Han Sol Kim

Year V, Group16

Efficacy of laser in Periodontal treatment

Master’s Thesis

Renata Šadzevičienė
Gyd. periodontologė

Kaunas, 2017
 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
CLINIC (Periodontics)

Efficacy of laser in Periodontal treatment

Master’s Thesis

The thesis was done

by student ................................................ Supervisor ...............................................
(signature) (signature)

..................................................... ........................................................................
(name surname, year, group) (degree, name surname)

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(day/month) (day/month)

Kaunas, 2017
Abstract
Objective: Laser has been introduced to dentistry for decades. Aim of this review is to analyze and
evaluate the efficacy efficacy of laser in Periodontal treatment
Material and Methods: For this review, articles were searched by using PMC, PubMed and google
scholar search. Keywords used for searching is : laser, dental, laser in perio, CO2 laser, Er:YAG, Er,
Cr:YSGG, Low level laser therapy, periodontal laser, laser healing.
Conclusion: Research on laser for periodontal treatment is expected to increase and effective lasers
will be developed, Laser therapy is expected to gradually expand into an additional and alternative
treatment for periodontal treatment.
Keywards: Laser, dental, periodontal treatment.

SELECTION CRITERIA OF THE STUDIES. SEARCH METHODS AND STRATEGY

Protocol of systemic review
Selected protocol : Year, language, publication condition
Articles were selected by protocol, articles published in 10 year (2007~2017) and language with
English.
Information sources
Articles were searched and found in internet. By using PMC, PubMed and google scholar search
Articles were searched in year 2016,2017. And last time of search was in March of 2017
Key words used for searching was laser, dental, laser in perio, CO2 laser, Er:YAG, Er, Cr:YSGG,
Low level laser therapy, periodontal laser, laser healing.
Total 56 article were selected.
Inclusion criteria for the selection were:
 Methods were useful nowadays.
 Contents are related with laser and medicine
 Contents are related with laser and dental
 Contents are related with laser and periodontics
 Contents are related with laser and implant
 Contents are related with laser and tissue healing
Exclusion criteria for the selection were:
 Contents are related with laser and making implant
 Contents are related with laser and making dental tools
 Contents are related with laser and healing but in negative way
CONTENTS

1 Summary
2 Introduction
3 The Basics of Lasers
3.1 Introduction
3.2 History and use of laser in medicine
3.3 Use of laser in dentistry
3.4 Clinical application after knowing penetration depth
3.5 Factors affecting tissue absorption of laser light
4 Types and characteristics of laser used in periodontics
4.1 Introduction
4.2 Characteristics of the main lasers used in dentistry
4.2.1 CO2 laser
4.2.2 Nd:YAG laser
4.2.3 Er:YAG, Er,Cr:YSGG
4.2.4 Diode laser
4.2.5 Argon laser
5 Uses of laser in periodontal treatment
5.1 Non-surgical periodontal treatment using laser
5.2 Surgical periodontal treatment using laser
5.3 Periodontal surgery using laser
5.4 Implant using laser
6 Low level laser therapy in periodontal disease
6.1 History of low level laser therapy
6.2 Effect of low level laser therapy
6.3 Clinical use of low level laser therapy
6.4 Treatment and management after surgery
6.5 Use of low level laser therapy in periodontal disease
7 Conclusion
8 References
1. SUMMARY
Lasers have long been introduced into dental clinics.[1] In the past, lasers in the dental field have
mainly been mainly used for area of conservation such as polymerization of composite and in-office
bleaching. But recently, Erbium-based lasers such as Er: YAG, Er, Cr: YSGG, which can be used to
incise tissue without causing any thermal damage to the surrounding tissues, have been introduced.
into soft tissues as well as soft tissues.[2] As a result, the laser can be used not only for hard tissue
surgery such as teeth and alveolar bone but also for soft tissue surgery.[1] Therefore, the current
research on laser application in dentistry is proceeding in almost all dental fields including oral
surgery, prosthodontics as well as preservation area such as apical surgery, endo treatment,
treatment of hypersensitivity by fluid movement through dentinal tubules.[2,3,4] In this paper, the
latest papers on the types of lasers used in periodontics and laser applications in periodontics were
searched and sorted by themes, and understanding of them would be especially useful for those
interested in periodontics.

2. INTRODUCTION
It has been only about 30 years since the laser was commonly used in dentistry.[1] The first lasers
used in dentistry were CO2 laser and Nd: YAG laser, which can be applied only to the soft tissues
and low efficiency on hard tissue removal and causes thermal damage to tissue. But nowadays
Erbium series lasers that cans be used on hard tissue of the teeth with little heat damage to the
surrounding tissues, is being produced.[5,6] And also there are ultraviolet lasers that is capable of
selectively removal of only calculus.[5,6] Research on the application of laser in the field of
periodontics will develop with the development of laser technology. Therefore, the usefulness and
necessity of clinical application for this will be also increased. At this point it is very important to
understand the current status of the use of laser in the field of periodontal science.

3. The Basics of Lasers

3.1 Introduction
The theoretical background for lasers was established 100 years ago, the laser was first applied to
the extraction teeth 60 years ago, and the laser was commercialized in dental clinics for 30 years.[1]
In dentistry, lasers are not used as the sole remedy, but as an adjunct to other existing therapies. In
most dental treatments, patient co-operation is important. The noise from handpieces, bleeding
during treatment, and edema of the skin that interferes with normal pronunciation and mastication
are factors that interfere with the cooperation in dental treatment.[1] The laser used in the dentistry
has an effective cutting ability on the tooth hard tissue, and also it has a bleeding-free incision on
the soft tissue, as well as a disinfection effect which removes the bacteria. In addition, the low level
laser with low output increases cell activity and is used to activate biochemical factors related to
tissue healing, and it is also used for polymerize composite resin.[50]

3.2 History and use of laser in medicine

Lasers emit light of a single wavelength with strong intensity. The first laser, developed by Maiman
of IBM lab, used ruby crystals pumped with electrical energy as the activation medium. Various
lasers have been developed since solid ruby lasers. In 1961, a H2-Ne laser was developed in a bell
lab, and in 1962, the first diode laser was developed in the GE lab. In 1964, neo-dymium-doped
yttrium aluminum garnet lasers and CO2 lasers were developed at the bell lab.[1]
After the laser was developed, scholars such as Dr. Leon Goldman started a clinical study of the
action and coherence of the laser on living systems including humans. Initially, there was a variety
of problems such as power control and energy delivery. However, in the mid-1960s, ruby lasers
were used for retinal surgery. In 1964, Argon lasers were developed that were easy to manipulate
and absorbed by hemoglobin and successfully used in retinal surgery.[1]
In 1964, Nd: YAG lasers and CO2 lasers were developed in a bell lab in the United States. The
CO2 laser emits a continuous wave of 10,600nm wavelength that is well absorbed in water, the near
infrared region. Because the soft tissue is mostly composed of water, it is expected to be used for
soft tissue incision without bleeding. In the early 19th century, clinicians such as Dr. Tomas Polanyi
and Geza Jako successfully established ENT and Gynecologic surgery using CO2 laser, but they
were used only in university hospitals.[1]
In the early 1980s, more powerful and miniaturized lasers were used. Most of them were CO2 lasers
used for tissue dissection and Argon lasers used in ophthalmology. These second generation lasers
were all continuous wave systems and required long laser treatment experience to prevent non-
selective thermal damage.
A remarkable improvement in the medical use of lasers is the introduction of the concept of pulsing
into the laser beam. This allows selective treatment of abnormal and pathological tissues without
spreading to surrounding normal tissues.[1] The first laser with this concept of selective thermolysis
was a pulsed dye laser used in the treatment of port wine stains in children in the late 1980s and an
ultra short pulsed laser used for tattoo removal.[1]

3.3 Use of laser in dentistry

Maiman's Ruby laser was used on the extraction tooth in 1960, but until 1989 when the first dental
laser was introduced in the United States, the laser was not used in dentistry.[1] The first
commercially available dental laser in 1989 was a Nd: YAG pulsed laser produced by the American
dentist Dr. Terry Myers. It was not available to use for tooth hard tissues because of its low power,
but it was used in oral soft tissues and became popular among dentists.[4] In the early 1990s,
various lasers commercialized in the field of medical surgery were modified and introduced into
dentistry.[1] Lasers such as Nd: YAG, CO2, semiconductor diodes lasers, those used as dental
lasers had many problems such as low deletion efficiency and lethal effects on surrounding tissues
in application of dental hard tissue removal, which was the main purpose of dentists.
In 1989, Keller and Hibst confirmed that they were able to successfully remove enamel, dentin, and
alveolar bone in an experimental study using an Er: YAG laser. The laser was first marketed in the
UK in 1995. Er, Cr: YSGG lasers, which have similar effects, were developed in 1997.[1]

3.4 Clinical application after knowing penetration depth

Each lasers have different wavelength and penetration depth to tissue. It is a dangerous idea to get
into clinical practice without even understanding basic knowledge like this.Because of the different
penetration depths of the lasers, the response to the tissue as well as the reflection of the laser beam
from the tissue should be properly prepared. Therefore, both the patient and the surgeon are
encouraged to wear safety goggles, and it is also important to control access to unnecessary objects
or persons in the area of the procedure.
Particularly, in the case of a diode laser or a Nd: YAG laser, the penetration depth to the tissue is
several times larger than that of other lasers, and therefore, the reflected light can be increased.
Therefore, when using these lasers, special care should be taken with special care. .

3.5 Factors affecting tissue absorption of laser light

There are several factors affecting tissue absorption of laser light.
 Laser wavelength
 Tissue composition
 Tissue thickness
 Surface wetness
 Angle of beam
 Exposure time
 Contact mode of laser

4. Types and characteristics of laser used in periodontics

4.1 Introduction
Laser systems are divided into different types depending on the activation mass to activate the
photons. There are solid, gas, diode, excimer, and dye lasers.[1] Depending on the output of the
emitted energy, it may be classified as soft if it has low output and hard if it has high output.[4]
Depding on emission mode it can be differed in to continues wave and pulse wave, and the laser
which generates pulse waves due to the nature of the laser is free-running pulse laser there are ND:
YAG, Er: YAG, Er, Cr: YSGG. Also, there is a gated or chopped pulse that artificially generates
pulses by putting an opening / closing device at the front of a laser such as a diode laser or a Co2
laser that generates a continuous wave.[1,4] diode In the case of diode lasers, a very high frequency
pulse can be produced by adjusting the current applied to the diodes in a very short time period.[4]
When laser light reaches tissue, there are four phenomena: reflection, scattering absorption, and
transmission. Absorption occurs mainly through water, proteins, pigments and other
macromolecules.[4] Er:YAG and CO2 lasers are known to be safe and easy to use because most of
the energy is absorbed to the skin surface in response to moisture by having a long wavelength
range of far infrared rays in the middle infrared ray. They can be used for soft tissue, periodontal
treatment, and implant treatment.
Periodontal disease is a chronic inflammatory disease caused by bacterial infection. Therefore,
using a laser with a bactericidal, detoxicifying effect is very useful for the treatment of periodontal
disease.[4,6] The laser used for periodontal therapy functions to sterilize, remove infected tissues
without bleeding, and stimulate normal healing by biologically stimulating and activating cells and
tissues.[4,6] Therefore, it has advantages such as reduction of the depth of the periodontal pouch
and promotion of regeneration of the periodontal tissue, compared with the mechanical
treatment.[3,8] The laser also has little noise and vibration, which reduces pain during and after
surgery and result increasing patient satisfaction with treatment.[3] The clinical use of lasers for
periodontal therapy began in the 1980s using CO2 lasers and in the 1990s Nd: YAG laser was
stated to used.[3] With the development of erbium lasers, it became possible to use lasers in hard
tissue.

4.2 Characteristics of the main lasers used in dentistry

Table 1. Characteristics of Dental Lasers

Laser Type Wavelength Mode Application

Carbon Didoide 10 600 nm Pulse or

continuous- 1. Soft tissue ablation

wave 2.Gingival contouring for esthetic

purposes
3.Treatment of oral ulcerative lesions
4.Frenectomy and gingivectomy
5. Elimination of necrotic epithelial
 tissue during regenerative periodontal
surgeries

Neodymium:Aluminu 1064 nm Pulse 1. Root canal therapy: Helps eliminate

m-Yttrium-Garnet pathogenic microorganisms and debris
(Nd:YAG) from the root canal
2. Extensive periodontal surgery and
scaling to eliminate necrotic tissues and
pathogenic microorganisms
3. Caries removal
Erbium:YAG 2940 nm Pulse
(Er:YAG) 1. Caries removal
2. Cavity preparation in enamel and
dentin
3. Root canal preparation

Eriubm,Chromium:Yt Pulse 1. Enamel etching

trium-Scandium- 2780 nm 2. Caries removal
Gallium-Garnet 3. Cavity preparation
(ER,CR:YSGG) 4. Bone ablation without over-heating,
melting or changing the calcium and
phosphorus ratios
5. Root canal preparation
Argon 572 nm Pulse or
continuous- 1. Polymerization of restorative resin

wave materials
2. Tooth bleaching
3. Elimination of necrotic tissue and
gingival contouring
4.Treatment of oral lesions such as
recurrent aphthous ulcers or herpetic
lesions
5.Frenectomy and gingivectomy

Diode 810 or 980 Pulse or 1.Proliferation of fibroblasts and

 nm continuous- enhancing the healing of oral lesions or
wave surgical wounds
2.Frenectomy and gingivectomy
3. Correcting the gingival contouring for
esthetic purposes
Holmium:YAG 2100 nm Pulse 1. Gingival contouring
(Ho:YAG) 2. Treatment of oral lesions
3. Frenectomy and gingivectomy
J Lasers Med Sci. 2015 Summer; 6(3): 96–101.
Published online 2015 Jun 28. doi: 10.15171/jlms.2015.01

4.2.1 CO2 laser

The co2 laser emits a wavelength of 10,600 nm and has two modes: pulse wave and continuous
wave.[6,9] CO2 laser is far infrared ray that has long wavelength. It's characteristic is that it is
absorbed by water which is composed in living tissue.[6,9] Because it has a high extinction
coefficient for water, it is very effective for soft tissue incision with high water content. Compared
to scapel assisted surgery, CO2 laser allows for bloodless sterilization and fast tissue dissection
while minimizing tissue contraction and scar formation.
However, when the co2 laser is applied to the hard tissue, the temperature rises rapidly and many
carbides are generated with dissolved root and bone surfaces Thus, the healing of periodontal tissue
will be delayed and the hard tissue will not removed well. When the CO2 laser is used on the tooth
hard tissue, hydroxy apatite absorbs more energy of the wavelength of co2 laser than moisture, so
more energy is absorbed by hydroxy apatite and heat accumulates and does not cut-out hard tissue.
Therefore, Co2 lasers cannot be used for hard tissue.[4]

4.2.2 Nd:YAG laser

The Nd: YAG laser emits near-infrared wavelengths of 1,064 nm in FRP mode and is used for soft
tissue incision and soap disinfection of the periodontal pouch.[4,6] Nd:YAG laser is in infrared
region but because it is close to visible ray heat reaches deep inside, so it is known that they have a
potential danger of being exposed to heat, but they are easy to apply in the field of surgery. Unlike
CO2 laser or Er:YAG laser, the Nd: YAG laser has a low extinction coefficient for water and
penetrates deeply into the tissue, resulting in a haemostatic effect.[6] Therefore, when it is incident
on a living tissue, it is scattered rather than absorbed or transmitted to the deep layer. Because of
this high permeability, thermal stimulation may be given below the laser irradiation site, causing
heat damage to the dimensions or bone tissue. However, using low power can penetrate the deep
part of the skin compared with the other lasers are absorbed mostly on the surface, and can enhance
the tissue healing ability through the physiological phototactic activity of the deep part of the
periodontal tissue and the surrounding tissue. Nd: YAG lasers are strongly absorbed selectively in
certain pigments such as melanin and hemoglobin. Therefore, germs and becterica containing most
of these pigments can be removed.[6]

4.2.3 Er:YAG, Er,Cr:YSGG

Erbium lasers in use are Er: YAG, Er, and Cr: YSGG, both of which operate in FRP mode. Er:YAG
laser is known to be safe and easy to use because most of the energy is absorbed to the skin surface
in response to moisture by having a long wavelength range of far infrared rays in the middle
infrared ray. Er: YAG, Er, and Cr: YSGG lasers have excellent incision ability for both soft and
hard tissues while minimizing heat damage to tissues and are used for tartar removal, cavity
formation, and pathological root surface and alveolar bone It is the most widely used laser for
dental treatment including periodontal treatment.[11,12]
Er: YAG and Er, Cr: YSGG lasers have highly absorbed by water and hydroxyapatitie.[6,11,12 ]
This property makes these lasers good in cutting bone as well as soft tissue. And also because of it
penetrate tissue shallow, it's risk of giving thermal damage is minimal[13]

4.2.4 Diode laser

Most frequently used diode laser is Gallium-Aluminum-Arsenide(GaAlAs) laser that has 810nm
and Indium-Gallium-Arsenide(InGaAs) laser that was 980nm.[4] Because wavelength of diode
laser is short it is poorly absorbed by water and hard tissue.[15] This characteristic of penetrating
tissue is similar to Nd:YAG. Also diode laser can be produced in really small size with high power
and high frequency.[1] Diode lasers are capable of continuous wave and pulsed wave modes and
have hemostatic, coagulation, and incisional effects.

4.2.5 Argon laser

Argon laser uses argon ion gas as its lasing medium. Light emitted from an argon laser has a very
low absorbance to water.[4,15] The laser emits visible light at two wavelengths: 488 nm of blue and
514 nm of blue green.[15] On the other hand, it is well absorbed in pigmented tissues and
pigmented bacteria containing haemoglobin or melanin.[4,15] Argon lasers are used more
conservatively than periodontics, that it is used for polymerization of restorative resin materials and
in office teeth bleaching. Argon laser is also used for blood control in gingival surgery and
transillumination technique for finding cracks and decay on tooth surface. .[15]
5. Uses of laser in periodontal treatment
5.1 Non-surgical periodontal treatment using laser
The pathogenesis of periodontal disease and the method of treating it have rapidly developed in
recent 40 years. The contributing factors of periodontal disease are host pathogens, host immune
responses, and host risk factors that affect disease progression.[17] Pathogenic bacterial plaques
accumulated in susceptible hosts cause immune response and affect the inflammatory response,
connective tissue and bone metabolism.[17] Initial periodontal therapies include non-surgical
debridement of dental tissues, topical application of antimicrobials, host modulators, and laser-
assisted reduction of periodontal bacteria.
Risk factors affect both the onset and progression of periodontal disease and the depth of
periodontal disease. Periodontal disease is now known to be an infectious disease caused by the
presence of pathogenic bacteria, and host response to pathogenic bacteria also has a significant
impact.[17] Therefore, the treatment of periodontal disease should proceed with minimal side
effects and risks to the patient.
Soft tissue lasers are very useful for bacterial reduction and hemostasis during periodontal
treatment.[18] Soft tissue lasers include argon lasers, diode lasers, and Nd: YAG lasers, and the
light emitted by these lasers is absorbed by melanin, haemoglobin, or other pigments in tissues
affected by periodontal disease.[4] Because of the nature of these soft tissue lasers, soft tissue lasers
can be used as tools for periodontal pouches with periodontal tissue with pigmented bacteria and
dark implanted tissue.[4] In addition, since the laser energy is transferred to a flexible optical fiber
having a thin diameter of about 300 to 400 μm, the periodontal disease can be easily applied to the
affected periodontal pouch.[37] Laser light energy emitting short wavelengths is mostly transmitted
through the fluid in the periodontal pouch and is mainly absorbed by inflammatory tissues and
stained bacteria.
Another laser used for soft tissue treatment is Er, Cr: YSGG. The laser energy of the erbium series
is absorbed very well in water. Therefore, when using this laser, a large amount of energy is
absorbed by the moisture of the tissue surface.[37] Therefore, in order to apply energy to the tissue,
the optical fiber to which the laser is incident must be adhered to the target tissue. Er, Cr: YSGG
lasers have a remarkable bactericidal effect against P. gingivalis and A. actinomycetemcomitans,
which are important causative bacteria of periodontitis.[37]
The application of Nd: YAG laser to the periodontal pouch can be used as an adjunctive therapy
after mechanical debridement with currettes or ultrasonic scaler. One of the advantages of laser-
based periodontal therapy is the ability to debridement soft tissue surfaces that were not possible
with conventional mechanical debridement. [4] The Nd: YAG laser can be delivered by a very thin
and flexible optical fiber, so that the poket-lining epithelium in the periodontium can be vaporized
and decontaminated without causing carbonization or necrosis of the underlying connective
tissue.[37] Since the Nd: YAG laser is well absorbed by the pigment, it can effectively remove
pigmented bacteria such as Porphyromonas gingivalis, which cause periodontal disease [4,37]

5.2 Surgical periodontal treatment using laser

If the periodontal disease is severe, periodontal surgery should be used to debridement the tooth
surface, remove the pathological granulation tissue of the bone defect, correct the contour of the
alveolar bone, and sterilize the surgical site. Eliminating all pathological granulation tissue is a
necessary process for the regeneration of new bone tissue. [4] However, the instrument approach to
the floor and root apices of narrow infrabony defects is very difficult, inefficient, and time
consuming. [4] Hand chisels and handpieces used to alveolar bone can cause noise and vibration,
which can increase patient discomfort. [4] These instruments are also difficult to access over the
posterior teeth. [4]
Most surgical lasers significantly reduce the bacterial population at the surgical site, which is
because laser energy is absorbed by pigmented bacteria found in the oral tissues.[38] In addition,
the operation with laser is superior in the hemostatic function, and the need for wound closure is
reduced.
Erbium-based lasers are very useful for bone surgery. Other lasers can not remove bone tissue
because they have low absorbance to water. CO2 laser has a relatively high absorbance to water, but
it has more absorbance to inorganic crystal structures that make up bone than water. Which can
induce bone grafting and produce carbides.[4] However, erbium-based lasers are selectively
absorbed in water and can accurately eliminate bone tissue without microbio-explosion. In addition,
the erbium laser can accurately and effectively mold the osseous tissues in areas that are difficult to
access with conventional equipment, with little heat damage to the surrounding tissues, and the
postoperative healing process is also histologically advantageous.[4,39]
Firoozmand Reported that the Er: YAG laser was less heat-damaged than the handpiece when used
for the removal of teeth and alveolar bone during surgical periodontal surgery. [39] For the
incisions of 30 cows in which the thickness of the dentin was reduced to 2.0 mm using three
equipment, high speed high torque handpiece, high spped low torque handpiece and Er: YAG laser,
Class V cavity was formed under water cooling and then thermocouple is placed inside the pulp
chamber, which is connected to the computer to measure the temperature rise in the pulp chamber.
[39] The results were analyzed by using ANOVA and Turkey statistical method. Average
temperature rise was 1.92 0.80℃, 1.34 .86℃,0.75 0.39℃ in low-torque handpiece, high-
torque handpiece and Er: YAG laser. All three devices did not exceed the temperature-rising
threshold of 5.5 ° C, which would impair the dimensions. [39] It was also confirmed that the
increase of temperature was lowest when Er: YAG laser was used.[39]
Erbium lasers can be used to remove the granular tissue attached to the bone during conventional
periodontal procedures. There is little noise and vibration, and the post-operative healing process is
more beneficial. [4] A follow-up study of 3 years after Er: YAG laser treatment of chronic
periodontal disease showed that the depth of the periodontal ligament was decreased and the clinical
attachment level was higher than conventional widman flap surgery.[40]
Erbium-based lasers can be used to accurately cut soft tissue. [4] The incision is as sharp as using a
surgical knife and the healing rate is also very fast. [4] The Er: YAG laser can remove tartar and
lipopolysaccharides without dissolving the root and forming a carbonized layer on the root surface.
The Er: YAG laser removes pathological soft tissues and hard tissues of the root surface, as well as
removes pathological tissue of the root crown and infrabony pockets without damaging the tooth
surface. [4,40] Nd: YAG, Co2 lasers leave a layer of carbonation on the tooth surface that interferes
with the adhesion of fibroblasts. Er: YAG lasers form a smooth tooth surface with no carbonized
layer on the tooth surface, no smear layer, and form collagen matrix exposed root surface.

5.3 Periodontal surgery using laser

The laser is useful for securing the visual field of the surgical site by closing the soft tissues of the
oral cavity through an easy dissection and hemostatic action through blood coagulation and
instantaneously depriving the microvasculature through peripheral protein denaturation.[41] In
addition, the laser is more effective because it reduces the pain and swelling at the surgical site with
the sterilization effect, the tissue heals fast, and because the oral tissues, especially the gingivae, are
complex and narrow, making it difficult to access traditional scapel blades laser is more effective.
Laser-induced wounds are more advantageous in terms of histology than wound caused by surgical
knives. Most importantly, there are few myofibroblasts that cause tissue contraction and
hemorrhage during wound healing, Therefore it is very advantageous for restoration of the normal
function of the post-operative tissue, which is very important for active soft tissues such as labial
mucosa or platelets in esthetic dentistry.
A laser destroys all of the bacteria in a very low energy level. In addition, the possibility of
bacteremia after surgery is greatly reduced due to the closure of vessels and lymphatic vessels after
laser treatment.
Electrosurgery has a very rapid rate of soft tissue dissection and a too severe hemorrhage due to
hear at the site of application. In addition, when the depth of anesthesia is low, contacting with the
root surface will results in severe pain, and contact with the bone can cause osteonecrosis due to
heat. On the other hand, lasers can be used better in soft tissue surgery, reducing the risk of tissue
injury compared to electrosurgery.[41]
If the depth of the surgery is not deep, the laser can be used without local anesthesia to perform
painless surgery. There will be almost no pain by using Er: YAG or Er: Cr: YSGG laser with water
spray at the same time.[42] In addition, the laser can be used to heal even after the operation
without any suture or dressing after opening.[42]
Lasers can be used for a variety of soft tissue surgeries. The first is gingiva. In the case of gingival
hyperplasia such as epulis fissuratum due to gingival hyperplasia caused by use of calcium channel
blockers or poorly fitting dentures, an erbium-based laser can be used for clean incision without
hemorrhage and carbonization without anesthesia. The second is frenectomy. Excessive frenum
causes excessive tension in the organization, interferes with accurate pronunciation, and is not
aesthetic. The use of a laser also has the same advantages as gingival resection. The third is crown
enlargement. More accurate and delicate gingival formation is possible with laser than with electro-
surgical instruments. Er: YAG lasers can precisely cut soft tissues using a variety of delicate contact
tips, thus enabling safe and precise treatment of periodontal soft tissue aesthetics.[43] In addition,
incision of the alveolar bone may be included in case of simple incision of the gingiva. Since the
erbium-based laser can be incised to both the soft tissue and the hard tissue, it is possible to expand
the crown by removing the gingival and alveolar bone.[4]
Diodes, including Co2 lasers, and Nd: YAG lasers are used to effectively treat melanin pigment.
[44]However, because the lasers penetrate deeply into the light and have a large thermal effect,
gingival ulcers and gingival recession can occur when the gingiva is weakened. On the other hand,
Er: YAG laser can safely remove pigments such as metal tatto caused by metal components
penetrating into connective tissues during melamine and preprocessing of metal prostheses.

5.4 Implant using laser

The laser can be useful for everything from implant placement, to the treatment of oral soft tissue
incision, which is the second implant implant, and to the treatment of periplasmic implants, as well
as the entire period of implant placement and post-implant periodontal tissue management.[4] The
most important consideration in implant placement is that the temperature of the osteotomy site for
implant placement should not exceed 47 ℃. When the laser beam is irradiated to the bone tissue,
the light energy is converted into thermal energy at the irradiation site, so how much the
temperature of the irradiation site is increased is a very important factor in using the laser for
implant removal of the implant.[45] In addition, the possibility of damage to the implant surface
caused by laser irradiation should be confirmed.[45] Co2 and Nd: YAG lasers, which are the first
dental lasers, have low bone removal efficiency as well as excessive heat when applied to the
implantation process. Therefore, it damages the implant's bone tissue, destroys the viability of the
bone, and does not cause osseointegration between the bone and the implant.[4, 45] Making hole for
implant fixture on bone by using Er: YAG laser and Er,Cr:YSGG, compared with the conventional
method using drilling burs, was possible to obtain better osseointegration because there was not
much heat generated with less mechanical stress on the bone tissue.[46] Animal experiments have
shown that better tissue healing and stronger osseointegration occurs for implant fixture placement
with an erbium-based laser than traditional methods using drills.[46] Using a laser in the second
implant surgery has several advantages over the conventional scalpel method. The use of laser in
the second implant surgery allows painless surgery without anesthesia. There is no hemorrhage at
the surgical site, and there is little inconvenience to the patient after the operation.[45] The use of an
erbium-based laser can prevent both ambient heat damage and the formation of carbonized layers.[4]
Sohn reported the case of laser application in the maxillary sinus lift in 2009.[47] Twelve sinus
bone grafts were performed in ten patients through bone window osteotomy using Er:Cr:YSGG.[47]
Of the 12 patients, 8 did not puncture the sinus membrane (perforation rate 33.3%), and the mean
time taken for bony window osteotomy was 3.4 1.4 min, and all implanted implants were reported
to be successful.[47]
Implant periostitis is summarized as implant failure due to production of bacterial toxins causing
rapid destruction of osseointegration, inflammatory changes of periodontal tissue, and alveolar bone
loss.
A method of decontamination of the peri-implant pocket using a laser has been proposed for the
treatment of peri-implantitis. Utra sonic scalers, metallic hand scalers, and Nd: YAG lasers will
cause damage to the titanium surface of implants and should not be used in the treatment of peri-
implantitis. Co2, diode, and Er: YAG lasers can safely and effectively treat peri-implant diseases
such as mucositis and peri-implantitis.[4,48] Co2 lasers do not damage the surface of implants or
interfere with the attachment of osteoblasts. In the study, it was reported that the implant periostitis
is well healed with the bone regeneration after co2 laser treatment.[49]

7. Low level laser therapy in periodontal disease

Low level laser therapy, also known as therapeutic laser treatment, has a number of advantages. As
a nonsurgical method, it promotes tissue healing, reduces edema, inflammation, and pain.[50]

7.1 History of low level laser therapy

The healing effects of sunlight on a variety of diseases have long been recognized, and the current
treatment is referred to as heliotherapy. In 1903, Finsen received the Nobel Prize for his treatment
of lupus vulgaris using a carbon arc lamp. The first laser was developed by Theodore Maiman in
1960, in the late 1960s, Mester found that low-power ruby lasers and He-Ne lasers were not
carcinogenic and animal wounds healed more when used with this laser.[51] In the 1980s, clinical
applications for Low Level Laser Therapy began. Low Level Laser Theraphy has gained popularity
in Europe, Asia and South America, and cheap, high power GaA1As or GaAs lasers have been
used.[50]

6.2 Effect of low level laser therapy

Photobiostimulation of Low Level Laser Therapy uses red visible light and near infrared light to
reduce pain and promote healing.[51] Near infrared rays penetrate the skin several millimeters and
are used to stimulate deep tissue cells. Light energy is absorbed by the cellular photo receptors
present in cytochromophores, and the initial light energy is used to produce ATP in mitochondria
inside the cells.[52] As a result, the increased amount of ATP promotes the activity of cells such as
bifroblast, which helps to heal tissue. In addition, some of the incident light is converted to thermal
energy and promotes local bicro blood circulation through vasodilation. The effect of Low Level
Laser Therapy will be listed below.
 Proliferation of fibroblasts
 Proliferation of lymphocytes
 Proliferation of endothelial cells
 Proliferation ofkeratinocystes
 Proliferation ofmacrophages
 Increased cell respiration
 Increased ATP synthesis
 Transformation of fibroblasts into myofibroblasts
 Collagen synthesis
 Release of growth fators and other cytokines

In addition, Low Level Laser Therapy has been reported to increase the synthesis of endorphin and
bradykinin, reduce the activity of C-fibers involved in pain transmission and also induce an increase
in pain thresholds.[52]

6.3 Clinical use of low level laser therapy

It can be applied to dermatologic conditions such as wounnds, inflammations and neural ailments at
various sites. It can also be used for degeneration of various sites and for bone trauma with
pain.[53,54]
Table 2.
Soft and Hard Tissue applications of Low Level Laser Therapy
Soft Tissue Application Hard Tissue Application
Herpetic Lesions Temporomandibular Disorders
Aphthous/ Traumatic Ulcers Orthodontic Treatment
Post Oncology Mucositis Dentinal Hypersensitivity
Post Extraction Socket/ Post trauma Sites Bone Remodelling
Trigeminal Nueralgia Erosion
Periodontal Pocket Disinfection/Periodontitis Stimulatory effect on root development
Edema Implants
Sinusitis
Gag Reflex/ Nausea
Postsurgical Pain

Laser Ther. 2015 Oct 2; 24(3): 215–223.

doi: 10.5978/islsm.15-RA-01

Copyright 2015, Japan Medical Laser Laboratory [55]

6.4 Treatment and management after surgery

One method of postoperative therapy can provide the best health care for patients by using Low
Level Laser Therapy. Low Level Laser Therapy minimizes discomfort and pain after dental
treatment and shortens healing time.[50] In addition, use of low-level laser therapy for post-
operative treatment, Can be applied in for all dental treatments including conservative treatment,
prosthetic treatment, surgical/non-surgical neurology, surgical/non-surgical periodontal therapy,
implant treatment, oral surgery.[50]

6.5 Use of low level laser therapy in periodontal disease

Low-level laser therapy can be used to control the symptoms and condition of periodontal disease.
Anti-inflammatory action can slow or prevent periodontal damage and can help to maintain oral
hygiene by reducing edema by root planning, scaling, surgical flap, and curretage. Therefore,
healing is promoted and postoperative discomfort can be reduced.[51] In some studies, fibroblasts
were stimulated and the immune system became active.[51]
Herpes Simplex is a major lesion that is induced by human herpes virus type 1 and type 2 and prone
to recurrence and latency. Symptoms may include painful vescicles or erosions involving gingiva
and tongue mucosa, heat and mucous membranes in the mouth accompanied by painful lymph
nodes. Helium-Neon Low-energy laser or diode lasers have proven effective in reducing analgesic
and inflammation in vesicle patches. Laser radiation has been suggested to support the
interpretation of laser radiation in the treatment of herpes simplex labialis by promoting the
formation of blood vessels in regenerated tissues that are secreted into inflammatory tissues along
with reproductive chemical agents.[55]
Low level laser therapy is recommended for the treatment of aphthous or traumatic ulcers because
of analgesic effects and shortened healing times. This can interfere with Na-K pump in cell
membrane and serotonin releas. Diode laser is considered an effective and safe treatment for oral
ulcers.[55]
Mucositis is reported to be an inevitable aftereffect of radiation therapy or chemotherapy regimens.
It has been demonstrated that Low level laser therapy can be used effectively in these cases and
can reduce the incidence of inflammation and pain. It has been shown that He-Ne lasers or infrared
lasers are beneficial in providing immediate symptom relief to patients.[55]
Diode lasers have been used extensively in periodontal treatments to remove diseased pocket lining
epithelium and disinfect periodontal pockets with low levels of energy. Fiber optic delivery systems
with 200-320μm diameters allows easy access to periodontal pockets. The anti-inflammatory effects
of Low level laser therapy slow or stop the deterioration of periodontal tissue and reduce the
swelling of hygiene with other scaling, root planning, curettage or surgical treatment. Some studies
show that diode lasers have better healing power because they are more effective at removing
bacteria.[55]

7. CONCLUSIONS
Since the introduction of dental lasers, lasers have been used for preserving and curing complex
resin in areas, photo activated in office bleaching, and fluoroscopic examination of adjacent caries.
However, the development of Erbium-based lasers capable of removing hard tissues as well as soft
tissues has made it possible to perform soft tissue surgery, alveolar bone formation, gingival
associations, and by irradiating the inside of the periodontal pouch with a laser beam through a thin
optical fiber, it is possible to remove dental plaque and sterilization toxin inside the periodontal
pouch. Since the purchase price of lasers is high and most of the periodontal treatments are
available with mechanical treatments, there is not much use for periodontal treatment. However,
research on the practical effect of periodontal treatment of lasers is expected to increase and
effective lasers will be developed, Laser therapy is expected to gradually expand into an additional
and alternative treatment for periodontal treatment.

8. REFERENCES
1. s. parker introduction, history of lasers and laser light production. British dental journal
2007;202:21-31
2. Ishikawa I, Aoki A, Takasaki AA. Clinical application of erbium:YAG laser in periodontology. J
int Acad Periodontol. 2008:10(1):22-30
3. Schwarz F, Aoki A, Becker J, Sculean A. Laser application in non-surgical periodontal terapy: A
systematic review. J Cin Periodontol 2008:35(Suppl 8):29-44
4. Aoki A, Mizutani K, Takasaki AA, Sasaki KM, Nagai S, Schwarz F, Yoshida I, Eguro T, Zeredo
JL, Izumi Y. Current status of clinical laser application in periodontal therapy, Gen Dent.
2008:56(7):674-87
5. Korean Academy of dental science. Guideline for the Use of laser in dental practice 2016.01.
6. Romanos G. Current concepts in the use of lasers in periodontal and implant dentistry. Journal of
Indian Society of Periodontology. 2015;19(5):490-494. Doi:10.4103/0972-124X. 153471
7. Asnaashari M, Safavi N. Application of Low level Lasers in Dentistry (Endodontic). Journal of
Lasers in Medical Sciences. 2013;4(2):57-66.
8. Yukna RA, Carr RL, Evans GH. Histologic evaluation of an Nd:YAG laser-assisted new
attachment procedure in humans. Int J periodontics Restorative Dent 2007;27(6):577-587
9. Omi T, Numano K. The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology. Laser
Therapy. 2014;23(1):49-60. doi:10.5978/islsm.14-RE-01.
10. Valério RA, da Cunha VS, Galo R, et al. Influence of the Nd:YAG Laser Pulse Duration on the
Temperature of Primary Enamel. The Scientific World Journal. 2015;2015:396962.
doi:10.1155/2015/396962.
11. Stubinger S, Nuss K, Landes C, von Rechenberg B, Sader R. "Harvesting of intraoral
autogenous block grafts from the chin and ramus region: preliminary results with a variable square
pulse Er:YAG laser". Lasers Surg Med 2008;40:312–318.
12. Schwarz F, Olivier W, Herten M, Sager M, Chaker A, Becker J. "Influence of implant bed
preparation using an Er:YAG laser on the osseointegration of titanium implants: a
histomorphometrical study in dogs". J. Oral Rehabil. 2007;34:273–281
13. Perio DNDC. Periodontal Bone Regeneration and the Er,Cr:YSGG Laser: A Case Report. The
Open Dentistry Journal. 2013;7:16-19. doi:10.2174/1874210601307010016.
14. Nazemisalman B, Farsadeghi M, Sokhansanj M. Types of Lasers and Their Applications in
Pediatric Dentistry. Journal of Lasers in Medical Sciences. 2015;6(3):96-101.
doi:10.15171/jlms.2015.01.
15. Nalcaci R, Cokakoglu S. Lasers in orthodontics. European Journal of Dentistry. 2013;7(Suppl
1):S119-S125. doi:10.4103/1305-7456.119089.
16. Rezaei Y, Bagheri H, Esmaeilzadeh M. Effects of laser irradiation on caries prevention: J Lasers
Med Sci. 2011;2(4):159–164
17. SILVA N, ABUSLEME L, BRAVO D, et al. Host response mechanisms in periodontal
diseases. Journal of Applied Oral Science. 2015;23(3):329-355. doi:10.1590/1678-775720140259.
18. Polansky, R., Haas, M., Heschl, A. and Wimmer, G. (2009), Clinical effectiveness of
photodynamic therapy in the treatment of periodontitis. Journal of Clinical Periodontology, 36:
575–580. doi:10.1111/j.1600-051X.2009.01412.x
37. Schwarz, F., Aoki, A., Becker, J. and Sculean, A. (2008), Laser application in non-surgical
periodontal therapy: a systematic review. Journal of Clinical Periodontology, 35: 29–44.
doi:10.1111/j.1600-051X.2008.01259.x
38. Kranendonk, A., Van Der Reijden, W., Van Winkelhoff, A. and Van Der Weijden, G. (2010),
The bactericidal effect of a Genius® Nd:YAG laser. International Journal of Dental Hygiene, 8: 63–
67. doi:10.1111/j.1601-5037.2009.00375.x
39. L Firoozmand, R Faria, M.A. Araujo, R. di Nicolo, M.F. Huthala. Temperature rise in cavities
prepared by high and low torque handpieces and Er:YAG laser. British Dental Journal
2008:205(1)28-30
40. Gaspirc B, Skaleric U. Clinical evaluation of periodontoal surgical treatment with an Er:YAG
laser: 5-year results. J Periodontol 2007;78(10)1864-1871
41. Parker S. Laser-tissue interaction. Br Dent J. 2007;202(6):309-15.
42. Mizuno R, Ting C-C, Fukuda M. Clinical evaluation of Er,Cr:YSGG laser in the treatment of
oral soft disease. J Jpn Soc Laser Den 2008;19:17-25
43. Stübinger S. Advances in bone surgery: the Er:YAG laser in oral surgery and implant
dentistry. Clinical, Cosmetic and Investigational Dentistry. 2010;2:47-62.
44. Murthy MB, Kaur J, Das R. Treatment of gingival hyperpigmentation with rotary abrasive,
scalpel, and laser techniques: A case series. Journal of Indian Society of Periodontology.
2012;16(4):614-619. doi:10.4103/0972-124X.106933.
45. S. Parker. Surgical laser use in implantology and endodontics. British Dental Journal
2007;202:377-86
46. Schwarz F, Olivier W, Herten M, Sagar M, Chaker A, Becker J. Influence of impland bed
preparation using an Er:YAG laser on the osseointegration of titanium implants: A
histomorphometrical study in dogs. J Oral Rehabil 2007;34(4):273-281
47. Sohn Ds, Lee JS, An KM, Romanos GE. Er,Cr:YSGG(Erbium,chromium:yttrium-scandium-
garnet laser-assisted sinus graft procedure, Lasers in Medical Science 2009;24(4):673-7.
48. Ashnagar S, Nowzari H, Nokhbatolfoghahaei H, Yaghoub Zadeh B, Chiniforush N, Choukhachi
Zadeh N. Laser Treatment of Peri-Implantitis: A Literature Review. Journal of Lasers in Medical
Sciences. 2014;5(4):153-162.
49. Romanos, Georgios E., and Georg H. Nentwig. "Regenerative Therapy of Deep Peri-implant
Infrabony Defects After CO 2 Laser Implant Surface Decontamination." International Journal of
Periodontics & Restorative Dentistry 28.3 (2008).
50. S. Parker. Low-level laser use in dentistry. British Dental Journal 2007;202:131-138
51. Chung H, Dai T, Sharma SK, Huang Y-Y, Carroll JD, Hamblin MR. The Nuts and Bolts of
Low-level Laser (Light) Therapy. Annals of Biomedical Engineering. 2012;40(2):516-533.
doi:10.1007/s10439-011-0454-7.
52. Gao, Xuejuan, and Da Xing. "Molecular mechanisms of cell proliferation induced by low power
laser irradiation." Journal of biomedical science 16.1 (2009): 4.
53. Oberoi, Sapna, et al. "Effect of prophylactic low level laser therapy on oral mucositis: a
systematic review and meta-analysis." PloS one 9.9 (2014): e107418.
54. Avci, Pinar, et al. "Low-level laser (light) therapy (LLLT) in skin: stimulating, healing,
restoring." Seminars in cutaneous medicine and surgery. Vol. 32. No. 1. Frontline Medical
Communications, 2013.
55. Kathuria V, Dhillon JK, Kalra G. Low Level Laser Therapy: A Panacea for oral maladies. Laser
Therapy. 2015;24(3):215-223. doi:10.5978/islsm.15-RA-01.
56. Parker S. Laser-tissue interaction. Br Dent J. 2007;202(6):309-15