laserinternational magazine of laser dentistry4

2012

i s sn 2193-4665 Vol. 4 • Issue 4/2012

| researchLasers in soft tissue dentistry

| overviewDiode lasers for periodontal treatment: the story so far

| industry reportLasers in the treatment of traumatically fracturedfrontal teeth

LI-PB77662EN NEW A4 Laser Dentistry advertisment - english print.pdf 1LI-PB77662EN NEW A4 Laser Dentistry advertisment - english print.pdf 1 10.10.12 10:3610.10.12 10:36

Dr Georg Bach

editorial I

I 03laser3_2012

Dear colleagues,

This year’s annual DGL Congress in Leipzig, Germany, has born eloquent witness to how muchlaser-supported therapies have become rooted in evidence-based dentistry and the dental worldof science. However, the congress is only one among many factors which have contributed tothis appreciation of laser dentistry.

Not only is laser dentistry’s becoming rooted deeply in the scientific field the outcome of thisdevelopment, but it has also become both the task and the aim not to linger on this sometimesdelightful and sometimes stony path, but to keep moving on.

This task also includes fields of laser dentistry which would not be in the focus of our inter-est in the first place, but which are of great importance nonetheless. In this regard, I would liketo recommend to you the baseline report on the preparation of medical products by our col-leagues from Bonn, Germany, which you can find on page twelve of this issue.

An exciting and fulfilling year of both applied laser dentistry and studies in laser dentistry iscoming to its end. I would like to use this opportunity to thank all authors who have contributedtheir articles to laser international magazine of laser dentistry over the past year. I furthermore want tothank DGL (Germany Society for Laser Dentistry) for supporting this publication as well as theeditors of OEMUS MEDIA AG. I sincerely hope that we will continue our harmonious and con-structive collaboration next year!

Dear colleagues and readers of laser international magazine of laser dentistry, I wish you all a happy,healthy and successful new year!

Warm regards,

Georg Bach

Laser dentistry—deeply rooted inscience

I content _ laser

04 I laser4_2012

I editorial

03 Laser dentistry—deeply rooted in science

| Dr Georg Bach

I research

06 Lasers in soft tissue dentistry

| Dr Vrinda Rattan

10 Lasers in endodontics

| Dr Enrico DiVito et al.

I overview

20 Diode lasers for periodontal treatment: the story so far

| Dr Fay Goldstep et al.

24 The key concept of laser dentistry

| Dr Rene Franzen

I case report

28 Does the tongue get the attention it deserves?

| Dr Darius Moghtader

I industry report

30 Lasers in the treatment of traumatically

fractured frontal teeth

| Dr Carlo Fornaini

34 Laser versus bur and dentinal bonding

| Dr Barbara Cvikl et al.

I education

40 Community board honors dentists for supporting drug

education in schools

| Dental Tribune America

I meetings

41 International events 2012 & 2013

42 New York City is open for business

| Dental Tribune America

43 Milan sees 40th anniversary of International Expodental

| Dental Tribune International

I interview

44 “I believe that the future is already here”

I news

38 Manufacturer News

48 News

I about the publisher

50 | imprint

page 30 page 40 page 43

page 10 page 20 page 28

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I research

_Introduction

Lasers have revolutionised the medical manage-ment since the 1960s. Unlike many fields of medicineand surgery, where laser treatment represents a solesource of remedy, in dentistry the use of a laser is con-sidered an adjunctive in delivering a stage of tissuemanagement conducive to achieving a completed hardor soft tissue procedure. The adjunctive use of lasers inthe field of periodontics has helped to achieve efficientcutting of dental hard tissue, haemostatic ablation ofsoft tissue, the disinfecting effect through bacterialelimination and an enhanced biochemical pathway as-sociated with tissue healing.

Wonders of “Light Amplification by Stimulated Emission

of Radiation”

LASERS are named according to the active elementsthat are involved in the creation of the energy beam.Thus, lasers commonly used in dentistry consist of a va-riety of wavelengths delivered as either a continuous,pulsed, or running pulse waveform, e.g., CO2, Nd:YAG,Ho:YAG, Er:YAG, Er, Cr:YSGG, Nd:YAP, GaAs (diode), andargon.

Lasers emit energy which is essentially a light of onecolour (i.e., monochromatic) and, therefore, of onewavelength. This wavelength defines its properties andits usage in various fields. The photons in its energybeam are emitted as a coherent (in phase), unidirec-tional, monochromatic light that can be collimated intoan intensely focused beam that exhibits little diver-gence. On focusing the energy beam on the target site,

the energy can become absorbed, reflected, or scat-tered. A photothermal phenomenon occurs when thislight is further converted into heat energy. This energycan cause coagulation, incision, or tissue vaporizationin a biological tissue, depending upon the wavelengthof laser used, power, waveform, pulse duration, energydensity, duration of exposure, angulation to the targetsurface, and optical properties of the tissue.

_History of lasers in dentistry

Maiman in 1960 used a crystal medium of ruby thatemitted a coherent radiant light from the crystal whenstimulated by energy for the extraction of teeth, basedon Albert Einstein’s theory of spontaneous and stimu-lated emission of radiation.1,2 In 1961, Snitzer put forthhis publication on the prototype for the Nd:YAG laser.3

Goldman et al.4 and Stern and Sognnaes5 described theeffects of the ruby laser on enamel and dentin.

Commercial use of lasers and its marketing was pio-neered by Dr Terry Myers.6 This laser used an activemedium of Nd:YAG, emitted pulsed light. In the early1990s, laser machines which were used in the field ofmedicine were modified to be made available for dentaluse.

Different laser systems have gained more signifi-cance in the treatment of periodontal diseases. At thesame time, it has become important for the surgeon toalways be aware of the possibilities and limitations oflasers. The application of lasers is to be regarded as anadjunct to the conventional treatment methods for pe-riodontal diseases.

Lasers in soft tissue dentistryAuthor_Dr Vrinda Rattan, India

06 I laser4_2012

[BACKGROUND: ©1001HOLIDAY ]

research I

The use of surgical lasers in periodontology is ex-plored in three areas of treatment:

– Removal of the lining epithelium of thediseased pocket wall.

– Antimicrobial effect of lasers onpocket microbiota.

– Removal of calculus and root sur-face detoxification.

Benefits of laser use can be em-ployed as an adjunctive, to maximisethe outcome of the treatment, butlasers cannot be used as an alternative toconventional periodontal therapy.

_Laser and Pocket Debridement

Access into the periodontal pocket was made simpleby the advent of the quartz optic fibre delivery systemassociated with the diode and Nd:YAG groups of lasers.The wavelength of these lasers ranged from 200 to 320 µm. Following the removal of calculus and plaquethrough scaling and/or root planing, the pocket depth isassessed. The laser fibre is adjusted to a length of one totwo millimetres short of the pocket depth. It is made surethat the angle of insertion makes contact with the softtissue wall at any time. In a light contact mode withsweeping stroke, the soft tissue lining of the pocket wallis ablated, beginning from the base of the pocket andproceeding upwards. Each pocket site should be ablatedfor a period of about 20–30 seconds, which would meantwo minutes per tooth site, with re-treatment nearly atweekly intervals during a maximum period of fourweeks. Multiple laser-based studies have been carriedout. Case reports7–10 have suggested that the diode laser(810 nm), along with the Nd:YAG laser (1,064 nm), hasshown appreciable improvement in the periodontal sta-tus for the treatment of periodontal pockets by lasersub-gingival curettage. A study by Evans11 reviewed thenew attachment procedure on a sample of six caseswhich showed new cementum and bone growth, in-cluding periodontal ligament regeneration. Variouscontrolled studies have assessed the use of laser ther-apy along with conventional scaling and root planing,although these investigations demonstrated no signif-icant benefit in the treatment outcomes.12,13

_Antimicrobial effect of lasers on pocketmicrobiota

The complexity of the subgingival microbiota hasbeen recognised by various microbiological techniques.The bacteria most commonly implicated in periodontaldisease are Actinobacillus actinomycetemcomitans,

Porphyromonas gingivalis, Bacteroides forsythus, Tre-

ponema denticola and Prevotella intermedia. Manystudies have been carried out to demonstrate the anti-

bacterial potential of laser energy on bacterial strainsfound in the diseased periodontal sites.14,15 The theoret-

ical basis of the use of laser as an antimi-crobial is based on the absorption

characteristics of the target bacte-rial structures like water contentand pigments.

The build-up of the dena-tured protein material on thedelivery fibre of the diode laser

results in the development of acarbonised tip, which causes a

rise in temperature beyond 700°C.This char, if not removed, leads to a hot

tip effect. The carbonised deposits cause sec-ondary emission of radiant energy which leads to an un-wanted damage. The bactericidal action can be en-hanced by the use of a chemical mediator, such as meth-ylene blue, which acts as a heat sink for the thermal en-ergy. Antimicrobial photodynamic therapy can bereadily applied, even in sites where there is limited ac-cess for mechanical instrumentation due to theanatomical complexity of the root. The antimicrobial ef-fect of photodynamic therapy can be easily regulated bycontrolling the amount of light applied to activate thereaction.

_Removal of calculus and root surfacedetoxification

Laser-induced root surface modification is basedon the selection of a wavelength that will effectivelyremove calculus and not allow any thermal damageto the pulp tissue and unwanted removal of soundroot structure. This can be achieved only by the use ofwavelength with minimal penetration depth in min-eralised tissue. Lasers like CO2, Nd:YAG, Er:YAG, andthe diode have been used to study the surface detox-ification of cementum and dentin.16

Hydroxyapatite forms the major mineral contentof cementum and dentin which has absorption bandsin the mid-infrared region. Of all the laser wave-lengths studied, the Er:YAG laser proved to be the con-vincing laser of choice for effective removal of calcu-lus, for root modification, and for surface modifica-tion for cell or tissue reattachment.

The CO2 laser was the first of the wavelengths to beassessed for effects on root surfaces. Studies utilisingCO2 laser-treated surfaces have given conflicting re-sults. Pant et al.17 and Crespi et al.18 found an increasedin vitro attachment of fibroblasts to laser treated sur-faces in comparison to controls of SRP or chemicallytreated surfaces. On the other hand, Fayad et al.19

found a total lack of fibroblast attachment to irradi-ated surfaces. Heat-induced cracking of the root sur-

I 07laser4_2012

[PICTURE: ©SEBASTIAN KAULITZKI ]

I research

face is a common observation when using the CO2

laser.

Israel et al.20 studied effects of CO2, Nd:YAG, andEr:YAG lasers on root surface changes. At energy densities of 100 to 400 J/cm2 for the CO2 and 286 to1,857 J/cm2 for the Nd:YAG lasers, the authors foundthat the degree of morphologic change post laser irra-diation was directly related to energy density, but unre-lated to the use of an air/water surface coolant. Changesin root surfaces included cavitation defects, globules ofmelted and resolidified mineral, surface crazing, andproduction of a superficial char layer.

Chen et al.21, carried out a study in which cell culturesof human periodontal ligament fibroblasts were

subjected to Nd:YAG irradiation at low energydensities. They reported significant decreasesin cellular viability and collagen synthesis atfive days post-treatment and evidence of min-eralisation of necrotic cells at 28 days post-

treatment. Laser parameters were 50 mJ ofpower and 10 Hz, with a defocused beam deliv-ered through a 400-mm-diameter optical fiber,and durations of exposure ranging from 60 to240 seconds. In contrast to studies reportingnegative results, two in vitro studies have

demonstrated that the Nd:YAG laser, when used at lowenergy densities or a combination of low energy densitywith a defocused beam, has the potential to remove rootsurface smear layers without causing collateral damageto underlying cementum and/or dentin, or causing irre-versible pulpal damage or heat cracking.

The first study22 used GaAs and GaAlAs diode lasersat energy densities between 0.95 and 6.32 J/cm2, re-ported the effect of laser irradiation on prostaglandin E2(PGE2) production and cyclooxygenase-1 (COX-1) andCOX-2 gene expression in lipopolysaccharide chal-lenged human gingival fibroblasts. The authors con-veyed that irradiation with the GaAlAs diode laser sig-nificantly inhibited PGE2 production in a dose depend-ent manner, which lead to significant reduction of COX-2 mRNA levels. In another study23, cell cultures ofhuman gingival fibroblasts were irradiated with anEr:YAG laser at energy densities ranging from 1.68 to3.37 J/cm2 and actually increased the production ofPGE2 and COX-2 mRNA.

_Conclusion

The use of lasers in periodontal treatment becomeseven more complex because the periodontium consistsof both hard and soft tissues. When lasers are applied tothe root surface and alveolar bone, carbonisation andmajor thermal damage have been reported on target aswell as adjacent tissues. Therefore, the use of lasers islimited to soft tissue procedures like gingivectomy,

frenectomy, removal of granulation tissue during flapsurgery, removal of melanin pigmentation and metaltattoos of the gingiva. The uses of lasers have also beeninvestigated for subgingival debridement and curet-tage, osseous recontouring, as well as in implant sur-gery, maintenance of implants, and management ofperiimplantitis.

_Lasers—a boon or a bane?

A boon

Dental lasers are an asset in soft tissue surgeries be-cause of their proven haemostatic effect. Lasers can beused either alone or in conjunction with conventionalsurgeries for the treatment of periodontitis. Their highantibacterial efficiency has also been shown to be use-ful for the resolution of periodontal pockets.

– Less operative time, minimum postoperative pain dueto protein coagulum that acts as a biological dressingand seals the ends of sensory nerves.

– Relatively bloodless surgeries, ability to coagulate, va-porise and cut.

– Less mechanical trauma, minimal swelling and scar-ring.

– Sterilisation of the wound site.– No incision, sutureless.– Recommended for patients with systemic conditions

like diabetes, heart diseases or for patients takingblood thinners.

A bane

Lasers have been claimed to be more efficient thanconventional therapy. But there is limited evidence re-garding lasers playing a role in root surface debride-ment, pocket sterilisation and elimination. Tissue char-ring or obnoxious fumes often prevent patient accept-ance. Although lasers are the painless alternative to sur-gical treatment, they are still regarded as an adjunct toconventional treatment methods.

_Conclusion

Given the same wavelength, different laser parame-ters will yield different levels of energy density for vary-ing periods of time and, thereby, different biological ef-fects on the target tissue._

08 I laser4_2012

Dr Vrinda Rattan, BDS

137, Anand Vihar, First floor,

Pitampura,

Delhi-34, India

Tel.: +91 8861106601

vrin24@gmail.com

_contact laser

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I research

_Introduction

This article will analyze some of the most importantresearch in the international literature today and thenew guidelines for the use of the laser as a source of ac-tivation of chemical irrigants.

_Laser-assisted endodontics

Preparation of the access cavity

The preparation of the access cavity can be per-formed directly with Erbium lasers, which can ablateenamel and dentine. In this case, the use of a short tipis recommended (from 4 to 6 mm), with diameters be-tween 600 and 800 µm, made of quartz to allow the use

of higher energy and power. The importance of thistechnique should not be underestimated.

Owing to its affinity to tissues richest in water (pulpand carious tissue), the laser allows for a minimally in-vasive access (because it is selective) into the pulpchamber and, at the same time, allows for the decont-amination and removal of bacterial debris and pulp tis-sue. Access to the canal orifices can be accomplishedeffectively after the number of bacteria has been min-imized, thereby avoiding the transposition of bacteria,toxins and debris in the apical direction during the pro-cedure. Chen et al. demonstrated that bacteria arekilled during cavity preparation up to a depth of 300 to400 µm below the radiated surface.20Moreover, Erbiumlasers are useful in the removal of pulp stones and inthe search for calcified canals.

Preparation and shaping of canals

The preparation of the canals with NiTi instrumentsis still the gold standard in endodontics today. In fact,despite the recognized ablative effect of Erbium lasers(2,780 and 2,940 nm) on hard tissue, their effective-ness in the preparation of root canals appears to be limited at the moment and does not correspond to the endodontic standards reached with NiTi tech-nology.21–23 However, the Erbium,Chromium:YSGG(Er,Cr:YSGG) and the Erbium:YAG (Er:YAG) lasers havereceived FDA approval for cleaning, shaping and en-larging canals. A few studies have reported positive re-

Lasersin endodontics Authors_Dr Enrico DiVito, Prof Dr Rolando Crippa, Prof Dr Giuseppe Iaria, Prof Dr Vasilios Kaitsas,

Prof Dr Stefano Benedicenti & Prof Dr Giovanni Olivi, USA

10 I laser4_2012

Fig. 3 Fig. 4Fig. 2

Fig. 1

research I

sults for the efficacy of these systems in shaping andenlarging radicular canals.

Shoji et al. used an Er:YAG laser system with a con-ical tip with 80 pe rcent lateral emission and 20 per centemission at the tip to enlarge and clean the canals us-ing 10 to 40 mJ energy at 10 Hz, obtaining cleanerdentinal surfaces compared with traditional rotarytechniques.24

In a preliminary study on the effects of the Er:YAGlaser equipped with a microprobe with radial emissionof 200 to 400 µm, Kesler et al. found the laser to havegood capability for enlarging and shaping in a fasterand improved manner compared with the traditionalmethod. The SEM observations demonstrated a uni-formly cleaned dentinal surface at the apex of thecoronal portion, with an absence of pulp residue andwell-cleaned dentinal tubules.25

Chen presented clinical studies prepared entirelywith the Er,Cr:YSGG laser, the first laser to obtain theFDA patent for the entire endodontic procedure (en-larging, clearing and decontaminating), using tips of400, 320 and 200 µm in succession and the crown-down technique at 1.5 W and 20 Hz (with air/waterspray 35/25 per cent).26,27

Stabholz et al. presented positive results of treat-ment performed entirely using a Er:YAG laser and en-dodontic lateral emission microprobes.28,29 Ali et al.,Matsuoka et al. and Jahan et al. used the Er,Cr:YSGGlaser to prepare straight and curved canals, but in thesecases, the results of the experimental group wereworse than those of the control group. Using theEr,Cr:YSGG laser with 200 to 320 µm tips at 2 W and 20 Hz on straight and curved canals, they concludedthat the laser radiation is able to prepare straight andcurved (less than 10 degree) canals, while more se-verely curved canals demonstrated side effects, such asperforations, burns and canal transportation.21–23

Inamoto et al. investigated the cutting ability andthe morphological effects of radiation of the Er:YAGlaser in vitro, using 30 mJ at 10 and 25 Hz with a veloc-ity of extraction of the fibre at 1 and 2 mm/seconds,again with positive results.30 Minas et al. reported pos-itive results using the Er,Cr:YSGG laser at 1.5, 1.75 and2.0 W and 20 Hz, with water spray.31

The surfaces prepared with the Erbium laser are wellcleaned and without smear layer, but often contain ledges, irregularities and charring with the risk of per-forations or apical transportation. In effect, canalshaping performed by Erbium laser is still a compli-cated procedure today that can be performed only inlarge and straight canals, without any particular ad-vantages.

Decontamination of the endodontic system

Studies on canal decontamination refer to theaction of chemical irrigants (NaClO) commonly usedin endodontics, in combination with chelating sub-stances for better cleaning of the dentinal tubules(citric acid and EDTA). One such study is that ofBerutti et al., who reported the decontaminatingpower of NaClO up to a depth of 130 µmon the radic-ular wall.32 Lasers were initially introduced in en-dodontics in an attempt to increase the decontami-nation of the endodontic system.2–7

All the wavelengths have a high bactericidalpower because of their thermal effect, which, at dif-ferent powers and with differing ability to penetratethe dentinal walls, generates important structuralmodifications in bacteria cells. The initial damagetakes place in the cell wall, causing an alteration ofthe osmotic gradient, leading to swelling and cellu-lar death.16,34

Decontamination with near infrared laser

Laser-assisted canal decontamination performedwith the near infrared laser requires the canals to beprepared in the traditional way (apical preparationwith ISO 25/30), as this wavelength has no affinityand therefore no ablative effect on hard tissue.

The radiation is performed at the end of the tradi-tional endodontic preparation as a final means of de-contaminating the endodontic system before obtura-tion. An optical fibre of 200 µm diameter is placed 1 mm from the apex and retracted with a helical move-ment, moving coronally (in five to 10 seconds accord-ing to the different procedures). Today, it is advisableto perform this procedure in a canal filled with en-dodontic irrigant (preferably, EDTA or citric acid; alter-natively, NaClO) to reduce the undesirable thermalmorphological effects.9,35–38

I 11laser4_2012

Fig. 5 Fig. 6

Fig. 7 Fig. 8

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Using an experimental model, Schoop et al. demon-strated the manner in which lasers spread their energyand penetrate into the dentinal wall, showing them tobe physically more efficient than traditional chemicalirrigating systems in decontaminating the dentinalwalls.8 The Neodymium:YAG (Nd:YAG; 1,064nm) laserdemonstrated a bacterial reduction of 85 per cent at 1 mm, compared with the diode laser (810nm) with 63 per cent at 750 µm or less. This marked difference inpenetration is due to the low and varying affinity ofthese wavelengths for hard tissue. The diffusion ca-pacity, which is not uniform, allows the light to reachand destroy bacteria by penetration via the thermal ef-fects (Fig. 1).

Many other microbiological studies have con-firmed the strong bactericidal action of the diode andNd:YAG lasers, with up to 100 per cent decontamina-tion of the bacterial load in the principal canal.39–43 Anin vitrostudy by Benedicenti et al. reported that the useof the diode 810 nm laser in combination with chemi-cal chelating irrigants, such as citric acid and EDTA,brought about a more or less absolute reduction of thebacterial load (99.9 per cent) of E. faecalis in the en-dodontic system.9

Decontamination with medium infrared laser

Considering its low efficacy in canal preparationand shaping, using the Erbium laser for decontamina-tion in endodontics requires the use of traditionaltechniques in canal preparation, with the canals pre-pared at the apex with ISO 25/30 instruments. The fi-nal passage with the laser is possible thanks to the useof long, thin tips (200 and 320 µm), available with var-ious Erbium instruments, allowing for easier reach tothe working length (1 mm from apex). In this method-ology, the traditional technique is to use a helicalmovement when retracting the tip (over a 5- to 10-sec-ond interval), repeating three to four times depending

on the procedure and alternating radiation with irri-gation using common chemical irrigants, keeping thecanal wet, while performing the procedure (NaClOand/or EDTA) with the integrated spray closed.

The 3-D decontamination of the endodontic sys-tem with Erbium lasers is not yet comparable to that ofnear infrared lasers. The thermal energy created bythese lasers is in fact absorbed primarily on the surface(high affinity to dentinal tissue rich in water), wherethey have the highest bactericidal effect on E. coli

(Gram-negative bacteria), and E. faecalis (Gram-posi-tive bacteria). At 1.5 W, Moritz et al. obtained an almosttotal eradication (99.64 per cent) of these bacteria.44

However, these systems do not have a bactericidal ef-fect at depth in the lateral canals, as they only reach300 µm in depth when tested in the width of the radic-ular wall.8

Further studies have investigated the ability of theEr,Cr:YSGG laser in the decontamination of tradition-ally prepared canals. Using low power (0.5 W, 10 Hz, 50 mJ with 20 per cent air/water spray), completeeradication of bacteria was not obtained. However,better results for the Er,Cr:YSGG laser were obtainedwith a 77 per cent reduction at 1 W and of 96 per centat 1.5 W.42

A new area of research has investigated the Erbiumlaser’s ability to remove bacterial biofilm from the api-cal third,46 and a recent in vitro study has further vali-dated the ability of the Er:YAG laser to remove en-dodontic biofilm of numerous bacterial species (e.g. A. naeslundii, E. faecalis, L. casei, P. acnes, F. nucleatum,

P. gingivalis orP. nigrescens), with considerable reduc-tion of bacterial cells and disintegration of biofilm. Theexception to this is the biofilm formed by L. casei.47

Ongoing studies are evaluating the efficacy of anew laser technique that uses a newly designed bothradial and tapered stripped tip for removal of not onlythe smear layer, but also bacterial biofilm.13 The resultsare very promising.

The Erbium lasers with “end firing” tips—frontalemission at the end of the tip—have little lateral pene-tration of the dentinal wall. The radial tip was proposedin 2007 for the Er,Cr:YSGG, and Gordon et al. andSchoop et al. have studied the morphological and de-contaminating effects of this laser system (Fig. 2).48–50

The first study used a tip of 200 µm with radial emis-sion at 20 Hz with air/water spray (34 and 28 per cent)and dry at 10 and 20 mJ and 20 Hz (0.2 and 0.4 W, re-spectively). The radiation times varied from 15 secondsto two minutes. The maximum bactericidal power wasreached at maximum power (0.4 W), with a longer ex-posure time, without water in dry mode and with a

12 I laser4_2012

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Fig. 11 Fig. 12

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99.71 per cent bacterial eradication. The minimum timeof radiation (15 seconds) with minimum power (0.2 W)and water obtained 94.7 per cent bacterial reduction.48

The second study used a tip of 300 µm diameter withtwo different parameters of emission (1 and 1.5 W, 20 Hz), radiating five times for five seconds, with acooling time of 20 seconds for each passage. The levelof decontamination obtained was significantly high,with important differences between 1 and 1.5 W, witha thermal increase contained between 2.7 and 3.2 °C.49

The same group from Vienna studied other parameters(0.6 and 0.9 W) that produced a very contained thermalrise of 1.3 and 1.6 °C, respectively, showing a high bac-tericidal effect on E. coli and E. faecalis.50

The need to take advantage of the thermal effect todestroy bacterial cells, however, results in changes atthe dentinal and periodontal level. It is important toevaluate the best parameters and explore new tech-niques that reduce the undesirable thermal effectsthat lasers have on hard- and soft-tissue structures toa minimum.

Morphological effects on the dentinal surface Nu-merous studies have investigated the morphologicaleffects of laser radiation on the radicular walls as col-lateral effects of root-canal decontamination andcleaning performed with different lasers. When theyare used dry, both the near and medium infrared lasersproduce characteristic thermal effects (Figs. 3 & 4).51

Near infrared lasers cause characteristic morphologi-cal changes to the dentinal wall: the smear layer is onlypartially removed and the dentinal tubules are prima-rily closed as a result of melting of the inorganic denti-nal structures. Re-crystallisation bubbles and cracksare evident (Figs. 5–8).52–55

Water present in the irrigation solutions limits thethermal interaction of the laser beam on the dentinalwall and, at the same time, works thermally activatedby a near infrared laser or directly vaporized by amedium infrared laser (target chromophore) with itsspecific action (disinfecting or chelating). The radia-tion with the near infrared laser—diode (2.5 W, 15 Hz)and Nd:YAG (1.5 W, 100 mJ, 15 Hz)—performed afterusing an irrigating solution, produces a better denti-nal pattern, similar to that obtained with only an irri-gant.

Radiation with NaClO or chlorhexidine produces amorphology with closed dentinal tubules and presenceof a smear layer, but with a reduced area of melting,compared with the carbonization seen with dry radia-tion. The best results were obtained when radiation fol-lowed irrigation with EDTA, with surfaces cleaned ofthe smear layer, with open dentinal tubules and less ev-idence of thermal damage.35–38 In the conclusion oftheir studies on the Erbium laser, Yamazaki et al. andKimura et al. affirmed that water is necessary to avoidthe undesirable morphological aspects markedly pres-ent when radiation with the Erbium lasers is performeddry.56,57The Erbium lasers used in this way result in signsof ablation and thermal damage as a result of thepower used. There is evidence of ledge cracks, areas ofsuperficial melting and vaporisation of the smear layer.A typical pattern arises when dentine is irradiated withthe Erbium laser in the presence of water. The thermaldamage is reduced and the dentinal tubules are openat the top of the peri-tubular more calcified and lessablated areas. The inter-tubular dentine, which isricher in water however, is more ablated. The smearlayer is vaporized by radiation with Erbium lasers andis mostly absent.58–64 Shoop et al., investigating the

Fig. 13 Fig. 14

Fig. 15 Fig. 16

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I research

variations of temperature on the radicular surface invitro, found that the standardised energies (100 mJ, 15 Hz, 1.5 W) produced a measured thermal increase ofonly 3.5 °C on the periodontal surface. Moritz proposedthese parameters as the international standard of usefor the Erbium laser in endodontics, claiming it as anefficient means of canal cleaning and decontamina-tion (Figs. 9–12).14,16

Even with Erbium lasers, it is advisable to use irri-gating solutions. Alternatively, NaClO and EDTA can beutilized during the terminal phase of laser assisted en-dodontic therapy with a resulting dentinal pattern,with fewer thermal effects. This represents a new areaof research in laser-assisted endodontics. Varioustechniques have been proposed, such as laser-acti-vated irrigation (LAI) and photon-initiated photo -acoustic streaming (PIPS).

Photo-thermal and photomechanical phenomenafor the removal of smear layer George et al. publishedthe first study that examined the ability of lasers to ac-tivate the irrigating liquid inside the root canal to in-crease its action. In this study, the tips of two laser sys-tems — Er:YAG and Er,Cr:YSGG (400 µm diameter, bothflat and conical tips) with the external coating chemi-cally removed — were used to increase the lateral dif-fusion of energy.

The study was designed to irradiate the root canalsthat were prepared internally with a dense smear layergrown experimentally. Comparing the results of thegroups that were laser radiated with the groups thatwere not, the study concluded that the laser activationof irrigants (EDTAC, in particular) brought about bettercleaning and removal of the smear layer from thedentinal surfaces.65 In a later study, the authors re-ported that this procedure, using power of 1 and 0.75 W, produces an increase in temperature of only

2.5 °C without causing damage to the periodontalstructures.66

Blanken and De Moor also studied the effects oflaser activation of irrigants comparing it with conven-tional irrigation (CI) and passive ultrasound irrigation(PUI). In this study, 2.5 per cent NaClO and theEr,Cr:YSGG laser were used four times for five secondsat 75 mJ, 20 Hz, 1.5 W, with an endodontic tip (200 µmdiameter, with flat tip) held steady 5 mm from the apex.

The removal of the smear layer with this procedureled to significantly better results with respect to theother two methods.67 The photomicrographic study ofthe experiment suggests that the laser generates amovement of fluids at high speed through a cavitationeffect. The expansion and successive implosion of irri-gants (by thermal effect) generates a secondary cavi-tation effect on the intra-canal fluids. It was not nec-essary to move the fiber up and down in the canal, butsufficient to keep it steady in the middle third, 5 mmfrom the apex.68 This concept greatly simplifies thelaser technique, without the need to reach the apexand negotiate radicular curves (Fig. 13).

De Moor et al. compared the LAI technique with PUIand they concluded that the laser technique, usinglower irrigation times (four times for five seconds),gives results comparable to the ultrasound techniquethat uses longer irrigation times (three times for 20seconds).69 De Groot et al. also confirmed the efficacyof the LAI technique and the improved results obtainedin comparison with the PUI. The authors underlined theconcept of streaming due to the collapse of the mole-cules of water in the irrigating solutions used.70

Hmud et al. investigated the possibility of usingnear infrared lasers (940 and 980 nm) with 200 µm fi-bre to activate the irrigants at powers of 4 W and 10 Hz,and 2.5 W and 25 Hz, respectively. Considering the lackof affinity between these wavelengths and water,higher powers were needed which, via thermal effectand cavitation, produced movement of fluids in theroot canal, leading to an increased ability to remove de-bris and the smear layer.71 In a later study, the authorsalso verified the safety of using these higher powers,which caused a rise in temperature of 30 °C in the in-tra-canal irrigant solution but of only 4 °C on the ex-ternal radicular surface. The study concluded that irri-gation activated by near infrared lasers is highly effec-tive in minimizing the thermal effects on the dentineand the radicular cement.72

In a recent study, Macedo et al. referred to the mainrole of activation as a strong modulator of the reactionrate of NaOCl. During a rest interval of three minutes,the consumption of available chlorine increased sig-nificantly after LAI compared with PUI or CI.73

16 I laser4_2012

Fig. 17 Fig. 18

Fig. 19 Fig. 20

research I

Photon initiated photoacoustic streaming (PIPS)

The PIPS technique uses the Erbium laser (Power-lase AT/HT and LightWalker AT, both Fotona) and its in-teraction with irrigating solutions (EDTA NaOCl or dis-tilled water).13 The technique uses a different mecha-nism from the preceding LAI. It exploits exclusively thephotoacoustic and photomechanical phenomena,which result from the use of subablative energy of 20 mJ at 15 Hz, with impulses of only 50 microseconds.With an average power of only 0.3 W, each impulse in-teracts with the water molecules with a peak power of400 W creating expansion and successive “shockwaves” leading to the formation of a powerful stream-ing of fluids inside the canal, without generating theundesirable thermal effects seen with other method-ologies.

The study with thermocouples applied to the radic-ular apical third revealed only 1.2 °C of thermal rise af-ter 20 seconds and 1.5 °C after 40 seconds of continu-ous radiation. Another considerable advantage is de-rived from the insertion of the tip in the pulp chamberat the entrance to the root canal only without the prob-lematic insertion of the tip into the canal or at 1 mmfrom the apex required by the other techniques (LAIand CI). Newly designed tips—9 mm in length, 600 µm

in diameter and with “radial and stripped” tip—areused. The final 3 mm are without coating to allow agreater lateral emission of energy compared to thefrontal tip. This mode of energy emission makes betteruse of the laser energy when, at subablative levels, de-livery with very high peak power for each single pulseof 50 microseconds (400 W) produces powerful “shockwaves” in the irrigants, leading to a demonstrable andsignificant mechanical effect on the dentinal wall (Figs.14–16). The resultant acoustic streaming allows for athree dimensional movement throughout the rootcanal system allowing the clinician to easier access thecomplex anatomy often seen in the apical one third.

The studies show the removal of the smear layer tobe superior to the control groups with only EDTA or dis-tilled water. The samples treated with laser and EDTAfor 20 and 40 seconds show a complete removal of thesmear layer with open dentinal tubules (score 1 ac-cording to Hulsmann) and the absence of undesirablethermal phenomena, which is characteristic in thedentinal walls treated with traditional laser tech-niques. With high magnification, the collagen struc-ture is maintained intact, suggesting the ability forminimally invasive endodontic treatment (Figs.17–19).

Now that´s something to get my teeth into.

Perio Green® effectively destroys bacteria in biofilm, periodontal pockets and dental implants, using photodynamic therapy (PDT).

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I research

18 I laser4_2012

The Medical Dental Advanced Technologies Group,in affiliation with the University of the Pacific Arthur A.Dugoni School of Dentistry, the University of Genoaand the University of Loma Linda School of Dentistry,University of Tennessee, Boston University, LouisianaState University and the Arizona School of Dentistryand Oral Health, are currently investigating the effectsof this technique of root-canal decontamination andthe removal of bacterial biofilm in the radicular canal.The results which are about to be published are verypromising (Figs. 20–25).

_Discussion and conclusion

Laser technology used in endodontics in the past 20years has undergone an important evolution. The im-proved technology has introduced endodontic fibersand tips of a caliber and flexibility that permit insertionup to 1 mm from the apex. Research in recent years hasbeen directed toward producing technologies (im-pulses of reduced length, “radial firing and stripped”tips) and techniques (LAI and PIPS) that are able to sim-plify its use in endodontics and minimize the undesir-able thermal effects on the dentinal walls, using lowerenergies in the presence of chemical irrigants. EDTAhas proved to be the best solution for LAI techniquethat activates the liquid and increments its chelatingcapacity and cleaning of the smear layer. The use of NaClO increases its decontamination activity. Finally,the PIPS technique reduces the thermal effects and ex-erts a potent cleaning and bactericidal action thanks to

its three dimensional streaming of fluids initiated bythe photonic energy of the laser. Further studies arecurrently under way to validate these techniques (LAIand PIPS) as innovative technologies available to en-dodontics._

Editorial note: An earlier version of this article was pub-

lished in the international edition of roots, issue 2/2011. A

complete list of references is available from the publisher.

Fig. 22Fig. 21

Fig. 24 Fig. 25Fig. 23

Enrico DiVito, DDS, the lead au-thor of this article, founded hisdental practice in Scottsdale,Ariz., in 1980. He is also thefounder and director of the state-accredited Arizona School of Den-tal Assisting. In addition to teach-

ing at the school, DiVito is also a clinical instructor atthe Arizona School of Dentistry and Oral Health and isresponsible for helping create the Department ofLaser Dentistry. He earned his undergraduate degreefrom Arizona State University and graduated withhonors from the Dental School at the University of thePacific in San Francisco, receiving several ClinicalExcellence Awards. He can be contacted at:edivito@azcld.com.

_about the author laser

Congress President:Pr S. Nammour

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DGL_A4_laser412.pdf 1DGL_A4_laser412.pdf 1 17.10.12 15:3417.10.12 15:34

_Introduction

The concept of using dental lasers for the treat-ment of periodontal disease elicits very strong reac-tions from all sides of the spectrum. Everyone has anopinion. Everyone is certain that their own opinion iscorrect. But the only certainty is confusion, and thelack of clear direction in the concept of Laser AssistedPeriodontal Therapy (LAPT).

Much of this uncertainty stems from not compar-ing “apples to apples,” in terms of the type of lasersutilized and the way that studies are designed. Certainlasers are used specifically for soft tissue treatment.These include the CO2, Nd:YAG, and diode lasers. Oth-ers can be used for both soft and hard tissue applica-tions. These are the Er:YAG and Er,Cr:YSGG lasers. Theymust be compared within their own category.

Many of these lasers have been shown to provideperiodontal treatment benefits. In order to achieve anelement of clarity and simplicity on this very complextopic, the following discussion exclusively addressesthe use of the diode laser for periodontal treatment.

_A specific instrument

The diode laser has become an important tool in thedental armamentarium due to its exceptional ease ofuse and affordability. It also has key advantages withregard to periodontal treatment. The diode laser is wellabsorbed by melanin, haemoglobin, and other chro-mophores that are present in periodontal disease.1

Hence the diode specifically targets unhealthy gingi-val tissues. The laser energy is transmitted through a

thin fibre that can easily penetrate into deep peri-odontal pockets to deliver its therapeutic effects.

The 2002 American Academy of Periodontologystatement regarding gingival curettage2 proposesthat “gingival curettage, by whatever method per-formed, should be considered as a procedure that hasno additional benefit to SRP alone in the treatment ofchronic periodontitis”. Also stated is that all the meth-ods devised for curettage “have the same goal, whichis the complete removal of the epithelium” and “noneof these alternative methods has a clinical or micro-bial advantage over the mechanical instrumentationwith a curette”.

This was the science in 2002. More recent studieshave shown that instrumentation of the soft peri-odontal tissues with a diode laser leads to completeepithelial removal while instrumentation with con-ventional curettes leaves significant epithelial rem-nants.3

_An effective bactericidal instrument

Periodontal disease is a chronic inflammatory dis-ease caused by a bacterial infection. Hence the bacte-ricidal and detoxifying effect of laser treatment is ad-vantageous in periodontal therapy.4 The diode laser’sbactericidal effectiveness has been well-docu-mented.5,6,7,8

Moreover, there is a significant suppression of A. actinomycetemcomitans, an invasive bacteriumthat is associated with aggressive forms of periodon-tal disease that are not readily treated with conven-

I overview

Diode lasers for periodontal treatment:the story so farAuthors_Dr Fay Goldstep, Dr George Freedman, Canada

20 I laser4_2012

[PICTURE: ©BIZROUG]

tional scaling and root planing (SRP). A. actino-

mycetemcomitans is not only present on the diseasedroot surface, but it also invades the adjacent soft tis-sues, making it difficult to remove by mechanical pe-riodontal instrumentation alone.7,9,10 This necessi-tates the use of adjunctive antibiotic therapy.10 Thediode laser provides a non-antibiotic solution. A. actinomycetemcomitans has also been found inatherosclerotic plaques11 and there has been evidenceto suggest that subgingival A. actinomycetemcomi-

tans may be related to coronary heart disease.12 Thismakes it even more compelling to seek methods tocontrol this aggressive pathogen.

_Wound healing

Diode lasers are very effective for soft tissue appli-cations including incision, hemostasis and coagula-tion.13 Many advantages of the laser vs. the scalpelblade have been discussed in the literature. These in-

clude a bloodless operating field, minimal swellingand scarring, and much less or no postsurgicalpain.14,15 When laser surgical procedures are carriedout, the surface produced heals favourably as an openwound, without the need for sutures or surgicaldressings.4 Studies have shown enhanced, faster andmore comfortable wound healing when the diodelaser is used in conjunction with scaling and rootplaning (SRP).7

_An adjunct to scaling and root planing(srp)

There is very compelling evidence in the dental lit-erature that the addition of diode laser treatment toSRP (the gold standard in non-surgical periodontaltreatment) will produce significantly improved re-sults. After SRP, the diode laser is used on the soft tis-sue side of the periodontal pocket to remove the in-flamed soft tissue and reduce the pathogens.16 Re-search has demonstrated better removal of thepocket epithelium compared to conventional tech-niques.3 Many studies have shown increased reduc-tion of bacteria (especially specific periopathogens)when diode lasers are utilized after SRP.5,17,18 Signifi-cant improvement in decontamination and effectivetreatment of periimplantitis also occurs with the ad-dition of diode laser therapy.19

Gingival health parameters are significantly im-proved with the addition of the diode laser to SRP.Studies have shown decreased gingival bleeding17,20

decreased inflammation and pocket depth,16,17 as wellas decreased tooth mobility and decreased clinical at-tachment loss.16 This improvement in gingival healthremains more stable than with conventional SRPtreatment alone and tends to last longer.21 Moreover,patient comfort is significantly enhanced during thepostoperative healing phase, with the addition ofdiode laser therapy.7

The research thus shows diode laser periodontaltreatment to be an effective procedure. It is also a

overview I

Fig. 1_Scaling and Root Planing are

performed first.

Fig. 2_The diode laser tip is placed

into the pocket.

I 21laser4_2012

Fig. 1 Fig. 2

I overview

Fig. 3_Laser energy is applied into

the pocket to decontaminate and

coagulate the soft tissue.

Fig. 4_Pocket depth is measured

before the treatment and three

months post treatment.

minimally invasive procedure. Patients are demand-ing less surgery and the diode laser provides thegeneral dentist with an excellent means of keepingperiodontal treatment in the general practice.

_A safe instrument

Histological testing of roots where the diode laserwas used after SRP demonstrated no detectable sur-face alteration to root or cementum. There were nosigns of thermal side effects in any of the teethtreated.22 Many studies have specifically indicated noadverse tissue events, demonstrating the safety of thediode laser.5,8,17,23

The diode laser’s very effective bactericidal actionon periodontal pathogens makes the adjunctive use ofantibiotics unnecessary.10 This eliminates the problemof bacterial resistance and systemic side effects en-gendered by antibiotic use.6 The laser is a safer, moreeffective treatment.

_The protocol so far

The above-cited research has demonstrated thatthe use of the diode laser after conventional scalingand root planing (SRP) is superior to SRP alone. Vari-ous protocols have been developed by clinicians to in-corporate this treatment into the busy dental practice.These protocols may be performed by the dentist and /or the hygienist as determined by the regulatingorganization in the geographic location of the dentalpractice.

Individual parameters vary depending on the clini-cian and the particular diode laser that is being used.However, most protocols do follow a simple formula.The hard side of the pocket (tooth and root surface) isfirst debrided with ultrasonic scalers and hand instru-mentation (Fig. 1). This is followed by laser bacterial re-duction and coagulation of the soft tissue (epithelial)side of the pocket (Figs. 2 & 3).1 The laser fiber is meas-ured to a distance of one mm short of the pocket depth.

The fiber is used in light contact with a sweeping ac-tion that covers the entire epithelial lining, from thebase of the pocket upward.24 The fiber tip is cleaned of-ten with a damp gauze to prevent the build-up of de-bris. Re-probing of treated sites should not be at-tempted for three months post operatively (Fig. 4), be-cause healing starts at the base of the pocket and thenew tissue remains fragile for this period of time.1

The power settings and time parameters are deter-mined by the particular laser used. The diode laser cli-nician must take training on the specific laser in thepractice to be fully able to implement Laser AssistedPeriodontal Therapy. With experience, the user will feelcomfortable enough to adapt the protocol to his or herparticular practice.

In the future, protocols will be modified and fine-tuned by various laser user groups after discussion oftheir experiences and results. These results will be in-corporated into new procedures which will bring LaserAssisted Periodontal Therapy to a new, more effectivelevel.

_The time has come

The time has come to embrace the routine use oflasers for the treatment of periodontal disease. Thediode laser has been shown to be effective and safefor this purpose. When, if not now? Patients needtreatment. Laser Assisted Periodontal Therapy isnon-invasive. With the diode laser, there is a reducedneed for systemic or locally applied antimicrobials.This leads to fewer allergic reactions and antibioticresistance.

There is significant proof that the addition ofLaser Assisted Periodontal Therapy to conventionalscaling and root planing improves outcomes. This isparticularly compelling when considering the peri-odontal health/systemic health link. It is time to openour minds to laser technology and apply the treat-ment that is in the best interest of our patients._

22 I laser4_2012

Fig. 3 Fig. 4

AEEDC_2012_A4.pdf 1AEEDC_2012_A4.pdf 1 05.03.12 14:0905.03.12 14:09

I overview

_In his new book “Principles of Medical and Den-tal Lasers”, Rene Franzen addresses the key issues oflaser dentistry in an accessible way, pointing out im-portant facts with regard to laser-tissue interactionrelevant for everyday clinical practice. Readers of laser international magazine of laser dentistry can now enjoy afree reprint of an original chapter from this piece of ba-sic laser literature.

_Introduction

If I would have to define a medical or dental lasersystem in just on sentence, this would be it:

A laser is a concentrator of energy.

This is what we want it to do for medical purposes.Its main properties, which are relevant here, are:

A high spectral energy or power density.

Now, since this is the core issue of medical lasertherapies, we need to look at this in detail. Let’s startwith energy and power. These are different parame-ters, the first one measured in Joules, the other inWatts. The Joules measure the amount of something,and this something can actually be interpreted as themedication you use on your patient. In pharmacology,we measure the amount of medication in milligrams.Often they are given orally, and the effect is a systemicone. With lasers, our medication is the amount of en-

ergy, of Joules, which will cause an effect. Almost al-ways the laser’s medication is working only locally asopposed to systemically, making lasers a highly suit-able tool for minimally invasive or selective proce-dures.

_Energy and time

The power, the Watts, is defined as energy per time.One Watt is 1 Joule in 1 second. If you apply the same1 Joule in only 0.1 seconds, you have a power of 10 Watt. The amount of medication (Joules) is thesame, but the effect will differ. Think of the power aswhat the dosage is in pharmacology. Example: Take100 pills of a pain killer. Applying these in a time frameof 100 days may be okay for chronic pain issues, butapplying the same amount in 10 minutes might be fa-tal. Same amount—different effect. The same is true

The key concept of laser dentistryWhat does a dental laser actually do?

Author_Dr Rene Franzen, Canada

24 I laser4_2012

[ORIGINAL BACKGROUND: ©QUINKY]

[PICTURE: ©ROBERT KNESCHKE]

overview I

for the laser’s Joules. The same amount of energy, 500 mJ in the example, can cause non-thermal removal of hard tissue when given in a fast way, andcauses no tissue removal but thermal carbonisationwhen given too slowly. The relationship between en-ergy and power is the time it takes to deliver thisamount of energy into the tissue. And this is the firstquality in which a laser concentrates energy. For somemedical or dental procedures we want to concentratea lot of energy within a small timeframe, using a pulsedlaser so we can have a high power during the pulse.

Let’s look at the other words in that line above. Sinceenergy and power are connected by time, high spec-tral power density remains. Now, high, is an easy prop-erty, isn’t it? Often we think about lasers being highpower devices, pure focussed light…but that is actu-ally not a property of a laser. To understand this, let usexamine one example:

_Compare a light bulb to a laser

Why don’t we use a 100 W light bulb instead of alaser? It costs about 1 or 2 Euros or Dollars. How muchdoes a 7 W diode laser cost? How much a larger Erbiumor Neodymium laser? 10,000 − 50,000 Euros or Dollars,depending on the manufacturer and what market youare in. And yes, the light bulb really gives you morepower than those laser systems. Power alone is noth-ing. It is one quality of the laser, namely the temporalconcentration of energy. But there is more. The lineabove says power density, not just power. And this isanother quality of lasers, the spatial concentration ofenergy.

Let us compare a laser to a light bulb. We take a 1mWlaser pointer, red laser light, and the 100 W bulb illumi-nating a room of roughly 25 square meters (sqm). Thepower of the light bulb is 100,000 times larger than thatof the pointer. For simplicity, let’s assume the pointersbeam diameter is about 1 square millimeter (sqmm). Itdoes not chance much when pointing it at different ob-jects in a common room. The power density (or inten-sity) will be 1 mW/sqmm or 1,000,000 mW/sqm whichequals 1,000 W/sqm. The light bulb illuminates thecomplete room, radiating in all directions since itsemission is based on spontaneous emission. The flooris lit, but so are the ceiling and the walls. Again for sim-plicity, let’s assume those add up to roughly 100 sqm,which means we talk about 100 W/100 sqm which isjust 1 Watt per square meter at the position of the floor.We can use rough approximates here since we just needto see the order of magnitude which is between them:the pointer has an intensity 1,000 times higher than thebulb, even though the bulb is 100,000 times more pow-erful. This is concentration of power in space—the laserconcentrates energy, in time (Watt) and space (energyor power density).

When we compare this laser pointer with a com-mon dental diode laser of 7–10 Watt we will arrive at apower density of roughly 7–10 million Watts persquare meter. If you would just buy power with yourlaser, the medical/dental laser should not exceed asales price of 10 ct, but when comparing power den-sity the bulb is at 1 Euro per 1 W/sqm, so the dental laserwould be at 7–10 million Euros. Luckily, the real priceis between those two extremes.

_Monochromasy

Going back once more, we see there is only oneword left: A high spectral energy or power density. Thepower density is not just high, it is spectrally high. Thisrelates to the position of the emission in the electro-magnetic spectrum, the wavelengths being involvedin the emission. The light bulb emits white light, whichmeans that all the visible colours are present. But thelight bulb is inefficient, less than 10 % of the power areemitted in the visible range; more than 90 % are emit-ted as infrared radiation. The red laser pointer is emit-ting its 1,000 W/sqm on just one narrow wavelengthwhich is around 650 nm for a common diode laserbased pointer. The light bulb is of course also emitting650 nm, among other wavelengths. But in a strictcomparison, when we use an optical filter to block outall the light of the bulb which is not between 649 and651 nm, then what remains? Of the 1 W/sqm only10 % are in the visible range at best, that’s a mere 0.1 W/sqm. And this power density is spread acrossthe complete visible area. So, in fact, we are looking atabout 0.001–0.005 W/sqm around 650 nm. This is thevalue which competes against 1,000 W/sqm of laserpointer intensity, about a million times higher. This iswhat we mean when we say high spectral power den-sity. A laser can concentrate the energy (the medica-tion!) in time, space and on only one wavelength. Just

I 25laser4_2012

[PICTURE: ©IR STONE]

I overview

having one wavelength in the emission is what iscalled monochromasy.

_The key concept for selective treatments

This is the key element of minimally invasive lasertreatments since it enables the doctor to put the med-ication exactly where it is needed to invoke a certaineffect. Monochromasy directly leads to selectivity, inthe sense that the optical properties of tissues can beused in conjunction with choosing a suitable laserwavelength, so that certain tissues or components in-side a tissue can absorb significantly higher amountsof energy than others. This key concept opens up atremendous amount of selective laser treatments.

_Selectivity

Using a medical laser system selectively in factmeans to not only concentrate energy into a small vol-ume of tissue in a certain time frame, but it also meansto concentrate energy on certain components in thetissue.

Let us start with an easy, every-day example. As-sume you are on vacation somewhere, staying at a nicehotel or resort with a lovely swimming pool. The poolis surrounded by tiles, white and black ones. The sky isblue and the sun is shining intensely. You walk aroundthe pool just after breakfast. What happens?

Walking on the white tiles, you will feel they arecool, maybe even still cold from the night. The blacktiles will feel hot when stepped upon (most pools will

therefore not even have black tiles!). This is because therelationship

power is energy divided by time

can also be expressed as

energy is power multiplied time.

Or in this case: absorbed energy (heat) in the tilesis power (sunshine) multiplied time (hours aftersunrise). In this simplified example, the absorbedpower in the white tiles will be low, because mostsunlight will be scattered and reflected. Indeed, thisis why they appear white in the first place: most ofthe sunlight is “bounced off” the tiles and reachesyour eyes—the tile is bright. The fact that the tile isbright white is a direct consequence of this“bounced off” light being collimated by your eyes,focussed onto your retinas, where an image is pro-jected. This is what we define as seeing.

The black tiles absorb most of the sunlight. Onlya small fraction of the light is being scattered andreflected, only a small amount of light reaches youreyes—the tile appears dark or black. Black is actuallyno colour in itself but the absence of light. The ab-sorbed energy will be converted mostly into heatand you will find the tile hot under the soles of yourfeet.

This is selective absorption of energy. A differentresponse by different components, even if in closespatial proximity, and under the same irradiation.

26 I laser4_2012

[PICTURES: ©SERGEJ KHAKIMULLIN; MCIEK]

overview I

However, there is an important lesson to learn. Yourevisit the pool at 5 p.m. in the afternoon. The sun hasbeen shining all day. The black tiles are hot. But now thewhite ones are also hot! The white tiles have heated upat a slower rate, since the absorbed power is lower. Butover enough time, an impressive amount of energy canstill be collected. At this time, we don‘t feel a thermal dif-ference between the different tiles. The selectivity is lost.

_You can lose selectivity if you irradiatetoo long

The example with the pool tiles can be expanded to adental example: A laser-supported endodontic treat-ment follows the same concept of selectivity.

One of the main problems of problematic endodon-tic cases are bacteria migrating into lateral tubes. Re-search has shown that the bacteria such as Streptococ-

cus mutans can migrate 1,100 µm into the tubules1,while rinsing agents are only effective to about 100 µm.2 Secondary canals, an isthmus or apical deltawill also make conventional cleaning in these cases nearto impossible.

But luckily we have a selective situation. More than95% of bacterial species in the canal system are pig-mented. The remaining fraction is highly sensitive to theresidual heat after irradiation. The dentin itself is notpigmented. The bacteria are acting as our black tiles andthe dentin acts as white tiles.

We can now choose a laser whose wavelength ishighly absorbed in pigments/melanin and is highly scat-tered and transmitted in dentin.

The question regarding the dose, the amount ofmedication, the amount of energy need is equivalent tothe question “At what time to I need to go to the pool tofind the white tiles cold and the black tiles hot“. Then wefind an answer, something like “At 10:23 a.m.“.

In laser medicine, this answer may not be so easy tofind. Actually, it involves tremendous efforts in research.For the laser-supported endodontic treatment, alreadyin the 1990’s, Prof Dr Norbert Gutknecht tested severalirradiation protocols at RWTH Aachen University, meas-uring bacterial reduction in different depths of dentin.The ideal technique, today known as the Aachen proto-col, which we also teach in-depth in courses on ourcampus, involves specific settings for the laser system,wavelength, average power, temporal modulation(pulsing), fiber diameter and kind, as well as the move-ment of the fiber inside the open root canal.

If we perform such a treatment, we will have excel-lent results, because we concentrate energy: in time(pulse duration, repetition rate, movement), in space

(movement, different absorption of components—wavelength, fiber diameter), and spectrally (absorptionresponse of dentin and pigments). Don‘t get lost in toomany laser parameters, they all go back to one of thesethree qualities of concentration. If ever you get con-fused by a parameter, ask yourself, is this influencing theenergy concentration in time, in space, or a certain com-ponent?

In our example of an infected root canal, the energywill be concentrated in the bacteria. They will locallyoverheat and die off due to the absorbed energy, with-out heating the surrounding dentin up to significanttemperatures. We aim to put the medication (energy)selectively into the microorganisms.

And just as in pharmacology, you can overdose andunderdose your treatment. If you are too careful, settingonly the lowest possible power on your laser, and moveout of the canal very quickly, no harm can be done to thedentin and underlying bone structures. But also noharm is done to the bacteria: under dose. This is the sameas if you visit the pool just after sunrise. Everything is stillcold.

On the other hand, if someone says, “I paid for 10W,so I will use it, no matter what“, and then moves slowlyinside the canal, the bacteria will be killed off—alongwith charring the dentin and destroying significant sec-tions of the bone structure. The same as going to thepool at 5 p.m.: Everything is hot. Selectivity is lost.

At this point I would like to stress that therefore it isvery important to learn and study (and understand!) thetreatment protocols in medicine. Some things are fun-damentally different than with a scalpel.

Continue reading in the book or ebook and learnmore about the successful use of laser energy in dentaltreatments._

Editorial note: The book Principles of Medical and DentalLasers by Rene Franzen can be obtained in German, English

and Greek, printed or as e-book via www.lulu.com/

spotlight/renefranzen and www.amazon.de/Principles-

M e d i c a l - A n d - D e n t a l - L a s e rs / d p / 1 4 70 9 0 5 9 2 2 /

ref=cm_cr_pr_product_top as well as via iTunes and iBook-

store. A complete list of references is available from the pub-

lisher.

I 27laser4_2012

Dr Rene Franzen

Roermonderstr. 112

52072 Aachen, Germany

rfranzen@ukaachen.de

_contact laser

Fig. 1_Initial situation.

Fig. 2_Situation after removal.

_Introduction

Removing fibromas and fraena is bread-and-but-ter work for dental practitioners. Laser dentists areeven happy to do it spontaneously during a routinecheck-up.

Laser cutting causes no bleeding at all. The risk ofcells being spread is minimized by immediate sealingof the blood vessels. Laser cutting dramatically re-duces the microbial count at the operation site andensures a clean primary wound. The result of success-ful laser excision is a cleaner, non-bleeding cut withpain-free healing.

The whole “magic” takes no more than ten minutesand includes explanation to the patient, anaesthesia

and signing the cost estimate. Patients are happy toaccept the offer because it means they do not have toattend the dental practice a second time. They can re-sume work the next day without any difficulty and donot have to give up a day’s holiday. None of my pa-tients want to take a sick leave any more.

_Case presentation

A new patient came to my surgery for a routinecheck-up, “just to take a look” as she emphasized.Everything was fine, she said, and she had no com-plaints or questions beforehand.

Examination revealed a 2 x 2 mm neoplasm on theright margin of the tongue. When asked about it, shetold me I was the first dentist to talk to her about it and

28 I laser4_2012

I case report

Does the tongue getthe attention it deserves?Author_Dr Darius Moghtader, Germany

Fig. 1 Fig. 2

[PICTURE: ©TOVKACH OLEG]

case report I

suggest removing it. This thing had been botheringher more and more for twelve months because sheworked the “bump” against her tooth and occasion-ally even bit onto it. She also thought it had grown alittle. She claimed to have talked to previous practi-tioners about it and received either no answer or an-swers such as “It’s not bad, you can leave it”. If it both-ered her so much, they said, it would be a job for thesurgeon and she might have to take a few days off.This is why she did not mention the problem at all.

In short, we decided to remove the neoplasmstraight away. It was removed using the pre-set pro-gram for fibroma removal with the elexxion claros 810 nm diode laser. Soft laser therapy with the pre-setwound healing program of the elexxion claros wasthen carried out.

After removalThe results of the diode laser technology of

elexxion claros are very clear to see. Because of thepatented digital pulse technology with up to 20,000 Hz, there are only minimal or no carbonizationof the tissue and its resulting unwanted side effects.

The neoplasm was sent to Pathology as a matter ofroutine. As well as the usual information, a note re-garding the laser excision should be included so thatthe pathologist is able to interpret the wound marginsproperly. I send along the photographs as well. Thepathologist is very pleased to receive these and regu-larly asks me whether he can use these photos in hislectures.

Check-up the next dayAs expected and predicted, the patient said she had

no bleeding, pain or restriction in her work. She toldme she was relieved to “finally get rid of this thing”.

One week laterThe pathology report revealed an irritation fi-

broma of the tongue. Without laser I would havethought long and hard about its removal. Any dentistwho has ever had to contend with a tongue injury isfamiliar with the heavy, uncontrolled bleeding of thetongue that can happen. Suturing poses a challengetoo. It can entirely disrupt the whole practice sched-ule. Consequently, I would rather use the laser to treata grateful patient safely, effectively and quickly in myown general dental practice._

Fig. 3_Check-up the next day.

Fig. 4_One week later.

I 29laser4_2012

Dr Darius Moghtader

In den Weingärten 47

55276 Oppenheim, Germany

dr-moghtader@hotmail.de

oppenheim-zahnarzt.de

_contact laser

Fig. 3 Fig. 4

I industry report

Fig. 1_Coronal fracture of the

permanent right central incisor.

Fig. 2_After treatment with

Er:YAG, SSP mode.

Fig. 3_The reposition of the

fragment.

Fig. 4_The preparation of the

borderline surface area.

Fig. 5_Completed treatment.

Fig. 6_Crown fracture of the

permanent, right central incisor.

_Introduction

Dental traumatology is a multidisciplinarybranch of dentistry that requires a number of spe-cific skills. In cases of emergency, decisions have tobe made within a limited time frame and with effectsthat can only be evaluated at a later date.1 The tech-niques of tooth fragment re-attachment should beadapted for cases of simple coronal fracture(enamel and superficial dentin) as well as compli-cated coronal fracture (deep dentin with pulp expo-sure).2

In cases of simple fracture, a fragment may be re-attached immediately, while in complicated coronalfractures, the main concern should be the protec-tion of the pulp and not necessarily the fragment,

which should be maintained hydrated and refriger-ated in a container marked with the patient’s fullname and the date of the trauma. The solution in thecontainer should be changed at regular intervalsand the seal checked, since in some cases fragmentsmay be stored for several months before being re-attached.3

The field of adhesive dentistry was born in 1955by Buonocore, with the description of the utilisationof orthophosphoric acid and composite resin in or-der to obtain restorations with high bond strengthand reduced microleakage.4,5 In 1990, laser technol-ogy was introduced in conservative dentistry by Hibst and Keller, who described the use of an Er:YAGlaser as an alternative to conventional instruments,such as the turbine and micromotor.6,7 Widespread

Lasers in the treatment oftraumatically fracturedfrontal teethAuthor_Dr Carlo Fornaini, Italy

30 I laser4_2012

Fig. 5 Fig. 6

Fig. 2 Fig. 3

Fig. 4

Fig. 1

industry report I

interest in employing this new technology is relatedto its significant number of advantages, as de-scribed in several scientific studies. Thanks to theaffinity of its wavelength to water and hydroxyap-atite, Er:YAG laser technology allows for the effi-cient ablation of hard dental tissues without the riskof micro- and macro-fractures, which have beenobserved when using conventional rotating instru-ments.8,10 The dentin surface treated by laser ap-pears clean, without a smear-layer and with thetubules open and clear.11

Thermal elevation in the pulp, recorded duringEr:YAG laser irradiation, is less than that recorded byusing turbine and micro-motor, in the same condi-tions of air/water spray.12,13 This wavelength also hasan antimicrobial decontamination effect on thetreated tissues, which destroys both aerobic andanaerobic bacteria.14 The most interesting aspectsof this new technology are related to the goals ofmodern conservative dentistry, namely “minimallyinvasive” treatments and better adhesive methods.Er:YAG lasers can reach spot dimensions smallerthan 1 mm, which allows the possibility to make aselective ablation of the affected dentin while pre-serving the sound tissue in order to realise very lim-ited restorations.15

Several in-vitro studies demonstrated that thepreparation of enamel and dentin by Er:YAG laser,followed by orthophosphoric acid-etching, en-hances effectiveness in terms of reduced microleak-age and increased bond strength.16 Several authorshave proposed the utilisation of laser technologyalso for the restoration of frontal teeth fractured bytraumatic events.17

In some cases of frontal teeth trauma, it is neces-sary to perform gingival recontouring because thetraumatic event has also damaged the soft tissue; inother cases, due to pulp exposure, a pulp-capping pro-cedure is needed. In both of these clinical situations,the utility of laser therapy was demonstrated.18-20

We prefer to use VSP Er:YAG laser technology for soft-and pulp-tissue treatments, without air/water sprayand with a long pulse duration in order to transformall the energy delivered into heat, although the com-plementary Nd:YAG wavelength (1,064 nm) present inthe same device can also be used.

The aim of this clinical study was to demonstratethe usefulness of the Er:YAG laser in the treatment oftooth fractures by showing several cases and de-scribing the advantages of using a device based onVSP technology21 and an additional integrated wave-length (Nd:YAG).

_Clinical cases

Case 1

A ten-year-old patient came to one of our clinicsafter an accident during a football game. Upon clin-ical examination it was evident that there was acoronal fracture of the permanent right central in-cisor (Fig. 1). The patient, instructed by his coach,had preserved the fractured portion of the tooth ina container of milk. It was decided to re-bond thefragment to the tooth by means of an Er:YAG laser-assisted technique after a vitality check. Both thefragment and the tooth were treated by Er:YAG laser(Fidelis Plus III, Fotona, Slovenia) with the followingparameters: SSP mode, 200 mJ, 10 Hz, tipless hand-piece (Fig. 2); subsequently they were etched by or-

Fig. 7_Exposed pulp.

Fig. 8_Nd:YAG laser pulp capping.

Fig. 9_Replaced fragment after the

preparation of fragment and tooth

bonding surfaces with Er:YAG, SSP

mode.

Fig. 10_Final result.

Fig. 11_ Permanent right central

incisor longitudinally fractured in

the distal portion.

Fig. 12_Gingival margin recontoured

with Nd:YAG laser.

I 31laser4_2012

Fig. 7 Fig. 8 Fig. 9

Fig. 10 Fig. 11 Fig. 12

I industry report

Fig. 13_Completed treatment.

Fig. 14_Gingival margin

recontouring and pulp capping with

Er:YAG, VLP mode.

Fig. 15a & b_Both hard dental

tissues prepared with Er:YAG, SSP

mode before the attachment

of the fragment.

Fig. 16_Completed intervention.

thophosphoric acid, after which bonding was ap-plied and the fragment was re-positioned with flowcomposite resin (Fig. 3).

In the borderline surface area, these steps were allrepeated to improve the aesthetic result (Fig. 4). Dur-ing the whole procedure, no anaesthesia were usedand the compliance of the patient was very high; heconfirmed that there was no pain or discomfort. Thetooth was checked monthly for six months and vital-ity tests were found to be positive (Fig. 5).

Case 2

A fourteen-year-old patient came to one of ourclinics presenting a traumatic crown fracture of thepermanent, right central incisor (Fig. 6). The patienthad preserved the broken fragment in her mouth. Tolessen the ordeal for the already traumatized youngpatient we decided to perform the treatment with theEr:YAG and Nd:YAG lasers we have at hand in ourpractice (Fidelis Plus III, Fotona, Slovenia). The traumahad left the pulp exposed (Fig. 7); our first decisionwas to perform a Nd:YAG laser pulp capping (SPmode, 4 W, 40 Hz, 300 µm contact fiber, Fig. 8). Wethen proceeded to use the same device but with an-other wavelength (Er:YAG) to prepare both the frag-ment's and tooth's bonding surfaces (SSP mode, 200 mJ, 10 Hz, tipless handpiece, Fig. 9). The same sur-faces were further prepared with orthophosphoricacid, bonding was applied and subsequently flowcomposite resin was used in order to replace the frag-ment (Fig 10).

The Er:YAG laser played a pivotal role in this par-ticular case; we were able to work without causingany additional pain to the patient, keeping trauma forboth patient and parents to a minimum. In addition,the Er:YAG’s inherent lasering effect provided de-contamination and increased bond strength. For aes-

thetic purposes, we prepared the borderline surfacearea with Er:YAG before once more applying or-thophosphoric acid and finally flow composite resin.No form of anaesthesia was deemed necessary by usor even requested by the patient. The tooth waschecked monthly for six months and vitality testswere found to be positive.

Case 3

An eight-year-old patient came to our clinic withhis permanent right central incisor longitudinallyfractured in the distal portion (Fig. 11). He had pre-served the fragment in physiological solution. After acheck of the vitality and the fragment's fit to thetooth, the gingival margin was recontoured with anNd:YAG laser (Fidelis Plus III, Fotona, Slovenia; SPmode, 4 W, 40 Hz, 300 µm contact fiber, Fig. 12) in or-der to expose all the borders of the restoration. Sinceit was impossible to use a rubber dam, it was decidedto use the same device but with the other wavelength(Er:YAG) to prepare both the surfaces of the fragmentand the tooth (SSP mode, 200 mJ, 10 Hz, tipless hand-piece). After a total etching of the laser-irradiatedsurfaces, the bonding was applied and the fragmentrepositioned with a coat of flow composite. A LEDlamp was used to polymerize the resin and abrasivediscs mounted on a micro-motor were used to polishthe restoration (Fig. 13).

During the intervention no anaesthetic was usedand the patient confirmed the absence of pain anddiscomfort. The tooth was checked monthly for sixmonths and vitality tests were found to be positive.

Case 4

An eighteen-year-old patient came to one of ourclinics after experiencing a trauma on the face. Dur-ing the clinical observation, damage to the right lat-eral permanent upper incisor was noticed. The whole

32 I laser4_2012

Fig. 13 Fig. 14

Fig. 15a Fig. 15b Fig. 16

industry report I

I 33laser4_2012

coronal portion of the tooth, while still in position,fractured vertically and in the frontal plane, and pulptissue was exposed. It was decided to use the Er:YAGlaser (Fidelis Plus III, Fotona, Slovenia) in two differentways: without air/water spray (VLP mode, 120 mJ, 15 Hz) to re-contour the gingival margin withoutbleeding (Fig. 14) and for pulp capping and withair/water spray (SSP mode, 200 mJ, 10 Hz) tiplesshandpiece to prepare the hard dental tissues in orderto provide stronger adhesion (Fig. 15). After the laserpreparation, a full-etching was performed with or-thophosphoric acid and the attachment of the frag-ment was made with bonding and flow compositeresin (Fig. 16). The intervention was conducted with-out using anaesthetics, and the compliance of the pa-tient was good since he did not experience pain or dis-comfort. The tooth was checked monthly for sixmonths and vitality tests were found to be positive.

_Conclusion

Er:YAG lasers may be used in conservative den-tistry as an alternative to conventional instrumentsand in association with orthophosphoric acid, withseveral advantages, such as better bond strength22

and reduced microleakage23, as well as lower discom-fort and higher patient satisfaction.24 The availabilityof different Er:YAG pulse durations and a comple-

mentary Nd:YAG laser in the same device make in-terventions easier and faster.

This clinical study, even if considered as prelimi-nary due to the limited number of samples, confirmsthat Er:YAG lasers can also be employed in dentaltraumatology to restore frontal teeth after coronalfractures, with the advantages of better cooperationfrom patients (in particular when young), reducedpain, sensitivity and discomfort during the restora-tion process, and better final results from an aestheticpoint of view._

Carlo Fornaini

MD DMD MSc

Via Varini, 10 29017 Fiorenzuola d'Arda, PC

Italy

Tel.: +39 0523 982667

Fax: +39 0523 242109

info@fornainident.it

www.fornainident.it

_contact laser

Please contact Claudia Jahn

c.jahn@oemus-media.de

AD

[PIC

TUR

E: ©

SU

KIY

AKI]

I industry report

Fig. 1_Bernhard Gottlieb University

Clinic of Dentistry, Medical University

of Vienna, Austria

_Introduction

In times of increased awareness of aesthetics, highquality ceramic restorations in dentistry are in greatdemand. Furthermore, demands for alternative dentalpreparation techniques like laser preparation whichaffords non-contacting and vibration-free working,increased. Therefore, laser research and laser applica-tion became more and more important in dentistry.However, constantly new developments and this con-centrated flow of information can occasionally be aproblem for the attending dentist, because it is hardlypossible in clinical everyday live to review all new prod-ucts and information that are given by manufacturers.The purpose of the present work is therefore to provideinformation about the stability of the adhesive com-pound between human dentin and ceramic using dif-ferent laser and conventional preparation tools.

Erbium-based lasers are approved devices for cav-ity preparation in dentistry.1-4 Er:YAG laser andEr,Cr:YSGG laser, hard tissue laser with a wavelengthof 2,940 nm and 2,780 nm, respectively, offer a high

surface effect with only a low depth effect on teeth.Due to the large proportion of water in carious tissue,caries will be removed particularly well. An auxiliarybactericidal effect exists. Furthermore the pulpal in-crease in temperature is not higher than 2,5°C throughan efficient water cooling system.5-8 According to astudy by Zach et al., temperature increases of less than6,1°C are considered to be inoffensive for the dentalpulp.9 All of those elements and other factors like pa-tient-friendly treatment by a vibration-free and con-tactless preparation technique make Erbium-basedlasers the ideal alternative to conventional prepara-tion techniques.1 Some researchers even suggest thatadditional acid etching before the adhesive ceramicfixation may not be necessary because of micro rough-ness, which is achieved by laser treatment.6,10,11 In con-trast, studies by Bahillo et al.,12 Lee et al.13 and oth-ers14,15 advice additionally acid etching after lasertreatment. Hence, there are still doubts about howlaser-treated dentin can bond to adhesive systems. Forthis reason, we investigated both laser preparationwith and without phosphoric acid etching.

As ceramic samples, Cerec®-blocks (VITABLOCSMark II®), conventional feldspar ceramic were used.We used these CEREC®-blocs because the industrialsintering process under vacuum at 1,170 °C, which canbe reproduced at any time, ensures a more homoge-nous microstructure with consistent material qualitycompared to laboratory sintered and lab-processedceramic restorations. We were thus able to minimizeinterference factors from the ceramic that otherwisemay influence our study results.16 As adhesive mate-rial for gluing the dentin discs on the ceramic blockswe used Variolink® II plus Syntac® (Ivoclar Vivadent,

Laser versus bur and dentinal bonding Authors_Dr Barbara Cvikl, Dr Alexander Franz, Dr Christoph Kurzmann & Dr Andreas Moritz, Austria

34 I laser4_2012

Fig. 1

Schaan/Liechtenstein), a classic etch and rinse adhe-sive system which acts very often as a gold standard.

_Materials and Methods

Extracted third molars were cleaned and stored inphysiological saline solution. Using a precision saw,cusps were removed and teeth were cut into uniformdentine discs of a thickness of 1 mm. After removal ofenamel, dentine discs were randomly divided into fivesubgroups representing five different preparationtechniques: (i) diamond bur and acid etching; (ii)Er:YAG laser (LiteTouchTM, Syneron), 2,940 nm, 4W, 20 Hz; tip of 0,8 mm; (ii) Er:YAG laser and additionalacid etching; (iv) Er,Cr:YSGG laser (Waterlase MDTM, Biolase), 2,780 nm, 2 W, 30 Hz with a conical tip of 600 µm (MC 6 Saphir); (v) Er,Cr:YSGG laser and addi-tional acid etching. All laser irradiation settings wereexecuted at an angle of inclination of 30° and with afeed rate of 1 mm per minute.

After treatment, dentine discs were fixed on CEREC®ceramic blocks using the system Syntac®/ Variolink® II(Syntac® etch & rinse adhesive and Variolink® II, IvoclarVivadent, Schaan, Liechtenstein). The system Syn-tac®/Variolink® II was applied according to the manu-facturer’s instructions. In addition, the application ofhuman dentin discs on CEREC® ceramic blocks wasperformed following the manufacturer’s instructions.

Sample size of each of the five subgroups wasn=15, resulting in a total of 75 dentine discs and 75CEREC® ceramic blocks. All samples were subjected tothermocycling (10,000 cycles, 5 °–55° respectively) tosimulate artificial aging. After thermocycling, a sheartest was performed using the universal testing ma-chine Zwick (Zwick/Roell, Ulm, Germany) at acrosshead speed of 0.8 mm per minute. The bondstrength was registered in megapascals (MPa). Datawere analysed using ANOVA with Tukey’s post hoc testwith a significance level of =0.05.

_Results

The results of the shear bond strength tests showedthe highest values for the group of the Er:YAG laserwith and without additionally acid etching. The dia-mond bur and acid etching group as well as theEr,Cr:YSGG laser group with and without additionallyacid etching showed similar but slightly lower values(Fig. 1 and Tab. 1). Overall, there was a trend towardsstronger bonding with the Er:YAG-laser treated dentinwith additionally acid etching; however, no statisti-cally significant differences were exposed when com-paring the five preparation methods (p=0.169). Thesefindings suggest that laser irradiation providesfavourable conditions for bonding between dentinand ceramics.

_Discussion

The results of this study suggest that a laser-treated dentin surface provides favourable conditionsfor bonding. Our findings that laser treatment can pro-vide coequal adhesive conditions to the diamond bur

industry report I

Fig. 2_LiteTouch™ Laser-in-the-

Handpiece™: The laser energy is

swiftly delivered to the tissue,

providing supreme cutting power

and precise incisions for hard tissue

and bone.

Fig. 3_Class V – Cavity Preparation

using LiteTouch™.

(Courtesy of Dr Avi Reyhanian)

I 35laser4_2012

Fig. 2

Fig. 3

I industry report

Fig. 4_Comparison of the five

preparation techniques with regard

to the bonding strength.

Table 1_ Means and standard

deviations of shear bond strength

tests (MPa)

are not supported by the majority of similar studies. Incomparable studies using human dentin laser treat-ment resulted in equivalent17 or even lower18–20 bondstrength to ceramic or composite. However, thesestudies differed in other experimental aspects (e.g., thelaser setting, angle of irradiation, storage conditionsfor the tooth samples, and the source and preparationof tooth discs).

An explanation for the advantageous results in thelaser group could be that we used a standardisedprocess of laser treatment with a constant feed rateand irradiation angle of 30 degrees to the dentin sur-face. We already obtained promising results with thissetting in preliminary tests. We suggest that the su-perficial part of the laser-irradiated surface is not af-fected and there are no micro fractures as described instudies with other laser settings.14, 21, 22

In this study we show that Er:YAG-laser treateddentin discs with and without additional acid etchingrevealed slightly higher mean values than Er,Cr:YSGGlaser or bur-treated dentin discs. However, no statisti-cally significant differences were exposed when com-paring the different preparation methods. Differencesbetween the results of this study and other studies,which seemed to be comparable at first sight, can bebased on a small number of divergences in the studydesign. A very important factor is the quality and na-ture of the used adhesive materials and of the dentindiscs.

While we used caries-free and mature third molarsfor the preparation of the dentin discs, other studiesapplied retained molars, teeth other than molars orenamel surfaces to compare laser preparation withconventional preparation techniques.23-25 Further-

more, the thickness and especially the size of thedentin discs are of crucial importance, because thebond strength is significantly influenced by the size ofthe discs.26 Another important factor of the achievedbond strength is the storage medium in which the ex-tracted molars have been stored pending further pro-cessing. While we used physiological saline solution toimitate the natural situation as well as possible, otherstudies applied distilled water, 0,5 % chloroform solu-tion and other storage solutions.27,28

Our findings have to be interpreted with care be-cause in vitro settings only partially reflect the in vivo

performance. Further studies are necessary to under-stand if these in vitro findings translate into clinicalpractice. Moreover, the in vitro system may not neces-sarily represent the in vivo conditions, in which thetemperature and humidity are closer to the physiolog-ical situation than in our room temperature setting.Other experimental conditions, such as bonding in aclimatic chamber and simulation of mastication cyclesor long-term storage, can change the bondingstrength. Future studies need to consider these phys-iological situations. There is still room for maximisingthe bonding strength of dentin to ceramics by im-proving the laser protocols for the preparation of den-tal cavities.

_Conclusion

Taken together, our findings show that dentin sur-faces prepared with the Erbium laser can provide afavourable dentin surface for binding ceramics, par-ticularly when using Variolink®II/Syntac® as the adhe-sive system. Overall, Erbium laser can be an attractivealternative to the conventional preparation techniqueusing a diamond bur._

36 I laser4_2012

Dr Barbara Cvikl

Division of Conservative Dentistry; BGZMK, MedicalUniversity of ViennaVienna, Austria

barbara.cvikl@meduniwien.ac.at

_contact laser

Fig. 3

Diamond bur

+

Acid etching

Er:YAG

laser

Er:YAG

laser

+

Acid etching

Er,Cr:YSGG

laser

Er,Cr:YSGG

laser

+

Acid etching

Variolink®IISyntac®

6.84+/-3.38

6.89+/-2.7

8.11+/-3.18

6.11+/-1.65

5.85+/-1.67

TribuneCME_A3_2012.pdf 1TribuneCME_A3_2012.pdf 1 30.08.12 12:0030.08.12 12:00

I manufacturer _ news

38 I laser4_2012

With the new photodynamic active ingredient PerioGreen, elexxion AG based in Radolfzell, Germany, isbringing colour into laser-assisted periodontal andperi-implantitis treatment.The new class IIa medicaldevice, which is based onthe clinically proven PDTdye indocyanine green andreacts specifically to thelight frequency of elexxionlasers, provides highly ef-fective and painless adju-vant treatment of periodontitisand peri-implantitis – with no risk to hard dental andsoft tissue and without causing discolouration orsystemic effects.

If the active ingredient is irradiated by a diode laserwith a wavelength of 810 nm, active oxygen is re-leased. This singlet oxygen changes the micro-or-ganisms so that they are no longer able tometabolise and are killed. The treatment is virtually

painless for patients because it causes no thermalor mechanical effects; anaesthesia is usually un-

necessary.

The actual Perio Green treat-ment, which can be repeatedany time in recall appoint-ments, takes about an hour. Ifthe method is used during aprofessional oral hygiene ses-sion, the time is reduced to only

about 30 minutes. Furthermore,as this type of laser-assisted therapy is non-inva-sive, it can be delegated to a suitably trained dentalnurse.

elexxion AG

Schützenstraße 84

78315 Radolfzell, Germany

info@elexxion.com

www.periogreen.com/en

elexxion

Antimicrobial periodontal and peri-implantitistreatment

Informing themselves about the latest develop-ments and methods in laser applications and takingpart in the respective trainings is mandatory for alllaser users. Therefore, Biolase has been supportingWCLI (World Clinical Laser Institute) for many years,thus operating in laser education on an internationalscale. In order to be able to offer certified high-levelcourses worldwide, Biolase has also recently starteda new cooperation with AALZ (Aachen Dental LaserCenter) in Aachen, Germany, presided by Prof Nor-bert Gutknecht. In addition, train-the-trainer semi-nars will be held for international training practices.For the first time, a workshop will be conductedwhich combines periodontology and aesthetic sur-gery/dermatology. Every laser user can gain furtherqualification in a certification course starting Janu-ary 2013. Moreover, the release of the new 10-Wattsdiode laser Epic is eagerly awaited by laser users. A

good price-performanceratio, its appeal-ing design and easyhandling have already led to such a high demand thatit has become hard keep pace with on the productionside, resulting in delivery delays. Now, finally, themodern diode-laser system Epic with 25 years of Biolase experience in development is made avail-able worldwide. German-speaking users can pre-order Epic under www.biolase-germany.de.

Biolase Europe GmbH

Paintweg 10

92685 Floss, Germany

info@biolase-europe.com

www.biolase.de

Biolase

Laser training and new diodelaser

Henry Schein, Inc. (NASDAQ: HSIC), the world'slargest provider of health care products and serv-ices to office-based dental, medical and animalhealth practitioners, is helping more than 2,400children in 21 U.S. and Canadian cities return to theclassroom well-dressed and well-prepared as partof the Company's 15th annual "Back to School" pro-gram. Each year Henry Schein's "Back to School"program is eagerly anticipated by the children whoparticipate, the human service organisations thatserve them, and the Team Schein Members whosponsor the children. The Program, which startedmodestly in 1998 by helping 150 children from LongIsland, has now sponsored more than 18,000 chil-dren in need from communities across North Amer-ica, providing the children with new school outfitsand backpacks filled with school supplies.

"It is the smiles of the children that we remember longafter the event is over, and we hope that they take thatsame happiness and enthusiasm into the class-room," said Gerry Benjamin, Executive Vice Presidentand Chief Administrative Officer for Henry Schein.

Henry Schein Dental

Deutschland GmbH

Monzastraße 2a

63225 Langen, Germany

info@henryschein.de

www.henryschein-dental.de

Henry Schein

15th Annual HenrySchein “Back toSchool” Program

[PICTURE: ©YURYIMAGING]

Manufacturer News

manufacturer _ news I

I 39laser4_2012

Fotona has seen increasing demand for its work-shops on aesthetic facial skin treatments usingthe company’s new LightWalker AT dental laser.The comprehensive workshops cover a widerange of aesthetic skin treatments that can beperformed with the award-winning LightWalkerlaser, without the need to invest in any additionalequipment other than an aesthetic handpiece.Some of the aesthetics & dermatology applica-tions that LightWalker is approved for include:treatments for wrinkles, scars, skin tags, acne,pigmented & vascular lesions, warts, and more.

LightWalker AT dental lasers feature the samecore technologies that are built into Fotona’sworld-class line of aesthetic & surgical laserssystems. As a highly mobile and multi-functionaltreatment platform, the LightWalker AT uniquelyappeals to a growing number of practices thatshare clinical space and other resources, sinceswitching between applications with Light-Walker is effectively as simple as switchinghandpieces. With the right training (and wherepermitted by local practice regulations) dental

professionals can now utilise their state-of-the-art LightWalker AT laser system for a whole newrange of treatment possibilities.

Fotona d.d.

Stegne 7

1000 Ljubljana, Slovenia

www.fotona.com

www.lightwalkerlaser.com

Fotona

Facial Aesthetic Treatments with LightWalker®

Syneron Dental Lasers, provider of innovative den-tal laser technologies and SCDistribution Laser inFrance have signed a distribution agreement.SCDistribution will market, sell and provide after-sales services to all LiteTouch™ users in France.

According to the national order of the French den-tal surgeons, France has over 40,000 dentists fora population of 60 million. However, the number ofpractitioners per 100,000 can vary quite signifi-cantly from 139 to 381. Dental lasers such as Lite-Touch™ can be easily integrated and enable den-tists to treat more patients in those areas wherethe ratio of professionals per population is muchlower.

Mr. Cédric Bouchereau, CEO of SCDistributionLaser commented, “I am delighted that SCDistrib-ution has been chosen as the exclusive distributorof LiteTouch in France; following years of experi-ence we had with other hard and soft tissue lasers,we witnessed the advantages of Er:YAG technol-ogy (wavelength 2,940 nm)”.

Syneron Dental Lasers

Tavor Building, Industrial Zone

20692 Yokneam Illit, Israel

dental@syneron.com

1http://www.ordre-chirurgiens-dentistes.fr/actu-a l i t es /annee-en-cours /ac tua l i t es .h tm l?tx_ttnews%5Bpointer%5D=3&tx_ttnews%5Btt_news%5D=251&tx_ttnews%5BbackPid%5D=53&cHash=c4f34de4cf

Syneron Dental Lasers

Distribution Partner-ship in France

To mark its 90th anniversary, Komet treats itselfand its customers to a brand new Corporate De-sign. Introduced on 1 September 2012, ourfresh and dynamic new CorporateDesign captures the spirit ofmodern times while stillrepresenting the tradi-tional Komet values ofquality, innovationand tradition.

Our new logo is im-pressive: The distinc-tive Komet lettering isnow placed above theKomet spiral. These twosymbols—standing for dynamicsand innovative power—will ensure globalbrand recognition with our 100,000 customersworld-wide. The eye-catching new design willsuccessively appear on all printed matters, ourwebsite and at trade fairs. Frank Janßen, our Headof Marketing, says: “We created a dynamic, up-to-date Corporate Design that reflects what we stand

for: A reputable company with a professional ap-proach.”

When asked how the company will be ad-dressed in future, Mr. Janßen stated:

“The brand name Komet will bepredominantly used in all our

communication, but we willcontinue to operate as Gebr.Brasseler GmbH & Co. KG.”

There’s nothing left for us toadd, other than, “Happy Birth-

day, Komet, and congratula-tions on your great new design!”.

Komet Dental

Gebr. Brasseler GmbH &Co KG

Trophagener Weg 25

32657 Lemgo, Germany

info@kometdental.de

www.kometdental.de

Komet Dental

All-round quality

[PICTURE: ©EDHAR]

I education

_The award acknowledged the dentists’ dedica-tion in fighting drug abuse in the greater New Yorkarea by supporting the office of Dr Bernard Fialkoffand the Fialkoff Dental Study Club’s free drug edu-cation program for New York City children. Theaward was given as part of a presentation to the 65attending dentists, encouraging all to get involvedin community activities such as this communityservice program and the “Healthy Mouths, HealthyLives” oral health care program for youth.

The event took place at the educational group’smonthly meeting at Laterna Restaurant in Bayside,Queens. Fialkoff, a Queens periodontist and dentalimplant specialist, founded the club in the mid ’90sand originated using the Foundation for a DrugFree World’s drug education program for New YorkCity children by providing free presentations toschools and after-school programs throughoutNew York.

Since February, his office has conducted morethan 80 free drug education events in the city’s fiveboroughs, including at schools such as JH 190, Drey-fus Intermediate School 11 and PS/IS 217, and suchafter-school programs as YMCAs, Bronx Works, Po-lice Athletic Leagues and numerous others.

The study club has an audience of 60 to 100 den-tists each month. It focuses on raising dental excel-lence, standards and camaraderie in the New Yorkboroughs. The club will continue its monthly meet-ings with a presentation in November by Dr StevenM. Katz and in December by Dr Harold Edelman, whowill be instructing on the New York State MandatoryInfection Control Course._

Source: Fialkoff Dental Study Club

Community board honorsdentists for supportingdrug education in schoolsAuthor_Dental Tribune America

40 I laser4_2012

International events

meetings I

I 41laser4_2012

2012Dental Hygiene Research Meeting

Pisa, Italy

14–15 December 2012

www.tueor.it

2013

UAE International Dental Conference &

Arab Dental Exhibition

Dubai, UAE

5–7 February 2013

www.aeedc.com

ALD Academy of Laser Dentistry Annual

Meeting – The 20th Conference and

Exhibition

Palm Springs, CA, USA

7–9 February 2013

www.laserdentistry.org

Pacific Dental Conference

Vancouver, CAN

7–9 March 2013

www.pdconfc.com

28th Annual Meeting of the

Academy of Osseointegration

Tampa, USA

7–9 March, 2013

www.osseo.org

35th IDS International Dental Show

Cologne, Germany

12–16 March 2013

www.ids-cologne.de

46th Scandefa

Copenhagen, DK

11–13 April 2013

www.scandefa.dk

4th Congress of the European Division—

WFLD

Brussels, Belgium

11–12 July 2013

www.wfldbrussels2013.com

I meetings

_Organisers of the Greater New York Dental

Meeting have announced that they would like tothank everyone for their thoughts and concerns dur-ing this difficult time in New York and New Jersey. “Wehave been receiving numerous calls, emails and faxesand would like to inform the world that we are open,”the organisers said in a statement. The meeting will beheld Friday through Wednesday, Nov. 23 to 28.

“The Javits Convention Center and all the hotelsare open, the roads and airports are now operatingand our registration numbers in all categories areahead of last year,” the organisers said. “We look for-ward to seeing you in a few weeks and welcomingeveryone to the largest and greatest educational andsales event dentistry has ever seen.”

Registration is open for the meeting, which is thelargest dental congress and health-care meeting inthe United States, with 53,789 attendees from all 50states and 127 countries in 2011. A significantly ex-panded international program accommodated 6,656international visitors in 2011, with sessions in French,Spanish, Portuguese, Italian and Russian.

The high-energy event, which never has a pre-reg-istration fee, draws top dental professionals with an

expansive exhibit hall and more than 300 educationalcourses, including full-day and half-day seminars, es-says, hands-on workshops and a live, 430-seat, high-tech patient demonstration area.

New York City is full of cultural enclaves that giveattendees the opportunity to experience foods, festi-vals, arts and more from all over the globe. Few citiesoffer a wider variety of iconic attractions, historicbuildings and cultural sites.

Three major international airports, Newark Liberty(EWR), Kennedy (JFK) and La Guardia (LGA) and dis-counted hotel rates for registrants, make it easy forany dental professional to visit New York City and at-tend the meeting.

The GNYDM staff encourages you to see all NewYork City has to offer during one of its most beautifultimes of year._

New York City is openfor businessAuthor_Dental Tribune America

42 I laser4_2012

[PICTURE: ©BLINKBLINK]

[PICTURE: ©ONLY FABRIZIO]

meetings I

I 43laser4_2012

_This autumn,more than 20,000 visitors and over300 exhibitors celebrated the 40th anniversary of theannual International Expodental. The event took placein the new exhibition halls at Fiera Milano City in Mi-lan and showcased the latest technologies for den-tists and dental technicians.

According to Gianfranco Berrutti, the President ofthe Italian Dental Industries Association, host of theexhibition held from 18 to 20 October, the event ex-ceeded his organisation’s expectations.

In his closing speech, he highlighted the 40th an-niversary as noteworthy for the numbers it had at-tracted: 323 companies exhibited in the 20,000 m²pavilion and an estimated 21,000 participants at-tended the three-day event. He mentioned that bothexhibitors and visitors appreciated particularly thenew exhibition spaces and the service provided byFiera Milano City.

In addition, more than 3,000 visitors joined thevarious cultural events organised in the scope of thefifth Expodental Forum held alongside the exhibition.At the forum, renowned academics and dental pro-fessionals lectured on various scientific topics relatedto dentistry.

Furthermore, Berrutti said that the event haddemonstrated that after 40 years the show is still amajor attraction for the entire dental industry. “Forthree days, our industry has forgotten about the eco-nomic crisis and has been able to look forward to thetechnologies that will shape the dental industry in theupcoming years,” he said.

The next International Expodental will take placein Milan from 17 to 19 October 2013. The sixth Expo-dental Forum will be organised alongside the eventand will focus on dental aesthetics, Berrutti said._

Milan sees 40th anniversaryof International ExpodentalAuthor_Dental Tribune International

I interview

“I believe that the future is already here”

44 I laser4_2012

_laser: Mr Prigat, how does the new LiteTouch

model differ from its predecessor?

The new CE-marked LiteTouch model was un-veiled at the World Federation of Laser Dentistry In-ternational Congress in Barcelona in mid April 2012,where Syneron Dental Lasers participated as a GoldSponsor. We showcased Laser-in-the-Handpieceinnovative technology and clinical applications ofLiteTouch in various fields, including endodontics,periodontics, pediatric dentistry and implantology.

The new LiteTouch model was especially de-signed to meet high regulatory standards and fea-tures an adjustable screen and an angled socket ex-tension to improve the ergonomic positioning of thelaser applicator, which is slightly thicker than that ofthe previous model, but is able to provide our userswith improved ergonomic and wider clinical capa-

bilities. Additional elements and accessories in thenew model were added based on the feedback pro-vided by users for enhanced device manoeuvrabilityand portability.

Users will also notice that the new LiteTouchmodel comes in a variety of new and existing colouroptions.

_Some of the previous models were found to not

fully comply with European regulatory standards.

Please elaborate how you have overcome this issue

over the past several months?

We at Syneron Dental Lasers believe in keepinghigh standards of safety, efficacy and service forLiteTouch and take much pride in the feedback wereceive from our world-wide users, enthusiastic re-searchers and speakers. As with other similar casesin the dental industry or other industries, companiescan experience deviations. Earlier this year, SyneronDental Lasers conducted a test which concludedthat some LiteTouch systems currently on the EUmarket were not fully compliant with the Electro-magnetic Compatibility (EMC) part of the Annex l ofthe Medical Devices Directive.

Our foremost concern was to ensure the safety ofthe machine to both users and patients and to pro-vide our users with an adequate solution, so theycould continue to benefit from their LiteTouch sys-tem. This is why we instantly commissioned an in-

At the latest congress of the World Federation forlasers Dentistry in Barcelona, laser specialist com-pany Syneron Dental Lasers introduced its newLiteTouch model of dental lasers for hard & soft tis-sue treatments. Laser magazine spoke with thecompany's President & CEO, Mr Ira Prigat, about thebenefits of the new model and future prospects oflaser technology in dentistry.

[BACKGROUND: ©CIFOTART]

interview I

dependent third-party expert analysis of the situa-tion. The results were that there was no risk what-soever to either users or patients. No safety or effi-cacy feature of our device was affected by the EMCissue. We then immediately put together a team ofinternational experts in order to provide our stake-holders with quick and reliable solutions covering allaspects, working hand-in-hand with the local au-thorities in each country. Last, but not least, we de-veloped a new model that not only solved the prob-lem but also provided our users with a new and im-proved alternative.

After putting in place all these necessary activi-ties to address this issue, Syneron Dental Lasers re-ceived reinstatement of the CE certification for itsnew LiteTouch model from its notifying Europeanbody, MDC. For complete user satisfaction and, to-gether with its parent company, Syneron MedicalLtd., the company decided to go beyond just repair-ing the existing equipment, and offer our users thenew LiteTouch model.

_How have the market and users responded?

Thanks to the special working relations and closesynergy with our world-wide partners we were ableto address the situation quickly and at the same time

receive support for all the actions that were taken.Our partners appreciated our transparent and re-sponsible approach as well as the seriousness withwhich Syneron Dental Lasers handled the matter.They continue to express their appreciation throughtheir unequivocal commitment to the Syneron Den-tal Lasers Family. Moreover, we managed to bring onboard new distributors in Europe and recently an-nounced the appointment of a new distributor inGermany, the well-known and respected LH MedicalGmbH, and a veteran distributor of cutting edgemedical, dental and aesthetic products. We spend alot of time and effort in selecting our distributorsbecause they are the ones who are most in contactwith our users and we can say that we are quite for-tunate to be able to work with very strong, ethicaland highly reputable partners such as LH MedicalGmbH in all of the other countries where we are cur-rently selling our products.

The reaction and feedback we are receiving fromLiteTouch owners who have already started to workwith the new model are excellent. Our users ac-knowledge that the look & feel of the machine issimilar and they are happy with the new featuresthat were incorporated into this new model. Thenew and modern design is slightly bigger, however,

AD

our users who operate at more than one locationcontinue to enjoy the portability of LiteTouch andcarry their unit from one clinic to another across dif-ferent locations.

_How can the new LiteTouch help dentists today?

In the category of hard and soft tissue lasers,LiteTouch is the world's first versatile and only non-fiber Erbium:YAG dental laser. Our system allowsdentists to focus on their performance of the clini-cal treatment and on their patients, ratherthan be constantly concerned aboutcausing damage to the laser fibre. Thus,dentists can quickly and easily integrateLiteTouch into their daily routines andenjoy the complete expression of theirdental mastery.

The new Laser-in-the-Hand-piece technology imitates the per-formance of the turbine drill whileintegrating all the advantages of alaser. The energy of the Erbium:YAGlaser is rapidly and massively ab-sorbed by the water in the tissues,offering thereby great cuttingpower and precise incisions ofboth hard tissue and bone.Thanks to LiteTouch, dentistscan obtain improved clinical re-sults and can gain lots of time.Their patients benefit from an over-all improved experience and re-duced healing time. Moreover, thecompact and friendly shape of Lite-Touch naturally fits into any dental of-fice without intimidating the patients.

Elsewhere, extensive research conducted over aperiod of three years by leading professors from Eu-rope and Asia concluded that LiteTouch owners en-joy an over 27 per cent increase in their annual rev-enue shortly after their initial training course. Inaddition to the technological advantages of Lite-Touch, these financial results are contributing tothe constant increase in sales per territory.

_What are the prospects of laser technology in

general?

It is clear that the dental industry has started ad-vocating lasers, as an increasing number of schol-ars have been involved in research activities thatprove the efficacy of lasers in a wide range of den-tal procedures. Furthermore, a growing number ofuniversities have already adopted special laser ed-ucation programs in their curriculums, thus send-ing a clear message that lasers are the future. Moresolid proof of this has recently emerged as we learned

that the organisers of the most influential event indentistry, the bi-annual International Dental Show,will be featuring dental laser technology as its majortheme during its next meeting in 2013.

I believe that the future is already here. More andmore researchers and scholars are becoming enthu-siastic about laser technology, because of its provenphysical and clinical advantages. Until recently, themain market entry barrier was the lack of knowledge

and the exiguous research in this field. Wehave largely contributed to help over-

come these shortcomings and areexpecting the market to remain

quite dynamic. By feeding backthe clinical information

gained from doctors to dis-tributors, following various

educational programmes, we canpursue the technological devel-opment that addresses the clini-cal needs of dentists, in particu-lar with regard to shorter healingtime and greater benefits for pa-tients, enjoy an overall improvedexperience each time they gosee a dentist.

I can tell you that it is excit-ing to take a central role in thelaser revolution and to see myvision brought to life. We areat the dawn of a new era in

dentistry thanks to lasers.Syneron Dental Lasers is committed to paving theway for greater access to this technology. Our Er-bium:YAG LiteTouch laser has opened the doors tonew dental treatment possibilities, significant timeand cost savings for a large majority of everydayprocedures for which patient comfort is signifi-cantly enhanced. Our mission now is to share thisknowledge around the world so that dentists mayfully enjoy the free expression of their mastery whilemore and more patients experience better dentistrywith laser treatments and finally eliminate theirfears of going to see the dentist._

I interview

46 I laser4_2012

Syneron Dental Lasers

Tavor Building, Industrial Zone

20692 Yokneam Illit, Israel

Tel.: +97 2 732442600

Fax: +97 2 732442610

dental@syneron.com

_contact laser

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

efforts to this year’s issues.

Issue 1/2012

| Dr Iris Brader, Germany| Dr Merita Bardhoshi, Albania| Patricia Bargiela-Perez, Germany| Antonio Batista-Cruzado, Spain| Dr Ute Botzenhart, Germany| Dr Andreas Braun, Germany| Dr Antoni España, Spain| Prof Matthias Frentzen, Germany| Prof Dr Norbert Gutknecht, Germany| Jose-Luis Gutierrez-Perez, Spain| Martin Jorgen, Spain| Dr G. Karakitsos, Greece| Dr J. Karakitsos-Kurz, Greece| Dajana Klöckner, Germany| Prof Frank Liebaug, Germany| Blanca Moreno-Manteca, Spain| Dr Gabriele Schindler-Hultzsch, Germany| Dr Kresimir Simunovic, Switzerland| Daniel Torres-Legares, Spain| Monica Tuzza, Switzerland| Prof Dr Gerd Volland, Germany| Dr Ning Wu, China

Issue 2/2012

| Dr Georg Bach, Germany| Patricia Bargiela-Perez, Spain| Antonio Batista-Cruzado, Spain| Dr Ute Botzenhart, Germany| Dr Andreas Braun, Germany| Dr Selma Christina Cury Camargo, Brazil| Prof Matthias Frentzen, Germany| Jose-Luis Gutierrez-Perez, Spain| Martin Jorgen, Spain| Dr Zafer Kazak, Turkey| Dr Kenneth Luk, China| Dr Ilay Maden, Turkey| Blanca Moreno-Manteca, Spain| Friedrich Müller, Germany| Dr Maximilian Schmidt-Breitung, Germany| Dr Ryan S.K. Seto, China| Daniel Torres-Legares, Spain| Prof Dr Aslihan Usumez, Turkey| Leon Vanweersch, Germany| Prof Dr Gerd Volland, Germany| Dr Anna-Maria Yiannikou-Loucaidou, Germany

Issue 3/2012

| Dr Ute Botzenhart, Germany| Dr Andreas Braun, Germany| Javier de Pison, Spain| Dr George Freedman, Canada| Prof Matthias Frentzen, Germany| Dr Fay Goldstep, Canada| Prof Dr Norbert Gutknecht, Germany| Prof Tzi Kang Peng, Taiwan| Hans-Joachim Koort, Germany| Samah S. Mehani, Egypt| Evgeniy Mironov, Bulgaria| Zhasmina Mironova, Bulgaria| Dr Darius Moghtader, Germany| Ali M. Saafan, Egypt| Prof Georgi Tomov, Bulgaria| Nermin M. Yussif, Egypt

Issue 4/2012

| Dr Georg Bach, Germany| Prof Dr Stefano Benedicenti, USA | Prof Rolando Crippa, USA| Dr Barbara Cvikl, Austria| Dr Enrico DiVito, USA| Dr Carlo Fornaini, Italy| Dr Alexander Franz, Austria| Dr Rene Franzen, Germany| Dr George Freedman, Canada| Dr Fay Goldstep, Canada| Prof Dr Giuseppe Iaria, USA| Prof Dr Vasilios Kaitsas, USA| Dr Christoph Kurzmann, Austria| Dr Darius Moghtader, Germany| Dr Andreas Moritz, Austria| Prof Dr Giovanni Olivi, USA| Dr Vrinda Rattan, India

Please contact Claudia Jahn

c.jahn@oemus-media.de

48 I laser4_2012

NEWS

Scientists have found that different types of smilingpositively affect an individual's ability to recover fromepisodes of stress. They investigated whether manip-ulation of facial expressions would influence cardio-vascular and affective responses to stress and foundthat study participants who were instructed to smilehad lower heart-rate levels after recovery from stress-ful activities than participants who adopted neutral fa-cial expressions, even if participants were not aware oftheir smile.

The study was conducted by researchers at the Uni-versity of Kansas with 170 healthy participants be-tween 18 and 25 (66 per cent female and 44 per centmale. Throughout the experiment, the researchersmeasured heart rate and self-reported stress level andfound that the smiling groups showed lower heart-ratelevels during recovery from the tasks, compared withparticipants in the neutral group. In order to determinewhether benefits are also present when awareness offacial expression is absent, half of the group membersin each smiling group were not explicitly told to smilebut also held the chopsticks in a manner that forcedthem to. The researchers observed that they too re-ported positive effects compared with those with neu-tral expressions although they were not aware of theirsmiles.

“These findings show that smiling during brief stres-sors can help to reduce the intensity of the body's stressresponse, regardless of whether the person actuallyfeels happy,” the researchers concluded. The study willbe published in the forthcoming issue of the Psycho-logical Science journal.

Smiling may

Reduce stress andhelp heart health

In recent years, researchers have noted a significantincrease in contact allergies to rubber additives amonghealth care professionals. Although the cause of thiscannot be stated with certainty, experts believe that

nitrile gloves, which are most commonly used in den-tal care today, have contributed significantly.

According to Michiel Paping, director of Budev, a Dutchresearch and development company focused on nat-ural rubber latex allergens, type I allergic reactions,which are immediate reactions to allergens in a prod-uct, are very rare nowadays owing to improved qualitystandards and production processes. Type IV reac-tions, however, are delayed reactions to the chemi-

cals used in the production process and are morecommon and can arise in response to nitrile or vinyl.

“In fact, I think that synthetic rubbers cause more con-tact allergies than natural rubber latex,” he told DentalTribune Netherlands.

Alongside the growing number of contact allergies inrecent years that are likely caused by added chemicalsor antimicrobial agents, Paping and his team have ob-served an increase in allergic reactions in daily prac-tice. “Recently, we have seen that the professionalbody is becoming alarmed. Despite this, I am con-cerned that the average dentist is not aware of thismatter,” he said.

Source: DTI

Contact allergies owing to gloves

A growing problem in dentistry

New research from the US strengthens the suggestionthat there is a mechanism linking the oral bacteriathat cause periodontal disease and pancreaticcancer. Scientists have found that people withhigh levels of antibodies to pathogenic bacteriafound in the oral cavity have a twofold higher riskof developing pancreatic cancer. However,high levels of another but harmless oralbacterium may indicate a reduced risk ofdeveloping the disease.

For the study, researchers from BrownUniversity measured antibodies to 25pathogenic and commensal oral bac-teria in blood samples from 405 pa-tients with pancreatic cancer and 416controls and found that participantsexhibiting high levels of antibodiesagainst Porphyromonas gingivalis, a bac-

terium that is implicated in some forms of periodontaldisease, were twice as likely to develop pancreatic

cancer than participants with lower levels in theirblood.

In addition, the researchers explored the associa-tion of pancreatic cancer with nonpatho-

genic oral bacteria and found that partic-ipants with overall higher levels of anti-bodies had a 45 per cent lower risk ofpancreatic cancer than participants withoverall lower levels of these antibodies.They thus speculate that this may indi-cate an innate highly active immune re-sponse that is protective against can-cer.

The study was published online on Sept.18 in the Gut journal ahead of print.

Periodontitis might increase

Pancreatic cancer risk

[PICTURE: ©SERRNOVIK]

[PICTURE: ©SEBASTIAN KAULITZKI]

[PICTURE: ©KARAMYSH]

I 49laser4_2012

Treatment costs for oral and dental conditions acrossEurope often exceed those of other major diseases, in-cluding cancer, heart disease, stroke, and dementia,according to a pan-European study released in Sep-tember 2012. The State of Oral Health in Europe Reportestimates current spending in dental treatment in theEU 27 to be close to € 79 billion per year, a figure set toreach € 93 billion by the year 2020 if adequate actionis not taken now. The report reveals that oral health-re-lated costs are still on the rise despite the fact thatcaries and their complications are highly preventablethrough a healthy, balanced diet and routine oral hy-giene practices.

The study was commissioned by the Platform for Bet-ter Oral Health in Europe, a forum that brings togetherEuropean organisations that work towards the promo-tion of oral health and the prevention of oral diseases inEurope. The report analysed data from 12 Europeancountries (Austria, Cyprus, Denmark, France, Ger-many, Ireland, Italy, Lithuania, Poland, Romania, Spain

and the United Kingdom). The report showsthat–despite significant achievementsin the prevention of cavities in Europe –much remains to be done in areas such as:promoting oral health awareness, tackling oral healthinequalities and addressing common risk factors. Fur-ther indispensable tools in the fight for better oralhealth in Europe include the development of high qual-ity, comparable oral health data and better cost-effec-tiveness studies to assess the impact of prevention ini-tiatives.

On the basis of the report findings, the Platform has developed a series of recommendations and calls onpolicymakers.

Presenting the results of the study at the first EuropeanOral Health Summit, held 5 September, 2012, at the Eu-ropean Parliament in Brussels, Member of the Euro-pean Parliament Ms. Karin Kadenbach said, “In a timeof austerity measures and growing pressure on health-

care budgets, this reportis a timely reminder that we

have to tackle the persisting dispari-ties in oral health across and within

EU countries, with regards to socioeconomicstatus, age, gender, or indeed general health status.”

Speaking at the Summit, Professor Kenneth Eaton,Chairman of the Platform for Better Oral Health in Eu-rope, called for more policy attention and action on thetopic of oral health. “At the EU level, there is currently alack of understanding about the integral role oral healthplays in overall health and well-being,” he said. “On be-half of the Platform for Better Oral Health in Europe, I hope and believe we finally have the adequate toolsand procedures in place to work effectively togetherand foster policy decisions which will benefit the oralhealth of everyone in Europe in the years to come.”

Source: www.oralhealthplatform.eu

New study reveals

Oral health’s growing price tag for Europe

More and more surgical procedures are being per-formed globally every year, driving the demand fornew and improved surgical equipment, states anew report by healthcare experts GBI Research.The new report Surgical Equipment Market to 2018—Increased Access to Ambulatory Surgical Cen-ters to Drive Outpatient Surgery Volumes showsthat this increase in surgical procedures is due toimproving healthcare infrastructure in emergingcountries, increasing cases of lifestyle diseasesand technological innovations boosting the possi-ble workload of surgeons.

According to the Centre for Disease Control (CDC),approximately 48 million surgical procedures areperformed in the US each year, while emergingcountries such as India and China hold huge futurepotential for surgery due to increased healthcareexpenditure and huge patient populations. Thespread of westernised living standards has led to aworldwide increase in diseases such as obesity,lung cancer, cardiovascular diseases and kidneydisorders, expanding the patient population eligi-ble for surgery.

Accessibility, affordability and patient comfort arealso driving up the demand for outpatient proce-dures. Outpatient surgery is found to be more cost-effective than inpatient surgeries, as they eliminatehospitalization costs, minimize the time spent inthe operating theatre, and cut costs for staffing andtravel. The increasing volume of surgical proce-dures being carried out is resulting in a growing de-mand for surgical equipment such as surgical su-tures, electrosurgical devices and hand instru-ments. The global market for surgical equipment istherefore forecast to exceed $7 billion by 2018, fol-lowing growth at a Compound Annual Growth Rate(CAGR) of 4.2% during 2011–2018.

Minimally Invasive Surgery

Boosts Outpatient Procedures

[PICTURE: ©VALERIY VELIKOV]

[PICTURE: ©ALMAGAMI]

After researching a number of current studies on theprocedure, scientists have found that tooth scalingdoes not offer any proven medical benefits to patients.The investigators of IGeL-Monitor, a website launchedearlier this year to monitor individual health services(i.e. those paid for privately) within the German healthsystem, evaluated current scientific studies of adultswithout periodontitis with regard to the medical bene-fits of tooth scaling. They said that they found no sig-nificant evidence that professional tooth scaling af-fects oral health positively, as study participants whohad undergone tooth scaling in addition to their dailydental care and regular check-ups did not have an im-proved oral health status. Moreover, possible damagecaused by the procedure was only inadequately cov-ered by the studies, they said.

Benefits of tooth scaling

Questioned by German organisation

[PICTURE: ©NOBEASTSOFIERCE]

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