• Clinical / Scientific Review: Caries Detection

• Clinical Review and Case Report: Implant PeriapicalLesion Therapy and Guided Bone Regeneration

• Case Reports: Treatment of Moderate ChronicPeriodontitis and Subcrestal Tooth Fracture

The Official Journal of the Academy of Laser Dentistry 2007 • Vol. 15 No. 3The Official Journal of the Academy of Laser Dentistry 2007 • Vol. 15 No. 3

Optimizing visualization and ergonomics.See the clinical review article on microscopy-assisted laser dentistry on page 122

Academy of Laser Dentistry3300 University Drive, Suite 704

Coral Springs, FL 33065

115

JOU

RN

AL

OF

LA

SE

RD

EN

TIS

TR

Y|

20

07

VO

L1

5,

NO

.3

TA B L E O F CO N T E N T SThe official journal of the

Academy of Laser Dentistry

Editor in ChiefJohn D.B. Featherstone, MSc, PhDSan Francisco, CA jdbf@ucsf.edu

Managing EditorGail S. Siminovsky, CAE, Executive DirectorCoral Springs, FL siminovsky@laserdentistry.org

Consulting EditorJohn G. Sulewski, MA Huntington Woods, MI john.sulewski@we-inc.com

Associate Editors Donald J. Coluzzi, DDSPortola Valley, CA don@laser-dentistry.comSteven P.A. Parker, BDS, LDS RCS, MFGDP Harrogate, Great Britain

thewholetooth@easynet.co.uk

Editorial BoardJohn D.B. Featherstone, MSc, PhDGail S. Siminovsky, CAEJohn G. Sulewski, MADonald J. Coluzzi, DDSSteven P.A. Parker, BDS, LDS RCS, MFGDPAlan J. Goldstein, DMDDonald E. Patthoff, DDSPeter Rechmann, Prof. Dr. med. dent.

PublisherMax G. MosesMember Media

1844 N. LarrabeeChicago, IL 60614

312-296-7864Fax: 312-896-9119

max@maxgmoses.com

Design and LayoutDiva Design

2616 Missum PointSan Marcos, TX 78666

512-665-0544Fax: 512-392-2967

kkolstedt@austin.rr.com

Editorial Office3300 University Drive, Suite 704

Coral Springs, FL 33065

954-346-3776 Fax 954-757-2598

www.laserdentistry.orglaserexec@laserdentistry.org

The Academy of Laser Dentistry is a not-for-profitorganization qualifying under Section 501(c)(3) ofthe Internal Revenue Code. The Academy of LaserDentistry is an international professional member-ship association of dental practitioners and sup-porting organizations dedicated to improving thehealth and well-being of patients through theproper use of laser technology. The Academy isdedicated to the advancement of knowledge,research and education and to the exchange ofinformation relative to the art and science of theuse of lasers in dentistry. The Academy endorsesthe Curriculum Guidelines and Standards forDental Laser Education.

Member American Association of Dental EditorsThe Journal of Laser DentistryThe mission of the Journal of Laser Dentistry is to provide a professional quarterly journalthat helps to fulfill the goal of information dissemination by the Academy of Laser Dentistry.The purpose of the Journal of Laser Dentistry is to present information about the use of lasersin dentistry. All articles are peer-reviewed. Issues include manuscripts on current indicationsfor uses of lasers for dental applications, clinical case studies, reviews of topics relevant tolaser dentistry, research articles, clinical studies, research abstracts detailing the scientificbasis for the safety and efficacy of the devices, and articles about future and experimental procedures. In addition, featured columnists offer clinical insights, and editorials describe personal viewpoints.

E D I TO R ’ S V I E WOptical Methods for the Enhancement of Dental Practice ..................116John D.B. Featherstone, MSc, PhD

G U E ST E D I TO R I A LThe Transformative Dental Experience ........................................................118Alan J. Goldstein, DMD

COV E R F E AT U R EC L I N I C A L R E V I E WUse of the Dental Operating Microscope in Laser Dentistry: Seeing the Light ..............................................................122Glenn A. van As, DMD

C L I N I C A L / SC I E N T I F I C R E V I E W Detection of Caries by DIAGNOdent: Scientific Background and Performance ....................................................130Raimund Hibst, PhD

Er:YAG Laser-Assisted Implant Periapical Lesion Therapy (IPL) and Guided Bone Regeneration (GBR) Technique: New Challenges and New Instrumentation ..............................................135Avi Reyhanian, DDS; Donald J. Coluzzi, DDS

A DVA N C E D P R O F I C I E N C Y C A S E ST U D I E SIntroduction ..........................................................................................................142

Nd:YAG Laser Use in Treatment of Moderate Chronic Periodontitis ....................................................................144Mary Lynn Smith, RDH

Treatment of a Subcrestal Tooth Fracture with the Er:YAG Laser ........151Charles R. Hoopingarner, DDS

R E S E A R C H A B ST R AC T SLaser Bactericidal Effects on Intraoral Implants ........................................156

Journal of Laser Dentistry

Optical Methods for the Enhancement ofDental PracticeJohn D.B. Featherstone, MSc, PhD, San Francisco, CaliforniaJ Laser Dent 2007;15(3):116-117

The use of light technology in thepractice of everyday clinicaldentistry is not restricted simply tolasers. Clinicians have examinedthe tissues of the mouth by eyeforever. The human eye is one ofthe best optical tools that we have.New optical tools are now availablefor the practitioner and additionalnew ones are on the horizon. Thesewill be highlighted in future issues.What remains is to understandwhat these tools have to offer andto make the best use of them forthe benefit of the patient.

Microscopes have been used inlaboratory settings and in clinicalmedicine for a long time. Morerecently the dental profession hasstarted to embrace the use ofmicroscopes on a routine basis,especially in endodontics. So whynot for dentistry with lasers? Inthis issue the Academy of LaserDentistry 2006 Leon Goldmanawardee, Dr. Glenn van As, reviewsthe background and how the use ofmicroscopes has revolutionized hisdaily practice.

Until recently caries detectionhas been largely visual, tactile, andhas relied on the use of radiog-raphy where the eye could not see.New tools are coming on themarket to aid the clinician in thedetection of carious lesions. Laserfluorescence is the science behindone such tool. Dr. Raimund Hibst,one of the scientists involved in theresearch that led to the practicaluse of this methodology, provides a

review in this issue of the science,laboratory assessment, and clinicalevaluation of one of these tools.

Periodontal therapy can beenhanced by the use of lasers. Astime goes on we are achieving abetter understanding not only ofthe science behind the use of lasersfor periodontal uses but alsolearning how better to use lasers ineveryday practice. Several articlesin this issue provide practical illus-trations of the benefits of lasertechnology in this area of dentistry.The dentist and the hygienist canwork closely together for thebenefit of the patient.

So what does all this mean? Thestandard of care in dental practiceis evolving. Judicious use of opticaltechnology in clinical practicerequires ongoing education, sharingof science, practice, clinical studies,case reports, and most importantlythe engaging of the brain beforeembarking on laser-assisted proce-dures. The Journal of LaserDentistry offers a mix of scienceand practice, including clinical andlaboratory studies, reviews, andcase studies. It is over to the readerto make the best use of the infor-mation for their education andmost importantly the better healthof the patient.

Finally, then, let us put this inperspective. In the guest editorialin this issue, Dr. Alan Goldsteinaddresses the philosophical issuethat is generated by my statementsin the preceding paragraph. He

states “In my office, I take the posi-tion that our task is to make everypatient experience transformative.”In order to do that we must trulyunderstand what we are doing,what the likely outcomes are, andcombine science, training, andexperience together to this end. Wemust all be continual learners andwork out how to apply our learningto whatever we do each day.

Please enjoy this issue of theJournal. Feel free to e-mail mewith suggestions, criticisms, orcompliments at jdbf@ucsf.edu.

A U T H O R B I O G R A P H YDr. John D.B. Featherstone isProfessor of Preventive andRestorative Dental Sciences andInterim Dean in the School ofDentistry at the University ofCalifornia, San Francisco (UCSF).He has a Ph.D. in chemistry fromthe University of Wellington (NewZealand). His research over thepast 33 years has covered severalaspects of cariology (study of toothdecay) including fluoride mecha-nisms of action, de- andremineralization of the teeth,apatite chemistry, salivary dysfunc-tion, caries (tooth decay)prevention, caries risk assessment,and laser effects on dental hardtissues with emphasis on cariesprevention and early cariesremoval. He has won numerousnational and international awardsincluding the T.H. Maiman awardfor research in laser dentistry fromthe Academy of Laser Dentistry in2002, and the Norton Ross Awardfor Clinical Research from theAmerican Dental Association in2007. In 2005 he was honored asthe first lifetime honorary memberof the Academy of Laser Dentistry.Dr. Featherstone has published

116

JOU

RN

AL

OF

LA

SE

RD

EN

TIS

TR

Y|

20

07

VO

L1

5,

NO

.3

E D I TO R ’ S V I E W

Featherstone

SY N O P S I SJohn Featherstone, editor-in-chief, describes some of the highlights of

this issue of the Journal of Laser Dentistry, emphasizing the broad

applications of optical technology in daily practice.

E D I TO R ’ S V I E W

Featherstone

more than 200 papers. He is theeditor-in-chief of the Journal ofLaser Dentistry.

Disclosure: Dr. Featherstone has nopersonal financial interest in anycompany relevant to the Academy ofLaser Dentistry. He consults for, hasconsulted for, or has done researchfunded or supported by Arm &Hammer, Beecham, Cadbury, GSK,KaVo, NovaMin, Philips Oralcare,Procter & Gamble, OMNII OralPharmaceuticals, Oral-B, Wrigley, andthe National Institutes of Health. nn

Editorial PolicyThe Journal of Laser Dentistry is devoted to providing the Academy and its members withcomprehensive clinical, didactic and research information about the safe and effective uses oflasers in dentistry. All statements of opinions and/or fact are published under the authority ofthe authors, including editorials and articles. The Academy is not responsible for the opinionsexpressed by the writers, editors or advertisers. The views are not to be accepted as the viewsof the Academy of Laser Dentistry unless such statements have been expressly adopted by theorganization. Information on any research, clinical procedures or products may be obtainedfrom the author. Comments concerning content may be directed to the Academy’s main officeby e-mail to laserexec@laserdentistry.org

SubmissionsWe encourage prospective authors to follow JLD’s “Instructions to Authors” before submittingmanuscripts. To obtain a copy, please go to our Web site www.laserdentistry.org/press.cfm.Please send manuscripts by e-mail to the Editor at jdbf@ucsf.edu.

Disclosure Policy of Contributing Authors’ Commercial RelationshipsAccording to the Academy’s Conflict of Interest and Disclosure policy, authors of manuscriptsfor JLD are expected to disclose any economic support, personal interests, or potential biasthat may be perceived as creating a conflict related to the material being published.Disclosure statements are printed at the end of the article following the author’s biography.This policy is intended to alert the audience to any potential bias or conflict so that readersmay form their own judgments about the material being presented.

Disclosure Statement for the Academy of Laser DentistryThe Academy of Laser Dentistry has no financial interest in any manufacturers or vendors ofdental supplies.

Reprint Permission PolicyWritten permission must be obtained to duplicate and/or distribute any portion of the Journalof Laser Dentistry. Reprints may be obtained directly from the Academy of Laser Dentistryprovided that any appropriate fee is paid.

Copyright 2007 Academy of Laser Dentistry. All rights reserved unless other ownership is indicated. Ifany omission or infringement of copyright has occurred through oversight, upon notification amend-ment will be made in a future issue. No part of this publication may be reproduced or transmitted inany fom or by any means, individually or by any means, without permission from the copyright holder.

The Journal of the Academy of Laser Dentistry ISSN# 1935-2557.

JLD is published quarterly and mailed nonprofit standard mail to all ALD members. Issues arealso mailed to new member prospects and dentists requesting information on lasers in dentistry.

Advertising Information and RatesDisplay rates are available at www.laserdentistry.org/press.cfm and/or supplied upon request. Insertion orders and materials should be sent to Bill Spilman, Innovative MediaSolutions, P.O. Box 399, Oneida, IL 61467, 877-878-3260, fax: 309-483-2371, e-mail bill@innovativemediasolutions.com. For a copy of JLD Advertising Guidelines go to www.laserdentistry.org/press_advguide_policy.cfm. The cost for a classified ad in one issue is$50 for the first 25 words and $2.00 for each additional word beyond 25. ALD membersreceive a 20% discount. Payment must accompany ad copy and is payable to the Academy ofLaser Dentistry in U.S. funds only. Classified advertising is not open to commercial enterpris-es. Companies are encouraged to contact Bill Spilman for information on display advertisingspecifications and rates. The Academy reserves the right to edit or refuse ads.

Editor’s Note on Advertising: The Journal of Laser Dentistry currently accepts advertisements for different dental laser educationalprograms. Not all dental laser educational courses are recognized by the Academy of Laser Dentistry.ALD as an independent professional dental organization is concerned that courses meet the stringentguidelines following professional standards of education. Readers are advised to verify with ALD whetheror not specific courses are recognized by the Academy of Laser Dentistry in their use of the CurriculumGuidelines and Standards for Dental Laser Education.

The Transformative Dental ExperienceAlan J. Goldstein, DMD, New York, New YorkJ Laser Dent 2007;15(3):118-119

In times of change, learners inheritthe Earth, while the learned findthemselves beautifully equipped todeal with a world that no longerexists.

— Eric Hoffer

The skills and knowledge thatcreated the problem will be insuffi-cient in the development of itssolution.

— Albert Einstein

The spring 2007 issue of theJournal of the New York StateAcademy of General Dentistrypublished an article by Dr. RobertWillis1 that emphasized the role ofemotions over logic as patientsmade decisions about proposedtreatment plans. It is a perspectivethat has its roots all the way backto Dale Carnegie’s decades-longbestseller first published in 1936,How to Win Friends and InfluencePeople.2 But is Dr. Willis right? Isthis emotional component valid orover-hyped? What are we, as scien-tists, researchers, and clinicians tobelieve in our statistically ladenand evidence-based world?

As well we might inquirewhether this logic/emotiondichotomy is valid. I don’t think so.I believe it is only when we synthe-size emotion and logic that we havethe capacity to move people, totransform them. This is a perspec-tive that is different from theteacher whose goal is to teach

laser-tissue interaction to herstudents or from the practitionerwhose goal is to fix teeth and eradi-cate periodontal disease. Whilethese are all good things to achieve,essential things if you will, I wantto achieve more.

In my office, I take the positionthat our task is to make everypatient experience transformative.I want our patients to be changedby their interaction with us. Somemight consider it preposterous andgrandiose, but I would happilyextend this challenge to all of us inevery activity we undertake, eitheras a scientist or clinician. I main-tain that it is the only attitude totake if leadership is embodied inour work. If we are alive and opento the ever-expanding world beforeus, every interaction that has itsbeginning in the world of testtubes, microscopes, or humans hasthe capacity to be transformative.

As scientists and clinicians weare both practitioners and learners.In the former sense we dispenseknowledge and craft; in the latterwe take it in. It is very difficult,probably impossible, to make thedistinction between the learner andwhat it is that is learned – thescientist from the science or theclinician from clinical outcomesachieved. Sure, there is a great dealto be employed, integrated, anddispensed in our scientific commu-nity — skills, content, updating, andinformation-gathering strategies —

and we are obligated to do the bestwe can. But I’d like to focus on theside that I think is most importantin the transformational experience:learning.

Learning has a vibrant andexploratory quality. Its root iseducation, a word that comes fromthe Latin verb educare, whichmeans to lead. Truly learning isleading – not only leading others,but leading ourselves to new waysand seeing, knowing, and doing.

Learning means going intouncharted territory, opening andreshaping knowledge. This ofcourse requires both a questioningmind and a courageous spirit. Whatdoes this involve for us in the worldof dentistry and laser technology?How do we use our learning toopen new horizons in the care weprovide, to explore new clinicalapplications while still appreciatingthe science that supports them, andto bridge new practice and estab-lished theory? In short, how do wecreate the transformative experi-ence?

Albert Einstein, whose life isexplored in the revealing new biog-raphy by Walter Isaacson,3 and towhose inquisitiveness and geniuswe owe the foundations of laserscience and laser dentistry said,“The value of a college education[we might add professional educa-tion] is not the learning of manyfacts but the training of the mindto think.” Thinking is far morechallenging and rewarding thansimply performing.

In our world of laser technology,we begin with valid scientific prin-ciples, ground them in soundclinical practice, apply our inquisi-tiveness to new techniques, and atthe end of this process wind upwith potential breakthroughs inpatient care. Of course, one has to

SY N O P S I S

Dr. Goldstein, past president of the Academy of Laser Dentistry, high-

lights how we can and should profoundly and beneficially affect our

patients during our interactions with them.

118

JOU

RN

AL

OF

LA

SE

RD

EN

TIS

TR

Y|

20

07

VO

L1

5,

NO

.3

G U E ST E D I TO R I A L

Goldstein

119

JOU

RN

AL

OF

LA

SE

RD

EN

TIS

TR

Y|

20

07

VO

L1

5,

NO

.3

G U E ST E D I TO R I A L

be radical to take the risks that ourconservative profession says arebeyond the bounds of our do-no-harm charge. But risk-free anddo-no-harm are not equivalents. Nocare is risk-free, and neither is life.We run risks when we invade teethwith a handpiece, we run riskswhen do a simple a procedure likea prophylaxis. Certainly even themost prudent in our professionwould acknowledge that risksincrease in direct proportion to ourzeal to do good and the scope of ourefforts. And yes, we can mitigatethese risks with education,training, and experience. But riskcannot be eliminated, ever. Donothing and the risk of malpracticelooms large.

There is irony here. Manycolleagues, often those leastfamiliar with the principles of lasertechnology, see our unique arma-mentarium through their ownconservative, do-no-harm prism. Adrill that creates micro (and not-so-micro) fractures is seen as proper;while laser energy that createssmall, easily restorable, virtuallysterile cavities without fractures isseen as radical. It is language thathas turned dentistry on its head.

This inversion of science extends tothe discussion of laser technologyfor soft-tissue care. Excisionaltreatment is deemed conservativeand appropriate, while care offeredat the multiple-cell layer level —which has the added benefit ofbeing bactericidal — is deemedradical and without value. Am Imissing something?

My point is that I sometimes seeour profession as learned, in thesense described by Eric Hofferabove — and yet it often refuses toacknowledge that learning is theactivity most urgently required.Confucius identified the first andessential virtue as courage. I havea feeling I know where he wouldcome down on this question ofwhether every interaction is poten-tially, and optimally, transformative— and what it takes to achieve it.

A U T H O R B I O G R A P H YBorn and raised in the Bronx, Dr.Alan Goldstein graduated from theCity College of New York beforereceiving his dental degree fromthe University of PennsylvaniaSchool of Dental Medicine in 1968.He is a frequent contributor to thedental literature as well as a

lecturer in a variety of venues. Hewas certified as a ProfessionalCoach in 2001 and often addressesaudiences on topics of personaleffectiveness, fulfillment, and lead-ership as well as dental practicemanagement and use of lasers. Heis a past president of the Academyof Laser Dentistry and a formereditor of Wavelengths. He serves onthe Dental Advisory Board ofDentistry Today and the Journal ofLaser Dentistry. Dr. Goldstein maybe contacted by e-mail at:llaama1@mindspring.com.

Disclosure: Dr. Goldstein hasprovided educational services for anumber of laser manufacturers andreceived honoraria for these services.Presently he has no commercial finan-cial relationships.

R E F E R E N C ES1. Willis R. What it takes to boost case

acceptance. J N Y State Acad GenDent 2007 Spring:16-17.

2. Carnegie D. How to win friends andinfluence people. New York: Simon &Schuster, Inc., 1936.

3. Isaacson W. Einstein: His life anduniverse. New York: Simon &Schuster, Inc., 2007. nn

Goldstein

Journal of Laser Dentistry: Guidelines for AuthorsThe Academy of Laser Dentistry Welcomes Your Articles for Submission

The Journal of Laser Dentistry publish-es articles pertaining to the art, science,and practice of laser dentistry andother relevant light-based technologies.Articles may be scientific and clinical innature discussing new techniques,research, and programs, or may beapplications-oriented describing specificproblems and solutions. While lasersare our preferred orientation, otherhigh-technology articles, as well asinsights into marketing, practice man-agement, regulation, and other aspectsof dentistry that may be of interest tothe dental profession, may be appropri-ate. All articles are peer-reviewed priorto acceptance, modification, or rejection.

These guidelines are designed tohelp potential authors in writing andsubmitting manuscripts to the Journalof Laser Dentistry, the official publica-tion of the Academy of Laser Dentistry(ALD). Please follow these instructionscarefully to expedite review and process-ing of your submission. Manuscriptsthat do not adhere to these instructionswill not be accepted for consideration.The Academy of Laser Dentistry and theeditors and publisher of the Journal ofLaser Dentistry endorse the “UniformRequirements of Manuscripts Submittedto Biomedical Journals” (www.icmje.org).The Journal reserves the right to reviseor rescind these guidelines.

Authors are advised to read the morecomprehensive Guidelines for Authorsand required forms available by mail oronline at www.laserdentistry.org.

Manuscript EligibilitySubmitted manuscripts must be writtenclearly and concisely in AmericanEnglish and appropriate for a scholarlyjournal. Write in active voice and usedeclarative sentences. Manuscripts willbe considered for publication on the con-dition that they have been submittedexclusively to the Journal, and have notbeen published or submitted for publica-tion in any part or form in another publi-cation of any type, professional or lay, orin any language elsewhere, and with theunderstanding that they will not bereprinted without written consent fromboth the managing editor and the author.

PermissionsDirect quotations of 100 or more words,and illustrations, figures, tables, orother materials (or adaptations thereof)that have appeared in copyrightedmaterial or are in press must be accom-panied by written permission for theiruse in the Journal of Laser Dentistryfrom the copyright owner and originalauthor along with complete informationregarding source, including (as applica-

ble) author(s), title of article, title ofjournal or book, year, volume number,issue number, pages. Photographs ofidentifiable persons must be accompa-nied by valid signed releases indicatinginformed consent. When informed con-sent has been obtained from anypatient, identifiable or not, it should benoted in the manuscript. The appropri-ate Permission Letters must be submit-ted with the manuscript. Suggestedtemplate letters are available online.

CopyrightAll manuscript rights shall be trans-ferred to the Journal of Laser Dentistryupon submission. Upon submission ofthe manuscript, authors agree to sub-mit a completed Copyright TransferAgreement form, available online. If themanuscript is rejected for publication,all copyrights will be retained by theauthor(s).

CommercialismALD members are interested in learn-ing about new products and serviceofferings, however ALD stresses thatsubmitted manuscripts should be edu-cational in nature. The emphasis is onscientific research and sound clinicaland practical advice, rather than pro-motion of a specific product or service.

Disclosure of Commercial RelationshipsAccording to the Academy’s Conflict ofInterest and Disclosure policy, manu-script authors and their institutions areexpected to disclose any economic orfinancial support, as well as any per-sonal, commercial, technological, aca-demic, intellectual, professional, philo-sophical, political, or religious interestsor potential bias that may be perceivedas creating a conflict related to thematerial being published. Such condi-tions may include employment, consul-tancies, stock ownership or other equityinterests, honoraria, stipends, paidexpert testimony, patent ownership,patent licensing arrangements, royal-ties, or serving as an officer, director, orowner of a company whose products, orproducts of a competitor, are identified.Sources of support in the form of con-tracts, grants, equipment, drugs, mate-rial donations, clinical materials, specialdiscounts or gifts, or other forms of sup-port should be specified. The role of thestudy or manuscript sponsor(s), if any,are to be described. Disclosure state-ments are printed at the end of the arti-cle following the author’s biography.This policy is intended to alert the audi-ence to any potential bias or conflict sothat readers may form their own judg-ments about the material being pre-

sented. Disclosure forms are to besigned by each author. Manuscripts willnot be reviewed without the Journalhaving this form on file.

The Academy of Laser Dentistry alsorequires that authors disclose whetherany product discussed in their manu-script is unlabeled for the use discussedor is investigational.

The Disclosure Statement form isavailable online and must be submittedwith the manuscript.

Manuscript TypesSubmissions to the Journal should belimited to one of the types indicatedbelow.• Scientific / Technology / Clinical

Review• Case Reports and Clinical Case

Studies• Scientific / Clinical Research• Randomized Clinical Trials• Advances in Dental Products• Trends• Practice Management• Guest Editorials and Essays• Letters to the Editor• Book Reviews

Manuscript Preparation andSubmissionFormatAll submitted manuscripts should bedouble-spaced, using 12 pt. font sizewith at least 6 mm between lines.Submit manuscripts in Microsoft Word(.doc), using either the Windows orMacintosh platform. Manuscripts mustbe submitted electronically in this for-mat. Hard copy-only submissions willnot be accepted.

Unacceptable FormatsThe following submission formats areunacceptable and will be returned:• Manuscripts submitted in desktop

publishing software• PowerPoint presentations• Any text files with embedded images• Images in lower than the minimum

prescribed resolution.

Manuscript ComponentsTitle PageThe title page of the manuscript shouldinclude a concise and informative titleof the article; the first name, middle ini-tial(s), and last name of each author,along with the academic degree(s), pro-fessional title(s), and the name andlocation (city, state, zip code) of currentinstitutional affiliation(s) and depart-ment(s). Authors who are private practi-tioners should identify their location(city, state, and country). Include allinformation in the title that will make

electronic retrieval of the article sensi-tive and specific. Titles of case studiesshould include the laser wavelength(s)and type(s) utilized for treatment (forexample, “810-nm GaAlAs diode”).

Identify the complete address, busi-ness and home telephone numbers, faxnumber, e-mail address, and Web siteaddress (if any) for all authors. Identifyone author as the corresponding author.Unless requested otherwise, the e-mailaddress is published in the Journal.

AbstractA self-standing summary of the text ofup to 250 words should precede theintroduction. It should provide an accu-rate summary of the most significantpoints and be representative of theentire article’s content. Provide the con-text or background for the article, basicprocedures, main findings and conclu-sions. Emphasize new or importantaspects. Do not use abbreviations (otherthan standard units of measurement) orreferences in the abstract.

Author(s) BiographyProvide a brief, current biographicalsketch of each author that includes pro-fessional education and professionalaffiliations. For authors who hold teach-ing positions, include the title, depart-ment, and school. For authors who arein federal service, include rank or titleand station.

ReferencesReferences are to be cited in the text bynumber in order of appearance, withthe number appearing either as asuperscript or in brackets. The refer-ence list should appear at the end of themanuscript with references in order offirst appearance in the text of the man-uscript. The reference list must betyped double-spaced on a separate pageand numbered in the same sequence asthe reference citations appear in thetext. Prior to submission, all referencesare to be properly prepared in the cor-rect format, checked for completeness,carefully verified against their originaldocuments, and checked for accuratecorrespondence between referencescited in the text and listed in theReferences section.• For journal citations, include sur-

names and all initials of all authors,complete title of article, name of jour-nal (abbreviated according to the U.S.National Library of Medicine(www.nlm.nih.gov/services/lpabbrev.html), year of publication,volume, issue number, and completeinclusive page numbers. If abstractsare cited, add the abstract numberafter the page number.

• For book citations, specify surnamesand initials of all authors, chapternumber and title (if applicable), edi-

tors’ surnames and initials, booktitle, volume number (if applicable),edition number (if applicable), cityand full name of publisher, year ofpublication, and inclusive page num-bers of citation.

• For government publications or bul-letins, identify the author(s) (if given);title; department, bureau, agency, oroffice; the publication series, report,or monograph number; location ofpublisher; publisher; year of publica-tion; and inclusive page numbers.

• For articles published online but notyet in print, cite with the paper’sDigital Object Identifier (DOI) addedto the end of the reference.

• For Web citations, list the authorsand titles if known, then the URLand date it was accessed.

• For presentations, list the authors,title of presentation, indication thatthe reference is a lecture, name ofconference or presentation venue,date, and location.

Illustration Captions and LegendsAll illustrations must be accompanied byindividual explanatory captions whichshould be typed double-spaced on a sepa-rate page with Arabic numerals corre-sponding to their respective illustration.

TablesTables must be typewritten double-spaced, including column heads, data,and footnotes, and submitted on sepa-rate pages. The tables are to be cited inthe text and numbered consecutively inArabic numerals in the order of theirappearance in the text. Provide a con-cise title for each table that highlightsthe key result.

IllustrationsIllustrations include photographs, radi-ographs, micrographs, charts, graphs,and maps. Each should be numbered andcited in the text in the order of appear-ance and be accompanied by explanatorycaptions. Do not embed figures withinthe manuscript text. Each figure andtable should be no larger than 8-1/2 x 11inches. Digital files must measure at

least 5 inches (127 mm) in width. Theimage must be submitted in the size itwill be printed, or larger. Illustrationsare to augment, not repeat, material inthe text. Graphs must not repeat datapresented in tables. Clinical photographsmust comply with ALD’s Guidelines forClinical Photography, available online.Authors are to certify in a cover letterthat digitized illustrations accuratelyrepresent the original data, condition, orimage and are not electronically edited.

Publisher and Copyright HolderThe Journal of Laser Dentistry is pub-lished by Max G. Moses, MemberMedia, 1844 N. Larrabee, Chicago, IL60614, Telephone: (312) 296-7864; Fax:(312) 896-9119. The Journal of LaserDentistry is copyrighted by TheAcademy of Laser Dentistry, 3300University Drive, Suite 704, CoralSprings, FL 33065, Telephone: (954)346-3776; Fax: (954) 757-2598.

Articles, Questions, IdeasQuestions about clinical cases, scientificresearch, or ideas for other articles maybe directed to John D.B. Featherstone,Editor-in-Chief, by e-mail: jdbf@ucsf.edu.

Submission of Filesby E-mail:Send your completed files by e-mail(files up to 10 MB are acceptable). Iffiles are larger than 10 MB, they maybe compressed or sent as more than onefile, with appropriate labels. Filesshould be submitted to:John D.B. Featherstone, Editor-in-Chiefby e-mail: jdbf@ucsf.edu.

By Federal Express or OtherInsured Courier:If using a courier, please send the file asa CD-ROM, include a hard copy of yourmanuscript and also send a verificationby e-mail to Gail Siminovsky (laserexec@laserdentistry.org).Gail SiminovskyAcademy of Laser Dentistry3300 University Drive, Suite 704Coral Springs, FL 33065Phone: (954) 346-3776.

Summary of Illustration Types and Specifications

IllustrationType

Definition and ExamplesPreferredFormat

RequiredResolution

Line Art andVector Graphics

Black and white graphic with noshading (e.g., graphs, charts, maps)

EPS or JPG 1200 DPI

Halftone Art

Photographs, drawings, or paint-ing with fine shading (e.g., radi-ographs, micrographs with scalebars, intraoral photographs)

TIFF orJPG

300 DPI (black &white) 600 DPI (color)

CombinationArt

Combination of halftone and lineart (e.g., halftones containingline drawing, extensive lettering,color diagrams)

EPS or JPG 1200 DPI

122

JOU

RN

AL

OF

LA

SE

RD

EN

TIS

TR

Y|

20

07

VO

L1

5,

NO

.3

COV E R F E AT U R E

van As

Use of the Dental Operating Microscope in Laser Dentistry: Seeing the LightGlenn A. van As, DMD, North Vancouver, British Columbia, CanadaJ Laser Dent 2007;15(3):122-129

I N T R O D U C T I O NThe virtue of high levels of magnifi-cation in the medical field had beenunderstood for many decades.1-7 In1981, Apotheker introduced anoperating microscope into dentistry,although it offered only a singlelevel of magnification and could beused only in a standing position.8

In the late 1980s and early1990s, endodontists began topromote the dental operatingmicroscope (D.O.M.) for its value instandard endodontic therapy andfor the improvements in outcome ofboth nonsurgical retreatments andfor surgical cases.9-24

At the same time, periodontistsutilized the D.O.M. along with theirmicrosurgical armamentarium,realizing reductions in postopera-tive pain and quicker healing.25-31

The use of lower-power tele-scopic loupes became more of thenorm for all of dentistry duringthe mid-to-late 1990s.32-33 Withbetter understanding of the roleand value of magnification, manypractitioners purchased a higher-power set of loupes along with anilluminating headlight. As thepresent decade has progressed,the greatest increase in new usersof the D.O.M. has been from thoseclinicians who routinely usedloupes. In fact, in 2001, theauthor coined the term “magnifi-cation continuum” to describe the

ever-increasing powers of magnifi-cation being used in dentistry.34

The use of the operating micro-scope for both diagnosis (newpatient examinations, earliervisualization of decay and

cracks35) and treatment (includinglaser dentistry) has become moreaccepted (Figure 1).36-51

This article examines the abilityof the microscope to provideimprovement in visual acuity andthe effect that high levels ofenhanced magnification and illumi-nation can have on improving thequality of laser dentistry that isprovided.

B E N E F I TS O F M I C R O -SCO P E - C E N T E R E DP R AC T I C ESWhen used routinely for all aspectsof dentistry, the microscope hasfour basic advantages:1. Improved precision of treatment2. Enhanced ergonomics (Figure 2)3. Ability to capture digital docu-

mentation (Figure 3)4. Enhanced communication

through integrated video.

SY N O P S I S

Dr Van As was the recipient of the Leon Goldman Award for clinical

excellence in laser dentistry in 2006. This article reviews his

pioneering work using microscopy-assisted laser dentistry.

A B ST R AC TThis article discusses the historyand role of the dental operatingmicroscope in dentistry. Themicroscope has become a stan-dard part of the endodonticarmamentarium since the 1980sas practitioners recognized thevalue of improved visual acuitythrough enhanced magnificationand illumination. Benefits of thedental operating microscopeincluding improvements in treat-ment outcomes, ergonomics,documentation, and communica-tion are described. Theimportance of high levels ofmagnification for hard tissue laserdentistry are emphasized anddetailed as this discipline, likeendodontics, is also largely relianton nontactile information for clin-ical success.

Figure 1: View of a microscope-centereddental operatory

Figure 2: Neutral and balanced ergonomicsof the author at the microscope

123

JOU

RN

AL

OF

LA

SE

RD

EN

TIS

TR

Y|

20

07

VO

L1

5,

NO

.3

COV E R F E AT U R E

van As

1. Improved Precision ofTreatmentThe visual information provided bythe operating microscope is in factnot indicative of the magnificationthat is being employed. The actualamount of visual information is thearea of view through the scope andis therefore the product of the hori-zontal times the vertical number ofpixels. Therefore, the clinicianusing the 2X magnification powerof entry-level loupes sees approxi-mately 4 times the visualinformation of a dentist not usingany magnification (unaided eye).Likewise, 3X loupes provide 9 timesthe visual information of theunmagnified view and more thandouble the view of the 2X set. Table1 summarizes the relative advan-tages of a variety of magnifications.

The author uses his microscopetypically at 10X magnificationwhich provides 100X the amount ofvisual information compared to theunaided eye view. This is 25 timesthe information from 2X loupes andmore than 10 times as that seenwith 3X.

Carr52 reported that the unaidedhuman eye has the inherent abilityto resolve or distinguish two sepa-rate lines or entities that are atleast 200 µm or 0.2 mm apart. Ifthe lines are closer together, theneven 20/20 unmagnified vision will

not allow theclinician toresolve them astwo separateentities and theobjects willappear as one.Thus withmagnificationthe resolution ofthe human eyeimprovesdramatically(Table 2).

Baldissara etal.53 showed thatthe experiencedclinician, whenusing a sharp,new explorer,can feelmarginal gaps ofaround 36 µm.Thus, when

Figure 3: Illustration of the convenientarrangement of video camera on the leftand a digital, single lens reflex camera(Nikon D70) on the right of the scope

Figure 4: Views of the same tooth area showing the effect of themagnification range of a typical microscope

Table 1: Comparison of Unaided Eye, 2X Loupes, and Other Levels ofMagnification

Magnification Visual Information (VI)VI Compared to 2X Loupes

Unaided eye 1X 1/4

2X loupes 4X Even = 1

3X loupes 9X 2.25

4X loupes 16X 4

6X microscope 36X 9

10X microscope 100X 25

20X microscope 400X 100

Table 2: Resolution vs. Assessment Method

Assessment Method MagnificationResolution

(µµm)Resolution

(mm)

Unaided eye 1X 200 0.2

Low-power loupes 2X 100 0.1

Medium-power loupes 4X 50 0.05

Sharp explorer NA 36 0.036

Low-magnification microscope 6X 36 0.036

Medium-magnification microscope 10X 20 0.02

High-magnification microscope 20X 10 0.01

124

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

COV E R F E AT U R E

van As

magnification is beyond 6X power,the effectiveness of tactile means ofinspection with an explorer signifi-cantly decreases. Many cliniciansusing a microscope now rely onvisual rather than tactile means ofdiscovery as their motor skillsimprove during the learning curve.

The increased amount of infor-mation provided by the microscopeoffers some challenges. As themagnification increases, the depthand diameter of the field of view inthe operating field decreases. Athigher magnification, there is anincreased demand for improvedcontrol of the micromotor musclesand joints (fingers and wrists) thatcan require stabilization of thegross motor joints (elbow andshoulder) with micro-surgeonchairs. Tibbets and Shanelec54

reported the medical literatureshowed that the clinician not usingmagnification made movementsthat were 1-2 mm at a time. Atmicroscope levels of 20X magnifica-tion, the refinement in movementscan be as little as 10-20 µm (10-20/1000ths of a millimeter) at atime. It is useful therefore to notethat the limitation to precision oftreatment is not in the hands butin the eyes.

Impact of Improved Visual Acuityin Laser DentistryThe ability to carefully evaluatelaser-tissue interaction at highmagnification is important in manyareas of laser dentistry. The micro-scope offers improved visual acuitythrough its enhancements inmagnification (Figure 4) and co-axial, shadow-free illumination,and these properties can be oftremendous benefit during bothsoft tissue and hard tissue ablationprocedures.

Soft Tissue Laser Procedures andthe Dental Operating MicroscopeThe microscope can be especiallyeffective for clinicians using laserwavelengths with small-diameterflexible optic fibers for soft tissue

procedures, such as with potassiumtitanyl phosphate (KTP), diode, andNd:YAG lasers. For example, usinga laser to trough around subgin-gival crown preparations can befrustrating because dragging theglass tip through inflamed tissuecreates more bleeding. A 300-micron fiber, which is close to theresolution of the human eye, mustbe accurately placed 1 mm or sointo the sulcus to distend it, not todeepen it or to remove the papilla.The ability to closely watch thelaser-tissue interaction is impor-tant to prevent excessive heat,while accurately aiming the end-cutting fiber at the target tissue.The magnified view should preventtissue charring, and thus decreaseany postoperative discomfort forthe patient (Figures 5a-5f).

Excisional or incisional surgicalprocedures using small optic

contact fibers can be performedwith added precision when viewedthrough the D.O.M. The cliniciancan easily visualize exactly whenall tissue fibers have been ablated,reducing the need for retreatmentdue to relapse.

In microscope-assisted noncon-

Figure 5a: Preoperative view of maxillaryincisors prior to veneer preps

Figure 5b: Veneer preps done

Figure 5d: High magnification ofcompleted trough

Figure 5e: Veneer impression

Figure 5f: Tissue health at 2 weeks

Figure 5c: Diode laser used to trougharound margin

Figure 5g: Postoperative result

Figure 5: Sequence showing the benefit of using magnification

125

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

COV E R F E AT U R E

van As

tact soft tissue ablation, the clini-cian can keep the laser powersettings lower and avoid iatrogenicdamage to nontarget adjacenttissues. Magnification providesanother advantage when the prac-titioner, using either erbium orcarbon dioxide laser energy, istrying to avoid accidental interac-tion with tooth structure or bone.

Other noncontact procedures,such as aphthous ulcer desensitiza-tion, hemostasis of extraction sites,and treatment of hemangiomas,can benefit from the visual acuityoffered by magnification. Examplesare shown in Figures 6a-6f.

The erbium laser wavelengths(Er:YAG, Er,Cr:YSGG) may be usedin contact or noncontact mode forsoft tissue procedures. Using thenoncontact mode can help to limitthe inherent weakness of theerbium energy to adequately coagu-late. The noncontact “plasty” orshaving down of tissue that ispossible with the chisel or largefootprint Er:YAG tips, when usedin conjunction with the microscope

Figure 6a: Preoperative view of lowersecond molar

Figure 6d: Hemostasis by diode lasertreatment

Figure 7a: Noncontact Er:YAG frenectomy.Note early charring before adjustingpower settings

Figure 7b: High-magnification view offrenectomy. Note lack of hemorrhage innoncontact mode

Figure 7c: Noncontact “plasty” of epulis onmaxillary lip. Note “flash” at ablation site

Figure 7d: High-magnification view offrenectomy after periosteum is “scored”with an Er:YAG laser

Figure 6b: Sinus tract on buccal aspect

Figure 6e: Hemostatic laser-induced clotviewed at low magnificationFigure 6c: Extraction complete

Figure 6f: Clot induced by diode laserviewed at high magnification

Figure 6: Examples of procedures that benefit from observation by magnification

Figure 7: Examples of Er:YAG or Er, Cr:YSGG laser procedures that can be better carriedout under magnification

126

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

COV E R F E AT U R E

van As

at high magnification, is awonderful technique for treatingepulis and tissue tags, as well as inthe creation of ovate pontics forfixed bridges where the tissue canbe “melted” away (Figures 7a-7d).

Hard Tissue Laser Ablation and theOperating MicroscopeLeknius and Geissberger55 as wellas Zaugg et al.56 demonstrated that,when magnification was incorpo-rated, procedural errors inrestorative treatment decreasedsignificantly. In the latter study,the use of a microscope resulted infewer errors than loupes. Utilizingconventional instruments, the clini-cian can rely upon tactile meansfrom burs or hand instruments todetermine when the carious lesionis fully excavated or when oldrestorations have been completelyremoved. These same tactilemethods become more unreliable inhard tissue laser dentistry whereso much of the evaluation of thelaser-tissue interface is based onvisual cues. Caries detection dyes

are not easy to use and can producefalse readings with hard tissuelaser preparations (Figures 8a-8f).Moreover, erbium lasers can useboth contact tips (where the actualdistance for effective ablation is 0.5- 1.5 mm from the surface) andnoncontact delivery systems, and itis difficult to “feel” the ablationprocess. Therefore the use of highmagnification is essential to deter-mine when the preparation iscomplete.

There are several more reasonsto employ magnification forrestorative procedures. A largeamount of water is needed for effec-tive and safe hard tissue ablation,but that amount of water canobscure good visualization. Whererigid contact tips are used todeliver laser energy, their clearcolor makes them difficult to see.They must have a nonchippedsurface, and be held at the properworking distance from the targettissue, without tactile feedback.This optimum distance can varywith different instruments, but

ablation efficiency will significantlydecrease as the delivery system isplaced farther from the tooth. If thelaser tip is brought into directcontact with the surface the cuttingefficiency decreases, and the waterflow is not able to wash away abla-tion byproducts and cool the tissue.Charring and patient sensitivitycan occur. Enamel bevels for ClassIII, IV, and V restorations requirethe clinician to “scrape” or alter theablated enamel prior to acidetching. High magnification withthe operating microscope showsthat enamel bevels have manyloose rods which, if not altered withan instrument (hatchet or spoon,air abrasion or diamond bur), willyield significantly lower bondstrength compared to bur-cutenamel. The fragments of enamelthat are scraped off are easilyvisible under high magnification.

The operating microscope is alsoan instrumental piece of the arma-mentarium for the ablation of bone.To prevent plucking or iatrogenicnotching, it is best to use lowersettings (1.5 - 3 Watts, for

Figure 8a: Preoperative interproximal decay

Figure 8d: Preparations completedFigure 8b: Decay visible on distal aspectof first primary molar

Figure 8e: Restorations finishedFigure 8c: High magnification showsdecay still visible on facial wall of box

Figure 9: Laser beginning closed flaposseous contouring

Figure 8: Views relating to cavity preparation and restorations illustrating the benefits of using magnification

127

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

COV E R F E AT U R E

van As

example), a noncontact mode, and ahigh water flow to prevent charringand necrosis. The amount of waterand slight bleeding can obscurevisibility, so the ability to increasethe magnification during the proce-dure is imperative to success.

Osseous crown lengthening togain or re-establish biologic widthcan be performed with erbiumlasers. The microscope is especiallyuseful for closed-flap procedures sothat the clinician can more accu-rately direct the laser energy andavoid iatrogenic troughing of thebone. Figure 9 shows the laserbeginning closed-flap osseouscontouring.

It is therefore very beneficial for

magnification to be used for manyaspects of hard tissue laserdentistry. The higher the level ofmagnification used, the greater theability of the dentist to directlyview the laser-tissue interactionand to use the lowest possibleenergy and power to complete theprocedure. This ultimatelyproduces less patient sensitivityand better tissue health.

Laser SafetySafety is of paramount importanceto laser practitioners whether theyare using no magnification, tele-scopic loupes, or higher levels ofmagnification. All dental operatingmicroscopes have holders thataccept wavelength filters for eyeprotection. As usual, the lasersafety officer must ensure that theappropriate filter is in place, andthe user must be sure to makeclose eye contact with the ocularsto avoid the possibility of irradia-tion by accidental stray light.Assistants and patients must wearappropriate eye protection. Figure10a shows a typical erbium laserfilter and Figure 10b shows a filterbeing placed into the microscope.

2. Improved ErgonomicsThe operating microscope allowsfor the dentist to sit with anupright, neutral, and balancedposture (Figure 2). This neutraland balanced posture obtainablewith the D.O.M. has been discussedas being helpful in preventingergonomic issues that plague somany dentists and seem to be anoccupational hazard.57-60

3. Ability to Capture DigitalDocumentationThe D.O.M. can be a beneficialaddition in documenting a clinicalcase, especially because of thedetailed image (Figure 3), whetherstill or video. Carr,61 Behle,62 andvan As63-64 have written articlesdiscussing the merits of digitaldocumentation with the D.O.M. andthe advantages of doing so.

4. Enhanced Communicationthrough Integrated VideoDentists who have added videocapability to the microscope havefound it useful in providing infor-mation to both patients and toauxiliaries since they can observetreatment in real time.65 Clinicianshave found that the images fromthe operating scopes are a benefitto educating their patients abouttreatment needs and help inpersuading patients to accept treat-ment plans.

The use of video transmitted todifferent monitors in the operatoryhas initiated the possibility ofworking solely from a monitor, amethod some surgeons now employ.The next improvement will be thedevelopment of three-dimensionaldisplays.65

CO N C LU S I O NThe operating microscope used forlaser dentistry provides benefits forany clinician. The advantages areimproved precision, improvedergonomics, ease of documentation,and the ability to more fullycommunicate with patients, staff,and colleagues. Practitioners usingthe combination of the dental oper-ating microscope and lasers havefound that the two technologieswork well in tandem and improvenot only the treatment outcome butthe enjoyment of providing it.

A U T H O R B I O G R A P H YDr. Glenn A. van As is a 1987 grad-uate of the University of BritishColumbia Faculty of Dentistry whomaintains a full-time private dentalpractice in North Vancouver, BritishColumbia, Canada. His areas ofinterest and expertise involve theutilization of the dental operatingmicroscope for all of his clinicaldentistry and in the use of multiplewavelengths of hard and soft tissuelasers for many procedures. Since1999, he has lectured more than200 times internationally, providedhands-on workshops, and publishedinternationally on the value of

Figure 10a: Nd:YAG (1064 nm) anderbium (2780-2940 nm) laser filter

Figure 10b: Placing a diode (800-830nm) laser filter in the microscope

Figure 10: Safety filter for use withvarious lasers

128

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

COV E R F E AT U R E

van As

multiple wavelengths of lasers andpracticing with the high magnifica-tions obtainable with the dentaloperating microscope. Dr. van As isa member of the British ColumbiaDental Association, the CanadianDental Association, the Academy ofMicroscope Enhanced Dentistry(AMED), and the Academy of LaserDentistry (ALD). He has obtainedboth Standard and AdvancedProficiency in laser usage from theAcademy of Laser Dentistry, andwas distinguished with the LeonGoldman award for clinical excel-lence in the field of laser dentistryin 2006. In addition, Glenn is afounding member of the Academy ofMicroscope Enhanced Dentistry,and in 2004-2005 served as thesecond president of the group(www.microscopedentistry.com). Dr.van As may be contacted by e-mailat glennvanas@shaw.ca.

Disclosure: Dr. van As receives hono-raria for lectures from the GlobalSurgical Corporation on microscopes,from HOYA ConBio on lasers, andfrom Ivoclar on lasers.

R E F E R E N C ES1. Nylén CO. The microscope in aural

surgery, its first use and later devel-opment. Acta Otolaryngol1954;Suppl 116:226-240.

2. Jacobsen JH II, Suarez EL.Microsurgery in anastomosis ofsmall vessels. Surg Forum1960;11:243-245.

3. Harms H, Mackensen G. Ocularsurgery under the microscope.Chicago: Yearbook MedicalPublishers, Inc., 1967.

4. Dohlman GF. Carl Olof Nylén andthe birth of the otomicroscope andmicrosurgery. Arch Otolaryngol1969;90(6):813-817.

5. Klopper PJ. Microsurgery andwound healing. In: Lie TS, editor.Microsugery. Proceedings of the 5thInternational Congress of theInternational Microsurgical Society,Bonn, October 4-7, 1978.Amsterdam: Excerpta Medica,International Congress Series No.465, 1979:280-282.

6. Banowsky L. A review of opticalmagnification in urological surgery.Chapter 13 in Silber SJ, editor.Microsurgery. Baltimore: Williamsand Wilkins, 1979:443-465.

7. Barraquer JL. The history of themicroscope in ocular surgery. JMicrosurg 1980;1(4):288-289.

8. Apotheker H, Jako GJ. A microscopefor use in dentistry. J Micosurg1981;3(1):7-10.

9. Carr GB. Microscopes in endodon-tics. J Calif Dent Assoc1992;20(11):55-61.

10. Carr GB. Common errors in peri-radicular surgery. Endod Rep1993;8(1):12-18.

11. Pecora G, Andreana S. Use of dentaloperating microscope in endodonticsurgery. Oral Surg Oral Med OralPathol 1993;75(6):751-758.

12. Ruddle CJ. Endodontic perforationrepair: Using the surgical operatingmicroscope. Dent Today1994;13(5):48, 50, 52-53.

13. Feldman M. Microscopic surgicalendodontics. N Y State Dent J1994;60(8):43-45.

14. Mounce RE. Surgical operatingmicroscope in endodontics: Theparadigm shift. Gen Dent1995;43(4):346-349.

15. Ruddle CJ. Nonsurgical endodonticretreatment. J Calif Dent Assoc1997;25(11): 769-771, 773-775, 777,779-786, 788-799.

16. Stropko JJ. Canal morphology ofmaxillary molars: Clinical observa-tions of canal configurations. JEndod 1999;25(6):446-450.

17. de Carvalho MC, Zuolo ML. Orificelocating with a microscope. J Endod2000;26(9):532-534.

18. Sempira HN, Hartwell GR.Frequency of second mesiobuccalcanals in maxillary molars as deter-mined by use of an operatingmicroscope: A clinical study. JEndod 2000;26(11):673-674.

19. Görduysus MO, Görduysus M,Friedman S. Operating microscopeimproves negotiation of secondmesiobuccal canals in maxillarymolars. J Endod 2001;27(11):683-686.

20. Buhrley LJ, Barrows MJ, BeGole

EA, Wenckus CS. Effect of magnifi-cation on locating the MB2 canal inmaxillary molars. J Endod2002;28(4):324-327.

21. Schwarze T, Baethge C, Stecher T,Geurtsen W. Identification of secondcanals in the mesiobuccal root ofmaxillary first and second molarsusing magnifying loupes or an oper-ating microscope. Aust Endod J2002;28(2):57-60.

22. Coutinho Filho T, La Cerda RS,Gurgel Filho ED, de Deus GA,Magalhães KM. The influence of thesurgical operating microscope inlocating the mesiolingual canalorifice: A laboratory analysis. BrazOral Res 2006;20(1):59-63.

23. Tsesis I, Rosen E, Schwartz-Arad D,Fuss Z. Retrospective evaluation ofsurgical endodontic treatment:Traditional versus modern tech-nique. J Endod 2006;32(5):412-416.

24. Schirrmeister JF, Hermanns P,Meyer KM, Goetz F, Hellwig E.Detectability of residual Epiphanyand gutta-percha after root canalretreatment using a dental oper-ating microscope and radiographs –An ex vivo study. Int Endod J2006;39(7):558-565.

25. Shanelec DA. Current trends in softtissue. J Calif Dent Assoc1991;19(12):57-60.

26. Tibbets LS, Shanelec DA. Anoverview of periodontal micro-surgery. Current Opin Periodontol1994:187-193.

27. Shanelec DA, Tibbetts LS.Periodontal microsurgery.Periodontal Insights 1994;1(2):4-7.

28. Michaelides PL. Use of the oper-ating microscope in dentistry. JCalif Dent Assoc 1996;24(6):45-50.

29. Shanelec DA, Tibbetts LS. Aperspective on the future of peri-odontal microsurgery.Periodontology 2000 1996;11:58-64.

30. Tibbetts LS, Shanelec D. Currentstatus of periodontal microsurgery.Curr Opin Periodontol 1996;3:118-125.

31. Belcher JM. A perspective on peri-odontal microsurgery. Int JPeriodontics Restorative Dent2001;21(2):191-196.

129

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

COV E R F E AT U R E

van As

32. Shanelec DA. Optical principles ofloupes. J Calif Dent Assoc1992;20(11):25-32.

33. Strassler HE, Syme SE, Serio F,Kaim JM. Enhanced visualizationduring dental practice using magni-fication systems. Compend ContinEduc Dent 1998;19(6):595-596, 598,600, 602, 604, 606, 608, 610-611,quiz 12. Erratum in: CompendContin Educ Dent 1998;19(9):894.

34. van As G. Magnification and thealternatives for microdentistry.Compend Contin Educ Dent2001;22(11A):1008-1012, 1014-1016.

35. Clark DJ, Sheets CG, Paquette JM.Definitive diagnosis of earlyenamel and dentin cracks based onmicroscopic evaluation. J EsthetRestor Dent 2003;15(7):391-401,discussion 401.

36. Martignoni M, Schönenberger A.Precision fixed prosthodontics:Clinical and laboratory aspects.Chicago: Quintessence PublishingCo. Inc., 1990.

37. Friedman MJ, Landesman HM.Microscope-assisted precisiondentistry – Advancing excellence inrestorative dentistry. ContempEsthetics Restorative Pract1997;1(1):45-49.

38. Sheets CG, Paquette JM. Enhancingprecision through magnification.Dent Today 1998;17(1):44, 46, 48-49.

39. Piontkowski PK. The renaissance ofdentistry: An introduction to thesurgical microscope. Dent Today1998;17(6):82-87.

40. Sheets CG, Paquette JM. The magicof magnification. Dent Today1998;17(12):61-67.

41. Cruci P. An operating microscope ingeneral dental practice. Dent Pract1999:37(9):1, 4-5.

42. Friedman M, Mora AF, Schmidt R.Microscope-assisted precisiondentistry. Compend Contin EducDent 1999;20(8):723-726, 728, 730-731, 735-736, quiz 737.

43. Paquette JM. The clinical micro-scope: Making excellence easier.Contemp Esthetics Restorative Pract1999;3(9):12-20.

44. van As GA. Using the surgical oper-ating microscope in general practice.Contemp Esthetics Restorative Pract2000;4(1):34, 36-40.

45. van As GA. The role of the dentaloperating microscope in fixedprosthodontics. Oral Health2002;92(6):11-14, 17-20, 23, 25.

46. van As GA. The use of extrememagnification in fixed prosthodon-tics. Dent Today 2003;22(6):93-99.

47. Christensen GJ. Magnification indentistry: Useful tool or anothergimmick? J Am Dent Assoc2003;134(12):1647-1650.

48. Clark DJ. Microscope-enhancedaesthetic dentistry. Dent Today2004;23(11):96, 98-101.

49. Garcia A. Dental magnification: Aclear view of the present and aclose-up view of the future.Compend Contin Educ Dent2005;26(6A Suppl):459-463.

50. Clark DJ. The big push to clinicalmicroscopes for esthetic dentistry.Contemp Esthetics Restor Pract2005;9(11):30-33.

51. Clark DJ, Kim J. Optimizing gingivalesthetics: A microscopic perspective.Oral Health 2006;96(4):116-118, 121-122, 124-126.

52. Carr GB. Magnification and illumi-nation in endodontics. In: HardinJF, editor. Clark’s Clinical Dentistry.New York: Mosby, 1998;4:1-14.

53. Baldissara P, Baldissara S, Scotti R.Reliability of tactile perceptionusing sharp and dull explorers inmarginal opening identification. IntJ Prosthodont 1998;11(6):591-594.

54. Tibbets LS, Shanelec D. Periodontalmicrosurgery. Dent Clin North Am1998;42(2):339-359.

55. Leknius C, Geissberger M. Theeffect of magnification on the

performance of fixed prosthodonticprocedures. J Calif Dent Assoc1995;23(12):66-70.

56. Zaugg B, Stassinakis A, Hotz P.Einfluss von vergrösserungshilfenauf die erkennung nachgestellterpräparations- und füllungsfehler[Influence of magnification tools onthe recognition of simulated prepa-ration and filling errors]. SchweizMonatsschr Zahnmed2004;114(9):890-896.

57. Lunn R, Sunell S. Posture, positionand surgical telescopes in dentalhygiene. J Dent Educ1996;60(2):122.

58. Rucker LM. Surgical magnification:Posture maker or posture breaker?Chapter 8 in: Murphy DC, editor.Ergonomics and the dental careworker. Washington, DC: AmericanPublic Health Association,1998:191-216.

59. Valachi B, Valachi K. Mechanismsleading to musculoskeletal disordersin dentistry. J Am Dent Assoc2003;134(10):1344-1350.

60. Valachi B, Valachi K. Preventingmusculoskeletal disorders in clinicaldentistry: Strategies to address themechanisms leading to muscu-loskeletal disorders. J Am DentAssoc 2003;134(12):1604-1612.

61. Carr GB. Microscopic photographyfor the restorative dentist. J EsthetRestor Dent 2003;15(7):417-425.

62. Behle C. Photography and the oper-ating microscope in dentistry. J CalifDent Assoc 2001;29(10):765-771.

63. van As GA. Digital documentationand the dental operating micro-scope. Oral Health2001;91(12):19-20, 22-25.

64. van As G. Erbium lasers indentistry. Dent Clin North Am2004;48(4):1017-1059.

65. Britto LR, Veazey WS, Manasse GR.Personal video monitor as an acces-sory to dental operatingmicroscopes. Quintessence Int2004;35(2):151-154. nn

130

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

SC I E N T I F I C R E V I E W

Hibst

Detection of Caries by DIAGNOdent: Scientific Background and PerformanceRaimund Hibst, PhD, Institut für Lasertechnologien in der Medizin und Meßtechnik (ILM),

Ulm, GermanyJ Laser Dent 2007;15(3):130-134

I N T R O D U C T I O NThe process of dental caries isaccompanied by changes in theoptical properties of the affectedenamel or dentin. These changes inscattering, absorption, or fluores-cence are the basis of visual/opticaldetection of carious lesions. First,demineralization of enamel resultsin an enlargement of intercrystallinespaces, which makes the tissue lesshomogeneous and results in anincrease in light scattering (espe-cially when the tooth is dried). As aresult, decalcified enamel becomesvisible as a highly scattering “whitespot.” Later, the presence of chro-mophores in the lesion enhanceslight absorption so that the cariouslesion appears brownish.

A further tissue property which isaffected by caries is fluorescence.Fluorescence is the re-emission oflight by molecules after absorption.The fluorescence light always has alonger wavelength than the excita-tion light used for illumination. Itsspecific spectrum depends on theexcitation wavelength and the molec-ular species. A variety of biologicalmolecules shows fluorescence, espe-cially proteins. Fluorescence of teethon ultraviolet (UV) excitation wasfirst described nearly one centuryago.1 When teeth were illuminatedwith invisible UV light from a Wood’slamp, a bright fluorescence wasobserved by the naked eye. As earlyas 1927 it was noted that plaque

shows different fluorescence proper-ties when compared to sound toothnecks.2 While all the early studieswere performed with UV-excitation,the first experiments with visiblelight were reported beginning in1981.3 In general, the investigationswith UV, blue or green excitationlight revealed a strong fluorescenceof enamel, which is slightly alteredwhen the tissue becomes carious.This phenomenon allows detection ofdemineralization in the outer surfaceregions (sometimes referred to asquantitative laser / light fluores-cence, or QLF). However, stronglyfluorescing healthy enamel opticallymasks changes in deeper layers, asscattering does, so that deeperlesions covered by intact tissue aredifficult to detect by direct fluores-cence changes.

R E D E XC I T E D F LU O R ESC E N C EThe detection of hidden (occlusal)caries requires a low fluorescencefrom the overlying sound enamel,and a stronger emission from thelesion. Such a situation was foundwhen excitation by red light wasinvestigated.4-6 Experiments showedthat fluorescence yield decreased forlonger excitation wavelengths, asexpected, but this decrease wasmuch more pronounced for soundsurfaces than for carious lesions.With red light excitation (e.g., 655nm) carious lesions fluoresce much

more strongly. This is true acrossthe entire emission wavelengthrange. Thus all fluorescence can beused for differentiation of healthyand diseased tissue. The possibilityto utilize the total fluorescence lightis an advantage of red excitation,which compensates in part for thelower intensities compared to exci-tation with shorter wavelengths.The considerable contrast betweencarious and sound enamel, ordentin, respectively, obtained for redexcitation is demonstrated in Figure1, which shows a hemisectionedtooth and the corresponding fluores-cence image. Both carious sites areclearly marked on the very lowbackground fluorescence level. Thisoffers a very elegant way to detectcaries, because only the bright fluo-rescence spots in an otherwise darkenvironment are readily observed.This does not require 2-dimensionalimages and analysis. Additionally,

A B ST R AC TCaries covered by macroscopicallyintact enamel can be detected byirradiating the teeth with red lightand capturing the re-emittedinfrared fluorescence radiation.This fluorescence originates frommetabolites produced by cariesbacteria. The optical cariesdetector DIAGNOdent® measuresthis fluorescence and displays itsintensity as a number. The instru-ment can detect hidden cariesbetter than traditional methodsand enables longitudinal moni-toring of lesions. In order to avoidfalse positive diagnostic decisions,one should pay attention thatcalculus, stains, and some fillingmaterials can also show fluores-cence similar to caries lesions.

SY N O P S I S

Professor Hibst was one of the inventors of the DIAGNOdent laser

fluorescence caries detection device. This article provides a review of

the history, mechanism of action, and application of the device.

the detection of hidden caries ispossible, since the weaker soundenamel fluorescence does notcompletely mask the signal from adeeper lesion. Red light, and alsoinfrared fluorescence radiation, isless absorbed and scattered byenamel than light of shorter wave-lengths, so that in general red andinfrared light penetrates deeper intothe tooth. This also helps to increasethe depth that can be examined.

F LU O R O P H O R E I D E N T I F I C AT I O N 6

In order to find the origin of fluo-rescence, one has to consider boththe baseline fluorescence of sounddental tissue and its increaseduring the carious process.

Sound enamel and dentinexhibit a low, but observable, fluo-rescence. The dominant componentof enamel and dentin is the substi-tuted hydroxyapatite (HA) calciumphosphate mineral. Experimentswith pellets pressed out ofpowdered HA and various othercalcium phosphates revealed verylow signals. So it seems unlikelythat calcium phosphates areresponsible for the baseline fluores-cence of sound teeth. By comparingteeth with different color one can

observe that whiter teeth exhibitless fluorescence compared todarker ones. Presumably the samestains cause color and fluorescence.

Demineralized enamel that wasproduced by chemical decalcifica-tion did not significantly enhancefluorescence. This corresponds tothe finding of low calcium phos-phate fluorescence described above.That is, simply removing mineralfrom these hard tissues does notsignificantly alter the fluorescence.

Carious lesions show microscopi-cally a strong correlation betweenbrownish discoloration and fluores-cence, so that brown chromophoresmight also act as fluorophores(substances that fluoresce). Besidesnatural carious lesions, calculus ofvarious types also fluoresce underred light, including white calculus.So besides the brown pigments otherfluorophores can be present. Likelycandidates are bacteria or bacterialmetabolites. To test this hypothesis,bacteria from carious lesions wereincubated on blood agar andanalyzed by fluorescence microscopy.6

Both the bacterial colonies and thesurrounding agar showed fluores-cence. Agar fluorescence decreasedwith increasing distance from thecolonies, indicating that there are

diffusible bacterial metabolites fluo-rescing under red light excitation(Figure 2). Candidates for bacterialmetabolites that fluoresce could bethe so-called porphyrins. Porphyrinsoccur as intermediate steps in thesynthesis of heme, and are alsoproduced by several types of oralbacteria, such as Prevotella inter-media or Porphyromonas gingivalis.In earlier work, porphyrins, espe-cially Protoporphyrine IX (PPIX),indeed could be extracted fromcarious lesions and were demon-strated to be useful in differentiatingcaries from sound tooth structure byviolet (406 nm) excited fluorescence.7

Although fluorescence yield ismaximal for this short wavelengthexcitation, porphyrins were known toalso show some fluorescence whenexcited by red light. Solutions ofthese molecules also fluoresce with655-nm excitation, and their emis-sion spectra are very similar to thosefound for caries.

Other substances occurring natu-rally in the mouth, like water, saliva,blood, or soft tissue do not exhibitfluorescence with red light excitationand thus do not interfere with cariesdetection. In contrast, chlorophylldoes fluoresce, so that stains origi-nating from food (leaves, wine, etc.)must also be considered as an originof fluorescence (see below).

D ET EC TO R SYST E MA N D A P P L I C AT I O NOn the basis of the investigationsdescribed above the optical cariesdetector DIAGNOdent® (DD) wasdeveloped as a joint projectbetween the Institut fürLasertechnologien in der Medizinund Meßtechnik (ILM, Ulm,Germany) and Kaltenbach andVoigt (KaVo, Biberach, Germany).

The set-up and function are asfollows. Light from a laser diode(655 nm) is coupled into an opticalfiber and transmitted to the tooth.The excitation fiber is surroundedby a bundle of fibers which gatherfluorescence as well as backscat-tered light and guide it to the

131

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

SC I E N T I F I C R E V I E W

Hibst

Normal image with white light illumination

Fluorescence image in false colors (655-nm excitation)

Figure 1: Hemisectioned tooth with approximal and occlusal caries

132

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

SC I E N T I F I C R E V I E W

Hibst

detection unit (Figure 3). By the useof a band pass filter in front of thephoto diode detector, the backscat-tered excitation and shortwavelength ambient light isabsorbed. To discriminate the fluo-rescence from the ambient light inthe same spectral region, the laserdiode is modulated (i.e., the laserdiode intensity is varied with acertain frequency). Due to its rela-tively short lifetime, fluorescencefollows this modulation. By ampli-fying only the modulated portion ofthe signal, the ambient light issuppressed. The remaining signal isproportional to the detected fluores-cence intensity and displayed as anumber (0 to 99, in arbitrary units).In order to compensate for potentialvariations of the system (e.g., laserdiode output power), the device canbe calibrated by a ceramic standardof known and stable fluorescenceyield. This makes the measurementabsolute (although in arbitraryunits) and allows comparisons offluorescing tooth spots over time.

Tests on solutions of varying PPIXconcentrations demonstrated alinear response of the system (whenthe fluorophore concentration isincreased by a factor of x, the signalincreases by the same factor).Sensitivity was tested by applyingsmall droplets of PPIX solution ontothe enamel or dentin area of ahemisectioned tooth. On average 1picomole of PPIX results in a signalincrease of 4 DD units. Thiscompares to the baseline levels ofsound teeth, and would be thedetectable amount of porphyrins insuperficial carious lesions.6

In practical use the DD should becalibrated regularly (maybe daily) toassure comparable readings overtime. After the tooth is cleaned, asound spot on the smooth surface ismeasured in order to provide abaseline value. This value is thensubtracted electronically from thefluorescence of the site to be meas-ured. In order to measure andcapture the signal from the entirecarious lesion, the instrument hasto be tilted around the measuringsite. This ensures that the tip picksup fluorescence from the slopes ofthe fissure walls where the cariesprocess often begins. A risingaudible tone helps the examiner tofind the maximum fluorescencevalue of the site under study.9

P E R F O R M A N C EA literature search (with Scopus;“DIAGNOdent” in title, keywords,or abstract) yields about 110published articles on the DD. A

Figure 3: Schematic of the optical set-upof the DIAGNOdent caries detector device

Figure 2: Fluorescence microscopic study of caries-related bacteria

Figure 2a Figure 2b

Figure 2a: Light microscopy of twodifferent bacterial colonies on agarFigure 2b: Corresponding fluorescenceimage. Note the fluorescence also fromthe agar surrounding the coloniesFigure 2c: Relative fluorescence intensityalong the line marked on the image inFigure 2b

Figure 2c

133

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

SC I E N T I F I C R E V I E W

Hibst

large portion of these address ques-tions concerning its:• reproducibility, reliability (proba-

bility that two measurements bythe same (intraexaminer) ordifferent (interexaminer)observers lead to the same result

• sensitivity (ratio: true positive /(true positive + false negative),i.e., probability to correctly iden-tify carious lesions)

• specificity (ratio: true negative /(true negative + false positive),i.e., probability to correctly iden-tify sound teeth).A systematic review on the DD

performance8 reveals persistenthigh intraexaminer and slightlylower but still good interexaminerreliability. The results on sensi-tivity and specificity are variableamong the studies; the data rangefor the majority is given in Table 1.

Sensitivity and specificity dependon the cut-off values used as thethreshold to discriminate cariousfrom sound tissue. As the thresholdis lowered, more lesions are detectedat the price of an increasing numberof false positives. The few reportedin vivo studies yielded a betterperformance than the majority of invitro investigations. This might bedue to changes in optical propertiesafter extraction of the teeth(increase of scattering, loss of fluo-rescence). In the in vivo studies, athreshold of 20 DD units was chosen(in one study, 30). This can serve asguidance for the user’s (individuallyvariable) threshold value.

CO N C LU S I O NIn conclusion, “the DD is clearlymore sensitive than traditional diag-nostic methods.”8 However, theincreased likelihood of false positivereadings compared with that ofvisual methods gives rise to someconcern. The specificity found in thestudies would mathematicallypredict numerous unnecessary treat-ments for a collective of patientswith low caries prevalence. However:• First, the studies were performed

on samples with very high caries

prevalence (typically 20 to 50%)with numerous suspicious areas.Specificity with respect to thesesamples cannot be extrapolated tothe general situation, since theDD will never show an increasedsignal for completely intact whiteteeth. The reason for false positivereadings is always fluorescence,originating from stains (seeabove), calculus, or filing material.

• Secondly, the DD is a detectorand not a “diagnostic robot.” Itsreadings should be interpreted inthe context of the situation. Forexample, if fissures of a toothexhibit increased fluorescencebut the surrounding area doesnot, it is more likely that it origi-nates from superficial stain thanfrom deeper caries. Even in thepresence of fluorescing compos-ites, information can be gained:An increase of fluorescence fromthe center to the periphery wouldindicate additional fluorophores(= caries) at the margin.In contrast to visual inspection

(and also radiography), the DDprovides quantitative data. These arenot directly reflecting to “classical”lesion parameters like mineral lossor depth extension, but are related tothe amount of fluorescingporphyrins. Since bacterialporphyrins accumulate in demineral-ized areas of increased depth andporosity, more severe lesions typi-cally have higher concentrations ofporphyrins. Therefore DD readingsmay provide quantitative data thatcan be related to the severity of toothdecay. DD readings are highly repro-ducible and this allows longitudinal

monitoring of lesions. In all question-able situations with moderatefluorescence signals, it is reasonableto follow up the suspicious site atperiodic examinations. Increasingfluorescence signals would indicate aprogression of the lesion and thusindicate enhanced preventive oroperative treatment. However, it isimportant to remember that theincrease in fluorescence is a result ofmore absorption of external fluo-rophores into the more porous toothstructure, rather than directlydetecting lesion size or extent.

Recently, a miniaturized versionof the DD was released(DIAGNOdent® pen). First compar-isons show that the new deviceperforms on occlusal surfaces as wellas the “classic” DIAGNOdent.10

A U T H O R B I O G R A P H YRaimund Hibst has been educated inphysics and biology. He received aPhD degree in physics from theUniversity of Bochum, the venialegendi in biomedical engineeringfrom the University of Ulm in 1995(medical faculty), and in 2000 hebecame professor for laser anddental technologies (Faculty ofEngineering, University of Ulm).Since 1986 he has been with theInstitut für Lasertechnologien in derMedizin und Meßtechnik, Ulm,Germany, where he is actually asso-ciate director and the head of theDental Technology Center. Hisspecial interest is in optical methodsin dentistry. Among his projects hasbeen the development of an Er:YAGlaser system for dental and oral ther-apeutic applications (KEY Laser®)

Table 1: Data Ranges for DIAGNOdent Performance*

Condition Sensitivity Specificity Results Obtained in:

enamel caries in vitro 0.72 - 0.95 0.68 - 0.95 9 of 13 studies

dentinal caries in vitro 0.73 - 1.0 0.65 - 1.0 14 of 16 studies

dentinal caries in vivo 0.92 - 0.96 0.63 - 0.86 3 of 4 studies

*Based on data collected by Bader and Shugars from the majority of published studies on occlusallesions. Bader JD, Shugars DA. A systematic review of the performance of a laser fluorescencedevice for detecting caries. J Am Dent Assoc 2004;135(10):1413-1426.

134

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

SC I E N T I F I C R E V I E W

Hibst

and caries detection by fluorescence,which is also now used in clinicalpractice (DIAGNOdent®). TheEr:YAG laser research was awardedby the University of Ulm in 1990. In1998 he received the award for bestcooperation with industry. RaimundHibst is an editor of the journalMedical Laser Application and aboard member of several journals.Dr. Hibst may be contacted by e-mailat raimund.hibst@ilm.uni-ulm.de.

Disclosure: The caries detectorDIAGNOdent has been developed incooperation between ILM and KaVo. Itis based on an invention made by theauthor and coworkers. For this, ILMreceives royalties from KaVo which inpart are passed down to the inventors.

R E F E R E N C ES1. Stübel H. Die fluoreszenz tierischer

gewebe in ultraviolettem licht. [Thefluorescence of animal tissues byirradiation with ultraviolet light.]Pflugers Arch Gesamte PhysiolMenschen Tiere 1911;142:1-14.

2. Bommer S. Hautuntersuchungen imgefilterten Quarzlicht.[Investigations on skin with filteredquartz light.] Klin Wochenschr1927;6(24):1142-1144.

3. Alfano RR, Yao SS. Human teethwith and without dental cariesstudied by visible luminescencespectroscopy. J Dent Res1981;60(2):120-122.

4. Hibst R, Gall R. Development of adiode laser-based fluorescence cariesdetector. Caries Res 1998;32(4):294,abstract 80.

5. Hibst R, Paulus, R. A new approachon fluorescence spectroscopy forcaries detection. In: FeatherstoneJDB, Rechmann P, Fried D, editor.Lasers in dentistry V, January 24-25, 1999, San Jose, California. ProcSPIE 3593. SPIE – TheInternational Society for OpticalEngineering, Bellingham,Washington, 1999:141-147.

6. Hibst R, Paulus R, Lussi A.Detection of occlusal caries by laserfluorescence: Basic and clinicalinvestigations. Med Laser Appl2001;16(3):205-213.

7. König K, Hibst R, Meyer H,Flemming G, Schneckenburger H.Laser-induced autofluorescence ofcarious regions of human teeth andcaries-involved bacteria. In: AltshulerGB, Hibst R, editor. Dental applica-tions of lasers, September 1-2, 1993,Budapest, Hungary. Proc SPIE 2080.SPIE – The International Society forOptical Engineering, Bellingham,Washington, 1993:170-180.

8. Bader JD, Shugars DA. A system-atic review of the performance of alaser fluorescence device fordetecting caries. J Am Dent Assoc2004;135(10):1413-1426.

9. Lussi A, Hibst R, Paulus R.DIAGNOdent: An optical method forcaries detection. J Dent Res2004;83(Spec. Issue C):C80-C83.

10. Lussi A, Hellwig E. Performance ofa new laser fluorescence device forthe detection of occlusal caries invitro. J Dent 2006;34(7):467-471.

For additional references, see the workscited within references 6, 8, and 9,above. nn

135

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L R E V I E W A N D C A S E R E P O RT

Reyhanian et al.

Er:YAG Laser-Assisted Implant PeriapicalLesion Therapy (IPL) and Guided BoneRegeneration (GBR) Technique: New Challenges and New InstrumentationAvi Reyhanian, DDS, Netanya, Israel; Donald J. Coluzzi, DDS, Redwood City, CaliforniaJ Laser Dent 2007;15(3):135-141

I N T R O D U C T I O NOsseointegrated implants have beenutilized as a successful treatmentmodality over three decades, with ahigh reported success rate, greaterthan 90 percent.1-4 The predictabilityand high rate of success of dentalimplants makes them a standardtreatment modality. Oftentimes inspite of exacting planning andprecise placement accompanying theprocedure, implant failure can anddoes still occur.5-8 A small number ofimplants fail because of operatorinexperience or clinically recogniz-able cause. Their widespread use inrecent years has produced differenttypes of complications which can bedivided into two categories:

1. Intraoperative Complications• Bleeding• Nerve injury• Mandibular fractures• Implant displacements• Accidental bone perforations• Incomplete flap closure

2. Postoperative Complications• Mucositis and peri-implantitis• Implant periapical lesion (IPL)• Surgical wound dehiscence• Lesions on adjacent teeth

• Incomplete osseointegration.Recent case reports introduced

the term retrograde peri-implan-titis as a lesion (radiolucency)around the most apical part of anosseointegrated implant.9-11 Itdevelops within the first monthafter insertion of the implant.

The Etiology of ImplantPeriapical Lesion6, 9-10, 12-15

1.Contamination of the implantsurface

2.Overheating of bone10, 16-18

3.Overloading of the implant19

4.Presence of preexisting bone andmicrobial pathology12, 16, 20

5.Presence of residual root frag-ments and foreign bodies in bone21

6. Implant placement in an infectedmaxillary sinus

7. Implant placement in a poorbone quality site22-23

8.Lack of biocompatibility9.Excessive tightening of the

implant and compression of thebone chips inside the apical hole,producing subsequent necrosis16, 24

10. Contaminated implants.9, 16

Predisposing Factors25

1.Patient characteristics: age,medical history

2.Recipient site: local bone qualityand quantity, cause of tooth loss22,

26-27

3.Periodontal and endodonticconditions of neighboring teeth7, 28

4. Implant characteristics: length,surface characteristics22, 29-32

5.Surgical aspect: guided boneregeneration, osseous fenestra-tion, or dehiscence.10

SY N O P S I S

The etiology and predisposing factors of implant periapical lesions

are described and a case report of treatment using an Er:YAG laser is

presented.

A B ST R AC TOsseointegrated implants haveenjoyed a success rate of morethan 90 percent. There are severalreasons for failure including chal-lenges during placement andpostoperative complications.

This article will discuss one ofthose failures, the implant peri-apical lesion (IPL) which is anaccumulation of granulation tissuearound the apical area of animplant. It is manifested as a radi-ographic radiolucency, and resultsin compromised osseous healthand often requires the removal ofthe implant fixture.

The etiology and predisposingfactors of IPL will be enumerated,and descriptions of the classifica-tion, prevention, and treatment ofIPL will be elaborated.

A clinical case of IPL, treatedwith an erbium:YAG laser, will bepresented. The detailed clinicalprotocol will be described. Theseven-month postoperative clinicaland radiographic findings showcomplete reversal of the lesionand change the prognosis fromhopeless to good for the implant.

136

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L R E V I E W A N D C A S E R E P O RT

Reyhanian et al.

ClassificationA classification of implant periapicallesions has been suggested thatseparate them into two categories:inactive and infected.9 The inactiveform is likely to appear as an apicalscar, resulting from a residual bonecavity created by placing an implantthat was shorter than the prepareddrill site. An example is shown inFigure 1. The infected form occurswhen an implant apex is placed inproximity to an existing infection orwhen a contaminated implant isplaced (Figure 2).

Prevention and TreatmentSuggested preventions of implantperiapical lesion include carefulmanagement of contaminants andheat generation during implantsurgery.

Treatment would vary accordingto the type of lesion. The inactivetype is observed and monitored.The infected type requires surgicalintervention, debridement of theinfected lesion, systemic antibiotic,and/or guided bone regeneration.An implant apical resection orimplant removal could beperformed depending on the extentof the infection and the stability ofthe implant.6, 9, 12, 27, 33

The Use of Er:YAG Laser in IPLTreatment34-37

• The erbium laser can make theinitial flap incision, such as acrestal incision, or an intrasul-

cular or vertical releasing inci-sion. The laser produces a wetincision (some bleeding) vs. a dryincision (no bleeding) such as thatproduced by the CO2 laser.34, 36-38

• After the flap is raised, theerbium laser is also very efficientat vaporization of any granula-tion tissue,34-35 with a lower riskof thermal damage to the bonethan current diode or CO2lasers.34, 39-40

• The erbium laser provides detoxi-fication of implant surfaces.41

Studies have demonstrated thislaser’s bactericidal potential.42-43

• Furthermore, implant surfacethreads can be disinfectedwithout damage by lasingdirectly on their surfaces with alow energy.44-46

• The erbium laser is also efficientat remodeling, shaping, andablating necrotic bone.34, 36, 38, 47-48

C AS E OV E R V I E WThis case describes the use of anEr:YAG laser in treatment of peri-implantitis of an implant periapicallesion and the advantages of thislaser wavelength in performing aguided bone regeneration (GBR)technique versus conventionalmethods.

ExaminationA 56-year-old female presentedwith a noncontributory medicalhistory. She was not taking anymedications. She presented twomonths after she had 4 implantsplaced in the maxillary anteriorarea for teeth #7, 8, 9, and 10. Thefixtures of #8 and 9 had failed theprevious month and were removed;the implant for #10 was inte-grating normally, but #7 wascompromised.

Figure 1: An example radiograph of inac-tive implant periapical lesion around twoimplants

Figure 2: An example radiograph of aninfected implant periapical lesion. Theimplant was later extracted

Figure 3: Labial fistula on implant attooth #7

Figure 4: X-ray image of the periapicallesion

137

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L R E V I E W A N D C A S E R E P O RT

Reyhanian et al.

The patient had fair oral hygieneand brushed and flossed daily.Periodontal probing showed 3-mmpockets with no bleeding. Theimplant for tooth #7 was nonsub-merged and a labial fistula waspresent; furthermore, insertion of aprobe into the fistula led to the endof the implant, and revealed loss offacial bone on the buccal side of theimplant (Figure 3). The soft tissuearound the failed implants in thearea of #8 and 9 had healed well,the implant at the location of #10was submerged without soft tissuecomplications, and all other oralsoft tissue appeared normal.

Panoramic and periapical filmsshowed a radiolucent area aroundthe apical portion of the implant(Figure 4). The extent of buccalbone resorption could not be deter-mined from the radiograph.

The implant was stable with nomobility.

DiagnosisThe provisional and final diagnosiswas peri-implantitis of the implantfixture for tooth #7 with an infectedimplant periapical lesion exhibitingsevere bone loss on the buccal sideof the implant.

Treatment PlanTreatment would involve the use ofan Er:YAG laser to perform:• the incision for a flap• ablation of granulation tissue

around the implant• remodeling, shaping, and decorti-

cation of the bone• decontamination of exposed

screw threads of the implant, and• a GBR procedure.

Since the implant was notmobile, this technique has a goodprognosis.

Treatment alternatives couldconsist of traditional scalpel,curettes, citric acid, air flow, airabrasion49 and rotary bone burs.

TreatmentAn Er:YAG laser (OpusDuo™

AquaLite E™, Lumenis Ltd.,

Yokneam, Israel) with a wave-length of 2940 nm was used.

An intrasulcular incision wasmade using a 200-micron sapphiretip in contact mode. The powersetting was 9 W, 450 mJ / 20 Hzwith a water spray. The incisionextended posteriorly from the distalarea of #8 to the distal of #6(Figure 5). Then a verticalreleasing incision was madeapically on #6, and a buccal flapwas lifted (Figure 6). The infectedarea was then visualized. Therewas massive bone loss on the

buccal apical aspect of the implantwith a great deal of granulationtissue. The lack of mobility of theimplant was confirmed.

The granulation tissue wasablated with the erbium laser innoncontact mode; the tip was a1300-micron sapphire tip at apower of 8.4 W, 700 mJ / 12 Hzwith a water spray (Figure 7). Theremoval of this granulation tissueproduced a crater around the endof the implant. Next, the laserparameters were reduced to 3 W,

Figure 5: Er:YAG laser being used for inci-sion. A 200-micron tip is used in contactmode at 9 W, 450 mJ / 20 Hz

Figure 6: Flap being raised

Figure 7: Er:YAG laser being used for gran-ulation tissue ablation. A 1300-micron tipis used at 8.4 W, 700 mJ / 12 Hz

Figure 8: View immediately after ablationof granulation tissue and bone remodeling

Figure 9: Bio-Oss® placement completed

Figure 10: Bio-Gide® absorbentmembrane in place

138

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L R E V I E W A N D C A S E R E P O RT

Reyhanian et al.

150 mJ / 20Hz and, with the sametip and water spray, the laserenergy was aimed at the surface ofthe screw thread to obtain deconta-mination. Lastly, the laser wasused to ablate the necrotic boneand to shape and remodel the sitefor GBR. A 1300-micron tip wasused in noncontact with a power of9 W, 450 mJ / 20 Hz and waterspray (Figure 8). After lasing, thedefect was filled with Bio-Oss®

(Geistlich Pharma AG, Wolhusen,Switzerland), a bone substitutexenograft material, and coveredBio-Gide® (Geistlich Pharma AG),an absorbent bilayer membrane

(Figures 9-10). The flap wassutured with 3-0 silk with carefulattention paid to good primaryclosure (Figure 11).

There are four important princi-ples to keep in mind whenperforming GBR.50-56

• Fixation of the implant (theimplant must be stable)

• There must be complete andpassive soft tissue coverage

• There must be cortical stimula-tion by the material, and

• The vertical releasing incisionshould be as far as possible fromthe GBR site to enable goodprimary closure.The purpose of GBR is to enable

new bone formation, treat theanatomical defect, and improve theimplant’s prognosis. Themorphology of the defect is impor-tant for healing: the more walls of

bone left, the better the implantreacts. Deficiency of blood supplycauses failure; to improve the bloodsupply to the bone graft, decortica-tions of the bone are performed.

Postoperative InstructionsClindamycin (150 mg x 50 tabs)was prescribed to prevent infection,and Motrin (800 mg x 15 tabs) forpain control. The patient wasinstructed to rinse with chlorhexi-dine 0.2% starting the next day for2 weeks, three times a day, and wasadvised to maintain good oralhygiene.

Management of Complicationsand Follow-Up CareThe patient was examined the nextday. She reported a moderate painand moderate swelling of the cheekon the right side; but there was notissue bleeding, the site was closed,and the flap was attaching withnormal healing. Figure 12 depictsthe 10-day postoperative viewwhen the patient returned forinspection and suture removal. Theswelling had resolved, there wereno signs of fistula, and healing wasprogressing well. At six weeks, thesoft tissue had healed over thebone and there were no bonyprojections (Figure 13), and the

Figure 11: Primary closure with sutures

Figure 12: Ten-day postoperative view

Figure 13: One-and-a-half-month postop-erative view

Figure 14: One-and-a-half-month postop-erative radiograph

Figure 15: Seven-month postoperativeview

Figure 16: Seven-month postoperativeradiograph

139

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L R E V I E W A N D C A S E R E P O RT

Reyhanian et al.

radiograph showed good integra-tion (Figure 14). The seven-monthintraoral view (Figure 15) and theradiograph (Figure 16) show fullhealing. The prognosis is very good.

CO N C LU S I O NThe Er:YAG laser can be used fordecontamination of infectedimplant surfaces and has beenshown to be effective and safe. Theuse of this laser wavelength forthose procedures presents advan-tages over conventional methodssuch as reducing the patient’sdiscomfort, and allowing bettervisualization in the surgical site. Inaddition, postoperative effects, suchas pain and swelling, are lesspronounced. This laser is an invalu-able tool for those procedures bysimplifying treatment and offeringpatients faster and less stressfuloral therapy.

A U T H O R B I O G R A P H I ESDr. Avi Reyhanian graduated fromthe University of Bucharest,Romania in 1988. He then partici-pated in a fellowship program atthe Oral and MaxillofacialDepartment, Rambam Hospital, inHaifa, Israel. He currently prac-tices general dentistry and oralsurgery in Netanya, Israel. Dr.Reyhanian first incorporateddental lasers in his practice inearly 2002, and currently usesEr:YAG, CO2, and diode (830 nm)lasers. He has been performingperiodontal surgery for the past 17years (the last four with lasers)and has completed more than 100cases of periodontal laser surgery.He is a member of the Academy ofLaser Dentistry and the IsraelSociety of Dental Implantology. Dr.Reyhanian may be contacted by e-mail at: avi5000rey@gmail.com.

Disclosure: Dr. Reyhanian has nocommercial affiliations.

Donald J. Coluzzi, DDS is a 1970graduate of the University ofSouthern California School of

Dentistry. He recently retired after 35years from his general dental prac-tice in Redwood City, California. Heis an Associate Professor at theUniversity of California SanFrancisco School of DentistryDepartment of Preventive andRestorative Dental Sciences. He ispast president of the Academy ofLaser Dentistry and holds AdvancedProficiency certificates in Nd:YAGand Er:YAG laser wavelengths. He isa fellow of the American College ofDentists, and has received the LeonGoldman Award for ClinicalExcellence and the DistinguishedService Award from the Academy ofLaser Dentistry. He has publishedpeer-reviewed manuscripts aboutlasers in dentistry, and along withRobert A. Convissar has co-authoredthe Atlas of Laser Applications inDentistry, published by QuintessencePublishing Company in 2006. Dr.Coluzzi may be contacted by e-mail atdon@laser-dentistry.com.

Disclosure: Dr. Coluzzi is a lecturerfor HOYA ConBio. He receives hono-raria for those services.

R E F E R E N C ES1. Adell R, Lekholm U, Rockler B,

Brånemark PI. A 15-year study ofosseointegrated implants in thetreatment of the edentulous jaw. IntJ Oral Surg 1981;10(6):387-416.

2 Albrektsson T. A multicenter reporton osseointegrated oral implants. JProsthet Dent 1988;60(1):75-84.

3. Buser D, Mericske-Stern R, Dula K,Lang NP. Clinical experience withone-stage, non-submerged dentalimplants. Adv Dent Res1999;13:153-161.

4. Olsson M, Friberg B, Nilson H,Kultje C. MkII – A modified self-tapping Brånemark implant: 3-yearresults of a controlled prospectivepilot study. Int J Oral MaxillofacImplants 1995;10(1):15-21.

5. Jaffin RA, Berman CL. The exces-sive loss of Branemark fixtures intype lV bone: A 5-year analysis. JPeriodontol 1991;62(1):2-4.

6. Esposito M, Hirsch J, Lekholm U,

Thomsen P. Differential diagnosisand treatment strategies for biologiccomplications and failing oralimplants: A review of the literature.Int J Oral Maxillofac Implants1999;14(4):473-490.

7. Brisman DL, Brisman AS, MosesMS. Implant failures associatedwith asymptomatic endodonticallytreated teeth. J Am Dent Assoc2001;132(2):191-195.

8. Ayangco L, Sheridan PJ.Development and treatment ofretrograde peri-implantitisinvolving a site with history offailed endodontic and apicoectomyprocedures: A series of reports. Int JOral Maxillofac Implants2001;16(3):412-417.

9. Reiser GM, Nevins M. The implantperiapical lesion: Etiology, preven-tion, and treatment. CompendContin Educ Dent 1995;16(8):768,770, 772, 774-777.

10. Piattelli A, Scarano A, Piattelli M,Podda G. Implant periapical lesions:Clinical, histologic, and histochem-ical aspects. A case report. Int JPeriodontics Restorative Dent1998;18(2):181-187.

11. Yoon J, Oh T-J, Wang H-L. Implantperiapical lesion: Potential etiologyand treatment. J Korean Dent Assoc2002;40(5):388-397.

12. McAllister BS, Master D, MefferRM. Treatment of implants demon-strating periapical radiolucencies.Pract Periodontics Aesthet Dent1992;4(9):37-41.

13. Scarano A, Di Domizio P, Petrone G,Iezzi G, Piattelli A. Implant peri-apical lesion: A clinical andhistologic case report. J OralImplantol 2000;26(2):109-113.

14. Oh TJ, Yoon J, Wang HL.Management of the implant peri-apical lesion: A case report. ImplantDent 2003;12(1):41-46.

15. Jalbout ZN, Tarnow DP. The implantperiapical lesion: Four case reportsand review of the literature. PractProced Aesthet Dent 2001;13(2):107-112, quiz 114.

16. El Askary AS, Meffert RM, Griffin T.Why do dental implants fail? Part I.Implant Dent 1999;8(2):173-185.

17. Eriksson A, Albrektsson T, Grane B,

140

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L R E V I E W A N D C A S E R E P O RT

Reyhanian et al.

McQueen D. Thermal injury to bone:A vital-microscopic description ofheat effects. Int J Oral Surg1982;11(2):115-121.

18. Yacker MJ, Klein M. The effect ofirrigation on osteotomy depth andbur diameter. Int J Oral MaxillofacImplants 1996;11(5):634-638.

19. Isidor F. Loss of osseointegrationcaused by occlusal load of oralimplants. A clinical and radi-ographic study in monkeys. ClinOral Implants Res 1996;7(2):143-152.

20. Sussman HI, Moss SS. Localizedosteomyelitis secondary toendodontic-implant pathosis. A casereport. J Periodontol 1993;64(4):306-310.

21. Park SH, Sorensen WP, Wang HL.Management and prevention ofretrograde peri-implant infectionfrom retained root tips: Two casereports. Int J PeriodonticsRestorative Dent 2004;24(5):422-433.

22. Saadoun AP, Le Gall MG. An 8-yearcompilation of clinical resultsobtained with Steri-Oss endosseousimplants. Compend Contin EducDent 1996;17(7):669-672, 674, 676,678, 680, 682-684, 686, 688, quiz688.

23. Hutton J, Heath MR, Chai JY,Harnett J, Jemt T, Johns RB,McKenna S, McNamara DC, vanSteenberghe D, Taylor R, WatsonRM, Hermann T. Factors related tosuccess and failure rates at 3-yearfollow-up in a multicenter study ofoverdentures supported byBrånemark implants. Int J OralMaxillofac Implants 1995;10(1):33-42.

24. Piattelli A, Scarano A, Balleri P,Favero GA. Clinical and histologicalevaluation of an active “implantperiapical lesion”: A case report. IntJ Oral Maxillofac Implants1998;13(5):713-716.

25. Quirynen M, Vogels R, Alsaadi G,Naert I, Jacobs R, van SteenbergheD. Predisposing conditions for retro-grade peri-implantitis, andtreatment suggestions. Clin OralImplants Res 2005;16(5):559-608.

26. Albrektsson T, Dahl E, Enbom L,Engevall S, Engquist B, ErikssonAR, Feldmann G, Freiberg N, Glantz

P-O, Kjellman O, Kristersson L,Kvint S, Köndell P-Å, Palmquist J,Werndahl L, Åstrand P.Osseointegrated oral implants. ASwedish multicenter study of 8139consecutively inserted Nobelpharmaimplants. J Periodontol1988;59(5):287-296.

27. Sussman HI. Periapical implantpathology. J Oral Implantol1998;24(3):133-138.

28. Shaffer M, Juruaz D, Haggerty PC.The effect of periradicularendodontic pathosis on the apicalregion of adjacent implants. OralSurg Oral Med Oral Pathol OralRadiol Endod 1998;86(5):578-581.

29. Quirynen M, Naert I, vanSteenberghe D, Dekeyser C, CallensA. Periodontal aspects of osseointe-grated fixtures supporting a partialbridge. An up to 6-years retrospec-tive study. J Clin Periodontol1992;19(2):118-126.

30. Lekholm U, van Steenberghe D,Herrmann I, Bolender C, Folmer T,Gunne J, Henry P, Higuchi K, LaneyWR, Linden U. Osseointegratedimplants in the treatment ofpartially edentulous jaws: Aprospective 5-year multicenterstudy. Int J Oral MaxillofacImplants 1994;9(6):627-635.

31. Wheeler SL. Eight-year clinicalretrospective study of titaniumplasma-sprayed and hydroxyapatite-coated cylinder implants. Int J OralMaxillofac Implants 1996;11(3):340-350.

32. Grunder U, Polizzi G, Goené R,Hatano N, Henry P, Jackson WJ,Kawamura K, Kohler S, Renouard F,Rosenberg R, Triplett G, Werbitt M,Lithner B. A 3-year prospectivemulticenter follow-up report on theimmediate and delayed-immediateplacement of implants. Int J OralMaxillofac Implants 1999;14(2):210-216.

33. Balshi TJ, Pappas CE, Wolfinger GJ,Hernandez RE. Management of anabscess around the apex of amandibular root form implant:Clinical report. Implant Dent1994;3(2):81-85.

34. Sasaki KM, Aoki A, Ichinose S,Yoshino T, Yamada S, Ishikawa I.Scanning electron microscopy and

Fourier transformed infrared spec-troscopy analysis of bone removalusing Er:YAG and CO2 lasers. JPeriodontol 2002;73(6):643-652.

35. Nelson JS, Orenstein A, Liaw LH,Berns MW. Mid-infrarederbium:YAG laser ablation of bone:The effect of laser osteotomy onbone healing. Lasers Surg Med1989;9(4):362-374.

36. Ishikawa I, Aoki A, Takasaki AA.Potential applications oferbium:YAG laser in periodontics. JPeriodontal Res 2004;39(4):275-285.

37. Watanabe H, Ishikawa I, Suzuki M,Hasegawa K. Clinical assessmentsof the erbium:YAG laser for softtissue surgery and scaling. J ClinLaser Med Surg 1996;14(2):67-75.

38. Ishikawa I, Sasaki KM, Aoki A,Watanabe H. Effects of Er:YAGlaser on periodontal therapy. J IntAcad Periodontol 2003;5(1):23-28.

39. Schwarz F, Bieling K, Sculean A,Herten M, Becker J. Laser undultraschall in der therapie periim-plantärer infektionen – Eineliteraturübersicht. [Treatment ofperiimplantitis with laser or ultra-sound. A review of the literature.]Schweiz Monatsschr Zahnmed2004;114(12):1228-1235.

40. Kreisler M, Al Haj H, d’Hoedt B.Temperature changes at theimplant-bone interface during simu-lated surface decontamination withan Er:YAG laser. Int J Prosthodont2002;15(6):582-587.

41. Schwarz F, Rothamel D, Becker J.Einfluss eines Er:YAG-lasers auf dieoberflächen-struktur von titan-implantaten. [Influence of anEr:YAG laser on the surface struc-ture of titanium implants.] SchweizMonatsschr Zahnmed2003;113(6):660-671.

42. Folwaczny M, Mehl A, Aggstaller H,Hickel R. Antimicrobial effects of2.94 microm Er:YAG laser radiationon root surfaces: An in vitro study. JClin Periodontol 2002;29(1):73-78.

43. Kreisler M, Kohnen W, Marinello C,Götz H, Duschner H, Jansen B,d’Hoedt B. Bactericidal effect of theEr:YAG laser on dental implantsurfaces: An in vitro study. JPeriodontol 2002;73(11):1292-1298.

141

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L R E V I E W A N D C A S E R E P O RT

Reyhanian et al.

44. Matsuyama T, Aoki A, Oda S,Yoneyama T, Ishikawa I. Effect ofthe Er:YAG laser irradiation on tita-nium implant materials andcontaminated implant abutmentsurfaces. J Clin Laser Med Surg2003;21(1):7-17.

45. Schwarz F, Rothamel D, Sculean A,George T, Scherbaum W, Becker J.Effect of an Er:YAG laser and theVector ultrasonic system on thebiocompatibility of titaniumimplants in cultures of humanosteoblast-like cells. Clin OralImplants Res 2003;14(6):784-792.

46. Kreisler M, Kohnen W, ChristoffersAB, Götz H, Jansen B, Duschner H,d’Hoedt B. In vitro evaluation of thebiocompatibility of contaminatedimplant surfaces treated with anEr:YAG laser and an air powdersystem. Clin Oral Implants Res2005;16(1):36-43.

47. Aoki A, Yoshino T, Akiyama F, MiuraM, Kinoshita A. Oda S, Watanabe H,Ishikawa I. Comparative study ofEr:YAG laser and rotating bur forbone ablation. In: Ishikawa I, Frame

JW, Aoki A, editors. Lasers indentistry: Revolution of dental treat-ment in the new millennium.Proceedings of the 8th InternationalCongress on Lasers in Dentistry, July31-August 2, 2002, Yokohama, Japan.Excerpta Medica InternationalCongress Series 1248. Amsterdam:Elsevier Science B.V., 2003:389-391.

48. Rupprecht S, Tangermann K, KesslerP, Neukam FW, Wiltfang J. Er:YAGlaser osteotomy directed by sensorcontrolled systems. J CraniomaxillifacSurg 2003;31(6):337-342.

49. Jovanovic SA. The management ofperi-implant breakdown aroundfunctioning osseointegrated dentalimplants. J Periodontol 1993;64(11Suppl):1176-1183.

50. Von Arx T, Kurt B, Hardt N.Treatment of severe peri-implantbone loss using autogenous bone anda resorbable membrane. Case reportand literature review. Clin OralImplants Res 1997;8(6):517-526.

51. Meffert RM. How to treat ailing andfailing implants. Implant Dent1992;1(1):25-33.

52. Artzi Z, Tal H, Chweidan H. Boneregeneration for reintegration inperi-implant destruction. CompendContin Educ Dent 1998;19(1):17-20,22-23, 26-28, quiz 30.

53. Mellonig JT, Griffiths G, Mathys E,Spitznagel J. Treatment of thefailing implant: Case reports. Int JPeriodontics Restorative Dent1995;15(4):384-395.

54. Lehmann B, Bragger U, HammerleCH, Fourmousis I, Lang NP.Treatment of an early implant failureaccording to the principles of guidedtissue regeneration (GTR). Clin OralImplant Res 1992;3(1):42-48.

55. Goldman MJ. Bone regenerationaround a failing implant using guidedtissue regeneration. A case report. JPeriodontol 1992;63(5):473-476.

56. Hammerle CH, Fourmousis I, WinklerJR, Weigel C, Brågger U, Lang NP.Successful bone fill in late peri-implant defect using guided tissueregeneration. A short communication.J Periodontol 1995;66(4):303-308. nn

The Dental Hygiene Laser CourseStandard Proficiency Certification

Laser Soft Tissue ManagementPatient Chairside Clinic

Course Designed for HygieneAll Courses Held in Your Office with Your Laser • Technique Driven Instruction • Advanced Skills Training

Academy of Laser Dentistry Recognized Course Provider

Soft Tissue LASER TrainingTeri Gutierrez, RDH Certified Laser EducatorPhone: 1-831-801-8210 or visit www.lasers4hygiene.com

CALL TODAY FOR COURSE AVAILABILITY

Advanced Proficiency Case Studies

142

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E ST U D I E S

Upcoming issues of the Journal will feature casestudies from the most recent recipients of AdvancedProficiency. These clinicians completed the two-yearprocess by successfully presenting one of these cases atthe Academy of Laser Dentistry’s 2007 AnnualConference in Nashville, Tennessee. They are: MaryLynn Smith, RDH; Charles Hoopingarner, DDS; andSteven Parker, BDS, LDS RCS, MFGDP.

In this issue, Mrs. Smith utilizes an Nd:YAG laseras part of the protocol for initial treatment of peri-odontal disease. She explains how the laser isintegrated into the therapeutic appointment anddemonstrates the wavelength’s benefits in helping tocontrol the disease.

Dr. Hoopingarner performs gingival and osseousclosed flap crown lengthening with an Er:YAG laser tohelp restore a bicuspid with a lingual cusp fracturethat extended subgingivally. This case depicts thelaser’s ability to ablate and contour both soft and hardtissue with precision and care, and ultimately to gainthe necessary biologic width and tooth structure for asuccessful restoration.

These cases show how different laser wavelengthscan be routinely employed in a variety of dental proce-dures to produce safe, efficient, and excellent clinicalresults. nn

Nd:YAG Laser Use in Treatment of ModerateChronic PeriodontitisMary Lynn Smith, RDHMcPherson, Kansas

Treatment of a Subcrestal Tooth Fracture withthe Er:YAG LaserCharles R. Hoopingarner, DDSHouston, Texas

144

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Smith

Nd:YAG Laser Use in Treatment of Moderate Chronic PeriodontitisMary Lynn Smith, RDH, McPherson, KansasJ Laser Dent 2007;15(3):144-150

P R ET R E AT M E N TA. Diagnostic Tests1. Full Clinical DescriptionA healthy 47-year-old Hispanic malepresented for examination. His chiefcomplaint was the dark spot at thegingival margin of tooth #9 andlimited chewing efficiency (Figure 1).His last dental visit was 6 monthsprior for an emergency extraction oftooth #19. He had never had anytype of dental hygiene appointment.The patient speaks Spanish predom-inately, and communication wasaccomplished by the dentist trans-lating information at specific timesin each appointment.

During the initial hygieneappointment, the health history wasreviewed and tissues were visuallyscreened for signs of oral cancer.Comprehensive restorative, peri-odontal, and radiographic examswere completed. Micro-ultrasonicscaling, biofilm removal, and coronalpolishing were performed. Thepatient was educated concerning hisoral health and probable progres-sion of untreated disease.

The patient was taking no

medications and had no known aller-gies. He was missing nine teeth: #1,16, 17, 19, 20, 25, 26, 30, and 32.Decay was noted on teeth #3, 15, and18. Significant fractures were notedon tooth #18 as well. The occlusionwas Angle’s classification I withnormal TMJ function. Supragingivalcalculus and gingival inflammationindicated possible periodontaldisease. Complete periodontalcharting revealed periodontalprobing depths of 2-7 mm. Areas ofrecession exposing 1 to 4 mm of rootsurface werepresent.Furcations andmobility werealso noted on themolars.

2. RadiographicExaminationA full-mouthseries with 4vertical bitew-ings and 14periapical filmswas taken tofurther evaluatebone loss andcarious lesions(Figure 2).

Decay wasnoted on teeth#3 and 18.Decay on #15was not detectedradiographically.

There wasmoderate gener-

alized horizontal bone loss with areasof severe vertical bone loss on posteriorteeth. Areas of particular concern wereteeth #2, 15, 18, and 31. These teethwere diagnosed as hopeless due to theperiodontal involvement and/or decaypresent and were scheduled for extrac-tion. Generalized moderate-to-heavycalculus was noted on the radiographs.

Figure 2: Full-mouth film series taken atinitial visit Figure 3: Initial periodontal probing chart

Figure 1: Preoperative full-smile photo-graph of patient at presentation

SY N O P S I S

This case report describes the use of an Nd:YAG laser as an integral

component of the initial treatment of periodontal disease.

145

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Smith

3. Soft Tissue StatusTissues appeared inflamed and irri-tated with the presence of plaqueand calculus. A complete six-pointperiodontal probing was performedwith 7 mm as the greatest pocketdepth. Generalized bleeding wasevident and moderate-to-heavysubgingival calculus was present inposterior areas, as well as supragin-givally on the lower anterior teeth.Gingival recession of 1-2 mm wasnoted on teeth #2, 3, 4, 5, 12, 13, 14,and 15 buccal surfaces and 1-4 mmon lingual surfaces of teeth #2, 3, 4,14, 15, 18, 23, 24, 27, 28, 29, 31.Mobility of class I was detected ontooth #14 and class II on #2, 15, 18,and 31. Class I furcations werefound on #2, 3, 14, 15, 18, and 31,and class II furcations on #2, 15, 18,and 31 (Figure 3). A statisticalsummary of overall periodontalhealth showed 36 hemorrhagingsites upon probing, 45 periodontalpockets of 4 mm or greater, and 19teeth exhibiting beyond-normallimits in pocketing. (This summaryexcludes teeth #2, 15, 18, and 31which were diagnosed as hopeless.)The oral cancer screening waswithin normal limits.

4. Hard Tissue Status• Missing teeth were #1, 16, 17, 19,

20, 25, 26, 30, and 32• All other teeth were vital• Occlusion was Angle’s Class I• Decay was present on teeth #3

DL, #15 O, and #18 DOL withfractures noted on the mesial,lingual and distal aspects

• Limited mastication was presentdue to missing posterior teeth.

5. Other TestsTMJ was normal.

B. Diagnosis and Treatment Plan1. Diagnoses• Provisional diagnosis included

chronic periodontitis with poorprognosis of molars.

• The doctor’s final diagnosis wasstated as severe generalizedchronic periodontitis. Carious

lesions were present on teeth #3DL, #15 O, #18 DOL, with signifi-cant fractures on #18 MLD.

2. Treatment Plan Outlinea. Restorative treatment to include:

• restoration of tooth #3 with adistolingual composite

• simple extractions of teeth#2, 15, 18, and 31

• replacement of teeth #19, 20,25, 26, and 30 with a partialdenture or implants.

b. Active phase-I periodontal infec-tion therapy to include fiveperiodontal infection therapyappointments, one hour eachand scheduled approximately aweek apart:• assessment of patient’s

plaque management, refiningtechniques and continuingmotivation for thorough dailycare

• micro-ultrasonic instrumen-tation and handinstrumentation for biofilmand calculus removal

• laser soft tissue decontami-nation and superficialcoagulation

• intraoral photographs.c. Six-week post-therapy re-infec-

tion assessment appointment toinclude:• one appointment for 30

minutes:• health history review• visual evaluation of tissue

rehabilitation• assessment of patient’s plaque

management, refining tech-niques and continuing motiva-tion for thorough daily care

• intraoral photographs• micro-ultrasonic biofilm

removal at gingival third oftooth

• probing and sulcular instru-mentation is avoided in orderto allow undisturbed matura-tion of connective tissue atthe base of the pocket.

d. Twelve-week post-therapyappointment to include:• health history review

• oral cancer screening• periodontal charting to

assess rehabilitation• assessment of patient’s

plaque management, refiningtechniques and continuingmotivation for thorough dailycare

• micro-ultrasonic instrumen-tation for full-mouthbacterial decontaminationand scaling as needed

• coronal polishing• laser decontamination of

unresolved areas• intraoral photos• determination of recare

interval.

3. Indications for TreatmentTreatment is indicated to halt theperiodontal destruction and rehabili-tate the affected tissues. Periodontalinfection therapy must includeremoval of biofilm and calculus fromthe root surfaces through scaling. TheNd:YAG laser furthers decontamina-tion of the pocket by addressing theperiodontal pocket wall. The 1,064-nm laser wavelength is highlyabsorbed in melanin and hemoglobin.Both of these chromophores arepresent in inflammatory tissue.Laser-tissue interaction reducespathogens in the pocket and coagu-lates hemorrhaging sites, assistingthe body’s healing response. Thislaser enhances the body’s healingprocess by reducing bacterial countsand achieving superficial coagulation.

4. Contraindications for Therapyand PrecautionsThough it could be beneficial to reducepathogens prior to extraction, teethdiagnosed as hopeless were notconsidered for therapy. There were nocontraindications for this patient toreceive Nd:YAG laser-assisted treat-ment of periodontal disease. Lasersafety precautions were followed forprotection of the patient and clinician.

The energy from the Nd:YAGlaser must be directed toward thesoft tissue and away from the toothand bone.

146

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Smith

5. Treatment AlternativesTreatment alternatives included:• No treatment and progression of

disease, eventual tooth loss andsystemic impact

• Conventional scaling and rootplanning

• Placement of localized antimicro-bials or antibiotics with possiblereactions

• Periodontal surgery.

6. Informed ConsentAfter being educated in theprogression of untreated peri-odontal disease and treatmentoptions, the patient gave verbaland written consent to proceedwith the planned therapy. This isdocumented in the patient’s record.

T R E AT M E N TA. Restorative TreatmentObjectiveTeeth #2, 15, 18, and 31 wereextracted prior to phase I activeperiodontal infection therapy.

Tooth #3 caries removal andcomposite restoration was placedafter completion of therapy per thepatient’s request.

B. Periodontal TreatmentObjectiveThe treatment objectives are tohalt the destruction of the peri-odontium due to disease processes.Laser-assisted periodontal treat-ment will reduce bacterial load inthe periodontal pocket wall, elimi-nating the related inflammatoryresponse by the body. The Nd:YAGlaser wavelength is well absorbedin pigmented and hemoglobin-richinflamed tissue. Signs of healing,such as decreased probing depths,elimination of hemorrhaging, andnormal tissue coloration andtexture, are desired. The appoint-ments are designed to allowpatient-customized education inspecific daily plaque managementtechniques, ensuring maximumrehabilitation of the tissues.Beginning with the most infectedteeth, each appointment will

address three to four teeth fordebridement of root surfacesthrough scaling, followed by tissuedecontamination and superficialcoagulation through lasing. At thesubsequent appointment, approxi-mately 7 to 10 days later, adifferent group of teeth will bedebrided and tissues lased. Thepreviously treated area will berevisited for ultrasonic biofilmremoval from tooth surfaces andlaser decontamination of tissues.Instrumentation with the ultra-sonic is concentrated on thecervical area of tooth structure andthe fiber is calibrated to 1 mm lessthan the previous application. Thiscontinues the reduction of bacterialload and enhances the body’shealing response. It also allowsreinforcement of behavior modifica-tion in daily plaque management.

C. Laser Operating ParametersA free-running pulsed Nd:YAGlaser (PulseMaster 600 IQ,American Dental Technologies,Corpus Christi, Texas) with a 1064-nm emission wavelength was usedwith a 400-micron contact fiber. Forbacterial reduction, the laserparameters were 30 mJ and 60 Hz,average power of 1.8 Watts forapproximately 40 seconds per site;for superficial coagulation, thesettings were 100 mJ and 20 Hz,with an average power of 2.0 Wattsfor approximately 20 seconds persite. The total laser emission timefor the five sessions of periodontalinfection therapy was 155 minutes.

D. Treatment DeliverySequenceThe treatment delivery sequence ateach therapeutic appointmentincluded:• review of health history• plaque management assessment

and instruction• anesthetic as needed• topical anesthetic administered

at the gingival margin andsubgingivally. A compoundedpreparation called TAC (20%

lidocaine, 4% tetracaine, and 2%phenylephrine) was used

• local anesthetic of 2% lidocainewith epinephrine 1:100,000 wasadministered for more profoundanesthesia

• infiltration with 4% articainewith epinephrine 1:100,000 wasadministered when a full blockwas not necessary

• micro-ultrasonic and handinstrument debridement of rootsurfaces

• laser decontamination and super-ficial coagulation

• postoperative care instructionsgiven.Laser safety measures included:

• use of 1,064-nm laser wavelengthprotective eyewear by all opera-tory personnel

• use of 0.1-micron filtration masks• environment secured to limit

access• laser-in-use warning sign placed• reflective surfaces minimized• high-volume evacuation utilized

for plume control and to cool thetissue.Chart documentation included

laser and wavelength used, fibersize and type, operating parame-ters, and emission time.

The laser fiber was cleaved andthe laser test-fired. The fiber wascalibrated to 1 mm less than thepocket depth (Figure 4). With thefiber remaining in constant contactwith the internal pocket tissue andin constant motion, treatment beganat the top of the pocket andprogressed apically, moving the fibervertically and horizontally until the

Figure 4: Laser fiber is calibrated to 1mm less than the pocket depth

147

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Smith

calibrated depth was reached. Thefiber was always directed away fromthe root surface and toward thetarget tissue. Accumulated debriswas wiped from the fiber and aproper cleave maintained (Figure 5).Figure 6 shows the laser techniqueon tooth #3, which is featured inthis case. The amount of lasing timewas influenced by tissue interaction,extent of disease, and depth of thepocket. When fresh bleeding wasvisible, the laser procedure was

deemed complete for that site(Figure 7). High-volume suction waspresent to eliminate the plume andcool the tissue.

Several figures demonstrate thetypical treatment protocol in twodifferent areas of the mouth.

Figure 8a shows initial mesialpocket depth of tooth #14, 8b showsthe laser treatment, and 8c showsthe immediate postoperative coagu-lation.

Figure 9a shows the mesio-lingual pocket of tooth #28, 9bshows the laser treatment, and 9cshows the immediate postoperativecoagulation.

E. Postoperative InstructionsPostoperative instructions weregiven in verbal and written form.The patient was instructed to avoid(for the first 24 hours) acidic, rough,or crunchy foods. Normal eating

Figure 5: Any debris clinging to the fibermust be wiped off

Figure 6: Intraoperative view showing thetechnique used on the upper right molar

Figure 7: Intraoperative view demon-strating fresh bleeding which indicatesthat the laser use for this site is complete

Figure 8a: Initial mesiobuccal pocket ontooth #14

Figure 8b: Laser treatment of pocket

Figure 8c: Immediate postoperative view

Figure 8: Tooth #14 procedure Figure 9: Tooth #28 procedure

Figure 9c: Immediate postoperative view

Figure 9b: Laser treatment of pocket

Figure 9a: Initial mesiolingual pocket ontooth #28

148

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Smith

could resume following that period.Avoidance of seeds, husks, andother foods that may lodge betweenthe gingiva and tooth was recom-

mended for a week. In the areaslased, subgingival flossing and thesmall Sulcabrush® (Sulcabrush Inc.,Niagara Falls, N.Y.) were to beavoided for several days. Use of anultrasoft toothbrush and supragin-gival cleaning was recommended.All other areas were to be cleanedas usual. If discomfort were tooccur, the patient was instructed touse warm salt water rinses andover-the-counter pain medication.The patient was informed that themost important aspect of thetherapy was the healing process,and minimizing plaque at thegingival margin was critical inpreventing re-infection.

F. ComplicationsThe patient experienced cold sensi-tivity. He was prescribed 1.1%neutral sodium fluoride with potas-sium nitrate for daily use. It waseffective and he had no othercomplications during or after thelaser treatments.

G. PrognosisPrognosis overall is good as long as

the patientconforms to goodoral hygiene andrecommendedintervals forprofessionalsupportive main-tenance visits.Periodontally,teeth #3 and 14will be monitoredfor continuedimprovement.Restorative treat-ment is needed toreduce functionalstresses onexisting teeth.

H. Documenta-tionAll treatment andrelated informa-tion was recordedin the patient’streatment record.

F O L LOW- U P C A R EA. Assessment of TreatmentOutcomesThe patient was assessed at 1week, 6 weeks, 12 weeks, and 6months following active phase-Iperiodontal infection therapy.Periodontal charts show compara-tive data of initial state to 12weeks post-therapy as well as 6months post-therapy. Percentage ofimprovement is seen with 92% inbleeding reduction, 80% in pocketsite reduction, and 68% fewer teethexhibiting periodontal pocketing.

The one-week examinationrevealed that the tissues werehealing and the patient’s skill inplaque management wasimproving. For example, Figure 10ashows the one-week view of tooth#14, and Figure 10b shows the one-week view of tooth #28.

Figure 10: One-week postoperative views

Figure 12: Twelve-week postoperativeprobing

Figure 10b: One-week postoperative viewof tooth #28

Figure 10a: One-week postoperative viewof tooth #14

Figure 11: Twelve-week postoperative periodontal probing chart Figure 12b: Tooth #28

Figure 12a: Tooth #14

149

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Smith

Six-week post-therapy re-infection assessmentappointment included:• confirmation that the patient is

maintaining plaque control.

Tissues are continuing toimprove.

• health history review• visual evaluation of tissue

rehabilitation• assessment of the

patient’s plaquemanagement,refining tech-niques andcontinuing moti-vation forthorough dailycare

• intraoral photo-graphs

• micro-ultrasonicbiofilm removalat gingival thirdof tooth

• probing andsulcular instru-mentation wasavoided in orderto allow undis-turbedmaturation ofconnective tissueat the base of thepocket.

Twelve-weekpost-therapyappointment:

Overall, a marked improvement wasseen in periodontal health, such asdecreased probing depths, decreasedbleeding on probing, normal tissuecoloration, firm texture, and lack ofmobility. Teeth #3 and 14 needcontinued refinement of plaquemanagement and further therapy.This appointment included:• health history review• oral cancer screening• six-point pocket and hemor-

rhaging periodontal charting toassess rehabilitation (Figure 11)

• assessment of the patient’splaque management, refiningtechniques and continuing moti-vation for thorough daily care

• micro-ultrasonic instrumentationfor full-mouth bacterial deconta-mination and handinstrumentation as needed

• coronal polishing• laser decontamination of appro-

priate areas• determination of recare interval

at 12 weeks.The previously mentioned

Nd:YAG laser was used with asetting for decontamination of 30 mJand 60 Hz, 1.8 Watts average power,and additional hemostasis applica-tion for teeth #3 and 14 at 100 mJand 20 Hz, 2.0 Watts delivered witha 400-micron contact fiber for 7minutes total emission time. Oralhygiene instructions were reviewed.Continued use of daily fluoride ascaries prevention was recommended.A 12-week supportive periodontaltherapy appointment was scheduled.Short-term follow-up for tooth #14 isshown in Figure 12a and for tooth#28 in Figure 12b.

Six-month post-therapyappointment:Tissue health is maintaining verywell. Tooth #3 is continuing toimprove while #14 remains an areaof concern. Periodontal chartingscompare the initial, 12-week, and

Figure 13: Six-month postoperative periodontal probing chart

Figure 14b: Tooth #28

Figure 14a: Tooth #14

Figure 14: Six-month postoperative probing

Figure 15: Comparison views

Figure 15b: Six-month postoperative fullsmile

Figure 15a: Preoperative full smile atpresentation

150

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Smith

6-month periodontal status. The 6-month therapeutic appointmentincluded:• health history review• oral cancer screening• six-point periodontal charting

(Figure 13)• assessment of the patient’s

plaque management, refiningtechniques and continuing moti-vation for thorough daily care;instructions to continue dailyfluoride applications

• micro-ultrasonic instrumentationfor full-mouth bacterial deconta-mination and handinstrumentation as needed

• coronal polishing• laser decontamination of appro-

priate areas• instruction to continue 12-week

maintenance interval.The previously mentioned

Nd:YAG laser was used with a 400-micron fiber and parameters of 30Hz, 60 mJ, average power of 1.8Watts for decontamination.Hemostatic assistance was accom-plished with 100 mJ, 20 Hz,average power of 2.0 Watts appliedto sites of tooth #14 due toincreased inflammation. Emissiontime totaled 8 minutes. Long-termfollow-up is illustrated: Figure 14ashows the 6-month probing of tooth#14 and 14b shows tooth #28.

B. ComplicationsContinued daily use of fluoride wasrecommended for caries prevention.The patient had no soft or hardtissue damage and was pleasedwith the results from the laser.

C. Long-Term ResultsAt 12 weeks post-therapy therewas marked improvement.Hemorrhaging sites were reducedby 92%, number of perio sites by80%, and number of teeth affectedby 68%. At 6 months post-therapy,the patient had an increase inhemorrhaging sites but otherimprovements continued. Thepatient’s health compared to hisinitial state showed improvementsof 81% in hemorrhaging, 91% inperio sites, and 90% number ofteeth affected (Table 1). Figures15a and 15b show the comparisonof tissues initially and at 6 monthspost-therapy.

D. Long-Term PrognosisThe patient was compliant with alltreatment aspects and a good prog-nosis exists. It will requireconformity to good oral hygiene andcontinued professional supportivemaintenance visits at 12-weekintervals. Periodontally, teeth #3and 14 will be monitored forcontinued improvement.

Adjustment of the maintenanceinterval and adjunctive use ofArestin® (OraPharma Inc.,Warminster, Pa.) are possible. Inthe case of acute and rapid progres-sion, surgical intervention orextraction may be indicated.Replacement of missingmandibular teeth will be veryimportant to alleviate excessivefunctional stress on existing teeth.If a partial denture is chosenrather than implants, cariesprevention and periodontalstability of supporting teeth will bea concern. Caries preventionstrategy includes effective dailyplaque management, daily use offluoride, and reduced acid sourcesin diet, as well as consistent profes-sional care. An oral irrigator fordaily use would be beneficial for allteeth present.

A U T H O R B I O G R A P H YMary Lynn Smith is a registereddental hygienist, working clini-cally for more than 12 years. Sheachieved her Standard Proficiencyin the Nd:YAG (1,064-nm) anddiode (810-nm) wavelengths in2003, and completed herAdvanced Proficiency in theNd:YAG in 2007. Mary Lynn hascontributed to the dental commu-nity through articles andspeaking to fellow hygienists oncare of implants, periodontal ther-apies, and laser-assisted hygienetechniques and principles. Shecurrently resides in McPherson,Kansas and is employed by Dr.Jon Julian, DDS. Mrs. Smith maybe contacted by e-mail at mlsrdh@swbell.net.

Disclosure: Mrs. Smith has nocommercial relationships relative tothis case presentation. nn

Table 1: Results of Laser-Assisted Therapy

TreatmentAssessment Interval

Number of Sites with Bleeding

on Probing

Number of Sites with PeriodontalPockets 4 mm or

Greater

Number of Teethwith Beyond-Normal

PeriodontalPocketing

Beginning 36 45 19 of 19

12 Weeks 3 9 6 of 19

6 Months 7 4 2 of 19

Rate of ImprovementAfter 6 Months

81% 91% 90%

151

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Hoopingarner

Treatment of a Subcrestal ToothFracture with the Er:YAG LaserCharles R. Hoopingarner, DDS, Houston, TexasJ Laser Dent 2007;15(3):151-155

P R ET R E AT M E N TA. Outline of Case1. Full Clinical DescriptionA 62-year-old Caucasian malepresented with severe pain onchewing in the area of tooth #13.Figure 1 shows a deep vertical frac-ture of an existing MOD ceramiconlay and the underlying palatalcusp. He had complained of occa-sional biting sensitivity at twoprevious recare visits. No definitivefindings were made at either visit. Atthat time a vital pulp test and radi-ographic evaluation were performed,and a minor occlusal adjustment wasmade. He had been an 11-yearpatient in the practice and main-tained a very good level of dentalhealth, and it was expected he wouldcontinue to be followed in our office.A recare evaluation and prophylaxishad been performed 3 months priorto the onset of the obvious fractureand extreme pain with no otherpathologic dental or significant peri-odontal findings. He is allergic to

penicillin and on presentation hisvital signs were within normal limits(blood pressure 115/68, pulse 64). Hewas taking no medications and hadno further contributing medicalhistory. He has a well-restored ClassI dental occlusion and has castrestorations on teeth #4, 15, 29, and30. He had existing intracoronalrestorations in teeth #2, 3, 6, 12, 14,18, 19, 20, 28, and 31.

2. Radiographic ExaminationPrevious panoramic X-ray showedno significant bone loss or anylesions present. A periapical X-raydid not show apical pathology orvertical bone loss present (Figure 2).

3. Soft Tissue StatusAn oral cancer screen and peri-odontal probing had been

performed within a three-monthperiod. When done, no soft tissuelesions were present, and no pocketdepth measurements were inexcess of 4 mm, as shown in Figure3. (As is the custom in our office, nopocket depths less than 4 mm wererecorded.)

Tooth #13 was probed and therewere no readings in excess of 3 mmexcept along the border of the frac-tured segment. There wasperiodontal attachment present onthe fractured segment and a 4-5mm measurement from the gingivalcrest to the remaining attachment.

SY N O P S I S

This article describes gingival and osseous closed flap crown length-

ening with an Er:YAG laser to help restore a bicuspid with a lingual

cusp fracture that extends subgingivally.

Figure 1: Preoperative view of fracturedlingual cusp at presentation

Figure 2: Periapical radiograph taken atpresentation Figure 3: Periodontal probe chart. Pockets less than 4 mm are not charted

152

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Hoopingarner

4. Hard Tissue StatusAll bone levels and ridge topog-raphy had historically been withinacceptable limits. The area aroundtooth #13 showed no vertical boneloss. The palatal cusp of tooth #13had fractured below the attach-ment level and after removal wouldshow a termination at the osseouscrest. There were signs of bruxismpresent and the patient reportedthat he was wearing a nighttimeprotective appliance that had beenprescribed many years prior to thispresentation. The tooth tested vitalto air spray stimulation and it wasnecessary to use injected localanesthesia to fully evaluate theextent of the fracture.

5. Other TestsTMJ evaluation showed normalrange of motion and no jointsounds were present.

B. Diagnosis and TreatmentPlan1. Provisional DiagnosisA provisional diagnosis of verticalfracture of the palatal cusp of tooth#13 was made. It was thought thatthe fracture would extend to theosseous crest in a limited area,making impression-taking difficult.The position of the osseous crestobviated a consideration of biologicwidth issues. There was no pulpalexposure evident.

2. Final DiagnosisA final diagnosis of vertical frac-ture of the palatal cusp of tooth #13was made. Figure 4 shows the frag-ment being removed. The extent ofthe fracture was limited to areascoronal to the periodontal attach-ment except for an approximate3-mm linear area in a readilyaccessible area of the palatalosseous crest, as seen in Figure 5.Since the fracture was observed toterminate at the osseous crest, anyrestoration would impinge on thebiologic width necessary to main-tain a healthy tooth supportsystem.

3. Treatment Plan OutlineThe objective was to restore thepatient’s tooth with a bondedceramic restoration that wouldrestore nearly ideal tooth form andpermit proper attachment levelswithout invasion of the biologicwidth necessary to maintain peri-odontal health. Initially the toothwould be prepared to allow forcoverage of the fractured areas. Thepreparation would be as conserva-tive as possible as utilization of abonded restoration did not requireapical preparation extension for thepurpose of retention. This proce-dure would be done withconventional rotary instruments. Ifthe fractured root structure couldbe smoothed to allow placement ofa margin at a more coronal level,that would become a part of theprocedure.

The 2940-nm Er:YAG laserwould be used for two procedures.The first would be to contour thesoft tissue in a manner that wouldleave the margins of the restora-tion at the gingival crest. Thesecond procedure would be toremove osseous tissue to a level 3mm below the intended margin andbevel the bone to a normal contour.

4. IndicationsAs the 2940-nm Er:YAG laserwavelength is highly absorbed byboth water and hydroxyapatite, itcan be used to both contour the softtissue and lower the bone levelwhere indicated to establish ahealthy attachment. With a closed

flap technique, the postoperativerecovery is shortened and thepatient discomfort level is mini-mized. With this approachimpressions could be taken at thetime of surgery and the restorationplaced within the time frame of anormal delivery.

5. ContraindicationsThere were no contraindications forperforming this procedure.

6. PrecautionsDuring the initial gingival recon-tour it is necessary to carefullyconsider the desired outcome afterhealing. The soft tissue ablationshould be performed by angling thetip in a manner to avoid damagingtooth structure. As the finalcontours are approached, care mustbe taken to avoid interacting withthe bone prior to the initiation ofwater spray. Rehearsal of the boneablating stroke is often necessaryas the water spray can impairdirect visualization.

7. Treatment AlternativesConventional flap surgery withgingival sculpting using scalpeltechnique and bone recontouringwith rotary instruments or chiselsis an alternative. Tooth extractionis an alternative.

8. Informed ConsentAfter a description of advantages,possible complications, and treat-ment alternatives were discussed,and all the patient’s questions were

Figure 4: Removal of fractured segment

Figure 5: Preoperative view of existingsound tooth structure, showing that theextent of the fracture is subgingival

153

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Hoopingarner

answered, the patient’s verbal andwritten informed consent wasobtained.

T R E AT M E N TA. Treatment ObjectivesThe objective is to remove the frac-tured fragment, prepare the tooth,smooth the root surface, contourthe gingiva, take an accurateimpression, recontour the osseouscrest to allow for proper biologicwidth formation, and place a well-formed provisional restoration sothat bonded cementation couldoccur in a timely fashion. TheEr:YAG laser will be used forrecontouring both the gingivaltissues and the osseous tissue.

B. Laser Operating ParametersLaser: Er:YAG (DELight, HOYAConBio, Fremont, Calif.):• Delivery system: Fiber-optic

system consisting of varyingquartz tips: 600-micron for initialtissue ablation, 400-micron forosseous recontouring, and 1200 x300-micron chisel tip for tissueand osseous beveling andsmoothing

• Wavelength: 2940 nm• Mode: Free-running pulsed• Pulse width: 300 microseconds• Power: 1.5 Watts (30 Hz and 50

mJ)• Beam Diameter: Varied, 400 to

600 microns using focused anddefocused patterns

• Repetition rate: 30 Hz• Continuous air (reduced volume

and water spray for osseous

procedures, and air only for softtissue)

Laser settings:• Soft tissue ablation: 30 Hz and

50 mJ, air cooling and no water• Osseous recontouring: 30 Hz and

50 mJ with air and water sprayTips were used in both light

contact and defocused modes.

C. Treatment DeliverySequencePretreatment: The operatory wassecured and the laser warning signwas posted. The laser unit wasproperly placed and connected toan air supply. Safety glasses with4+ optical density for the 2940-nmlaser wavelength that met ANSIstandards Z136.1 and Z136.3 wereused. All shiny reflective objectswere removed. The operatory wasset up and supplied according tothe standard for a restorative and asurgical procedure. Charting andradiographs were visible to theoperator. The procedure wasreviewed with staff in the morningreport meeting. Prior to adminis-tration of anesthesia, the treatmentwas reviewed with the patient andinformed consent was confirmed.The patient was properly drapedand approximately 1.5 cc prilocaine4% 1:200,000 epinephrine wasdistributed by infiltration in themaxillary premolar segment.Approximately 0.4 cc prilocaine 4%1:200,000 epinephrine was injected6 mm below the palatal gingivalcrest of tooth #13. Eye protectionwas placed on the patient as well

as the operator and assistant. Thelaser was test-fired in a safe direc-tion after eye protection was placedand prior to the first soft tissueprocedure. The first laser procedurewas to recontour the soft tissue toapproximate the intended marginof the preparation. This was donewith near but noncontact strokeswith a 600-micron tip and energysettings of 30 Hz and 50 mJ(Figure 6). The tissue was beveledas necessary to produce a physio-logic crestal roll. This entailed anexposure time of less than 3minutes. No water was used forthis part of the procedure and thetip was carefully aligned to avoidscarring the tooth.

The distance from the fracturemargin to the osseous crest wasdetermined to be less than 1 mm.The probing of this depth is shownin Figure 7. It was felt that amargin could be placed 1 mmcoronal to the extent of the fractureif the root were shaped andpolished using rotary instrumentsand curettes. After this procedurewas accomplished, there was still adistance of only 2 mm from theintended margin to the osseouscrest. With copious water spray, a400-micron tip, and the sameenergy settings (30 Hz and 50 mJ),the bone was ablated to allow for adistance of slightly more than 3mm from the osseous crest to theintended preparation margin. Thiswas done with short, noncontactstrokes, with care being taken toavoid scarring the tooth. The 3-mm

Figure 6: The Er:YAG laser is used first tocontour and establish the height of thegingival marginal tissue

Figure 7: A probe is used to determinethat the osseous crest is less than 1 mmapical to the gingival margin

Figure 8: Osseous tissue is removed andcontoured with the laser, with the tipsleeve being used as a depth guide

154

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Hoopingarner

sleeve on the 400-micron tip wasused as a guide, as shown in Figure8. Had this convenient markingapparatus not been available, inkor stopper material could havebeen used as a measuring guide.With the 600-micron tip and thechisel tip, the bone was beveled toapproximate a normal crestalcontour. Total exposure time for theosseous segment was less than 7minutes. This gave a total exposuretime of less than 10 minutes.

With the depth of the fracturearea left untouched where the rootwas smoothed, the tooth wasprepared in a conservative mannerto receive a ceramic restoration(Empress®, Ivoclar Vivadent Inc.,Amherst, N.Y.), as shown in Figure9. Figure 10 shows the confirmationof the new osseous level to be justover 3 mm from the intended prepa-ration margin. A deep chamfer/shoulder margin was then placed inthat area, with care being taken tomaintain the desired crest-to-margindistance, and the preparation wascompleted (Figure 11).

With care taken to operate in a

noncontact mode, gingival hemor-rhage was greatly reduced. The finalimpression was obtained during theoperative visit. The crisp, clearimpression again confirmed theosseous crest depth (Figure 12).

A provisional restoration oftemporary crown and bridge mate-rial (IntegrityTM, Dentsply, York,Pa.), shown in Figure 13, wasplaced to maintain tissue contour.The provisional was evaluated at48 hours and no signs of infectionor significant inflammation werepresent.

Due to patient travel require-ments it was necessary to bond thefinal restoration just 10 days afterpreparation. There was minimalsoft tissue invasion in the deepmarginal area (Figure 14) whichwas easily removed with a 3%hydrogen peroxide scrub. Therestoration was bonded with a totaletch protocol using a single-compo-nent adhesive (Optibond® SoloPlus™, Kerr Corporation, Orange,Calif.) as a bonding agent and anadhesive resin (Nexus II, KerrCorporation) as a cement. This was

performed in light-cure-only mode,and cured for 10 seconds at all fourinterproximal corners and 20seconds on the buccal, occlusal, andpalatal surfaces (Figure 15).

D. Postoperative InstructionsThe patient was told to avoid foodswarmer than room temperature for48 hours and then begin hot salinemouth rinses. The area was to becleaned with hydrogen peroxide oncotton tip applicators for the first48 hours. After the first postopera-tive visit, the patient was clearedfor normal hygiene procedures

Figure 9: Initial tooth preparationshowing contouring of fractured area

Figure 10: A probe is used to confirmadequate biologic width

Figure 11: Final tooth preparationcompleted

Figure 12: Impression clearly showslingual margin of preparation

Figure 13: Provisional restoration in place

Figure 14: Ten-day postoperative view ofpreparation and tissue prior to bondingof restoration

Figure 15: Immediate post-bondinglingual view

155

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

C L I N I C A L C A S E

Hoopingarner

which included brushing with anultrasoft brush dipped in hot water.He was told not to floss around theprovisional restoration and to avoidsticky foods in that area.Emergency care contact numberswere given. No narcotic analgesicswere prescribed and the patientwas instructed to use over-the-counter ibuprofen if necessary.

E. ComplicationsThere was slight soft tissue inva-sion under the provisionalrestoration. This was removed witha 3% hydrogen peroxide scrub. Theshade of the restoration was a littleopaque but well within thepatient’s acceptable expectationlimits.

F. PrognosisThe prognosis for maintenance ofthe restoration is excellent. Thetissue appeared to be healingnicely, giving an expectation of anexcellent prognosis. The prognosisfor continued pulpal vitality wasstill somewhat guarded.

G. Treatment RecordsAll appropriate details described

above were entered into thepatient’s record.

F O L LOW- U P C A R EA. Assessment of TreatmentOutcomeThe patient was very pleased withthe treatment outcome, especiallysince he was seen on an emergencybasis and treatment was completedin a short time frame to meet histravel schedule. He reported nopostoperative pain and the tissuesshowed no sign of inflammation orinappropriate pocket depth. Nodeep probing was indicated forthree months postoperatively.

B. ComplicationsThe patient reported no postopera-tive complications.

C. Long-Term ResultsAt 3 months the restorationshowed no signs of failure and hadintact margins. The tissues weremaintaining a good level of healthwith a palatal probing depth of 2mm (Figure 16).The periapicalradiograph (Figure 17) demon-strated normal tissue.

D. Long-Term PrognosisBecause of the biocompatibility of

the pressed ceramic restoration andthe exact treatment planning of theattachment levels, the long-termtissue prognosis remains excellent.

A U T H O R B I O G R A P H YDr. Charles Hoopingarner attendedthe University of Texas HealthScience Center at Houston(UTHSCH) Dental Branch, gradu-ating with a DDS in 1973. He hasmaintained a private practice inHouston, Texas since 1973. He wasan adjunct associate professor inanatomical sciences at UTHSCHDental Branch for 11 years.Currently he is adjunct clinicalfaculty in the Restorative DentistryDepartment at UTHSCH and hasbeen a clinical instructor at the LasVegas Institute for AdvancedDental Studies since 1997, teachingAdvanced Anterior Aesthetics andComprehensive AestheticReconstruction and LaserDentistry. Dr. Hoopingarner is amember of the Academy of LaserDentistry (ALD) and has useddental lasers of various wave-lengths as integral parts of hispatient care delivery system for thelast 10 years. He holds Advancedand Standard Proficiency certifica-tion from the ALD and has lecturedinternationally on the safety anduse of laser technology in thedental practice. He may becontacted by e-mail atchoop@swbell.net.

Disclosure: Dr. Hoopingarner has nodirect financial or ownership posi-tions with commercial companiesrelative to this case presentation. Hehas received honoraria and expensesfrom HOYA ConBio to present mate-rial on laser dentistry. nn

Figure 16: Three-month postoperativeprobing shows healthy sulcular depth of2 mm

Figure 17: Three-month postoperativeperiapical radiograph

156

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

R E S E A R C H A B ST R AC T S

In their article on Er-YAG laser-assisted implant peri-apical lesion therapy (135-141), Dr. Avi Reyhanian andDr. Donald Coluzzi mention the bactericidal potential oflaser irradiation of implant surfaces. The notion ofutilizing laser energy to reduce surface bacteria onintraoral implants as a means to help ensure successfulosseointegration and reduce the incidence of peri-implantitis has been studied by a number ofresearchers investigating a variety of wavelengths,including excimer, diode, Nd:YAG, erbium, and carbondioxide lasers. Abstracts from a sampling of publishedpapers representing various wavelengths appear below.

Most researchers to date have investigated the antimi-crobial effect, primarily due to heat generated by variouslasers, on implant surfaces in in vitro experiments.Heinrich and colleagues take a different approach: use aKrF excimer (248 nm) laser to promote mucosal adhesionas a biological barrier against bacterial infection. Anothergroup (Dörtbudak et al.) studied the effects of “soft” diodelaser exposure on implants in patients.

Overall, results are mixed. Certain lasers do appearto have bactericidal potential on selected microorgan-

isms on certain types of implants under certain condi-tions. Questions regarding the relative efficacy of laservs. conventional treatment remain, as do concernsrelated to potential alteration of implant surfacemorphology, thermal damage to adjacent tissues, andinability to reestablish the biocompatibility of contami-nated surfaces. Nevertheless, the potential for laserapplication in promoting long-term implant success viabacterial reduction exists. Further study is warranted,especially to determine effectiveness and safety in aclinical environment, with special emphasis placed onappropriate parameter settings and duration of laserexposure.

For U.S. readers, no laser has been cleared by theU.S. Food and Drug Administration for “decontami-nating” or inducing bactericidal effects on intraoralimplants.

As always, clinicians are advised to review thespecific indications for use of their lasers and to reviewtheir operator manuals for guidance on operatingparameters before attempting similar techniques ontheir patients.

Editor’s Note: The following eight abstracts are offered as topics of current interest. Readers are

invited to submit to the editor inquiries concerning laser-related scientific topics for possible

inclusion in future issues. We’ll scan the literature and present relevant abstracts.

L AS E R BAC T E R I C I DA L E F F EC TS O N I N T R AO R A L I M P L A N TS

157

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

R E S E A R C H A B ST R AC T S

Concerning dental implant systems, a main problem isthe adhesion of peri-implant mucosa in the cervicalregion. The aim of the present study was to use a laserfor modifying titanium implants to promote mucosaladhesion, which is indispensable as a biological barrieragainst bacterial infection. By the use of a KrF excimerlaser, it was possible to induce a holey structure on thepolished area of the implant surface, which wasanalysed by a scanning electron microscope. In addi-

tion, the attachment of fibroblast cells to the createdstructures was investigated with the aid of an environ-mental scanning electron microscope. It turned out thatthe cells preferentially attach to the holey structure.Thereby, the cells form bridges inside, leading to acomplete covering of the hole. In this way, a more effec-tive biological barrier against bacteria can be created.

Copyright 2007 Springer

L AS E R - M O D I F I E D T I TA N I U M I M P L A N TS F O R I M P R OV E D C E L L A D H ES I O N

Andreas Heinrich, Katrin Dengler, Timo Koerner, Cornelia Haczek,

Herbert Deppe, and Bernd StritzkerUniversität Augsburg, Augsburg, Germany

Lasers Med Sci 2007 Apr 28; [Epub ahead of print] 10.1007/s10103-007-0460-z

Peri-implantitis is considered to be a multifactorialprocess involving bacterial contamination of theimplant surface. A previous study demonstrated that acombination of toluidine blue O (100 microgram/ml)and irradiation with a diode soft laser with a wave-length of 905 nm results in an elimination ofPorphyromonas gingivalis (P. gingivalis), Prevotellaintermedia (P. intermedia), and Actinobacillus actino-mycetemcomitans (A. actinomycetemcomitans) ondifferent implant surfaces (machined, plasma-flame-sprayed, etched, hydroxyapatite-coated). The aim of thisstudy was to examine the laser effect in vivo. In 15patients with IMZ implants who showed clinical andradiographic signs of peri-implantitis, toluidine blue O

was applied to the implant surface for 1 min and thesurface was then irradiated with a diode soft laser witha wavelength of 690 nm for 60 s. Bacterial sampleswere taken before and after application of the dye andafter lasing. The cultures were evaluated semiquantita-tively for A. actinomycetemcomitans, P. gingivalis, andP. intermedia. It was found that the combined treat-ment reduced the bacterial counts by 2 log steps onaverage. The application of TBO and laser resulted in asignificant reduction (P < 0.0001) of the initial valuesin all 3 groups of bacteria. Complete elimination ofbacteria was not achieved.

Copyright 2001 Blackwell Publishing and the European Association for Osseointegration

L ET H A L P H OTO S E N S I T I Z AT I O N F O R D ECO N TA M I N AT I O N O F I M P L A N TS U R FAC ES I N T H E T R E AT M E N T O F P E R I - I M P L A N T I T I S

Orhun Dörtbudak, Robert Haas, Thomas Bernhart, Georg Mailath-PokornyUniversity of Vienna, Vienna, Austria

Clin Oral Implants Res 2001;12(2):104-108

158

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

R E S E A R C H A B ST R AC T S

Purpose: This study was conducted to investigate theantimicrobial effect of an 809-nm semiconductor laser oncommon dental implant surfaces. Materials and Methods:Sandblasted and acid-etched (SA), plasma-sprayed (TPS),and hydroxyapatite-coated (HA) titanium disks wereincubated with a suspension of S. sanguinis (ATCC10556) and subsequently irradiated with a gallium-aluminum-arsenide (GaAlAs) laser using a 600-micromoptical fiber with a power output of 0.5 to 2.5 W, corre-sponding to power densities of 176.9 to 884.6 W/cm2.Bacterial reduction was calculated by counting colony-forming units on blood agar plates. Cell numbers werecompared to untreated control samples and to samplestreated with chlorhexidine digluconate (CHX). Heatdevelopment during irradiation of the implants placed inbone blocks was visualized by means of shortwave ther-mography. Results: In TPS and SA specimens, laserirradiation led to a significant bacterial reduction at allpower settings. In an energy-dependent manner, the

number of viable bacteria was reduced by 45.0% to 99.4%in TPS specimens and 57.6% to 99.9% in SA specimens.On HA-coated disks, a significant bacterial kill wasachieved at 2.0 W (98.2%) and 2.5 W (99.3%) only (t test,P < .05). For specimens treated with CHX, the bacterialcounts were reduced by 99.99% in TPS and HA-coatedsamples and by 99.89% in SA samples. Discussion: Theresults of the study indicate that the 809-nm semicon-ductor laser is capable of decontaminating implantsurfaces. Surface characteristics determine the necessarypower density to achieve a sufficient bactericidal effect.The bactericidal effect, however, was lower than thatachieved by a 1-minute treatment with 0.2% CHX. Therapid heat generation during laser irradiation requiresspecial consideration of thermal damage to adjacenttissues. Conclusion: No obvious advantage of semicon-ductor laser treatment over conventional methods ofdisinfection could be detected in vitro.

Copyright 2003 Quintessence Publishing Co., Inc.

A N T I M I C R O B I A L E F F I C AC Y O F S E M I CO N D U C TO R L AS E R I R R A D I AT I O N O N I M P L A N T S U R FAC ES

Matthias Kreisler, Wolfgang Kohnen, Claudio Marinello, Jürgen Schoof,

Ernst Langnau, Bernd Jansen, Bernd d’HoedtJohannes Gutenberg University, Mainz, Germany

Int J Maxillofac Implants 2003;18(5):706-711

Microbiologic examinations of implants have shown thatcertain microorganisms described as periodontalpathogens may have an influence on the developmentand the progression of peri-implant disease. This experi-mental study aimed to examine the bactericidal effect ofirradiation with a soft laser on bacteria associated withperi-implantitis following exposure to a photosensitizingsubstance. Platelets made of commercially pure titanium,either with a machined surface or with a hydroxyapatiteor plasma-flame-sprayed surface or with a corundum-blasted and etched surface, were incubated with a puresuspension of Actinobacillus actinomycetemcomitans orPorphyromonas gingivalis or Prevotella intermedia. Thesurfaces were then treated with a toluidine blue solution

and irradiated with a diode soft laser with a wavelengthof 905 nm for 1 min. None of the smears obtained fromthe thus-treated surfaces showed bacterial growth,whereas the smears obtained from surfaces that hadbeen subjected to only one type of treatment showedunchanged growth of every target organism tested (P <0.0006). Electron microscopic inspection of the thus-treated platelets revealed that combined dye/lasertreatment resulted in the destruction of bacterial cells.The present in vitro results indicate that lethal photosen-sitization may be of use for treatment of peri-implantitis.

Copyright 1997 Blackwell Publishing and the European Association for Osseointegration

E L I M I N AT I O N O F BAC T E R I A O N D I F F E R E N T I M P L A N T S U R FAC ES T H R O U G HP H OTO S E N S I T I Z AT I O N A N D SO F T L AS E R : A N I N V I T R O ST U DY

Robert Haas, Orhun Dörtbudak, Nikoletta Mensdorff-Pouilly, Georg MailathUniversity of Vienna, Vienna, Austria

Clin Oral Implants Res 1997;8(4):249-254

159

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

R E S E A R C H A B ST R AC T S

Titanium platelets with a sand-blasted and acid-etchedsurface were coated with bovine serum albumin andincubated with a suspension of Porphyromonas gingivalis(ATCC 33277). Four groups with a total of 48 specimenswere formed. Laser irradiation of the specimens (n = 12)was performed on a computer-controlled XY translationstage at pulse energy 60 mJ and frequency 10 pps.Twelve specimens were treated with an air powdersystem. After the respective treatment, human gingivalfibroblasts were incubated on the specimens. The prolif-eration rate was determined by means of fluorescenceactivity of a redox indicator (Alamar Blue Assay) which isreduced by metabolic activity related to cellular growth.Proliferation was determined up to 72 h. Contaminatedand nontreated as well as sterile specimens served aspositive and negative controls. Proliferation activity was

significantly (Mann-Whitney U-test, P < 0.05) reduced oncontaminated and nontreated platelets when comparedto sterile specimens. Both on laser as well as air powder-treated specimens, cell growth was not significantlydifferent from that on sterile specimens. Air powdertreatment led to microscopically visible alterations of theimplant surface whereas laser-treated surfaces remainedunchanged. Both air powder and Er:YAG laser irradia-tion have a good potential to remove cytotoxic bacterialcomponents from implant surfaces. At the irradiationparameters investigated, the Er:YAG laser ensures a reli-able decontamination of implants in vitro withoutaltering surface morphology.

Copyright 2005 Blackwell Publishing and the European Association for Osseointegration

I N V I T R O E VA LUAT I O N O F T H E B I O CO M PAT I B I L I T Y O F CO N TA M I N AT E D I M P L A N T S U R FAC ES T R E AT E D W I T H

A N E R : YAG L AS E R A N D A N A I R P OW D E R SYST E M

Matthias Kreisler, Wolfgang Kohnen, Ann-Babett Christoffers, Hermann Götz, Bernd Jansen,

Heinz Duschner, Bernd d’HoedtJohannes Gutenberg-University Mainz, Mainz, Germany

Clin Oral Implants Res 2005;16(1):36-43

The Nd:YAG dental laser has been recommended for anumber of applications, including the decontaminationor sterilization of surfaces of dental implants that arediseased or failing. The effects of laser irradiation invitro (1) on the surface properties of plasma-sprayedtitanium and plasma-sprayed hydroxyapatite-coatedtitanium dental implants, and (2) on the potential tosterilize those surfaces after contamination with sporesof Bacillus subtilis have been examined. Surface effectswere examined by scanning electron microscopy, energydispersive spectroscopy, and X-ray diffraction afterlaser irradiation at 0.3, 2.0, and 3.0 W using eithercontact or noncontact handpieces. Controls received no

laser irradiation. Melting, loss of porosity, and othersurface alterations were observed on both types ofimplants, even with the lowest power setting. For thesterilization study, both types of implants were firststerilized by exposure to ethylene oxide and thencontaminated with spores of B. subtilis. After laser irra-diation, the implants were transferred to sterile growthmedium and incubated. Laser irradiation did not ster-ilize either type of implant. The spore-contaminatedimplants in the control group were successfully steril-ized with ethylene oxide.

Copyright 1992 Quintessence Publishing Co., Inc.

E F F EC TS O F T H E N D : YAG D E N TA L L AS E R O N P L AS M A - S P R AY E D A N D H Y D R OX YA PAT I T E - COAT E D T I TA N I U M D E N TA L I M P L A N TS :

S U R FAC E A LT E R AT I O N A N D AT T E M P T E D ST E R I L I Z AT I O N

Carl M. Block, John A. Mayo, Gerald H. EvansLouisiana State University Medical Center, New Orleans, Louisiana

Int J Oral Maxillofac Implants 1992;7(4):441-449

160

JOU

RN

AL

OF

LA

SE

R D

EN

TIS

TR

Y

|

2

00

7 V

OL

15

, N

O.

3

R E S E A R C H A B ST R AC T S

Background and Objective: The aim of this study was toassess CO2 laser ability to eliminate bacteria from tita-nium implant surfaces. The changes of the surfacestructure, the rise in temperature, and the damage ofconnective tissue cells after laser irradiation were alsoconsidered. Study Design/Materials and Methods:Streptococcus sanguis and Porphyromonas gingivalis ontitanium discs were irradiated by an expanded beam ofCO2 laser. Surface alteration was observed by a light,and a scanning electron, microscope. Temperature wasmeasured with a thermograph. Damage of fibroblastic(L-929) and osteoblastic (MC3T3-E1) cells outside the

irradiation spot and adhesion of the cells to the irradi-ated area were also estimated. Results: All theorganisms (108) of S. sanguis and P. gingivalis werekilled by the irradiation at 286 J/cm2 and 245 J/cm2,respectively. Furthermore, laser irradiation did notcause surface alteration, rise of temperature, seriousdamage of connective tissue cells located outside theirradiation spot, or inhibition of cell adhesion to theirradiated area. Conclusion: CO2 laser irradiation withexpanded beam may be useful in removing bacterialcontaminants from implant surface.

Copyright 1998 Wiley-Liss, Inc. nn

BAC T E R I C I DA L E F F I C AC Y O F C A R B O N D I OX I D E L AS E R AG A I N ST BAC T E R I A - CO N TA M I N AT E D T I TA N I U M I M P L A N T A N D

S U B S EQ U E N T C E L LU L A R A D H ES I O N TO I R R A D I AT E D A R E A

Taku Kato, Haruka Kusakari, Etsuro HoshinoNiigata University, Niigata, Japan

Lasers Surg Med 1998;23(5):299-309

Background: The aim of the present study was to eval-uate the influence of an erbium, chromium-dopedyttrium, scandium, gallium, and garnet (Er,Cr:YSGGlaser [ERCL]) on (1) the surface structure and biocom-patibility of titanium implants and (2) the removal ofplaque biofilms and reestablishment of the biocompati-bility of contaminated titanium surfaces. Methods:Intraoral splints were used to collect an in vivosupragingival biofilm on sand-blasted and acid-etchedtitanium disks for 24 hours. ERCL was used at anenergy output of 0.5, 1.0, 1.5, 2.0, and 2.5 W for theirradiation of (1) noncontaminated (20 and 25 Hz) and(2) plaque-contaminated (25 Hz) titanium disks.Unworn and untreated nonirradiated, sterile titaniumdisks served as untreated controls (UC). Specimenswere incubated with SaOs-2 osteoblasts for 6 days.Treatment time, residual plaque biofilm (RPB) areas(%), mitochondrial cell activity (MA) (counts per

second), and cell morphology/surface changes (scanningelectron microscopy [SEM]) were assessed. Results: (1)ERCL using either 0.5, 1.0, 1.5, 2.0, or 2.5 W at both 20and 25 Hz resulted in comparable mean MA values asmeasured in the UC group. A monolayer of flattenedSaOs-2 cells showing complete cytoplasmatic exten-sions and lamellopodia was observed in both ERCL andUC groups. (2) Mean RPB areas decreased significantlywith increasing energy settings (53.8 +/- 2.2 at 0.5 W to9.8 +/- 6.2 at 2.5 W). However, mean MA values weresignificantly higher in the UC group. Conclusion:Within the limits of the present study, it was concludedthat even though ERCL exhibited a high efficiency toremove plaque biofilms in an energy-dependentmanner, it failed to reestablish the biocompatibility ofcontaminated titanium surfaces.

Copyright 2006 The American Academy of Periodontology

I N F LU E N C E O F A N E R B I U M , C H R O M I U M - D O P E D Y T T R I U M , SC A N D I U M , G A L L I U M , A N D G A R N ET ( E R , C R : YSGG ) L AS E R O N T H E R E ESTA B L I S H M E N T O F T H E B I O CO M PAT I B I L I T Y

O F CO N TA M I N AT E D T I TA N I U M I M P L A N T S U R FAC ES

Frank Schwarz, Enaas Nuesry, Katrin Bieling, Monika Herten, Jürgen BeckerHeinrich Heine University, Düsseldorf, Germany

J Periodontol 2006;77(11):1820-1827