laser international No. 1, 2014

Cover / About the publisher / Editorial / Content / Use of lasers in periodontal bone defects / Mucocele of the lip treated by using 980 nm diode laser / Pain reduction of recurrent aphthous stomatitis / Diclofenac - dexamethasone or laser phototherapy? / Er:YAG laser and composite resin ablation / Erbium lasers in pediatric dentistry / Gain power at your laser clinics! / International events / ISMI: A new Society for Implantology / LaserCUSING: Laser melting with metals / “Technology has allowed my work to evolve enormously” / News / About the publisher

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Table of contents

issn 2193-4665

Vol. 6 • Issue 1/2014

laser

international magazine of

laser dentistry

1

2014

| research
Use of lasers in periodontal bone defects

| case report
Er:YAG laser and composite resin ablation

| industry report
Erbium lasers in pediatric dentistry

[2] =>

Tel: +49 341 48474 302 / email: request@tribunecme.com

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editorial

Welcome to
Paris 2014

I

Prof. Dr Norbert Gutknecht
Editor-in-Chief

Dear reader,
First of all, I would like to wish all our friends and DGL members a happy, healthy and successful 2014! I am sure many of you already have fixed dates and venues on their schedules,
which are hopefully both obligatory and relaxing. I assume that you, being an active reader of
laser international magazine of laser dentistry, are not only interested in new technologies and application concepts, but you also wish to participate in direct discussions with speakers and users at
our WFLD (World Federation for Laser Dentistry) Congress on 2–4July in Paris.
Scientists, practitioners and postgraduate students from all parts of the world will meet in
Paris to exchange their latest findings and opinions as well as controversial problems. It will be
your decision whether you let yourselves be charmed by either the various wavelengths or Paris’
irresistible flair.
It is my special pleasure to welcome you all in the name of the WFLD board and the Paris organizational team to this year’s most exclusive laser event.
Looking forward to meeting you in Paris
You’re sincerely,

Prof. Dr Norbert Gutknecht

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I content

page 18

page 24

I editorial

I meetings

03

37

Welcome to Paris 2014
| Prof. Dr Norbert Gutknecht

I research
06

| Prof. Dr Aslan Yaşar Gokbuget et al.

10

Mucocele of the lip treated by using 980 nm diode laser

International events 2014

I science
38

Use of lasers in periodontal bone defects

page 30

ISMI: A new Society for Implantology

I interview
40

LaserCUSING: Laser melting with metals

44

“Technology has allowed my work to evolve
enormously”

| Dr Merita Bardhoshi et al.

18

Diclofenac, dexamethasone or laser phototherapy?
| Jan Tunér

| An interview with Dr Carlo Fornaini, president-elect of the

I case report
14

World Federation for Laser Dentistry

Pain reduction of recurrent aphthous stomatitis
| Dr Maziar Mir et al.

24

46

Er:YAG laser and composite resin ablation
| Carlo Fornaini

News

I about the publisher
50

I industry report
30

I news

| imprint

Erbium lasers in pediatric dentistry
| Giovanni Olivi et al.

I economy
34

Gain power at your laser clinics!

Cover image courtesy of Fotona,
www.fotona.com

| Dr Anna Maria Yiannikos

page 38

04 I laser
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page 40

page 46

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I research

Use of lasers in
periodontal bone defects
A case report with six years follow-up
Authors_Prof. Dr Aslan Yaşar Gokbuget & Necla Aslı Kocak, Turkey

_Introduction
The use of lasers in periodontal treatment has
been well documented over the past ten years.
Lasers can be used for initial periodontal therapy
and surgical procedures. When used in deep periodontal pockets with associated bone defects, not
only does laser remove the diseased granulation tissue and associated bacteria, but it also promotes osteoclast and osteoblast activity, often resulting in
bone regrowth. This usage becomes more complicated because the periodontium consists of both
hard and soft tissues. The many lasers available,
such as CO2, Nd:YAG and diode lasers, can be used in
periodontics because of their excellent ablation and
haemostatic characteristics.
Chronic periodontitis is initiated by microbial
plaque, which accumulates on the tooth surface at
the gingival margin and induces an inflammatory
reaction. The inflammatory response in patients
with chronic periodontitis results in destruction of
the periodontal tissues. With a constant bacterial
challenge, the periodontal tissues are continuously
exposed to specific bacterial components that have

the ability to alter many local cell functions. The
function of the inflammatory process is to protect
the host and limit the effect of the biofilm. Some tissue destruction occurs as part of this process. Extent
and severity of damage vary among individuals and
over time, and may involve attachment loss. This
variation in disease expression is the result of the interaction of host genetics and environmental and
microbial factors.
A major goal of periodontal therapy is to achieve
a biocompatible root surface through the removal
of bacterial biofilms and smear layer. Ultrasonic
scalers and hand instrumentation are the most
commonly used procedures for root debridement in
periodontal therapy. To achieve more efficient subgingival instrumentation at deeper probing depths
(PDs), the tips of scalers have evolved to smaller diameters and longer working lengths. Clinical studies reported similar results when comparing ultrasonic scalers and manual instrumentation for root
debridement, even though manual instrumentation
requires more time and physical effort. Mechanical
root debridement results in a smear layer containing bacteria, bacterial endotoxins, and contami-

Fig. 1_Bone defect.
Fig. 2_First radiographic
examination.
Fig. 3_Probing.

Fig. 1

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Fig. 2

Fig. 3

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research

Fig. 4_Surgery.
Fig. 5_Augmentation.

Fig. 5

Fig. 4

nated root cementum. Furthermore, it does not remove plaque and calculus completely from interradicular septa or root concavities. Individually or
collectively, these factors are likely to hamper the
periodontal healing process. A significant disadvantage of ultrasonic scalers, for the patient and the clinician, is the formation of a contaminated aerosol.
Dentistry has changed tremendously over the past
decade to the benefit of both the clinician and the
patient. One technology that has become increasingly utilized in clinical dentistry is that of the laser.
Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. Laser is a device that
utilizes the natural oscillations of atoms or molecules between energy levels for generating coherent
electromagnetic radiation usually in the ultraviolet,
visible, or infrared regions of the spectrum. It is a device that produces high intensity of a single wavelength and can be focused into a small spot. Initially
introduced as an alternative to the traditional halogen curing light, the laser now has become the instrument of choice, in many applications, for both
periodontal and restorative care. Because of their
many advantages, lasers are indicated for a wide variety of procedures.
Presently, various laser systems have been used
and in recent years, laser radiation has been suggested as an alternative instrumentation modality
for the treatment of chronic periodontitis. In vitro
studies reported effective results for Nd:YAG laser
root debridement. When used at low-energy densities with a water-spray surface coolant, the Nd:YAG
laser provides a homogeneous and smooth root surface topography. In addition, laser is effective at removing dental calculus and smear layer and exhibits
bactericidal effects without inflicting any significant thermal damage to the root surface. Several
clinical studies compared traditional instrumentation to the Nd:YAG laser for treatment of periodontal disease. However, laser usage for such purposes
remains controversial, probably because of insufficient evidence that any specific wavelength of laser
is superior to traditional instrumentation. The lack

of evidence supporting laser usage results from
poorly designed studies and the lack of continuity of
design between studies, e.g., wide variations in laser
parameters, energy densities, experimental designs,
and the lack of proper controls in many studies.

_Advantages and disadvantages
Advantages of laser treatment are greater
haemostasis, bactericidal effect, and minimal
wound contraction. Compared with the use of a
conventional scalpel, lasers can cut, ablate and reshape the oral soft tissue more easily, with no or
minimal bleeding and little pain as well as no or only
a few sutures. The use of lasers also has disadvantages that require precautions to be taken during
clinical application. Laser irradiation can interact
with tissues even in the noncontact mode, which
means that laser beams may reach the patients eyes
and other tissues surrounding the target in the oral
cavity. Clinicians should be careful to prevent inadvertent irradiation to these tissues, especially to the
eyes. Protective eyewear specific for the wavelength
of the laser in use must be worn by the patient, operator, and assistant. Laser beams can be reflected
by shiny surfaces of metal dental instruments, causing irradiation to other tissues, which should be
avoided by using wet gauze packs over the area surrounding the target. However, previous laser systems have strong thermal side effects, leading to
melting, cracking, and carbonization of hard tissues.

_Clinical presentation and
case management
A 44-year-old female patient presented at our
private clinic PGG for treatment of the periodontal
problems at the right maxillar molar site (Fig. 1).
Upon review of her medical history she was otherwise healthy. She had previously been treated for
chronic periodontitis with a non-surgical approach.
Then radiographic examination was made (Fig. 2). It
revealed a combined marginal and vertical radiolucency. On clinical examination, deep probing depths

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Fig. 7

Fig. 6

Fig. 6_Suturing.
Fig. 7_ Six years after radiation.
Fig. 8_Radiograph six years after
radiation.

were isolated (Fig. 3). No clinically detectable mobility of the teeth was present. One day prior to surgery,
the patient was given 2,000 mg of amoxicillin and
following surgery put on a regimen of amoxicillin
(1,000 mg tid) for five days post-op. A crestal incision is scalloped around the teeth necks to eliminate
the internal epithelium and granulation tissue from
the pocket (Fig. 4). A mucoperiostal flap is rised to
expose the teeth, and bone tissue and granulation
tissue are eliminated from the bone defect with
Nd:YAG laser with 300 µm tip, VSP, 1.5 Hz, 10 W
power setting was used and Er:YAG laser with power
settings of VSP, 120 mJ, 10 Hz with water and air
flushing was used for teeth surface detoxification.
Due to defect morphology we used a combined
technique with enamel matrix derivative (Emdogain). Then, xenogenous bone grafts (Bio-Oss®)
were compacted into the defect (Fig. 5). A Bio-Gide®
barrier was placed over the defect and was extended
both buccally and lingually.

Fig. 8

though the use of lasers in dentistry is relatively new,
the future looks very bright. In summary, laser treatment is expected to serve as an alternative or adjunctive to conventional mechanical periodontal
treatment. Currently, among the different types of
lasers available, Nd:YAG, Er:YAG and Er,Cr:YSGG
laser possess characteristics suitable for dental
treatment, due to their dual ability to ablate soft and
hard tissues with minimal damage. In addition, the
bactericidal effect of laser with elimination of
lipopolysaccharide, its ability to remove bacterial
plaque and calculus, an irradiation effect limited to
an ultra-thin layer of tissue, faster bone and soft tissue repair make it a promising tool for periodontal
treatment including scaling and root surface debridement. The decision to use a laser should be
based on the proven benefits of haemostasis, a dry
field, reduced surgical time and the general experience of less postoperative swelling.

_Conclusion
The buccal and lingual flaps were released and
tension-free primary closure was achieved with 4-0
silk sutures (Fig. 6). The patient was instructed to
continue antibiotics as prescribed and to rinse with
the 0.12 % chlorhexidine gluconate bid for 30 sec
twice a day. Finally, a strict maintenance and oral hygiene protocol were established. The area healed
uneventfully after six months. Periapical radiographs were taken throughout the healing process
to evaluate the mineralization of the graft over time,
bone formation within the bony defect was evident.
Radiographically it appeared that there was increased mineralization of the bone surrounding the
teeth.The patient was again examined every year.
Six years after treatment (Fig. 7), a new radiograph
(Fig. 8) was taken which demonstrated complete
resolution of the bony defect surrounding the teeth.

_Discussion
As technology advances into dentistry, whether
it is laser or another exciting venue, the options
available to clinicians will continue to increase. Al-

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Although no definitive conclusion can be drawn
from a single case report, the guided bone regeneration combined laser technique described in this
case report effectively eliminated teeth associated
three-wall bony defect and deep pocket. Under the
conditions of the present case, it may be concluded
that the Nd:YAG and Er:YAG laser combination can
be safely and effectively utilized for degranulation
and implant surface debridement in the surgical
treatment of periodontal infection._

_contact
Prof. Dr Aslan Y. Gokbuget
PGG Dental Clinic
Tesvikiye Casddesi Kismet Apt. 133 d.8
34365 Nisantasi
Istanbul, Turkey
Tel.: +90 212 2480317
Fax: +90 212 2475118

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I research

Mucocele of the lip
treated by using
980 nm diode laser
Authors_Dr Merita Bardhoshi, Prof. Dr Norbert Gutknecht, Dr Esat Bardhoshi, Dr Alketa Qafmolla, Dr Edit Xhajanka &
Dr Neada Hysenaj, Albania & Germany

_Introduction

Fig. 1_Clinical diagnosis.
Fig. 2_Laser treatment.

Mucoceles are defined as mucus-filled cavities
that can appear in the oral cavity, paranasal sinuses
or lacrimal sac. They are characterised by the accumulation of liquid or mucoidmaterial, giving rise to
a rounded, well circumscribed transparent and
bluish-colored lesion of variable size.1,3,5,7 The consistency is tipically soft and fluctuant in response to
palpation. Mucoceles are painless and tend to relapse. Etiologically, most mucoceles are considered
to be secondary to traumatic or obstructive disorders of the mainly minor salivary glands—the preferential location being the humid mucosa of the
lower lip. Mucoceles are usually asymptomatic, although in some patients they can cause discomfort
by interfering with speech, chewing or swallowing.
They can be different in size, small and large. How-

ever, in most cases these lesions rupture spontaneously or traumatically a few hours after being
formed, with the release of a characteristic viscous
mucoidfluid. This may give the mistaken impression
of healing, since the lesion decreases in size or disappears. However, once the small perforation allowing release of the mucocele contents has healed,
the secretions accumulate again and the lesion relapses.5,9,15 In case of repeated trauma, the lesion
may become nodular and firmer in response to palpation with rupture being more difficult in this situation. Treatment may be performed by conventional surgery, cryotherapy and more recently laser
surgery. Carbon dioxide laser and high-intensity
diode laser both have provided satisfactory results.8
The purpose of this study was to evaluate the effectiveness of 980 nm diode laser in the treatment of
mucocele of the lower lip and also to compare the
results obtained after mucocele resection with
scalpel versus 980 nm diode laser.

_Patients and method

Fig. 1

Fig. 2

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A total of 10 patients (six males and four females)
aged 15 to 40 were treated for mucocele of the lip by
a 980 nm diode laser. An initial clinical examination
consisting of the past medical and dental history as
well as thorough extra- and intraoral examination
were performed on all patients. Complementary
blood test, complete blood count and erythrocyte
sedimentation rate made it possible to exclude infectious diseases. The collected data were evaluated
and a clinical diagnosis for the type of lesion was established (Figs. 1). All patients were given a written
and verbal information on the nature of laser treatment and signed informed consent forms were obtained prior to treatment. Treatments were con-

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ducted from January 2007 to January 2011 at the
Department of Oral Surgery (Dental Clinic of the
University of Tirana, Albania). For all treatments, a
diode laser was used (Sirona, 980 nm, cw, optical fibre 300 micrometer, 4 W). Treatments were conducted with infiltration anaesthesia of 2 % lidocaine, 1 cc and excision was performed by surgical
technique. The treatment area was cooled by the application of ice 2 to 5 minutes after treatment. Surgical fields were bloodless, no sutures were required
and time of surgery was 2–4 minutes (Fig. 2). The
specimens obtained were fixed in 10 % formalin solution for posterior histological study to establish
the definitive diagnosis. The resulting surgical
wounds were allowed to heal by second intention
(Fig. 3). After treatment, analgesic medication was
prescribed to be used if necessary, but no antibiotics
were prescribed. Ten clinical cases of mucoceles
were treated by scalpel. An elliptic incision was
made to fully enucleate the lesion along with the
overlying mucosa and the affected glands. The operation proved more complicated when the lesion
ruptured, since the loss of references made it more
difficult to ensure complete elimination of the lesion. The wounds were finally sutured. The followup visits were scheduled ten days, one month, six
months, one year and three years after surgery. All
lesions were photographically documented at all
stages of treatment and healing.

_Results
The study comprised 20 patients (twelve males &
eight females ), six cases presented between ten and
20 years of age, nine cases between 20 and 30 years
of age, three cases between 30 and 40 years of age

and two cases between 40 and 50 years of age. In
most of the cases, there was no evident etiological
factor. Mucoceles ranged from 1–3 cm in diameter,
no pain was reported by all patients, and only seven
patients referred discomfort associated with nibbling of the lesion. Immediately after the excision, all
surgical fields were bloodles (Fig. 4). Histopathological examination confirmed the initial diagnosis. All
patients were followed up seven days postoperatively for pain and swelling .
After four weeks, the wound healing characteristics of all clinical cases were evaluated. Patients
treated with diode laser reported good, comfortable
healing without complications (Fig. 4) or functional
disturbances, versus ten scar formations and four
relapses with scalpel. After six months to one year,
no recurrence was observed in patients treated with
laser versus three cases treated with scalpel. No lip
paresthesias were recorded after the treatment of
both of the two groups of patients.

_Statistical analysis
We have presented some of the cross tabulations
using SPSS16 (Statical Package for Social Sciences).
Data for patient characteristics are given as mean
and standard deviation in order to obtain information and to observe the difference between the
scalpel and laser procedure. For each step we have
recorded pain, functional disturbance, swelling and
recurrence on a standard visual analogue scale from
0 to 4. The maximum value for pain is one, showing
that the response is mild pain. We recorded just one
case with such kind of pain in the laser procedure.
The mean is 0.625 and the standard deviation is 0.25.

[PICTURE: ©SUKIYAKI]

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

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Fig. 3

Fig. 4

Fig. 3_Healing by second intention.
Fig. 4_ Immediately after the
excision, all surgical fields were
bloodless.

We have also checked for any relationship between
pain and age. A cross tabulation is presented in the
case processing summary as well as a Pearson correlation for both of the two procedures. The Pearson
correlation in this case shows that the correlation
between pain caused in laser procedure and age is
correlated negatively with the coefficient of -0.02,
which is however not sufficient statistically at 5 %
and 1 % (p-value is 0.943).1 This correlation between
these two variables is not genuinely significant at
the rate of significance as chosen above. While the
Pearson correlation between pain and age for the
scalpel is also negative, suggesting that these two
variables are correlated negatively and still not sufficiently statistically significant at the rate of 5 and
1 % level of significance.

_Discussion
In our study 52 % of the lesions were found in
males. In all our clinical cases, mucocele growth was
generally found to be slow. In the course of the
anamnesis, some patients reported accidental traumatism and suction habits. Lesions vary in diameter
between 0.2 mm and 2 cm without symptoms. Using the scalpel, some authors1,3,5,8,9 propose the removal of both the affected and neighboring glands
in order to prevent relapse. Special care is required
to avoid damaging other glands or ducts with the
suture needle, as this may become a cause of recurrence. The total treatment time with laser was 3 to
5 minutes, the same as authors state in the literature
reports.2,7,12 This was lower than the treatment time
by scalpel which required sutures after the full enucleation of lesion by an elliptic incision, whereas
wounds treated by laser surgery healed by secondary intention regardless of their depth. However, the
size of the surgical wound is increased compared to
the size of the lesion.

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Laser surgery is an option of choice for pediatric
and geriartric patients who have difficulties tolerating long surgical procedures. Authors recorded no
postoperative bleeding or healing complications
with laser surgery.15,17,20 This was reflected in our
study’s postoperative period as the patients recovered without complications. We recorded no recurrence, no lip paraesthesias, no relapses after treatment of mucocele with 980 nm diode laser. Furthermore, we observed complications in the healing
process of the patients treated with scalpel. These
complications ranged from recurrence, scarring
and relapse attributable to damage to the neighboring minor salivary glands cause by scalpel or needle
upon suturing. Other advantages of the laser versus
cold surgery include bloodlessness and a highly decontaminated surgical bed which allow for less
swelling and pain during the postoperative period.
Moreover, as is reported in literature,14,16,17,18,19,20
these advantages also allow for the appearance
of fewer myofibrobasts resulting in comparatively
lesser wound contraction.12,13 Our postoperative results of minimal pain and no or minimal swelling coincides with the observations of other authors.1,3,5,7
No analgesics or antibiotics were needed in any of
the patients treated with laser, other than all patients treated with cold scalpel.

_Conclusion
Laser surgery is a modality for the treatment of
mucocele with beneficial effects and advantages.
Intraoperative advantages were a good coagulation, a good visualization of the operative field and
the short operating time, which made it possible to
minimise fear and anxiety in the patients during the
procedure. The advantages of laser surgery also include a reduction of relapses and scar formation, offering the best aesthetic outcome in comparison to
the scalpel. Laser surgery is therefore an asset not
only for the patient but also for the surgeon._
Editorial note: A list of references is available from the
publisher.

_contact
Dr Merita Bardhoshi
University of Medicine
Department of Oral Surgery
Dibra Street 63
Tirana, Albania
Tel.: +335 5672042658
Fax: +335 542253675
meritabardhoshi@yahoo.com

laser

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th

14 World Congress for

LASER DENTISTRY

PARIS, July 2nd, 3th & 4th, 2014

ZIOG#FOTJURXSFRP

www.dental-laser-academy.com

WFLD-paris2014.com

[14] =>

I case report

Pain reduction of recurrent
aphthous stomatitis
Evaluation of class 2M diode laser as a home care device
Authors_Dr Maziar Mir, MSc, Dr Masoud Mojahedi, MSc, Dr Jan Tunér DDS, Dr Hassan Adalatkhah, MSc,
Dr Amir Mansour Shirani, MSc & Dr Masoud Shabani, Germany & Iran

_Introduction
Recurrent aphthous stomatitis (RAS) is a common
condition, restricted to the mouth, and typically starts
in childhood or adolescence as recurrent small, round
or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or gray floors. RAS has
three clinical types: minor, major and herpetiform ulcers. Ulcers with similar clinical features (aphthouslike ulcers) may be associated with systemic conditions such as Behçet syndrome, auto-inflammatory
syndromes, gastrointestinal disease or immune defects such as HIV/AIDS.The etiology of recurrent aphthous stomatitis (RAS) is not entirely clear. A genetic
basis exists for some RAS.

Fig. 1_Low Level Laser
Aphthous Pen.
Fig. 2_Minor aphthous ulcer.

This is shown by a positive family history in about
one third of patients with RAS, an increased frequency of HLA types A2, A11, B12, and DR2, and susceptibility to RAS which segregates in families in association with HLA haplotypes. RAS probably involves
cell-mediated mechanisms but the precise immunopathogenesis remains unclear. Phagocytic and
cytotoxic T cells probably aid in destruction of oral epithelium that is directed and sustained by local cytokine release. Patients with active RAS have an increased proportion of gamma-delta T cells compared

with control subjects and patients with inactive RAS.
Gamma-delta T cells may be involved in antibody-dependent cell-mediated cytotoxicity (ADCC). Compared with control subjects, individuals with RAS
have raised serum levels of cytokines such as interleukin (IL)–6 and IL-2R, soluble intercellular adhesion
modules (ICAM), vascular cell adhesion modules
(VCAM), and E-selectin. However, some of these do
not correlate with disease activity.1-4
LLLT has been reported as a useful treatment for
several conditions, such as reduction of the destructive interleukins and TNF-production, improvement
of the immune system function, reduction of pain and
the healing time period.5-12
Lasers (high power and low power) have been used
in some case reports and studies for pain reduction
and shortening healing time of RAS.13-32 Most of these
reports focussed on office treatment, but many patients have recurrent lesions and there were no
known home care devices for laser treatment of RAS.
Therefore, to assist patients in using lasers at home by
themselves, a class 2M low level laser was inserted in
a pen-like device. This laser is called LLLAP (Low Level
Laser Aphthous Pen) and it seems that it was the first
time that such a device is introduced to dental professionals. Therefore, the aim of this pilot study was
to evaluate the pain reduction efficiency of this particular instrument.

_Material and method

Fig. 1

Fig. 2

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1_ 2014

A prospective randomised trial was conducted
with 30 patients. Inclusion criteria were: having at
least one minor aphthous ulcer smaller than 5 mm,
satisfaction and ability to take part in the study, fulfilment of the patient consent form according to the
Code of Ethics and having new lesions in the first two

[15] =>

case report

days. Exclusion criteria were: pregnancy, carcinoma,
taking steroids or anticoagulant and anti-inflammatory agents, eye problems or mental retardation or
impairment and patients with aphthous-like ulcers
with signs and symptoms of systemic diseases like
Behçet syndrome, auto-inflammatory syndromes,
gastrointestinal disease, or immune defects such as
HIV/AIDS and severe anaemia. Ethically, all these
patients were treated as well but were not counted as
study cases.
The samples were allocated into three groups:
Group 1 received laser therapy (low-level laser
aphthous pen, registration number in Iran: 72619).
The device was prepared by insertion of the diode laser
in the tooth brush, then it was calibrated and tested
(Fig.1). Group 2 received topical triamcinolone acetonide 0.1 % in orabase (gelatin, pectin, and carboxymethyl cellulose sodium in Plastibase® (Plasticized Hydrocarbon Gel), a polyethylene and mineral
oil gel base, Adcortyl in orabase, Bristol-Myers Squibb
Company). Group 3 received placebo (red LED light).
Laser parameters were: InGaAlP diode class 2M
laser, wavelength 660 nm, continuous, 40 mW, irradiation diameter 3 mm, spot size 0.19625 cm2, 30 seconds, 1.2 J, 6 J/cm2 twice per day for five consecutive
days, near non-contact mode and near at a perpendicular angle (Figs. 2-4). Class 2 laser was used because
this laser was used at home and it is necessary to use
a relatively safe laser. For this kind of laser, natural reaction of a person like shutting of the eyelid is sufficient for eye protection. But patients were educated
in the application of the laser, not to stare into the
beam or view it directly with optical instruments and
to put it in a place which is not reachable by children.
The Research Ethical Committee approval was
adopted with number 01391023 for this research
from Ardebil University of Medical Sciences.
The VAS scale was used for the evaluation of pain,
in the range of 0 to 10 so that 0 is no pain and 10 is very
severe pain. Evaluations were performed before
treatment, immediately after irradiation and every
day during the first five days. The data were analysed
by one way ANOVA and PostHoc tests.

_Results
Thirty patients took part in the study, 16 were men
and 14 were women. The location of minor RAS was the
upper lip in 20 patients and the lower lip in 10 patients.

Fig. 3

Fig. 4

during the first five days (p = 0.001).The data for
Mean, Standard deviation and PostHoc test results
are presented in table 1. There was no significant difference between laser and Adcortyl groups but both
were significantly better than the red light pen. Chart
1 shows the pain reduction during five consecutive
days among the groups.

Fig. 3_Laser irradiation with
aphthous laser pen.
Fig. 4_Four days after treatment.

_Discussion
Many different treatments are considered for RAS.
Relief of pain and reduction of ulcer duration are the
main goals of therapy. Topical corticosteroids remain
the mainstays of treatment.4 Thus, in this study, one
group received topical Adcortyl™ in Orabase™ for better comparison.
Different kinds of laser were successfully used in
studies for treatment of RAS. The GaAlAs diode laser,15
He-Ne laser,16,17 argon laser,20 InGaAlP laser,14,21
Nd:YAG laser,22,29 diode 830 nm,29 GaAs (904 nm),24
CO2,26,30,31 diode lase32 were used in case reports and
studies. For cases with aphthous-like lesion in Behçet
syndrome, CO2 laser23 and GaAs (904 nm)25 have been
applied successfully. For cases with aphthous-like ulcer in AIDS (Acquired Immune Deficiency Syndrome)
cases, diode 660 nm laser has been used with good result.27

Fig. 5_ Pain reduction during five
consecutive days among intervention
groups.

8
VAS
7
6
5
laser
4
placebo
ointment

3
2

In ANOVA data analysing, there was no significant
VAS difference between the groups before treatment
(p=0.500). After treatment, there was significant difference between the LLLT/Adcortyl groups and the
placebo group immediately after the first session and

1
0
VAS before

VAS immediate

VAS first day

VAS second day

VAS third day

VAS fourth day

VAS fifth day

Fig. 5

laser
1
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_ 2014

[16] =>

I case report
Variable

N

Mean

Std.D

Groups

Sig

CI95%

VAS before treatment

Laser
Placebo
Ointment

10
10
10

7.4
6.8
6.8

1.07
1.39
1.39

Laser-Ointment
Laser-Placebo
Ointment-Placebo

0.56
0.56
1

(-0.8)-(2.04)
(-0.8)-(2.04)
(-1.44)-(1.44)

VAS imm. after treatment

Laser
Placebo
Ointment

10
10
10

1.8
6.4
2.4

0.42
5.8
0.51

Laser-Ointment
Laser-Placebo
Ointment-Placebo

0.3
0
0

(-1.6)-(0.41)
(-5.61)-(-3.95)
(-5.01)-(-2.9)

VAS 1st day after treatment

Laser
Placebo
Ointment

10
10
10

1.6
5.8
2.2

0.51
1.3
0.78

Laser-Ointment
Laser-Placebo
Ointment-Placebo

0.3
0
0

(-1.6)-(0.47)
(-5.2)-(-3.1)
(-4.6)-(-2.5)

VAS 2nd day after treatment

Laser
Placebo
Ointment

10
10
10

1
5.2
1.8

0.6
1.3
0.78

Laser-Ointment
Laser-Placebo
Ointment-Placebo

0.19
0
0

(-1.91)-(0.31)
(-5.3)-(-3.08)
(2.28)-(4.51)

VAS 3rd day after treatment

Laser
Placebo
Ointment

10
10
10

1
4.4
1.4

0.6
1.7
1.07

Laser-Ointment
Laser-Placebo
Ointment-Placebo

0.74
0
0

(-1.7)-(0.96)
(-4.7)-(-2.03)
(-4.3)-(-1.63)

VAS 4th day after treatment

Laser
Placebo
Ointment

10
10
10

0.8
3.6
0.6

0.42
1.71
0.51

Laser-Ointment
Laser-Placebo
Ointment-Placebo

0.9
0
0

(-0.97)-(1.37)
(-3.9)-(-1.6)
(1.82)-(4.17)

VAS 5th day after treatment

Laser
Placebo
Ointment

10
10
10

0.6
2.8
0.6

0.51
1.39
0.51

Laser-Ointment
Laser-Placebo
Ointment-Placebo

1
0
0

(-1.01)-(1.01)
(-3.2)-(-1.1)
(-3.2)-(-1.1)

Table 1_Result of PostHoc test for
multiple comparisons between
groups.

As the low level laser can modulate inflammatory
mediators such as TNF-alpha, IL-6 and others, reduction of pain can be achived. The healing of the aphthous ulcer can be attributed to increase of the cellular activity, especially fibroblasts, keratinocytes and
immune cells. Therefore, wound healing and boosting
of the natural function can be achieved.

reduced healing time in recurrent aphthous stomatitis in comparison to the control group (topical lidocaine) in some studies.33

Most studies focus on in-office treatment. The low
level laser therapy often requires additional treatment sessions and there is no known home care device for laser treatment of RAS. Patients with RAS
have recurrent ulcers and in-office treatment for
each recurrent lesion requires several visits to the
dental office and consequent economic problems.
Therefore, a class 2M low level laser was inserted in a
pen-like device in order to assist patients to use lasers
at home.

_Conclusion

In this study, laser pen was statistically better than
laser placebo in pain reduction. This was simillar to
another study.21 The laser pen statistically had an efficiency similar to topical corticosteroids (as a routine
treatment) in pain reduction. This finding was consistent with other studies.24,29 In the present study, only
pain reduction was evaluated but in the Salman
study24: the laser treatment group had a shorter healing time in comparison to Adcortyl™. Laser therapy

16 I laser
1_ 2014

As corticosteroids have several side effects, laser
treatment may have some advantages for the treatment of recurrent aphthous stomatitis.

In this clinical pilot study, the laser pen seems to be
useful for the treatment of RAS as a home care device.
Editorial note: A list of references is available from the publisher.

_contact

laser

Dr Masoud Shabani
Oral Health Department, Official Complex of Ardebil
University of Medical Sciences, Daneshgah Street
5618985991 Ardebil, Iran
Tel.: +98 451 5521417
Fax: +98 451 5522196
m.shabani@arums.ac.ir

[17] =>

[18] =>

I research

Diclofenac, dexamethasone
or laser phototherapy?
Part I
Author_Jan Tunér, Sweden

[PICTURE: ©ROBERT KNESCHKE]

_Introduction
In the May 2013 edition of Photomedicine and
Laser Surgery, the editorial written by Prof. Tina Karu
is titled “Is it time to consider photobiomodulation as
a drug equivalent?” Well, is it? Let us have a look and
see what the literature has to say about two very popular drugs:
NSAIDs (non-steroidal anti-inflammatory drugs)
are the best sold pharmaceuticals ever. The shortterm effects on pain and inflammation are obvious
and valuable. The long-term effects, however, have
been questioned and this is especially valid considering the many side effects of NSAIDs. Millions of patients are on long-term medication with NSAIDs, and
even lifelong. Indeed, many persons die from their
medication. So an alternative option is required. I believe it is already available: laser phototherapy! First,
let us have a look at the strength of the scientific evidence for NSAIDs as such, and long term use of these
in particular:
The meta-analysis by Bjordal1 on the effect of
NSAIDs on knee osteoarthritis pain appears to become important for the recognition and future development of LPT. Let us read the abstract: The research
group summarises that non-steroidal anti-inflam-

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matory drugs (NSAIDs), including cyclo-oxygenase-2
inhibitors (coxibs), reduce short-term pain associated
with knee osteoarthritis only slightly better than
placebo, and long-term use of these agents should be
avoided. Up for analysis were 23 placebo-controlled
trials involving 10,845 patients, 7,767 of whom received NSAID therapy and 3,078 placebo therapy. All
in all 21 of the NSAID-studies were funded by the
pharmaceutical industry, and the results of 13 of
these studies were inflated by patient selection bias as
previous NSAID-users were excluded if they had not
previously responded favourably to NSAID. Such an
exclusion criterion for non-responders has never
been seen in any controlled trial of LPT or other nonpharmacological therapies of osteoarthritis. In the remaining ten unbiased NSAID-trials, the difference
from placebo was only 5.9 mm on a 100 mm pain
scale.
This is far less than established data on differences
that are considered minimally perceptible (9 mm) or
clinically relevant (12 mm) for knee osteoarthritis patients. In addition, none of the trials found any effects
beyond 13 weeks. This bleak support for long term use
of NSAIDs is an excellent support for non-pharmaceutical methods, such as LPT. Diclofenac is one of the
best-selling NSAIDs. Several investigators have compared the effect of LPT and diclofenac.

[19] =>

research

Ramos3 investigated the effects of LPT (810 nm) in
rat-induced skeletal muscle strain. Male rats were
anaesthetised with halothane prior to the induction
of muscle strain. Previous studies have determined
that a force equal to 130 % of the body weight corresponds to approximately 80 % of the ultimate rupture
force of the muscle tendon unit. In all animals, the
right leg received a controlled strain injury while the
left leg served as control. A small weight corresponding to 150 % of the total body weight was attached
to the right leg in an appropriate apparatus and left to
induce muscle strain twice for 20 minutes with threeminute intervals. Walking index, C-reactive protein,
creatine kinase, vascular extravasation and histological analysis of the tibial muscle were performed after
six, twelve and 24 hours of lesion induction. LPT in an
energy-dependent manner markedly or even completely reduced the Walking Index, leading to a better
quality of movement. C-reactive protein production
[PICTURE: ©INESBAZDAR]

The aim of a study by Marcos2 was to evaluate the
short-term effects of LPT or sodium diclofenac
treatments on biochemical markers and biomechanical properties of inflamed Achilles tendons.
Wistar rats Achilles tendons (n = 6/group) were injected with saline (control) or collagenase at peritendinous area of Achilles tendons. After one hour
animals were treated with two different doses of LPT
(810 nm, 1 and 3 J) at the sites of the injections, or
with intramuscular sodium diclofenac. Regarding
biochemical analyses, LPT significantly decreased
COX-2, TNF-alpha, MMP-3, MMP-9, and MMP-13
gene expression, as well as PGE2 production when
compared to collagenase group. Interestingly, diclofenac treatment only decreased PGE2 levels. Biomechanical properties were preserved in the lasertreated groups when compared to collagenase and
diclofenac groups.

was completely inhibited by laser treatment, even
more than observed with Sodium diclofenac inhibition (positive control). Creative Kinase activity was
also significantly reduced by laser irradiations. In conclusion, LPT operating in 810 nm markedly reduced inflammation and muscle damage after experimental
muscle strain, leading to a highly significant enhancement of walking activity.
The aim of the study by de Almeida4 was to analyse
the effects of sodium diclofenac (topical application),
cryotherapy, and LPT on pro-inflammatory cytokine
levels after a controlled model of muscle injury.
For such, we performed a single trauma in the tibialis
anterior muscle of rats. After one hour, animals
were treated with sodium diclofenac (11.6 mg/g of
solution), cryotherapy (20 min), or LPT (904 nm;
superpulsed; 700 Hz; 60 mW mean output power;

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[20] =>

I research
1.67 W/cm2; 1, 3, 6 or 9 J; 17, 50, 100 or 150 s). Assessment of interleukin-1 and interleukin-6 (IL-1 and
IL-6) and tumour necrosis factor-alpha levels was
performed at six hours after trauma employing enzyme-linked immunosorbent assay method. LPT with
1 J dose significantly decreased IL-1, IL-6, and TNF-alpha levels compared to non-treated injured group as
well as diclofenac and cryotherapy groups. On the
other hand, treatment with diclofenac and cryotherapy does not decrease pro-inflammatory cytokine
levels compared to the non-treated injured group.
Therefore, the authors conclude that 904 nm LPT with
1 J dose has better effects than topical application of
diclofenac or cryotherapy in acute inflammatory
phase after muscle trauma.

tion (1 Joule, 100 mW, 10 sec) on the inguinal lymph
nodes; GP+LY group received laser irradiation on both
paw and lymph nodes one and two hours after the
carrageenan injection. MPO activity was similar in the
sodium diclofenac as well as in the GP and GLY groups,
but significantly lower than the GC and GP + LY
groups. Paw oedema was significantly inhibited in GP
and GD groups when compared to the other groups.
Interestingly, the GP+LY groups presented the biggest
oedema, even bigger than in the control group. LPT
showed an anti-inflammatory effect when the irradiation was performed on the site of lesion or at the correlated lymph nodes, but showed a pro-inflammatory
effect when both paw and lymph nodes were irradiated during the acute inflammatory process.

The purpose of a study by Albertini5 was to investigate the effect of LPT on the acute inflammatory
process. Male rats were used. Paw oedema was induced by a sub-plantar injection of carrageenan, the
paw volume was measured before and one, two, three
and four hours after the injection, using a hydroplethysmometer. To investigate the action mechanism of the GaAlAs laser on inflammatory oedema,
parallel studies were performed using adrenalectomised rats or rats treated with sodium diclofenac.
Different laser irradiation protocols were employed
for specific energy densities (EDs), exposure times and
repetition rates. The rats were irradiated with laser for
80 s each hour. The EDs that produced an anti-inflammatory effect were 1 and 2.5 J/cm2, reducing the
oedema by 27 % and 45.4 %, respectively. The ED of
2.5 J/cm2 produced anti-inflammatory effects similar
to those produced by the cyclooxigenase inhibitor
sodium diclofenac at a dose of 1 mg/kg. In adrenalectomised animals, the laser irradiation failed to inhibit
the oedema. These results suggest that LPT possibly
exerts its anti-inflammatory effects by stimulating
the release of adrenal corticosteroid hormones.

The aim of a study by Barretto23 was to investigate
the analgesic and anti-inflammatory activity of LPT
on the nociceptive behavioural as well as histomorphological aspects induced by injection of formalin
and carrageenan into the rat temporomandibular
joint. The 2.5 % formalin injection (FRG group) induced behavioural responses characterized by rubbing the orofacial region and flinching the head
quickly, which were quantified for 45 min. The pretreatment with systemic administration of diclofenac
sodium-DFN group (10 mg/kg i.p.) or irradiation with
infrared LPT (LST group, 780 nm, 70 mW, 30 s, 2.1 J,
52.5 J/cm2), significantly reduced the formalininduced nociceptive responses. The 1 % carrageenan
injection (CRG group) induced inflammatory responses over the time-course of the study (24 h, three
and seven days) characterised by the presence of
intense inflammatory infiltrate rich in neutrophils,
scanty areas of liquefactive necrosis and intense interstitial oedema, extensive haemorrhagic areas, and
enlargement of the joint space on the region. The DFN
and LST groups showed an intensity of inflammatory
response that was significantly lower than in CRG
group over the time-course of the study, especially in
the LST group, which showed exuberant granulation
tissue with intense vascularization, and deposition of
newly formed collagen fibres (three and seven days).

The aim of a work by Meneguzzo6 was to investigate the effects of infrared 810 nm on the acute inflammatory process by the irradiation of lymph
nodes, using the classical model of carrageenan-induced rat paw oedema. Thirty mice were randomly divided into five groups. The inflammatory induction
was performed in all groups by a sub-plantar injection
of carrageenan (1 mg/paw). The paw volume was
measured before and 1, 2, 3, 4 and 6 hours after the
injection using a plethysmometer. Myeloperoxidase
(MPO) activity was analysed as a specific marker of
neutrophil accumulation at the inflammatory site.
The control group did not receive any treatment (GC);
GD group received sodium diclofenac (1mg/kg) 30
minutes before the carrageenan injection; GP group
received laser irradiation directly on the paw (1 Joule,
100 mW, 10 sec) one and two hours after the carrageenan injection; GLY group received laser irradia-

20 I laser
1_ 2014

The aim of a study by de Almeida7 was to analyse
the effects of sodium diclofenac (topical application)
and LPT on morphological aspects and gene expression of biochemical inflammatory markers. The researchers performed a single trauma in the tibialis anterior muscle of rats. After one hour, animals were
treated with sodium diclofenac (11.6 mg/g of solution) or LPT (810 nm; continuous mode; 100 mW; 1, 3
or 9 J; 10, 30 or 90 s). Histological analysis and quantification of gene expression (real-time polymerase
chain reaction-RT-PCR) of cyclooxygenase 1 and 2
(COX-1 and COX-2) and tumour necrosis factor-alpha
(TNF-alpha) were performed at six, twelve and 24 h after trauma. LPT with all doses improved morphologi-

[21] =>

FDI 2014 · New Delhi · India
Greater Noida (UP)

Annual World Dental Congress

11-14 September 2014
Deadline for
early bird registration
31 May 2014

A billion smiles welcome the world of dentistry
www.fdi2014.org.in
www.fdiworldental.org

[22] =>

I research
ing tibialis anterior muscle of rats. Injured groups received either no treatment, or a single treatment with
topical or intramuscular diclofenac (TD and ID), or LPT
(3 J, 810 nm, 100 mW) 1 h after injury. Walking track
analysis was the functional outcome and biochemical analyses included mRNA expression of COX-1 and
COX-2 and blood levels of prostaglandin E2 (PGE2). All
treatments significantly decreased COX-1 and COX-2
gene expression compared to the injury group. However, LPT showed better effects than TD and ID regarding PGE2 levels and walking track analysis. The
author concludes that LPT has more efficacy than
topical and intramuscular diclofenac in treatment of
muscle strain injury in acute stage.

[PICTURE: ©RACORN]

cal aspects of muscle tissue, showing better results
than injury and diclofenac groups. All LPT doses also
decreased COX-2 compared to injury group and to diclofenac group at 24 h after trauma. In addition, LPT
decreased TNF-alpha compared both to injury and diclofenac groups. LPT mainly with dose of 9 J is better
than topical application of diclofenac in acute inflammation after muscle trauma.
Yet another study by Marcos8 investigated if a
safer treatment such as LPT could reduce tendinitis
inflammation, and whether a possible pathway could
be through inhibition of either of the two-cyclooxygenase (COX) isoforms in inflammation. Wistar rats
(six animals per group) were injected with saline (control) or collagenase in their Achilles tendons. Then
they were treated with three different doses of IR LPT
(810 nm; 100 mW; 10 s, 30 s and 60 s; 3.57 W/cm2; 1 J,
3 J, 6 J) at the sites of the injections, or intramuscular
diclofenac, a nonselective COX inhibitor/NSAID. It
was found that LPT dose of 3 J significantly reduced
inflammation through less COX-2-derived gene expression and PGE2 production, and less oedema formation compared to non-irradiated controls. Diclofenac controls exhibited significantly lower PGE2
cytokine levels at 6 h than collagenase control, but
COX isoform 1-derived gene expression and cytokine
PGE2 levels were not affected by treatments. As LPT
seems to act on inflammation through a selective inhibition of the COX-2 isoform in collagenase-induced
tendinitis, LPT may have the potential to become a
new and safer non-drug alternative to coxibs.
9

The aim of the study by de Paiva Carvalho was to
evaluate the effect of single and combined therapies
(LPT, topical application of diclofenac and intramuscular diclofenac) on functional and biochemical aspects in an experimental model of controlled muscle
strain in rats. Muscle strain was induced by overload-

22 I laser
1_ 2014

Crystalopathies are inflammatory pathologies
caused by cellular reactions to the deposition of crystals in the joints. The anti-inflammatory effect of HeNe laser and that of the non-steroidal anti-inflammatory drugs (NSAIDs) diclofenac, meloxicam, celecoxib, and rofecoxib was studied in acute and chronic
arthritis produced by hydroxyapatite and calcium pyrophosphate in rats. The presence of the markers fibrinogen, L-citrulline, nitric oxide, and nitrotyrosine
was determined. In the study by Rubio10, crystals were
injected into the posterior limb joints of the rats. A
dose of 8 J/cm2 of energy from a HeNe laser was applied for three days in some groups and for five days
in other groups. The levels of some of the biomarkers
were determined by spectrophotometry, and that of
nitrotyrosine was determined by ELISA. In arthritic
rats, the fibrinogen, L-citrulline, nitric oxide, and nitrotyrosine levels increased in comparison to controls
and to the laser-treated arthritic groups. When comparing fibrinogen from arthritic rats with disease induced by hydroxyapatite to healthy and arthritic rats
treated with NSAIDs, the He-Ne laser decreased levels to values similar to those seen in controls. Inflammatory and oxidative stress markers in experimental
crystalopathy are positively modified by photobiostimulation._
Editorial note: To be continued with further studies on the
effectiveness of diclofenac and LPT and conclusion in laser
2/2014. An list of references is available from the author.

_contact
Jan Tunér
Spjutvagen 11
772 32 Grängesberg
Sweden
jan.tuner@swipnet.se

laser

[23] =>

Dental Tribune International
The World’s Largest News and
Educational Network in Dentistry
www.dental-tribune.com

[24] =>

I case report

Er:YAG laser
and composite
resin ablation
Author_Carlo Fornaini, Italy

[PICTURE: ©STASIQUE]

_Introduction
In 1954, Buonocore1 initiated a real revolution in
dentistry by proposing the possibility of obtaining
stronger adhesion between composite resin and
enamel through an etching process using orthophosphoric acid. The practical application of his
theory completely changed the rules of conservative dentistry, shifting from the concept of “extension for prevention”2 to that of “minimally invasive
dentistry”3 and, subsequently it was applied, with
several advantages, also in orthodontics4 and pediatric dentistry.5 Although such adhesive systems are
largely employed in dentistry today, there are still
some unsolved problems.
In fact, the etch depth is variable and not predictable6, as well as the type of acid-etching pattern
according to the Silverstone classification7, 8; moreover, rinsing does not necessarily completely arrest
the acid etching process in the depth of the exposed

24 I laser
1_ 2014

enamel9 and, last but not least, there is a clinical
challenge in controlling the geometry and extent of
the etched enamel area.10
With the aim to eliminate these disadvantages,
several methods were proposed over the years as an
alternative to orthophosphoric acid, such air abrasion and maleic acid11-13, but the results were not encouraging. In 1990 Hibst and Keller14 described the
possibility of using the Er:YAG laser for cavity preparation in conservative dentistry.
This wavelength (2,940 nm), being very close to
the absorption peaks of water (3,000 nm) and hydroxyapatite (2,800 nm), which are largely present
in enamel and dentine, causes the explosion of the
intracellular water and thus the destruction of the
dental tissues (15).
In recent years many advantages of using laser
technology, as compared to the traditional rotating

[25] =>

case report

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

I

Fig. 1_Case 1, initial situation.
Fig. 2_Extensive resorption
of the root.
Fig. 3_After laser application.
Fig. 4_Application of orthophosphoric acid.
Figs. 5 & 6_Application of composite
resin, polymerisation and polish.
Fig. 7_Case 2, initial situation.
Fig. 8_Bleaching.
Fig. 9_Post-treatment results.
Fig. 10_Laser application.

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[26] =>

I case report
Fig. 11_Application of
orthophosphoric acid.
Fig. 12_Application of composite
resin, polymerisation and polish.
Fig. 13_Case 3, initial situation.
Fig. 14_Removal of amalgams,
preparation of the cavities.

Fig. 11

Fig. 12

Fig. 13

Fig. 14

instruments, have been described and demonstrated by in vitro, ex vivo and in vivo tests.16-19

fact that these two molecules are present in great
concentrations in composite resin.

An interesting study, based on a questionnaire
given to 100 patients, recorded the patients’ satisfaction after receiving conservative dental treatments by Er:YAG laser: all the patients reported that
they wished to be treated only by laser in the future,
and they also wanted to suggest this opportunity to
their friends.20

This, from a clinical point of view, makes the
Er:YAG laser very effective in the removal of old
composite restorations, with the result of obtaining
a rough surface, able to be bonded to a new coat of
resin, which is not possible to achieve with conventional rotating instruments.23-24

_Clinical cases
One controversial aspect regards the need to use
orthophosphoric acid also after Er:YAG laser preparation. The most validated theory is that to obtain
the maximum bond strength and the minimum of
microleakage, it is necessary to also perform a conventional etching after laser conditioning.21
Recently, a great deal of importance has been
given to the mode of the irradiation, in particular to
the pulse duration: an interesting in vitro study22
based on strength analysis by traction test and morphological analysis by SEM and Atomic Force Microscope, showed the same effects with Er:YAG irradiation alone as with acid etching. This was obtained by using the so-called “QSP” mode (Fotona,
Ljubljana, Slovenia) in which each pulse is split into
several shorter pulses that follow each other at an
optimally fast rate. In this way, a specific surface
roughness is achieved, representing a real alternative to acid etching. Water and hydroxyapatite are
not the only elements with which the Er:YAG laser
has a high affinity—its interactions with PMMA and
Silicon Dioxide are also very interesting due to the

26 I laser
1_ 2014

Case 1
Patient DK, a 24-year-old woman, came to our
clinic to improve the aesthetic aspect of her upper
left central incisor, which had been treated many
years earlier with an extensive re-construction using composite resin (Fig. 1).
The patient reported that during a road accident
twelve years earlier, she experienced a traumatic
self-extraction of the tooth, which was re-implanted after a root-canal therapy. At the X-ray examination, extensive resorption of the root was noticed, which did not allow the preparation of a crown
(Fig. 2).
The superficial coats of resin of tooth 21, and also
of 11 in its distal portion, were removed by Er:YAG
laser (LightWalker AT, Fotona, Slovenia) with these
parameters: 250 mJ, 10 Hz, SSP mode, non-contact
handpiece, air-water spray. The duration of the operation was around seven minutes. No anesthetics
were used and the patient reported no pain or dis-

[27] =>

case report

I

Fig. 15_Laser application.
Figs. 16 & 17_Same procedure on
the internal surfaces of the bridge.
Figs. 18-22_Results of laser
application.
Fig. 23_Application of
orthophosphoric acid.
Fig. 24_Application of composite
resin, positioning of the bridge,
polymerisation.
Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Fig. 20

Fig. 21

Fig. 22

Fig. 23

Fig. 24

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[28] =>

I case report
Fig. 25_Application of composite
resin, positioning of the bridge,
polymerisation.
Fig. 26_Case 4, initial situation.
Fig. 27_Planning of a composite
“Maryland bridge”.
Fig. 28_Laser application.

Fig. 25

Fig. 26

Fig. 27

Fig. 28

comfort (Fig. 3). A gel of 37 % orthophosphoric acid
was subsequently applied on the treated surface for
15 minutes (Fig. 4).

thophosphoric acid was then applied to the treated
surface for 15 minutes (Fig. 11).

The area was rinsed, dried and a coat of bonding
was applied and polymerized by LED lamp. Subsequently, a coat of composite resin was applied, polymerized and polished (Figs. 5–6).
Case 2
Patient PG, a 21-year-old female, came to our
clinic for a bleaching treatment in the dental arches
(Fig. 7). A bleaching gel containing 35 % hydrogen
peroxide and a red coloring agent was used for the
treatment (Fig. 8). The bleaching reaction was accelerated by Nd:YAG laser (Fidelis Plus III, Fotona,
Slovenia). The patient had been previously informed that due to the fact that the bleaching
agent is active only in the enamel and not in the
composite, the post-treatment results would leave
a chromatic difference between the two parts of
the crown (Fig. 9).
To solve this problem, the superficial coat on the
distal part of the upper right central incisor was ablated by Er:YAG laser (Fidelis Plus III, Fotona, Slovenia) with the following parameters: 250 mJ, 10 Hz,
SSP mode, non-contact handpiece, air-water spray
(Fig. 10).
The duration of the operation was around 140
sec. No anaesthetic was used and the patient reported no pain or discomfort. A gel of 37 % or-

28 I laser
1_ 2014

The area was rinsed, dried and a coat of bonding
was then applied and polymerized by LED lamp. Subsequently, a coat of composite resin was applied,
polymerized and polished (Fig. 12).
Case 3
Patient LC, a 37-year old male, came to our clinic
because of a missing first lower molar. Due to the
presence of large, old amalgam restorations in the
nearby teeth (45 and 47) it was decided to remove
these old fillings and to apply a “California bridge”
bonded with composite resin (Fig. 13).
The removal of the amalgams and the preparation of the cavities was performed by conventional
rotating instruments and carbide burs (Fig. 14); then
the impression was taken to construct the bridge.
Before cementation, in order to enhance the adhesion, an Er:YAG laser (Fidelis Plus III, Fotona, Slovenia) was used for the enamel conditioning with the
following parameters: 150 mJ, 10 Hz, SSP mode,
non-contact handpiece, air-water spray (Fig. 15).
The duration of the operation was around 70 seconds. No anaesthetic was used and the patient reported no pain or discomfort. The same treatment,
with the same parameters, was performed on the internal surfaces of the bridge, completed in composite resins reinforced with glass fibers (Targis-Vectris,
Ivoclar Italia, Italy, Figs. 16 & 17).

[29] =>

case report

Fig. 29_Laser application.
Figs. 30 & 31_Application of
composite resin, positioning of the
bridge, polymerisation.

Fig. 29

Fig. 30

Fig. 31

Optical microscope observation showed that, in
addition to the creation of a rough surface in the
composite, the action of the laser also removed the
resin around the fibers, thus allowing for penetration of the bonding agent, with a resulting stronger
adhesion (Figs. 18–22). Subsequently, a 37 % orthophosphoric acid gel was applied on the treated
surfaces of the teeth for 15 minutes (Fig. 23). The
surfaces were rinsed, dried and a coat of bonding
was applied and polymerized by LED lamp. Subsequently, a coat of composite resin was applied and
the bridge positioned and polymerized (Figs. 24–25).
Case 4
Patient MP, a 42-year-old female, came to our
clinic for a rehabilitation of the left upper arch,
where the first premolar was missing (Fig. 26). Due
to financial considerations, it was decided to apply
a composite “Maryland bridge” bonded to the
nearby teeth (teeth 13 and 15, Fig. 27).
Before cementation, to enhance the adhesion,
the surfaces of the teeth and the bridge were irradiated by Er:YAG laser (LightWalker AT, Fotona, Slovenia) with the following parameters: 150 mJ, 10 Hz,
SSP mode, non-contact handpiece, air-water spray
(Figs. 28–29).
The surfaces were rinsed, dried and a coat
of bonding was applied and polymerized by LED
lamp. Subsequently, a coat of composite resin was
applied, the bridge positioned and polymerized
(Figs. 30–31).

_Conclusion
Since its introduction in dentistry, the Er:YAG
laser has demonstrated its ability to treat an ever
wider range of clinical situations with significant
advantages in term of results, patient satisfaction
and comfort.
Today, thanks to its efficacy in composite resin
ablation, it is also possible to apply this technology
to re-make old composite restorations with sound
aesthetics results, and to enhance the adhesion of
non-metallic prosthetics with good results in term
of bond strength._
Editorial note: A list of references is available from the publisher.

_contact

laser

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

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[30] =>

I industry report

Erbium lasers in
pediatric dentistry
Authors_Giovanni Olivi, Matteo Olivi & Maria Daniela Genovese, Italy

Fig. 1

Fig. 2

Fig. 1_Upper labial frenum with deep
papillary insertion at the palatal site,
in a 9-year-old child.
Fig. 2_Er:YAG laser labial
frenectomy.

30 I laser
1_ 2014

_Introduction
Taking care of a pediatric patient’s oral health is a
challenging task, but one that can be exceptionally rewarding. Providing a positive experience to children
enables them to have a trusting, long-term relationship with a dental professional. Combining skill,
knowledge and cutting-edge diagnostic and operative technologies help to guide children toward a lifetime of good oral health. Among the many motivational, diagnostic and operative innovations to consider, one must include lasers. Laser technology in pediatric dentistry today is a new treatment modality for
children and teens; it represents an alternative instrument that sometimes complements, and at other
times substitutes for traditional techniques. Laser
treatment of hard and soft tissues allows for a more

comfortable and minimally invasive intervention. In
addition to the use of high technology, the psychological effect on the child represents an important
benefit which may positively influence the acceptance of subsequent dental treatments.
Several of the factors that make laser therapy an
elective procedure in pediatric dentistry are:
– Its minimally invasive nature, with more affinity for
carious tissue (higher water content);
– Higher safety, because it does not use rotating instruments or blades in a small mouth (which can
move unpredictably);
– It is more comfortable for the patient due to the lack
of direct contact and vibration on the tissue surface;
– It is more acceptable because in many cases the use
of local anaesthetics can be avoided;

[31] =>

industry report

Table 1

Table 2

Operative Advantages:
Comfort:
non-contact—no vibration/noise
Safety:
no rotating or cutting instruments
used in the mouth
Painless:
reduced need for local anaesthesia
or no anaesthesia
Approach: improved patient compliance

Operative Advantages:
Comfort:
non-contact mode
Safety:
no cutting instruments used in the
mouth
Painless:
reduced need for local anaesthesia
or no anaesthesia
Approach: improved patient compliance
Easy use:
intuitive, knowledge of the science
more important than skill

Clinical Advantages:
Minimally invasive:
selective for carious tissue
Decontaminating effect for deep caries
Micro-retentive surface:
a cleaned and debrided surface
Less rise in temperature in pulp and periodontal
surface during irradiation
Direct pulp capping:
coagulation/bactericidal effect
Soft-tissue application:
exposure of subgingival tooth margins during cavity
preparation

– It allows for easier and faster minor gingival and
mucogingival surgery without scalpel or suture,
and with good control of bleeding;
– Secondary intention healing and the postsurgical
period are predictable and usually asymptomatic;
– The use of an innovative technology such as the
laser is also well accepted by parents, who appreciate being able to offer their children the advantages
of laser care. It also provides a favourable psychological impact on the child, who with his or her
imagination, may see the laser as a magical tool that
uses "light and water to clean teeth".
All these advantages allow laser therapy to improve patient compliance by positively influencing
both the objective factors that affect the perception
of pain (see the operative advantages of laser technology in Tables 1 & 2) and the subjective factors of

I

Table 1_Operative and clinical
advantages of lasers in restorative
treatments.
Table 2_Operative and clinical
advantages of lasers in soft-tissue
treatments.

Clinical Advantages:
Minimally invasive:
selective for fibrous and/or inflamed tissues
Decontaminating effect of the surgical site
Coagulating effect of near-infrared lasers
No rise in temperature in tissue for mediuminfrared lasers
Soft-tissue healing:
comfortable post-operative period

pain, by raising the threshold of pain (analgesic effect)
and the threshold of suffering (reducing the incidence of the anxiety or fear related to a negative personal or family experience when "needles, drills,
scalpels, sutures, etc." are used, thus influencing the
cognitive and emotional state of the patient).1
For these reasons the use of the laser with pediatric
patients has proved to be a valid method of intervention, as noted by a number of authors who have reported good levels of patient acceptance during hard
and soft tissue therapy. 1,3,4,5,6,7,8,9,10,11,12,13

_Clinical laser applications
Various applications are possible on both hard and
soft tissues using different laser wavelengths. Each
wavelength has its own applications due to the spe-

Fig. 3_Typical secondary intention
healing after one week.
Fig. 4_Complete and stable healing
of the labial frenum, with new
attachment on the mucogingival
junction, after one year.

Fig. 3

Fig. 4

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[32] =>

I industry report
Table 3_Common applications of
lasers in pediatric dentistry.

Table 3
Hard-Tissue Laser Applications
Preventive Dentistry: laser-assisted fissure sealing,
MIH
Restorative Dentistry: carious removal and cavity
preparation
Endodontics: laser-assisted pulp capping, pulpotomy and pulpectomy;
root canal debriding and decontamination
Soft-Tissue Laser Applications
Oral Pathology: gingival hyperplasia, fibrous hyperplasia, fibroma, epulis, mucocele, eruption cyst,
dentigerous cyst, foreign bodies
Orthodontics: exposure of impacted teeth, distal
molar operculectomy,
gingival contouring, intraoral attachment welding,
ceramic bracket debonding
Periodontics: gingival contouring, labial
frenotomy/frenectomy, lingual frenum release
Laser Applications for Dental Trauma
Trauma to hard tissue and pulp
Trauma to periodontal tissue
Low Level Laser Therapy
TMJ pain, orthodontic pain;
Muscular trismus and contracture;
For accelerating orthodontic movements;
Herpes, aphthous or orthodontic ulcers;
Dental trauma

haemoglobin and melanin and are used in the treatment of soft-tissues pathologies. On the other side,
the Erbium lasers, in the medium infrared spectrum,
are absorbed by water in gum and mucosa and by
water surrounding the hydroxyapatite, and are therefore used on both soft and hard tissues. Among all the
wavelengths used in dentistry, the Er:YAG laser
(2,940 nm) is the most highly absorbed in water and
has proven to be the most flexible, all-purpose laser in
dentistry. In the far-infrared spectrum, the CO2 lasers
(9,300 and 10,600 nm) are also primarily absorbed by
water in gum and mucosa and are used in oral surgery
for the incision and vaporization of soft tissues. It is
important to underline that with healthy gum and
mucosa, the water chromophore is prevalent—while
haemoglobin (blood) is prevalent in inflamed and in
vascular tissue.
If a dentist has multiple lasers, the wavelength
choice must be taken according to the type of healthy
or pathologic tissue: mucosa, keratinized and nonkeratinized gingival, fibrous tissue. Additional differences are dependent on location, health condition,
pigmentation, vascularization, hydration and can be
summarized as biotype variances.14,15 All wavelengths
absorbed by either water or haemoglobin are also
used for the coagulation, vaporization or removal of
the pulp tissue (vital and non-vital pulp therapy). For
the application of laser energy in pediatric dentistry,
the Erbium:YAG laser is considered as the most usable,
all-tissue laser.

_Laser analgesia: an advantage in
pediatric dentistry
Fig. 5_Proximal caries in lower
primary molars in a 6-year-old
patient. LightWalker Er:YAG laser,
treating both carious tissue and
marginal gingiva for healthy tissue
exposure.
Fig. 6_Cavity preparation and
gingivectomy performed:
note absence of bleeding and
thermal damage to the soft tissue.
Fig. 7_Restoration completed.

cific type of biological absorption of each tissue that
is targeted: visible, near, medium and far infrared
lasers interact differently with different chromophores (melanin, haemoglobin, water and hydroxyapatite) contained in different target tissues (mucosa, gingiva, dental tissues) and therefore the laser
choice is regulated by the optical affinity and coefficient of absorption of the tissues for each particular
wavelength.
Lasers in the visible and near-infrared electromagnetic spectrum are specifically absorbed by

Among the several advantages of lasers in dental
applications, laser-induced analgesia represents a
unique way to treat an infantile patient with minimal
or no discomfort. Laser irradiation of the operatory site
with low energy prior to any surgical or non-surgical
procedure generates disruption of the NA+/K+ pump
of the cell membrane of the nervous fibers, causing a
temporary loss of conductance of the nervous impulse
and a consequent analgesic effect in the irradiated
area. Naturally, operating below the threshold of pain
(by using the minimum effective energy and power)
helps to avoid betraying the child’s trust.14

_Hard and soft tissue laser
The high affinity for water, the main chromophore
in carious and soft tissues, makes this laser the safest
and easily used in many procedures on healthy, demineralised and carious dental tissues (enamel and
dentin) as well on gingival and mucogingival tissues.
Fig. 6

Fig. 5

32 I laser
1_ 2014

Fig. 7

When approaching the panel setting, it is important to consider the different water content of the dif-

[33] =>

industry report

Fig. 8_Uncomplicated
enamel-dentin fracture in a
10-year-old patient.
Fig. 9_LightWalker Er:YAG laser is
used for cleaning, decontamination
and roughening of dental structure.
Fig. 10a & b_Fractured upper
central incisor cleaned and
prepared with erbium laser: before
(a) and after (b).
Fig. 8

Fig. 9

Fig. 10a

Fig. 10b

ferent tissues, such as enamel and dentin, and the different composition of the primary tooth compared to
the permanent tooth (newly erupted versus aged) and
adjust the parameters accordingly.16,19 As previously
reported, the pulp tissue is high in water content and
is readily vaporized with the Erbium:YAG laser, and
therefore care must be taken with deep cavities that
are very close to pulp chamber (Figs. 8–10).20,21 Vaporization and coagulation of the pulp is very well performed by the latest technology of the Er:YAG laser,
with a very low rise in temperature in the remaining
tissue, which is important for the pulp vitality during
pulp coagulation or pulpotomy. The LightWalker
(2,940 nm; Fotona, Ljubljana, Slovenia) at 5 or 10 mJ,
15 Hz, at 300 microseconds pulse duration, 5 to 10
seconds defocused exposure, is very effective for pulp
coagulation during a pulp-capping procedure. Softtissue procedures are easily performed and the Erbium:YAG laser never produces tissue carbonisation
even at high energy (Figs. 1–7).

_Conclusion
Lasers have demonstrated their effectiveness and
safety for pediatric dental care. The Erbium:YAG laser,
in particular, allows the clinician to perform an innovative, minimally invasive form of dentistry that is
very well accepted by children.
Before starting to use a laser, it is important to understand the physical characteristics of the different
laser wavelengths and their interaction with biological tissues to assure that they are used in a safe way,
in order to provide the benefits of this technology to
young patients. It is therefore highly recommended to
invest in the appropriate training and education before applying this technology on pediatric patients._

_contact

laser

Dr Giovanni Olivi
The use of water spray and the possibility to modulate the duration of the pulse allows for greater or
lesser thermal interaction for different procedures
(the interaction is more thermal with a low ratio of water spray and less thermal when a higher water spray
ratio is used). A gingivectomy or a frenectomy will be
performed with a longer pulse duration (300–600 microseconds) than a cavity preparation (50–100 micros) and with different energy. When treating multiple tissues in the same intervention, for example bone
and gingiva/mucosa in a labial frenectomy or impacted tooth exposure, care must be taken in varying
the settings according to the different tissues.

Prof.a.c.of Laser Paediatric Dentistry — University of Genoa
SIOI — Italian Society of Paediatric Dentistry
SIE — Italian Society of Endodontics
AIOM — Italian Academy of Microscope Dentistry
private practice: InLaser Rome
Advanced Center for Esthetic and Laser Dentistry

Piazza F. Cucchi,3 00152
Tel.: +39 065815190
olivilaser@gmail.com
www.inlaser.it

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[34] =>

I economy

Gain power at
your laser clinics!
Author_Dr Anna Maria Yiannikos, Germany & Cyprus

_During the last two issues we have discussed
the importance of marketing in our clinics starting
with the first element of marketing mix-service.
Let’s move on now to the second P of the marketing
mix-Price!

c) Place (different prices for patients in a village
than in a town)
d) Time (20 years ago, an implant was very expensive in relation to others applied in recent
years)

First we should decide upon our pricing method.
Our possible options are the following:

The pricing method that we choose is based upon
our:

– Competition-Oriented Pricing: We set up the price
based on ours key competitors’ prices.
– Cost-Oriented Pricing: First we calculate our costs
and then we add in a suitable profit margin.
– Demand-Oriented Pricing: Different prices for the
service according to the type of
a) Patients (for example, we give discounted
prices to an insurance)
b) Service version (We might charge less if we
have our own CAD/CAM machine in our practice)

– Competitive advantage (how our patients perceive us when they compare us to our colleagues)
– Patient reaction – based on their demand
– Competitive reaction (how our colleagues react)
A very sensitive and very important issue that
needs our attention is to avoid Price wars – Why?
a) Our patients’ expectations are distorted
b) Price advantage is short-lived
c) Patients will become sensitive to price at the expense of value and benefits
Price is what we are going to charge for our treatments and actually represents the value of our service. Value is expressed as equal to benefits received
(= tangible or emotional) over expectations (=price).

1%
3%
5%
9%
Death

14%

Relocation

68%

New Relationships

Benefits can be tangible or emotional. Tangible
benefits for our patients are the larger amount of
fillings that we can finish in one session due to our
lasers. Emotional benefits are when they feel that
they belong in an exclusive or expensive clinic.
Value = benefits/price

Lower Price
Product Dissatisfaction
Company Indifference

34 I laser
1_ 2014

There are two ways that we can change the value of
our services:
1. The “boring” way: We increase the benefits without changing the price or reduce the price without changing the benefits

[35] =>

economy

2. The creative way: By being different! This is the
way that we will be able to gain the desirable competitive advantage!
What is a competitive advantage? It is our ability
to perform better than our colleagues and to maintain being different (superior longevity = remain in
the market longer in superiority).
Since we are talking about performance we can
achieve the highest in two ways: differentiation and
cost. Being a cost leader requires offering the lowest prices in the market. This business level strategy
has two main disadvantages: Firstly, a colleague will
imitate us sooner or later by offering lower prices
than we do. Secondly our patients will not perceive
us as professionals in the long run since will not upgrade our services by investing in new technologies
or in further education due to the low cost. Let us remember that research has proven that the reason
that companies/clinics loose customers/patients
are divided into many aspects (Fig. 1).
Clearly, the most profound cause of loosing patients is our company’s lack of difference towards
our colleagues. It is so obvious that the most creative
strategy to attract more patients, to create value and

to gain the desirable competitive advantages, is by
being different, by being unique. It is by being faster
than other offices (easily achieved with our lasers)
or also by being more exclusive or expensive.
Why do people queue for hours and pay hundreds of Euros to buy a Louis Vuitton or a Jimmy
Choo handbag? Why do you think? The real answer
is: because of its emotional benefits! For these brand
names and many more, people are willing to pay
more than for the functional benefits in order to
gain a feeling of belonging to a higher social class, a
feeling of uniqueness, of their position, an item or a
service that makes them feel exceptional.
How can we create those feelings and competitive advantages for our services?
1. By promoting care and compassion. This of course
cannot be achieved by words – we cannot only say
to our patients that we care. People have to walk
out of our office and be absolutely shocked by
how much we care about them.
2. By our competitive advantage based on the number of services we offer.
3. By our level of customer service. Is our team composed by incredible people, so that when patients
walk in our clinic, they are overwhelmed by the
AD

www.DTStudyClub.com

Y education everywhere

and anytime
Y live and interactive webinars
Y more than 500 archived courses
Y a focused discussion forum
Y free membership
Y no travel costs
Y no time away from the practice
Y interaction with colleagues and

experts across the globe
Y a growing database of

scientific articles and case reports
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ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

[36] =>

I economy
hospitability and our team? Will our team go the
extra mile for our patients and let them know how
much they care?
4. Another potential competitive advantage could
be our location. We need to have a location that is
vibrant, growing; populated with people who can
afford the dentistry we want to offer.
5. Convenience can also be considered a possible
competitive advantage. Many people cannot afford to take time off and they want to come in the
evening or on a weekend.
6. It is our choice of course if we want to meet
their demand.

DU
B IN
CH
UK]

We are professionals, therefore we can
increase our profits in this competitive era
that we are working in and be different in a
creative way by applying the following simple formula:
laser equipment + continuous
education
:
RE
TU
[PIC

This will lead to our specialization in the field of lasers, resulting
in our uniqueness. To continue, let
us also refer to the moments that we
do not feel comfortable of telling the
price—when we might be afraid that the patient
might react negatively. We have high-tech clinics,
we offer exclusive treatments, therefore premium
services. Let us not forget to charge for them!
Now, more practically: For example, we have the
patient on the chair how do we present the price? It
would be better to tell the price dividing it in units—
let the patient do the calculations for the whole cost
of the treatment. We could also use the sandwich
technique to present the price.

_The sandwich technique
This technique sandwiches the price between
positive statements. For example if we are dealing
with laser treatments, we say one benefit at the beginning, for example “Using a laser is a very relaxed
experience since we avoid drilling” and then we add
the second benefit, “You will be very satisfied because we perform the treatments without anaesthesia”— and then we add the price in the middle—
“The cost of the treatment will be 400 €”. Then, without a break, we insert the last benefit on top— “You
will also feel very comfortable since the procedure
will be without the need of sutures”.
Finally, remember never to argue about the price
— do not forget that there is no objective price — for
one patient the price can be perceived cheap and for
another one extremely expensive.

36 I laser
1_ 2014

Studies have shown that:
a) Consumer behavior is often based on the individual’s perception and other psychological characteristics.
b) The more unique a product/service offering is perceived by the consumer, the greater is a company’s
freedom to set prices above those of competitors’.
Therefore, the value is affected by what the patient perceives — If our patients perceive us as a
credible office, offering services based on high
quality and technology, derived from our
knowledge from our premium studies, then
they will have a good reason to pay the requested amount for the treatments.

_The patient says Yes!
Never forget to praise them—saying for example—“Mr Smith, your decision is the best for the
health of your mouth and your wellbeing”. Psychological experiments have shown that whatever
we say the next 25 sec. will be registered in the
patient’s long-term memory, meaning that
they will never forget it. And when Mr Smith
goes home and tries to recall what happened
previously in our clinic, he will remember immediately that he made the best possible choice!
All the above topics and proposals can be elaborated further and new conclusions and ideas can be
created from them. Our medical studies leave a gap
where the business department of our clinics is concerned. That is why we have created DBA. DBA is the
new innovative Dental Business Administration Mastership Course by AALZ. It is created exclusively from
dentists for dentists, dental managers/administrators
and will be launched in Aachen, Germany, on the
5 May 2014. It is all about preparing dentists to undertake their business as entrepreneurs, presenting all
the business-oriented material they will need in order
to be managers and directors of their own clinic and
have full control and maximum utilization of resources and team. The course will be launched at
5 May 2014, immediately after the completion of the
2nd WALED Congress at AALZ — RWTH Aachen University Campus._

_contact

laser
Dr Anna Maria Yiannikos
Adjunct Faculty Member of
AALZ at RWTH Aachen University Campus, Germany
DDS, LSO, MSc, MBA
dba@aalz.de
www.dba-aalz.com

[37] =>

meetings

I

International events
2014

Oral Implantology World Congress

30th AACD 2014—Annual Scientific

Paris, France

Session American Academy of Cosmetic

2–4 July 2014

Dentistry

www.oiwc-paris2014.com

Orlando, FL, USA
30 April–3 May 2014

23rd Annual DGL Congress

www.aacd.com

LASER START UP
Düsseldorf, Germany

SIDEX 2014

26–27 September 2014

Seoul, Korea

www.oemus.com

10–11 May 2014
www.sidex.or.kr
28th EAED Annual Meeting
Athens, Greece
29–31 May 2014
www.eaed2014.com

SINO-DENTAL 2014
Beijing, China
9–12 June 2014
www.sinodent.com.cn
APDC 2014—The 36th Asia Pacific Dental
Congress
Dubai, UAE
17–19 June 2014
apdentalcongress.org
WFLD—5th Congress
Paris, France
3–4 July 2014
www.wfld.info

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1
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_ 2014

[38] =>

I science

ISMI: A new Society for
Implantology
Aim of the new society is promoting metal-free implant dentistry as an innovative and particularly futureoriented direction within the field of implantology. In
this context, ISMI supports its members with training
and education opportunities as well as with regular expert and market information. In addition, ISMI campaigns in their public relations, i.e. in circles of experts as
well as in patient communication, for a comprehensive
establishment of metal-free implant treatment concepts.

In addition to patient advertising and public relations, ISMI offers its members a range of benefits, such
as an individual homepage for every member, a specialist online archive and a chat on „Metal Free Implantology“, training opportunities and a monthly newsletter.

_Metal-free implantology
For more than 40 years, titanium implants have
proven to be excellent dental implants. Although the
roots of implantology were metal free, the then available aluminium oxide ceramic has not worked for reasons of stability. The developer of these implants, Prof.
Dr Willi Schulte, told Dr Volz shortly before his death in
a personal letter that he was still convinced that the future belongs to zirconia implants.
Dr Rudelt from Hamburg has worked very successfully with zirconia implants for over 30 years. He handed
on human histologies to Dr Volz, documenting a 20year span of results. Unfortunately, his promising work
could not be continued due to the economic crisis in
Japan and the thus affiliated end of financial support by

38 I laser
1_ 2014

[PICTURE: ©DOOMU]

_The International Society of Metal Free Implantology (ISMI) was establishedin January 2014 in Constance (Germany). Founding president of the new society is Dr Karl Ulrich Volz from Constance, a resident implantologist and pioneer in the field of ceramic implants. Members of the founding group are renowned
dental implantologists from Germany and abroad.

the main sponsor KODAK. Dr Ulrich Volz then took up the
issue again in the year 2000 because the patients of his
environmental medical clinic, as well as the resident
doctors Dr Joachim Mutter and Dr Johannes Naumann
(formerly Environmental Medicine, University of
Freiburg/Breisgau) persisted on the use of metal-free
implants. Over the past 13 years, Dr Volz successfully inserted more than 8,000 zirconia implants and characterised the trend towards metal free implantology.
Today, zirconia is an established material for dental
implants. Stability, osseointegration and prosthetic options more and more achieve the level of conventional
titanium implants. The broad use of titanium dioxide in
cosmetics and medicines causes an growing number of
incompatibilities. The patients’ demand for highly aesthetic, tissue-friendly, anti-allergic and metal-free zirconia increases year by year. Market experts estimate
that the proportion of zirconia implants is to reach at
least 10 per cent, more likely 25 per cent in the next years.
For more information on metal-free implantology,
visit www.ismi.me._

_contact
ISMI—International Society of
Metal Free Implantology
Lohnerhofstr. 2
78467 Konstanz, Germany
Tel.: +49 7531 991603
Fax: +49 7531 991604
office@ismi.me
www.ismi.me

laser

[39] =>

P R O F E S S I O N A L

M E D I C A L

C O U T U R E

EXPERIENCE OUR ENTIRE COLLECTION ONLINE
WWW.CROIXTURE.COM

[40] =>

I interview

LaserCUSING:
Laser melting
with metals

40 I laser
1_ 2014

If there’s one thing currently generating excitement
in terms of production methods, it’s 3-D printers. At
all the trade fairs, 3-D printers are the big attraction
in the industry. Does this signal a departure from a
form-based way of thinking in favor of the geometrical freedom of components produced using additive methods? Interested parties are already finding
out whether it’s possible to print Lego blocks, or—
more ambitiously—food items. With so much creativity out there, we wanted to explore what can be
accomplished realistically using laser melting with
metals in an industrial context. We spoke with
Dr Florian Bechmann, Head of Development at
Concept Laser, about the current state of technology, trends and options for the near future.

_Which applications do you mean? Probably those
in the automotive industry…?
Yes, but not only there. Sectors that are defining
and driving the process forward include the automotive and medical technology sectors, as well as aerospace. These technology drivers not only demand
high standards in terms of quality and choice of materials, but also with regard to quantitative aspects,
such as increasing productivity. These customers require shorter construction times and more parts in a
single-build chamber. We developed the X line 1000R,
which currently has the largest build chamber, for the
automotive industry. The transition from a 400 W
laser to a 1,000 W laser is an important milestone for
the process. It was developed in close cooperation
with laser specialists from the Fraunhofer Institute.
The goal was to develop quicker processes that are
also more affordable. One of the applications we had
in mind was time-saving development of engines for
modern vehicles.

_You recently opened a new development center. It
sounds like the industry is rapidly expanding?
That's true. The industrial applications are currently exploding, literally. Laser melting with metals
exerts a strong fascination when it comes to the components of the future. As the technology leader, we
must support this market process by introducing innovations. When it comes to complex systems, we
must ensure a wide-ranging interplay between optics, design, control technology, software and powder
material. At our new development center, my colleagues and I are hard at work on “discrete innovations” not intended for disclosure to the general public. Certain industries are quite sensitive…

_You mentioned the aerospace sector. How does
this industry use the process?
The aerospace sector is driving forward innovations. High quality solutions are in demand here, including the use of reactive materials such as titanium
or aluminum-based alloys that can only be produced
reliably to a high quality in a closed system. In general,
users such as the following are convinced that the
process will become increasingly well-established:
NASA, the German Aerospace Center, Honeywell,
Snecma, Aerojet/Rocketdyne and Astrium Space
Transportation from the EADS Group. NASA engineers are even considering using additive manufacturing to produce components on the ISS—in orbit.
The advantage of this is the ability to produce parts in

[41] =>

interview

Fig. 1

space using CAD data, provided there is a sufficient
stock of powder.
_Are the USA playing a leading role?
In terms of the USA, it can be said that a lot of capital and staff resources are in use. The engineers and
students at universities there are fascinated by the
possibilities presented by laser melting. Americans
are considered to be creative and believers in progress,
and to have the necessary drive. Unfortunately, we
still have little contact with the aerospace industry in
China. At present, we're outside that market. But that
doesn't mean it has to stay that way. We Europeans
can contribute our research and mechanical engineering capabilities mainly in the USA and Europe.
In Europe, the EU promotes this process through
projects like AMAZE due to a strong belief in the
process’s sustainability and high level of innovation.
_Are other sectors getting on board as well?
Of course. After all, the options are attractive. The
approach is currently revolutionizing medical technology, for example: traditional process chains are
being completely reconceptualised. LaserCUSING
parts are in demand as implants since their porous
surfaces incorporate well into the body, yet also provide the necessary elasticity. One rising application is
the affordable and rapid production of dental prosthetics from biocompatible materials. These are
highly adaptable, long-lasting dental solutions instead of dental prosthetics that have to be crafted
manually with much effort. The process is even advantageous for retrofitting: worn-out turbine parts
can be quickly and affordably regenerated. This kind
of application is relevant in power plant engineering
and aircraft construction. In this hybrid technique,

layers of the exact same material can be applied additively to the existing part. In addition to regeneration,
new whole parts are also produced for turbine technology applications. LaserCUSING also allows functionalities such as cooling channels to be integrated,
which improve the performance of components. The
offshore industry is considering installing laser-melting systems on drilling platforms, which would allow
for independent, on-site production of certain components. The technology is not fixed to a specific location and can be operated locally.

Fig. 1_”We are constantly improving
our patented Quality Management
Module (‘QM Module’) in order to set
the standard in terms of prediction
quality and operability, as well as influencing the ongoing construction
process.”

_Environmental friendliness is one of the major issues of our time. What is the situation from an environmental perspective?
The Laser melting process is highly sustainable: on
the one hand, due to the localized production options,

Fig. 2_ “3-D mapping can be expected in the future: this capability
would increase the transparency of
the process and captures the component in its structural entirety.”

Fig. 2

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I interview

_If you wanted to describe what makes your system technology special, what would you mention?
Our Quality Management Modules are definitely
an important distinguishing feature for us and our
customers. I would also mention the separation of the
build chamber and handling area, which is characteristic of our products; this offers maximum occupational safety and ergonomics. Our automated powder transport in containers is also practical. Handling
materials in a closed system has many advantages.
It's important for safety, but also to prevent contamination, such as by oxygen. Safety is very important to
us. We comply with the ATEX Directive of the EU very
conscientiously. I would also mention interfaces with
the production environment, e.g., crane accessibility
for building boards weighing up to 80 kg. This is convenient for the operator. Some details are interesting
as well: such as filter replacement in processes using
reactive materials, such as titanium. The contaminated filter is flushed with water and its contents are
then safely disposed of in an environmentallyfriendly manner.

Fig. 3a

Figs. 3a & b_Sector components
(application examples).

Fig. 3b

which reduce logistic complexity, and on the other,
because the process reduces the quantity of material
required. There aren't any oil or coolant emissions either, as is often still the case in mechanical engineering processes. Even the residual heat can be used. A
1,000 W laser produces approximately 4 kW of heat,
which can be used by building systems if channeled
into a cooling water circuit. There are good reasons
why laser melting is considered a green technology.

Fig. 4_Discrete innovations:
the largest build envelope yet for
large parts in the automotive and
aerospace sectors.

42 I laser
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_Will 3-D printers soon become a fixture on our
desks, like laser printers are today?
The additive process encompasses this option. But
to remain serious: we should distinguish between
consumer and industrial applications. Producing
LEGO blocks oneself from plastic, using 3-D printing
will soon be realistic. The range of materials and
scope of applications for ordinary people will remain
very limited, however. Producing replacement parts
for vintage cars, or cars in general, is certainly also
conceivable—but these are industrial applications,
once again. We always focus on purely industrial
solutions with particular quality standards and
material requirements, through to certification of
the materials and process. Industrial solutions
would be too heavy for a desk (laughs); here,
we focus on current metal-processing methods in a production environment.
Fig. 4

_Which other impulses do you see in the future for
industrial laser melting?
The scope of applications is growing, which means
the range of materials is expanding as well. This requires strong consulting services, which we must provide to the market. The system must also be repeatedly adjusted to accommodate these new materials.
At the same time, design requirements for components are also becoming more demanding. This
ranges from lightweight construction and largely
foam structures to functional integration, such as
cooling technology in components. This is very exciting for us since certain developments become possible beyond the confines of one sector thanks to multiplication effects. Another aspect is the growing importance of quality among users. Customers expect
active process monitoring and series production capability, i.e., reproducibility at an industrial level.

[43] =>

interview

_What's going on in terms of quality requirements?
From the customer's perspective, this is currently
the most important area. Customers are interested in
geometry, density, productivity and, above all—quality. Two approaches are expedient here: active
process monitoring using machine technology and
developments in materials. This includes the certification of materials, such as in medical technology, or
manufacturer-specific instructions, which must be
complied with in the automotive and aerospace sectors.
_What does quality mean in concrete terms for
mechanical engineering?
First of all, it's the interplay in the system among
optics, mechanics, control technology and software
that I mentioned at the outset. The key factors, however, are situated in comprehensive quality monitoring. Active QA means checking, comparing, analyzing
and evaluating process data in real time. We are constantly improving our patented Quality Management
Module (“QM Module”) in order to set the standard in
terms of prediction quality and operability, as well as
influencing the ongoing construction process.
_Could you describe this QM Module more specifically?
It involves two approaches: 1. QMmeltpool and 2.
QMcoating. QMmeltpool means that the system uses
a camera and photo diode to record signals during the
laser process. This data can then be compared to reference values. The optical system is designed coaxially. It allows the camera to record a very small area of
the melting pool approx. 1x1 mm². In other words, it
takes a very detailed picture. It can detect impaired
laser performance due to contamination of the
F-theta lens or caused by natural aging of the laser, as
well as deviations in the dosing factor. The second approach is the QMcoating QM module, which ensures
that the optimal powder quantity is used. Because
only what's needed is used, it saves powder material
—up to 25 per cent—while also reducing set-up times.
QMcoating monitors the layer surface while powder
is being applied. If too little or too much powder is
dosed, the dosing factor is adjusted accordingly, i.e.,
actively counteracted. The two QM modules monitor
and document the process, thereby ensuring reproducible quality.
_What developments can be expected in the future?
In the area of process signal analysis in general,
also known as the “component map.” 2-D maps are
generated during the construction process and must
ultimately be represented in 3-D models. This is comparable to the images from CT measurement, which is
computer tomography, like that familiar from med-

Fig. 5

Fig. 6

ical technology. This mode of imaging and capability
would increase the transparency of the process and
captures the component in its structural entirety.
Transparency is a highly dynamic, rapid process,
which operators can only master with special aids.
Another point is the speed of component construction. This figures high on customers' wish lists. There
are two methods: on one hand, higher laser output,
such as in the X line 1000R (i.e., the jump from a
400 W to a 1,000 W laser) and on the other, using multiple lasers. Multiple laser sources will be able to significantly increase the build rate in the future, though
the advantage of employing familiar process parameters has to be weighed against the increasing complexity of the optical arrangement. These concepts involve multiplication not only of the lasers themselves,
but also of most of the other optical components as
well._

Fig. 5_Active quality assurance using
QMmeltpool: although the human eye
is incapable of detecting defects,
QMmeltpool nevertheless identifies
deviations in component quality.
Fig. 6_QMcoating: without
QMcoating, the layer may be
insufficiently coated (the red areas
indicate a lack of powder material);
with the QMcoating approach,
however, the powder dosing factor is
adjusted within the tolerance range.

Thank you for this conversation.

_contact

laser

Concept Laser GmbH
An der Zeil 8
96215 Lichtenfels, Germany
Tel.: +49 9571 949238
Fax: +49 9571 949249
www.concept-laser.de

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[44] =>

I interview

“Technology has allowed my
work to evolve enormously”
An interview with Dr Carlo Fornaini, president-elect of the World Federation for Laser Dentistry
Author_Nathalie Schüller

Pr. Carlo Fornaini is teacher at the University of
Parma(Italy) and Researcher at the university of
Nice (France). He is also Coordinator of EMDOLA
Master in these two Universities. He published
more than 100 papers , mainly on the use of laser in
dentistry. He is President-elect of the World Federation for Laser Dentistry (WFLD).

said, it is normal that each president will have his or her
own way of leading the federation, and I too have my
own vision, which is concentrated on three main related points.
I think it is now necessary for a renewal of the federation’s leadership including the divisions, there are
several colleagues who served since many years the
Association and are now able to actively participate to
its leadership. This is related to the second point of my
vision, the need to promote young members by
encouraging them to participate in the association’s
activities and in congresses.
Then, my goal is to expand the federation to new
countries and thereby disseminate information on the
use of laser technology to people who are still not using lasers, through the organisation of courses and
events in these countries.

Dr Carlo Fornaini

_Dr Fornaini, congratulations on your election as
the next president of WFLD. I understand you will assume your post during the next congress in Paris, in July
2014. Are you already able to discuss your goals for your
two-year tenure?
First of all, I would like to say that the governance of
our federation entails teamwork and results are
achieved with the contributions of all the executive
committee members. This is the reason for the nomination of the president-elect two years before his or her
effective start as president: in this way, he or she has the
opportunity to work with the other members of the executive committee, including the past president. That

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But I must say that the organising and scientific
committees for the Paris congress pre-empted me by
choosing to invite many new young speakers, and this
makes me very happy.
_Could you tell us more about the European Master
Degree in Oral Laser Applications (EMDOLA)? What do
you think makes it stand out from other programmes?
It seems to be an important part of WFLD congresses.
Do all students have to defend a master’s thesis in front
of the international jury during the congress?
The EMDOLA is one of the most important postgraduate opportunities for comprehensive education
on the use of laser in dentistry and it is unique in that
all five universities involved in it (the University of
Parma and Sapienza University of Rome in Italy, Nice
Sophia Antipolis University in France, University of
Liège in Belgium and University of Barcelona in Spain)

[45] =>

interview

offer the same programme in eight modules. A student
may thus choose to attend a module at any one of these
universities.
I think it is important to distinguish between universities and scientific societies and, while in some
cases EMDOLA graduation ceremonies have been held
during WFLD congresses, the difference between these
two entities must be pointed out: the EMDOLA is offered at the universities and all the academic activities,
including the master’s thesis defence, take place at the
universities.
That said, I think that EMDOLA is a great resource for
WFLD and in recent years I have seen many of its graduates start participating in WFLD congresses, giving
lectures and publishing in journals.
So, EMDOLA can be considered to bring new blood
to WFLD to avoid its ageing, and WFLD can be considered to represent the new ground where little plants of
the EMDOLA may grow into large trees.
_You had a lecture on laser welding at the IMAGINA
Dental congress in February in Monaco. Would you tell
our readers why this topic is important? Since you coauthored the book Laser Welding, published three years
ago, has much changed in this area?
IMAGINA Dental is a very interesting event on new
technologies in dentistry and this was the second edition to which I have been invited. I am very eager to be
participating for two main reasons. The first is that the
laser session will be combined with the congress of the
EMDOLA ACADEMY, of which I am president. The second is that laser welding is a topic about which I am passionate: I spent several years of my life discovering a
way to weld intra-orally and, once I had achieved this
and published my papers, many people from different
countries congratulated me.
The invitation to contribute a chapter to the book
Laser Welding was most satisfying for me, giving me
the opportunity to collaborate with engineers and
physicists, each of us describing in our chapter our
study.
I think intra-oral laser welding is still today a field of
dentistry full of potential applications in orthodontics,
prosthetics and implantology.
_The use of laser treatment in the dental practice
appears to be very limited still. What are the reasons in
your opinion, and do you feel this will change in the future?
Even if the percentage of laser users among dentists
is still not high, in recent years, there has been a dramatic increase in publications, courses and the establishment of scientific societies concerned with this

topic. The course I give on laser to the undergraduate
students at the dental school at my university serves as
an example of the extent to which laser is given consideration today at university.
In any case, the number of laser users in dentistry is
growing and this is probably due to the reduced prices
of the devices and the increased number of treatments
possible today. If I think back to the first appliance I
used, with their great dimensions, high costs and poor
ergonomics, I think I was really a pioneer!
Fortunately, technological expertise is increasing
rapidly and I am often surprised when visiting countries
where, some years ago, I had helped my colleagues to
start using laser in their practice to find that they have
become expert laser dentists.
_As with any medical field, the industry is constantly
changing. The integration of CAD/CAM dentistry is constantly being promoted and it will become increasingly
easier to integrate it into a dental practice. Is the situation the same for lasers, and how has this affected your
curriculum or the way you teach your students?
When I recall when I started to work as a dentist
(around the Middle Ages!), it is evident that technology has allowed my work to evolve enormously. I am
happy to have had the opportunity to live in a time of
such great technological progress. I think that laser is
able to integrate with every dental technology device,
in particular CAD/CAM devices. When I began my last
study on a laser scanning handpiece, which led to the
realisation of X-Runner (Fotona), I had in mind the
possibility of fully assisted prosthetics: the inlay
preparation programmed in advance and performed
with a laser scanning handpiece, optical impression
taking and fabrication with a CAD/CAM device. The
result? Perfection!
_What are the advantages and/or limitations of
using laser in dental practice?
I think that the main aspect that in the past damaged the image of laser in dentistry was that it was presented as being something almost magical that was
able to produce the best results possible in the hands of
anybody. Evidently, it is not so and we must be honest
and realise its limits and the importance of knowledge
of all aspects of this technology, physics and laser–tissue interactions included.
Only with comprehensive theoretical and practical
training is it possible to use laser in every clinical situation to advantage and without risk to patients.
I always say to my students, “Laser is not the magic
wand that transforms the worst of dentists into stars!”.
Thank you very much for the interview.

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[46] =>

NEWS
World Oral Health Day

Scientists discover that

Calls attention to high risk of oral diseases

Microorganism
prevents mouth
infection

The figures are stark: the average density of dentists to head of population in Africa is 1 to 150,000;
in industrialized countries, the average is 1 to
5,000. In Ethiopia, the lack of access is even more dramatic with a density of
only 1 dentist per
1 million people. This
information derives
from the Oral Health
Atlas developed by FDI
World Dental Federation, which
provides a clear picture of dental health around
the world.1 Even in countries with fast growing
populations of dentists, unequal access to dental
care is a major obstacle to optimal oral health.
“Developing countries face great challenges in
their quest for optimal oral care”, stated Dr Tin
Chun Wong, FDI President. “Oral health is integral
to general health and a basic human right, and we
must ensure cost-effective solutions become
available to all. Promoting better research and obtaining valid data will help us achieve this objective.”

The damage to oral health due to poor access to care
is exacerbated by the fact that many developing
countries are disproportionally affected by a number of oral diseases. The combination of high risk of
oral disease and low access to care, results in many
patients not getting adequate treatment in time.
World Oral Health
Day is celebrated
every year on 20th
March. The theme of
World Oral Health
Day 2014 was ‘Celebrating
Healthy
Smiles’. It reflects the major contribution oral
health makes to our lives. Around the world, FDI
member dental associations, schools, companies
and other groups will celebrate the day with events
organized under this single, unifying and simple
message. For more information, visit: www.worldoralhealthday.org

A U.S. research project has shown that Pichia, a beneficial fungal yeast, inhibits growth of the harmful fungal
yeast Candida, which also causes oral thrush. The researchers hope that the findings will contribute to the
development of a therapeutic agent to fight the painful
mouth infection, as well as other fungal infections.
The study involved testing the mouths of twelve healthy
individuals and twelve patients diagnosed with HIV for
the presence of fungi and bacteria. HIV-infected participants were selected for comparison because oral candidiasis is the most common oral complication in these
patients, the researchers explained. Using DNA analysis, the researchers observed no differences with regard to bacteria between the two study groups. “However, what changed significantly was the composition
of the fungal community,” said senior author Dr Mahmoud A. Ghannoum. “We found that when Candida is
present, Pichia is not, and when Pichia is present, Can-

1 Beaglehole, R., Benzian, H., Crail, J., and Mackay, J. (2009) The
Oral Health Atlas. Mapping a neglected global health issue. FDI
World Dental Federation. Cointrin, Switzerland.

SIROLaser Factbook

Comprehensive information on diode lasers
Sirona reports on the wide range of applications of
diode lasers in a special edition of the English-language laser international magazine of laser dentistry.The
"SIROLaser Factbook—Clinical articles about SIROLaser Advance and Xtend applications" includes research by well-known experts as well as informative
field reports from experienced
users of laser technology.
Compact and informative: Sixty
pages full of solid expertise and
practical applications await the
readers of English texts collected by Sirona in “SIROLaser
Factbook—Clinical
articles
about SIROLaser Advance and
Xtend applications.” Academic
articles and real-life user reports
by well-known experts provide
information on the many uses

46 I laser
1_ 2014

and treatment options of diode lasers with a wavelength of 970 nm. Interesting facts and figures, study
results, documented case studies with descriptive
pictures, and recommendations for further reading
complete the compendium.
“Anyone with an interest in laser
dentistry should read the SIROLaser
Factbook,” says Ingo Höver, product
manager at Sirona. The book is especially meant for beginners, says
the laser specialist. “However, experienced users will also find it
worth reading. I am sure that they
will be surprised to learn the many
possibilities of diode lasers and
the range of applications that are
open to them with models like the
SIROLaser Advance or SIROLaser
Xtend.”

dida is not, indicating Pichia plays an important role in
treating thrush.”
In the second phase of the study, the researchers conducted laboratory experiments on the fungi.When they
grew Candida in test tubes in the presence of Pichia,
there was a striking reduction in Candida growth.
“One day, not only could this lead to topical treatment
for thrush, but it could also lead to a formulation of therapeutics for systemic fungal infections in all immunecomprised patients,” Ghannoum said. “In addition to
patients with HIV, this would benefit very young patients and patients with cancer or diabetes.”
The study, titled “Oral Mycobiome Analysis of HIV-Infected Patients: Identification of Pichia as an Antagonist of Opportunistic Fungi,” was published online on
March 13 in the PLOS Pathogens journal. It was conducted by Case Western Reserve University and the
University Hospitals Case Medical Center.

[47] =>

WFLD will hold
th

14 World Congress for
Laser Dentistry in Paris

Breast and prostate
cancer
Bisphenol A (BPA) is a widely used chemical in plastics,
such as food containers, and is also found in dental
composites and sealants. Now, two recently published
studies have suggested that BPA may play a crucial role
in cellular transformation and disease progression in
prostate cancer patients, and may promote breast cancer growth.

This event will gather dental specialists for all around
the world and the scientific program has been designed with different speakers trying to cover all the different fields regarding laser use in dentistry and the appliance if laser in implantology.The combination of scientific studies, substantiating the scientific evidence of
treatments performed with laser, as well as the clinical
experiences of recognized professionals are a huge attraction and a not-to-miss congress.
Nowadays WFLD is present on five continents, in almost 50 countries with the mission of propagating science with no economic interest. The WFLD World Congress and Paris,as a city,come together to make a great
scientific event. Do not miss what may be one of the
best congress in laser dentistry from 2 to 4 July in Paris.
Submit your abstract and register already on the congress website www.wfld-paris2014.com.

New studies link BPA to

The first study, titled “Exposure to Bisphenol A Correlates with Early-Onset Prostate Cancer and Promotes
Centrosome Amplification and Anchorage-Independent Growth In Vitro,” was conducted at the Cincinnati
Congress President :
Ass. Prof. Dr Frederick Gaultier
Chairman of the scientific committee :
Prof. Dr Jean-Paul Rocca
Chairman European Divison of WFLD :
Prof. Josep Arnabat
WFLD Chairman of International and legal affairs :
Prof. S. Nammour

Prolonged breastfeeding may increase

Risk of cavities in primary teeth
In order to establish an association between breastfeeding and severe early
childhood caries, researchers examined the oral health status of 715 infants from low-income families in
Porto Alegre.

They found that the prevalence of
caries was highest in children who
were breastfed at 24 months or beyond compared with babies who had
been breastfed until twelve months or
younger. In addition, they observed
that high-frequency breastfeeding increased the association between long-duration breastfeeding and
caries.
Exclusive breastfeeding up to six months of age is recommended by the World Health Organization. However, the organization also recommends continuing
breastfeeding along with appropriate complementary
foods up to two years of age, even though several case
studies have linked prolonged on-demand and nocturnal breastfeeding to early childhood caries, primarily

because breast milk is considered a critical source of
energy and nutrients.
The study, titled “Association of Long-Duration Breastfeeding and Dental Caries Estimated With Marginal
Structural Models”, was published online on Feb. 19 in
the Annals of Epidemiology. It was conducted by scientists at the University of California, San Francisco, in
collaboration with the Universidade Luterana do Brasil
and Universidade Federal de Ciências da Saúde de
Porto Alegre.

Cancer Center and included 60 urology patients. Overall, they found higher levels of BPA in prostate cancer
patients compared with study participants without the
disease. The difference was even more significant in
patients under the age of 65, the researchers reported.
In addition, they observed that exposure to low doses
of BPA increased the percentage of cells with centrosome amplification two- to eightfold, said Dr. Shuk-mei
Ho, principle investigator and director of the cancer
center. The study was published online on March 3 in
the PLOS ONE journal.
In the second study, researchers at the University of
Texas at Arlington found abnormal amounts of HOTAIR
expression in breast cancer cells and mammary gland
cells exposed to BPA. HOTAIR is a molecule that can
suppress genes that would normally slow tumor
growth or cause cancer-cell death. The findings suggest that BPA disrupts the normal function in such molecules and is linked to tumor growth in breast cancer
patients. The study, titled “Bisphenol-A and Diethylstilbestrol Exposure Induces the Expression of Breast
Cancer Associated Long Noncoding RNA HOTAIR In
Vitro and In Vivo,” will be published in the May issue of
the Journal of Steroid Biochemistry and Molecular Biology.

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[48] =>

Could chewing gum prevent

Crucial role of schools in

Implant failure in the future?

Promoting oral
health

Chemistry at the University of Würzburg explained that this increase could be identified through a special chewing gum using a
small peptide chain that is bound to a bittertasting compound. Once enzyme concentrations in a patient’s saliva exceed a certain
level owing to complications with the implant, the peptide chain will snap, releasing
the bitter compound. In the future, special
chewing gum could be part of post-operative care in addition to routine check-ups.
Patients would have to contact their dentist
upon recognising the bitter taste.

About 6 to 15 per cent of patients suffer from periimplantitis, inflammation that destroys soft and hard
tissue surrounding the implant after placement. It is
known that the concentration of matrix metalloproteinase-8, an enzyme that is also responsible for periodontitis, increases significantly when inflammation around the dental implant arises. Prof. Lorenz
Meinel from the Institute of Pharmacy and Food

In addition to the development of the chewing gum, the researchers are considering
developing a coating that uses the peptide
chain system and can be applied to the implant directly.

Although dental caries rates among children have
declined in several high-income countries over the
last decades, the opposite trend has been noted for
low-income countries. A survey conducted at the
University of Copenhagen has shown, however,
that school programmes can contribute significantly to a gradual reduction of inequalities in dental health.
Through analysis of data from the World Health Organization’s Global School Health Initiative, a programme that was launched in 1995 in 61 countries
to improve the health of students and other mem[PICTURE: ©AN NGUYEN]

The project will be carried out in collaboration with
Swiss dental implant manufacturer Thommen Medical and various other European companies and scientific institutions. The research has received funding of €1 million for two years from the European
Union.

Mothers' oral bacteria may predict

Likelihood of early childhood caries
In their study, researchers at the University of California collected dental and salivary bacterial samples at
three- to six-month intervals from low-income Hispanic mothers and their children from pregnancy
through 36 months postpartum to calculate the child
caries incidence. In total, the study included 243
mother–child dyads.
Over the course of the study, the researchers found that
salivary levels of mutans streptococci and lactobacilli
were greater among mothers of caries-affected children compared with caries-free children. Overall, they
observed that the incidence of caries was twice as high
in children with mothers who had higher levels of bacteria.
According to the American Dental Association, cariogenic bacteria, and mutans streptococci in particular,
are transmitted soon after the first teeth erupt. The as-

48 I laser
1_ 2014

sociation thus recommends that parents, including
expectant parents, visit a dentist to decrease the
mother's mutans levels to decrease the child's risk of
developing early childhood caries.
The study, titled “Maternal Oral Bacterial Levels Predict
Early Childhood Caries Development”, was published
online in Dec. 19, 2013, in the Journal of Dental Research ahead of print.

bers of the community through schools, the researchers observed that about 60 per cent of the
countries give formalised instruction on how to
bush teeth. However, not all countries have access
to clean water and the necessary sanitary conditions, which constitutes a major challenge for the
health and school authorities in Asia, Latin America and Africa in particular. Dental health inequalities may also arise in high-income countries.
Overall, the survey showed that schools have a
central role in promoting health and preventing
diseases because healthy school environments
that offer children education on dental health are
generally well placed to set children on a path to a
healthy lifestyle throughout their lives, Petersen
explained. The study, titled “Promoting oral health
of children through schools—Results from a WHO
global survey 2012”, was published in the December issue of the Community Dental Health
journal.

[49] =>

Gingival implant supports
Saliva may indicate

Reduction of cluster
headache

Susceptibility to
depression in boys

Cluster headache is one of the most severe forms of
headache. It is usually unilateral and occurs mostly
around the eye or in the temple. Attacks last up to several hours. In many people, cluster headache leads to a
significant loss of quality of life. A new type of cluster
headache treatment is the stimulation of the
sphenopalatine ganglion (SPG). The ATI Neurostimulation System stimulates the SPG in order to break the
pain cycle. The neurostimulator, which is the size of an
almond, is inserted through a small incision in the gingiva and programmed by the physician. As cluster
headache occurs unilaterally, the implant is inserted on
the relevant side. The surgery is performed under general anaesthetic and takes about an hour.

For the first time, researchers at the University of
Cambridge have identified a biomarker for major or
clinical depression in human saliva. An examination
of saliva samples of hundreds of teenagers revealed
that boys especially may be at the greatest risk of
depression.
Following a group of boys and girls over 12 to 36
months by measuring levels of cortisol in their saliva,
as well as collecting self-reported information on
symptoms of depression, the researchers found that
boys with depressive symptoms and elevated morning cortisol were 14 times more likely to develop clinical depression compared to boys with neither.
However, the connection was not as distinctive in female participants. Girls with high cortisol and depressive symptoms were four times more likely to
develop depression, suggesting differences between the sexes in how depression develops.

The study, titled “Elevated morning cortisol is a stratified population-level biomarker for major depression in boys only with high depressive symptoms”,
was published on 18 February in the Proceedings of
the National Academy of Sciences of the United
States of America journal.

Calculating risk of infection

In mere minutes from a droplet of blood
Neutrophils are a vital part of the body’s immune
system. Recognized as the most abundant
type of white blood cell present in human
blood, neutrophils function primarily as
the body’s first line of defence
against infection and inflammation. Within minutes of
stimulation, neutrophils
migrate from the blood to
tissue where they accumulate at sites of infection. One
of the most common lab
tests ordered on a regular
basis is the counting of neutrophils in the blood (absolute neutrophil count).
“However, simply counting the
neutrophils may not be enough in
many cases. If neutrophils do not
migrate well and cannot reach in-

side the tissues, this situation could have the same
consequences as a low neutrophil count,” says Dr
Daniel Irimia, Assistant Professor at the BioMEMS
Resource Center at Massachusetts General Hospital. The team recently designed miniaturized
silicon-based devices that can be used to
measure neutrophils’ migration patterns
from just a finger prick of blood in a few minutes. He also says, “The device was designed
such that probing neutrophil mobility becomes extremely easy to perform.”

By being able to measure the risk for infections that a particular patient has at a
particular time from just a droplet of blood
in a matter of minutes is a significant improvement and one that will improve current treatment. For more information on
this research, refer to: www.worldscientific.com/doi/pdf/10.1142/
S2339547813500040.

The patient can control his or her therapy independently via a remote control.When a cluster attack occurs,
he or she holds the device against the cheek to activate
the implant. This stimulates the SPG and abates the attack. In many patients, the frequency of attacks decreases permanently.
The effectiveness of the ATI Neurostimulation System
has been clinically proven in the most comprehensive
medical study on cluster headache. With the ATI neurostimulator, 82 per cent of all attacks—even medium
to severe—can be treated effectively, the manufacturer, Autonomic Technologies, stated. In 46 per cent of
patients, the attack frequency was reduced significantly—from an average of 14 down to two attacks
per week. The ATI Neurostimulation System has been
introduced at nine clinics in Germany and is in use in
Belgium.

laser
1
I 49
_ 2014

[50] =>

I about the publisher

laser

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laser dentistry

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laser international magazine of laser dentistry
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50 I laser
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[51] =>

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[52] =>

26–27 September, 2014
Düsseldorf, Germany
Hilton Hotel

LASER
START UP
2014

23rd
Annual Congress
of the DGL e.V.
Get the programme!
FAX REPLY
+49 341 48474-290

NAME/E-MAIL

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Further information about

 LASER START UP 2014

 23rd Annual Congress of the DGL e.V.

26–27 September, 2014, Düsseldorf, Germany.

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[cover] => laser international No. 1, 2014

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