laser international No. 2, 2011

Editorial / Content / Laser-assisted immediate implantation at infected site / Enamel alterations / Utilising laser technology / Treatment of gingival hyperpigmentation for aesthetic purposes using the diode laser / Diode-laser-assisted combination therapy of a lip haemangioma / Periodontitis therapy with 3 - 000% more power / The antibacterial effects of lasers in endodontics / TwinLightTM laserassisted endodontics / TouchWhiteTM Er:YAG laser-assisted Tooth Whitening / Infection control / New double-wavelength-laser— successful launch at IDS / The Joint Fellowship Course of Tehran and Aachen Universities / International events / XI Congress of SELO / Biggest IDS ever / Manufacturer News / about the publisher _ imprint

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issn 1616-6345

Vol. 3 • Issue 2/2011

laser
international magazine of

laser dentistry

2

2011

| overview
The antibacterial effects of lasers in endodontics

| interview
New double-wavelength-laser—successful
launch at IDS

| meetings
XI Congress of SELO

[2] =>

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[3] =>

editorial _ laser

IDS approves use of
laser in dentistry

I

Prof Dr Norbert Gutknecht
WFLD President
Editor-in-Chief

_The IDS—International Dental Show—in Cologne showed once again the further dissemination and awareness of laser therapy in dentistry. A significant higher number of distributors
showed their laser devices to the dental world with new innovations and treatment concepts.
Seeing this I am even more sure that laser therapy will play an improving role in the wide field of
modern dental therapy.
The upcoming European Division Congress of the WFLD in Rome promises to be an outstanding congress, especially with the location Rome as a special attraction. If you have not made
your decision to participate in this congress it is more then high time now and I am sure you will
not regret it!
Hope to see you in Rome!

Prof Dr Norbert Gutknecht
Editor-in-Chief

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I content _ laser

page 12

page 20

I editorial

I special

03

40

IDS approves use of laser in dentistry
| Prof Dr Norbert Gutknecht

Infection control
| Dr Frank Yung

I case report

I laser

06

42

Laser-assisted immediate implantation at infected site
| Drs Avi Reyhanian et al.

12

44

Utilising laser technology
Treatment of gingival hyperpigmentation for aesthetic
purposes using the diode laser

The Joint Fellowship Course
of Tehran and Aachen Universities
| Reza Fekrazad et al.

| Dr Patrick J. Broome

18

New double-wavelength-laser—
successful launch at IDS
| An interview with Frederico Pignatelli

Enamel alterations
| Dr Giuseppe Iaria

14

page 26

I meetings
45

International events 2011 & 2012

46

XI Congress of SELO

| Drs M. L. V. Prabhuji et al.

I clinical technique
20

23

| Paloma Montero et al.

Diode-laser-assisted combination therapy
of a lip haemangioma

48

| Dr Georg Bach

I news

Periodontitis therapy with 3,000 % more power

49

Biggest IDS ever

Manufacturer News

| Dr Darius Moghtader

I about the publisher

I overview
26

50

| Imprint

The antibacterial effects of lasers in endodontics
| Dr Selma Christina Cury Camargo

I industry report
32

TwinLightTM laser-assisted endodontics
| Dr Kresimir Simunovic

36

TouchWhiteTM Er:YAG laser-assisted Tooth Whitening

Cover image courtesy of A.R.C. Laser GmbH,
www.arclaser.de

| Jugoslav Jovanovic

page 44

04 I laser
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page 46

page 48

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[6] =>

I case report _ immediate implantation

Laser-assisted
immediate implantation
at infected site
Authors_Drs Avi Reyhanian, Natan Fuhrman, Israel & Costas Ioannou, Cyprus

_Abstract
Fig. 1_Mobility and fistula
of tooth #11.
Fig. 2_X-ray image of teeth
# 11 and 21.
Fig. 3_The CO2 laser used
for the frenectomy.
Fig. 4_The Er:YAG laser used
for incision.
Fig. 5_The intrasulcular and vertical
incisions and the frenectomy.
Fig. 6_Lifting the flap.

Osseointegration of dental implants has become
a routinely recommended procedure in the clinical
practice of dentistry.1–4 Over the years, patients have
begun to demand a shortened treatment time and
that treatment be done in one visit, to the extent
possible. This clinical case study will discuss and
demonstrate the correct use of the Er:YAG laser
(2,940nm) in immediate placement of implants (in
one visit) at the infected site: extraction, degranulation, decontamination, placing the implant, and
treating the bone defect (guided-bone regeneration—GBR).

Fig. 2

Fig. 1

Fig. 4

Fig. 5

06 I laser
2_ 2011

This technique using the Er:YAG laser presents
several advantages compared with conventional
treatment methods, and there are minimal post-operative complications coupled with a high success
rate.
Introduction of the clinical case
A 21-year-old soldier presented to the clinic
with the chief complaint of mobility of tooth #11.
There was no medical history. He had undergone
trauma to the tooth a year before, which had been
untreated. Clinical examination revealed mobility
grade 3+ at tooth #11 with fistula and a change of

Fig. 3

Fig. 6

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case report _ immediate implantation

I

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

colour of tooth #21. A periodontal probe indicated
a depth pocket of 9mm and bleeding on probing.
Radiographs revealed horizontal and vertical bone
loss due to trauma around teeth #11 and 21 with
root canal (Figs. 1 & 2).
Implant indications for laser treatment:
_frenectomy using the CO2 laser;
_incision using the Er:YAG laser;
_lifting a flap.
Simultaneous (combined) approach:
_extraction;
_ablation of granulation tissue using the Er:YAG
laser;
_insertion of immediate implant using the Er:YAG
laser—lasing just the cortical bone;
_GBR using the Er:YAG laser;
_primary closure.

and immediate placement of a submerged implant,
using a CO2 laser for the frenectomy, then using
an Er:YAG laser for incision, ablation of granulation
tissue, bone remodelling and shaping decortication
for GBR. Uncovering of the submerged implant with
an Er:YAG laser was to be done a year later.
Rational for treatment
The pulsed Er:YAG laser can cut and ablate tissue
with excellent surgical precision without excessive
heat or thermal injury. Healing time is shortened
when compared with a scalpel or hand instruments.
Using a CO2 laser for a frenectomy results in no
bleeding, no pain post-operatively, and a reduced
healing time compared with conventional methods.
Indications/contra-indications and alternative
treatment

Treatment alternatives:
_Using conventional treatment
- scalpel
- surgical bur
- high-speed rotary instruments
- GBR
- sutures
_Multiple post-operative appointments: staged
approach
_Placement of the fixture after healing.

There were no contra-indications for use of the
laser on this patient. Care must be taken to set
proper parameters and use a proper technique, so
that both hard and soft tissues are not ablated when
only one of the tissues is being targeted. Maximum
water spray cooling must be used with the Er:YAG
laser to avoid thermal damage.

Diagnosis and treatment plan

The lasers selected for the frenectomy were a
CO2 laser (AquaLite, Lumenis Dental; 10,600 nm, 6 W,
SP, non-contact), a free-running, pulsed Er:YAG
laser (LiteTouch, Syneron Medical Ltd; 2,940nm,
repetition rate of 17–10Hz, 400–700mJ). The tips

Severe periodontitis with massive bone loss
around tooth #11 was diagnosed. The treatment
plan entailed lifting a flap, extraction of the tooth

Fig. 7_The extracted tooth.
Fig. 8_The bone defect.
Fig. 9_The Er:YAG laser ablates the
granulation tissue.
Fig. 10_The bone defect after ablation and marking the location of the
implant with the Er:YAG laser.
Fig. 11_The pilot hole.
Fig. 12_Decortication with the
Er:YAG laser.

Clinical technique, laser wavelength and laser operating parameters

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I case report _ immediate implantation

Fig. 13

Fig. 14

Fig. 16

Fig. 15

Fig. 17

Fig. 13_Immediately after
decortication.
Fig. 14_Xenograft using
Bio-Oss for GBR.
Fig. 15_Resorbable membrane.
Fig. 16_Primary closure.
Fig. 17_X-ray image
immediately post-op.
Fig. 18_Three months post-op.

used were 200µ and 1,300µ sapphire tips. The laser
selected for uncovering the submerged implant was
an Er:YAG laser (LiteTouch) with a 200µ sapphire tip
and a power setting of 300mJ/25Hz.

excellent ability to ablate soft tissue effectively
without producing major thermal side-effects to
adjacent tissue has been demonstrated in numerous studies.12–15

Treatment sequence

Granulation tissue was ablated with the Er:YAG
laser with a 1,300µ tip in non-contact mode and
with a power setting of 600mJ/12pps (Figs. 8 & 9).
Detoxification of the infected site was done by lasing directly on the bone, using a low-energy setting.
In this way, the target tissue was disinfected without injuring the bone. The laser is bactericidal.15,16
The necrotic bone was ablated using the Er:YAG
laser with a 1,300µ sapphire tip in non-contact
mode and with a power setting of 350mJ/
20pps.8,10,17,18

Verbal consent was obtained from the patient
and his parents after explaining the advantages of
laser treatment compared with conventional surgical techniques.
Local anaesthetic was first given to the patient.
The frenectomy was then performed with the CO2
laser set in non-contact mode and to 6W SP (Fig. 3).5–7
Er:YAG lasers can be used to make an incision for
flap lifting, such as crestal, intrasulcular or vertical
release incisions, and produce a wet incision (some
bleeding) as opposed to the dry incision (no bleeding) produced by the CO2 laser.8–11
The Er:YAG laser with a 200µ sapphire tip and set
in contact mode was used to perform intrasulcular
incision and two vertical incisions (Figs. 4 & 5). A
full-thickness flap was lifted (Fig. 6) and tooth #11
was extracted (Fig. 7).
Vaporisation of granulation tissue (if any exists)
after lifting a flap can be done efficiently with the
Er:YAG laser, with a lower risk of overheating the
bone than with the current diode or CO2 lasers.11,17,14
There is no need for any hand instruments. Results
from both controlled clinical and basic studies have
pointed to the high potential of the Er:YAG laser. Its

08 I laser
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Fig. 18

The placement site for the implant was marked
with the Er:YAG laser (Fig. 10), and the entire length
of the implant was prepared using rotary instruments (Fig. 11). The laser does not replace the pilot
drill; it is used to create a pilot hole for the drill. The
preparation for the entire length of the implant
should not be lased with the laser.
An implant with a length of 13mm and diameter
of 3.75mm (MIS Implants Technologies Ltd) was
placed manually (Fig. 12). The bone defect required
GBR. Decortication was performed with the Er:YAG
laser with a 1,300µ sapphire tip in non-contact
mode and with a power setting of 400mJ/12pps
(Figs. 12 & 13). The bone defect around the implant
was filled with Bio-Oss bone substitute (Geistlich
Biomaterials) and covered with Bio-Gide (Geistlich
Biomaterials), an absorbent, bilayer membrane

[9] =>

case report _ immediate implantation

Fig. 19

Fig. 20

Fig. 21

Fig. 22

Fig. 23

Fig. 24

(Figs. 14 & 15). Sutures were applied and primary
closure was achieved (Fig. 16). An X-ray was taken to
confirm the placement of the implants (Fig. 17).

_Biological rationale for immediate
implantation

Complications
The patient had no complications related to laser
treatment either during or after laser therapy. There
was no soft or hard tissue damage.
Follow-up and long-term results

_Simplified procedure that reduces the surgical
stages;
_conservation of bone volume surrounding natural
tooth;
_combination of post-extraction healing phase
with osseointegration;
_maximum stimulation of natural healing processes;
_shortened healing phase and rehabilitation time;
_positive psychological effect on the patient.
Post-operative assessment
The patient was prescribed Clindamycin (150mg
x 50 tabs) to avoid infection. He was also given
Motrin (800mg x 15 tabs) for pain. Instructions were
given to rinse with a 0.2% chlorhexidine mouthwash, starting the next day for two weeks (three
times a day). The patient returned for his first followup the next day with a moderate swelling and pain.
The flap was closed. At ten days, the patient returned
for the stitches to be removed and there were no
signs of swelling haematoma or pain. After one
month, the soft tissue had healed. A three-month
evaluation of the area showed complete healing and
no complications (Fig. 18). The soft issue had healed
over the bone and there were no bony projections
observed under the soft tissue. The prognosis was
excellent.

The patient was assessed once a week in the first
month, at six weeks, three months and six months
after the start of the treatment. At the fifth-month
supportive periodontal therapy appointment, the
patient had excellent healing and had improved tissue colour, contour and consistency (Fig. 19).

Fig. 19_Five months post-op,
showing complete closure.
Fig. 20_A year post-op.
Fig. 21_Using the Er:YAG laser to
uncover the submerged implant.
Fig. 22_The uncovered implant.
Fig. 23_The abutment.
Fig. 24_The alloy part of the
rehabilitation – porcelain-fusedto-gold crowns.

A year post-treatment the submerged implant
was uncovered with the Er:YAG laser with an 800µ
sapphire tip in non-contact mode and with a power
setting of 400 mJ/25 pps (Figs. 20–23). Five months
after this, the rehabilitation was completed: three
crowns on teeth #12, 11 (eight implants) and 21
(Figs. 24 & 25).
This case was followed-up for three years and
two months (Figs. 26 & 27). An X-ray image shows
a small absorption of bone around the neck of the
implant.

_Conclusion
We conclude that using the 2,940nm wavelength
laser for these procedures offers many advantages
compared with conventional methods, such as the
reduction of patient discomfort, enhancement of
the surgical site and reduced treatment time.21 This

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I case report _ immediate implantation

Fig. 25

Fig. 26

Fig. 25_Final result a year and
five months post-op.
Fig. 26_Three years and
two months post-op.
Fig. 27_X-ray image three years
and two months post-op.

wavelength can be employed for the purpose of the
decontamination of infected sites and it has been
shown to be effective and safe.12,19,20 In addition,
post-operative effects such as pain and swelling are
less pronounced. This laser has become an invaluable
tool for many procedures by simplifying treatment
and offering patients faster, less stressful oral therapy with enhanced outcomes.
This case demonstrates that the Er:YAG laser is
a very valuable tool that shows promise and safety
as an effective new technical modality for implant
therapy. However, further clinical and basic investigations are required to establish the clinical effectiveness and safety of the Er:YAG laser in implant
site preparation._

_References
1. Adell R, Lekholm U, Rockler B, Brånemark PI, “A 15-Year Study
of Osseointegrated Implants in the Treatment of the Edentulous
Jaw”. Int J Oral Surg. 1981 Dec;10(6):387–416.
2. Albrektsson T,“A Multicenter report on Osseointegrated Oral Implants”. J Prosthet Dent. 1988 Jul;60(1):75–84.
3. Buser D, Mericske-Stern R, Dula K, Lang NovaPulse,“Clinical Experience with One-Stage, Non-Submerged Dental Implants”.
Adv Dent Res. 1999 Jun;13:153–61.
4. Olsson M, Friberg B, Nilson H, Kultje C, “Mkll – a Modified SelfTapping Branemark Implant: 3-Year Results of a Controlled
Prospective Pilot Study”. Int J Oral Maxillofac Implants. 1995
Mar-Apr;10(2):243.
5. Shetty K, Trajtenberg C, Patel C, Streckfus C. “Maxillary frenectomy using a carbon dioxide laser in a pediatric patient: a case
report”. Gen Dent. 2008 Jan-Feb;56(1):60–3.
6. Haytac MC, Ozcelik O. “Evaluation of patient perceptions after
frenectomy operations: a comparison of carbon dioxide laser and
scalpel techniques”. J Periodontol. 2006 Nov;77(11): 1815–9.
7. Fiorotti RC, Bertolini MM, Nicola JH, Nicola EM. “Early lingual
frenectomy assisted by CO2 laser helps prevention and treatment of functional alterations caused by ankyloglossia”. Int J
Orofacial Myology. 2004 Nov;30:64–71.
8. Ishikawa I, Aoki A, Takasaki AA, “Potential Applications of Er:YAG
Laser in Periodontics” J Perio Res. 2004 Aug;39(4): 275–85.
9. Watanabe H, Ishikawa I, Suzuki M, Hasegawa K, “Clinical Assessments of the Erbium:YAG Laser for Soft Tissue Surgery and
Scaling", J Clin Laser Med Surg. 1996 Apr,14(2):67–75.

10 I laser
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Fig. 27

10. Ishikawa I, Sasaki KM, Aoki A., Watanabe H, “Effects of Er:YAG
Laser on Periodontal Therapy”, J Int Acad Periodontol. 2003
Jan:5(1): 23–8.
11. Sasaki KM, Aoki A., Ichinose S, Yoshino T, Yamada S, Ishikawa L,
“Scanning Electron Microscopy and Fourier Transformed Infrared Spectroscopy Analysis of Bone Removal Using Er:YAG and
CO2 Lasers”, J Perio, 2002 Jun; 73(6):643–52.
12. Sasaki KM, Aoki A., Ichinose S, Yoshino T, Yamada S, Ishikawa L,
“Scanning Electron Microscopy and Fourier Transformed Infrared Spectroscopy Analysis of Bone Removal Using Er:YAG and
CO2 Lasers”, J Perio, 2002 Jun; 73(6):643–52.
13. Kreisler M, Al Haj H, d'Hoedt B. “Temperature Changes at the Implant-Bone Interface During Simulated Surface Decontamination with an Er:YAG Laser”. Int J Prosthodont. 2002 NovDec;15(6):582–7.
14. Schwarz F, Rothamel D, Becker J, “Influence of an Er:YAG Laser
on the Surface Structure of Titanium Implants”, Schweiz
Monatsschr Zahnmed. 2003;113(6):660–71.
15. Schwarz F, Bieling K, Sculean A, Herten M, Becker J, “Treatment
of Periimplantitis with Laser or Ultrasound. A Review of the
Literature”. Schweiz Monatsschr Zahnmed. 2004; 114(12):
1228–35.
16. Kreisler M, Kohnen W, Marinello C, Gotz H, Duschner H, Jansen
B, d'Hoedt B. „Bactericidal Effect of the Er:YAG Laser on Dental
Implant Surfaces: An In Vitro Study”, J Periodontol. 2002
Nov;73(11):1292–8.
17. Kreisler M, Kohnen W, Christoffers AB, Gotz H, Jansen B,
Duschner H, d'Hoedt B. “In Vitro Evaluation of the Biocompatibility of Contaminated Implant Surfaces Treated with an Er:YAG
Laser and an Air Powder System”. Clin Oral Implants Res. 2005
Feb;16(1):36–43.

Editorial note: The whole list of references is available from
the publisher.

_contact

laser

Avi Reyhanian, DDS
Shaar Haemek Street, Netanya 42292, Israel
Natan Fuhrman, DDS
Institute of Advanced Dental Education, Haifa, Israel
Costas Ioannou, DDS
35 Ifigenias str 2007, Nicosia, Cyprus

[11] =>

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In cooperation with the University
of Excellence RWTH Aachen

[12] =>

I case report _ tooth restoration

Enamel alterations
Author_Dr Prof Giuseppe Iaria, Italy

Fig. 1_A 56-year-old male patient
presented with a tooth that showed
enamel alterations.
Figs. 2_The use of the dam is
suggested.

Fig.3_The use of the
DELight Er:YAG laser.
Fig. 4_The craters left by the laser
are visible.
Fig. 5_The use of the bur to remove
the unsubstained enamel.
Fig. 6_Acid etching.
Fig. 7_After acid etching.
Figs. 8–11_Result.

Fig. 1

Fig. 2

_A healthy 56-year-old male patient presented
with enamel alteration of tooth #7. The oral examination showed a healthy periodontium and temporomandibular joint, and the teeth were in a Class I occlusion (Figs.1–4). The radiographic examination showed
no other radicular lesions. The soft-tissue status indicated good periodontal health. For the hard-tissue test,
percussion was normal, and there was no mobility or
tenderness to touch or air spray. The tooth tested vital
with the electric pulp tester and cold testing.

d. Restore the cavities with a hybrid composite resin.

The objective was to restore tooth #7 using an
Er:YAG laser in the following sequence:
a. Prepare the cavities of the tooth.
b. Decontaminate bacteria in the treated surfaces.
c. Prepare the margins using a bur to obtain an adequate surface with a maximum area of adhesion.

Precautions
Adequate water spray must be maintained as the
procedure is performed. Good visibility and low power
are necessary for careful preparation in order to avoid
both thermal damage and excessive removal of tooth
structure.

The Er:YAG laser wavelength is readily absorbed by
hard tissue; therefore, it is possible to conserve healthy
tooth structure more easily than using a conventional
high-speed handpiece. In addition, the relative lack of
tactile stimulation offered by laser treatment compared with a conventional high-speed handpiece often
allows the procedure to be performed without the need
for an anaesthetic.

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

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[13] =>

case report _ tooth restoration

Fig. 9

Fig. 10

Fig. 11

Fig. 12

Fig. 13

Fig. 14

Treatment alternatives
The treatment alternatives would have been
conventional dental drills to roughen the dental surfaces. Such burs could have caused a greater loss of
hard tissue, microfractures of the tooth enamel and
tenderness.

non-contact mode. Thereafter, Clearfil SE Bond (Kuraray America, Inc.) was applied to enamel and dentine
surfaces and a nano-composite Adonis (Sweden &
Martina S.p.A.) was used as the restorative material.
Finishing of the restoration was performed with coarse
diamond burs, 12-blade finishing burs, and finishing
discs (Figs. 5–15).

_Laser operating parameters
_Post-operative instructions
An Er:YAG laser (DELight, HOYA ConBio) with a
wavelength of 2,940nm was used with its fibre delivery system and a 600µ quartz tip. It operates in a freerunning pulse mode with a pulse duration of 300ms.
The laser was used at 5W (200mJ, 25Hz) with an 80°
quartz tip and water mist in non-contact mode for
enamel ablation and at 3.2W (160mJ, 20Hz) with an
80° quartz tip and water mist in non-contact mode for
dentine ablation. Prior to commencing the procedure,
the patient was familiarised with the procedural steps.
Subsequently, all laser safety precautions were performed. These included, but were not limited to, the administering of laser safety glasses to the patient and
operators, displaying laser hazard signage, and inspecting the mechanical components of the laser.
Once safety systems were in place, the laser was
test-fired to ensure proper beam function and water
spray delivery. As the target tissue was addressed, highvolume suction was used continuously. The laser pulse
rate was set to 25Hz and the laser energy was set to
200mJ, which produced a power of 5W. Enamel ablation was achieved using an 80° quartz tip with water
mist in non-contact mode.
After this had been done, the laser pulse rate was set
to 20Hz and the laser energy was set to 160mJ, which
produced a power of 3.2W. Dentine ablation was
achieved using an 80° quartz tip with water mist in

The patient was told that he could resume normal
activities owing to the lack of numbness because of no
anaesthetic having been administered.

Fig. 8_The result immediately posttreatment.
Fig. 9_Font view of the restored
enamel.
Fig. 10_Angled view of the teeth
post-treatment.
Fig. 11_The patient showing his
restored smile.
Fig. 12_Enamel alteration of tooth
#7 before treatment.
Fig. 13_The restored tooth #7
post-treatment.
Fig. 14_One year post-treatment.

_Follow-up care
The objectives originally set were achieved. The
entire procedure was performed with success without
the use of dental anaesthetic. In addition, satisfactory
aesthetic results were obtained (Fig. 16). The long-term
results are in keeping with the objectives of the original
treatment plan. The tooth maintained healthy vitality
tests._

_contact

laser

Dr Prof. Giuseppe Iaria
University of Genoa Italy
President IAHT– Int Ac of High Tech
President ALDI–ALD Italian study Club
Dental Laser Educator ALD
Office:
19, Via S. Eustacchio–25128 Brescia, Italy
Tel.: +39 030 391239
Fax: +39 030 3392399
iariagiuseppe@virgilio.it

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[14] =>

I case report _ minimally invasive treatment

Utilising laser
technology
Obtaining better clinical results and creating
better patient experiences
Author_Dr Patrick J. Broome, USA
_If your patients are like the majority of our patients, they are always in a rush and seeking the quickest way to accomplish the dentistry they need or desire. We live in a world of instant gratification and
everyone is seeking convenience, speed, cost savings
and a better end result. It is rare to find a product or
device that makes our clinical success easier and more
predictable and saves time.
Laser-assisted dentistry offers the clinician all of
the above. Today, we are performing old procedures in
new ways and obtaining equal or better results in a
minimally invasive manner. Who would have thought
that procedures such as gingival recontouring,
frenectomies and restorative dentistry could even be
attempted without local anaesthesia? Today, in the
hands of a trained and competent dentist, these procedures are becoming routine and an increasing
number of patients are hearing of the positive experiences of their friends who have undergone laser
dentistry.
Few dentists will pass up any technology that can
differentiate their practice from all the rest and that
offers undeniable benefits to their patients. Clinical
dental lasers are just that type of technology. I encourage everyone to ask questions and take the time
to deliberate the investment, but be open-minded
enough to recognise the enormous benefits for your
patients and your dental office.
Fig. 1_Pre-op situation.
A 25-year-old patient desired elimination of a “gummy smile”
and bulbous areas of her teeth in an effort to obtain a more
mature appearance. Orthodontic correction had been completed
one year prior to consultation. The patient desired “rock star” white
teeth (value) and a new smile to harmonise with her facial features
and skin tone. She specifically requested porcelain veneers.

Fig. 1

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[15] =>

[16] =>

I case report _ minimally invasive treatment

Fig. 3a

Fig. 2a

Fig. 3a

Fig. 2b

Fig. 4

Fig. 2c

Figs. 2a–2c_1:2 view of pre-op natural smile.
The patient has a beautiful natural smile. The options
presented to the patient were: 1) whitening; 2) gingival
recontouring and enameloplasty to recontour existing bulbous
cervical areas that were of concern to the patient; and
3) porcelain veneers with gingival recontouring and osseous
crown lengthening in areas in which biological width would
have to be violated in order to obtain correct gingival zenith
heights determined during smile design.
Figs. 3a & b_Gingival zeniths are marked and raised with
the Waterlase MD Er,Cr:YSGG laser system. Osseous
correction is accomplished over teeth #7 to 10 utilising a closed
technique to modify the bone architecture between the line
angles and not encroaching into the interproximal area.
Fig. 4_Temporary restorations are placed and gingival
tissue is evaluated for the desired aesthetic outcome.
Once the patient is satisfied with the corrections,
the fabrication of the final porcelain restorations proceeds.
Figs. 5a & b_Porcelain restorations prior to try-in and evaluation.

16 I laser
2_ 2011

Fig. 5a

Fig. 5d

[17] =>

case report _ minimally invasive treatment

The following is a case I would like to share that illustrates the typical patient seeking cosmetic care in
our office. By utilising laser technology, we were able
to accomplish a complex treatment in a short period,
while obtaining excellent tissue health and a nice cosmetic result that yielded an advocate for our office
and for laser technology.
At our first consultation, the patient elected just
whitening. One year later, she returned and elected to
proceed with the porcelain veneers and laser gingival
recontouring and crown lengthening as needed to
design the smile she desired.
This case illustrates that our conservative approach to treatment can be achieved by utilising minimally invasive tools such as the Waterlase MD. There
are many ways to accomplish any given dental task
and no one uses the same bur for every preparation or
the same hand instrument for every task. With that in
mind, consider the Waterlase MD another tool that

can be utilised and added to your clinical “tool-box”.
When presented with daily tasks such as crown
lengthening and gingival recontouring, remember
that there may be many ways to accomplish the same
task and today they involve minimally invasive techniques that eliminate scalpel and/ or other mechanical methods. A positive patient experience is a powerful tool that you can utilise to expand your practice. It
is an exciting time in dentistry and every visit is an opportunity to show our patients the reason that they
should be excited as well!_

_contact
Dr Patrick J. Broome
2809 Coltsgate Rd Ste 200
Charlotte, NC 28211
USA
pjbroome@hotmail.com

laser

Figs. 6a–d_Final bonded restorations and finial tissue contours four
weeks after initial preparation. Note
tissue contour stability and health.
Figs. 7_The patient is satisfied that
her aesthetic goals were accomplished and pleasantly surprised that
a complete solution was possible in
such a short period (three weeks).

Fig. 6a

Fig. 6b

Fig. 6c

Fig. 6d

Fig. 7

laser
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[18] =>

I case report _ depigmentation

Treatment of gingival hyperpigmentation for aesthetic
purposes using the diode laser
Author_Drs M.L.V. Prabhuji, S.S. Madhupreetha & V. Archana, India

_The colour of the gingiva is various among different individuals and it is thought to be associated
with cutaneous pigmentation. It depends on the
vascular supply of the gingiva, epithelial thickness,
degree of keratinisation of the epithelium and the
presence of pigmented cells.
Oral pigmentation is the discolouration of the
mucosa or gingiva. It can be either due to physiological or pathological conditions. Melanin, a brown
pigment, is the most common pigment associated
with the etiology of oral pigmentation.
Gingiva is the most common site of pigmentation in the oral cavity. This hyperpigmentation is
seen as a genetic variation in some populations independent of their age and sex. Hence it is termed
as physiological or racial gingival pigmentation.
Melanosis of the gingiva is frequently present is dark
skinned ethnic groups as well as in different medical
conditions. Although pigmentation of the gingival
is completely a benign condition, is an esthetic problem in many individuals.
Fig. 1_Pre-op situation.
Fig. 2_Use of the FOX diode laser to
treat gingival pigmentation.
Fig. 3_Immediate post-op situation.

Fig. 1

Gingival depigmentation is a periodontal surgical procedure in which the gingival hyperpigmention is eliminated or reduced by different techniques.

Fig. 2

18 I laser
2_ 2011

_Gingival depigmentation techniques
Various depigmentation techniques have been employed with similar results .Selection of a technique
should be based on clinical experience and individual
preferences.
The various methods includes gingivectomy, gingivectomy with free gingival autografting, electrosurgery, cryosurgery, radiosurgery, chemical agents
such as 90% phenol and 95% alcohol,abrasion with
diamond bur, Nd:YAG laser, semiconductor diode laser
and CO2 laser.
One of the most common techniques for depigmentation is the surgical removal of undesirable
pigmentation using scalpels. In this procedure,
gingival epithelium is removed surgically along
with a layer of underlying connective tissue. The
denuded connective tissue then heals by secondary
intention.
Laser ablation of gingival depigmentation has been
recognized as one of the effective techniques. Different lasers have been used for gingival depigmentation
including carbon dioxide (10.600nm), diode (810nm),
Neodymium:Yttrium Aluminium garnet (1.064nm)
and Erbium: YAG (2.940nm) lasers.

Fig. 3

[19] =>

case report _ depigmentation

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

The diode laser has been introduced in dentistry
few years back. The diode laser is a solid-state semiconductor laser that typically uses a combination of
Gallium (Ga), Arsenide (Ar), and other elements, such
as Aluminium (Al) and Indium (In), to change electrical
energy into light energy. It also can be delivered
through a flexible quartz fiber optic handpiece and has
a wavelength of 819nm.This energy level is absorbed
by pigmentation in the soft tissues and makes the
diode laser an excellent hemostatic agent. It is used for
soft tissue removal in a contact mode. The power output for dental use is generally around 2 to 10 watts. It
can be either pulsed or continuous mode.
The present case series describes simple and effective depigmentation techniques using A.R.C. Fox™
(semiconductor diode laser), which have produced
good results with patient satisfaction.

_Case report 1
A 22 year old female patient visited the department of Periodontics, Krishnadevaraya College of
Dental sciences, Bangalore with the chief complaint
of “blackish gum”. The medical history was non-contributory. Intra-oral examination revealed generalized blackish pigmentation of the gingiva, however it
was healthy and completely free of any inflammation.
Considering the patient’s concern, a laser depigmentation procedure was planned.

ization with a flexible ,hollow-fiber delivery system
with a non-contact, air cooling handpiece, under standard protective measures. The procedure was performed on all pigmented areas. Remnants of the ablated tissue were removed using sterile gauze damped
with saline. This procedure was repeated until the desired depth of tissue removal was achieved. Analgesics
and chlorhexidine 0.2% mouthwash were prescribed.

_Case report 2
A 24 year old female patient
visited the department of Periodontics, Krishnadevaraya College of Dental sciences, Bangalore with the chief complaint of
“blackish gum”. The medical history was non-contributory. Intra-oral examination revealed generalized
blackish pigmentation of the gingiva, however it was
healthy and completely free of any inflammation.
Considering the patient’s concern, a laser depigmentation procedure was planned.

Fig. 10
Fig. 10_Three months post-op.

Procedure

_contact

The depigmentation was performed identically to
the first case. Analgesics and chlorhexidine 0.2%
mouthwash were prescribed.

Department of
Periodontics
Krishnadevaraya College of
Dental Sciences
Hunasamaranhalli,
Via Yelahanka
Bangalore, 562157
India

_Results
Procedure
Diode Laser (A.R.C. Fox™) with wavelength of
810nm was selected for the procedure. No topical or
local anaesthesia was given to the patient. Melanin
pigmented gingiva were ablated by diode laser vapor-

Fig. 4_One week post-op.
Fig. 5_Three months post-op.
Fig. 6_Pre-op situation.
Fig. 7_Use of the FOX diode laser to
treat gingival pigmentation.
Fig. 8_IImmediate post-op situation.
Fig. 9_One week post-op.

No post-operative pain, haemorrhage, infection
or scarring occurred in first and subsequent visits.
Healing was uneventful. Patient’s acceptance of the
procedure was good and results were excellent as
perceived by the patient._

laser

prabhujimlv@gmail.com

laser
2
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_ 2011

[20] =>

I clinical technique _ ice/fibre-holding block

Diode-laser-assisted
combination therapy of
a lip haemangioma
Author_Dr Georg Bach, Germany

Fig. 1_Equipment needed for
creating an ice-block: toothpick,
rubber bands, fibre holder and cut-off
bottom portion of a single-serving
yoghurt container.
Fig. 2_To prevent the fibre-holding
channel from icing up, its end is
sealed with sticky wax, which can
also be used for placement on the
bottom of the plastic container.

Fig. 3_To affix the fibre holder
securely, it is stabilised with rubber
bands and a toothpick, which serves
as a holding strip.
Fig. 4_The container is filled with
water.
Fig. 5_An ice-block with a fibre
holder is moulded in the freezer.

Fig. 3

Fig. 1

Fig. 2

_As a general rule, haemangioma—also referred
to as a “blood sponge”—is a broader term for many
different vascular abnormalities. The treatment of
haemangiomas, especially in dental practice, requires
a clear distinction between congenital vascular
tumours and vascular malformations.

tered in dental practice and affects primarily the lip
area. A multitude of possible treatment options is
mentioned for treatment of a vascular malformation of the lip.

Congenital vascular haemangiomas are relatively rare in dental practice. They occur in babies
and toddlers and show a typical three-phase
course: the initial phase is often marked by massive
growth (“proliferation phase”), and the subsequent
remission phase is then followed by an obligatory
regression (“regression phase”). The typical threephase clinical course usually enables a unique differentiation from a malformation, which—contrary
to congenital haemangiomas—is often encoun-

Owing to intra-surgical complication rates
(haemorrhaging), which are the exception to the rule
today, surgery is only carried out in special clinics,
especially if functional disruptions are expected
because of a rapidly growing haematoma and nonsurgical treatments do not promise success.

Fig. 4

20 I laser
2_ 2011

Surgical treatment

Modified surgical procedure according to Prof H.
Deppe:
_tapping of the haemangioma;

Fig. 5

[21] =>

clinical technique _ ice/fibre-holding block

_aspiration of the blood;
_injection of polyether impression material;
_hardening of the material; then
_surgical removal of the haemangioma into which
the impression material has been injected with considerably reduced intra-surgical haemorrhaging.

_Making a combination ice/fibre-holding block
The ice-block should be an ideal size and shape.
Based on our experience, this can easily be achieved
by using the cut-off bottom portion of a singleAD

Cryotherapy
This treatment is usually successful in haemangiomas with a thickness of up to 5mm, with very few
side-effects. However, cryotherapy for the lip is the
subject of controversial discussion because of the
risk of scar formation.

_Laser-assisted treatment
Nd:YAG and diode lasers are primarily used here;
isolated cases of treatment with yellow-light and
argon lasers are also described in the literature. Medication (corticosteroids, in some cases also cytostatics) often used in the treatment of other haemangiomas is not relevant in the case of lip haemangiomas.
This report describes a combination treatment
consisting of pre-surgical cooling and intra-surgical
diode-laser use with simultaneous cooling with an
ice-block into which the fibre is directed.

$"!

#$)

"!$%"

Goal
Diode lasers are the most common dental lasers in
German dental clinics and dental clinics worldwide.
These lasers are used primarily and very successfully
for combating biofilm in the treatment of peri-implantitis, marginal periodontitis and endodontics.
Diode-laser light with a wavelength of 810nm is
absorbed extremely well by dark surfaces and thus
also by blood. Use of a diode laser for the treatment
of haemangiomas in an ideal situation, that is, with
controlled thermal coagulation, would thus be conceivable. Reports on treatment with other laser
wavelengths (Nd:YAG, CO2, Argon and yellow-light
lasers), which have been used for treating haemangiomas for years, often mention tissue necrotisation
and post-surgical complications after laser treatment. These consequences are undesirable for tissue
in aesthetically relevant areas, which most certainly
include the lips, and are viewed critically by patients.
The central idea of the treatment of lip haemangiomas with diode-laser-assisted therapy is to combine the excellent absorption of diode-laser light
with a wavelength of 810 nm and simultaneous cooling with an ice-block in order to keep the side-effects
described to a minimum or, ideally, to prevent them.

(&%
%&$&%' %"!!

$($%&$&"!%!

* "'2745+
/7/14
(923821071/50
#1/01,)

"+ %$
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laser
2
I 21
_ 2011

[22] =>

I clinical technique _ ice/fibre-holding block

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 6_Hemangioma on right
half of lower lip.
Fig. 7_The fibre can be pushed
through the fibre channel in the
ice-block to the lip haemangioma
that requires treatment.
Fig. 8_Pre-surgical cooling
around the haemangioma using an
ice-block without a fibre holder.
Fig. 9_Ice-block application;
laser application.
Fig. 10_Note the circular
“injections”, which demonstrate the
expansion of the haemangioma.
Fig. 11_Condition four weeks
post-treatment.

serving drinkable yoghurt container as a mould for
the ice-block. In order to direct the fibre through this
ice-block, a disposable fibre holder (diameter must
fit the fibre to be inserted) must be placed with the
aid of a toothpick and rubber bands in such a way
that it is centred and in contact with the bottom of
the container. The container is then filled with water and placed in a freezer to freeze the block. A second (and possibly third) ice-block without a fibre
holder should be created for the pre-surgical “cooling phase”, which should occur approximately ten
minutes prior to the laser treatment. The block’s bulbous form conforms ideally to the shape of the lips.

laser

Dr Georg Bach
Oral surgery specialist
Rathausgasse 36
79098 Freiburg/Breisgau,
Germany
doc.bach@t-online.de

22 I laser
2_ 2011

It is recommended that a second ice-block with
fibre holder be available as a back-up to ensure that
the haemangioma is constantly and perfectly covered. During treatment, the patient is covered with
absorbent sheets to catch the melting water from the
ice-block running from the lip to the ventral area.

_Laser parameters
_Clinical application
Prior to the laser-assisted treatment, small
amounts of local anaesthetic (approximately 8 x
0.1ml) are injected around the haemangioma. The
number of areas in which anaesthetic is injected can
be reduced slightly in the case of smaller haemangiomas (this treatment is not suitable for very large lip
haemangiomas).

_contact

cation of the laser, the fibre is removed and the position of the ice-block adjusted a little; then the same
procedure is followed on a different, untreated area
of the haemangioma. Treatment is completed when
all areas of the haemangioma have been treated.

Immediately after the local anaesthetic, the iceblock without fibre is used to cool the area for ten minutes (if possible, covering the entire haemangioma).
The ice-block is then exchanged, the ice-block with the
integrated fibre holder is placed onto the haemangioma, fitting it as closely as possible, and the laser
fibre is then pushed through. Fibres with a diameter of
400µm have proven to be suitable for this application;
they are a good compromise between the achievable
surface effect and minimum tissue trauma.
In the subsequent application of the laser, the
fibre penetrates the lip surface and is inserted into
the haemangioma up to a maximum of 5mm. Ideally,
the final position of the fibre will be in the centre of
the haemangiomal surface. After a ten-second appli-

A diode laser that uses high pulse or digital pulse
technology (elexxion) and emits laser light with a wavelength of 810nm was used for combination treatment
of a lip haemangioma. Pulse performance is 30W at a
frequency of 20,000Hz with a pulse duration of 16 µs.

_Conclusion
The combination treatment presented here, which
entails simultaneous cooling during the use of a laser
for treatment of a lip haemangioma, is a high-quality
alternative to established procedures.
Its application is fairly simple and the advantage is
that there are only minimal post-surgical complaints
(minimal pain or swelling, very little scarring). Laserassisted treatment of a lip haemangioma using a diode
laser has distinct advantages compared with lasers with
other wavelengths for treatment of medium-sized and
small haemangiomas. The application of diode lasers is
limited in the case of extensive haemangiomas.
The prevalence of diode lasers in dental and oral
and maxillofacial surgical clinics supports the availability of this treatment._

[23] =>

clinical technique _ Elap-p

Periodontitis therapy
with 3,000% more power
Author_Dr Darius Moghtader, Germany

_Sometimes by asking questions that nobody
has ever asked before you break new ground. In my
case, this was: how can I help periodontitis patients
even more effectively? And the simple answer is:
with the “3,000% more power” therapy.
What’s that?
Is that dangerous?
How is that supposed to work?
Why do we need this?
What’s that supposed to mean?
Fig. 1

No one had asked me these questions when I presented the concept developed in our office in 2007
as a pilot project at IDS. Nevertheless, I shall answer
these previously unasked questions here.

_The idea
I came upon the idea of a different way to
treat periodontitis while researching literature
on the topic of lasers. The 2003 Yukna Report1
described the LANAP method. This Laser-Assisted
New Attachment Procedure promised regeneration instead of repair, combined with a spectacular design. Dr Yukna of New Orleans, Louisiana,
had three female patients, each of whom agreed to
undergo the study on two single-rooted teeth with
plaque. One tooth in each patient was treated using the LANAP method and the other with the
Nd:YAG laser in accordance with a standard
protocol.

So far so good—anyone who knows me knows
that, as a general dentist, I am a fan of the diode
laser. The only Nd:YAG laser that can handle the
LANAP procedure and is patented for the job is
the Millennium Laser from the undisputed master
inventor and laser pioneer Dr Robert H. Gregg.

Fig. 2
Fig. 1_Initial scenario.
Fig. 2_Opening the socket.

_The method
I analysed which factors were different from a
standard laser protocol and tried to adapt the diodelaser procedure accordingly. Thanks to the support
of elexxion, I was able to develop a protocol for the
claros at 30W and 20,000Hz.
What clinical indication of successful treatment can
we expect based on the Yukna Report?

Fig. 3_Elap-p, the first time around.
Fig. 4_Plaque and toxin removal.

And here’s the kicker (this would happen only
in the US): after monthly recalls, both teeth were
removed from the bone block in all three patients!
The histological results showed regenerated
bone and new periodontal ligament in two of the
three LANAP teeth. The control group had only
one long functional epithelium. Neither the root
surface nor the pulp showed histological
changes.

Fig. 3

Fig. 4

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2
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_ 2011

[24] =>

I clinical technique _ Elap-p

Fig. 5_Elap-p, the second time
around.
Fig. 6_Soft laser treatment.

Fig. 5

Fig. 6

Such an indication is bleeding from the treated
socket. As a laser user, I am sure you know that
treated sockets can become very dry after normal
laser treatment. Many manufacturers even use this
as a selling point, and the patient is satisfied as well—
after all, there is no more bleeding. The problem is,
no blood means no regeneration, no healing, no
new bone. Every dentist is familiar with the problems caused by dry sockets. Schulte addressed this
concept in the filling of cysts with autologous blood.

Why do we need this?
The goal is greater regeneration instead of repair.
How does this work?
This works using elap-p, a procedure developed
in the dentist’s office for the dentist’s office.
What is elap-p?
Simply put, elap-p means the following: 3,000%
more power with up to 20% less heat generation
with no carbonisation or coagulation.

_The questions
How do we achieve this?
We achieve this with extremely short impulses
at very high wattage levels.

Fig. 7_Follow-up after 48 hours.
Fig. 8_Comparison between treated
side and untreated side.

Is this safe for the patient?
In order to answer this question, we asked Dr
I. Krejci of the University of Geneva to conduct a
pilot study in 2007. The results of the study can be
summarised as follows. At the recommended tested
settings, a temperature reduction of up to 20%
occurred compared with treatment with a 1.11W
continuous wave. There were no significant electron
microscopical changes to the root. At these settings,
no carbonisation of the root surfaces took place. Of
course, further studies are necessary and desirable
to corroborate these results.

Every dentist has experienced first-hand the scenario below.

_Case study
Initial scenario
The patient comes into the office on Friday
evening with sharp shooting pains and was not able
to sleep the night before. Pain medication works
only for a short period. Redness and bleeding clearly
indicate an acute periodontal cause.
Opening the socket
After local anaesthesia, a traditional cleaning, including plaque removal, is first performed, either with
an Er:YAG laser or, as shown here, through an ultrasonic periodontal probe. Of course, manual instruments can also be used if preferred. This allows the
laser fibre easy access to the site of the inflammation.
Elap-p, the first time around

Fig. 7

Fig. 8

24 I laser
2_ 2011

Laser decontamination is performed using the
810nm, 30W, 5,000Hz diode laser at a pulse duration of 10µs. The average measured output from the
400µm fibre tip is 1.2W. Using the periodontal
handpiece, the surface of each tooth is treated in a
grid pattern for 5 seconds, i.e. about 20 seconds per
tooth. Forced intentional bleeding occurs with no
coagulation or carbonisation.

[25] =>

clinical technique _ Elap-p

Plaque and toxin removal

Soft laser treatment

The Er:YAG laser, ultrasonic periodontal probe or
manual instruments are once again used to remove
bacterial debris, toxins (antigens) and plaque.

Soft laser treatment is then performed at 75MW,
8,000Hz and 9µs for two minutes to alleviate pain
and accelerate wound healing.

Elap-p, the second time around

Follow-up after 48 hours

Laser decontamination is repeated using the
810nm, 30W, 5,000Hz diode laser at a pulse duration of 10µs with an average output from the 400µm
fibre tip of 1.2W. Using the periodontal handpiece,
the surface of each tooth is treated in a grid pattern
for 5 seconds, i.e. about 20 seconds per tooth. With a
knock-on effect (repeated laser decontamination)
on bacteria and intentional forced bleeding with no
carbonisation or coagulation, the unique effect of
the 30W pulse on the tissue shows an excellent healing prognosis and minimal damage to the gingival
tissue, as the blood contains everything necessary
for tissue regeneration or repair.

The patient comes in on Monday at 8:30 a.m. and
reports immediate pain relief directly after treatment. She was able to enjoy the weekend without
pain medication or antibiotics and was able to eat
anything she wanted later in the evening following
treatment.

Wound closure
The socket is closed through bidigital pressing of
the gingiva.

_Comparison between treated side and
untreated side
For mobility grades higher than 1, simple acidetch composite splinting is required. Premature
contact leading to non-physiological stress must
generally be removed. Naturally, after successful
acute treatment, systematic periodontal treatment
is to be performed.

_contact

laser

Dr Darius Moghtader
In den Weingärten 47
55276 Oppenheim,
Germany
www.oppenheim-zahnarzt.de
www.laser-zahn-arzt.de

Wishing you successful tooth maintenance!_
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[26] =>

I overview _ endodontic applications

The antibacterial effects
of lasers in endodontics
Author_Dr Selma Cristina Cury Camargo, Brazil

Fig. 1_Success in endodontic treatment: apical radiolucency repair.

Fig. 1

_Endodontic infection

Clinically, apical periodontitis is not evident
as long as the necrotic tissue is not infected with
microorganisms.4–6 There are up to 40 isolated
species of bacteria present in the root canal. Cocci,
rods, filaments, spirochetes, anaerobic and facultative anaerobic are frequently identified in primary
infection, fungus can also be isolated.2,7 Endodontic
microbiota can be found suspended in the main root
canal, adhered to the canal walls and deep in the
dentinal tubules at a depth of up to 300µm (Fig. 2).
The absence of cementum dramatically increases
bacteria penetration into dentinal tubules.8–11
It has been shown that bacteria can also been
found outside the root-canal system, located at
the apical cementum and as an external biofilm on
the apex.12–15 Following conventional endodontic
treatment, 15 to 20 per cent of non-vital teeth with
apical periodontitis fail.16–18 The presence of bacteria after the decontamination phase or the inability
to seal root canals after treatment are reasons for
failure.2 The remaining contamination in endodontically treated teeth is able to maintain the infectious disease process in the periapical tissue.

The success of endodontic treatment reaches
values between 85 to 97 per cent.1 Adequate treatment protocols, knowledge and infection control
are the basic components to achieve such values
(Fig. 1).2 It is well known that apical periodontitis
is caused by the communication of root-canal microorganisms and their by-products with the surrounding periodontal structures. Exposure of dental pulp directly to the oral cavity or via accessory
canals, open dentinal tubules or periodontal pockets, are the most probable routes of the endodontic
infection.2,3

Retreatments are the first choice in failed root
canals. The microbiota found in persistent infections

Fig. 2

Fig. 3

Fig. 2_Primary infection. Black
pigmented strains (a) and G-rods (b).
Fig. 3_Persistent infection.

26 I laser
2_ 2011

[27] =>

overview _ endodontic applications

Fig. 4a

differs from that in primary infection (Fig. 3). Facultative anaerobic gram positive (G+) and negative
(G-) microorganisms and fungus are easily found.19–21
Special attention is given to E. faecalis, a resistant
facultative anaerobic G+ cocci, identified in a much
higher incidence in failed root canals.22–25 The importance of bacterial control plays a significant role in endodontic success. Adequate and effective disinfection
of the root-canal system is necessary. Based on that,
all efforts must be done in order to achieve this result.

_Endodontic therapy
The bacterial flora of the root canal must be actively eliminated by a combination of debridement
and antimicrobial chemical treatment. Mechanical
instrumentation eliminates more than 90 per cent of
the microbial amount.26 An important point of note is
the adequate shaping of the root canal. Evaluating
the antibacterial efficacy of mechanical preparation
itself, Dalton et al.27 concluded that instrumentation
to an apical size of #25 resulted in 20 per cent of
canals free of cultivable bacteria, when a #35 size was
made, 60 per cent showed negative results.
Irrigating solution has been associated with
mechanical instrumentation to facilitate an instrument’s cutting efficiency, remove debris and the
smear layer, dissolute organic matter, clean inaccessible areas and act against microorganisms.
Sodium hypochlorite is the most common irrigant
used in endodontics.28 It has an excellent cleansing
ability, dissolves necrotic tissue, has a potential
antibacterial effect and, depending on the concentration, is well tolerated by biological tissues. When
added to mechanical instrumentation, it reduces
the number of infected canals by 40 to 50 per cent.
Other irrigating solutions are also used during
endodontic preparation. EDTA, a chelating agent used

Fig. 4b

primarily to remove the smear layer and facilitate the
removal of debris from the canal has no antibacterial
effect.29 Chlorhexidine gluconate has a strong antibacterial activity to an extensive number of bacteria
species, even the resistant E. faecalis, but it does not
breakdown proteins and necrotic tissue as sodium
hypochlorite does.30

Fig. 5
Fig. 4a & b_Nd:YAG laser intra canal
irradiation.
Fig. 5_Nd:YAG laser irradiation,
deep penetration.

Because the association of mechanical instrumentation and irrigating solutions are not able to
totally eliminate bacteria from the canal system—
a status that is required for root-canal filling—
additional substances and medicaments have been
tested in order to suppress the gap that occurs in
standard endodontic protocols. The principal goal
of dressing the root canal between appointments is
to ensure safe antibacterial action with a long-lasting effect.31 A great number of medicaments have
been used as dressing material, such as formocresol,
camphorated parachlorophenol, eugenol, iodinepotassium iodide, antibiotics, calcium hydroxide and
chlorhexidine.
Calcium hydroxide has been used in endodontic
therapy since 1920.31 With a high pH at saturation
over pH 11, it induces mineralisation, reduces bacteria and dissolves tissue. For extended antibacterial
effectiveness, the pH must be kept high in the canal
and in the dentine as well. This ability depends on the
diffusion through dentine tubules.32
Although most microorganisms are destroyed at
pH 9.5, a few can survive over pH 11 or higher, such
as E. faecalisand candida.21 Because of the resistance
of some microorganisms to conventional treatment
protocols—and the direct relation between the presence of viable bacteria in the canal system and the
reduced percentage of treatment success—additional effort has to be made to control canal system
infection.

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[28] =>

I overview _ endodontic applications

Fig. 6a

Fig. 6b

Fig. 6a & b_Diode 980 nm
intra-canal irradiation.
Fig. 7_Er:YAG laser.
Fig. 8_Endodontic laser
therapeutic plan.

Fig. 7

_Lasers in endodontics
Lasers were introduced in endodontics as a complementary step to increase antibacterial efforts in
conventional treatments. The antibacterial action of
Nd:YAG, diodes, Er:YAG and photo activated disinfection (PAD) have been explored by a number of investigators. In the following section, each laser is evaluated
with the aim of selecting an adequate protocol that
will result in a high probability of success in teeth with
apical periodontitis.

_Nd:YAG laser
The Nd:YAG laser was one of the first lasers tested in
endodontics. It is a solid-state laser. The active medium
is usually YAG-yttrium aluminum grenade (Y2AL5O12)
where some Y3+ are substituted for Nd3+. It is a fourlevel energy system operating in a continuous or pulsed
mode. It emits a 1,064nm infrared wavelength. Thus,
this laser needs a guide light for clinical application.
Flexible fibers with a diameter between 200nm and
400µm are used as delivery systems. It can be used
intra canal, in contact mode (Fig. 4).
The typical morphology of root-canal walls treated
with the Nd:YAG laser show melted dentine with a
globular and glassy appearance, and few areas are
covered by a smear layer. Some areas show dentinal
tubules sealed by fusion of the dentine and deposits
of mineral components.33,34 This morphologic modification reduces dentine permeability significantly.35,36
However, because the emission of the laser beam from
the optical fiber is directed along the root canal, not
laterally, not all root-canal walls are irradiated, which
gives more effective action at the apical areas of the
root.37 Undesirable morphologic changes, such as carbonisation and cracks, are seen only if high parameters
of energy are used.
One of the major problems for intra-canal laser
irradiation is the increase of temperature at the external surface of the root. When laser light reaches a tis-

28 I laser
2_ 2011

Fig. 8

sue, a thermal effect occurs. The heat is directly associated to energy used, time and irradiation mode. An
increase in temperature levels over 10° Celsius per one
minute can cause damage to periodontal tissues, such
as necrosis and anquilose.
Lan (1999)38 evaluated in vitro, the temperature increase on the external surface of the root after irradiation with a Nd:YAG laser under the following parameters of energy: 50mJ, 80mJ and 100mJ at 10, 20 and
30 pulses per second. The increase of temperature was
less than 10 degrees. The same results were obtained
from Bachman et al.(2000)39, Kimura et al.(1999)40 and
Gutknecht et al. (2008).41 In contrast to the external
surface, intra-canal temperature rises dramatically at
the apical area, promoting an effective action against
bacteria contamination. For the Nd:YAG laser, 1.5W
and 15Hz, are safe parameters of energy for temperature and morphological changes.33,41
The primary use of the Nd:YAG laser in endodontics
is focused on elimination of microorganisms in the
root-canal system. Rooney et al. (1994)42 evaluated the
antibacterial effect of Nd:YAG lasers in vitro. Bacterial
reduction was obtained considering energy parameters. Researchers developed different in vitro models
simulating the organisms expected in non-vital, contaminated teeth. Nd:YAG irradiation was effective
for B. stearothermophilus,43,44 S. faecalis, E. coli,45 S.
mutans,46 S. sanguis, P. intermedia47 and a specific
microorganism resistant to conventional endodontic
treatment, E. faecalis.48–50 Nd:YAG has an antibacterial
effect in dentine at a depth of 1,000µm (Fig. 5).50
Histological models were also developed in order to
evaluate periapical tissue response after intra-canal
Nd:YAG laser irradiation. Suda et al. (1996)51 proved in
dog models that Nd:YAG irradiation that 100mJ/30pps
(pulses per second) during 30 seconds was safe to
surrounding root tissues. Maresca et al. (1996),52 using
human teeth indicated for apical surgery, confirmed
Suda et al.51 and Ianamoto et al. (1998)53 results. Koba
et al. (1999)54 analysed histopathological inflamma-

[29] =>

overview _ endodontic applications

Fig. 9

tory response after Nd:YAG irradiation in dogs using
1 watt and 2 watts. Results showed significant inflammatory reduction in 4 and 8 weeks compared to the
non-irradiated group.
Clinical reports published in the literature confirm
the benefits of intra-canal Nd:YAG irradiation. In 1993,
Eduardo et al.55 published a successfully clinical case
that associated conventional endodontic treatment
with Nd:YAG irradiation for retreatment, apical periodontitis, acute abscess and perforation. Clinical and
radiographic follow-up showed complete healing
after 6 months.
Similar results were shown by Camargo et al.
(1998).56 Gutknecht et al. (1996)57 reported a significant improvement in healing of laser-treated infected
canals, when compared to non-irradiated cases.
Camargo et al. (2002)58 compared in vivo the antibacterial effects of conventional endodontic treatment and conventional protocol associated to the
Nd:YAG laser. Teeth with apical radiolucency, no symptoms and necrotic pulps were selected and divided into
two groups: conventional treatment and laser irradiated. Microbiological samples were taken before canal
instrumentation, after canal preparation and/or laser
irradiation and one week after treatment. Results
showed a significant antibacterial effect in the laser
group compared to the standard protocol. When no
other bactericidal agent was used, it is assumed that
the Nd:YAG laser played a specific role in bacterial reduction for endodontic treatment in patients.

_Diodes
The diode laser is a solid-state semiconductor
laser that uses a combination of galium, arsenide,
aluminium and/or indium as the active medium. The
available wavelength for dental use ranges between
800 and 1,064nm that emits in continuous and gated
pulsed mode using an optical fibre as the delivery
system (Fig. 6). Diode lasers have gained increasing

importance in dentistry due to their compactness
and affordable cost. A combination of smear layer removal, bacterial reduction and less apical leakage
brings importance to this system and makes it viable
for endodontic treatment. The principal laser action is
photo-thermal.

Fig. 10

Fig. 9_Intra-canal laser irradiation,
molars.
Fig. 10_Intra-canal laser irradiation,
technique.

The thermal effect on tissue depends on the irradiation mode and settings. Wang et al. (2005)59 irradiated root canals in vitroand demonstrated a maximum
temperature increase of 8.1° Celsius using 5 watt for
seven seconds. Similar results were obtained by da
Costa Ribeiro.60 Gutknecht et al. (2005)61 evaluated
intra-canal diode irradiation with an output set of 1.5
watts observed a temperature increase in the external
surface of the root of 7 degrees Celsius with 980nm of
diode irradiation at a power setting of 2.5 watts at a
continuous and chopped mode and demonstrated
that the temperature increase never exceeded 47 degrees Celsius, which is considered safe for periodontal
structures.41
Clean intra-canal dentine surfaces with closed
dentinal tubules, indicating melting and recrystallisation, were morphological changes observed at the apical portion of the root after intra-canal diode irradiation.62 In general, near infrared wavelengths, such as
1,064nm and 980nm, promote fusion and recrystallisation on the dentine surface, closing dentinal tubules.
The apparent consensus is that diode laser irradiation has a potential antibacterial effect. In most cases,
the effect is directly related to the amount of energy
delivered. In a comparative study designed by
Gutknecht et al. (1997),63 an 810nm diode was able to
reduce bacteria contamination up to 88.38 per cent
with a distal output of 0.6 watts in CW mode. A 980 nm
diode laser has an efficient antibacterial effect in root
canals contaminated with E. faecalis at an average
between 77 to 97 per cent. Energy outputs of 1.7 watts,
2.3 watts and 2.8 watts were tested. Efficiency was
directly related to the amount of energy and dentine
thickness.64

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[30] =>

I overview _ endodontic applications
_Er:YAG laser
Er:YAG lasers are solid-state lasers whose lasing
medium is erbium-doped yttrium aluminium garnet
(Er:Y3Al5O12). Er:YAG lasers typically emit light with
a wavelength of 2,940nm, which is infrared light.
Unlike Nd:YAG lasers, the output of an Er:YAG laser is
strongly absorbed by water because of atomic resonances. The Er:YAG wavelength is well absorbed by
hard dental tissue. This laser was approved for dental
procedures in 1997. Smear layer removal, canal
preparation and apicoectomy are the indications for
endodontics (Fig. 7).
The morphology of dentinal surface irradiated with
an Er:YAG laser is characterised by clean areas showing opened dentinal tubules free of smear layer in a
globular surface. The effects on bacterial reduction by
Er:YAG was observed by Moritz et al. (1999).65 Stabholz
et al. (2003)37 described a new endodontic tip that can
be used with an Er:YAG laser system. The tip allows
lateral emission of the radiation rather than direct
emission through a single opening at the far end. It
emits through a spiral tip located along the length of
the tip. In order to examine the efficacy of the spiral tip
in removing smear layer, Stabholz et al. (2003)66
showed cleaned intra-canal dentine walls free of
smear layer and debris under SEM evaluation.

_Photo-activated disinfection

_contact

laser

Dr Selma Camargo
University of Cidade de São
Paulo, Brazil
Rua Pinto Gonçalves,
85/54 Perdizes
São Paulo, SP 05005-010,
Brazil
selmacris@me.com

30 I laser
2_ 2011

Another method of disinfection in endodontics is
also available. PAD is based on the principle that
photo-activatable substances that bind to the target
cells and are activated by light of suitable wavelength.
Free radicals are formed, producing a toxic effect to
bacteria. Toluidine blue and methylene blue are examples of photo-activatable substances. Tolonium chloride is able to kill most of the existing bacteria. In vitro
studies, PAD has an effective action against photosensitive bacteria such as E. faecalis, F. nucleatum, P. intermedia, P. micros and Actinomycetemcomitans.67,68
On the other hand Souza et al.(2010),69 evaluating PAD
antibacterial effects as a supplement to instrumentation/irrigation in infected canals with E. faecalis,
did not prove significant effect regards to intra-canal
disinfection. Further adjustments in the PAD protocols
and comparative research models may be required to
before clinical usage recommendations.

_Discussion and conclusion
There are good reasons to focus the treatment of
non-vital contaminated teeth upon the destruction
of bacteria in the root canal. The chances for a
favourable outcome of the treatment are significantly higher if the canal is free from bacteria when it
is obturated. If, on the other hand, bacteria persist at

the time of root filling, there is a higher risk of failure
treatment. Therefore, the prime objective of treatment is to achieve the complete elimination of all
bacteria from the root-canal system.2,31
Today, the potential antibacterial effect of laser
irradiation associated with the bio-stimulation action
and accelerated healing process is well known. Research has supported the improvement of endodontic
protocol. An endodontic laser therapeutic plan brings
benefits to conventional treatment, such as minimal
apical leakage, effective action against resistant microorganisms and on external apical biofilm, and an
increase in periapical tissue repair. Based on that, laser
procedures have been incorporated into conventional
therapeutic concepts to improve endodontic therapy
(Fig. 8).
Clinical studies have shown the benefits of an
endo-laser protocol in apical periodontitis treatment.
For endodontic treatment, laser protocol is a combination of standard treatment strategies associating
cleaning and shaping the root canal with a minimal
adequate shape up to #35, irrigating solutions with
antibacterial properties and intra-canal laser irradiation using controlled parameters of energy. Ideal sealing of the root canal and adequate coronal restoration are needed for an optimal result.
In practice, little additional time is required for
laser treatment. Irradiation technique is simple once
flexible optical fibres of 200µm in diameter are used.
The fibre can easily reach the apical third of the root
canal, even in curved molars (Fig. 9). The released laser
energy has an effect in dentine layers and beyond
the apex in the periapical region. The laser’s effect is
applicable in inaccessible areas, such as external
biofilm adhered at the root apex.
Irradiation technique must follow basic principles.
A humid root canal is required and rotary movements
from the coronal portion to the apex should be carried
out, as well as scanning the root canal walls in contact
mode (Fig. 10). The power settings and irradiation
mode depend on one’s choice of a specific wavelength.
Nd:YAG, diodes in different wavelength emissions,
Er:YAG, Er:CrYSGG and low-power lasers can be used
for different procedures with acceptable results.
Laser technology in dentistry is a reality. The development of specific delivery systems and the evolution
of lasers combined with a better understanding of
laser-tissue interaction increase the opportunities
and indications in the endodontic field._
Editorial note: A complete list of references is available from
the publisher.

[31] =>

September 29-th - October 2-nd 2011
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Dedeman Princess Hotel

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Implantology

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Prof. Thomas Cangialosi, USA
Prof. dr. Steven Chussid, USA
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Dr. Aslan Gokbuget, Turkey
Prof. dr. Pekka Vallitu, Finland
Dr. Angelo Putignano, Italy
Dr. Julian Osorio, Columbia
Prof. dr. Cobi Landsberg, Israel
Prof. dr. Giancarlo Gambarini, Italy
Prof. dr. Marcel Le Gall, France
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and a lot of Bulgarian lecturers

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[32] =>

I industry report _ endodontics

TwinLight laserassisted endodontics
Author_Dr Kresimir Simunovic, Switzerland

preparation of side canals and other branches, as
well as the complete removal of the smear layer, are
impossible using classical means.

Fig. 1
Fig. 1_Absorption coefficient in
human tissues, a as a function of
laser wavelength. The absorption
coefficient is at a minimum with the
Nd:YAG laser wavelength (1,064 µm),
and at the maximum with the Er:YAG
laser wavelength (2,940 µm).
Fig. 2_Removal of the debris and
smear layer from the root canal walls
using the Er:YAG laser. The treatment
is accompanied by collateral
irrigation with saline solution.
Fig. 3_Deep decontamination with
the Nd:YAG laser
(3–5 times per session).

_Classical root treatment involves cleaning the
root canal using mechanical means and rinsing with
antibacterial solutions and solvents. However, there
are two major disadvantages of standard chemomechanical preparations.1 First, the bactericidal effect of the rinsing solutions is limited to the root
canal. Because of the narrow diameter of the dentinal
tubules and the high surface tension of the liquid
solutions, they are able to penetrate only a small
distance down the tubules. The penetration depth of
chemical disinfectants reaches only 100µm into the
dentinal tubules2, while the bacteria can penetrate
over 1,000µm from the canal lumen3, and remain
protected in the deeper layers of dentin. The second
important disadvantage is that the mechanical

Over the past twenty years many types of laser
sources have been studied and used as a means to
improve upon the classical dental treatments.1, 4 No
single “universal” laser source has been found that
could be effectively and safely used for every dental
procedure. Instead, as studies have demonstrated,
each of the laser-assisted procedures should be
performed with a laser that produces laser pulses at a
wavelength that is known to be most effective for that
particular procedure. In addition, many treatments
would benefit immensely if they were performed with
a succession or simultaneously using a multiplicity of
laser sources. Of course, having a large number of laser
sources in a practice would be impractical and very
expensive. For this reason, the TwinLight™ treatment
concept has been developed by Fotona d.d., based on
the scientific understanding and clinical experience
that for most laser-assisted treatments there exists
an optimal combination of two basic complementary
crystal laser sources, namely the Nd:YAG and the
Er:YAG laser sources. The Nd:YAG laser wavelength
(1,064nm) is the most versatile and most deeply
penetrating laser wavelength, while the Er:YAG laser
wavelength (2,940nm) is the wavelength with the
highest absorption in human tissues (Fig. 1).
The use of the TwinLightTM laser-treatment concept
in the field of endodontics was recently introduced by
Dr Norbert Gutknecht.5

_The Nd:YAG laser wavelength
in endodontics

Fig. 2

Fig. 3

32 I laser
2_ 2011

For addressing the problem of deeply lying bacteria, lasers with a deep penetration into dentin, and
preferably with a high peak-pulse power, are now
being routinely used for disinfecting root canal systems.6-15 As a result of their capability to spread and

[33] =>

industry report _ endodontics

penetrate deeply into the dentinal walls, lasers have
been demonstrated to be physically more efficient
than traditional chemical irrigants in the decontamination of the dentinal walls.13 The pulsed Nd:YAG laser
has become the gold standard for this procedure.1, 6–9
Of all dental laser wavelengths, the Nd:YAG laser
wavelength has the deepest penetration in dentin, and
the bactericidal effect of this laser has been demonstrated up to a depth of 1,000µm.7–9 The pulsed
Nd:YAG (1,064nm) laser results in a bacterial reduction of 85% at 1,000µm, while the continuous-wave
diode lasers show a much lower disinfection effects
(63% at 750µm for the 810nm diode14, and 33% at
500µm for the 980nm diode.15 Recent studies have
shown that the higher effectiveness of the Nd:YAG
laser in comparison to diode lasers can be attributed
not only to the penetrating wavelength but also to the
Nd:YAG laser’s high peak-pulse power capability,
which results in disinfecting temperature pulsing in
the bacteria’s immediate micro environment.16

_The Er:YAG laser wavelength
in endodontics
In recent years, a laser solution has been proposed
and developed that also addresses the second disadvantage of classically performed root canal treatments.7–23 For the effective debridement and cleaning
of the complex root canal system, the extremely high
absorption of the pulsed Er:YAG laser wavelength
(2,940nm) in water and chemical irrigants is utilized
to create a “cleansing” photo-acoustic effect within
the root canal system.5,21–24 Here, the erbium laser tip
is placed into the tooth canal filled with either a saline
solution or chemical irrigant. As the Er:YAG laser
pulses are emitted from the fiber tip, they are immediately fully absorbed by the irrigant, creating shock
waves within the irrigant that mechanically clean and
debride the root canal system, even in otherwise difficult-to-reach side canals and branches. Since the
action is purely mechanical, there is minimal thermal
effect on the dentin. Canal walls treated photoacoustically with the Er:YAG laser show a complete
removal of the smear layer with open dentinal tubules
and intact collagen structure.23
TM

I

Fig. 4_Initial finding (10.12.2008)
and follow-up (4.3.2009) after a
TwinLightTM laser assisted
endodontic treatment.

Fig. 4a

Fig. 4b

laser wavelength for the non-thermal, photoacoustic cleaning and debridement of the complex
root canal system.
In our practice, we use a dental laser system that
incorporates both laser wavelengths, Nd:YAG and
Er:YAG, in one device (the Fidelis AT, manufactured by
Fotona d.d.). The TET procedure consists of the following three laser treatment steps.
In the first laser treatment step, the hard-tissue
ablative capability of the Er:YAG laser is utilized to
obtain free access to the pulp chamber. Compared to
the classical procedure, this step allows a selective,
pressure free and less painful opening of the irritated
tissue. The bacterial load is not pushed into deeper
root areas, and the danger of spreading of the bacterial wave throughout the body system is significantly
reduced.
In the second laser treatment step, the root canal
system is cleaned and debrided via the Er:YAG laserinduced photo-acoustics (Fig. 2). A saline solution and
Preciso or Xpulse side-firing tips are used for this procedure (20–65mJ, 15–25Hz). Alternatively, the PIPS
procedure23 can be performed using EDTA @ 15–17%
solution and special radial, end stripped PIPS fiber tips
(20mJ, 10–50Hz).
In the third laser-treatment step, the root canal is
rinsed and dried, and then deeply decontaminated
using the Nd:YAG laser (200µm fiber, 1.5W, 15Hz) as
is shown in Figure 3.

_Conclusion

_TwinLight Endodontic Treatments
The latest TwinLight™ Endodontic Treatment (TET),
as proposed by Dr Norbert Gutknecht of the University of Aachen5, is based on the Fotona TwinLight™
complementary laser-wavelength treatment concept. The TET procedure successfully addresses the
two disadvantages of classical root canal treatments
since it combines both of the complementary “gold
standard” wavelengths: the deeply penetrating
Nd:YAG laser wavelength for the deep thermal disinfection of the dentin, and the highly absorbed Er:YAG

A combination of laser treatments using two “gold
standard” dental laser wavelengths can dramatically
improve the prognosis of root-filled teeth. The integration of the Nd:YAG and Er:YAG laser wavelengths
into a combined TwinLight™ procedure represents
an endodontic therapy that successfully addresses
both factors that complicate achieving sterility in
the tooth: the anatomical root configuration and
the characteristics of deeply resident bacterial flora.
The TwinLight™ laser-assisted endodontic treatment
starts with vibration-free removal of the hard tissue,

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I industry report _ endodontics
to be continued by the selective removal of the smear
layer and debris throughout the root-canal system,
and finally followed by deep decontamination of the
dentin tubules. The TwinLight™ approach represents
a progressive decontamination from the first to the
last step of the laser-assisted therapy. It reduces the
risk of bacteria spreading into the perioperative area
and the body system, which is particularly important
for immuno-compromised patients. It also produces
a clean three-dimensional root canal wall anatomy
with open and decontaminated dentin tubules, which
allows for a precise three-dimensional root filling.
And lastly, the laser treatment may have a biomodulation effect on the immuno response as well as a
biostimulation effect on the fibroblasts. A typical case
is shown in Figure 4.
Besides root canal therapy, there are other
excellent indications for the TwinLight™ treatment
concept. In my practice we also apply the TwinLight™
concept (using the latest Er:YAG fiber tips, Preciso,
and Xpulse) with laser-assisted implant setting in
surgery, and to pin root canal management in temporaries or before cementation in prosthetic dentistry.
Similarly, recent studies further suggest that the use
of a combination of Nd:YAG and Er:YAG lasers in
periodontal therapy, such as WPT (Wavelength-optimized Periodontal Therapy), can be associated with
cementum-mediated new connective tissue attachment and apparent periodontal regeneration of diseased root surfaces.25-26
In conclusion, the combination of the two
TwinLightTM complimentary laser wavelengths comes
very close to being a truly “universal” dental laser
system._
_References
01. Moritz A et al, Oral Laser Application, Quintessence Verlag
Berlin; 2006: 241–313.
02. Berruti E et al, Penetration ability of different irrigants into
dentinal tubules, J. Endod 2007; 23 (12): 725–7.
03. Kouchi Y et al, Location of Streptococus mutans in the dentinal
tubules of open infected root canal system, J. Dent Res 1980;
59(12): 2038–2046.
04. Gutknecht N et al, Proceedings of the 1st International Workshop of Evidence Based Dentistry on Lasers in Dentistry, Quintessence Publishing; 2007: 101–113.
05. Gutknecht N, A new treatment concept in endodontics—the
laser supported crown-down technique, 12th Congress of
World Federation for Laser Dentistry (WFLD) in Dubai; Conference Booklet; 2011: 22.
06. Gutknecht N, Behrens V.G., The Nd-YAG laser as an aid to root
canal obturation. Milan, Monduzzi Editore, 79th Annual World
Dental Congress of FDI, 1991, p. I/275–I/280.
07. Gutknecht N, Kaiser F, Hassan A, Lampert F. Long-term clinical evaluation of endodontically treated teeth by Nd:YAG
lasers. J Clin Laser Med Surg 1996;14:7–11.

34 I laser
2_ 2011

08. Gutknecht N, Moritz A, Conrads G, Sievert T, Lampert F. Bactericidal effect of the Nd:YAG laser in in-vitro root canals. J Clin
Laser Med Surg 1996;14:77–80.
09. Klinke T et al, Antibacterial effects of Nd:YAG laser irradiation
within root canal dentin. J Clin Laser Med Surg, 1997;
15:29–31.
10. Gutknecht N, Gogswaardt D van, Conrads G, Apel C, Schubert
C, Lampert F. Diode laser radiation and its bactericidal effect in
root canal wall dentin. J Clin Las Med Surg 2000;18:57–60.
11. Moritz A, Gutknecht N, Schoop U, Goharkay K, Doertbudak O,
Sperr W. Irradiation of infected root canals with a diode laser in
vivo: results of microbiological examinations. Lasers Surg Med
1997;21:221–226.
12. Gouw-Soares S, Gutknecht N, Conrads G, Lampert F, Matson
E, Eduardo CP. The bactericidal effect of Ho:YAG laser irradiation within contaminated root dentinal samples. J Clin Las Med
Surg 2000;18:81–87.
13. Schoop U et al, Bactericidal effect of different laser systems
in the deep layers of dentin. Lasers Surg Med. 2004;35(2):
111–6.
14. Klinke T et al, Antibacterial effects of Nd:YAG laser irradiation
within root canal dentin. J Clin Laser Med Surg, 1997; 15:
29–31.
15. Gutknecht N et al, Bactericidal effect of a 980-nm diode laser
in the root canal wall of bovine teeth. J Clin Laser Med Surg,
2004; 22:9–13.
16. Pirnat S et al. Thermal tolerance of E. faecalis to pulsed heating in the millisecond range. Lasers med. sci., [in press] 2010.
17. Gutknecht N, Franzen R, Lampert F. Finite Element Study on
Thermal Effects in Root Canals During Laser Treatment with a
Surface-absorbed Laser. Lasers Med Sci, 17:137–144, 2002.
18. Franzen R, Esteves-Oliveira M, Meister J, Wallerang, Vanweersch L, Lampert F, Gutknecht N. Decontamination of deep
dentin by means of erbium, chromium:yttrium-scandium-gallium-garnet laser irradiation. Lasers Med Sci, 2009, vol. 24 (1)
pp. 75–80, DOI 10.1007/s10103-007-0522-2.
19. Aranha AC, Domingues FB, Franco VO, Gutknecht N, Eduardo
de CP. Effects of Er:YAG and Nd:YAG lasers on dentin permeability in root surfaces: a preliminary in vitro study. Photomed
Laser Surg. 2005 Oct;23(5):504–8. PMID: 16262582.
20. Minas N, Meister J, Franzen R, Gutknecht N, Lampert F. In vitro
investigation of intra-canal dentine-laser beam interaction
aspects: I. Evaluation of ablation capability (ablation rate and
efficiency). Lasers Med Sci, 2009, DOI 10.1007/s10103009-0701-4.

Editorial note: The whole list of references is available from
the publisher.

_contact
Dr. Kresimir Simunovic
Seefeldstr. 128, 8008 Zurich, Switzerland
Tel.: +41 44 3834070
ksimunovic@smile.ch
www.simident.ch

laser

[35] =>

[36] =>

I industry report _ tooth whitening

TM

TouchWhite
Er:YAG laser-assisted
Tooth Whitening
Author_Jugoslav Jovanovic, Republic of Srpska

_Cosmetic dentistry has become a very important part of dental practice. Studies show that at
least one-third of the population is not satisfied
with the color and form of their natural teeth.1–3
It has been estimated that among patients who
present themselves for cosmetic treatments, up to
15 % suffer from psychiatric conditions termed
Body Dysmorphic Disorder (BDD), also known as
dysmorphophobia, which literally means “fear of
ugliness”.4,5 BDD has an estimated prevalence of 1 %
to 2 % in the general population and is characterized by a preoccupation with a slight or imagined
defect of some aspect of physical appearance. With
the increasing demand for esthetic dental care, it is
clear that tooth bleaching can present a minimally
invasive cosmetic approach.
Vital tooth bleaching is an increasingly popular
treatment in dentistry. In order to enhance or to accelerate the whitening process, heat activation of
the bleaching agent by light, heat, or laser has been
introduced. Some manufacturers of laser- or lightbased bleaching systems claim that there is improved light absorption, reduced tooth heating,
and even photochemical activation of the bleaching gel following the addition of an activator, absorber or colorant.6,7
In a systematic review, Buchalla and Attin concluded that there was no real evidence of photochemical bleaching, and that power bleaching was
a result of photothermal activation.8 Additionally,
they have also warned that activation of bleaching
agents by light or laser may have an adverse effect
on pulpal tissue due to an increase of intrapulpal
temperature exceeding the critical value of 5.6 °C.
This is due to the fact that in a typical laser- or lightactivated bleaching, the light is not fully absorbed

36 I laser
2_ 2011

in the relatively thin layer of the gel that is deposited
on the tooth surface. As a result, the laser energy is
transmitted into the dental tissue. This can lead to
an undesired heating of the whole tooth and of the
dental pulp, possibly leading to pain and irreversible
damage.

_TouchWhiteTM
Er:YAG laser-assisted bleaching
The review by Buchalla and Attin6 was performed
before the introduction of the TouchWhite™
method for Er:YAG laser-assisted tooth whitening.9
The TouchWhite™ method makes use of the fact
that the Er:YAG laser wavelength has a water absorption peak in the vicinity of 3 µm. Since water is
the major component of the aqueous bleaching
gels, this eliminates the need for any additional absorbing particles in the bleaching gels. More importantly, taking into account thermal burden considerations, the TouchWhite™ procedure represents
the most effective and least invasive laser-assisted
tooth whitening method possible. Due to its high
absorption in bleaching gels, the Er:YAG laser beam
is fully absorbed in the gel and does not penetrate
to the hard tissue or the pulp. All of the laser energy
is thus effectively used for the heating of the gel.
There is no direct heating of the dental tissue and
the pulp, as is the case with other laser-assisted
whitening methods.
Figure 1 shows the side view thermal image of a
tooth during Er:YAG or diode laser (810 nm) illumination of the bleaching gel.10 Since the Er:YAG
wavelength is fully absorbed in the gel, there is no
direct heating of the underlying tooth. On the other
hand, the diode wavelength is relatively weakly absorbed in the gel, and the transmitted light directly

[37] =>

industry report _ tooth whitening

heats up the whole tooth. For this reason, the
Er:YAG laser power is utilized more effectively, and
the gel can be heated to higher temperatures without compromising the safety of the tooth or of the
pulp. As a consequence, the TouchWhiteTM procedure can be performed with a minimal undesirable
thermal burden on the tooth, and the tooth
whitening speed can be safely increased by 5–10
times.10
The TouchWhite™ method was first proposed
and studied by the Laser and Health Academy in
partnership with Fotona. Later, the Aachen Dental
Laser Center (AALZ) in Germany performed a detailed in vitro study of the temperature elevation in
the pulp chamber under different Er:YAG laserwhitening scenarios, followed by a clinical study of
Er:YAG laser-assisted whitening.10–12 Both studies
confirmed the TouchWhiteTM method to be safe and
very effective in shortening the activation times of
the bleaching gels.
An introductory clinical study of the TouchWhiteTM procedure was also made by Dr Jugoslav
Jovanovic of the Kozarac Dental clinic in the Republic of Srpska, BH. This study tested an Er:YAG
laser-assisted whitening method in which the
bleaching gel was illuminated in three sequences of
20 seconds, with 10 seconds of waiting time between the illumination sequences (according to the
studies made by Fotona and AALZ, this illumination
mode can shorten the bleaching time from 10 minutes down to 1.5–2 minutes). A Fotona Fidelis Plus
Er:YAG laser with an R093 collimated bleaching
handpiece was used in the study. The laser settings
were as follows: laser power 0.55 W, repetition rate
10 Hz and pulse duration VLP. Five patients with 16
intrinsically stained teeth (12 vital and 4 non-vital)
were treated with the Fotona teeth whitening gel
(35 % H2O2). One to three treatment sessions were
made depending on the intensity of discoloration.
The results of this introductory study confirmed
that the Er:YAG laser applied in the three sequence
mode can be safely and effectively used for teeth
whitening of vital and non-vital tooth discoloration. None of the patients felt any heating of
their teeth or pain during the treatment. Only one
patient developed a temporary hypersensitivity after the bleaching, however, this sensitivity was attributed to the gel activity itself. The results of this
study have already been presented at the 5th SOLA
Congress in Vienna in 2009.13 Since then, the
TouchWhiteTM tooth bleaching procedure has been
performed on more than 40 patients. In comparison with diode and Nd:YAG bleaching, the Er:YAG
laser-assisted whitening method proved to be
more comfortable for patients while achieving the
same or better whitening efficacy at shorter treat-

ment times. As an example, Fig. 2 shows before and
after photos for one of the cases.

_The Er:YAG laser-assisted
bleaching procedure
An appointment for Er:YAG laser bleaching is
typically scheduled to last approximately 45 minutes. Before the start of the initial preparation, photographs are taken and general health status is established regarding possible indications or contraindications such as: leaking restoration, periodontal problems, caries, neck sensitivity, enamel
fractures and cracks, insufficient oral hygiene, expectations of the patient, endodontic problems or
TMJ disorders.
The steps of the procedure are performed in the
following order:
A) Placement of cheek and lips retractor
(OptraGate, Ivoclar Vivadent; Schaan, Liechtenstein)
B) Teeth preparation
Extrinsic stains, plaque, debris are removed with
pumice in order to obtain optimal results. Any organic material remaining on the tooth surface
would interact with the bleaching agent, thus reducing effectiveness. Conventional polishing
pastes should not be used because they may contain oils that inhibit the bleaching reaction.
C) Photographs of teeth before procedure
Once the pre-treatment photos are completed the
procedure may begin.
D) Insertion of bite blocks
Bite blocks or a combination bite block and saliva
aspirator is placed.
E) Gingival protection
Soft tissues should be protected from the hydrogen peroxide gel and laser light. Also, the hypersensitive dental neck should be protected from the

Fig.1_Side view thermal images
of a tooth under Er:YAG laser (a),
and diode laser (b) illumination.

Fig. 1

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[38] =>

I industry report _ tooth whitening

Fig. 2a

Fig. 2b
Fig. 2a & b_Photos before and after
Er:YAG laser assisted whitening
procedure.

bleaching gel in order to
avoid undesirable pain during the procedure. The teeth
and gums are dried with
compressed air and a gingiva
protector (that comes with
the Fotona bleaching kit) is
placed on the exposed cervical root surface (1–1.5 mm)
and cervical gingival tissues
(4–5 mm).
F) Application of the bleaching gel
The Fotona Bleaching
kit contains gingival protection flowable resin material, bleaching gel and after-bleaching care material,
packed in a syringe. The complete bleaching kit should be
stored in a refrigerator (temp. 3–8 °C). Before the
application, the kit is taken out of the refrigerator,
the gel is mixed in the amount needed for the procedure, and the mixed gel is left to rest for 4–8 min
at room temperature. The gel is then applied to the
teeth with a spatula in a predetermined sequence
11-21-13-23-24-14-15-25-12-22 for the upper
teeth and 33-43-34-44-35-45-32-42-31-41 for
the lower teeth.
G) Protection of the patient, assistant and dentist
with protective goggles
Although the Er:YAG laser beam is less dangerous for the eyes in comparison to other laser wavelengths that are transmitted through to the retina
(KTP, diode or Nd:YAG), protection goggles are
mandatory.
H) Irradiation with the Er:YAG laser
Every tooth is irradiated for 20 sec in the same
sequence as the gel application. The parameter settings are as follows: Fotona Er:YAG laser, frequency
10 Hz; power 0.55 W; pulse duration VLP, handpiece
R093.
The handpiece is moved in a sweeping manner
across the gel surface. If undesirable pain or sensitivity occurs on any tooth (rarely) go to the next
tooth. Pay attention not to irradiate two neighboring teeth at the same time. The whole procedure is
repeated three times so that every tooth is irradiated for 3 x 20 seconds.
I) Removal of the bleaching gel and color check
When the three-cycle illumination of all teeth
has been completed, the gel is removed with an aspirator and the tooth surface is thoroughly rinsed

38 I laser
2_ 2011

with a water spray. The color is checked with a shade
guide and shown to the patient.
J) Re-checking the gingival protection and repeating the procedure
The procedure can be repeated up to 3 times in
one appointment if necessary.
K) After-treatment photographs
At the end of the treatment, the teeth are
cleaned of the gel, and the gingival protection is removed. The achieved color is checked, compared
with the shade guide (VITA B1–C4) and included in
the image to serve as a reference point.
Teeth are gently dried. Patients are instructed
not to eat or drink colored food for 72 hours (coffee, tea, red wine). Smoking should also be avoided.
An appointment is made for a control session after
14 days. If there is need for a second treatment, the
interval is 14 days. _
_References
1. Goldstein RE, Survey of patient attitudes toward current esthetic procedures, J. Prosthet Dent 1984;52;775–780.
2. Truin GJ, Burgersdijk RC, Kalsbeek H, van’t Hof MA, Cosmetic
dentistry, Ned Tijdschr Tendheelkd 1989;96;378–381.
3. Willemsen WL, Burgesdijk RC, Truin GJ, Mulder J. Cosmetic
dental treatment in an adult Dutch population. Comunity Dent
Health 1994;11:378–381.
4. Sarver DB, Wadden TA, Pertschuk MJ, Witaker LA. Body image
dissatisfaction and body dysmorphic disorder in 100 cosmetic
surgery patients. Plast Reconstr Surg 1998;101:1644–1649.
5. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder
and cosmetic surgery. Plast Reconstr Surg 2006;118:167–180.
6. Baik JW, Rueggeberg FA, Liewehr FR. Effect of light-enhanced
bleaching on in vitro surface and intrapulpal temperature rise.
J Esthet Restor Dent 2001;13:370–378.
7. Verheyen P, Walsh LJ, Wernisch J, Schoop U, Moritz A. Laser assisted bleaching in: Moritz A, Beer F, Goharkay K, Schoop U,
Strassl M, Verheyen P, et al (eds). Oral Laser Application. Quintessence:Berlin, 2006:407–448
8. Buchalla W, Attin T, External bleaching therapy with activation
by heat, light or laser—a systematic review. Dent Mater
2007;23:586–596.
9. TouchWhiteTM is a registered trade mark of Fotona d.d.
(www.fotona.com).

Editorial note: The whole list of references is available
from the publisher.

_contact
Jugoslav Jovanovic, DDS
Kozarac General Dentistry Clinic
Republic of Srpska, BH

laser

[39] =>

www.idem-singapore.com

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Tel: +65 6500 6721
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Dennis Tarnow

Michel Magne

Clinical Professor of
Periodontology and Director of
Implant Education, Columbia
School of Dental Medicine,
New York

Associate Professor of
Clinical Dentistry and
Director of Dental Technology,
University of Southern California,
Los Angeles

Pascal Magne

Robert Boyd

Associate Professor,
Chair of Aesthetic
Dentistry, University
of Southern California,
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Professor & Chairman
of Orthodontics,
School of Dentistry,
University of California
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Held In

In Co-operation With

Co-organiser

[40] =>

I special _ sterilisation

Infection control
Author_Dr Frank Yung, Canada

Fig. 1_An example of a highfiltration protective mask,
which is recommended
for use with dental lasers.
Fig. 2_An example of the submission
of indicators to a testing service for
assessment of office sterilisation
equipment’s effectiveness.

More than 20 years ago, a dental patient named
Kimberly Bergalis was diagnosed with Aids. The source
of her HIV infection was her dentist. Even though the
exact path of transmission is still not known, this first
proven transmission of HIV from dentist to patient—
and the subsequent intense coverage by the media—
set off tremendous confusion and panic amongst
dental patients. It was her unfortunate death in 1991
that changed the dental profession almost overnight,
prompting all sorts of new regulations and guidelines,
including the sterilisation of dental instruments. The
document Guidelines for Infection Control in Dental
Health-care Settings was published by the US
Centers for Disease Control and Prevention (CDC) on
19 December 2003, providing some of the current and
available scientific rationale for infection-control
practices, for which recommendations were made.1
These suggestions were followed closely by various
governing dental health organisations, including the

US Occupational Safety and Health Administration
(OSHA) and Health Canada.
In dentistry, we see patients from different
walks of life every day and they bring all kinds of
pathogens to our dental offices. It is our responsibility
to arrest the path of these pathogens and attempt
to prevent them from infecting others and spreading
beyond our practices. Following the CDC recommended infection-control guidelines and procedures
can help stop and prevent transmission of infectious
organisms through blood, oral and respiratory secretions and contaminated equipment during the course
of dental treatment. One factor to consider in assessing the risk of contamination is the type of bodily substances to which dental health-care personnel (DHCP)
are exposed. It is generally understood that human
blood has a high infectious potential.2 In addition to
bacteria and fungi, human saliva has been found to
be capable of harbouring many kinds of infectious
viruses.3, 4 Without the benefits of a quick and reliable
reference, DHCP have to assume that everyone is a
potential carrier. This is the fundamental reason that
dental practices should have a universal infection prevention protocol.
Amongst many other related issues, the CDC guidelines explain the manner in which to wear surgical
gloves properly and implement a glove protocol. These
recommendations will help properly prevent contamination from our patients’ oral tissues and fluids. Regarding surgical masks, laser ablation of human tissue
or dental restorations can cause thermal destruction
and can create smoke by-products containing dead
and live cellular material (including blood fragments),
viruses, and possible toxic gases and vapours. One
concern is that aerosolised infectious material in the
laser plume, such as the herpes simplex virus and
human papillomavirus may come into contact with the
nasal mucosa of the laser operator and nearby DHCP.
Although no evidence exists that HIV or the hepatitis B
virus (HBV) has been transmitted via aerosolisation and
inhalation, there are scientific studies that confirm the
risk of this possible route of contamination.5,6 The risk
to DHCP from exposure to laser plumes and smoke is
real, and, along with other measures such as strong
high-volume suction, the use of a high-filtration mask
is strongly recommended (Fig. 1).

Fig. 1

Fig. 2

40 I laser
2_ 2011

[41] =>

special _ sterilisation

Fig. 3

Sterilisation is a multistep procedure that must be
performed carefully and correctly by the DHCP to help
ensure that all instruments are uniformly sterilised
and safe for patient use. Cleaning, which is the first
basic step in all decontamination and sterilisation
processes, involves the physical removal of debris and
reduces the number of micro-organisms on an instrument or device. If visible debris or organic matter
is not removed, it can interfere with the disinfection
or sterilisation process. Proper monitoring of sterilisation procedures should include a combination of
process indicators and biological indicators, and
should be assessed at least once a week (Fig. 2).
Patient-care items are generally divided into three
groups, depending on their intended use and the
potential risk of disease transmission. Critical items
are those that penetrate soft tissue, touch bone or
contact the bloodstream. They pose the highest risk of
transmitting infection and should be heat sterilised
between patient uses. Examples of critical items are
surgical instruments, periodontal scalers, surgical
dental burs, optical fibres (Fig. 3) and contact tips (Fig.
4). Therefore, it is extremely important to examine,
cleave, polish and sterilise optical fibres and contact
tips after each use. Alternatively, sterile, single-use,
disposable devices can be used. Semi-critical items
are those that come into contact with only mucous
membranes and do not penetrate soft tissues. As
such, they have a lower risk of transmission. Examples
of semi-critical instruments are dental mouth mirrors, amalgam condensers and impression trays.
Most of the equipment in this category is heat tolerant, and should therefore be heat sterilised between
patient uses. For heat-sensitive instruments, highlevel disinfection is appropriate. Non-critical items
are instruments and devices that come into contact
only with intact (unbroken) skin, which serves as an
effective barrier to micro-organisms. These items
carry such a low risk of transmitting infections that
they usually only require cleaning and low-level dis-

Fig. 4

infection. Examples of instruments in this category
include X-ray head/cones, blood pressure cuffs, lowlevel laser emission devices and laser safety glasses.
For low-level laser therapy, the use of a transparent
barrier similar to disposable sleeves for curing lights
is acceptable. For safety glasses, the use of a low-level
disinfectant is suitable as long as it has a label claim
approved by OSHA for removing HIV and HBV. The
disposal of used instruments and excised biological
tissues should be managed separately. A cleaved optical fibre, broken contact tips, or disposable fibres
should be disposed of properly in a sharps container.
Harvested biological waste should be placed in a container labelled with a biohazard symbol. In order to
protect the individuals handling and transporting
biopsy specimens, each specimen must be placed in a
sturdy, leak-proof container with a secure lid to prevent leakage during transport. By following these
guidelines, the spread of pathogens amongst dental
patients, DHCP and their families can be prevented,
and the passing of Kimberly Bergalis will not have
been in vain._

Fig. 3_An example of sterilised
optical fibres and handpieces.
Fig. 4_An example of sterilised rigid
glass tips and handpieces.

Disclosure
Dr Yung has no commercial or financial interest regarding this article.
This article was first published in the Journal of Laser
Dentistry,18/2 (2010): 68–70.
Editorial note: A list of references is available from the
publisher.

_contact

laser

Dr Frank Y. W. Yung
Toronto, Ontario, Canada
frankyung@rogers.com
www.drfrankyung.com

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[42] =>

I laser _ interview

New double-wavelength-laser—
successful launch at IDS
An interview with Federico Pignatelli, Chairman and CEO Biolase Technology Inc.

_You have four different dental lasers in your
range of products. Can you please explain, in short,
for which indications which laser is suited best?
The iLase 940nm diode laser is a very convenient
and affordable way to get started in laser dentistry.
Completely wireless and handheld, it is perfect for
troughing around crown preps to eliminate packing
retraction cord, gingivectomies, treating periodontal
pockets in a soft-tissue management program plus
root canal decontamination. With 5 watts of power
in pulse mode, it is capable of most soft tissue procedures.

_Mr Pignatelli, Biolase is predominantly known
to dentists as a manufacturer of dental lasers, but
also develops lasers for other medical sectors. Which
corporate tradition and which competences underline this high specialization in the medical laser
technology?
Federico Pignatelli: Biolase is redefining surgery in dentistry and medicine. We have more than
140 issued patents and 143 patents pending in the
field of dental and medical lasers of which approximately 70% are focused on our core Er,Cr:YSGG
laser technology, which combines our patented
laser energy at 2,780nm with water to precisely cut
hard tissue, soft tissue and bone. In addition to dentistry, our YSGG technology has broad applications
in ophthalmology, dermatology, orthopedics, and
ENT. In 2011 you will see us begin expansion into
these new markets starting with our YSGG laser and
methodologies for treating presbyopia, a condition
that affects more than 2.5 billion people worldwide.
Our innovative R & D team combined with a senior
management staff with many years of medical laser
experience are the keys to us expanding into the
medical laser sectors.

42 I laser
2_ 2011

The EzLase, Total Diode Solution performs all
diode soft-tissue, hygiene procedures, endo and perio indications plus full-mouth teeth whitening and
LLLT for biostimulation and pain relief. The EzLase
features higher power and more pulse modes than
the iLase for even greater control and patient comfort. Full-mouth teeth whitening takes less than 20
minutes. The EzLase is the only dental laser in the US
with FDA clearance for temporary pain relief for TMD
and other facial pain indications. We have developed
a new deep tissue handpiece specifically for biostimulation and our doctors are seeing amazing results.
The WaterLase MD Turbo was a major breakthrough in all-tissue laser technology when it was introduced a few years ago. This laser is an ideal entry
level all-tissue laser for pediatric and restorative dentistry including cavity preps of all classes. It is also
FDA cleared for periodontal indications including
subgingival calculus removal and new attachment
procedures. For endodontic indications, it is clinically
proven to disinfect root canals three times more effectively than using NaOCl when using our patented
EndoLase™ radial firing tips.
The new dual wavelength WaterLase iPlus has
advanced laser technology to its ultimate. The combination of the 2,780nm and 940nm wavelengths in
a single unit provides maximum versatility for performing all dental laser indications. With 600mJ per
pulse and pulse repetition rates from 5 to 100Hz., this
laser can cut hard-tissue as fast as a high-speed
drill—or any other dental laser—without the pain or

[43] =>

laser _ interview

creation of micro-fractures in healthy tooth structures the drill can cause. It also reduces the—risk of
cross-contamination from dental burs that has been
shown in recent studies. The intuitive, indicationsbased graphic interface makes operating the iPlus as
quick and easy to learn as using a smart phone.
_With the Er,Cr:YSGG laser with a wavelength
of 2,780nm, Biolase has developed the Erbium laser
further and owns the patent for this wavelength.
What advantages does the Er,Cr:YSGG laser offer
compared to a Er:YAG laser?
BIOLASE is one of the research pioneers in dental
lasers. In our experiments with many kinds of lasers for
over 20 years, we have found the Er,Cr:YSGG laser
wavelength of 2,780nm to be the most efficient for
cutting not only hard-tissue, but also soft-tissue and
bone as well. And that’s one feature of our company
that also distinguishes us from everyone else. Rather
than taking a readily available commercial laser, such
as Er:YAG, and then asking doctors to use it, we took
the opposite approach. We first learned which laser
would be most applicable for dental procedures, regardless of commercial availability, and then worked
to bring it to market. The result is a biological and therapeutic treatment that provides minimum trauma and
superior healing. Our YSGG
technology is also more
efficient than the Er:YAG
which allows us to generate
high power and high hertz
rates in a small package using a standard power outlet.

them, including experienced laser dentists, couldn’t
believe it even after they tried it.
They also loved our new system interface. Rather
than requiring the doctor to enter values for power,
air and water spray, and pulses per second, the
Waterlase iPlus simply asks doctors to select what
indication they want to perform. The iPlus takes care
of all the technical details of setting up the laser
parameters and recommends the optimum tip and
handpiece combination.
Doctors have been waiting for a powerful, yet
simple laser to use. Now they finally have it with the
Waterlase iPlus.
_Are the reactions of the IDS visitors similar?
The reaction to the cutting speed and intuitive
indications-based user interface of the iPlus at the
IDS was similar to the Chicago Midwinter, but the
international doctors and distributors really liked the
new more flexible fiber delivery system with higher
illumination and larger diameter tips and the ability
to order an iPlus in custom colors, especially the red
and the black versions.

“Doctors have
been waiting for
a powerful, yet
simple laser
to use.”

You may have also noticed that our diode wavelength of 940nm is different than the more traditional diode wavelengths of
810nm and 980nm. The reason we chose 940nm is
very similar to our choice of Er,Cr:YSGG. From a laser
physics standpoint, we considered it because it is on
an absorption peak for hemoglobin and oxyhemoglobin with higher absorption in water than the
810nm. This provides an excellent balance of cutting
and coagulation of all types of oral tissues. We then
gave our clinical advisors unmarked multi-wavelength units to evaluate. Clinically, they all selected
the 940nm over other the common diode wavelengths.
_At the Midwinter Meeting in Chicago at the end
of February, the presentation of the new Er,Cr:YSGG
laser Waterlase iPlus was extremely successful.
Which product features were received best?
Doctors were most impressed that the iPlus cuts
hard-tissue as fast as a high-speed drill. Many of

_Did you experience at the
IDS that dentists and dental
assistants have the need for
more information regarding
dental lasers?
Yes. Recent market research supports your observation that dentists and dental assistants need more information on all aspects of
dental lasers. At Biolase we
are working very hard to educate dentists and their staffs
on the wide range of indications that can be performed by diode and all-tissue lasers, how they can
be integrated into the practice to generate a return
on their investment, the amount of clinical training
and support that is available to help them master
laser dentistry and finally how much easier our new
lasers are to learn and operate compared to lasers in
the past.
_What sales channels do you use for your products?
Internationally, we sell through a large network of
distributors. We are currently selling in about 50
countries and in addition to Biolase-Europe in Floss,
Germany, we are opening up company offices in
China, India and South America to better support our
dealers in these fast growing markets.
Mr Pignatelli, thank you very much!

laser
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_ 2011

[44] =>

I laser _ education

The Joint Fellowship Course of
Tehran and Aachen Universities
An academic and scientific joint program
Authors_Reza Fekrazad, Katayoun AM Kalhori

_When Plan of Development and Advancement
of Laser in Dentistry (PDALD) was accepted by the
Ministry of Health and Medical Education in Iran, the
education department of Laser national committee of
the Ministry of Health authored an educational curriculum in two units for laser in Dentistry, which has
to be taught in 34 hours. It has been scheduled and
confirmed that all undergraduate and post-graduate
students ought to pass these two units.
To teach the course, some well-trained and fully
experienced professors were needed.

_contact

laser

Reza Fekrazad DDS, Ms
Periodontologist–Head of
Fellowship Course
dr_rfekrazad@yahoo.com
Katayoun AM Kalhori
Oral and Maxillofacial
Pathologist–Educational
Manager of Co
dr_kalhori@yahoo.com

44 I laser
2_ 2011

Twenty top professors were chosen among applications from all universities of the country. The University of Tehran as the oldest and largest university
of the country was selected for handling the program.
On the other hand the University of Aachen was
elected among top Universities of the world which are
active teaching laser in the world as the partner.
After some negotiations authorities of both Universities signed an agreement to run the program of
training 20 professors in 18 months in three phases.
Phase one was concentrated on basics. Iranian
professors managed this phase. Participants were
supposed to pass the course with good grades.
They had to learn how to work with different types
of laser in the market practically even on real patients'.

E –learning education was also practiced to help them
more. They also were asked to have review article on a
key subjects which was found very helpful.
In the second phase, a team of international professors from the University of Aachen held class in the
second 6-months course in the University of Tehran.
It was the advanced course, which started in December 2009 and is going to be in Jul 2010.Course participants have to pass a final exam at the end. They would
be awarded a certificate after the exam.
For the last phase, they are asked to have a study
case for their thesis. Finally, they ought to present the
project and defend it during the 3 phases students
have been in touch with their professors on-line and
have received up-dated information and have raised
any probable questions.
The course is still going on, besides its academic
values the program PDALD has already taken a giant
step in the knowledge of laser in Iran and has added
to the value of two well reputable Universities of
Tehran and Aachen. We are proud to say that the program has been handled in a very friendly and scientific atmosphere.
We hope in the near future the level of these relationships goes higher in education and research
fields._

[45] =>

meetings _ events

I

International events
2011
FDI Annual World Dental Congress
Mexico City, Mexico
14–17 September 2011
www.fdiworldental.org
Annual Congress of DGZI
Cologne, Germany
30 September–1 October 2011
www.dgzi.de
20th Annual Scientific
Congress of the EAO
Athens, Greece
12–15 October 2011
www.eao-congress.com

IDEM International Dental Exhibition
Singapore
20–22 April 2012
www.idem-singapore.com
13th WFLD World Congress
Barcelona, Spain
26–28 April 2012
www.wfld-barcelona2012.com
90th General Session & Exhibition
of the IADR
Rio de Janeiro, Brazil
20–23 June 2012
www.iadr.org

Annual Congress of DGL
Düsseldorf, Germany
28–29 October 2011
www.startup-laser.de
Greater New York Dental Meeting
New York, NY, USA
25–30 November 2011
www.gnydm.org

2012
LaserOptics Berlin
Berlin, Germany
19–21 March 2012
www.laser-optics-berlin.de

laser
2
I 45
_ 2011

[46] =>

I meetings _ SELO

XI Congress of SELO
Authors_Paloma Montero, Isabel Sáez de la Fuente, Josep Arnabat, Spain

_On 11–12 February, the XI National Congress of
the Spanish Society of Laser in Odontostomatology
(SELO) was held in Seville, with the title: “Excellence in
operating lasers”.
The President of the Congress, Doctor Isabel
Sáez de la Fuente, with Doctor Daniel Torres Lagares, coordinator of the area of Oral Surgery of
the University of Seville and Vice-President of
the Congress, and the rest of the organising
committee (Patricia Bargiela, Paloma Montero,
Betina Pérez, Eloy Cano, Carlos Valdivieso,
Rocío Velázquez and Ignacio Arregui) organized a scientific programm of a high level that
was of interest to all participants of the Congress. It achieved accreditation from the
Agency of Medical Care s side of Andalucia,
meaning that the training given at this event
is considered as credits for continuous
training in the national system. The Congress was held in the hotel Silken Al Andalus
Palace and attended by 200 assistants, in-

46 I laser
2_ 2011

cluding dentists, hygienists and students. There were
many commercial companies who displayed the latest laser technologies to the assistants.
During the inauguration, carried out by the Honorable Rector of the University of Seville, the importance of technology in the improvement of the daily
practice was emphatisized. Institutions with scientific boards should approve the incorporation of this
in the dental office. This message was emphasized by
members of the inaugural table: the Rector of the
University of Seville (Joaquín Luque), the Director
Manager of the Andalusian Service of Health (José
Luis Gutiérrez Pérez), accompanied by Silvestre Ripoll
(Member of the Scientific Commission of the School
of Dentists of Seville), Josep Arnabat (President of
SELO), the teacher Cosme Gay Escoda (President of
the Scientific Committee of the Congress) and Isabel
Sáez de la Fuente (President of the Congress).
Moving onto the scientific program, the pre-congress course took place on Friday morning attended

[47] =>

meetings _ SELO

by the doctors Francisco Enrile and José Miguel
Romero (Huelva), Pedro Buitrago (Valencia), Ignacio
Arregui (León) and Ignacio Sanz (Madrid).
The rest of the scientific program was concerned
with current matters: treatment of periimplantitis
and periodontal treatments (Georgios Romanos,
Francesco Martelli, Vanessa Ruiz, Antón Sculean,
Gerd Volland and Jan Tuner), aesthetic dentistry and
adhesion (Martín Jorgens, Henrik Holm, María Pérez
and Carlo Fornaini), oral surgery (Rolando Crippa,
Antonio Bowen, Antonio España, Gonzalo López and
Patricia Bargiela Pérez). To sum up, the scientific program, was attended by speakers of great national and
international prestige.
Simultaneously, the V meeting SELO for hygienists
and assistants was celebrated, to which came near
to 50 of these professionals interested in the study of
the physique bases of laser, its utilization in areas of
odontology (periodontics, endodontics, oral surgery,
aesthetic, etc) and its integration in he daily office. The

I

speakers Cristina Vaquero, Daniel Abad, Marcela
Bisheimer, Sofia Raja, Luis Suárez, Rocío Velázquez
and Ángela Rodríguez talked about these topics
throughout the morning.
The social program was very successful among the
assistants. The speaker’s dinner took place in the
restaurant Casa Robles in the Placentines street, and
the dinner gala in the Exhibition Casino. The dinner
was livened up with a jazz group, and later a flamenco
dance performance, which was to the liking of all the
assistants.
Without a doubt, the organisers of the Congress
agreed that of having a city like Seville as a venue, was
key to the success of this Congress, preparing the
sphere for the next big event related to laser dentistry
that will be celebrated in our. The 13th World Congress
of the World Federation Laser Dentistry will take place
in Barcelona the last week of April 2012, organized by
Doctor Antonio España, where we look forward to
seeing you soon again._

laser
2
I 47
_ 2011

[48] =>

I meetings _ IDS 2011

Biggest IDS ever
_The upbeat mood at IDS 2011 was especially due to the large number of visitors. Accordingly, the trade fair’s halls were very busy
and the exhibitors' stands were extremely well
visited. Exhibitors confirmed that representatives of all important professions—ranging
from dental practices and dental labs to the dental trade, plus the higher education sector—visited their stands. Exhibitors were particularly
pleased with the large number of international
visitors to the trade fair. This year there was a
strong increase in visitors not only from Latin
America and South America, Australia, the
United States and Canada, but also from Italy,
France, the Netherlands, Spain, the United Kingdom, Switzerland, Russia, Ukraine, Turkey, Israel,
China and India. IDS was also a huge financial
success for many exhibitors. Countless orders
were placed, both domestically and internationally, and so numerous companies were able to
boast a long list of orders. Of equal if not greater
importance to many exhibitors were the opportunities to establish and maintain contacts, generate customer loyalty, win new customers and
open up new foreign markets. All of these goals
were also reached at the 34th International Dental Show. Last but not least, the exhibitors expressed great satisfaction with the visitors' high
decision-making authority. This finding is confirmed by the initial results of an independent
visitor survey, as 85 per cent of all trade visitors
are involved in purchasing decisions at their
company. “We’ve succeeded in making the International Dental Show even more attractive,
both domestically and internationally. The

48 I laser
2_ 2011

strong increase in international participants especially shows that IDS is the world’s leading
dental trade show,” says Dr Martin Rickert,
Chairman of the Association of German Dental
Manufacturers (VDDI). “What's more, participants were able to forge high-quality business
contacts, both between industry and trade professionals as well as between the industry, dentists and dental technicians. Thus the trade fair
once again signalled better times ahead and
generated momentum that will help the dental
sector stay on course for a successful business
year.”

_Enormous interest in innovation
The specialist trade and users were especially
interested in the innovative new products and
technologies on display. According to Dr Martin
Rickert (VDDI), the trade fair demonstrated that
digital processes and technologies are becoming increasingly popular since they facilitate
even more efficient and higher quality treatments. Hence a major focus of IDS 2011 was on
products and systems that offer users and patients improvements in preventative care, diagnostics and dental treatment. These include expanded ultrasound systems that enable painless
professional preventative care, digital intraoral
scanners, improved root canal treatment methods, new dental filling materials, aesthetic dental crowns and bridges that look especially natural, and improved digital X-ray diagnostics
that are especially useful in the area of implantology._

[49] =>

manufacturer _ news

I

Manufacturer News
Hager & Werken

A plaster for
implantology
Implantology offers some very interesting application
fields for Hager & Werken’s Reso-Pac plaster which remains soft: First of all the adhesive cellulose-based
periodontal dressing is a great help in implant healing
by covering the wound and its sutures, consequently
protecting the intra-oral wound area from the oral milieu with its germ settlements. Reso-Pac is hydrophilic
and, therefore, offers an ideal adhesion to the oral cavity tissue. Upon modeling it, Reso-Pac turns into a
smooth paste-like surface which is pleasant to the

Henry Schein

Number 1 for social
responsibility
Henry Schein, the largest distributor of health care
products and services to office-based dental, medical and veterinary practitioners,
has been ranked number one in the
“Wholesalers: Health Care” industry in Fortune Magazine’s 2011 list
of “World’s Most Admired Companies” in the categories of Social
Responsibility and Global Competitiveness. The mission of Henry Schein Cares, the
Company’s global corporate social responsibility
program, is to enhance access to care for under-

Syneron Dental Lasers

Cross-Continental
Clinical Research
Collaboration
Syneron Dental Lasers continues to advance laser
dentistry education and clinical research across the
globe, this time connecting between the Faculty of
Medicine at Plovdiv Medical University in Bulgaria,
and the Department of Dentistry at the Cheng Hsin
General Hospital in Taipei, Taiwan. The two academic
institutions were introduced to one another via
Syneron Dental Lasers, as Plovdiv University already
has strong cooperation with the company and has already began conducting extensive clinical research

patient. The applied periodontal dressing remains
soft and dissolves completely after approximately
30 hours without leaving any residues, making a later
removal by the dentist unnecessary. Furthermore,
Reso-Pac can be used as a medicament carrier for
periimplantitis treatment. Reso-Pac is available in
useful 2g single doses as well as in an economical
25g tube. Further information can be found at:
Hager & Werken GmbH & Co. KG
PF 100654
47006 Duisburg, Germany
info@hagerwerken.de
www.hagerwerken.de

served populations globally through the support of
not-for-profit organizations, institutions, and communities dedicated to increasing the delivery of
health education and care. Henry Schein establishes strategic public-private partnerships to carry
out this mission with a special emphasis on three
areas of focus: wellness, prevention, and treatment;
emergency preparedness and
relief; and capacity building.
“Henry Schein is honored to be
included together with some of
the most respected companies
in the world in Fortune’s
‘World’s Most Admired Companies’ list,” said Stanley M. Bergman, Chairman
and Chief Executive Officer of Henry Schein, Inc.
“Since our Company’s beginning nearly eight

decades ago, Henry Schein has retained a deep
commitment to social responsibility. This commitment to giving back to society has endured and, in
fact, has steadily grown, as Henry Schein has rapidly expanded our business around the world. Being
recognized by our peers and other business leaders
for our accomplishments in social responsibility as
well as for our global competitiveness, is a source of
great pride for us.”

in laser dentistry, with the LiteTouch™ dental laser.
This brand new cooperation means that Assistant
Professor Dr. Georgi Tomov, PhD., from the Department of Operative Dentistry and Endodontics at
Plovdiv University will assume the role ofa supervisory researcher at an interdepartmental project with
the goal to facilitate cooperation between the two
universities in the field of higher dental laser education and science, as well as promote the cooperation
of research in laser-assisted dental treatment.
Working with Professor Tzi Kang Peng, PhD., Professor and Chair of the Dept. of Dentistry at Cheng Hsin
General Hospital in Taipei, the study in the area of Erbium:YAG Laser in Clinical Dentistry will compare
Laser Assisted Periimplantitis Treatment with the
Erbium:YAG LiteTouch™ dental laser vs. traditional

surgical treatments, from the perspective of periodontal clinical attachment level gain.

Henry Schein Dental
Deutschland GmbH
Monzastraße 2a
63225 Langen, Germany
info@henryschein.de
www.henryschein-dental.de

Syneron Dental Lasers is the Gold Sponsor of the
WFLD-European Congress, which will convene in
Rome on June 9–11. The company will host a multidisciplinary Laser Dentistry Education & Technology
Industry Think Tank session at the culmination of the
conference.
Syneron Dental Lasers
POB 223
Yokneam 20692, Israel
dental@syneron.com
www.synerondental.com

laser
2
I 49
_ 2011

[50] =>

I about the publisher _ imprint

laser
international magazine of

laser dentistry

Publisher
Torsten R. Oemus
oemus@oemus-media.de
CEO
Ingolf Döbbecke
doebbecke@oemus-media.de
Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de
Chief Editorial Manager
Norbert Gutknecht
ngutknecht@ukaachen.de
Co-Editors-in-Chief
Samir Nammour
Jean Paul Rocca
Managing Editors
Georg Bach
Leon Vanweersch
Division Editors
Matthias Frenzen
European Division
George Romanos
North America Division
Carlos de Paula Eduardo
South America Division
Toni Zeinoun
Middle East & Africa Division
Loh Hong Sai
Asia & Pacific Division

Senior Editors
Aldo Brugneira Junior
Yoshimitsu Abiko
Lynn Powell
John Featherstone
Adam Stabholz
Jan Tuner
Anton Sculean

Designer
Sarah Fuhrmann
s.fuhrmann@oemus-media.de

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

Published by
Oemus Media AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de
www.oemus.com

Executive Producer
Gernot Meyer
meyer@oemus-media.de

Customer Service
Marius Mezger
m.mezger@oemus-media.de

Printed by
Messedruck Leipzig GmbH
An der Hebemärchte 6
04316 Leipzig, Germany

laser
international magazine of laser dentistry
is published in cooperation with the World Federation for Laser Dentistry (WFLD).
WFLD President
Prof Dr Norbert Gutknecht
University of Aachen Medical Faculty
Clinic of Conservative Dentistry
Pauwelsstr. 30
52074 Aachen, Germany
Tel.: +49 241 808964
Fax: +49 241 803389644
ngutknecht@ukaachen.de
www.wfld-org.info

Copyright Regulations
_laser international magazine of laser dentistry is published by Oemus Media AG and will appear in 2011 with one issue every quarter. The
magazine and all articles and illustrations therein are protected by copyright. Any utilization without the prior consent of editor and publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed
for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty
representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.

50 I laser
2_ 2011

[51] =>

laser
international magazine of

laser dentistry

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

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[52] =>

The Dual Wavelength Waterlase iPlus
Advancing Laser Technology to Its Ultimate

NCOMPARABLe
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• No Pain, Therefore No Shot Necessary
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• Best Ergonomic & Smallest Design

NTUiTiVe
GRAPhiCAL UseR iNTeRFACe

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POweR

• Cutting Speed that Surpasses the High
Speed Handpiece and Any Other Dental
Laser on the Market
• Cuts Faster and More Efficiently than
Lasers with More Power Watts
• Combines 0.5-10 Watts Power with 100 Hz
& Short Pulse for 600 mJ of Laser Energy
• Patented Laser Technology

LAse 940nm
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©2011

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• 5 Watts of Power with ComfortPulse
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) [page_count] => 52 [pdf_ping_data] => Array ( [page_count] => 52 [format] => PDF [width] => 595 [height] => 842 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => laser international No. 2, 2011

[toc] => Array ( [0] => Array ( [title] => Editorial [page] => 03 ) [1] => Array ( [title] => Content [page] => 04 ) [2] => Array ( [title] => Laser-assisted immediate implantation at infected site [page] => 06 ) [3] => Array ( [title] => Enamel alterations [page] => 12 ) [4] => Array ( [title] => Utilising laser technology [page] => 14 ) [5] => Array ( [title] => Treatment of gingival hyperpigmentation for aesthetic purposes using the diode laser [page] => 18 ) [6] => Array ( [title] => Diode-laser-assisted combination therapy of a lip haemangioma [page] => 20 ) [7] => Array ( [title] => Periodontitis therapy with 3 - 000% more power [page] => 23 ) [8] => Array ( [title] => The antibacterial effects of lasers in endodontics [page] => 26 ) [9] => Array ( [title] => TwinLightTM laserassisted endodontics [page] => 32 ) [10] => Array ( [title] => TouchWhiteTM Er:YAG laser-assisted Tooth Whitening [page] => 36 ) [11] => Array ( [title] => Infection control [page] => 40 ) [12] => Array ( [title] => New double-wavelength-laser— successful launch at IDS [page] => 42 ) [13] => Array ( [title] => The Joint Fellowship Course of Tehran and Aachen Universities [page] => 44 ) [14] => Array ( [title] => International events [page] => 45 ) [15] => Array ( [title] => XI Congress of SELO [page] => 46 ) [16] => Array ( [title] => Biggest IDS ever [page] => 48 ) [17] => Array ( [title] => Manufacturer News [page] => 49 ) [18] => Array ( [title] => about the publisher _ imprint [page] => 50 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

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