laser international No. 2, 2013

Cover / Editorial / Content / Nd:YAGlasers in intraoral welding / Perfect soft tissue management in the oral use / Post-cure irradiation of pit and fissure sealant by diode laser Part II / Diode lasers for periodontal treatment / Industry report / Manufacturer news / Master of Science in Lasers in Dentistry: Professional education programme / Meetings / News / Imprint

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) ) [pdf_filetime] => 1729567111 [s3_key] => 60050-6e93a71a [pdf] => laser0213.pdf [pdf_location_url] => https://e.dental-tribune.com/tmp/dental-tribune-com/60050/laser0213.pdf [pdf_location_local] => /var/www/vhosts/e.dental-tribune.com/httpdocs/tmp/dental-tribune-com/60050/laser0213.pdf [should_regen_pages] => 1 [pdf_url] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/60050-6e93a71a/epaper.pdf [pages_text] => Array ( [1] =>

issn 2193-4665

Vol. 5 • Issue 2/2013

laser

international magazine of

laser dentistry

2

2013

| research
Nd:YAG lasers in intraoral welding

| overview
Diode lasers for periodontal treatment

| industry report
Er:YAG laser etching of hypoplastic enamel

[2] =>

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[3] =>

editorial

Summertime in
Brussels is
WFLD-ED laser time

I

Prof. Dr Norbert Gutknecht
Editor-in-Chief

Dear readers of laser international magazine of laser dentistry,
A very special event is rising on the laser horizon. Laser users, laser specialists and laser researchers from all over Europe are invited to participate in the 4th European Division Congress
of the World Federation for Lasers in Dentistry (WFLD).
Coincidently, Brussels is not only the capital of the European Union, but it will also be the
hosting city of the conference of the European Division (ED) of WFLD from July 11 to 12, 2013.
Although this event has been announced as a European conference, participants from other
parts of the world are expected as well.
Aside from the official WFLD ED Congress, the award ceremony of the European Master
Certificates (EMDOLA) will be celebrated during this congress.
I think that a lot of “stimulated emission” will therefore be found under the Atomium, one
of Brussels iconic landmarks, during this event.

On behalf of laser international magazine of laser dentistry, I wish the organising chairman Prof.
Nammour, his team, and all participants an exciting congress time in Brussels.
Yours sincerely,

Prof. Dr Norbert Gutknecht

laser
2
I 03
_ 2013

[4] =>

I content _ laser

page 22

34

I editorial
03

page 26

SEM analysis of the laser activation of final irrigants for
smear layer removal

Summertime in Brussels is

| Dr Vivek Hegde et al.

WFLD-ED laser time
| Prof. Dr Norbert Gutknecht

I education

I research

40

06

I meetings

Nd:YAG lasers in intraoral welding
| Prof. Dr Carlo Fornaini

12

44

16

47

Post-cure irradiation of pit and fissure sealant

Master of Science in Lasers in Dentistry

IDS 2013 sets new records
| Koelnmesse

Perfect soft tissue management in the oral use
| Hans J. Koort

page 30

Why use laser if you can do without?

I news

by diode laser—Part II
38

Manufacturer News

I overview

48

News

22

Diode lasers for periodontal treatment

I about the publisher

| Dr Fay Goldstep et al.

50

| Nermin M.Yussif et al.

| imprint

I industry report
26

Photodynamic therapy with the new active
ingredient Perio Green
| Dr Ralf Borchers

30

Cover image courtesy of Syneron,
www.synerondental.com
background image: ©Click Bestsellers
Design by Sarah Fuhrmann, OEMUS MEDIA AG.

Er:YAG laser etching of hypoplastic enamel
| Prof. Dr Georgi Tomov et al.

page 44

04 I laser
2_ 2013

page 47

page 48

[5] =>

Education. Technology. Family.
Join the Syneron Dental Lasers Family
presenting

The unique fiber-free Er:YAG laser

To learn more about our innovative technology solutions,
contact: dental@syneron.com, www.synerondental.com

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that has changed the face of laser dentistry

EMEA 2011 Winner

[6] =>

I research

Nd:YAG lasers in
intraoral welding
Author_Prof. Dr Carlo Fornaini, Italy

_Introduction
Laser welding was introduced in jewellery in the
1970s and later successfully used also by dental
technicians.1 The wavelengths that were used
firstly were CO2 and Nd:YAG, but, finally,
the market was rapidly conquered by
the latter because of the results that
were obtained.2 Laser welding, in fact,
gives a great number of advantages in
contrast to traditional welding.
First of all, the laser device saves time
in the commercial laboratory because all
welding is done directly on the master
cast. Inaccuracies in assembly caused by
transfers from the master cast and investments are reduced.3 Furthermore, the
heat source is a concentrated light beam
of high power, which can minimise distortion problems on the prosthetic pieces.4
Interesting is its possibility to weld very
closely to acrylic resin or ceramic parts
with no physical (cracking) or colour

Fig. 3

Fig. 2

damage.5 This results in saving both time
and money during the restoration of broken
prosthetics or orthodontic appliances because remaking to the not-metallic portions
is not necessary.
This welding technique may be used
on every kind of metal, but its property
to be very active on titanium makes it
specifically qualified for prosthetics
over endosseous implants.6 Many laboratory tests demonstrated that laser
welding joints have a high reproducible strength for all metals consistent with that of the substrate alloy.7
All these advantages resulted in this
procedure causing a great unrest in the
technicians’ laboratories and stimulated the companies to put more and
more upgraded appliances on the
market.

Some aspects, such as its extensive
dimensions, high costs and high costs
Fig. 1
and fixed-lenses delivery system today
still characterise these machines, which
strictly limit their use only to technician laboratories.
The first aim of this study was to evaluate the possibility to utilise the same device normally used in
dental office for laser welding. The second aim was to
achieve welding directly in the mouth by employing a
fibre-delivered laser after an accurate evaluation of
the biological compatibility of the procedure.8

_Material and methods

Fig. 5

Fig. 4

06 I laser
2_ 2013

The first step of our research was to determine the
wavelength most appropriate for our work among
those normally used by the dentist and those applied
for welding in the industrial field (CO2—10,600 nm,
Diode laser—810 nm, and Nd:YAG—1,064 nm). We
made some tests on metallic plaques for each wave-

[7] =>

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[8] =>

I research
length and we saw that the one able to weld was the
Nd:YAG.
While the pulse durations of the dental CO2 laser
are too short and cannot give the thermal elevation
necessary to obtain a fusion of metal, the output
power of the dental diode laser is too low (from 5 to
10 Watts) and cannot give the energy necessary to
support a real welding process. Therefore, we decided
to use the appliance FIDELIS PLUS III (FOTONA, Slovenia, Fig. 1) which combines two different wavelengths, Er:YAG (␭ = 2,940 nm) and Nd:YAG (␭ =
1,064 nm).

We decided to use a fiber of 900 µm in diameter,
normally used for bleaching and biostimulation. Initially, a handpiece with a 2 mm spot (Fotona R 30),
normally used in dermatology, was chosen and, by
reducing the working distance, a spot of 1 mm was
obtained. We asked the manufacturer to construct
an experimental hand piece capable of generating a
0.6 mm spot. The aim was to increase fluence (J/cm2),
which is the most important parameter determining
the quantity of energy delivered to a surface, by a factor of 10, while also utilising the device’s maximum
energy output (9.90 J).

_”In vitro ” tests
The first wavelength allows the dentist to treat
hard tissues (enamel, dentin and bone) by a mechanism which causes the explosion of intracellular water molecules by utilizing the affinity of this laser with
water and hydroxyapatite, thus resulting in the ablation of the tissues.9 The Nd:YAG laser allows the dentist to perform surgery with complete haemostasis,
utilising the affinity of this wavelength with haemoglobin, therefore avoiding sutures.10 It is also employed for the periodontal pockets and root canal decontamination, for bleaching and to treat dentinal
hypersensitivity.11
The peculiarity of FIDELIS PLUS III is given by the
possibility to have pulse durations in milliseconds
(15 and 25), in addition to a pulse duration in seconds,
which is necessary during dental interventions. These
high pulse durations can be utilised in phlebology, in
the treatment of inestethisms of vascular origin,
thanks to the affinity of this wavelength for haemoglobin.12 The optic fiber delivery system is a very important advantage of this device with regard to intraoral welding, because it is very flexible and ergonomic
and therefore able to penetrate into the oral cavity.

Fig. 7

Fig. 6

The first in vitro test was conducted by irradiating
CrCoMo plates with various combinations of welding
parameters. The spot’s configuration was analysed by
an interferometric technique. Interferometry is a
non-contact, optical technique for measuring surface height and shape with great speed and accuracy.
Interferometry makes it possible to precisely measure
the shape and size of the laser’s crater in the metal
surface in three dimensions, and allowed us to choose
laser parameters that welded well, but minimised collateral damage to the surrounding area (Fig. 2). In
these preliminary tests, the best parameters found
were: output power = 9.90 W, frequency = 1 Hz, pulse
duration= 15 ms, working distance = 30 mm, energy
= 9.90 J, fluence = 3,300 J/cm2.
The subsequent tests were performed on CrCoMo
plates and steel orthodontic wires to compare the
welding by dental laser (Fidelis, Fotona) to this obtained by the use of a device normally utilised in dental laboratories (Rofin, Germany).14 In addition, metal
fillers were used. Different techniques (Fig. 3) were
employed to analyse the results: SEM (Scanning Electron Microscope), EDS (Energy Dispersive Spectroscopy) and DMA (Dynamic Mechanical Analysis).
The results of the two sample groups were similar
with regard to microstructure, elemental distribution
on the welding fillets, strength off the joints and elastic modules.
In order to obtain a device able to weld every kind
of metal and alloy, including titanium, we added an
argon gas cylinder connected to a pipe to the appliance, spreading the gas to the laser impact beam by
means of an additional pedal. The titanium samples
welded under this shielding atmosphere did not show
any trace of oxidation.

_”Ex vivo ” tests

Fig. 9

Fig. 8

08 I laser
2_ 2013

In order to define the thermal increase in the biological structures close to the zones which are thermally affected by the welding process (sulcus, pulp

[9] =>

research

chamber, bone and root), an ex vivo study was performed.15,16
Two fresh calf jaws were kept at room temperature
and holes were made in the disto-labial area in six
molars of each jaw by micro motor drill. Then, four
k-type thermocouples were connected to each tooth
and fixed with thermoplastic paste (Impression Compound Red Sticks, Kerr) in the pulp chamber, sulcus,
bone and root.
The thermocouples were then connected to a PCintegrated four-channel thermometer (LUTRON TM946) in order to record and save the data. Twenty-four
metallic CrCoMo plaques were curved to hemispherical shape (15 mm ray) and a couple of them were
placed on every previously prepared tooth. Since the
first examination was performed by an IR thermal
camera, limited in that it only provides the surface
evaluation of the jaw, it was decided to use the fourthermocouples system which, although its application is more difficult and will take longer, allows
checking the internal temperature of the structures.
A rise in temperature was recorded in the pulp chamber. However, for all the twelve samples tested, the
maximum temperature rise was lower than 5.5 °C,
which is considered a critical value for pulp vitality.
A similar test was then performed on pork jaws
by welding a titanium bar to implants previously inserted into the bone under argon gas atmosphere
(Fig. 4). The values recorded by thermocouples placed
closely to the implants showed a thermal elevation
much lower than those considered dangerous for
bone necrosis (5 to 7° = protein coagulation). After
these in vitro and ex vivo experiments, it was decided
to apply this technique to in vivo clinical situations.

_Clinical cases
Case 1
A 59-year-old male patient presented with implant-prosthetic treatment which consisted in the
apposition of a fixed prosthetics placed in to the upper arch with two crowns and five endosseous implants (Fig. 5). After crown preparation and impression taking, the dental technician constructed the
metallic structure of the bridge in two sections to assure its fit and, to avoid the risk of inaccuracies in the
impression, it was decided to connect them by intraoral laser welding.
In order to protect the soft tissues from the ejection of warm metal splinters, we utilised the silicon
mass normally used to take prosthetic impressions
with a little hole corresponding to the contact of the
two portions of prosthesis (Fig. 6). The entire process
had a duration of seven minutes, the effective weld-

Fig. 10

Fig. 11

Fig. 12

Fig. 13

ing time was 150 seconds, the parameters used were
the same as described before and it was utilised a filler
metal. After removing the bridge from the mouth, it
was sent to the laboratory to complete its realisation
(Fig. 7). During and after the welding process, the patient said the he did not felt any discomfort. After four
weeks we could seal the bridge and finish the rehabilitation of the patient (Fig. 8).
Case 2
A 14-year-old female patient, in orthodontic
treatment with a fixed appliance (modified “VELTRI”
distaliser) for the insertion of the first premolars into
the upper arch, came to our clinics for a check and we
noticed that an arm of the appliance was broken (Fig.
9). We evaluated that the removal of the appliance
was full of risks, in particular the impossibility to reinsert it after the repairing due to space closure. Therefore, it was decided to laser-weld the arm intraorally.
In order to protect the soft tissues from the ejection

Fig. 14

Fig. 15

Fig. 16

Fig. 17

laser
2
I 09
_ 2013

[10] =>

I research
not reveal any aspects of concern and the patient confirmed he did not take any kind of medication.

Fig. 18

Fig. 19

Fig. 20

Fig. 21

of metal pieces during irradiation, we used a silicon
sheet (Fig. 10). After repairing the arm (Fig. 11), the appliance was reactivated by turning the screw, until
the space required to insert the premolar was
reached (Fig. 12). During the laser welding process,
which had a total duration of 2 min and a time of irradiation of 20 sec, the patient didn’t feel pain or discomfort and the vitality of the teeth and the periodontal and gingival health was not damaged, even
months and years later.

An impression of the upper arch was taken in order
to construct a template for correctly positioning the
implants. The insertion of the four implants 4.5 ×
11 mm (AoN, Vicenza, Italy) was performed flapless
and with the aid of the template (Fig. 16). After the
surgical procedure, four abutments were screwed to
the implants. Then, a bar previously constructed by the
dental technician previewing the position of the implants by the maxillary arch impression was inserted in
the four abutments (Fig. 17). The bar was welded intraorally by dental Nd:YAG laser in order to fix the position. The whole intraoral welding procedure had a
duration of 47 sec, during which the patient confirmed
he did not experience any pain or discomfort (Fig. 18).
The bar was removed from the mouth with the abutments and the welding procedure was completed extraorally with the device previously used (Fig. 19). The
abutments were cut and polished, and then they were
reapplied to the mouth (Fig. 20). The prosthesis was then
connected to the bar with four silicon OT Cap (Rhein 83,
Italy), fixed by acrylic (Fig. 21). The patient was checked
after two, seven, and fifteen days, then monthly for six
months. During this period, no problems were reported
by the patient who has thus regained his comfort.

_Conclusion
Case 3
A 45-year-old male patient came to our office for
a fixed prosthetic rehabilitation of the lower arch. In
the upper arch, he had a gold-resin fixed prosthesis
which was broken in the middle, between the two
central incisors (Fig. 13). Therefore, we decided to use
the intraoral laser-welding technique to repair the
bridge intraorally. We removed a little portion of resin
by the two incisors with a bur and welded by Fidelis III
with a metal apposition. In this case, the protection of
soft tissues was achieved by a plastic cylinder (Fig. 14).
After welding, we put a layer of composite resin to
complete the restoration aesthetically (Fig. 15). During the welding process, which had a duration of
seven minutes with an irradiation time of 130 seconds, the patient did not felt any discomfort. Subsequent checks, made after one month, two, six, twelve
and eighteen months, evidenced no problems.
Case 4
A 67-year-old male came to our clinic for an examination. At the clinical observation, the man appeared
edentulous on the upper arch where he wore removable full dentures. His problem was that the device was
not stable and he had a great discomfort in speaking
and eating. Due to his economic condition, it was decided to stabilise his appliance by the insertion of four
implants in the maxillary bone. The medical history did

10 I laser
2_ 2013

Intraoral Laser welding (ILW), even if it is only at its
beginning, is a procedure which is both promising and
relevant for the restoration of a damaged prosthesis.
It can be done without the risks related to prosthesis
removal as well as during prosthesis construction in
order to eliminate the accuracies related to the impression. The most interesting application of this
technique regards the possibility to weld a bar on endosseous implants intraorally in order to immediately
charge them. Further studies will find other applications for this new approach._

_contact
Prof. Dr Carlo Fornaini
MD, DDS, MSc
Dental School, Faculty of Medicine,
University of Parma,
Via Gramsci 14
43126 Parma, Italy
Tel.: +39 0521 292759
Fax: +39 0523 986722
info@fornainident.it
www.fornainident.it

laser

[11] =>

Let there be light!
4th Congress
of the
European Division

Brussels, July 11–12, 2013
www.wfldbrussels2013.com
You are cordially invited to participate
For information, please visit our website

Congress President:

Honorary Presidents:

Pr S. Nammour

Pr Lynn Powel; Pr Isao Ishikawa ,
Pr Hong Sai Loh, Pr Jean Paul Rocca,
Pr Norbert Gutknecht

International Organizing Committee
Chairman: Pr Roly Kornblit
Dr Boris Gaspirc (Slovenia)
Dr Peter Fahlstedt (Sweden)
Pr Anton Sculean (Switzerland)
Dr Miguel Vock (Switzerland)
Pr Ferda Tasar (Turkey)
Pr Sevil Gurgan (Turkey)
Pr Christopher Mercer (UK)
Dr Miguel Martins (Portugal)
Dr Marina Vitale (Italy)
Dr Sharonit Sahar-Helft (Israel)
Pr Lajos Gaspar (Hungary)
Dr Dimitris Strakas (Greece)
Dr Kallis Antonis (Greece)
Pr Matthias Frentzen (Germany)
Dr Frederick Gaultier (France)
Dr Gérard Navarro (France)
Pr Marita Luomanen (Finland)
Dr Peter Steen Hansen (Denmark)
Pr Julia Kamenova (Bulgaria)
Dr Emina Ibrahimi (Austria)
Dr Anna Maria Yiannikou (Cyprus)
Pr Igor Shugailov (Russia)
Dr. Oleg Tysoma (Ukraine)
Pr Assem Soueidan (France)

International Scientific Committee
Chairman: Pr Carlo Fornaini (Italy)
Pr Jean Paul Rocca (France)
Pr Norbert Gutknecht (Germany)
Pr Paolo Vescovi (Italy)
Pr Umberto Romeo (Italy)
Pr Antoni J. Espana Tost (Spain)
Pr Josep Arnabat (Spain)
Pr Carmen Todea (Romania)
Pr Adam Stabholz (Israel)
Dr Thierry Selli (France)

Local Organizing Committee:
Chairman: Pr Roeland De Moor
Marc Tielemans
Daniel Heysselaer
Amaury Namour
Secretariat: Cristina Barrella Penna
Chairman for commercial relations & Promotion:
Pr Roly Kornblit

www.wfldbrussels2013.com

[12] =>

I research

Perfect soft tissue
management in the
oral use
Author_Hans J. Koort, Germany

_The use of alternating electric current for
bloodless interventions in the oral soft tissues has
been established for nearly a century, first in the form
of the electric knife, then later in the form of radio frequency devices. Laser devices have been introduced
in the 1980s as new, additional tools and have become
significantly more important until today.
Both of the two technologies are based on the local, rapid heating of the cells in the tissue, and they
can be used for cutting and for coagulating.

Fig. 1_The combination of a diode
laser and radio frequency technology
offers a wide range of applications.

With the introduction of the laser, however, an
almost antagonistic “argy-bargy” was common in
marketing. For decades, the manufacturers of lasers
and radio frequency devices argued about who can
provide the better method for oral soft tissue treat-

Laser

High
Frequency

L + HF

Oral surgery

Periodontics

Implantology

Endodontics

Bleaching

PDT

LLLT

12 I laser
2_ 2013

ment: “Laser is better than radio frequency”—“Radio
frequency is better than laser”—“But with laser you
get better results if the power is high enough”—“But
if the power is too high, a laser is hardly to control”
—“But with special pulse techniques, the thermal
damage can be controlled”—“The cutting speed with
a laser is already limited, it is much slower than radio frequency. And with pulse technique, it will then
slow down again”.
However, combining a diode laser with a modern
radio frequency generator will make competition
obsolete, but you will then have a useful and perfect
tool for the soft tissue management. With a laser,
the relatively thin and complicated oral tissue can be
treated selectively and shows successful results in
periodontics, endodontics and implant surgery. The
radio frequency technology, on the other hand, simply because of the much higher cutting speed and
perfect coagulation, brings about benefits for oral
surgery. Photodynamic therapy (PDT), low level laser
therapy (LLLT) and the use of the laser for tooth
bleaching open additional new treatment options
(Fig. 1).

_Why is this approach so promising?
Lasers have been and still are often understood
and advertised as general purpose devices. However, there are many applications that cannot be
carried out satisfactorily with these devices. Of the
many lasers that have been "tried out" in the oral
soft tissues for decades, such as the CO2 laser, the
Nd:YAG laser and diode lasers, essentially only the
latter can prevail in the market because of their
broad spectrum of treatment and their relatively inexpensive equipment designs.

[13] =>

research

Its strength lies in its applications in periodontics, endodontics and the removal of the superficial
soft tissues such as overgrown implants.
A significant disadvantage, however, can be observed in surgical applications. The oral tissue is very
thin, delicate and has complicated structures. In addition, it is often in close proximity to jaw bone and
tooth structure. While laser radiation is absorbed in
the tissue and converted into heat, it will also be partly
transmitted through the tissue. It can thus cause unpredictable and undesired side effects in adjacent
healthy areas. The cutting speed of the laser beam is
limited by the fact that the tissue can be removed only
in layers. Neither increasing the laser power nor using
laser pulses can eliminate this problem.
However, in radio frequency technology, the tissue will be heated and cut simultaneously, homogeneously and rapidly in the entire length of the inserted metal electrode. Damages to adjacent
healthy areas are unlikely and if they do occur, they
are predictable and can be planned.
The relatively low frequencies (200 to 400 kHz) in
high frequency devices used in human medicine
usually generate distinct thermal necrosis with extended healing times, increased swelling and tissue
retractions as sequelae. They have been used in dentistry for many years, but they have been replaced by
modern radio frequency technologies with working
frequencies of 2 to 4 MHz.

_Which are the similarities between
diode laser and the radio frequency
and what makes them different?
Similarities
Both the laser light from the diode unit as well as
the electric current from the radio frequency device
are transformed in the tissue to heat. The cells in the
tissue will be heated in a fraction of a second, this results in a cut or in a coagulation. While in the laser
the power is passed through an optical fiber to the
site and the light energy emitts from the fiber tip, in
the radio frequency the high-frequency current is
directed through a metal electrode into the tissue.

Fig. 2

depth. The RF field heats the area simultaneously
and uniformly to the entire physical length (Fig. 3).
The cutting speed of the RF electrode therefore is
much faster than with a diode laser. Also, in the intraoral use of radio frequency technology it is very
positively accepted that the local increase in temperature is less than 60 to 80 °C. Using a laser or an
electric knife, however, a temperature increase of
more than 400 °C must be considered.
In a leukoplakic, exophytic growing alteration at
the left border of the tongue, the histology after the
use of radio frequency at 2.2 MHz shows just little
thermal damage in the striated muscle (Fig. 4). The
thermal reaction layer in the stroma is minimal,
vacuoles are invisible.

Fig. 3

Fig. 2_Cutting in tissue with a diode
laser. The tissue cut is removed
layer-by-layer. The deeper the cut,
the greater is the heat damage at the
base of the lesion. The emitted laser
radiation also heats the fiber end,
thus the tissue is exposed to additional stress.
Fig. 3_Cutting of tissue with radio
frequency: The tissue is removed by
only one precise, uniform section in
the entire length of the inserted electrode. The metal electrode remains
cold at 2.2 MHz.

Figure 5 shows a histological comparison of the
thermal reaction zone in an excidate, which was removed using a 980 nm laser. Recognisable is the
much wider and partially merged reaction zone as a
result of the significant thermal effect.

_The situation in dentistry
The estimated more than 20 providers of diode
lasers use mostly marketing arguments such as laser
wavelength, performance and the possibility of using pulses. A jour, wavelengths of 810 nm and
980 nm are advertised, although there are only very
small differences. Thus, for example, 980 nm shows
a higher absorbance in water, which promises a better coupling to aqueous environments and thus a
better cutting behaviour. The laser of 810 nm shows

Fig. 4_Histology of tongue specimen,
radio frequency (2.2 MHz).
Fig. 5_Histology of tongue specimen,
diode laser (980 nm).

The main difference
A laser fiber a priori can not be inserted deeply
into the tissue to produce a cut. The laser radiation
emitts from the front end of a fiber and heats only
the uppermost layer of the tissue and ablates it. To
get into the depth therefore, the tissue must be removed layer by layer (Fig. 2).
In contrast, the metal electrode at the high frequency can be introduced into the tissue in a desired

Fig. 4

Fig. 5

laser
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available in various forms for specific indications—
a better tactile feeling than does glass fiber. This results from the predetermined length of the electrode as well an exact depth of penetration. The high
speed is advantageous for larger and deeper cuts.

Fig. 6_LaserHF – Combination of
diode laser and radio frequency.

Requests for higher laser output power or for
constructing appropriate pulse technology will affect the price of the devices, which will become more
expensive. Additional costs of the supplies, especially the often in surgical operations at high power
damaged glass fibers must be considered as a considerable part.

a lower water absorption and a higher absorption
haemoglobin, which promises a good coagulation.
The differences, however, are actually rather low.
And there is a historical explanation: Laser diodes
with 810 nm were introduced to the market long before laser diodes with 980 nm. In addition, 980 nm
laser diodes are now mainly used for many industrial applications.
High laser power and shorter pulse durations are
propagated by the providers. The pulsed application,
in fact, has advantages, especially if very short
pulses of a few µs are used. The thermal influence is
significantly lower. However, it also means that the
already low working speed is further reduced. Moreover, with any increase of laser power, the risk of
damage to adjacent healthy tissue may become
greater than the desired therapeutic effect.
The advantage of the laser, however, can be seen
particularly in superficial applications, for example
for killing of bacteria in periodontic and endodontic
applications, to expose overgrown implants or for
trimming the gingiva. The use of photodynamic
therapy, in laser therapy (soft laser) and tooth
bleaching, are additional and can be attained only
with lasers. In oral surgical applications, such as the
removal of fibroma and haemangioma and performing frenectomy and in larger invasive applications, the radio frequency provides clear advantages
because of a faster and more precise interaction.
Using very thin, flexible electrodes made of special metal alloys, the electro-magnetic waves are
passed into the tissue. This approach allows fast,
precise, pressure-free and nearly athermal cutting.
In addition, bleeding is controlled effectively by the
adjustable coagulation.
Compared to laser, radio frequency provides—
because of the rigid metal electrodes, which are

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For hygienic points of view and also taking into
account the necessary quality assurance system in
a dental practice, the consideration is to use sterile
fiber tips instead of repeatedly preparing laser fibres.
The radio frequency technology, however, can be
realized relatively inexpensively in the device design. Compared to optical fibres, the metal electrodes can be prepared relatively simply and sterilised many times.
Figure 6 shows the combination device LaserHF
(Hager & Werken, Germany). It consists of a 975 nm
laser with a power of 6 W, combined with a 2.2 MHz
radio frequency generator with a power of 50 W and
with a 660 nm laser with a power of 100 mW as a
therapy supplement for photodynamic and low
level laser therapy.

_Conclusion
With regard to its potential applications, the
combination of a diode laser with a radio frequency
device meets the desire for a perfect system for
complete soft tissue management._

_contact
Hans-Joachim Koort
MedLas Consult
Auf der Schleide 18
53225 Bonn, Germany
Tel.: +49 228 6955-20
Fax: +49 228 6955-30
ceo@medlas.com
www.medlas.com

laser

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st

1 International Congress
of WALED and GLOBAL
June 14-15, 2013
Istanbul, Turkey, Point Hotel Taksim
Fees: 250 EUR, inclusive full day catering and 2 evening events
Congress Presidents: Prof Norbert Gutknecht, Dr Zafer Kazak

Enjoy dental science and fun in Istanbul!

More Information: info@aalz.de

Copyright © Sadik Gulec

Preliminary List of Speakers:
Prof Norbert Gutknecht

Prof Aslihan Üsümez

Prof Matthias Frentzen

Prof Gerd Volland

Ass.-Prof Ilay Maden

Ass.-Prof Jörg Meister

Dr Iris Brader

Dr Masoud Mojahedi

Dr Miguel Martins

Dr Peter Fahlstedt

Dr Zafer Kazak

Dr Merita Bardoshi

Dr Stefan Grümer

Dr René Franzen

Dr Nasrin Kianimanesh

Dr Alireza Fallah

Dr Dimitris Strakas

Dr Gabriele Schindler-Hultzsch

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I research

Post-cure irradiation of
pit and fissure sealant
by diode laser
Part II
Authors_Nermin M.Yussif, MSc, Ali M. Saafan & Samah S. Mehani, Egypt

_Introduction
Due to its peculiar anatomical shape, the occlusal
surface is highly susceptible to carious lesions.1 Several methods of prevention have been tried to reduce
its prevalence.2 A widely used technique affecting the
caries incidence is fissure sealing3, in which the fissure
systems are sealed with a material. This material is retained on the enamel surface either by the acid etch
technique (resin sealants) or through chemical bonding (GIC sealants).4 The preventive benefits of such
treatment rely directly upon the sealant‘s ability to
thoroughly fill pits, fissures, and/or anatomical defects, as well as to remain completely intact and
bonded to enamel surfaces without marginal micro
leakage at the resin-tooth interface and consequent
development of a carious process underneath the
sealant material.5,6
The majority of resin materials utilised in restorative dentistry today consists of a methacrylated resin
matrix (i.e. usually a blend of several resins) that is
mixed with various glass filler particles. Bis-GMA
continues to be the most used monomer for manufacturing present day composites; whether alone or
in conjunction with other resin matrices. As a general
rule, the lower the mean molecular weight of the
monomer or monomer combination, the greater the
percentage of shrinkage. Because Bis-GMA is highly
viscous, in order to facilitate the manufacturing
process and clinical handling it is diluted with less
viscous monomers (low molecular weight) which are
considered viscosity controllers, such as ethylene

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glycol dimethacrylate (EGDMA), triethylene glycol
dimethacrylate (TEGDMA), or urethane dimethacrylate (UDMA).7,8
The chemical composition affects mainly the material behaviour during exposure to different oral
conditions such as temperature, pH, stress, pressure,
and humidity. The total amount of shrinkage, the rate
of shrinkage, and the elastic modulus (i.e., stiffness)
of the composite are just some of the factors that influence the degree of stress and strain (i.e., deformation) induced at the adhesive interface during composite polymerisation which result in shrinkage.9
Shrinkage depends solely on the organic matrix and
on the number of reactions that take place. It rises
with the degree of conversion and falls with increasing monomer molecular weight.10
The filler particles are added to the organic phase
to improve the physical and mechanical properties
of the organic matrix, so incorporating a percentage
of the filler as high as possible is a fundamental aim.
The filler reduces the thermal expansion coefficient
and overall curing shrinkage, provides radio-opacity, improves handling and improves the aesthetic
results.11 Improving the fluidity of composite resins
is an important issue, so there are various options:
lowering the viscosity of the monomeric component12, adjusting the filler components, or improving the surface treatment of the filler.13 The findings
of clinical trials indicate that unfilled sealant performs better than filled sealants. In some cases, the
manufacturers have added fillers to resin sealants

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Groups

Group 1 control

Group 2

Group 3

Group 4

Treatment

Artificial caries

Laser+ artificial
caries

Fissure sealant
+artificial caries

Fissure sealant
+diode laser
+artificial caries

as fluoride. In general, variation in the filler content
heavily affects thermal expansion, thermal conductivity, polymerisation shrinkage, and mechanical
strength of the sealant material.14 Decreasing the
filler loading eventually weakens the physical properties of resins, such as microhardness and wear resistance.15
Nowadays, the vast majorities of resin-based materials cure or polymerise by initiating free radical
generation with a visible light curing device.16 The
manufacturers tried to develop light sources that will
give the greatest conversion with the least curing
stress, as this helps to improve the functional and aesthetic results of composite materials. Four types of
polymerisation sources have been developed and applied: quartz tungsten halogen (QTH) lamps, light
emitting diodes (LED) units, plasma-arc lamps and argon-ion lasers.17
LED’s use a combination of two different doped
semiconductors instead of a hot filament.17 The spectral output of blue LED conveniently falls within the
absorption spectrum of camphoroquinone.18 Therefore, they do not require filters to produce blue light
and they convert electricity into light more efficiently.19 They produce less heat so no cooling fan is
required and they can be smaller and cordless.20

I

Table 1_Grouping.

cially at the interface between organic matrix and inorganic particles.
This would increase the adhesion between both of
the two phases and the cross linking between the
methacrylate groups.26 In the past, the most commonly
used method as a secondary treatment is heating in a
furnace as a means to improve the degree of conversion.27 The used ovens and stoves must have temperatures ranging from 60 to 170 °C, and a heating time
varying from seven minutes to one hour.28
Also, laser was used as an additional curing
method to potentiate the material properties as CO2
laser as its effect mainly consists of heat action.29
Diode lasers are in the category of devices that emit
light from semiconductor materials.30 They are
portable, compact surgical units with efficient reliable benefits. Diode lasers have a wavelength between
805 and 980 nm. They can be used in the continuous
as well as pulsed mode.31
The current study was conducted as a morphological and microhardness evaluation of the effect
of the post curing application of diode laser
(980 nm) on specific fissure sealing material in
caries prevention.

_Materials and method
The depth of cure is dependent on different cofactors such as filler particle size and distribution,
colour and optical translucency of the composite,
and refractive index ratio of the single components
being used.21, 22 Curing light is absorbed and scattered by composite resins, resulting in higher light
intensity at the top than the bottom surface.23 For
this reason, Bayindir and Yildiz found significantly
different top and bottom surface hardness values,
whereby those of the top surface were consistently
higher than those of the bottom surface.24
Full polymerisation of the material is determined
by the degree of conversion of monomers into polymers, indicating the number of methacrylated
groups that have reacted with each other during the
conversion process.25 The application of heat, as an
additional polymerisation method, increases the
conversion rate of monomers, reflecting in improvement of surface hardness, compressive, modulus of
elasticity and flexural strength. Composites submitted to heat might present internal stress relief, espe-

Sample preparation
Forty extracted caries-free permanent molars (wisdoms) and premolars were used in the current study.
Extraction had been done for orthodontics treatment.
Selected teeth were cut into two halves bucco-lingually with a low speed diamond disc, which were divided into groups (Tab. 1).

_Surface treatment
Artificial caries
The specimens of all groups were individually submitted to the process of the caries induction using
artificial caries media (6% hydroxyethyl cellulose to
a 50 m mole lactic acid solution) of 4.5 pH for seven
days.32 The specimens were then washed and kept in
distilled water.
Laser irradiation
In groups 2 (sound enamel) and 4 (fissure sealing
material), occlusal depressions of the experimental

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Fig. 1

Fig. 2

Fig. 1_ESEM image of group 1
showed carious enamel surface with
aggregated granules (red arrows)
(BSED) x800.
Fig. 2_ESEM image of group 2
shows pitted surface and destructed
unlased part (arrowhead) x400.
Fig. 3_ESEM image of group 2
showed the nearby enamel with
typical keyhole appearance
(arrowheads) (BSED) x3,000.

samples were irradiated using diode laser irradiation
of 980 nm wave length, 2 W power for 15 sec, in contact mode (Quanta system, Italy) and optic fiber transmission system. The fiber tip was positioned perpendicularly to the occlusal pit and fissure areas. Laser
irradiation was performed by hand, screening the
enamel surface in a uniform motion.33
Sealant material
Groups 3 and 4 were treated with Clinpro pit and
fissure sealing material, unfilled and fluoride releasing
type (3M ESPE, USA).
Curing process
A DEMI LED was used to photocure the resin
sealant. These curing lights have a light intensity of
approximately 1,100 mV/ cm2 and emit light in the
wavelength range of 450–470 nm (sds Kerr, USA). The
curing time is up to 20 seconds.
Environmental scanning electron microscope
analysis
The specimens were examined occlusally and
proximally using an ESEM (Inspect S ESEM, FEI).
Microhardness detection
Surface hardness was measured using Vickers
microhardness tester (HMV-2 Shimadzu, Columbia,
US). Measurements were done proximally at the
depth of the fissure and at the lateral sides of the
fissure depth. Indentations were made with the
long axis of the Knoop diamond perpendicular on
the inner enamel surface laterally and at the depth
of the fissures. Each group underwent a load of
19.61 N, applied for 20 sec in order to evaluate the
variations of surface hardness eventually caused by
laser treatment in comparison with unlased
enamel. The hardness values were calculated automatically by a computerised machine.
Statistical analysis
The data were gathered and analysed using ANOVA
(Analysis Variance) test. Statistical results were
processed by SPSS software (17.0, SPSS Inc., Chicago,
USA).

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Fig. 3

_Results
Environmental scanning electron microscope
analysis
Disappearance of the normal architecture of the
enamel structure was detected clearly. Few enamel
crystalline aggregations reprecipitated on the decayed surface indicating the massive demineralisation of enamel. Rods and interrod regions in group 1
were detected at the wall of the fissure due to loss of
the surface rodless enamel (Fig.1).
Contrarily, melted irregular areas of the irradiated occlusal grooves were detected in specimens of
group 2 (Fig. 2). However the high pH of the artificial
caries media used, preservation of the surface integrity was observed clearly in most of the examined
specimens (Fig. 3).
As in group 1, loss of the enamel integrity was detected in group 3. The sealant surface revealed widely
distributed voids and cracks with variable sizes (Fig.
4). Multiple aggregations of enamel crystals which
reprecipitated on the sealant surface indicated a
massive demineralising effect of the artificial caries
media. Intimate contact between the enamel and the
sealant was noticed, barring few cracks extended
from the sealant to the adjacent enamel (Fig. 5). The
lateral wall of that enamel exhibited atypical enamel
rods and interrod regions (Fig. 6). The lateral borders
of the sealant material did not show a normal separation, but erosion was observed at its border which
may be due to the fluoride-releasing effect of the
sealant material.
Finally, group 4 revealed intact tooth and restoration integrity related to the lased part (Figs. 7 & 8).
Contrarily to group 3, where the sealant surface and
enamel were destructed totally, the sealant revealed
slightly irregular surface with few small voids and
cracks in group 4. The bond between the sealant and
the enamel seemed to be intact and revealed a neglected effect of acid on the restoration. Sporadic areas
of melted sealant were clear at the interface, masking
some of the enamel rod ends (Fig. 9). The lased enamel

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also showed intermittent melted areas which appeared as a homogenous layer that masked the
enamel rod ends (Fig. 10). Destruction of the unlased
part of the enamel surface was detected near the intact lased part, but there was also clear and intact
smooth sealant surface free of voids and cracks. Contrarily to group 3, the difference of the sealant surface
reflected the laser effect as even the inherent defects
of the sealant surface can be detected easily.

Group

Mean ± standard deviation S.D.

79.250 ± 33.9894

191.890 ± 22.7996

77.360 ± 11.4723

1069.30 ± 486.693*

Table 2_Vickers microhardness
tests results.

* Statistically significant value

Statistical analysis
Statistical analysis of the microhardness data was
made using the ANOVA test in order to compare the
resulted data from the examined groups. Results were
presented as mean ± standard deviations and a p-value
of less than 0.05 was considered as statistically significant (Tab. 2). The degree of demineralisation and
the ability of each group to resist caries were reflected
as changes in the microhardness measurements. The
comparison of the groups showed highly significant
differences (p = 0.0001). As a result, the Post-Hoc test
and the Pairwise test were done as multiple comparisons in order to determine the most significant mean
in reference to the measured control group scores.
Also, comparing all the groups with reference to the
artificial caries group, group 4 showed a highly significant difference (p = 0.0001). No significant difference was detected between group 1, group 2 and
group 3. The opposite was found when comparing all
groups and group 4 (p > 0.05) which means that the
main positive effect was owing to laser only.

_Discussion
Caries is a pathologic process of external origin involving softening of the hard tissues and proceeding to
the formation of a cavity.35 Microscopically, caries begins with the integration of enamel prisms after decalcification of the interprismatic substances, events
which lead to the accumulation of debris and microorganisms. When the process reaches the dentinoenamel junction, it spreads laterally and also penetrates the dentin along the dentinal tubules.3

Fig. 4

Unfortunately, incipient lesions in tooth pits and
fissures respond less favourably to fluoride therapy
than lesions isolated to smooth surfaces. Today, there
is a wide choice of different sealing materials used
clinically. In 1990, Jensen demonstrated that fluoride
releasing sealants had a slightly higher retention rate
after one year than the sealant without fluoride.35 In
this study, the 3M™ ESPE™ Clinpro fissure sealant was
used (light-cured, nearly unfilled, and of low viscosity
with a colour-change feature). Also, it contains a
patented soluble organic fluoride source. BIS-GMA/
TEGDMA resins are the main components.36
Clinpro fissure sealant contains only 6 % fillers
which are mainly fluoride. The effect of this fluoride
is clinically beneficial because it exerts a protective
action on the tooth along the tooth restoration interface.37 The fluoride is released as long as the gel
layer exists. Consequently, the protective action is
effective until there is the gel layer around the filler
particle. The dissolution of the gel layer produces loss
of the filler particle and then cavity formation38
which strongly affects the integrity and the main
structure of the restoration. In this study, ESEM micrographs of group 3 reflected the later negative effect of fluoride releasing on the material surface that
showed in voids, cracks and loss of bonding at the
sealant enamel interface. Massive destruction of the
enamel surface and the lowest surface hardness was
also detected in this group, which reflected the inability of the sealant material to provide enough protection to the sealed enamel.

Fig. 4_ESEM image of group 3
showed multiple voids on the
sealant surface (red arrows) and
reprecipitated enamel crystals
(yellow arrows) (BSED) x3,000.
Fig. 5_ESEM image of group 3
showed destructed enamel (E)
and sealant (S) (BSED) x400.
Fig. 6_ESEM image of group 3
showed atypical rods and interred
region (yellow arrowheads) at
the interface, voids on the
sealant surface (red arrow) and
reprecipitated enamel crystals
(red arrow head) (BSED) x3,000.

Fig. 5

Fig. 6

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Fig. 7_ESEM image of group 4
showed the lased enamel with
homogenous melted areas
(asterisks) intermingled with the
rod ends (arrows) (BSED) x3,000.
Fig. 8_ESEM image of group 4
showed smooth, clear sealant
surface with minimal cracks or
surface defects (BSED) x3,000.

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Fig. 7

Fig. 8

The curing process is affected by the composition
of cured material and curing light. LED was used in
this experiment in order to achieve a very narrow
range of blue light which is more likely to be absorbed by chomphorquinone (450–500 and a peak
at 465nm). As a result, there is no overheating of the
restoration. In order to achieve a maximum conversion rate, some authors recommended curing at
lower intensities (< 500 mW/cm2) within extended
polymerisation intervals.39 But with LED units providing output levels consistently between 1,500 to
2,000mW/cm2, polymerisation time can be reduced
to 20 seconds.40

tion contraction seems to be the cause of the cracks
that were detected in group 3. Those cracks originated from both bubbles and the filler-resin interface
as they are considered weak points. The filler does not
shrink during the setting reaction, thus producing
additional stress at the filler-matrix interface.42
Massive destruction of the enamel surface and
the lowest surface hardness was detected as well as
in group 1. This massive destruction was obvious due
to the low pH of the used artificial caries media that
reached 4.5. However, by using diode laser, the lased
areas were not affected by this media (group 2). Also,
increased microhardness levels that were detected in
this group provide protection of these areas even
with pH decay, especially with uncontrolled diseased
patients, who are for example handicapped, have a
high caries index or young permanent teeth. Patients
prior to radiation therapy are also included.

There are many factors that control the success
of the sealing process, some of which depend on the
tooth and the other depend on the material itself and
the environment of the application. In this study, we
used the traditional way of application mentioned in
the sealant pamphlet. In single-paste visible lightcured materials, it has been supposed that the porosities are air introduced as the unpolymerised material
is extruded through the nozzle of the syringe. The
cured materials are characterised by different concentrations, dimensions and distribution of porosity.
Often, dimensions and concentration of porosity
decrease in light-cured materials when the unpolymerised paste is extruded through a needle. The
smaller the needle’s inner diameter, the more extensive is its effect. This rule, however, shows exceptions.
In some cases, the extrusion through a small tip results in the decrease of large porosities and in an
increase of small porosities. This is due to the fragmentation of large porosities.41

According to the fissure system morphology,
complete penetration of the etchant material into
the fissure system is an essential step in the sealing
retention. Converting the enamel surface into a hydrophilic highly reactive one, the etching process
needs a highly penetrating etchant.43 The most commonly used etchant is phosphoric acid; there have
been reports on the insufficient penetration on the
phosphoric acid etchant into the fissure system.44
Also, failure to achieve a satisfactory bond for fissure
sealants may be due to the lack of tag formation following etching due to the prismless structure of the
fissure walls which had been demonstrated microscopically by Hoh et al.45

The small nozzle available with Clinpro™ sealant
aiming to provide better introduction of the material
into the fissure system caused an inherent defect in
its application technique. Probably it is impossible to
remove all porosities as the unpolymerised pastes
contain 0.05–1.4 % porosities by volume. The stress
induced by the polymerisation contraction also affects the success of the sealing process. Polymerisa-

Wavelengths in the near infrared and red region
of the visible spectrum are poorly absorbed by dental
mineral, but they are optimally transmitted and scattered through the sound enamel. This holds true for
diode lasers and Nd:YAG laser.46,47 Laser and fluoride
varnish showed 43% inhibition of pits and fissure
lesions and 80% inhibition of smooth surface lesions
compared to the untreated groups.48

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Fig. 9_ESEM image of group 4
showed few cracks on the sealant
(arrows) and enamel ends
(arrowheads) at the interface (C)
(BSED) x3,000.
Fig. 10_Higher magnification of
the previous figure showed sporadic
areas of melted sealant material at
the interface (C) (BSED) x6,000.

Fig. 9

Fig. 10

In this study, a 980nm diode laser was used in order to assess its ability to provide partial to complete
closure of the occlusal depressions as an alternative
method to pit and fissure sealants.

used sealant in this research could result from a light
attenuation of the thinner sealant which is less than
that seen in 2 mm composite increment. Another factor causing this higher DC might be a lower viscosity
as fissure sealants have less filler content to penetrate into pits and fissures. This great DC of the used
sealant was reflected into greater curing shrinkage
and consequently, poor marginal adaptation.36

Some reports have shown that the low power red
laser can induce caries prevention and as it does not
promote heating, the mechanism of action must be
different.49, 50 ESEM micrographs revealed a great
difference between lased and unlased ones. So far,
no published data are available concerning the effect of a 980nm high-power diode laser on enamel
microhardness.51 The resulting amorphous and heterogeneous tissues might be due to enamel melting
and resolidification.52 The low absorption coefficient of diode laser wavelength in enamel53 showed
a great benefit as it caused rapid elevation of the
surface energy during exposure and rapid decay of
temperature once stopped. As a result, the action
needed is carried out, but in the same time it did not
penetrate deeply so it did not affect the pulp or the
underling structures.
The detected surface temperature also provides
sterilisation of the fissure depth as streptococcus
bacteria die at 60°C. Group 2 also revealed irregular
lateral walls of the pits that might be due to the
presence of areas of melted enamel intermingled
with carious enamel. In group 4, combination between laser and fissure sealant material was used.
The use of different polymerisation methods as the
application of heat for additional curing time after
polymerisation increases the compressive, flexural
strength, hardness, tensile strength and wears resistance.26 This secondary curing procedure caused
increase in the chain vibration amplitude, allowing
free radicals and methacrylate groups to collide and
establish covalent links, increasing the degree of
conversion.54
Light cured materials have disadvantages such as
limited depth of cure and poor distribution of degree
of conversion (DC) in cured resin.55 The high DC of the

To overcome this shrinkage probability of the
sealant, laser was applied to the sealant enamel interface areas to melt the enamel and the sealant
material found at the interface as well as get rid of
the possible gap formation by melting and recrystallisation of enamel layer at this interface. These
findings were in accordance with Yoshiharu et al.
who proved that the Knoop hardness at the surface
of composite was increased with CO2 laser super
pulse irradiation 10 sec with 1 W after light curing.29
The fluoride content of the sealant may also increase the caries resistance due to the formation of
flour apatite in order to overcome the failure of
sealant enamel interface. Thus, the recorded microhardness in group 4 that was the greatest between
the groups was explained by flour apatite crystals as
well as the presence of melted enamel that caused
the rod and interrod region._
Editorial note: A list of references is available from the
publisher.

_contact

laser

Nermin M. Yussif, MSc
BDCs
Dental Laser Application Department
National Institute of Laser Enhanced Sciences
Cairo University, Giza, Egypt
Tel.: +20 011 827 1929
nermin.yussif@yahoo.com

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I overview

Diode lasers for
periodontal treatment
The story continues
Authors_Drs Fay Goldstep & George Freedman, Canada

_Introduction
Lasers have been a part of the dental scene for
over 25 years. Unfortunately, they used to be perceived as large, unwieldy, difficult-to-use, expensive machines and thus they were largely ignored.
Affordable, effective, user-friendly diode lasers
seem to have arrived on the scene only recently. In
fact, the diode laser has proven itself to be the
ideal soft-tissue handpiece in a considerably short
time.

Fig. 1_Picasso diode laser.
Fig. 2_Picasso high energy tip
(left and middle).
Biostimulation tip (right).

The diode laser functions as the essential handpiece for all soft-tissue procedures just as the dental handpiece is essential for all hard-tissue procedures. The advantages of the diode laser for softtissue applications include surgical precision,
bloodless surgery, sterilisation of the surgical site,
minimal swelling and scarring, minimal suturing,
and virtually no pain during and after surgery.
What about using the diode laser for the treatment of periodontal disease (laser-assisted peri-

odontal treatment)? An early version of the diode
laser was used effectively in the treatment of periodontal pockets in 1998.1 Since there is still so
much confusion and controversy regarding the
use of lasers in the treatment of periodontal disease today, clarification and simplicity seem to be
needed.
First, as the term “laser-assisted periodontal
therapy” implies, the laser is only one part of the
treatment equation. Therefore, the laser should
not be viewed as a stand-alone treatment for periodontal disease. Second, the laser may not be of
any help in advanced cases of periodontal disease
because these cases may require a surgical approach. Third, when discussing the benefits of
laser-assisted periodontal therapy, we must specify the particular type of laser used. Several categories of lasers have shown positive results. For the
sake of clarity and simplicity, the following discussion will deal exclusively with the diode laser, since
its ease of use and its affordability have made it the
predominant laser in dentistry.

_Diode lasers for
periodontal treatment
Two types of diode lasers have been studied for
their effects in laser-assisted periodontal therapy:
(a) the diode laser, which emits high levels of light
energy; and (b) the low-level diode laser, which
emits low-intensity light energy.

Fig. 1

Fig. 2

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There is very compelling evidence in the dental
literature that the addition of diode laser treatment to scaling and root planing will produce significantly improved and longer-lasting results.2
Scaling and root planing is the gold standard in
non-surgical periodontal treatment.

[23] =>

overview

Low-level lasers have
been used for biostimulation in
Fig. 3
medicine since
the 1980s. The therapeutic effect is non-cutting and
of low intensity, and covers a much
wider area than the traditional laser. Low-level
laser therapy is a treatment in which the light energy emitted by the laser elicits beneficial cellular
and biological responses. At a cellular level, the
metabolism is increased, stimulating the production of adenosine triphosphate, the fuel that powers the cell. This increase in energy is available to
normalise cell function and promote tissue healing.3, 4
The functions of the diode and low-level diode
laser have remained separate until recently. With
the introduction of the biostimulation delivery tip,
the diode laser is able to provide both cutting and
therapeutic effects. When the low-level tip is used,
the laser energy is delivered over a wider area, decreasing the energy level and producing the therapeutic effect of the low-level diode laser. Two
laser companies have made these auxiliary tips
available (Figs. 1–4).

Used together, these two laser treatment
modalities provide benefits that help to heal the
chronic inflammatory response in the periodontal
pocket. This works well in treating mild to moderate periodontitis.

Fig. 3_Picasso biostimulation tip.

Patients can be treated in a minimally invasive
way, without surgery and in the general practice.

_The periodontal pocket
Periodontal disease is a chronic inflammatory
disease caused by bacterial infection. The inflammation is the body’s response, seeking to destroy, dilute or wall off the injurious agent.5 If the situation
remains chronic, this selfprotective mechanism becomes destructive to the tissue. In periodontal
disease, the periodontal pocket contains several
substances that contribute to the continuation of
the unhealthy condition (Fig. 5):

Fig. 4_Ezlase biostimulation tip.

1. calculus and plaque on the tooth surface;
2. pathogenic bacteria; and
3. an ulcerated, epithelial lining with granulation
tissue and bacterial by-products.
AD

1. BodenseeLaser-Symposium
7 – 8 June 2013 |
Überlingen

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).
For more information: www.periogreen.com

[24] =>

I overview

Fig. 5

Fig. 5_The periodontal pocket
containing calculus, bacteria and
granulation tissue.

What do we need for healing of the pocket?
1. scaling and root planing to eliminate calculus,
plaque and other debris on the tooth to create a
completely clean surface;
2. decontamination to eliminate any pathogenic
bacteria dispersed through the pocket;
3. curettage to eliminate granulation tissue, bacterial products, and ulcerated areas to create a
clean, even epithelial lining without tissue tags
(epithelial remnants); and
4. biostimulation to kick-start the healing process.
The following is a sequence to demonstrate how
this can be easily accomplished in a minimally invasive, non-surgical way:

Fig. 6_Scaling and root planing
is performed first.
Fig. 7_The diode laser tip is placed
into the pocket.
Fig. 8_Laser energy is applied to the
pocket to decontaminate and
coagulate the soft tissue.

Fig. 6

1. Calculus is removed with scaling and root planing.
This procedure has been well documented
throughout the dental literature as the gold standard of care for non-surgical periodontal treatment. The diode laser and the low-level diode laser
are ideal for the remaining steps.
2. Since a bacterial infection is the initiator of the
chronic inflammatory response of periodontitis,
the bactericidal and detoxifying effect of laser
treatment is advantageous.6 The diode laser’s
bactericidal efficacy, particularly against specific
perio-pathogens, has been well documented.7–10
Moreover, there is a significant suppression of Ag-

Fig. 7

24 I laser
2_ 2013

gregatibacter actinomycetemcomitans, an invasive bacterium that is not easily treated with conventional scaling and root planing. This bacterium
is present on the diseased root surface and invades the adjacent soft tissue, making it virtually
impossible to remove with mechanical means
alone.11–13 The diode laser energy is able to penetrate the soft tissue to eliminate this pathogen.
3. The diode laser is an instrument well suited to
dealing with diseased soft tissue. Its energy is well
absorbed by melanin, haemoglobin and other
chromophores present in periodontal disease.14
The 2002 American Academy of Periodontology
statement regarding gingival curettage proposes
that “gingival curettage, by whatever method performed, should be considered as a procedure that
has no additional benefit to scaling and root planing alone in the treatment of chronic periodontitis”.15 However, the diode specifically targets unhealthy gingival tissue, performing an effective
curettage that produces a clean, even epithelial lining without tissue tags. It is also stated that all the
methods devised for curettage (including lasers)
“have the same goal, which is the complete removal
of the epithelium” and “none of these alternative
methods has a clinical or microbial advantage over
the mechanical instrumentation with a curette”.15
This was the state of the art in 2002. To date, this
statement has not been updated. Studies have
demonstrated that instrumentation of the soft tissue in the diseased periodontal pocket with the
diode laser leads to complete epithelial removal,
while conventional instrumentation with curettes
leaves significant epithelial remnants.16 Thus, in
fact, the diode laser does have a clinical advantage
over mechanical instrumentation with a curette.
4. This step requires the low-level laser tip. Studies
have demonstrated that low-level laser light affects
damaged and not healthy tissue. Laser biostimulation normalises cell function and promotes healing
and repair.17 Secondary effects include increased
lymphatic flow, production of endorphins, increased microcirculation, increased collagen formation and stimulation of fibroblasts, osteoblasts
and odontoblasts. This stimulates immune response, pain relief and wound healing.4

Fig. 8

[25] =>

overview

Fig. 9_The biostimulation tip is
applied at right angles to the external
surface of the pocket.
Fig. 10_Pocket depth is measured
pretreatment and three months
post-treatment.

Fig. 9

Studies have demonstrated that low-level laser
therapy performed in conjunction with scaling and
root planing on patients with both mild periodontitis18 and chronic advanced periodontitis19 can significantly improve treatment outcomes and the
long-term stability of periodontal health parameters. The above four steps create an ideal environment in the periodontal pocket for healing. Lasers
are an adjunct to scaling and root planing, not a
stand-alone procedure. Scaling and root planing
too is not a stand-alone procedure. We need all the
pieces of the puzzle to create health.

_The protocol so far
The protocol must incorporate the four steps
discussed above to establish the ideal environment
for periodontal healing: a clean, calculus-free
hard-tissue surface; no pathogenic bacteria; a
smooth, clean soft-tissue surface; and biostimulation. Biostimulation tips, which help prepare the final step, are at present only available for two diode
lasers, the Picasso (AMD LASERS) and EZLASE (BIOLASE). Individual parameters vary, depending on
the clinician and the particular diode laser used.
However, most protocols follow a simple formula:
1. The hard-tissue side of the pocket is debrided
with ultrasonic scalers and hand instruments
(Fig. 6).
2. This is followed by laser bacterial reduction and
coagulation of the soft-tissue side of the pocket
(Figs. 7 & 8).14 The laser fibre is measured to a distance of 1 mm short of the depth of the pocket.
The fibre is used in light contact with a sweeping
motion that covers the entire epithelial lining,
starting from the base of the pocket and moving
upward.20 The fibre tip is cleaned frequently with
damp gauze to prevent debris build-up.
3. The low-level laser tip is applied at right angles
and with direct contact to the external surface of
the pocket for biostimulation (Fig. 9).
4. Reprobing of the treated sites should be performed no earlier than three months after treatment to allow for adequate healing (Fig. 10), as
the tissue remains fragile for this period.

Fig. 10

The power settings and duration are determined
by the particular laser used. The manufacturers
should be consulted in order to apply the proper parameters to achieve the best results. With experience,
the user will feel comfortable enough to adapt the
protocol to his or her particular practice. This protocol may be performed by the dentist and/or hygienist as determined by the regulatory organisation in
the geographic location of the dental practice.

_Conclusion: The implication is clear
Many of our patients have periodontal disease,
but they want to be treated in a minimally invasive
way. They are not rushing out to the periodontist to
have surgery. We need to treat their disease before
it spirals out of control, especially when considering the periodontal health or the systemic health
link. There is significant proof that the addition of
laser-assisted periodontal therapy to scaling and
root planing improves outcomes in cases of mild to
moderate periodontitis, thus contributing to general health. The treatment is comfortable and not
invasive. We now have the tools and protocol to
treat our periodontal patients with an effective
procedure that they are ready to accept. What are
we waiting for?_

_contact

laser

Dr Fay Goldstep
DDS, fellow of the American College of Dentists,
the International Academy for Dental Facial
Esthetics and the American Society for Dental
Aesthetics
goldstep@epdot.com
Dr George Freedman
DDS, fellow of the American Academy of Cosmetic
Dentistry, the American College of Dentists and the
American Society for Dental Aesthetics
epdot@rogers.com

laser
2
I 25
_ 2013

[26] =>

I industry report

Photodynamic therapy
with the new active
ingredient Perio Green
Author_Dr Ralf Borchers, MSc, Bünde

_Introduction
Indocyanine green combats pathogenic bacteria
simply, effectively and without side effects.
Until now, systematic periodontal treatments have
often required the additional use of systemic antibiotic
medication as well as the normal manual treatment involving cleaning, curettage and after-care in order to
eliminate treatment-resistant pathogens more effectively and to achieve a long-lasting therapeutic effect.

In periodontology, the laser is frequently used as adjuvant therapy because of its bactericidal mode of action. Various studies using laser light to decontaminate
gingival pockets have delivered promising results.
Diode lasers (810 to 980 nm) with output levels of 1 to
2 watts are mostly used for this purpose. Depending
on the practitioner’s manual dexterity and experience,
this laser adjuvant therapy can be performed without
anaesthetic.

_Pain-free periodontal therapy without
However, the administration of antibiotics is always
cytotoxic effects

Fig. 1_Gingival redness with signs
of inflammation.

associated with side effects which unfortunately cannot be avoided with classic therapy. In the following article, a case study will therefore be used to illustrate a
new, gentle method of bacterial reduction in gingival
pockets: minimally invasive photodynamic therapy
(PDT) with indocyanine green (Perio Green, elexxion
AG) which works without antibiotics and causes no
systemic side effects or unsightly discolouration.

Photodynamic therapy is a new and promising approach to eliminating periodontal pathogens and bacteria. Unlike laser application on its own, a photodynamic active ingredient (photosensitiser) is absolutely
essential to this technique. This dye adheres to matrix
proteins in the bacterial membrane and, when exposed
to laser light of the corresponding wavelength, reacts
with the release of free oxygen radicals. This singlet
oxygen alters the plasma proteins so that they are unable to continue metabolising and hence die.
Correct use of the defined laser light source in combination with the photosensitiser is essential in this
process. This means that the dye must be specifically
coordinated with the wavelength used. If not, no absorption of the laser light takes place in the active ingredient. The energy settings employed lie within milliwatt range (mainly 100 mW) so that pain-free treatment is possible for patients.
A systemic effect (as with antibiotic administration)
can be prevented completely by choosing the right
photodynamic sensitiser. As the photosensitiser only
docks onto the bacterial membrane, no side effects
such as cytotoxic effects occur in endogenous cells. In

Fig. 1

26 I laser
2_ 2013

[27] =>

industry report

addition, no heating of the tissue ensues and there is no
evaporation of tissue or bacterial residues; anaesthesia
is usually unnecessary.

_Green photosensitiser leaves
no dye residues
While blue PDT dyes such as methylene or toluidine
blue were mainly used until recently, green photosensitisers such as indocyanine green are now available. As
the green dye is used with diode lasers with 810 nm
wavelength, it is not necessary to purchase a special
laser for PDT—compared with blue dyes this is an economic advantage to dental practices that should not be
underestimated.

Fig. 2

Indocyanine green is a “true” photosensitiser
which only reacts when the appropriate laser light is
supplied but otherwise displays no therapeutic effect
—neither negative nor positive. By contrast, the blue
PDT active ingredients have a bacteriostatic or bactericidal action even without the supply of light; strictly
speaking, therefore, they are not true photosensitisers.

ally cause prolonged blue discolouration of the tissue
and/or teeth, which patients find extremely unsightly.
Indocyanine green deals with this problem because
the sensitiser as a unique laser-activatable ingredient
has the property of coupling selectively to bacterial
cells while at the same time it is far easier to rinse off
with water than the “blue products” found on the
market.

Another disadvantage of methylene and toluidine
blue: particularly in the anterior area, they continu-

The indocyanine green that is used as the raw material for the new Perio Green is identical to the dye that

Fig. 2_The microbiological test
shows the bacterial spectrum in the
reddened area.

[PICTURE: ©SUKIYAKI]

Please contact Claudia Jahn
c.jahn@oemus-media.de

laser
2
I 27
_ 2013

[28] =>

I industry report
_Photodynamic therapy

Fig. 3

Fig. 4
Fig. 3_Drawing up the resulting
laser-activatable dye solution into a
disposable syringe.
Fig. 4_Pulsed light activation with
the elexxion laser.

Fig. 5_The microbiological germ
identification after PDT shows that
the micro-flora was eliminated
effectively.
Fig. 5

has been used successfully in medical diagnostics for
many years and is licensed worldwide. In other words,
the photosensitiser by elexxion is clinically safe and
furthermore is a certified class IIa medical device. The
use of Perio Green in combination with a diode laser
of a wavelength of 810 and variable pulsing (claros,
elexxion) is presented below.

_Initial situation
The patient was treated by me for severe periodontal disease (pocket depths from 5 to 7 mm) and had already received conservative treatment (professional
tooth-cleaning, education and motivation, debridement and curettage of pockets plus ultrasonic rinsing).
Nevertheless, clearly visible gingival redness with signs
of inflammation persisted (Fig. 1). Microbiological testing revealed a remaining bacterial spectrum in the reddened area (Fig. 2). Such refractory cases inevitably lend
themselves to treatment with antibiotics. After a detailed discussion with the patient, however, we opted
for an alternative that would be freer of side effects:
photodynamic therapy.

As the photosensitiser mixed into Perio Green is only
effective for about two hours, the tablet was dissolved
in sterile water only shortly before treatment was carried out. The resulting laser-activatable dye solution
was drawn up into a disposable syringe (Fig. 3), then
spread into the gingival pockets by a thin, blunt application tip. Owing to the low viscosity of the active ingredient, penetration down to the floor of the pocket is
guaranteed. After two minutes’ exposure to the solution and subsequently rinsing of the mouth, pulsed
light activation was performed with the elexxion laser.
To do this, a laser fibre 200 to 300 µm in diameter was
inserted into the pocket and the active ingredient was
irradiated for 30 seconds (Fig. 4).

_After-care
The patient came back a week later for recall when
another Perio Green treatment was carried out. Microbiological testing to identify germs was repeated under
the same conditions as the first test in order to monitor the success of the treatment. The results of the test
(Fig. 5) suggest that the new active ingredient Perio
Green in combination with the specific laser light of the
elexxion laser is a suitable tool for effective elimination
of micro-flora.

_Conclusion
The photodynamic therapy with indocyanine green
presented here is not only effective at combatting bacteria in the oral cavity, but it is also free of side effects,
offers uncomplicated handling for practitioner and patient and involves minimal treatment time (approx. 45
minutes for a complete UJ/LJ treatment). Other patient
treatments performed in my practice as well as current
clinical trials with Perio Green also confirm the success
of this minimally invasive form of therapy. Thus the
positive aspects of indocyanine green treatment were
presented in detail by several speakers during the DGL
(German Association for Laser Dentistry) and LEC congress (Laser Beginners Congress) held last year in early
September in Leipzig, Germany._

_contact

laser

Dr Ralf Borchers, MSc
Master of Science in Lasers in Dentistry
European Master of Oral Laser Application
Bahnhofstraße 14, 32257 Bünde, Germany
Tel.: +49 5223 10222
Dr.Borchers@praxis-borchers.de
www.praxis-borchers.de

28 I laser
2_ 2013

[29] =>

[30] =>

I industry report

Er:YAG laser etching of
hypoplastic enamel
Authors_Prof. Dr Georgi Tomov, Dr Ana Minovska, Birute Rakauskaite & Laura Navasaityte

Fig. 1_Dentition represents a pitted
hypoplastic variant of EH (a).
The extracted tooth is treated with
37% phosphoric acid for 600 sec.
(right side) and irradiated by Er:YAG
radiation (LiteTouch 200 mJ/355 Hz,
left side) and then examined
under SEM (b).

Fig. 2_Type 2 etching pattern in
normal enamel: prism peripheries
are preferentially removed (a).
Acid etching of hypoplastic enamel
showed a patchy loss of surface tooth
structure without evidence of etching
patterns (b).

Fig. 2a

30 I laser
2_ 2013

Fig. 1a

Fig. 1b

_Introduction

brown stain.1 Enamel hypoplasia is endemic in many
countries of the world and is commonly reported in association with disease of childhood. The hypoplastic
enamel has differences in structure and composition
that may affect it’s etching patterns.2 Enamel etch by
the acid can be additionally complicated by variability
of penetration depth, and strong washing and drying
affecting the bond strength.3 Er:YAG lasers are discussed as an alternative of acid etching, but there are
no scientific evidences to support this hypothesis.

Enamel hypoplasia is the most common abnormality of development and mineralisation of human teeth.
The lesion is characterised by a quantitative defect in
enamel tissue resulting from an undetermined metabolic injury to the formative cells—the ameloblasts.1
Clinically, enamel hypoplasia is seen as a roughened
surface with discreet pitting or circumferential bandlike irregularities which posteruptively acquire a yellow

Fig. 2b

[31] =>

industry report

_Aim

_Results

This in vitro study compares the etching effects of
acid etchant and Er:YAG laser on hypoplastic enamel
(HE) and normal enamel (NE) of extracted human teeth.

Normal enamel (NE) after acid etching
After treatment with 37 % phosphoric acid for
60 sec., the etched area generally showed a type 1
pattern with the prism cores preferentially removed.
However, in small, isolated areas, the etching pattern was similar to that of type 2, i.e., prism peripheries were preferentially removed (Fig. 2a). A type 3
etching pattern (general removal of tooth structure
without exposing prism structure) was also observed in other isolated areas.

_Material and methods
Teeth extracted due to advanced periodontal diseases were collected by patients. All the HE patients
had been previously diagnosed by G. Tomov and
G. Nikolova using clinical and radiographic criteria.1
Clinically, all HE teeth have showed many round,
pin head-sized pits, which were concentrated mainly
on the buccal and lingual surfaces. The teeth had been
kept in saline until the time of study. The buccal surface of each tooth (10 HE and 10 NE, all frontal teeth)
was divided and the right side was treated with 37 %
phosphoric acid for 60 sec. while the left side was irradiated by Er:YAG radiation (LiteTouch 200 mJ/35 Hz
for 10 sec., Figs. 1 a and b). The treated surfaces were
evaluated using a scanning electron microscope
(SEM), Phillips 505 scanning electron microscope
(Phillips Electronic Eindhoven, Netherlands). For SEM
analysis, the samples were fixed (2.5 % glutaraldehyde, 12 h, 4 °C), dehydrated (25–100 % ethanol),
dried, and sputter-coated with gold and examined
under different magnifications. The observed
changes were photographed and analysed.

Hypoplastic enamel (HE) after acid etching
The acid etched HE do not exhibit the typical etching pattern seen in control enamel. In the areas where
intact surface enamel was presented (without pits),
37 % phosphoric acid etching for 60 sec. leads to irregular and patchy loss of surface tooth structure
without evidence of uniform etching patterns (Fig. 2b).
After etching, no uniform removal of hypoplastic
(and hypomineralised) enamel is evident.
Normal enamel (NE) and hypoplastic enamel (HE)
after laser conditioning
A comparison of the laser-treated surfaces
showed that laser radiation caused a uniform
roughness of the enamel for both HE and NE teeth.
The morphology patterns were similar without
melted or damaged surfaces (Figs. 3a and b).
AD

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[32] =>

International
annual congress
of the DGZI

October
4–5,
2013
Berlin, Germany
Hotel Palace Berlin

FAX REPLY // +49 341 48474-390

Office Stamp

Please send me further information on the
43rd International annual congress of the DGZI
on October 4–5, 2013, in Berlin, Germany.
laser 2/13

[33] =>

I industry report

Fig. 3a

Fig. 3_The laser-treated surfaces
showed that laser radiation caused a
desired and uniform roughness of the
enamel for both HE (a) and NE (b)
teeth.

Fig. 3b

_Discussion
As the failure rates of adhesive restorations in HE
teeth may be high, the question often arises as to
whether this type of dental enamel may be successfully
etched.3 The present study addresses this important
clinical issue in one clinical variant of Amelogenesis imperfecta, namely, pitted hypoplastic type, using extracted permanent teeth. The common features of normal enamel, as well as the abnormal HE, have been described in previous publications.4-6 However, there have
been no previous studies comparing the effects of acid
etching and Er:YAG laser conditioning on hypoplastic
enamel. Our study shows that the three classical acidetching patterns found in normal enamel cannot be reproduced in the HE type. In the case of the pitted hypoplastic variant, the etching pattern was similar to that
of type 1, in which the prism cores were preferentially
removed. The pattern of prism dissolution was irregular
and did not appear to be related to prism structure. Additionally, it is also likely that, because of smaller or
weaker prisms, the length of time of the acid etch or the
concentration of etchant may not be optimal to produce
the classical etch patterns. These hypotheses are based
on findings of previous studies which found abnormalities of prism structure, as well as reduction in enamel
thickness by more than half compared to normal
enamel.6 The acid etching of a less organised hypoplastic enamel structure may result in a pattern that is not
the classic etched pattern, which may have a detrimental effect on bonding between the adhesive materials
and the affected enamel.

sues without overheating and without smear layer formation. The program “hard tissue mode” removes
enamel, dentin and dental caries effectively and without visible carbonisation or disturbance of the dental
microstructure. Evaluated under SEM, the dental tissues
treated with LiteTouch Er: YAG laser showed rough and
irregular surface without presence of smear layer.7
Treated enamel shows preserved prismatic structure,
but also strong retentions.7 These results suggested
Er:YAG lasers to be effective in the treatment of hypoplastic enamel in order to avoid acid etching. From a
clinical point of view, the presence of typical and uniform morphological changes after Er:YAG laser treatment in both normal and hypoplastic enamel suggests
that bonding of composite resins may be feasible in
most patients with HE. However, the possible advantages of Er:YAG laser conditioning of HE needs further
clinical investigation to be approved.

_Conclusions
1. In the pitted hypoplastic type of EH, classical etching
patterns after treatment with 37 % phosphoric acid
like those seen in normal enamel, are generally not observed.
2. Er:YAG laser conditioning produces similar morphological changes in both normal and hypoplastic
enamel.
Editorial note: A list of references is available from the
publisher.

_contact
The Er:YAG laser etching seems to be an alternative
approach for adhesive treatment of hypoplastic enamel
defects. LiteTouch Er:YAG laser used in this study
(Syneron, Israel) emits a beam with a 2,940 nm wavelength which is absorbed mostly by water. The mechanism of ablation is based on interaction between laser
energy and hydroxyapatite incorporated water which
results in microexplosions. It is believed that this process
is the mechanism of ablating particles from dental tis-

32 I laser
2_ 2013

laser

Prof. Dr Georgi Tomov
DDS, MSc, PhD
3 Hristo Botev Blvd., 4000 Plovdiv, Bulgaria
Oral Pathology Department, Faculty of Dental
Medicine, Medical University, Plovdiv
Mobile: +359 896742065

[34] =>

I industry report

SEM analysis of the laser
activation of final irrigants
for smear layer removal
Authors_Dr Vivek Hegde, Dr Naresh Thukral, Dr Sucheta Sathe, Dr Shachi Goenka & Dr Paresh Jain, India

_Introduction

Table 1_Subgroups depending on
the final irrigant used.
Fig. 1_Access opening.
Fig. 2_Stainless steel 10# no. K-file
for patency.

The complete restoration of the root canal
space with an inert filling material and the creation of a fluid tight seal are the goals of successful endodontic therapy.1 In order to create a fluid
tight seal, it is imperative that the endodontic
filling material closely adapts or bonds to the
tooth structure. This, however, is impaired by the
presence of a smear layer, which invariably forms
after endodontic instrumentation.2, 3 The smear

GROUPS
SUB-GROUPS

layer contains organic material, odontoblastic
processes, bacteria and blood cells.

GROUP I
(Hand Activation)

GROUP II
(Er:YAG with PIPS)

Sub Group A
(5.25 % NaOCl)

n = 10

n = 10

Sub Group B
(17 % EDTA)

n = 10

n = 10

Various materials and techniques have been reported with wide variations in their efficacy regarding the removal of the intra-canal smear
layer.2, 4 The most widely used chemical for the purpose is EDTA, used in different formulations.5 They
have been reported to consistently produce canals
with patent dentinal tubules.6 However, it has
been found to be less efficient in narrow portions
of the canal7, it requires a long application time for
optimum results8 and can seriously damage the
dentin, if used in excess.9
Clinically, endodontic procedures use both mechanical instrumentation and chemical irrigants
in the attempt to three dimensionally debride,
clean and decontaminate the endodontic system.10,11
Even after doing this meticulously, we still fall
short of successfully removing all of the infective
microorganisms and debris. This is because of the
complex root canal anatomy and the inability of
common irrigants to penetrate into the lateral
canals and the apical ramifications. It seems,
therefore, appropriate to search for new materials, techniques and technologies that can improve
the cleaning and decontamination of these
anatomical areas.12

Fig. 1

Fig. 2

34 I laser
2_ 2013

Some of these mechanically activated irrigation techniques include manual irrigation with
needles, K-file, Master cone GP points, Irrisafe,
ultrasonics, Endo-activator, Rotobrush, Roeko-

[35] =>

industry report

Fig. 3

brush, etc. The newest of the lot is PIPS, i.e PhotonInduced Photoacoustic Streaming via laser. Hence
it was chosen for the study.

_Material and methods
Forty single-rooted, extracted human teeth
were used in the study. Teeth with fractures, cracks
or any other defects were excluded. Subsequently,
they were scaled with ultrasonics for the removal
of calculus or any soft-tissue debris, washed with
distilled water and then stored in normal saline.
Standard endodontic access cavity preparations
were performed and then a stainless-steel #10
K-file (Mani K-File) was inserted into the canal
until the tip was just visible at the apical foramen
to check for patency. Chemo-mechanical preparation was done up to F3 using rotary protapers
(DENTSPLY Maillefer) along with EDTA gel (Glyde –
DENTSPLY Maillefer) for all the samples.
Irrigation of all the samples during preparation
was accomplished using 5 ml of 5.25 % sodium
hypochlorite between each file. Samples were
then divided randomly into two groups, depending upon the method of activation of the final irrigant used.

Fig. 4

Fig. 5

Group II with a newly designed 12 mm long, 400 µm
quartz tip. The tip was tapered and had 3 mm of
the polyamide sheath stripped away from its end.
The laser operating parameters used for all the
samples (using the free-running emission mode)
were as follows: 40 mJ per pulse, 20 Hz, at very
short pulse (MSP) mode, which provides the same
400 W of peak pulse power as the parameters recommended by Olivi (20 mJ, 15 Hz, SSP). The coaxial water spray feature of the handpiece was set to
‘off’ while air settings were kept at 2. The tip was
placed into the coronal access opening of the
chamber just above the orifice, and was kept stationary. During the laser irradiation cycles, the
root canals were continuously irrigated with the
final irrigant to maintain hydration levels using a
hand syringe with a 25 gauge needle positioned
above the laser tip in the coronal aspect of the access opening, according to the above protocol.
After preparation, the root canal walls were
dried using paper points. Longitudinal grooves

Figs. 3 and 4_Chemo-mechanical
preparation up to F3.
Fig. 5_Group I – Hand activation
using stainless steel #25 K-file
(n = 20).

Figs. 6a & b and 7_Group II – Er:YAG
activation using Photon-Induced
Photoacoustic Streaming tip (n = 20).

These groups were further divided into two
subgroups, depending upon the final irrigant used
(Tab. 1):
– Subgroup A: 5.25 % NaOCl (n = 10)
– Subgroup B: 17 % EDTA (n = 10)

Fig. 6a

Activation of the irrigant for group I was done
mechanically by agitating a stainless steel #25
K-file (2 % taper) in the canal when it was filled
with the final irrigant solution.
An Er:YAG laser with a wavelength of 2,940 nm
(Fotona) was used to irradiate the root canals in

Fig. 7

laser
2
I 35
_ 2013

[36] =>

I industry report
were made on the distal and mesial root surfaces,
preserving the inner shelf of the dentin surrounding the canal. Roots were then sectioned with the
help of a chisel and mallet. Samples were then subjected to SEM to visualize the surface characteristics.

_Results
Fig. 8a

Fig. 8c

Fig. 8b

Fig. 9a

Fig. 9b

Fig. 9c

Fig. 10a

Fig. 10b

Group I specimens (hand activation) consistently exhibited a thick smear layer with NaOCl
(subgroup A, Figs. 8a–c) while comparatively less
smear layer was observed with EDTA (subgroup B,
Figs. 9a–c). SEM examination demonstrated that
when NaOCl irrigation was applied, a noticeable
smear layer and occluded dentinal tubules remained on the treated surface. Debris, defined as
dentin chips and pulp remnants loosely attached
to the internal surface of the root canals, was present in the specimens in subgroup A (Group I). In the
specimens of EDTA, mostly open dentinal tubules
were observed in the coronal and the middle third
while in the apical third of all specimens occluded
tubules were observed.
Group II specimens treated with the Er:YAG
laser with PIPS showed the most effective removal
of the smear layer from the root canal walls
compared to Group I (hand activation) specimens. At higher magnifications (1,000x–2,000x)
subgroup B (17 % EDTA) showed better results
with exposed and intact collagen fibers and
open dentinal tubules, even in the apical third
(Figs.11a–c), when compared with subgroup A
(5.25 % NaOCl), where open dentinal tubules
along with scattered dentinal chips were observed
(Figs. 10a–c). None of the SEM images indicated
signs of dentin melting.

_Discussion

Fig. 10c

Fig. 11b

Fig. 11a

Fig. 11c

Current instrumentation techniques using rotary instruments and chemical irrigation still fall
short of successfully removing the smear layer
from inside the root canal system. Mechanical activation of the chemical irrigant plays an important role in removing the smear layer. Fiber-guided
lasers have also been used hoping to achieve some

Fig. 8_Group I—Hand Activation (5.25 % NaOCl—Subgroup A):
coronal third (a), middle third (b), apical third (c).
Fig. 9_Group I—Hand Activation (17 % EDTA—Subgroup B):
coronal third (a), middle third (b), apical third (c).
Fig. 10_Group II—Er:YAG with PIPS (5.25 % NaOCl—Subgroup A):
coronal third (a), middle third (b), apical third (c).
Fig. 11_Group II—Er:YAG with PIPS (17 % EDTA—Subgroup B):
coronal third (a), middle third (b), apical third (c).

36 I laser
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[37] =>

industry report

degree of success, however, there is limited availability of literature regarding this topic.
The concept of laser-activated irrigation is based
on cavitation. Because of the high absorption of
water by the mid-infrared wavelength of lasers, the
cavitation process generates vapor-containing
bubbles, which explode and implode in a liquid environment.13 This subsequently initiates pressure/
shock waves by inducing shear force on the dentinal wall. In a water-filled root canal, the shock
waves could potentially detach the smear layer and
disrupt bacterial biofilms. To efficiently activate irrigant and generate shock waves in the root canal,
lasers with wavelengths from 940–2,940 nm have
been used.14–22
5.25 % sodium hypochlorite was used in Group I
because the majority of practitioners still use only
sodium hypochlorite as the irrigant along with
hand instruments. Hence sodium hypochlorite was
used in Group I. To remove inorganic debris of the
smear layer, use of aqueous EDTA had been recommended. But prolonged use of EDTA can cause
dentinal erosion of the root canal by decalcifying
the peritubular dentin. The recommended time in
endodontic literature is only 1–2 minutes. Hence,
17 % aqueous EDTA was used for one minute in
Group II to minimise time and damage.
The results of this study indicate that NaOCl subgroups could remove the smear layer in the coronal
third; however, it did not remove the smear layer
from the middle and apical third of the canal wall.
EDTA is efficient in removing the smear layer, which
is evident in this study for both groups. The effects
of EDTA were limited to the coronal and middle third
in Group I (hand activation) while it was effective
even in the apical third for Group II (Er:YAG-PIPS).
Ciucchi et al. stated that there was a definite decline
in the efficiency of irrigating solutions along the
apical part of the canals.23 This can probably be explained by the fact that dentin in the apical third is
much more sclerosed and there are fewer dentinal
tubules present there.24 Also apical reach, canal
configuration, and smooth transition are a few of
the anatomical key factors. Hence root canal success is dependent on apical third anatomy.
The Er:YAG laser used in this investigation
proved to be more effective than the conventional
technique in removing the smear layer. This finding
can be attributed to the photomechanical effect
seen when light energy is pulsed in liquid.25-27 When
activated in a limited volume of fluid, the high absorption of the Er:YAG wavelength in water, combined with the high peak power derived from the
short pulse duration that was used for five seconds

(three cycles), resulted in a photomechanical phenomenon. A profound “shockwave-like” effect is
observed when a radial and stripped tip is submerged in a coronal chamber above the orifice. As a
result of the very small volume, this effect may remove the smear layer and residual tissue tags and
potentially decrease the bacterial load within the
tubules and lateral canals.28-30 By using lower subablative energy (40 mJ) and restricting the placement of the tip to within the coronal portion of the
tooth only, the undesired effects of the thermal energy, as previously described in the literature, was
avoided.31-45 In the current study, the smear layer
and debris were not removed by thermal vaporisation, but probably by photomechanical streaming
of the liquids, which were laser activated in the
coronal part of the tooth.
Giovani Olivi and Enrico DiVito have described
this light energy phenomenon as photon-induced
photoacoustic streaming (PIPS). The effect of irradiation with the Er:YAG laser equipped with a tip of
novel design at sub-ablative power settings (20 mJ,
15 Hz, SSP, 400 W peak power) is synergistically enhanced by the presence of EDTA. This leads to a significantly better debridement of the root canal,
contributing to an improvement in treatment efficacy. Hence, the PIPS technique resulted in pronounced smear layer removal when used together
with EDTA and at the settings outlined.

_Conclusion
Within the limitations of this study, the Er:YAG
laser with PIPS showed significantly better smear
layer removal than the hand-activation group. At
the energy levels and with the operating parameters used, no thermal effects or damage to the
dentin surface was observed. With the described
settings, the Er:YAG laser produced a photomechanical effect, demonstrating its potential as an
improved alternative method for debriding the
root canal system in a minimally invasive manner._
Editorial note: A list of references is available from the
publisher.

_contact

laser

Prof. Dr Vivek Hedge
Professor and Head
Department of Conservative Dentistry and
Endodontics
M A Rangoonwala Institute of Dental Sciences
Pune, India

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_ 2013

[38] =>

I manufacturer _ news

Manufacturer News
BIOLASE

Syneron Dental Lasers

Royalty agreement with Lambda

Bronze Winner at the
A’Design Award

[PICTURE: ©WAVEBREAKMEDIA]

In April, international dental laser manufacturer BIOLASE announced that it has entered into an agreement with Lambda, an Italian laser company. The
agreement involves payment from Lambda for past
royalties and established royalty rates for future
sales involving BIOLASE’s technology. The royalties
from Lambda relate to intellectual property that
BIOLASE owns in connection with Er:YAG lasers and
does not involve the company’s patented WaterLase
technology, which uses Er,Cr:YSGG lasers, or its de-

livery systems, including handpieces and consumables. Federico Pignatelli, Chairman and CEO of
BIOLASE, said that the company is very pleased
about the agreement.
“We have invested heavily in our intellectual property for laser dentistry, as well as other medical
fields. Currently, we have over 340 US and international patents and patents pending. We will not
tolerate what we believe to be any infringement of
these patents and will continue to protect our rights,”
he stated.

Syneron Dental Lasers has been selected the
Bronze winner of the A’Design Award in Scientific Instruments, Medical Devices and Research Equipment Design Category. The international A’Design
Award recognises the best designs, design concepts and design-oriented products & services. The
A’Design Award was born out of the desire to underline the best designs and well-designed products.

BIOLASE Europe GmbH
Paintweg 10
92685 Floss, Germany
info@biolase-europe.com
www.biolase.de

Fotona

X-Runner™ Automated Handpiece Technology
Fotona’s new X-Runner™ digitally controlled laser
handpiece is the industry’s first dental handpiece
to offer instantly adjustable spot size and shape.
Designed for the award-winning LightWalker AT
dental laser, the X-Runner™ handpiece enables
routine hand movements to be fully automated,
making it an ideal tool whenever deep, wide or precise cuts are required.
Dental laser professionals at IDS were impressed
by X-Runner’s performance and were amazed by
the completely new treatment possibilities that an
automated handpiece enables. With X-Runner, the
shape and size of an ablation area can be selected
in advance to facilitate a wide range of hard- and
soft-tissue treatments, from standard cavity and
veneer preparations to high-precision surgical and
implantology procedures.
Practitioners can also switch instantly between the
new automated mode and the classical, singlespot mode without need to swap handpieces, thus
maximizing convenience and efficiency.

38 I laser
2_ 2013

LiteTouch™, highlighted at the A’Design Award Exhibition 2013, Ex-Chiesa di San Francesco Museum, Como,
Italy.

The X-Runner handpiece can be installed with only
a simple software upgrade and is compatible with
all standard Fotona handpiece parameters. Visit
www.Fotona.com for more information.

Mr Ira Prigat, president & CEO of Syneron Dental
Lasers, accepted the Bronze Award on Sunday, April
14, 2013, at a stunning Gala Night held at the Villa
Gallia in the Lake Como area in Italy. The award-winning products and designs are highlighted at the
international public via the A’Design Award exhibition at the MOOD: Museum of Outstanding Design
(www.museumofdesign.com/exhibitions.php).
Syneron Dental Lasers participated at the A’Design
Award Exhibition 2013 and exhibited its winning
LiteTouch™ design at the Ex-Chiesa di San
Francesco between 15 and 27 April, 2013.

Fotona d.d.
Stegne 7
1000 Ljubljana, Slovenia

Syneron Dental Lasers
Tavor Building, Industrial Zone
20692 Yokneam Illit, Israel

www.fotona.com

dental@syneron.com

www.lightwalkerlaser.com

www.synerondental.com

[39] =>

implants

elexxion

Antimicrobial periodontal and peri-implantitis
treatment
With the new photodynamic active ingredient Perio
Green, elexxion AG based in Radolfzell, Germany, is
bringing colour into laser-assisted periodontal and
peri-implantitis treatment. The new class IIa medical device, which is based on the clinically proven
PDT dye indocyanine green and reacts specifically
to the light frequency of elexxion lasers, provides
highly effective and painless
adjuvant treatment of periodontitis and peri-implantitis
—with no risk to hard dental
and soft tissue and without
causing discolouration or
systemic effects.

causes no thermal or mechanical effects; anaesthesia is usually unnecessary.

If the active ingredient is irradiated by a diode laser with a wavelength of 810 nm,
active oxygen is released. This singlet oxygen
changes the micro-organisms so that they are no
longer able to metabolise and are killed. The treatment is virtually painless for patients because it

elexxion AG
Schützenstraße 84
78315 Radolfzell, Germany

The actual Perio Green treatment, which can be repeated any time in recall appointments, takes
about an hour. If the method is used during a professional oral hygiene session,
the time is reduced to only
about 30 minutes. Furthermore, as this type of laserassisted therapy is non-invasive, it can be delegated
to a suitably trained dental
nurse.

You can also subscribe via
www.oemus.com/abo

info@elexxion.com
www.periogreen.com/en

Henry Schein

I hereby agree to receive a free trial subscription of
implants

(4 issues per year). I would like to subscribe to implants
for € 44 including shipping and VAT for German customers,
€ 46 including shipping and VAT for customers outside of
Germany, unless a written cancellation is sent within 14 days
of the receipt of the trial subscription. The subscription will
be renewed automatically every year until a written cancellation is sent to OEMUS MEDIA AG, Holbeinstr. 29,
04229 Leipzig, Germany, six weeks prior to the renewal date.

MoonWalk© London to raise awareness
of Breast Cancer
on the massive task of organising the Baggage Tent
as volunteer Crew. Travelling from Henry Schein’s
Gillingham location for the 6.00 pm to Midnight
shift, the volunteers made up mainly of Henry
Schein team members from Gillingham and Maidstone but also including some of their family members and a supplier partners (Diverse Catering)
helped to look after the 17,000 bra-clad walkers
who were raising money for this important cause. Apart from the responsibility of safekeeping the thousands of
bags, and ensuring the weary walkers
didn’t have a long wait when they returned, walkthewalk© was looking to
Henry’s Angels for their special brand
of enthusiasm to cheer and spur on the
walkers throughout the evening.

Led by Henry’s Angels, a total of 54 volunteers—the
largest number of volunteers that walkthewalk©
have ever had join them from one company—
made their way to Battersea Power Station to take

Reply via Fax +49 341 48474-290 to OEMUS MEDIA AG
or per E-mail to grasse@oemus-media.de

Last Name
First Name
Company
Street

ZIP/City/County
E-Mail
Signature

Henry Schein UK
Centurion Close
Gillingham Business Park
Gillingham ME8 0SB, England

Notice of revocation: I am able to revoke the subscription within
14 days after my order by sending a written cancellation to
OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.
Unterschrift

www.henryschein.co.uk

Henry’s Angels, a group of volunteers from Henry
Schein UK, based in Gillingham, Kent, supported
the MoonWalk© London on Saturday, 11 May 2013.
The MoonWalk© is organised by breast cancer
grant making charity walkthewalk© which has to
date raised over £84 million for vital breast cancer
care and cancer research causes. The MoonWalk©
London is already in its 16th year.

OEMUS MEDIA AG
Holbeinstraße 29, 04229 Leipzig
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
E-Mail: grasse@oemus-media.de

[40] =>

I education

Master of Science
in Lasers in Dentistry
Professional education programme
_Patients are increasingly seeking alternative
therapies, expecting their dentist to be well informed and to provide information regarding more
gentle treatments. Through the use of laser technology, dentists can meet these expectations and
provide patients with added benefits compared to
more traditional methods.
The master programme, MSc in Lasers in Dentistry, has been developed in order to enable dentists
to specialize in the full range of dental laser thera-

pies. Building upon a first higher education degree
in dentistry, this two-year modular master’s course
enables practicing dentists to specialize in dental
laser applications by providing both theoretical and
practical training.
Approximately 150 dentists, from all over the
world, have successfully graduated from our MSc
programme and, together with graduates from our
mastership and fellowship courses, we are pleased
to have a globally active alumni network.

_Course objectives
The course balances the teaching of the medical
aspects with extensive practical skill training on the
dental application of laser systems. The close interdisciplinary cooperation between dentistry and
physics is of significant importance in this field. In
addition to teaching the latest research results,
proactive problem solving to improve dental laser
therapies is addressed.
After extending participants’ basic knowledge in
this subject area, the study goals focus on the transfer of specialist knowledge that is at the forefront of
laser dentistry. Treatment methods, the planning
and preparation of treatments, the systematic organisation of scientific and clinical findings, as well
as independent, responsible conduct, are of central
importance.

_What to expect
During the course you can expect the following:
– Use of different laser systems from leading manufacturers, covering all available wavelengths,
during skill training sessions and practical exercises
– Live operations on patients or via direct monitor
broadcasting
– Provision of all necessary organic materials and
safety glasses for individual practice with lasers

40 I laser
2_ 2013

[41] =>

NOVEMBER 15–16,
2013// BERLIN,
GERMANY//MARITIM HOTEL

LASER
START UP
2013
22nd
ANNUAL
CONGRESS
OF THE
DGL e.V.

impressions
DGL / / LASER
START UP 2012
Scan QR-Code with
your Smartphone
(Quick Scan, etc.)

PLEASE FAX THIS FORM

NAME/E-MAIL

+49 341 48474-390
OFFICE STAMP

Further information about:

❏ LASER START UP 2013

❏ 22nd ANNUAL CONGRESS OF THE DGL e.V

November 15–16, 2013, Berlin, Germany
laser 2/13

[42] =>

Call for papers
DGL | German Society for Laser Dentistry
22nd International Annual Congress
15 - 16 November 2013 in Berlin, Germany
Titel

Author(s)

Institute(s)
Adress
Phone/Fax/E-Mail

/

/

Abstract

Session:
(1) Scientific Session
(2) Case Presentation

Presentation:
(1) Lecture
(2) Poster Presentation
(3) Video Presentation

Abstract:
Please arrange the text in the order of:
• Purpose: Give a brief overview of the topic and in this
context state the main objective of the study.
• Material and Methods: Describe the basic design, subjects
and scientific methods.
• Results: Give main results of the study including confidence
intervals and exact level of statistical significance, whenever
appropriate.
• Conclusion: State only those conclusions supported by the
data obtained and whenever appropriate, the direct clinical
application of the findings (avoid speculations)

Authors:
The name of the person presenting the paper should be marked by an asterisk
Please include a copy on CD!
Presentation:
Only via computer/beamer
Adress:
Prof. Dr Norbert Gutknecht, Universitätsklinikum Aachen,
Klinik für ZPP/DGL, Pauwelsstraße 30, 52074 Aachen, Germany
Tel.: +49 241 8088164, Fax: +49 241 803388164
E-Mail: sekretariat@dgl-online.de

[43] =>

education

– Meticulously compiled course documentation
and additional specialist literature which serve as
a future work of reference
– Encouragement to participate actively in international scientific congresses and to publish in scientific journals
– Independent access to a modern e-learning environment, supported by scientific staff.

Attendance Required
Home study & E-learning

Laser safety and optics
5 days, 4 CP

Caries diagnose & Laser physics
5 days, 5 CP

Clinical treatments/case
documentation in your own
practice

Home study & E-learning

Home study
150 hrs, 5 CP

Erbium Laser
5 days, 4 CP

Master Thesis
Experiments/research

Home study & E-learning

LLLT, Statistics, Symposium
5 days, 4 CP

Participants must be approbated dentists with a
minimum of two years of experience in a clinic or
dental practice. Candidates who are not native
speakers of English must provide appropriate proof
of language qualification.

Home study,
incl. use of the laboratory
300 hrs., 10 CP

Home study & E-learning

Diode lasers & PDT
4 days, 3 CP
Home study & E-learning

Nd:YAG lasers
5 days, 4 CP

2nd Academic year

This career-accompanying course requires dentists to attend ten modules (38 days) over two years.
These attendance modules are supplemented by
e-learning enabling contact with the lecturers
throughout the duration of the course. This mix of
learning methods allows dental practitioners to balance their studies with their professional commitments.

Home study & E-learning

1st Academic year

This master programme is aimed at dental practitioners who want to train as specialists in laser
dentistry and who wish to qualify with a highly
recognised degree, while continuing with their career.

Master Thesis
Experiments/research

Clinical treatments/case
documentation in your own
practice

Home study,
incl. use of the laboratory
300 hrs., 10 CP

Home study
150 hrs, 5 CP

Home study & E-learning

CO2 lasers, statistics
4.5 days, 4 CP
Home study & E-learning

Marketing, symposium
4 days, 2 CP
Home study & E-learning

Graduates are awarded the academic title “Master of Science“ and, as such, are recognized as specialists in the field of laser therapy in dentistry. The
awarding body is the RWTH Aachen University. Successful participants receive a total of 60 credit
points in accordance with the European Credit
Transfer and Accumulation System (ECTS). Graduates receive master diplomas in English and in German. An EU-recognised diploma supplement is also
provided.
For each module that is successfully completed
training points for the German Federal Dental Association (Bundeszahnärztekammer) are awarded. A
total of 466 training points are awarded during the
two year programme. Furthermore, on completion
of the appropriate training module, participants receive Laser Safety Officer (LSO) certification.
The MSc in Lasers in Dentistry has been accredited by the accreditation agency, ASIIN e.V. It is the
first of its kind in Germany and the first worldwide
accredited master programme in the field of laser
dentistry. It is recognized in the EU, all countries of
the Washington Accord and the Bologna-Reform as
a national and internationally valid academic degree. Lectures as well as skill training sessions are
held in the modern facilities of the Aachen Dental

Final examination

Laser Center and the University Hospital Aachen.
Course participants have access to scientific staff of
world-class experts in their specialised fields. The
course attracts dentists from across the globe and
participants are encouraged to network with their
fellow students during numerous social events, additional networking opportunities at international
scientific conferences and through the alumni network, WALED._

_contact

laser

RWTH International Academy
Verena Jacoby, MA
Programme Manager Lasers in Dentistry
Kackertstraße 10
52072 Aachen, Germany
Tel.: +49 241 80-23543
Fax: +49 241 80-92525
info@academy.rwth-aachen.de
www.academy.rwth-aachen.de

laser
2
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_ 2013

[44] =>

I meetings

IDS 2013 sets new records
Source_Koelnmesse

_The 35th International Dental Show (IDS)
posted record-setting results when it closed on
Saturday, 16 March 2013, after five days in Cologne.
The world’s leading dental trade fair attracted
125,000 trade visitors from 149 countries. That figure
represents an increase of six per cent compared to the
previous event. Records were also set in terms of the
number of exhibitors and the occupied exhibition
area. This year 2,058 companies (+5.3 per cent) from
56 countries presented a wide range of innovations,
products and services on 150,000 square metres of
exhibition area (+3.4 per cent). With 68 per cent of the
exhibitors and 48 per cent of the visitors coming from
abroad, the fair was also more international than ever
before. “The degree to which IDS’s global attraction
increases from one event to the next is impressive,”
said Dr Martin Rickert, Chairman of the Executive
Board of the Association of German Dental Manufacturers (VDDI). “Thanks especially to the trade visitors’
high level of internationality and decision-making
authority, we expect the positive effects of the fair to
continue for the rest of the business year. We’re also
expecting sustained growth in the German and inter-

44 I laser
2_ 2013

national healthcare markets.” Katharina C. Hamma,
Chief Operating Officer of Koelnmesse, added, “IDS
has good reason to consider itself the world’s leading
dental trade fair. It provides the perfect conditions for
sharing information, communicating and doing
global business. The exhibitors were delighted with
the large number of excellent business contacts they
were able to make, and the visitors were excited by the
comprehensive product range, as well as the numerous innovations that were presented.”

_Highly satisfied visitors
The visitor survey revealed that 74 per cent of visitors said they were (very) satisfied with IDS. What’s
more, the fair's comprehensive spectrum of products
and numerous innovations caused 79 per cent of the
visitors to rate the product range as either good or
very good. In terms of reaching their trade fair goals,
74 per cent of the visitors surveyed said that they were
satisfied or very satisfied. Overall, 95 per cent of the
visitors surveyed would recommend a visit to IDS to
their business partners.

[45] =>

meetings

I

laser
2
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_ 2013

[46] =>

I meetings
has impressively demonstrated its ability to meet
this challenge. But brainstorming for a (dentally)
healthy future isn’t required within the dental sector alone. It also has to come from public policymakers. Germany is at an excellent international
level technically and scientifically, as was demonstrated by this year's IDS. However, austerity regulations are making it more difficult for innovations
to make their way to the dentists' practices.” At the
end of IDS 2013, Uwe Breuer, President of the Association of German Dental Technicians' Guilds (VDZI),
said in summary, “IDS has proven itself as the meeting place for specialists from dental technology laboratories and dental practices. At this leading global
trade fair, both of these groups were once again able
to get a comprehensive picture of the new developments and product refinements in the dental industry and make their evaluations together. From
the point of view of the VDZI, it is becoming increasingly clear that master dental technicians and
dentists, each group with its own specialised expertise, will have to work together even more closely
in the future. A clear indication of this collaboration
was given at IDS when the VDZI and the German Association for Oral Implantology (DGOI) presented
the programme for the annual DGOI convention
which will take place in September.”

_Tremendous interest in innovations
Individuals from the specialist trade as well as
end users were especially interested in innovative
products and technologies. Nowadays it is almost
taken for granted that developers will come up
with functional enhancements, more rational digital workflows and software updates for existing
CAD/CAM systems. Even so, many participants
were still impressed by the large number of new
materials for computer-controlled processing. In
addition to the always popular areas of CAD/CAM,
there have also been advancements in the details
of various specialist disciplines—for example, in
prophylactic care, the preservation of teeth and
implantology.

_Positive conclusions reached by BZÄK
and VDZI
“IDS is the top event for the dental market. In
2013, it again drew the attention of the international dental world,” concluded Dr Peter Engel,
President of the German Dental Association (BZÄK).
*The figures concerning visitors,
exhibitors and stand space for this
trade fair were determined and certified
according to the standardized definitions
used by the Society for Voluntary Control
of Fair and Exhibition Statistics (FKM).

46 I laser
2_ 2013

“Demographic developments will make continuous updates of healthcare structures necessary, and
they will be dependent on technical advances and
innovative therapies. At the trade fair, the industry

IDS—the International Dental Show is held in
Cologne every two years. The event is organized by
the Gesellschaft zur Förderung der Dental-Industrie
mbH (Society for the Promotion of the Dental Industry, GFDI), which is the commercial enterprise of
the Association of German Dental Manufacturers
(VDDI). The trade fair is staged by Koelnmesse GmbH,
Cologne.

_IDS 2013 in figures
At IDS 2013 a total of 2,058 companies from 56
countries (2011: 1,954 companies from 58 countries) occupied a gross exhibition space of 150,000 m²
(2011: 145,000 m²). Among the participants were
643 exhibitors and 12 additionally represented
companies from Germany (2011: 654 exhibitors and
17 additionally represented companies) and 1,347
exhibitors and 56 additionally represented companies from abroad (2011: 1,250 exhibitors and 33 additionally represented companies). The proportion
of visitors from abroad was 68 per cent (2011: 66 per
cent). Including the estimates for the last day of the
fair, around 125,000 trade visitors from 149 countries came to IDS (2011: 117,697 trade visitors from
149 countries); 48 per cent (2011: 42 per cent) of
them came from abroad.*
The next IDS—36th International Dental Show will
take place from 10 to 14 March 2015._

[47] =>

meetings

Why use laser
if you can do without?
Invitation to the 22nd Annual Congress of DGL
Dear Colleagues,
Our 22nd International Annual Congress, which
takes place in Berlin from 15 to 16 November, 2013,
has the provocative title “Why use laser if you can do
without?”. On the one hand, this choice of title implies
critical questions by dentists who have not yet included laser to their repertoire. On the other hand, scientific evidence will be presented which states that
professional and purposeful application of laser tech-

Invitation
DGL General Meeting
Friday, 15 November 2013
Hotel Maritim, Berlin
2 to 3 p.m.
TOP 1

Approval of the agenda

TOP 2

Report of the DGL executive board

TOP 3

Auditor Report

TOP 4

Ratification of the current members of the board

TOP 5

Election of the DGL executive board

TOP 6

Accounting/GOZ

TOP 7

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DGL Congress 2014

TOP 9

Requests for the general meeting

TOP 10

Various

nology can entail decisive advantages for both patient
and dentist in various indications.
For this reason, speakers from German universities
and experienced specialists from various international universities will contribute to the scientific lectures. Simultaneous interpretation from English to
German will ensure that our German participants will
be able to follow all abstracts easily. In order to make
theoretical statements and scientific research “come
to live”, colleagues with a more practical background
and from universities will introduce clinical cases and
their treatment. In addition, DGL workshops will be
offered, in which treatment concepts for various indications can be presented and discussed.
We invite all our colleagues to send in their
speeches, case presentations and posters until 31 May,
2013. Furthermore, we would like to inform our more
science-oriented colleagues that congress abstracts
will be printed in the renowned specialist magazine
“Laser in Medical Science” (LIMS), and are thus acknowledged as a valid scientific effort.
Take part in the 22nd International Annual Congress of DGL and contribute to its scientific success!
For any questions or requests, please contact our
headquarters (Ms Speck).
Best wishes from Aachen, Germany!

Prof. Dr Norbert Gutknecht
- DGL President -

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[48] =>

NEWS
Launch of

Israeli society of
laser dentistry

Herbal lollipops may

Recently, the Israel Association of Laser Dentistry
(ISLD) was launched at an event sponsored by international dental laser technology provider Syneron
Dental Lasers in collaboration with Oral-B. Many Israeli practitioners from all over the country joined the
event at the Dan Tel Aviv Hotel. The society aims to
advance laser dentistry in Israel.

Fight periodontal
pathogens
Researchers from the US have found new evidence
that glycyrrhizol A from the Chinese herb Glycyrrhiza
uralensis, more commonly known as licorice root, in
lollipops improves oral health. In a recent study, they
found that the herbal compound reduced the activity
of the main agents of periodontal disease and tooth
decay.

In the in vitro study, researchers from the University
of Iowa inoculated agar plates with a number of
pathogens, including agents associated with periodontal disease, such as Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia
and Streptococcus mutans, which causes dental
caries.
“The results suggest that the sugar-free herbal lollipops may play a role in decreasing the levels of
certain periodontal pathogens in the oral cavity,” the
researchers concluded. “More research, including

clinical research, is needed to assess the efficacy of
glycyrrhizol A in reducing periodontal pathogens,”
they added.
Glycyrrhizol A is isolated from the Chinese plant Glycyrrhiza uralensis. Another study, published in the
Journal of Natural Products in 2011, also found that
the substance has antibacterial properties. The researchers reported that it killed the main bacteria responsible for tooth decay and gum disease. The findings were presented at the International Association
for Dental Research’s annual meeting last month.

ISLD is the result of the joint vision of and intensive
collaboration between Prof. Adam Stabholz, the Dean
of the Hadassah School of Dental Medicine at the Hebrew University of Jerusalem, and Ira Prigat, President and CEO of Syneron Dental Lasers.The founders
hope that it will help promote awareness of the important role of dental lasers in oral treatment in Israel
by encouraging research and other activities to advance the field of laser dentistry among Israeli dentists. Prigat said that country’s dental market and citizens will benefit from the initiative.
[PICTURE: ©YURI ARCURS]

Emotional intelligence affects

Dentist–patient relationship
Educators at Case Western Reserve University wondered why some high-performing students did not fare
as well in the clinic. The researchers thus examined
whether EI was a determining factor.
The study involved 100 third- and fourth-year students
from the university’s School of Dental Medicine, who
completed a questionnaire about self-awareness,
self-management, social awareness and relationship
management. Their overall clinical performance, including diagnosis, treatment planning skills, organisation and patient management, was assessed by two
preceptors.
After a thorough analysis, the researchers found a correlation between high EI scores and high clinical performance. They said that EI skills in self-management,
which involves self-control, initiative, trustworthiness
and adaptability, were significant predictors of clinical

48 I laser
2_ 2013

grades. However, no such correlation with self- and social awareness was found. In addition, the researchers
found the EI scores regarding relationship management difficult to determine owing to the transient nature of the interaction between student and patient
during the two-year training. The study, titled “What is
the Relationship Between Emotional Intelligence and
Dental School Clinical Performance?” was published in
the April issue of the Journal of Dental Research.

“The idea was to launch the ISLD as a forum for sharing and exchange among scientists, clinicians and
the industry’s dental laser companies that are providing the technology and making it available at dental clinics. The ISLD will establish hands-on practice
seminars, education, training and regular meetings
to study the various laser technology solutions,”
Stabholz said.

[49] =>

Fear of tooth loss greater than

Parents' saliva (on paciﬁers) reduces

Fear of root-canal treatment

Allergy risk in infants

Although it is generally believed that root-canal treatment is considered one of the most unpleasant medical procedures by the majority of patients, a recent
survey has revealed that most people are more afraid
of losing their permanent teeth than undergoing rootcanal treatment or getting the flu—despite the particularly high flu activity this season. The survey was
conducted at the beginning of the year by members of
the American Association of Endodontics.Among other
findings, they found that 74 per cent of survey partici-

pants hoped to avoid losing a permanent tooth, while
73 per cent said that they wanted to avoid the flu. In addition, 70 per cent of the participants said that they
would avoid undergoing root-canal treatment and 60
per cent were more anxious about root-canal treatment than getting a tooth pulled (57 per cent) or receiving a dental implant (54 per cent). According to the
association, an estimated 15.1 million root-canal
treatments were performed in 2005 and 2006, of
which 10.9 million (72 per cent) were performed by
general dentists and 4.2 million (28 per cent) by endodontists.

Researchers from Sweden have suggested that
parental saliva stimulates a baby’s immune system
owing to the altered oral flora and thus reduces the risk
of allergy development. In a study of almost 200 infants, they found that children whose parents sucked
their pacifiers to clean them during the first six months
of life had a significantly reduced risk of eczema and
asthma.

The survey was conducted in preparation for the seventh annual Root Canal Awareness Week taking place
in the US from March 17 to 23. The aim of the program
is to encourage collaboration between general dentists
and endodontists in order to preserve patients' natural
teeth and to help anxious patients. Several documents
about the subject can be downloaded free from the association's website.

The study involved 184 children whose mothers were
recruited between 1998 and 2003 from a larger European allergy study at the Mölndal Hospital in Gothenburg, Sweden, when they were still pregnant.

US adults delay dental care

Due to uncertain
economy
A survey of more than 1,000 US adults has revealed
that 36 per cent have delayed or would delay dental
treatments owing to their current financial situation.
Although more than 80 per cent knew about the
long-term financial implications of neglecting oral
health, many people seemed to put dental care off
until they experienced significant pain or had a dental emergency, the investigators said. The survey involved 501 men and 504 women aged 18 and older.
It was conducted as a telephone survey by market
research agency ORC International on behalf of Aspen Dental, one of the largest networks of dental care
providers in the US, between Feb. 28 and March 3.
Overall, the results were in line with other studies
that found a general decline in health care spending.
More than 30 per cent of the people surveyed re-

ported that their net salary was lower this year than
in 2012. Moreover, 44 per cent had no dental insurance. The number was especially high among those
with an annual income below $35,000 (61 per cent),
the investigators said. They also found that only 1 in
10 agreed that routine dental visits were critical to
their overall well-being.
“The survey is a stark reminder of the need to improve public understanding about the importance of
dental care to overall health, as well as create a better understanding about the long-term effects of ignoring dental visits, including the link between gum
disease and other serious conditions such as diabetes and stroke,” said Dr Nathan Laughrey, who
runs a number of Aspen Dental practices.

Overall, the study suggested that parental pacifier
sucking could be a simple and safe method to reduce
allergy development in infants and young children.
However, further studies are needed to confirm the
findings.
According to the researchers, parental cleaning of the
pacifier by sucking was associated with a decreased
risk of allergy development. The incidence of both
eczema and asthma was greatly reduced in children
whose parents sucked their pacifier. In addition, the
analysis found that parents of vaginally delivered infants were more likely to have this habit than parents
of infants delivered by caesarean section were.
The study, titled “Pacifier cleaning practices and the
risk of allergy development”, was published online on
6 May in the Pediatrics Journal ahead of print.

laser
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_ 2013

[50] =>

I about the publisher _ imprint

laser

international magazine of

laser dentistry

Publisher
Torsten R. Oemus
oemus@oemus-media.de
CEO
Ingolf Döbbecke
doebbecke@oemus-media.de
Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de
Editor in Chief
Norbert Gutknecht
ngutknecht@ukaachen.de
Coeditors in Chief
Samir Nammour
Jean Paul Rocca
Managing Editors
Georg Bach
Leon Vanweersch
Division Editors
Matthias Frentzen
European Division
George Romanos
North America Division
Carlos de Paula Eduardo
South America Division

Senior Editors
Aldo Brugneira Junior
Yoshimitsu Abiko
Lynn Powell
John Featherstone
Adam Stabholz
Jan Tuner
Anton Sculean
Editorial Board
Marcia Martins Marques, Leonardo Silberman,
Emina Ibrahimi, Igor Cernavin, Daniel Heysselaer,
Roeland de Moor, Julia Kamenova, T. Dostalova,
Christliebe Pasini, Peter Steen Hansen, Aisha Sultan, Ahmed A Hassan, Marita Luomanen, Patrick
Maher, Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit Sahar-Helft,
Lajos Gaspar, Paolo Vescovi, Marina Vitale, Carlo
Fornaini, Kenji Yoshida, Hideaki Suda, Ki-Suk Kim,
Liang Ling Seow, Shaymant Singh Makhan, Enrique Trevino, Ahmed Kabir, Blanca de Grande, José
Correia de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep Arnabat,
Ahmed Abdullah, Boris Gaspirc, Peter Fahlstedt,
Claes Larsson, Michel Vock, Hsin-Cheng Liu, Sajee
Sattayut, Ferda Tasar, Sevil Gurgan, Cem Sener,
Christopher Mercer, Valentin Preve, Ali Obeidi,
Anna-Maria Yannikou, Suchetan Pradhan, Ryan
Seto, Joyce Fong, Ingmar Ingenegeren, Peter Kleemann, Iris Brader, Masoud Mojahedi, Gerd
Volland, Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz, Herbert
Deppe, Friedrich Lampert, Jörg Meister, Rene
Franzen, Andreas Braun, Sabine Sennhenn-Kirchner, Siegfried Jänicke, Olaf Oberhofer, Thorsten
Kleinert

Toni Zeinoun
Middle East & Africa Division
Loh Hong Sai
Asia & Pacific Division

Editorial Office
Georg Isbaner
g.isbaner@oemus-media.de

Claudia Jahn
c.jahn@oemus-media.de
Executive Producer
Gernot Meyer
meyer@oemus-media.de
Designer
Sarah Fuhrmann
s.fuhrmann@oemus-media.de
Customer Service
Marius Mezger
m.mezger@oemus-media.de
Published by
OEMUS MEDIA AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de
www.oemus.com
Printed by
Löhnert Druck
Handelsstraße 12
04420 Markranstädt, Germany
laser
international magazine of laser dentistry
is published in cooperation with the World
Federation for Laser Dentistry (WFLD).
WFLD Headquarters
University of Aachen Medical Faculty
Clinic of Conservative Dentistry
Pauwelsstr. 30, 52074 Aachen, Germany
Tel.: +49 241 808964
Fax: +49 241 803389644
ngutknecht@ukaachen.de
www.wfld-org.info

Copyright Regulations
_laser international magazine of laser dentistry is published by OEMUS MEDIA AG and will appear in 2013 with one issue every quarter. The
magazine and all articles and illustrations therein are protected by copyright. Any utilization without the prior consent of editor and publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
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for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty
representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.

50 I laser
2_ 2013

[51] =>

laser
international magazine of



laser dentistry

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[52] =>

The ﬁrst digitally controlled
dental laser handpiece

X-Runner
92734/1

instantly adjustable spot size and shape
precise coverage of large areas
lightweight, ergonomic design
for Fotona LightWalker AT laser systems

The universe at your ﬁngertips.

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[cover] => laser international No. 2, 2013

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