Presentation: A Guided Tour to Lasers in the CDM Practice

See the remarkable ability of the CO2 1401 laser used to vaporize unwanted tissue

See an actual CO2 laser decontamination visit

CO2 Laser Slide Presentations including before & after Treatment
Introduction to CO2 Lasers
Laser Perio and soft tissue treatment
Laser Oral Surgery
Laser Implantology

Diamond Age Systems offers the most gentle laser for effective non-contact and bloodless cutting, vaporization and coagulation of soft tissue. It provides power and performance in a compact design, is easily transported from room to room and is clinically versatile. This device can perform all of the essential periodontal treatment functions plus other valuable dental applications including decontamination, tissue debridement and tissue regeneration, sterile soft tissue surgery; it can be used to vaporize tooth decay, create sterilized cavities, pulp capping, coagulate blood vessels and facilitate endodontic procedures. Using advanced laser treatment along with an ultrasonic scaling and root planing the following can be accomplished with minimal anesthesia and minimal post-op discomfort:

Using advanced laser treatment along with an ultrasonic scaling and root planing the following can be accomplished with minimal anesthesia and minimal post-op discomfort:

• Decontamination
• Debridement
• Biostimulation
• Tissue Regeneration

• Elimination of diseased sulcular epithelium
• Minimize intrasulcular pathogens
• Halt apical migration of epithelial attachment
• Minimize pocket depth
• Encourage healing and growth of healthy tissue

• The Dual Purpose (hard tissue and soft tissue) lasers- Erb:YAG, Erb:YSSG and ND:YAG- price range $50,000 +
• The CO2 Laser (Soft Tissue only)-price range $40,000+
• The Diode Laser (soft tissue only)- $7,000-$24,000

• Longest Wavelength 10.6 micrometers= Least Tissue Penetration- .03-.1 mm
• Negligible sub-surface tissue damage
• Good Hemostasis
• Fastest, cleanest cut for surgical operations
• Minimal Post Op. Morbidity
• True Tissue Regeneration & re-attachment- vaporizes organic material & endo toxin
• Most Sanitary- nothing touches the patient/ Autoclavable handpieces

The Dual Purpose (hard tissue and soft tissue) lasers- Erb:YAG, Erb:YSSG & ND:YAG
Since dentistry focuses primarily on teeth, the dual purpose lasers have been marketed heavily to relieve the fear factor in dentistry - "No Drill, no going back to work with a numb mouth". While this has worked for some dentists, the busy ones find that the hard tissue cutting action of the laser is much slower than their high speed hand piece, and therefore they resort to using the high speed, at least as an adjunct in most cases. Hence they lose the no drill-no anesthetic advantage.

While the Erb:YSSG Waterlase can perform soft tissue operations, the cutting action is much slower and more ragged than the CO2 and thus the CO2 offers better performance for periodontal treatment.

Secondly, the danger of the dual purpose laser is that it can attack the hard tissue during a soft tissue operation.

The most authoritative paper describing this phenomenon is : : PRACTICAL SCIENCE Lasers in dentistry " Separating science from hype" JADA Feb. 2004
DOUGLAS N. DEDERICH, B.S.E.E., D.D.S., M.Sc., Ph.D.; RONALD D. BUSHICK, D.M.D., Ph.D., M.S.

"Laser energy penetration". The wavelength of the light is the primary determinant of the degree to which the light is absorbed in the target material (in our case, oral tissue).Depending on the tissue, some lasers penetrate deeper than others. By contrast, other laser wavelengths are limited to a shallow penetration and have a surface effect on tissue. The deeper the laser energy penetrates, the more it is scattered and distributed throughout the tissue. The degree to which this occurs also is affected by the power of the laser and exposure duration, but wavelength is the primary factor.

The depth of penetration that is characteristic of a wavelength is a critical feature that can influence its utility for any particular application. For example, the CO2 laser penetrates only about 0.03 to 0.1 millimeters into tissue. This provides just enough depth to seal blood vessels, lymph vessels and nerve endings measuring up to 0.5 mm in diameter. The clinical result of this penetration is good hemostasis and minimal postoperative morbidity. By comparison, the Nd:YAG laser penetrates 2 to 5 mm into tissue. While this deeper exposure may be desirable for hemostasis in more vascular tissue such as the liver or kidney, it has caused concern about the risk of collateral damage in oral sites where bone and other hard tissue are within the range of energy."

In addition, the diminished localization of the energy on the tissue’s surface makes vaporization of soft tissue with an Nd:YAG laser slower than with the better-absorbed laser wavelengths, such as those produced by the CO2 laser. Tissue vaporization can require a lag time until the activation point occurs (that is, the point at which the tissue begins to vaporize). To enhance the surface absorption of the energy (and shorten this lag time), some have recommended the topical application of photo absorbing black dyes to the tissue. (The Nd:YAG seeks pigment..ed)

Another source of references is the AAP Lasers on Periodontics Position Paper http://www.perio.org/resources-products/pdf/37-lasers.pdf

This paper had several comments on adherence of fibroblasts which is of course a key element in periodontal treatment. Some of their conclusions:

"The application of the Nd:YAG laser to root surfaces results in alterations to root surface protein to mineral ratio , affects the ability of fibroblasts to attach in vitro…(51-55,58)"

"..no publication has shown attachment of human gingival fibroblasts to a root surface previously treated by the Erb:YAG laser."

And regarding the diode laser:

" ..the presence of root surface damage following laser assisted subgingival curettage has been reported (61,103)"

Diode lasers are clearly a less expensive category and have been used for Perio and Bleaching. The main limitation compared to the CO2 is that all energy is focused to a point at the end of a fiber optic chord which causes localized heating. The energy is characterized by heat rather than pure photon energy giving more adjacent morbity and thus is not as effective at de-epithelization or surgery.

It is important to avoid hard tissue contact with the Diode Laser as it may damage tooth cementum and bone during subgingival curettage.
Additionally it is currently not possible to sterize the fiber or the sheath covering it. The fiber must contact the patient, the fibers can break off in the sulcus.


The variables involved in CO2 Lasers are:
Tube Type: Metal or Glass. The metal tube is to be preferred because it offers a more precisely focused beam and has a life of 20,000 hours compared to the glass tube's 5,000 hours. It can accomplish the same tasks with lower wattage and is much less subject to damage.
Delivery System: Hollow Wave Guide or Reflective. The original CO2 lasers in dentistry employed a hollow wave guide for convenience. However this compromised focus and recent systems have used a reflective system. A comparison of the available CO2 lasers follows:

Brand	Tube Type	Power	Delivery System	Autoclavable
CTL	Metal	12W	Reflective	Yes
Opus/Luxar	Metal	20W	Hollow Wave Guide	No
Deka	Glass	25W	Reflective	No

Thus the CTL is the only product available with both a metal tube and reflective delivery, which users report gives a superior focused beam with little or no charring even in cw mode.. It is also the only one with autoclavable hand pieces. A recent development by Diamond Age is their innovative "Perfect Diffusion 100" perio hand piece which provides a diffused output to the pocket for Perio and endodontic procedures with a more predictable output, less independent of arm position than previously possible.

Perhaps the most important research finding demonstrating the effectiveness of the CO2 laser in tissue regeneration:

Fibroblast attachment on laser treated root surfaces

Effects of CO2 Laser Treatment on Fibroblast Attachment to Root Surfaces. A Scanning Electron Microscopy Analysis / Crespi, R / Barone, A / Covani, U / Ciaglia, R N / Romanos, G E 1308-1312 Journal of Periodontology 2002; 73 (4)

The group of specimens treated by laser and scaling showed the highest number of fibroblastic cells and a prevalence of well attached fibroblasts higher than control group and scaling/root planing group. The SEM observation didn't show any damages such as cracks and fissures of root surfaces treated by laser and scaling. These findings could suggest that CO2 laser treatment could be considered as an adjunctive tool to detoxify and to condition the root surfaces in periodontal treatment.

It should be noted that in contrast the application of the Nd:YAG laser to root surfaces results in alterations in root surface protein to mineral ratio which affects the ability of the fibroblasts to attach in vitro.

Laser de-epithelialization for enhanced guided tissue regeneration. A paradigm shift?

Dent Clin North Am 2000 Oct;44(4):793-809 (ISSN: 0011-8532)
Rossmann JA; Israel M Department of Periodontics, Baylor College of Dentistry, Texas A&M University System Health Science Center at Dallas, USA. jrossman@ont.com.

The rationale for laser de-epithelialization stems from the attempts to block the down-growth of epithelium into the healing periodontal wound after surgery and prevent formation of a long junctional epithelial attachment. This concept has seen numerous techniques for accomplishing the blockage of epithelium. The advent of GTR was an offshoot of this concept and led Gottlow et al [table: see text] to examine the effects of selectively blocking certain cell types from contacting the root surface during periodontal wound healing. The use of a CO2 laser to de-epithelialize the gingival flaps is an attempt to exclude this cell type from the healing wound and has been used with and without the benefit of GTR membranes. In a study on beagle dogs, the histologic results of using membranes and the laser procedure enhanced the wound healing and regeneration of new bone, cementum, and connective tissue attachment when compared with paired defects using the membranes alone. The results from the human studies and case reports combined with the animal studies indicate a positive benefit in wound healing because of the laser de-epithelialization technique.

Advantages of a pulsed CO2 laser in direct pulp capping: a long-term in vivo study.

Lasers Surg Med 1998;22(5):288-93 (ISSN: 0196-8092)Moritz A; Schoop U; Goharkhay K; Sperr W Department of Conservative Dentistry, School of Dentistry, University of Vienna, Austria.

BACKGROUND AND OBJECTIVE:
A previous study [Moritz et al., Z Stomatol 1996; 93:451-454] had shown that favourable results in direct pulp capping could be achieved using a continuous wave CO2 laser in addition to the conventional calcium hydroxide dressing technique. In this study, these results are compared to those achieved using a CO2 laser working in superpulsed mode.

STUDY DESIGN/MATERIALS AND METHODS:
A total of 260 direct pulp capping procedures were carried out; 130 were performed with a superpulsed CO2 laser, followed by a calcium hydroxide dressing, and 130 conventionally by applying only a calcium hydroxide preparation. Recall examinations were performed after 1 week and monthly for 18 months after treatment. A final examination was carried out 2 years after treatment. Thermal tests were used for vitality assessments and laser Doppler flowmetry for direct measurement of pulpal blood flow.

RESULTS:
In the group of pulps treated with the superpulsed CO2 laser, the last recall examination at 2 years revealed that 93% of the teeth had remained vital. In the control group, the success rate was considerably lower (66.6%). Exposure site sizes and average patient age were nearly identical in both groups.

CONCLUSION:
The CO2 laser seems to be a valuable aid in direct pulp capping; the efficiency of laser treatment can be increased by using a pulsed CO2 laser.