laser kedokteran gigi

146 Australian Dental Journal 2003;48:3.

The current status of laser applications in dentistry

LJ Walsh*

AbstractA range of lasers is now available for use indentistry. This paper summarizes key current andemerging applications for lasers in clinical practice.A major diagnostic application of low power lasersis the detection of caries, using fluorescence elicitedfrom hydroxyapatite or from bacterial by-products.Laser fluorescence is an effective method fordetecting and quantifying incipient occlusal andcervical carious lesions, and with further refinementcould be used in the same manner for proximallesions. Photoactivated dye techniques have beendeveloped which use low power lasers to elicit aphotochemical reaction. Photoactivated dyetechniques can be used to disinfect root canals,periodontal pockets, cavity preparations and sites ofperi-implantitis. Using similar principles, morepowerful lasers can be used for photodynamictherapy in the treatment of malignancies of the oralmucosa. Laser-driven photochemical reactions canalso be used for tooth whitening. In combinationwith fluoride, laser irradiation can improve theresistance of tooth structure to demineralization,and this application is of particular benefit forsusceptible sites in high caries risk patients. Lasertechnology for caries removal, cavity preparationand soft tissue surgery is at a high state ofrefinement, having had several decades ofdevelopment up to the present time. Used inconjunction with or as a replacement for traditionalmethods, it is expected that specific lasertechnologies will become an essential component ofcontemporary dental practice over the next decade.

Key words: Lasers, dental applications, dbridement,photosensitization, resin curing.

(Accepted for publication 6 February 2003.)

of the usefulness of lasers in the armamentarium of themodern dental practice, where they can be used as anadjunct or alternative to traditional approaches.

Traditionally, lasers have been classified according tothe physical construction of the laser (e.g., gas, liquid,solid state, or semiconductor diode), the type ofmedium which undergoes lasing (e.g., Erbium: YttriumAluminium Garnet (Er:YAG)) (Table 1), and the degreeof hazard to the skin or eyes following inadvertentexposure (Table 2). Lasers have been availablecommercially for use in dental practice in Australiasince 1990, and the currently available systemsrepresent a high state of technical refinement in termsof both performance and user features.

The purpose of this paper is to provide an overviewof various laser applications which have beendeveloped for dental practice, and to discuss in moredetail several key clinical applications which areattracting a high level of interest.

Diagnostic laser applicationsLow power laser energy has found numerous uses in

diagnosis, both in clinical settings (Table 3) and indental research (Table 4). By way of background, lowpower lasers operate typically at powers of 100milliwatts or less, and may produce energy in the visiblespectrum (400-700nm wavelength), or in the ultraviolet(200-400nm), or near infrared regions (700-1500nm).At the present time, there are few purpose built lowpower lasers for the middle infrared (1500-4000nm) orfar infrared regions (4000-15000nm). Rather, lasersoperating in the middle and far-infrared regions areused in health care primarily for hard and soft tissueprocedures.

Laser fluorescence systems for detection of dentalcaries have been particularly popular in Australia. Theoriginal technique employed visible blue light from theargon laser, relying on the lack of fluorescence fromcarious enamel and dentine to demonstrate thepresence of the lesion. Subsequent development of thetechnique allowed visible red laser light from asemiconductor diode laser to be used to elicitfluorescence from bacterial deposits, and from calculus.Combining a detection system with a therapeutic laserhas allowed automated removal of subgingival calculus

INTRODUCTION

The past decade has seen a veritable explosion ofresearch into the clinical applications of lasers in dentalpractice, and the parallel emergence of organizations tosupport laser dentistry with an international focus.Once regarded as a complex technology with limiteduses in clinical dentistry, there is a growing awareness

*Professor of Dental Science, School of Dentistry, The University ofQueensland.

Australian Dental Journal 2003;48:(3):146-155R E V I E W

from teeth and dental implants, a point discussed infurther detail below.

For detection of dental caries in pits and fissures,laser fluorescence offers greater sensitivity thanconventional visual and tactile methods.1,2 Thetechnique is also well suited to smooth surface lesionson cervical surfaces of teeth,3,4 and to recognition ofcaries beneath clear fissure sealants.5 Detection ofproximal lesions is technically more difficult, and inthis setting, argon laser-induced fluorescence offers avaluable adjunct to conventional methods.6-9 Thedifferential water content of early fissure caries andsound occlusal enamel has also led to the developmentof methods using the carbon dioxide laser to revealsuch lesions,10-12 and to modify the fissure system toincrease resistance to future carious attack.11

Two key advantages of laser-based systems are theirhigh sensitivity, and the lack of attendant risks ofionizing radiation. This has allowed their frequent usefor monitoring lesions of dental caries and dentalerosion.13-16 Extension of the principles of laserfluorescence from the visible to the near infrared andterahertz portions of spectrum opens the possibility formore detailed analysis of the internal composition ofthe tooth.17 Moreover, the use of dyes in conjunctionwith laser fluorescence holds promise for using themethod for delineating cavitated from non-cavitatedlesions in sites of poor clinical access, such asapproximal surfaces.18,19

Bacterial porphyrins in dental calculus give a strongfluorescence signal,20 which can be used to controllasers used for scaling. The same principle could beapplied to lesions of dental caries, where a targetinglaser could induce fluorescence and provide feedback to

the user as to the presence of residual bacteria (i.e., thepresence of infected carious dentine), and could alsocontrol the action of a pulsed laser to achieveautomated caries removal. There are already data onthe spectral changes which occur during infrared lasertreatment of enamel and dentine21,22 which couldsimilarly be applied clinically when assessing thepresence or absence of carious tooth structure duringlaser-based cavity preparation.

Photoactivated dye disinfection using lasersLow power laser energy in itself is not particularly

lethal to bacteria, but is useful for photochemicalactivation of oxygen-releasing dyes. Singlet oxygenreleased from the dyes causes membrane and DNAdamage to micro-organisms. The photoactivated dye(PAD) technique can be undertaken with a range ofvisible red and near infrared lasers, and systems usinglow power (100 milliwatt) visible red semiconductordiode lasers and tolonium chloride (toluidine blue) dyeare now available commercially (Fig 1). The initialwork which demonstrated the PAD technique usedhelium-neon lasers.23 However, such units have beensurpassed with high efficiency diode lasers whichoperate at the same wavelength.

The PAD technique has been shown to be effectivefor killing bacteria in complex biofilms, such assubgingival plaque, which are typically resistant to theaction of antimicrobial agents.24-26 It can be usedeffectively in carious lesions, since visible red lighttransmits well across dentine,27 and can be madespecies-specific by tagging the dye with monoclonal

147Australian Dental Journal 2003;48:3.

Table 1. Common laser types used in dentistryLaser type Construction Wavelength(s) Delivery system(s)

Argon Gas laser 488, 515nm Optical fibreKTP Solid state 532nm Optical fibreHelium-neon Gas laser 633nm Optical fibreDiode Semiconductor 635, 670, 810, Optical fibre

830, 980nmNd:YAG Solid state 1064nm Optical fibreEr,Cr:YSGG Solid state 2780nm Optical fibreEr:YAG Solid state 2940nm Optical fibre,

waveguide, articulated arm

CO2 Gas laser 9600, 10600nm Waveguide,articulated arm

Table 2. Laser classification according to potentialhazardsClass Risk Example

I Fully enclosed system Nd:YAG laser welding systemused in a dental laboratory

II Visible low power laser Visible red aiming beam of aprotected by the blink reflex surgical laser

IIIa Visible laser above No dental examples1 milliwatt

IIIb Higher power laser unit Low power (50 milliwatt)(up to 0.5 watts) which diode laser used formay or may not be visible. biostimulationDirect viewing hazardousto the eyes

IV Damage to eyes and skin All lasers used for oral surgery,possible. Direct or indirect whitening, and cavityviewing hazardous to preparationthe eyes

Table 3. Diagnostic laser applications for clinical practiceArgon Helium-neon Diode Diode CO2488nm 633nm 633nm 655nm 10600nm

Laser fluorescence detection of dental caries Laser fluorescence detection of subgingival calculus Detection of fissure caries lesions by optical changes Laser doppler flowmetry to assess pulpal blood flow Scanning of phosphor plate digital radiographs Scanning of conventional radiographs for teleradiology


antibodies.28 Photoactivated dye can be appliedeffectively for killing Gram-positive bacteria (includingMRSA), Gram-negative bacteria, fungi and viruses.29,30

Major clinical applications of PAD includedisinfection of root canals, periodontal pockets, deepcarious lesions, and sites of peri-implantitis.31,32 In suchlocations, PAD does not give rise to deleterious thermaleffects,33 and adjacent tissues are not subjected tobystander thermal injury. Photoactivated dye treatmentdoes not cause sensitization and killing of adjacenthuman cells such as fibroblasts and keratinocytes.34

Neither the dye nor the reactive oxygen speciesproduced from it are toxic to the patient. Toloniumchloride is used in high concentrations for screeningpatients for malignancies of the oral mucosa andoropharynx,35,36 and does not exert toxic effects at thelow concentrations used in the PAD technique.Moreover, residual reactive oxygen species are rapidlydealt with by the enzyme catalase, which is present inall tissues and in the peripheral circulation,37 and bylactoperoxidase, which is a normal component ofsaliva.

Photodynamic therapyA more powerful laser-initiated photochemical

reaction is photodynamic therapy (PDT), which hasbeen employed in the treatment of malignancies of theoral mucosa, particularly multi-focal squamous cellcarcinoma. As in PAD, laser-activation of a sensitizingdye in PDT generates reactive oxygen species. These in

turn directly damage cells and the associated bloodvascular network, triggering both necrosis andapoptosis.38

Of interest, while direct effects of PDT destroy thebulk of tumour cells, there is accumulating evidencethat PDT activates the host immune response, andpromotes anti-tumour immunity through the activationof macrophages and T lymphocytes.37 For example,there is direct experimental evidence for photodynamicactivation of the production of tumour necrosis factor-alpha,39 a key cytokine in host anti-tumour immuneresponses.

Clinical studies have reported positive results forPDT treatment of carcinoma-in-situ and squamous cellcarcinoma in the oral cavity, with response ratesapproximating 90 per cent.40,41 The treated sitescharacteristically show erythema and oedema, followedby necrosis and frank ulceration. The ulcerated lesionstypically take up to eight weeks to heal fully, andsupportive analgesia is required in the first few weeks.Other than short-term photosensitivity, the treatment istolerated well.39

Other photochemical laser effectsThe argon laser produces high intensity visible blue

light (488nm) which is able to initiate photo-polymerization of light-cured dental restorativematerials which use camphoroquinone as thephotoinitiator.42-44 The temperature increase at the levelof the dental pulp is much less with argon laser curingthan when conventional quartz tungsten halogen lampunits are used.45,46 Argon laser radiation is also able toalter the surface chemistry of both enamel and rootsurface dentine,47,48 which reduces the probability ofrecurrent caries. This clinical benefit is arguably moreimportant than the reduced curing time and improveddepth of cure achieved with the argon laser.

A further photochemical effect produced by highintensity green laser light is photochemical bleaching(Table 5). This effect relies upon specific absorption ofa narrow spectral range of green light (510-540nm)into chelate compounds formed between apatites,

Table 4. Diagnostic laser applications used as research toolsNd:YAG Er:YAG Argon Helium-neon Diode1064nm 2940nm 488 and 515nm 633nm 633 and 670nm

Raman spectroscopic analysis of tooth structure Terahertz imaging of internal tooth structure Breakdown spectroscopic analysis of tooth structure Confocal microscopic imaging of soft and hard tissues Flow cytometric analysis of cells and cell sorting Profiling of tooth surfaces and dental restorations

Fig 1. Laser system for photo-activated dye therapy, which uses adiode laser (635nm) and tolonium chloride dye (SaveDent, Asclepion

Meditec, Fife, UK).

Table 5. Laser-enhanced tooth whiteningArgon KTP Diode CO2515nm 532nm 810-980nm 10600nm

Photochemical bleaching Photothermal bleaching

porphyrins, and tetracycline compounds.49 The argonlaser (515nm) and potassium titanyl phosphate (KTP)

laser (532nm) can both be used for photochemicalbleaching, since their wavelengths approximate theabsorption maxima of these chelate compounds (525-530nm).50 Argon and KTP lasers can achieve a positiveresult in cases which are completely unresponsive toconventional photothermal power bleaching (Fig 2).

Laser applications in the dental laboratoryThere is a range of laboratory-based laser

applications (Table 6). Laser holographic imaging is awell established method for storing topographicinformation, such as crown preparations, occlusaltables, and facial forms. The use of two laser beamsallows more complex surface detail to be mapped usinginterferometry,51,52 while conventional diffractiongratings and interference patterns are used to generateholograms and contour profiles.53-56

Laser scanning of casts can be linked tocomputerized milling equipment for fabrication ofrestorations from porcelain and other materials. Analternative fabrication strategy is to sinter ceramicmaterials, to create a solid restoration from a powderof alumina or hydroxyapatite.57 The same approach canbe used to form complex shapes from dental wax andother materials which can be sintered, such that thesecan then be used in conventional lost wax casting. Avariation on this theme is ultraviolet (helium-cadmium)laser-initiated polymerization of liquid resin in achamber, to create surgical templates for implantsurgery and major reconstructive oral surgery. Thesetemplates can be coupled with laser-based positioningsystems for complex reconstructive and orthognathicsurgical procedures.

Laser procedures on dental hard tissuesCavity preparation using lasers has been an area of

major research interest since lasers were initiallydeveloped in the early 1960s. At the present time,several laser types with similar wavelengths in themiddle infrared region of the electromagnetic spectrumare used commonly for cavity preparation and cariesremoval. The Er:YAG, Er:YSGG and Er,Cr:YSGG lasersoperate at wavelengths of 2940, 2790, and 2780nm,respectively. These wavelengths correspond to the peakabsorption range of water in the infrared spectrum (Fig 3), although the absorption of the Er:YAG laser(13,000cm-1) is much higher than that of the Er:YSGG(7000cm-1) and Er,Cr:YSGG (4000cm-1)58-60 Since allthree lasers rely on water-based absorption for cuttingenamel and dentine, the efficiency of ablation(measured in terms of volume and mass loss of toothstructure for identical energy parameters) is greatest forthe Er:YAG laser.58,60

These laser systems can be used for effective cariesremoval and cavity preparation without significantthermal effects, collateral damage to tooth structure, orpatient discomfort.61-64 Normal dental enamel containssufficient water (approximately 12 per cent by volume)that a water mist spray coupled to an Er-based laser

Australian Dental Journal 2003;48:3. 149

Fig 2. KTP laser photochemical bleaching. A. Initial clinicalappearance of the dentition in a 9-year-old patient with intensediscolouration of the incisor teeth caused by prolonged childhoodillnesses and associated medications. B. The situation immediatelyafter three 60-minute appointments of power bleaching using aconventional quartz tungsten halogen curing lamp and 35 per centhydrogen peroxide gel. The incisal enamel shade has improvedsomewhat, but the areas of discolouration at the gingival third areunchanged. The arrow indicates a residue of the protective gingivaldam. C. Clinical appearance immediately after one session ofphotochemical bleaching using the KTP laser and proprietaryalkaline hydrogen peroxide (Smartbleach ) gel. The laser treatmentwas targeted to the gingival third. The patient and her parents werepleased with the immediate post-operative result and did not request

any additional treatment.


system can achieve effective ablation at temperatureswell below the melting and vapourization temperaturesof enamel.61 Er-based dental lasers can also be used toremove resin composite resin and glass-ionomer cementrestorations, and to etch tooth structure (Fig 4).

A characteristic operating feature of Er-based lasersystems is a popping sound when the laser is operatingon dental hard tissues. Both the pitch and resonance ofthis sound relate to the propagation of an acousticshock wave within the tooth, and vary according to thepresence or absence of caries. This feature assists theuser in determining that caries removal is complete.66 Incontrast to the popping sound during caries removal,one current generation Er,Cr:YSGG laser system createsa loud snapping sound even when not in contact withany structure in the mouth. This seeming paradox canbe explained by an effect termed plasma de-couplingof the beam, in which incident laser energy heats the airand water directly in front of the laser handpiece. In theEr,Cr:YSGG laser, this is done intentionally in order todeliver energy onto the rear surface of atomized watermolecules, with the aim of accelerating them to a higherspeed (so-called HydroKinetic cutting).67 Detailedstudies of the cutting mechanisms of Er:YAG andEr,Cr:YSGG lasers have revealed that the mechanismby which enamel is removed is basically the same forboth laser systems, namely explosive subsurfaceexpansion of interstitially trapped water.65 The sameinvestigations also failed to show Er,Cr:YSGG lasercutting of a variety of materials which were free ofwater, which the authors stated was contradictory tothe existence of the hydrokinetic phenomenon.65

An important theoretical extension to the principleof water-based laser ablation of tooth structure is therecently described effect of laser abrasion, in whichEr:YAG laser energy is used to accelerate the movementof particles of sapphire 30-50 micrometers in diameterin aqueous suspension. As in air abrasion, the impact ofthese particles causes brittle splitting, resulting in toothsubstance removal. In the laser abrasion method, highspeed photography has documented particle velocitiesin the range of 50-100 metres per second, which enablea rate of enamel removal higher than that of high speedturbines with a very low volume of abrasive particles.68

This technique could be employed with currentgeneration lasers once a suitable dispensing system forthe suspension of particles has been developed. As wellas the potential of even more rapid cutting rates thanconventional rotary instrumentation, laser abrasionoffers the promise of laser-based cutting of structureswhich are not otherwise amenable to this, such asceramic restorations.

Intensive research over the past three decades onother non-Erbium laser-based cavity preparationsystems has yet to be translated to direct clinicalapplication. To date, alternative laser systems,including super-pulsed CO2, Ho:YAG, Ho:YSGG,Nd:YAG, Nd:NLF, diode lasers and excimers, have notproven feasible for use for cavity preparation in generalpractice settings.

Other than caries removal, this is a range of otherwell established laser hard tissue procedures includedesensitization of cervical dentine (using Nd:YAG,Er:YAG, Er,Cr:YSGG CO2, KTP, and diode lasers),laser analgesia (using Nd:YAG, Er:YAG, andEr,Cr:YSGG lasers), laser-enhanced fluoride uptake(using Er:YAG, Er,Cr:YSGG, CO2, argon, and KTPlasers). Furthermore, there is a considerable range ofperiodontal procedures (Table 7), and endodonticprocedures (Table 8) which can be undertaken withlasers as an alternative to conventional approaches.

Soft tissue laser proceduresThere are numerous soft tissue procedures which can

be performed with lasers.69-71 Two key features of theseare reduced bleeding intra-operatively and less painpost-operatively compared to conventional techniquessuch as electrosurgery. The degree of absorption in keytissue components dictates the type of effect gained bythe laser on soft tissues, and in this regard the contentof water and haemoglobin in oral tissues is important

Table 6. Laser applications in the dental laboratoryHelium neon Diode Nd:YAG CO2 Helium-Cadmium

633nm 635nm 1064nm 10600nm 300nm

Scanning of models for orthodontics or holographic storage Scanning of crown preparations for CAD-CAM Welding of metals (Co:Cr, titanium) Sintering of ceramics CAD-sintering fabrication CAD-polymer fabrication of splints or surgical models Cutting of ceramics

Fig 3. The absorption curve of water in the middle infrared region.Data on the vertical axis are units of absorption, while the horizontalaxis shows wavelength in micrometers. The plot shows the positionof two laser wavelengths used for cavity preparation: Er,Cr:YSGG2.78 micrometers, and Er:YAG 2.94 micrometers. The figure is based

on data from reference 59.

Er,Cr:YSGG

Er:YAG

14000

12000

10000

8000

6000

4000

2000

02.6 2.65 2.7 2.75 2.8 2.85 2.9 2.95 3 3.05 3.1 3.15 3.2 3.25 3.3

for the efficient absorption of many commonly useddental lasers.72 Certain procedures in patients withbleeding disorders are better suited to lasers withgreater haemostatic capabilities (Table 9). Examples ofsimple soft tissue procedures are presented in Fig 5.

CONCLUSIONS

Laser technology for caries detection, resin curing,cavity preparation and soft tissue surgery is at a highstate of refinement, having had several decades ofdevelopment up to the present time. This is not to say

that further major improvements cannot occur. Indeed,as is in the case with laser abrasion, the fusion ofconcepts from differing technologies may open thedoor to novel techniques and treatments. The field oflaser-based photochemical reactions holds greatpromise for additional applications, particularly fortargeting specific cells, pathogens or molecules. Afurther area of future growth is expected to be thecombination of diagnostic and therapeutic lasertechniques in the one device, for example the detectionand removal of dental caries or dental calculus. For


Fig 4. Restorative procedures using the Er:YAG laser, in anxious dental patients, without local anesthesia. The Er:YAG laser was used with a non-contact handpiece. A. Pre-operative appearance of a 22-year-old male with salivary dysfunction, and associated cervical and approximalcaries. B. Areas of caries and defective resin composite have been removed. The intense white appearance of the margins is typical of laser etching.C. The restored teeth immediately post-operatively. The etched appearance of the margins disappears once bonding resin has been placed. D. 30-year-old female patient with areas of hypoplastic enamel. E. The enamel surface has been peeled using a series of pulses from the laser. F. The two areas have been restored with resin composite. G. 65-year-old female patient undergoing anti-cancer chemotherapy, with recurrentcaries at the margins of several restorations. H. Areas of caries and undermined resin composite have been removed. I. The cavity preparations

have been restored.


example, an autopilot system for subgingivaldebridement has been developed (for detailed review,see ref 73), and the potential exists to extend thisconcept further.

There is a large research effort internationallyfocused on developing new laser applications for dentalpractice, and each year several large meetings are heldwhich bring together this research. Examples includethe International Society for Lasers in Dentistry (ISLD),the European Society for Oral Laser Applications(ESOLA), and the Academy of Laser Dentistry (ALD).With the further development of laser dentistry as anarea of clinical pursuit, there will be considerableopportunity for clinicians to become involved in theseresearch meetings and in specific research projects. TheAustralasian region has played a substantial role in thedevelopment of hard tissue laser applications,74,75 andthis level of involvement is expected to continue in thefuture, as various research groups examine uses forlasers in conjunction with or as a replacement fortraditional methods.

There is little argument that over recent years the useof lasers in dentistry in Australia has moved beyond

academic centres and specialist units into themainstream of general practice. Looking to the future,it is expected that specific laser technologies willbecome an essential component of contemporary dentalpractice over the next decade.

ACKNOWLEDGMENTSI thank the dental practitioners who have referred

patients to the Laser Clinic over the past 12 years, andthe numerous staff and students who have contributedto the dental laser research programme at theUniversity of Queensland.

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Table 7. Periodontal laser proceduresEr:YAG Er,Cr:YSGG KTP Argon 488 Diode Nd:YAG Helium-neon Diode 635, CO22940nm 2780nm 532nm and 515nm 810-980nm 1064nm 633nm 670 or 830nm 10600nm

Calculus removal Periodontal pocket

disinfection Photoactivated dye

disinfection ofpockets

De-epithelialization toassist regeneration

Table 8. Endodontic laser proceduresCO2 Erbium:YAG Er,Cr:YSGG KTP Argon 488 Diode Nd:YAG Helium-neon Diode 635,

10600nm 2940nm 2780nm 532nm and 515nm 810-980nm 1064nm 633nm 670, or 830nm

Direct pulp capping Drying of the

root canal Removal of

smear layer Root canal

disinfection Photoactivated dye

disinfection of pockets

Table 9. Surgical laser applicationsEr:YAG 2940nm Er,Cr:YSGG CO2 KTP Diode Argon 488 Nd:YAG 1064nm

(least haemostasis) 2780nm 10600nm 532nm 810-980nm and 515nm (most haemostatis)

Minor softtissue surgery

Major softtissue surgery

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Bone cutting Implant exposure

with bone removal

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Fig 5. Soft tissue procedures using middle and far infrared lasers. A. Pre-operative clinical appearance of a 22-year-old female with marked gingivalovergrowth from nifedipine and cyclosporin. The patient has received a kidney transplant, is immuno-suppressed, and has a bleeding tendency. B. the immediate post-operative appearance following gingivoplasty with the carbon dioxide laser. Complete haemostasis is maintained during theprocedure. C. Initial clinical appearance of a 16-year-old female patient with marked gingival overgrowth, which has obscured the orthodonticbrackets and caused the cessation of fixed orthodontic treatment. D. Immediate post-operative view of quadrant 1 following gingival recontouringwith the carbon dioxide laser. E. Immediate post-operative view of quadrant 2 following recontouring with the Er:YAG laser in contact mode.Note the different appearance of the tissues compared to quadrant 1. Both segments were treated at the same appointment. F and G. Clinical

appearance of the two sites two weeks following surgery. The tissue contours are identical to those determined at the time of surgery.


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35. Epstein JB, Oakley C, Millner A, Emerton S, van der Meij E, LeN. The utility of toluidine blue application as a diagnostic aid inpatients previously treated for upper oropharyngeal carcinoma.Oral Surg Oral Med Oral Pathol Oral Radiol Endod1997;83:537-547.

36. Feaver GP, Morrison T, Humphris G. A study to determine theacceptability in patients and dentists of toluidine blue inscreening for oral cancer. Prim Dent Care 1999;6:45-50.

37. Walsh LJ. Safety issues relating to the use of hydrogen peroxidein dentistry. Aust Dent J 2000;45:257-269.

38. Dougherty TJ. An update on photodynamic therapy applications.J Clin Laser Med Surg 2002;20:3-7.

39. Vowels BR, Cassin M, Boufal MH, Walsh LJ, Rook AH.Extracorporeal photophoresis induces the production of tumornecrosis factor-alpha by monocytes: implications for thetreatment of cutaneous T-cell lymphoma and systemic sclerosis. JInvest Dermatol 1992;98:686-692.

40. Fan KFM, Hopper C, Speight PM, Buonaccorsi GA, Bown SG.Photodynamic therapy using mTHPC for malignant disease inthe oral cavity. Int J Cancer 1997;73:25-32.

41. Biel MA. Photodynamic therapy and the treatment of head andneck neoplasia. Laryngoscope 1998;108:1259-1268.

42. Tarle Z, Meniga A, Ristic M, Sutalo J, Pichler G. Polymerizationof composites using pulsed laser. Eur J Oral Sci 1995;103:394-398.

43. Bouschlicher MR, Vargas MA, Boyer DB. Effect of compositetype, light intensity, configuration factor and laserpolymerization on polymerization contraction forces. Am J Dent1997;10:88-96.

44. Fleming MG, Maillet WA. Photopolymerization of compositeresin using the argon laser. J Can Dent Assoc 1999;65:447-450.

45. Anic I, Pavelic B, Peric B, Matsumoto K. In vitro pulp chambertemperature rises associated with the argon laser polymerizationof composite resin. Lasers Surg Med 1996;19:438-444.

46. Cobb DS, Dederich DN, Gardner TV. In vitro temperaturechange at the dentin/pulpal interface by using conventionalvisible light versus argon laser. Lasers Surg Med 2000;26:386-397.

47. Hicks MJ, Flaitz CM, Westerman GH, Blankenau RJ, Powell GL,Berg JH. Caries-like lesion initiation and progression aroundlaser-cured sealants. Am J Dent 1993;6:176-180.

48. Westerman G, Hicks J, Flaitz C. Argon laser curing of fluoride-releasing pit and fissure sealant: in vitro caries development.ASDC J Dent Child 2000;67:385-390.

49. Lin LC, Pitts DL, Burgess LW. An investigation into the feasibilityof photobleaching tetracycline-stained teeth. J Endodont1988;14:293-299.

50. Davies AK, Cundall RB, Dandiker Y, Sifkin MA. Photo-oxidation of tetracycline adsorbed onto hydroxyapatite inrelation to the light-induced staining of teeth. J Dent Res1985;64:936-939.

51. Fogleman EA, Kelly MT, Grubbs WT. Laser interferometricmethod for measuring linear polymerization shrinkage in lightcured dental restoratives. Dent Mater 2002;18:324-330.

52. Rosin M, Splieth CH, Hessler M, Gartner CH, Kordass B,Kocher T. Quantification of gingival edema using a new 3-D laserscanning method. J Clin Periodontol 2002;29:240-246.

53. Wakabayashi K, Sohmura T, Takahashi J, et al. Development ofthe computerized dental cast form analyzing system threedimensional diagnosis of dental arch form and the investigationof measuring condition. Dent Mater J 1997;16:180-190.

54. Ayoub AF, Wray D, Moos KF, et al. Three-dimensional modelingfor modern diagnosis and planning in maxillofacial surgery. Int JAdult Orthodon Orthognath Surg 1996;11:225-233.

55. Motohashi N, Kuroda T. A 3D computer-aided design systemapplied to diagnosis and treatment planning in orthodontics andorthognathic surgery. Eur J Orthod 1999;21:263-274.

56. Ryden H, Bjelkhagen H, Soder PO. The use of laser beams formeasuring tooth mobility and tooth movements. J Periodontol1975;46:421-425.

57. Walsh LJ. Burgeoning technology: future directions in oralhealth. In: Dental Perspectives. An overview of clinical issuesfacing community dentistry. The Rowland Company: Issue 2,1998;6-8.

58. Stock K, Hibst R, Keller U. Comparison of Er:YAG andEr:YSGG laser ablation of dental hard tissues. SPIE2000;3192:88-95.

59. Weber MJ. Handbook of optical materials. Boca Taon, Florida:CRC Press, 2002;375-377.

60. Belikov AV, Erofeev AV, Shumilin VV, Tkachuk AM.Comparative study of the 3 micron laser action on different hardtissue samples using free running pulsed Er-doped YAG, YSGG,YAP and YLF lasers. SPIE 1993;2080:60-67.

61. Hibst R, Keller U. Experimental studies of the application of theEr:YAG laser on dental hard substances: I. Measurement of theablation rate. Lasers Surg Med 1989;9:338-344.

62. Hibst R, Keller U. Experimental studies of the application of theEr:YAG laser on dental hard substances: II. Light microscopicand SEM investigations. Lasers Surg Med 1989;9:345-351.

63. Walsh JT, Flotte TJ, Deutsch TF. Er:YAG laser ablation of tissue:effect of pulse duration and tissue type on thermal damage.Lasers Surg Med 1989;9:314-326.

64. Walsh JT, Deutsch TF. Er: YAG laser ablation of tissue:measurement of ablation rates. Lasers Surg Med 1989;9:327-337.

65. Freiberg RJ, Cozean C. Pulse erbium laser ablation of hard dentaltissue: the effects of atomised water spray vs water surface film.SPIE 2002;4610:74-84.

66. Clark J, Symons AL, Diklic S, Walsh LJ. Effectiveness ofdiagnosing residual caries with various methods during cavitypreparation using conventional methods, chemo-mechanicalcaries removal, and Er:YAG laser. Aust Dent J 2001;46(Suppl):S20.

67. Riziou I, Kimmel A. Atomized fluid particles forelectromagnetically induced cutting. US Patent 5,741,247. 1998.

68. Altschuler GB, Belikov AV, Sinelnik YA. A laser-abrasive methodfor the cutting of neamle and dentine. Lasers Surg Med2001;28:435-444.

69. Walsh LJ. Soft tissue management in periodontics using a carbondioxide surgical laser. Periodontol 1992;13:13-19.

70. Walsh LJ. The use of lasers in implantology: an overview. J OralImplantol 1992;18:335-340.

71. Walsh LJ. The clinical challenge of laser use in periodontics.Periodontol 1996;17:66-72.

72. Walsh LJ. Dental lasers: Some basic principles. Postgrad Dent1994;4:26-29.

73. Walsh LJ. Emerging applications for infrared lasers inimplantology. Periodontol 2002;23:8-15.

74. Cernavin I. Laser dentistry revolution of dental treatment in thenew millennium. ADA News Bulletin 2002;304:8-9.

75. Walsh LJ. Laser dentistry: 14 years of laboratory and clinicalresearch at The University of Queensland. ADAQ News2002;477:12-13.

Address for correspondence/reprints:Professor Laurence J Walsh

School of DentistryThe University of Queensland

200 Turbot StreetBrisbane, Queensland 4000

Email: [email protected]


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