beingsought after as highly educated professionals. Withsuch history and reputation, the school of Dentistryat Aristotle University of Thessaloniki is always tryingto offer the highest education and research standardspossible for their students. With this in mind, Prof.Kosmas Tolidis started the modern and innovativetechnology clinic with a laser and a CAD/CAM divisionin 2012. It was a breakthrough for laser dentistry inGreece. The vision of bringing future dentists closer tothe latest developments and becoming the firstschool in Greece to treat patients and producing fun-

damental and clinical research in laser den-tistry had finally become real.

As Prof. Tolidis explains: “It is mystrong belief that it is of paramount im-

portance that education and researchfoundations, such as our school, incor-porate latest dental technology intoevery day usage. I consider that the best

way for a student or even a dentist to fa-miliarise with such procedures is a well-

organised curriculum in such institu-tions. This is why I tried to get the

Dental School of AristotleUniversity enters laser familyAuthor_Dr Dimitris Strakas, Greece

40 I laser4_2014

[PICTURE: © VALERY ROKHIN]

education I

infrastructure as well as the appropriate manpower toperform such a demanding task. Laser procedures arealready part of our postgraduate programme in Oper-ative Dentistry and very soon an elective programmewill start for our senior undergraduate students. Con-currently, in close cooperation with RWTH Aachen Uni-versity in Germany, the world leading University in thefield of Laser in Dentistry, and personally Prof. NorbertGutknecht, the world opinion leader in this field, we areworking on laser’s research within the context of twoPhD theses as well as on a number of research papers.I am pretty certain that despite difficulties (especiallyfinancial) the dental school of Aristotle University willvery soon be considered as part of the group of dentalschools leading the way in dental technology for thebenefit of both our students as well as our patients.“

Inevitably, a co-operation with the highest qualityeducation institute of AALZ and RWTH Aachen Uni-versity has started. Prof. Norbert Gutknecht, directorof AALZ–Aachen Dental Laser Centre, has fully sup-ported Prof. Tolidis’ vision from the very beginning.

Prof. Gutknecht states: “Since Greek students havebeen the first students in our MSc programme whichstarted at RWTH Aachen University in 2004, I am veryproud and happy that out of these first Greek studentsDr Dimitris Strakas became a faculty member of Aris-totle University. With his capacity, being a Master ofScience in Lasers in Dentistry achieved at RWTHAachen University, he was appointed as the head ofthe high-tech department, giving first introductionlectures on lasers in dentistry to undergraduate stu-dents, as well as cooperating with AALZ and RWTHAachen University in the master degree programmeLaser Therapy in Dentistry in Greece.

Furthermore, I am happy that out of this collabo-ration we will have our first common PhD candidateworking on the aspect of aesthetic dentistry with theuse of different laser devices. It is of great importancethat Prof. Tolidis is leading his department into themodern world of laser dentistry with us.”

The general manager of AALZ, Mr Leon Van -weersch, comments on this collaboration: “I am veryhappy and excited that my very good friend Dr Dim-itris Strakas became this very prestigious position asthe first head of the new established high tech centreat the dental faculty of Aristoteles University in Thes-saloniki. In my opinion, this is an important milestoneto impart knowledge about the therapeutic use oflasers in dentistry to all existing and future dentists inGreece. With Dr Strakas, being also the president ofthe Greek Society of Laser Dentistry and presidentelect of the European Division of WFLD, Aristotle Uni-versity and AALZ are having the right person to pushforward the scientifically approved use of lasers indentistry! Having met in person both Prof. Tolidis andProf. Gerasimou, I strongly believe that the coopera-tion with us will be more than fruitful, also providingus the means to organise and complete more multi-centre studies on laser therapy.”

This initiation has been supported by many lasercompanies as Biolase, Fotona, Sirona, Lambda, A.R.C.and Lasotronic that has provided us with a number oflaser devices of various wavelengths already. Withtheir help and support many future dentists will be in-troduced to the world of laser dentistry and manymore publications on both high-power and LLLT lasersystems will be published. The dental school of Aris-totle University is leading the way in Greece towardsthe future in modern dentistry and is empowering itsreputation amongst European faculties._

Fig. 1_The new ambulance of the

department with some of the laser

and CAD/CAM devices.

Fig. 2_AALZ manager Mr Leon

Vanweersch with the pioneers of the

laser department Prof. Kosmas

Tolidis, Prof. Paris Gerasimou and

PhD candidate Dimitris Strakas.

I 41laser4_2014

Dr Dimitris Strakas

DDS, MSc in Lasers in Dentistry,

RWTH-Aachen University

PhD cand. Department of Operative Dentistry

Aristotle University of Thessaloniki

www.auth.gr/en/dent

_contact laser

Fig. 1 Fig. 2

I meetings

Fig. 1_DGL president Prof. Dr Norbert

Gutknecht opened the 23rd annual

congress.

_On 26 and 27 September, members of theDeutsche Gesellschaft für Laserzahnheilkunde (Ger-man Association of Laser Dentistry, DGL) met for theassociation’s 23rd Annual Congress in Duesseldorf inGermany. Parallel to the congress, LASER START UP2014 was held in collaboration with and under thescientific guidance of the DGL. At both events,novices in the field of laser dentistry, as well as expe-rienced users, learnt about the technical possibilitiesof current lasers and their integration into variousdental treatment procedures. More than 500 people

attended the joint event, which combined the an-nual congresses of the DGL and of the German Asso-ciation of Dental Implantology, LASER START UP2014, and Oral Hygiene Day 2014, in the Rhine me-tropolis.

The use of technology has permeated many as-pects of daily practice in dentistry; nevertheless, min-imally invasive technologies, such as laser, are not yetwidely used in dentistry. During the annual meeting,the DGL and LASER START UP informed participantsabout laser technology and its applications. Thetheme of the meeting was “Microinvasive—minimallyinvasive: Integrative laser technology”, and Prof. Nor-bert Gutknecht (Aachen, Germany) and Dr Georg Bach(Freiburg/Breisgau, Germany) chaired the scientificprogramme committee for both events.

_Lasers in dentistry

On Friday morning, Prof. Gutknecht, President ofthe DGL, opened the two-day congress with a lectureon bundled light. He was followed by top-classspeakers, including Prof. Hendrik Meyer-Lueckel(Aachen), Dr Michael Hopp (Berlin, Germany), Prof.Matthias Frentzen (Bonn, Germany), Dr Collin Jacobs(Mainz, Germany), Prof. Andreas Braun (Marburg,Germany), Dr Michael Krech (Marburg) and RuthSchulte-Luenzum (Aachen). The researchers offered

Focus on laser: Annual Congress of the DGLand LASER START UP 2014Author_Katrin Maiterth

42 I laser4_2014

[PICTURE: © MIKHAIL MARKOVSKIY]

Fig. 1

meetings I

I 43laser4_2014

Fig. 2_The scientific programme offered a lot of interesting presentations. – Fig. 3_At the information booth of the DGL. – Fig. 4_At the dental exhibition, participants

learnt about the latest products. – Fig. 5_Dr Georg Bach at LASER START UP 2014.

Fig. 2 Fig. 3

Fig. 4 Fig. 5

I meetings

Fig. 6_ Prof. Gilles Chaumanet from

Nice, France.

Fig. 7_The DGL board at the

members meeting, from left:

Dr Thorsten Kleinert, Dr Matthias

Frentzen, Dr Detlef Klotz,

Prof. Dr Norbert Gutknecht,

Dr Stefan Grümer.

insights into their current work, demonstrating thevarious application possibilities of laser.

In the afternoon, the DGL held its members’ meet-ing. Directly afterwards, the scientific programmecontinued with interesting presentations by Prof.Gilles Chaumanet (Nice, France), Dr Michael Schaefer(Duesseldorf), Dr Rene Franzen (Aachen), Dr DariusMoghtader (Oppenheim, Germany), Dr Claudia Dehn(Bonn), Dr Florian Stelzle (Erlangen, Germany) and DrThorsten Kuypers (Cologne, Germany). Prof. MeritaBardhoshi (Tirana, Albania) finished the first day ofthe congress with a comparison of the treatment ofvascular lesions in the oral and maxillofacial areawith a 980 nm diode laser and with a conventionalmethod. Participants of LASER START UP had the op-portunity to learn about the fundamentals of laserand its various applications. In his welcome speechon Friday afternoon, Dr Bach addressed laser from ascientific perspective and from the viewpoint of es-tablished dentists. The topics of the presentationsthat followed included physical fundamentals oflaser, and its application in implantology, oral sur-gery and endodontics. Speakers included well-known experts Dr Joerg Meister (Bonn) and Prof.Herbert Deppe (Munich, Germany).

On both congress days, participants were able tovisit the dental exhibition during the breaks to learnabout the latest developments in laser dentistry. OnFriday evening, the first congress day ended with asocial gathering at the dental exhibition, where par-ticipants further discussed the topics of the day in arelaxed atmosphere.

_Selecting the correct laser

On Saturday, the congress participants were of-fered another interesting programme. Dr RalfBorchers (Buende, Germany) started the second day

off with a lecture on clinical experiences with periogreen (elexxion). Afterwards, Dr Gottfried Gisler(Maennedorf, Switzerland) spoke about the use oflaser in clinical emergency cases. He was followed byProf. Gerd Volland (Heilsbronn, Germany), GiannisPapadimitriou (Duesseldorf), Dr Simona Baur (Zirn-dorf, Germany), Dr Carsten Philipp (Berlin) and DrMichael Bauer (Kiel, Germany). In a workshop by DrsDetlef Klotz (Duisburg, Germany) and Peter Esser(Simmerath, Germany), the participants were ad-vised on the correct billing of laser treatments.

Billing and the profitability of laser treatmentwere topics at LASER START UP too and the focus ofa presentation by Dr Kuypers. The second day of theevent also dealt with laser types and wavelengths,and selecting the correct laser in a panel discussionunder the guidance of Dr Bach and Prof. Frentzen. Inpractical workshops led by Dr Moghtader, Dr KresimirSimunovic (Zurich, Switzerland) and Prof. Volland,participants had the opportunity to learn about thepractical application of laser systems offered by different companies.

Finally, participants of the DGL meeting andLASER START UP were brought together for a jointprogramme on Saturday afternoon, which includeda lecture and panel discussion. The lecture coveredlaser as an interdisciplinary interface in dentistryfrom the perspective of a practice owner and was complemented by a panel discussion, whichprompted lively professional exchange among theparticipants.

In 2015, the two events, which have been com-bined since 2009, will again take place jointly. On 27and 28 November, the 24th Annual Congress of theDGL and LASER START UP 2015 will be held in Berlin._

www.dgl-online.de

44 I laser4_2014

Fig. 6 Fig. 7

Croixture_280x400_2014.pdf 1Croixture_280x400_2014.pdf 1 09.09.14 14:3209.09.14 14:32

NEWS

In order to evaluate whether dental treatment mayenhance oral antisepsis, thus preventing lower res-piratory tract infections among critically ill patientsmore effectively, researchers at the University of SãoPaulo analysed data from 294 adult patients who hadspent at least 48 hours in a general ICU. In addition toroutine oral hygiene care, half of the patients in thestudy received enhanced dental care provided by adental surgeon four to five times a week, while thecontrol group received routine oral care only, whichincluded the use of chlorhexidine as a mouth-rinseand was performed by ICU nursing staff three timesa day. Enhanced dental care included tooth-brush-ing, tongue scraping, the removal of calculus, atrau-matic restorative treatment of caries, and tooth ex-traction.

Overall, dental treatment was considered to be safeand effective for the prevention of lower respiratorytract infections. The researchers suggested that thetreatment provided by the dental surgeon helpedprevent 56 per cent of infection episodes in the ex-perimental group. In addition, the advent of death re-lated to such infections was 38.1 per cent less in theexperimental group than in the control group (3.9 percent compared with 6.3 pe rcent).

Usually, oral care in ICUs around the world is per-formed by nursing staff. However, they do not havesufficient training or the legal authority to treatcaries, remove calculus, drain intraoral abscesses,or perform tooth extractions, the researchers stated.

“This study suggests that having a dentist provideweekly care as part of the ICU team may improve out-comes for vulnerable patients in this setting,” con-cluded lead author Dr. Fernando Bellissimo-Ro-drigues.

Dental care may reduce

Respiratory infectionrisk in ICU patients

Almost a year after construction started, HenrySchein opened its new headquarters in the Gilling-ham Business Park at the beginning of October. Thenew state-of-the-art and energy-efficient facility,which includes two floors of office space and a ware-house, will serve as the main office and distributioncentre for the company’s dental and medical cus-tomers in the UK.

The new facility was built adjacent to the existingHenry Schein UK facility at the site, which was es-tablished in 1991. Its new warehouse includes aneducation centre with a showroom for product

demonstrations featuring a wide range of innovativehigh-tech digital technology. The company is alsoplanning to develop additional warehouse space ifmore storage capacity is needed.

“This new, outstanding facility is a source of greatpride for our company, underscoring our commit-ment to environmental sustainability, as the project’splanning and construction has taken into accountthe impact on the surrounding environment,” saidStanley M. Bergman, Chairman of the Board and CEOof Henry Schein, at the opening on 8 October, whichwas attended by over 500 people.

Henry Schein celebrates

Opening of new UK headquarters

The FDI has opened its ‘data hub for global oral health’,an evolving online database of oral health statistics andindicators. It has started out with a limited amount ofinformation but it is anticipated that the content will ex-pand and deepen in the coming months.

The ‘hub’ has been developed under the guidance ofthe FDI Oral Health Atlas Task Team. The OralHealth Atlas has proved to be a land-mark achievement since it waspublished in 2009; neverthe-less, with data dating back, insome cases, to the 1990s,and only a limited number ofindicators available, its in-formation is now in need ofan update.

From the perspective of health pol-icy, the lack of oral health data has ham-

pered the World Health Organisation’s (WHO) efforts todevelop, for oral health, a comprehensive global mon-itoring framework including a set of indicators to mon-itor trends and to assess progress in the implementa-tion of health care strategies and plans. Thus, it is an-ticipated that the ‘data hub for global oral health’ cre-ated by FDI will also help to provide a sound basis for a

future global oral health monitoring framework.

As for content, the ‘data hub’ will castthe net much wider for information.

For example, the crucial role ofsocial determinants in oralhealth will make socio-eco-nomic data a key component.So will the data on incidence of

Non-Communicable Diseasessuch as diabetes where a close re-

lationship with oral disease has beenclearly established.

FDI opens online

Hub for global oral data

46 I laser4_2014

[PICTURE: © SFAM_PHOTO]

[PICTURE: © SARUNYU_FOTO]

According to figures from the Medicines and Health-care Products Regulatory Agency (MHRA) in London,over 12,000 individual pieces of counterfeit and un-approved dental products were seized in the UK upto April this year. At the BDIA Dental Showcase in Oc-tober, the British Dental Industry Association (BDIA)announced that it will partner with major dental andgeneral media outlets, including the BBC, to heightenawareness among dental professionals and the gen-eral public of the dangers these products can poten-tially pose. While they still represent a small marketshare, the number of substandard devices pur-

chased by dental professionals has steadily grown inrecent years across all segments.

“We are now seeing copies and substandard ver-sions of more complex devices, such as dental X-raymachines and handpieces, being increasingly pur-chased through the Internet and other sources,”Bruce Petrie from the MHRA said. In order to addressthe situation, the agency in partnership with the BDIAlaunched the Counterfeit and substandard Instru-ments and Devices Initiative earlier this year, whichaims to make more dentists aware of the problemand to report questionable products to the relevantauthorities.

BDIA Executive Director Tony Reed commented, “Weare pleased with the very positive reception that ourinitiative has received and the next step in growingawareness amongst the dental team is the launch ofour advertising campaign.”

UK dental industry pushes

Campaign to contain influx of fake products

Sirona, the world's largest manufacturer of dentaltechnology, has announced that it has recently enteredinto a unique digital dentistry partnership with theBoston University Henry M. Goldman School of DentalMedicine. Through the agreement, the school will be-come the first all-digital dentistry school in the US, pro-viding dental students with the opportunity to learnabout the current digital dentistry landscape in fullyequipped operatories. The university will purchase dig-ital equipment exclusively from Sirona in order to pro-vide its dental students with access to a complete dig-ital dentistry workflow, including both dental and labo-ratory techniques and applications. In addition, theschool's Patient Treatment Centre, at which studentsprovide affordable dental treatment, will be furnishedwith equipment from Sirona's CEREC, Schick,GALILEOS and inLab product lines.

In May 2013, the university established a special taskforce to implement digital dentistry at the dentalschool. With the goal of providing students with thetools to deliver the highest level of oral health care us-ing digital dental technologies, the task force evaluatedthe facilities, equipment and technical support re-quired to create a seamless all-inclusive system.Sirona was chosen as a partner in this project becausethe company offers a comprehensive product portfo-lio, strong technical support and seamless technologyintegration capabilities, the university stated.

“We are honoured to enter into this first of its kind en-deavour with Boston University,” said Sirona presidentand CEO Jeffrey Slovin. “Students will get to experiencethe true workings of a current dental practice environ-ment and we commend the University for leading theway towards educating its students on using digitaldentistry techniques. We are pleased to collaboratewith Boston University in setting the stage for the futureof dental education.”

Sirona and Boston University form

First all-digital dentalschool

I 47laser4_2014

In the past, bisphenol A (BPA), a endocrine-disruptingchemical that can also be found in dental compositesand sealants, has been linked to a number of healthconditions, including obesity, allergies and cancer.Now, researchers have found evidence that prenatalexposure to BPA is associated with diminished lungfunction and the development of persistent wheeze inchildren, which are indicators for asthma, one of themost common chronic childhood disorders.

In order to examine the effect of BPA on lung functionand wheeze in children, researchers at the Universityof Maryland School of Medicine followed womenthrough pregnancy and their children through age 5. Intotal, the study included 398 mother–infant dyads.They collected maternal urine samples at 16 and 26 weeks of pregnancy and maternal urine samplesannually to assess BPA exposure.

According to the study, prenatal BPA exposure duringearly pregnancy was associated with diminished lungfunction, increased likelihood of wheeze, and a per-sistent wheeze phenotype in young children.

According to estimates by the Centres for Disease Con-trol and Prevention, about 7 million children under the

age of 18 are affected. Although secondhand smokeand air pollution have been identified as factors for thedevelopment of asthma in children, the reasons for in-creasing rates of the disease in the past decades arestill poorly understood by scientists. The present studythus provides new evidence that BPA may contributeto this development.

BPA exposure may contribute to

Asthma development in children

[PICTURE: © KRITCHANUT ]

Thousands of patients treated by a dentist at DaybrookDental Surgery in Gedling near Nottingham have beenrecalled by NHS England in Nottinghamshire to betested for blood-borne viruses. Dr Desmond JudeD’Mello was recently suspended for 18 months by theGeneral Dental Council for violation of cross-infectioncontrol standards in multiple cases.

Police are also investigating the death of a woman be-lieved to have been treated by the dentist and who diedof viral acute myocarditis last year. Charges againstD’Mello arose after a whistle-blower sent secretlyfilmed footage to the NHS. Overall, he is believed tohave treated more than 20,000 patients since hestarted practising at the clinic in the early 1980s.

While NHS investigations found that he did not carryblood-borne viruses himself, the patients he saw couldhave been placed at low risk of being exposed to Hep-atitis B or C and HIV, Medical Director for NHS Englandin Nottinghamshire Dr Doug Black said. He said that hisorganisation is currently working with Public HealthEngland and the General Dental Council to resolve theissue. Support is also being provided by Southern Den-tal, which has been running D’Mello’s former practicesince August, according to Black. Patients believed tohave been treated by the dentist are advised to contactthe authorities for further advice. NHS has set up a com-munity clinic at the health centre in Arnold, as well as atelephone line, to support patients treated by the den-tist.

“Effective treatments are available for all blood-borneviruses,” Dr Vanessa MacGregor, Consultant in Com-municable Disease Control for Public Health England inthe East Midlands, said.

Massive patient recall after

Breach by dentist inNottinghamshire

NEWS

Over 90 per cent of the world’s population will sufferfrom some form of dental disease in their lifetime, butmany of these diseases can easily be treated or pre-vented with a good oral care routine. The WOHD 2015“Smile for life” campaign includes a call to action(“It’s time to …”), which campaigners can adapt totheir local needs and circumstances.

Dentists at the FDI Annual World Dental Congress inNew Delhi in September endorsed the “Smile for life”campaign both literally and figuratively when they

took turns to “Smile for life” infront of WOHD 2015 campaignposter. FDI President Dr Tin ChunWong commented, “The ‘Smilefor life’ campaign reminds usthat oral disease can be pre-vented by practising good oralhygiene throughout life, fromchildhood to mature adulthood.After tripling the number ofcountries celebrating World OralHealth Day between 2013 and

2014, we are now looking to reach an even larger au-dience in even more countries, as well as online.”

FDI Executive Director Jean-Luc Eiselé added, “Wewant to encourage everyone to celebrate this impor-tant day. Participants can download materials such aslogos, posters and toolkits to plan their activities fromthe ‘Smile for life’ campaign website—where theycan also read inspiring stories from last year’s cam-paign to help them plan their World Oral Health Day2015.”

FDI launches World Oral Health Day

“Smile for life” campaign

November 14, 2014, the first dental laser multi-centricresearch agreement was signed between Peking Uni-versity School of Stomatology in China and The HebrewUniversity, Hadassah School of Dental Medicine theleading Dental University from Jerusalem, Israel. Initi-ated by Prof. Adam Stabholz, Prof. Chuanbin Guo andMr. Ira Prigat, with a strong vision to offer better den-tistry to patients, reduce dental fear, enhance preven-tion awareness and improve overall health of humanbeing, the research collaboration between two coun-

tries will bring significant impact on both dental andhealthcare industry.

A special ceremony was hosted in the PKU School ofStomatology VIP reception room, Dean Prof. ChuanbinGuo and Dean Prof. Aharon Palmon signed the agree-ment. After the signing ceremony, an impressive aca-demic symposium on dental laser application was heldwith outstanding lectures from both Israeli and Chinesedental laser professionals.

First dental laser multi-centric research agreement

Signed between dental schools from Chinaand Israel

48 I laser4_2014

[PICTURE: © MINERVA STUDIO]

US researchers have found that certain variants ofkeratin, proteins that are key structural compo-nents of hair, also help in the formation of toothenamel. In order to establish a connection betweenhair disorders and susceptibility to dental caries,the researchers used genetic and oralexamination data from 386 childrenand 706 adults. For their study, theyfocused on the protein keratin 75,because mutations in its geneshave been linked to certain hairdisorders, such as shavingbumps, persistent irritationcaused by shaving.

The researchers observed thatparticipants carrying mutationsin keratin 75 had an increased

number of cavities. In addition, they found thatthese participants had altered enamel structuresand showed a marked reduction in enamel hard-ness, suggesting that hair keratins stabiliseenamel tufts and rod sheaths to support enamel

rods during their formation, which is similarto their function in supporting the hair

shaft. Thus, they concluded that tufts androds destabilised by the presence of themutant protein have a reduced capac-ity to protect against caries.

These insights may help in the develop-ment of new strategies for combatingtooth decay, the scientists believe. Thedisease affects 60–90 per cent ofschoolchildren and nearly 100 per cent

of adults worldwide.

People with hair disorders

May be prone to dental caries

Smoking and alcohol abuse are the mostrecognised factors in the causation of can-cers of the oral cavity.However, a new 10-year study has shownthat non-smokers too are atsignificant risk of oral squamouscell carcinoma. The study suggeststhat chronic dental or denture irritation inparticular could be an important causativefactor.

In order to determine whether oral cavitycancers occurred more commonly at sites ofdental trauma, a comprehensive analysis of themedical records of 334 patients diagnosed withoropharyngeal cancer and 390 with oral cavitycancer was undertaken at Princess Alexandra Hos-pital in Brisbane between 2001 and 2011. Of theoropharyngeal cancer patients, almost 86 per centwere smokers or ex-smokers and about 14 percent were non-smokers. Of the 390 patients withmouth cancer, 80 per cent were current or ex-smokers and about 20 per cent were non-smokers.

The researchers found that overall most mouthcancers occurred on the edge of the tongue.

A significantly higherproportion of non-smokers (66 per cent, comparedwith 33 per cent in smokers), however, had mouthcancer in this location. In addition, they observed ahigher incidence of mouth cancer in female non-smokers compared with male non-smokers.

As oral cavity cancers occurred predominantly atsites of potential dental and denture trauma, espe-cially in non-smokers without other risk factors, theresearchers concluded that the irritant effect ofchronic dental trauma may induce the develop-ment of oral cavity cancers on the lateral tongue.

Location of oral cancer

Varies in smokers and non-smokers

I 49laser4_2014

Interest in wearable head-mounted display sys-tems such as Google Glass is increasing, even in thedental setting. However, their effect on vision is stilllargely unknown. Now, researchers from the Uni-versity of California, San Francisco, have found thatthe glasses partially obstructed peripheral vision.

In order to assess the effect of the head-mounteddevice on visual function compared with regulareyewear, the researchers performed perimetric vi-sual field tests with three healthy individuals whoused Google Glass in accordance with the manu-facturer's instructions for 60 minutes. Afterwards,the test was repeated with the participants wear-ing a control frame of similar colour and templewidth.

According to the researchers, the testing demon-strated significant scotomas, also known as blindspots, in all three participants while wearing the de-vice, creating a visual field obstruction in the upperright quadrant. The scotomas were due to theframe design only and not to software-related in-terference, they said.

In addition, 132 photographs of people wearingGoogle Glass were analysed to assess how the de-vice is worn by general consumers. The re-searchers stated that many wear the device almostoverlapping their pupillary axis, which may inducescotomas and thus interfere with daily activities(such as driving), pedestrian safety, and sports.

Google Glass may

Obstruct peripheralvision

[PICTURE: © HATTANAS KUMCHAI]

[PICTURE: © MARC DIETRICH]

[PICTURE: © FILMFOTO]

I about the publisher

50 I laser4_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.

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Customer ServiceMarius Mezgerm.mezger@oemus-media.de

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laser international magazine of laser dentistryis published in cooperation with the World Federation for Laser Dentistry (WFLD).

WFLD Headquarters

University of Aachen Medical FacultyClinic of Conservative DentistryPauwelsstr. 30, 52074 Aachen, GermanyTel.: +49 241 808964Fax: +49 241 803389644ngutknecht@ukaachen.dewww.wfld-org.info

www.laser-magazine.com

laserinternational magazine of laser dentistry

The editors of laser would like to thank all authors for dedicating their time and

efforts to this year’s issues.

Issue 1/2014

| Prof. Dr Nobert Gutknecht, Germany

| Prof. Dr Aslan Yaşar Gokbuget,Turkey

| Necla Aslı Kocak, Turkey| Dr MeritaBardhoshi, Albania| Dr. Esat Bardhoshi, Albania| Jan Tunér, Sweden| Dr Carlo Fornaini, Italy| Dr Maziar Mir, Germany| Dr Masoud Mojahedi, Germany| Dr Hassan Adalatkhah| Dr Amir Mansour Shirani, Iran| Dr Masoud Shabani, Iran| Giovanni Olivi, Italy| Matteo Olivi, Italy| Maria Daniela Genovese, Italy| Dr Anna Maria Yiannikos, Germany & Cyprus

Issue 2/2014

| Jan Tunér, Sweden| Prof. Dr Nobert Gutknecht, Germany

| Roeland Jozef Gentil De Moor,Belgium

| Maarten Meire, Belgium| Dr Christina Boutsiouki, Germany

| Dr Dimitris Strakas, Greece| Dr Fabrice Baudot, France| Dr Kresimir Simunovic, Switzerland

| Assoc. Prof Dr Sajee Sattayut,Thailand

| Assist. Prof Dr Piyachat Pacharanuchat, Thailand

| Assoc. Prof Suwit Undompanich,Thailand

| Dr Anna Maria Yiannikos, Germany & Cyprus

Issue 3/2014

| Dr Frank Liebaug| Dr Ning Wu, China| Prof. Dr Nobert Gutknecht, Germany

| Dr Brice Savard, France| Roeland Jozef Gentil De Moor,Belgium

| Maarten Meire, Belgium| Dr Maziar Mir, Germany| Dr Masoud Mojahedi, Germany| Jan Tunér, Sweden| Dr Amir Mansour Shirani, Iran| Dr Masoud Shabani, Iran| Ass. Prof. Ani Belcheva, Bulgaria| Maria Shindova, Bulgaria| Prof Dr Jean-Paul Rocca, France| Dr Sylvaine Lesnik-Cannavo,France

| Prof Dr Carlo Fornaini, Italy

Issue 4/2014

| Prof. Dr Nobert Gutknecht, Germany| Prof. Dr Praveen R. Arany, USA| Prof. Ass. Merita Bardhoshi, Albania

| Prof. Ass. Edit Xhajanka, Albania| Dr Esat Bardhoshi, Albania| Dr Alketa Qafmolla, Albania| Dritan Gjini, Albania| Elda Gjini, Albania| Dr Fabrice Baudot, France| Dr Zulala Tasneem, India| Dr Salika Sheikh, India| Dr Rahul Kale, India| Dr Naresh Thukral, India| Dr Sangeeta Muglikar, India| Dr Anna Maria Yiannikos, Germany & Cyprus

| Dr Dimitris Strakas, Greece| Dr George Freedman, Canada

Hand in your article.

Editorial managerGeorg Isbanerg.isbaner@oemus-media.de

EditorKatrin Maiterthk.maiterth@oemus-media.de

Please contact:

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