Clinical applications of dental lasers

Mitchell A. Lomke, DDS

A
ll dental lasers exert their
desired clinical eect on a
patients target tissue by a
process called absorption.
1
Tis
target may consist of hard tissue,
including natural tooth structure,
carious enamel and dentin, dental
calculus, bone, or even an existing
defective composite restoration
within the tooth. Many dierent
types of intraoral soft tissue targets
commonly are observed upon rou-
tine examination, such as redundant
gingival tissue, aberrant frenum,
operculum, epulus, or benign
lesions in the form of a broma or a
papilloma.
Dental lasers function by pro-
ducing waves of photons (quanta
of light) that are specic to each
laser wavelength.
2
Tis photonic
absorption within the target tissue
results in an intracellular and/or
intercellular change to produce the
desired result.
Dental lasers may be separated
into three basic groups: soft tissue
lasers, hard tissue lasers, and non-
surgical devices such as diagnostic/
composite and photodisinfection
lasers. Tis article will provide
details on each of these laser
classication groups; however, it
also is important to be familiar
with the common terms related to
dental lasers.
Chromophore refers to the
substance or quality within a
specic target tissue that serves as
an attractant for a laser photon.
3

Tis photonic absorption within a
target tissues chromophore is the
basis for a dental lasers functional
dynamic process, referred to as a
laser/tissue interaction.
1
Nearly all
surgical dental lasers function via
this wavelength-specic photonic
absorption, which causes the
temperature within the target tissue
cells to increase very rapidly to an
evaporative state. Tese dental lasers
cut tissue by a functional process
known as a photothermal interaction
or photothermal ablation.
2

A typical example is the clinical
use of a diode, a laser that is utilized
in dentistry to treat soft tissue only.
3

Te chromophore of diode lasers
is pigmented (or colored) tissues,
specically melanin, hemoglobin
(Hb), and oxyhemoglobin.
3
Te
diode is ecient for treating a
patients soft tissues because gingival
tissues have a concentration of these
chromophores; as a result, a diode
photon has a high anity for gingi-
val tissues. Diode lasers are used in
contact with a patients soft tissue to
perform common dental procedures
such as gingivectomies or soft tissue
lesion (broma) removal.
4
Dental lasers oer a number of
clinical advantages (especially for
soft tissues), including hemostasis
(the sealing of local vasculature),
the ability to seal nerve endings and
lymphatic vessels, reduced post-
operative pain and swelling (thus
reducing the need for postoperative
analgesics/narcotics), reduced
bacterial counts, and a minimized
need for sutures in most surgical
procedures.
5

Although clinicians can control
some of the factors that aect laser/
tissue interactions, two factors
remain independent of the operator:
the unique characteristics of the
laser wavelengths emissions and the
qualities inherent within the specic
target tissue.
Among the factors that clinicians
can control are the power setting of
the laser (power density), the total
power delivered over a given surface
area (energy density or uence), the
rate and duration of exposure (con-
tinuous versus pulsed, and pulse
duration and repetition), and the
method by which energy is delivered
to the target tissue (contact versus
non-contact).
6
In fact, clinicians will
have precise control over the laser
to achieve the desired tissue eect
by adjusting any of four variables
(power, spot size, total treatment
time, and repetition rate).
2

For example, when an area of
inammatory tissue and an equiva-
lent volumetric area of brotic tissue
are treated with a diode laser at the
same power setting, two very dier-
ent interactions will occur. Te laser
will cut the brotic tissue at a far
Dental lasers currently have 24 clinical indications for use that are
recognized by the FDA. This article explores the scientic basis
for these clinical indications in patient diagnosis and treatment.
Multiple examples of relevant clinical applications for these
wavelengths are explored in detail and illustrated via clinical
photographs.
Received: April 1, 2008
Accepted: June 20, 2008
www.agd.org General Dentistry January/February 2009 47
Laser Therapy
slower rate, as there is more collagen
in the thicker dermal layer, which
scatters the diodes energy and
prevents that energy from reaching
the underlying blood vessels. Con-
versely, the laser will cut the inam-
matory tissue much faster because of
the higher concentration of Hb-rich
red blood cells (RBCs).
Using the same laser power setting
and decreasing the diameter of the
laser tip used (spot size) by 50%
(for example, from 1.0 mm to 0.5
mm) will cause the power density
exerted on the target to quadruple,
due to the inverse square rule.
2

Clinicians should understand that
by using a smaller diameter laser tip
(and increasing the power density
to the target as a result), the rate of
ablation will increase dramatically.
Te clinical technique will need to
be adjusted accordingly by either
defocusing the beam (moving the
tip farther away from the target) or
decreasing the lasers power setting.
Te dental laser wavelengths used
most commonly are located within
the near, mid, and far infrared
portions of the electromagnetic
spectrum (EMS).
2
Within these spe-
cic areas of the EMS, the photons
emitted by these lasers are an invis-
ible, non-ionizing, non-mutagenic
type of radiation.
6
Tese laser
wavelengths are clinically eective
when they are used at proper power
settings by trained hands.
Dentists should always use the
lowest possible power setting to
achieve the intended treatment
objective.
2
Merely increasing a lasers
power settings will not necessarily
cut tissue faster or more eciently;
in fact, it can cause an adverse result
or even lead to treatment failure.
Using too much power unnecessar-
ily will increase the target tissues
temperature too rapidly and by too
much, resulting in collateral thermal
damage.
1
Tis eect can manifest
as tissue necrosis and/or sloughing
of tissue due to the wide zone of
edema that has been created. Tese
complications defeat the clinical
advantage for using a dental laser:
to achieve treatment goals in a more
eective and conservative manner
(due to the laser's specic ablative
capacity) than conventional instru-
mentation would allow.
Lasers are named according to
the chemical elements or molecules
that make up their core (also known
as the active medium).
2
Te active
medium serves to retain a specic
lasers dopant ions and may consist
of a man-made crystal rod, a gas, or
a semi-conductor.
2
When reading
a free-running pulsed laser wave-
lengths specic name, the elements
to the left of the colon refer to the
dopant ions; the elements to the
right of the colon are its active
medium.
2
For example, an Er:YAG
laser includes a crystal rod active
medium consisting of yttrium, alu-
minum, and garnet (YAG), which
is doped (or externally coated) with
a layer of erbium ions. Examples
of other dopant ions used in lasers
include chromium (Cr), neodynium
(Nd), and holmium (Ho). Te
dopant ion within a free-running
pulsed laser produces a specic
wavelength. Diode lasers use a semi-
conductor containing aluminum (or
indium), gallium, and arsenide as its
active medium.
6

Currently, the only gas laser
used in dentistry is carbon dioxide
(CO
2
), whose active medium is a
tube lled with a mixture of CO
2
,
nitrogen (N), helium (He), and
neon (Ne) gases. Tis laser uses a
beam of energy that lases soft tissue
in a non-contact mode.
2
In the past,
CO
2
laser models were superpulsed
or millipulsed machines that
measured pulses by 10
-3
seconds.
By contrast, the newer micropulsed
CO
2
lasers pulses are measured
in 10
-6
seconds, which is 1,000
times faster. Te newer ultrafast,
micropulsed CO
2
lasers are capable
of ablating soft tissue without
charring.
7
(Charring is dened as
the carbonization of a patients
tissues, which happens when they
are heated to temperatures above
200C.) Te newer CO
2
lasers can
deliver more power to the intended
target with shorter pulse intervals,
making more ecient ablative
eects with less potential for col-
lateral thermal damage to adjacent
tissues.
Te FDA has four dierent laser
classes, based on the potential
danger posed by the lasers within
each class as a result of their inher-
ent power. Most lasers used in den-
tistry are considered Class IV lasers.
2
Tese lasers require eye protection
(in the form of safety glasses) for the
patient, the dentist, and the assisting
stain short, anyone located with
the Nominal Hazard Zone.
2
Tese
safety glasses must be wavelength-
specic and must have protective
side shields and a specic optic
density.
2
Failure to use proper eye
protection could cause severe and
possibly irreversible eye damage.
2
Clinical laser applications
Conventional dentistry involves
using rigid metal or diamond
instruments to drill, cut, or abrade
hard and soft tissues. Traditional
dental treatment is recognized as
the process of removing infected
or pathologic tissue by either drill-
ing or cutting away the diseased
component.
2
Dental lasers can
be used to cut, incise, and ablate
hard and soft tissues. Te inherent
properties of laser lightsuch as
selective absorption, coagulation,
sterilization, and stimulatory eects
on vital structuresmake lasers the
treatment of choice in certain clini-
cal scenarios.
2

48 January/February 2009 General Dentistry www.agd.org
Laser Therapy Clinical applications of dental lasers
Proper clinical technique is
extremely important when lasing a
patients oral tissues. It is strongly
recommended that the operator
use proper magnication and illu-
mination to assess the treatments
progress accurately and determine
that photothermal ablation is occur-
ring. A denitive color change will
be observed at the initial moment
of tissue ablation; at that point, the
clinician should move the laser tip in
a slow and deliberate paint brush-
ing motion that corresponds to the
patients specic tissues, always evalu-
ating the laser/tissue interaction to
obtain the optimal result. Many new
laser users make the common error
of using a fast and constant painting
motion and moving the beam too
quickly; this improper technique will
not allow proper ablation to occur.
Electrosurgery, or electrocautery,
is not absorption-specic within a
target tissue; as a result, extremely
high temperatures are created within
the tissue mass to produce a desired
clinical eect known as fulguration.
Electrosurgical techniques used at
present for tissue ablation are unable
to control the depth of necrosis in
the tissue being treated. Most electro-
surgical devices rely on the creation
of an electric arc (between the
treating electrode and the tissue that
is being cut or ablated) to cause the
desired localized heating. Tese high
temperatures cause a depth of necro-
sis of more than 500 m (often more
than 800 m and sometimes as high
as 1,700 m); the inability to control
such depth of necrosis is a signicant
disadvantage to using electrosurgi-
cal techniques for tissue ablation.
8

Lasers do not suer from electrical
shorting in conductive environments
and certain types of lasers allow for
very controlled cutting with limited
depth of necrosis, due to their inher-
ent ability to absorb chromophores
within a specic target tissue.
For the purpose of this article,
clinical applications for lasers in
dentistry are separated into three
dierent groups: soft tissue treat-
ment, hard tissue treatment, and
non-surgical treatment.
Soft tissue lasers
Overall, dental lasers are relatively
easy to use, as long as the clini-
cian has been trained properly. It
is important to understand that
lasers function with an end cut-
ting action (that is, laser energy is
emitted from the end of the laser),
while most other dental instruments
are side cutting, with the cutting
edges or abrasive surfaces located on
the lateral surface. Although most
laser soft tissue treatments heal by
secondary intention, the postopera-
tive course usually is uneventful.
9

Most laser excisional or incisional
procedures are accomplished at
100C, where vaporization of intra-
and extracellular water causes abla-
tion or removes biological tissue.
Clinicians must be wary of the heat
generated within tissues during a
procedure. If the tissue temperature
exceeds 200C during a lasing pro-
cedure, carbonization and irrevers-
ible tissue necrosis will occur.
6
Tis
adverse consequence can be avoided
completely by using the lowest
power setting necessary to achieve
the desired treatment goal.
Tere are specic soft tissue indi-
cations for the clinical use of lasers,
including anterior gingival esthetic
recontouring, gingivectomy/gin-
givoplasty (for crown lengthening
procedures), operculectomy, removal
of epuli, incisions when laying a
ap, incision and drainage proce-
dures, frenectomy, vestibuloplasty,
coagulation of extraction sites,
treatment of herpetic and recurrent
aphthous ulcer lesions, uncovering
of an implant, pre-impression sul-
cular retraction, and ablation of an
intraosseous dental pathology (such
as a granuloma or an abscess). Other
excisional laser procedures involve
the removal of soft tissue targets that
may appear as benign lesions (such
as bromas or papillomas) on the
lip, tongue, buccal mucosa, or pala-
tal area; the removal of coronal pulp
as an adjunct to root canal therapy;
excisional biopsy; and sulcular deb-
ridement.
4

Diode (810 nm, 940 nm, 980 nm,
1,064 nm), Nd:YAG (1,064 nm),
CO
2

(10,600 nm), Er:YAG (2,940
nm), Er,Cr:YSGG (2,780 nm), and
potassium-titanyl-phosphate (KTP)
(532 nm) lasers are the wavelengths
used most commonly for soft tissue
procedures.
2
Diode and Nd:YAG
lasers are alike in that these lasers are
absorbed in pigmented tissues (mela-
nin and Hb) and both wavelengths
are transmitted to their targets in
contact with a thin exible quartz
ber. CO
2
laser energy is absorbed
in the target tissues water content
and transmitted to the intended
target using a hollow waveguide or
an articulated arm. Erbium laser
energy is transmitted to the intended
target tissue by a clear sapphire
or quartz tip, either in contact or
approximately 0.5 mm from the
target.
2
Each wavelength has its own
unique interactive qualities and a
dierent clinical feel that operators
must experience to attain a certain
comfort level.
A soft tissue crown lengthening
procedure can be accomplished by
using any of the laser wavelengths
mentioned above. Figures 1 and 2
demonstrate the degree of accurate
visibility on the preparations nish
lines that can be achieved with this
technique.
Lasers also make it possible to
combine two or more separate proce-
dures into one appointment. It is not
unusual to see the need for perio-
dontal correction after a defective
www.agd.org General Dentistry January/February 2009 49
Fig. 1. An example of inamed, hypertrophied
gingival tissues.
Fig. 2. The patient in Figure 1, after crown
lengthening with a diode laser.
Fig. 3. A 45-year-old woman with an aberrant
frenum pull.
Fig. 5. The patient in Figure 3, three weeks
postsurgery.
Fig. 6. Marginal detail in an impression taken
after Er:YAG treatment.
crown or other restoration has been
removed. Lasers oer tremendous
advantages in terms of precision
cutting and hemostasis; as a result,
tooth preparation, periodontal cor-
rection, and nal impressions can be
combined into one appointment
and the nal restoration can be
inserted at the following appoint-
ment. Of course, the ability to
accomplish all three steps in a single
visit depends on the dentists level of
expertise and the patients tolerance.
A diode laser can be used for clini-
cal scenarios in which an aberrant
frenum pull causes recession and a
loss of attached gingiva. In one case,
a 45-year-old woman sought treat-
ment for an aberrant frenum pull
in the mandibular anterior region
(Fig. 3). After proper debridement
of the roots to remove any residual
calculus, the diode laser was used
to ablate the aberrant frenum. Te
laser incision was widened carefully
by dissecting the underlying tissue
bers to remove any tension (or
pull) still on the remaining zone of
keratinized tissue (Fig. 4). Te ten-
sion from the aberrant frenum was
released and the zone of attached
gingiva increased. Te concomitant
increase in available vestibular
depth improved the patients access
to daily proper plaque control,
improving the overall prognosis for
long-term retention of her anterior
mandibular teeth (Fig. 5).
Te author has used an Er:YAG
laser to dessicate the marginal gin-
gival tissues adjacent to vital nish
lines prior to taking nal crown and
bridge impressions. Tis technique
is especially valuable for clinical
scenarios in which laser periodontal
correction has been completed and
the gingival tissues are still moist
with minor bleeding or sulcular
uid that can ruin the nal impres-
sion. Te lasers water spray must
be turned o and the energy setting
reduced to a very low range (1,000
sapphire tip, 100200 mJ with a
repetition rate of 12 Hz). Tis tech-
nique takes advantage of erbiums
photonic anity for water mole-
cules. Te water spray is turned o
during this procedure, allowing the
patient to absorb the erbium pho-
tons via the water in their tissues.
Te Er:YAGs sapphire tip is moved
carefully (slightly out-of-contact)
around the gingival sulcular areas in
a circumferential motion. Te uids
around the tooth preparations nish
lines evaporate, leaving these areas
with a dry, opaque, whitish surface,
which enhances the quality of the
nal impression (Fig. 6).
Fig. 4. The patient in Figure 3, immediately fol-
lowing a diode laser frenectomy/vestibuloplasty.
50 January/February 2009 General Dentistry www.agd.org
Laser Therapy Clinical applications of dental lasers
Soft tissue lasers make precision
control possible, even when clinical
access is very dicult. Figures 7
and 8 illustrate a case involving a
21-year-old woman with a healing
cap that had come loose from an
aberrantly placed implant in the
maxillary anterior region, where
there was little or no discernable
vestibular depth. A millipulsed CO
2

laser was used carefully to dissect the
overgrowth of redundant gingival
tissue and expose the underlying
implant platform so that the nal
impression could be taken. It is
important to direct the laser tips
emissions away from the implant
platform to avoid possible negative
thermal eects on the supporting
bone. CO
2
laser photons are not
readily absorbed in the titanium
composition of the implant. To
avoid possible thermal damage,
always be careful to avoid contact
with either the implant or the sur-
rounding bone.
10
In some clinical cases, the author
has found that using dierent laser
wavelengths in combination can
achieve a more predictable level of
care. In one case, a 15-year-old girl
who had recently completed ortho-
dontic treatment had both a high
maxillary anterior midline frenum
attachment and an excessive
overgrowth of keratinized tissue,
preventing proper exposure of
the clinical crowns on teeth No.
8 and 9 (Fig. 9). A CO
2
laser was
used to perform the extensive
frenectomy and a diode laser
was used to perform the gingival
esthetic recontouring. Outstanding
hemostasis was attained and the
lasers precise cutting ability made
it possible to preserve the original
peak of the interdental papilla
(Fig. 10). One month later, the
patient demonstrated outstanding
healing and no appreciable wound
contraction (Fig. 11).
Many adolescent patients suer
from ankyloglossia, in which the
existing heavy lingual frenum
attachment prevents normal
functioning. Tese patients often
are introverted because they have
diculty with normal speech. Fig-
ures 1216 show a 13-year-old girl
with excessive frena both superior
and inferior to Whartons duct,
which prevented a normal range
of lingual protrusion. Micropulsed
CO
2
lasers have a unique ability
to ablate soft tissues accurately
with char-free power settings (30
Hz, 300 mJ), resulting in minimal
collateral thermal damage.
11
Tere
was little or no bleeding during
the procedure and suturing was
contraindicated, as healing from
this technique occurs via secondary
intention. In the present case, heal-
ing was excellent and the patients
range of motion was increased
greatly. Tis patients speech
improved so much that her parents
reported a dramatic and positive
change in her personality.
Te author has used diode lasers
Fig. 7. A patient with redundant tissue under a
loosened implant healing cap.
Fig. 8. The patient in Figure 7, following laser
ablation.
Fig. 9. A preoperative view of a 15-year-old girl
with excessive overgrowth of keratinized tissue.
Fig. 11. The patient in Figure 9, after healing
was complete.
Fig. 10. The patient in Figure 9, immediately
following a CO2 laser frenectomy and diode
laser recontouring.
www.agd.org General Dentistry January/February 2009 51
Fig. 12. A 13-year-old
patient with ankyloglos-
sia. Note excessive frena
superior and inferior to
Whartons duct.
Fig. 13. A
preoperative view of
the patient in Figure
12. Note the tongue
protrusion.
Fig. 14. An immediate
postoperative view of the
patient in Figure 12.
Fig. 15. The patient in Figure 12,
5.5 weeks postoperatively.
Fig. 16. A post-
treatment view of
the patient in Figure
12 with enhanced
tongue protrusion
and mobility.
Fig. 17. The bleeding pulp chamber of a maxil-
lary molar undergoing endodontic treatment.
Fig. 18. A diode laser is used to ablate the
diseased intrapulpal tissue.
Fig. 19. The patient in Figure 17, after laser
ablation.
as an adjunctive tool during the
initial phase of endodontic therapy.
During routine endodontic proce-
dures, the 810 nm diode laser can
be used to eliminate bleeding from
the pulp chamber.
12
Tis process
takes advantage of the diode lasers
inherent hemostatic action and
bacteriocidal properties and aids
with overall healing. Tis procedure
should be done at a lower power
setting (2 W, .1/.1 repeat pulse
mode) in a wet eld with water
only. Te case can be completed
with conventional endodontic
instrumentation and obturation;
Figures 1719 show this procedure
used during routine endodontic
therapy for a maxillary molar. Te
hemostatic advantage of the diode
lasers photonic interaction with the
inamed intrapulpal tissue results
in a clean, dry eld.
Lasers can be a useful treatment
modality for excisional biopsies
of benign soft tissue lesions in the
oral cavity. After local anesthesia
is administered, the lesion is
outlined with the diode, Nd:YAG,
Er:YAG, Er:YSGG, or CO
2
laser
to attain sound tissue margins.
At that point, retraction pressure
is applied, either by using a tissue
forceps or by placing a single suture
into the lesion and applying retrac-
tion to visualize the lesions base.
Te lasers ablative beam is directed
at the lesions base rather than at
the lesion itself. Te lesion literally
will peel away from the base tissue
until it releases completely, with
little or no bleeding. All specimens
should be sent to a pathology labo-
ratory for analysis; the pathologist
should be informed when a laser
has been used for a biopsy. Normal
sensation returns to the treatment
zone within the natural course of
tissue healing.
Figures 2023 illustrate how lasers
were used to remove a traumatic
broma from the midline of the
tongue of a 52-year-old man. Tere
was total hemostasis during the pro-
cedures and no scar formation.
Te author also has used lasers for
operculectomies. A 12-year-old boy
52 January/February 2009 General Dentistry www.agd.org
Laser Therapy Clinical applications of dental lasers
had moderate pericoronitis around
the operculum of unerupted tooth
No. 18 (distal to orthodontically
banded tooth No. 19) (Fig. 24).
Te redundant soft tissue ap was
ablated with a CO
2
laser, surgically
exposing tooth No. 18 and faciliat-
ing its proper eruption (Fig. 25). In
addition, the lasers unique bacte-
riocidal ability reduced the resident
pathogens within the infected
pericoronal zone (Fig. 26).
Lasers can be used when perform-
ing anterior gingival periodontal
correction in conjunction with
prosthetics in the esthetic zone.
Many procedures can be done
without laying a full-thickness ap,
provided that an adequate zone
of keratinized tissue exists and
the biologic width of attachment
is not violated. In one case (Fig.
2729), a 68-year-old woman had
defective, ill-tting prosthetics that
Fig. 20. A 52-year-old man with a
traumatic broma located on the
mid-dorsum of the tongue just to
the right side of the midline.
Fig. 21. An example of the diode
laser outlining technique.
Fig. 22. The excisional biopsy is
completed with total hemostasis.
Fig. 23. The patient in Figure
20, four weeks after treatment.
Note complete healing and no
scarring.
Fig. 27. The defective, ill-tting prosthetics of a 68-year-old woman. Fig. 28. Diode laser-assisted soft tissue crown lengthening is performed.
Fig. 24. A 12-year-old boy with moderate to
severe pericoronitis around the operculum of
tooth No. 18.
Fig. 25. The patient in Figure 24, after a CO2
laser operculectomy.
Fig. 26. An intraoral view of the patient in
Figure 24, six months postsurgery. Note that
tooth No. 18 is fully erupted.
www.agd.org General Dentistry January/February 2009 53
Fig. 29. A retracted postoperative view of the patient in Figure 27.
she wished to replace. Te anterior
crowns on teeth No. 710 were
removed, revealing recurrent caries,
periodontal disease, and inadequate
preparation height to support the
replacement ceramic crowns. Te
remaining roots were scaled thor-
oughly to remove residual calculus.
All remaining recurrent decay was
eradicated and the supporting core
buildups were redone. A diode laser
was used to perform a crown length-
ening procedure to increase the clin-
ical crown height of the nal crown
preparations and to predictably and
precisely recontour the existing bul-
bous gingival tissue architecture. Te
result was excellent gingival healing
that allowed for a dramatic improve-
ment in the esthetic appearance of
the nal prosthesis.
Hard tissue lasers
At present, erbium lasers are the
only hard tissue laser wavelengths
available commercially. Te main
chromophore for erbium lasers is
water, although they also are well-
absorbed in carbonated hydroxyapa-
tite, a component of natural tooth
structure and bone. Tese inherent
absorption qualities allow erbium
lasers to ablate tooth and bone.
Erbium lasers are unique in that
they are the only lasers that can
cut both hard and soft tissues.
2
Te
erbium lasers ability to remove
composite restorations is due to
their photonic absorption in the
water that exists within all compos-
ite restorations. Hard tissue abla-
tion results from microevaporative
expansive events that occur within
the target due to an extremely
rapid buildup of heat and sponta-
neous evaporation of the available
water content. Tis process also is
referred to as a thermomechanical
eect due to the pressure buildup
involved.
1
Tis type of laser/tissue
interaction results in a characteris-
tic popping sound. In the authors
experience, most patients prefer
this popping sound to the whirring
of the dental drill.
In certain clinical cases, an
erbium laser can be used to remove
a defective composite restoration,
eradicate recurrent decay found
underneath, and perform any soft/
hard tissue crown lengthening that
may be necessary. Figures 3032
illustrate how an erbium laser was
used to remove the decay from a
Fig. 30. A Class V abfractive defect with recurrent caries.
Fig. 31. Er:YAG laser ablation is used to remove decay and initially etch
the tooth defect area.
Fig. 32. The nal composite restoration was cured into place.
54 January/February 2009 General Dentistry www.agd.org
Laser Therapy Clinical applications of dental lasers
Class V abfractive lesion prior to
placing the composite bonding
restoration. In Figures 33 and 34,
an Er:YAG laser was used con-
servatively to remove an existing
composite from the distal aspect of
tooth No. 7. Te tooth was restored
(using composite bonding) to its
proper contour (Fig. 35).
An Er:YAG laser allows for
conservation of sound tooth struc-
ture, even in cases where an existing
composite restoration needs to be
removed and extended interproxi-
mally. An 18-year-old woman had a
defective composite restoration on
tooth No. 30 (Fig. 36) and recur-
rent distal decay that was evident
on the preoperative radiograph (Fig.
37). Te Er:YAG laser was used to
remove the defective composite res-
toration and ablate the distal carious
lesion while a tunneling technique
(in which the lasers sapphire tip
was angled directly toward the distal
carious lesion) was used to preserve
the tooths distal marginal ridge
(Fig. 38). A sectional matrix band
was placed to protect the integrity
of the adjacent tooths mesial
surface and to help restore the
tooths natural contour, both during
condensation and while curing
the nal composite with an LED
device. A postoperative radiograph
conrmed the proper condensation
of the composite ll, as there was
no evidence of voids and the distal
marginal ridge of this tooth was
preserved (Fig. 39).
As a provisional service for
patients in certain clinical scenarios,
it is possible to use the erbium laser
to remove recurrent decay around
accessible defective margins and
repair these areas with composite
cured with an LED, rather than
removing an extensive restoration
completely. Te LED curing light
used in this case emits a blue light
that is absorbed in camphorqui-
none, the photoactivator in most
Fig. 33. A patient with a defective composite
on tooth No. 7.
Fig. 34. The patient in Figure 33, after the
composite was removed with an Er:YAG laser.
Fig. 35. A lingual view of the patient after
receiving a complete composite restoration.
Fig. 36. A radiograph of an 18-year-old woman
with a defective composite restoration on
tooth No. 30.
Fig. 37. An occlusal view of the defective
restoration on tooth No. 30.
Fig. 38. The lasers sapphire tip is angled,
allowing it to tunnel under the distal marginal
ridge.
Fig. 39. A postoperative radiograph of the
patient in Figure 36.
www.agd.org General Dentistry January/February 2009 55
composite materials. Figures 4042
illustrate a case in which the Er:YAG
laser was used to remove recurrent
caries prior to repairing a composite.
When performing a bony pro-
cedure (such as an osteoplasty or
ostectomy), it is imperative to use
less power (1,000 sapphire tip,
500550 mJ, 12 Hz) than would
be used when cutting enamel; in
addition, a copious amount of
water spray must be used to avoid
overexposing the bone to erbium
irradiation and the resultant unde-
sirable sequelae of bony necrosis,
sloughing, and delayed healing.
2
Te Er:YAG laser can be eective
for clinical cases that involve full-
thickness aps and osseous recon-
touring. Figures 4347 illustrate a
case in which the full-thickness ap
was initiated by using the Er:YAG
laser to make the initial sulcular
incision and thus gain access to the
underlying pathology. Te internal
aspect of the soft tissue ap was
debrided thoroughly and the bony
defect was ablated using the Er:YAG
laser (with a 1,000 sapphire tip
at 550 mJ, 12 Hz) and water spray.
Te bactericidal eects of the erbium
photonic energy can be eective
for this type of minimally invasive
technique.
13
After proper healing,
the pocketing was reduced to 2 mm
and the nal tissue contour showed
signicant improvement.
Diagnostic/curing lasers
Tese types of devices can be used
for caries and calculus detection.
Fig. 40. A composite inlay with defective
margins.
Fig. 42. The patient in Figure 40, after comple-
tion of the composite bonded restoration.
Fig. 41. The patient in Figure 40, after an
Er:YAG laser was used to remove decay around
the defective margins.
Fig. 43. A palatal abscess on a maxillary central
incisor, with pocketing to 8 mm.
Fig. 44. The Er:YAG laser is used to make the
initial incision to lay the full-thickness ap.
Fig. 45. The patient in Figure 43, after the
Er:YAG laser was used to perform the osseous
recontouring with a copious water spray.
Fig. 46. The patient in Figure 43, after the
inner lining of the ap was debrided and the
continuous sling suture technique was used
for closure.
Fig. 47. A two-week postoperative view of the
patient in Figure 43.
56 January/February 2009 General Dentistry www.agd.org
Laser Therapy Clinical applications of dental lasers
Argon lasers (488 nm) can be used
for curing composites, while optical
coherence tomography (OCT) can
be used for imaging soft and hard
tissue without using any ionizing
type of radiation. Argon photonic
wave energy is highly absorbed in
camphorquinone, the photo-acti-
vator contained in light-activated
composite materials.
2
Argon curing
lasers, while clinically eective,
have fallen out of use with the
advent of LED curing lights. An
important distinction to be made
is that an LED curing light is not a
laser, as its light energy is inherently
polychromatic.
Caries and calculus detection
Te DIAGNOdent (KaVo Dental
Corporation, Lake Zurich, IL;
800.323.8029) is used for caries
and calculus detection by emit-
ting a non-ionizing laser beam at
a wavelength of 655 nm (at a 90
degree angle) toward a specic
darkened groove on the occlusal
surface of a patients tooth where
bacterial decay is suspected,
or along the long axis of a root
surface to detect the presence of
bacteria-laden calculus.
14
Tis
diagnostic technology, in which the
photons of this laser wavelength are
absorbed into any existing bacteria
in these areas of the patients tooth,
is called laser-induced uorescence.
15

Te instruments digital display
indicates the number of bacteria
in this area of the tooth and may
correspond to the extent of decay
or existence of calculus.
14
It is
important to remember that a
diagnosis of decay or periodontal
disease should not depend solely
on the instruments digital readout;
the patients history, the clinical
examination, the dentists experi-
ence, and radiograph evaluation all
are factors necessary for a proper
diagnosis.
While laser-induced uorescence
enables a clinician to diagnose the
presence of bacteria, it is the absence
of uorescence that provides the
diagnostic basis for the VELscope
device (LED Dental Inc., White
Rock, British Columbia, Canada;
888.541.4614). It should be noted
that the VELscope is an LED
device that produces a narrow range
of wavelengths and technically
is not a laser. Te mortality rate
for oral cancer has not improved
signicantly within the last 50
years. Te VELscope appears to be
an important advance in the war
against oral cancer.
Te VELscope makes it pos-
sible to scan the soft tissues of the
mouth, allowing a trained eye to
see an otherwise undetectable mass
beneath the patients soft tissue
epithelial surface. Te device uses
changes in the pattern of blue light-
induced uorescence that result
from disease processes occurring in
the oral mucosa, including underly-
ing oral cancer.
14
Te inside of the
oral cavity has an inherently normal
degree of healthy uorescence when
scanned with the VELscope (Fig.
48). When performing an oral
examination through the VEL-
scope, areas that have an absence
of uorescence (and thus appear
darkened) may indicate possible
underlying pathology (Fig. 49).
16

If there are any suspicious nd-
ings, the dentist can oer the patient
an expedient referral to an oral
surgeon for a more extensive evalu-
ation. In some cases, a patients life
can be saved by detecting a previ-
ously undiagnosed neoplasm before
it becomes more invasive.
Optical impressions
Computer-aided design/computer-
aided manufacture (CAD/CAM)
technology uses computerized laser
systems to assist with the fabrica-
tion of custom restorations, such
as inlays, onlays, and crown and
bridge prosthetics.
CAD/CAM technology elimi-
nates the need for conventional
intraoral impression materials;
instead, laser scanners take an opti-
cal impression of a prepared tooth
and the opposing dentition and
take a bite registration to produce
an interactive three-dimensional
image. Te iTero system (Cadent,
Carlstadt, NJ; 201.842.0800) uses
Fig. 48. The normal intraoral uorescence of
the VELscope. (From: http://www.velscope.
com/velscope/images.php. Accessed August
2008. Reprinted with permission.)
Fig. 49. The loss of uorescence indicates
possible pathology. (From: http://www.
velscope.com/velscope/images.php. Accessed
August 2008. Reprinted with permission.)
www.agd.org General Dentistry January/February 2009 57
this three-dimensional laser-based
imaging technology and enables the
dentist to take an optical impres-
sion and create a computer le with
this data. Te iTero unit transmits
this le to the Cadent company,
where a virtual model is created
based on the transmitted data and
a precise working master model is
made. Te physical master model
is sent to the laboratory of the
dentists choice, where a nal resto-
ration is fabricated. When making
the desired nal cast restoration,
the laboratory uses whichever mate-
rial is appropriate for the specic
prosthetic application, be it gold,
porcelain-fused-to-gold (PFG), or
all-ceramic.
Tis system eliminates the need
to apply powders to the patients
tooth preparation prior to the
scan, as required by the CEREC
system (Sirona, Charlotte, NC;
800.659.5977). Te main advan-
tage of the CEREC system is that
the restoration is made in a milling
machine within the dentists oce
while the patient waits, eliminating
the need for a temporary restora-
tion. Te chief disadvantage to this
in-house milling technology system
is that it limits the user to ceramic
restorations.
Current advances/research
Optical coherence tomography
Optical coherence tomography
(OCT) is a new type of dental
diagnostic imaging of both hard and
soft tissues that uses an intense, safe
laser light beam that is backscattered
from the tissue to capture two-
dimensional and three-dimensional
images. It is noninvasive, with no
x-rays or any other type of ionizing
radiation required. OCT represents
a major advancement in dental
imaging due to its ability to provide
detailed characterization of the
dental microstructures, enabling
dentists to make earlier and more
accurate diagnosis of oral diseases
(including decay and periodontal
disease). OCT, with a resolution of
up to 10 times that of radiography,
is the rst modality to image both
hard (teeth and bone) and soft (gin-
gival tissue and mucosa) tissues.
17

At present, OCT is not available
commercially for dentistry.
Titanium:Sapphire laser
Titanium(Ti):Sapphire lasers are
femtosecond lasers (10
-15
second
pulsed) that are

ultrafast and
extremely accurate; they perform
hard tissue ablation without any
thermal damage of natural tooth
structure. Figure 50 is a scanning
electron microscopy (SEM) image
of a Ti:Sapphire laser cut in healthy
enamel at a pulse duration of 770
femtoseconds and a pulse energy
of 100 mJ. Te cut achieved by the
Ti:Sapphire laser is precise, clean,
and superior in quality when com-
pared to conventional diamond burs
in high-speed dental handpieces,
while generating far less heat.
1
Te fast and clean hard
tissue ablative properties of the
Ti:Sapphire laser may provide a
long-awaited alternative to the
mechanical dental drill or current
erbium lasers that leave microcracks
and may cause collateral thermal
and/or pulpal damage within
a tooth. One drawback to the
Ti:Sapphire laser is the acoustic
damage (mechanical vibration) in
underlying tissues; this damage
manifests as fractures and cracks
within the healthy parts of the
tooth.
1
At present, Ti:Sapphire lasers
are not available commercially.
Photodynamic therapy
Research is ongoing for the
treatment of oral cancer using
photodynamic therapy (PDT).
18

Te advantage of PDT for early
carcinomas of the oral cavity is the
ability to preserve normal tissues
while eectively treating cancers up
to 1 cm in depth. Clinical studies
have demonstrated that PDT is an
eective method for the treatment
of dysplastic, microinvasive, and
early forms of cancer. Mang et al
used PDT successfully to treat max-
illary gingival squamous cell carci-
noma, avoiding the use of surgery or
radiation therapy at this point in the
management of the disease.
19

Tis treatment regimen involves
applying Photofrin dye (Axcan
Pharma, Birmingham, AL;
800.472.2634) to a conrmed
oral malignant lesion. Te dye is
attracted to the diseased area and
is absorbed rapidly and selectively
within the malignant cells. Te
tissue is exposed to a 630 nm laser
with dye applications and subse-
quent laser exposures repeated at
specic intervals. As a result, these
early tumors are resolved with a
minimum of side eects compared
to conventional radical surgical
resection (maxillectomy or mandi-
bulectomy).
18
While direct eects
destroy the majority of tumor cells,
there is accumulating evidence
Fig. 50. A photomicrograph of a cavity in
enamel achieved with a Ti:Sapphire laser.
(From: Niemz M. Laser tissue interactions,
ed. 2. Berlin, Germany: Springer;2002:149.
Reprinted with permission.)
58 January/February 2009 General Dentistry www.agd.org
Laser Therapy Clinical applications of dental lasers
that PDT activates the host
immune response and promotes
anti-tumor immunity through the
activation of macrophages and T
lymphocytes.
20,21

Photodisinfection lasers utilize
low-intensity lasers and wavelength-
specic, light-activated photosensi-
tive compounds to specically
target and destroy microbial patho-
gens and reduce the symptoms of
disease. Tese photosensitive com-
pounds are applied topically to the
intended target; at that point, the
treatment site is disinfected with
lasers at the appropriate wavelength
and power settings.
22
Summary
Lasers oer many useful clinical
applications for general dentists
in the diagnosis and treatment of
patients, as long as the clinician
receives the proper training to use
this technology safely and eectively.
Acknowledgements
Te author would like to thank
Donald Coluzzi, DDS, for his
editorial assistance with this article.
Disclaimer
Te author has no nancial relation-
ship with any of the manufacturers
listed in this article.
Author information
Dr. Lomke is in private practice in
Montgomery County, Maryland,
and a member of the Board of
Directors for the Academy of Laser
Dentistry. He is a clinical instructor
as a member of the Deans Faculty at
the University of Maryland Dental
School in Baltimore.
References
1. Niemz M. Laser tissue interactions, ed. 2. Berlin,
Germany: Springer;2002.
2. Miserendino LJ, Pick RM. Lasers in dentistry.
Chicago: Quintessence Publishing Co.;1995.
3. Waynant RW, ed. Lasers in medicine. Boca Ra-
ton, Florida: CRC Press;2002.
4. Coluzzi D. Soft tissue surgery with lasers
Learn the fundamentals. Available at: http://
www.contemporaryestheticsonline.com/issues/
articles/2007-03_01.asp. Accessed August
2008.
5. Coluzzi D. Types of lasers and what your prac-
tice needs: Laser dentistry made easy and prof-
itable. Available at: http://www.
dentaleconomics.com/articles/article_display.
html?id=289751. Accessed September 2008.
6. A brief overview of dental lasers. Available at:
http://www.laserdentistry.org/join/professionals.
cfm. Accessed September 2008.
7. Stubinger S, Henke J, Donath K, Deppe H. Bone
regeneration after peri-implant care with the
CO2 laser: A uorescence microscopy study. Int J
Oral Maxillofac Implants 2005;20(2):203-210.
8. Eggers P, Thapliyal HV, inventors; ArthroCare
Corporation, assignee. Methods for electrosurgi-
cal tissue treatment in conductive uid. U.S.
patent 6,224,592. July 27, 1998.
9. Pecaro BC, Garehime WJ. The CO2 laser in oral
and maxillofacial surgery. J Oral Maxillofac Surg
1983;41(11):725-728.
10. Walsh LJ. The role of lasers in implant dentistry.
Austral Dent Pract 2007;18(2):138-140.
11. Park CY, Kim SG, Kim MD, Eom TG, Yoon JH, Ahn
SG. Surface properties of endosseous dental
implants after Nd:YAG and CO2 laser treatment
at various energies. J Oral Maxillofac Surg 2005;
63(10):1522-1527.
12. da Costa Ribeiro A, Nogueira GE, Antoniazzi JH,
Moritz A, Zezell DM. Effects of diode laser (810
nm) irradiation on root canal walls: Thermo-
graphic and morphological studies. J Endod
2007;33(3):252-255.
13. Bornstein ES, Lomke MA. The safety and effec-
tiveness of dental Er:YAG lasers. A literature
review with specic reference to bone. Dent
Today 2003;22(10):129-133.
14. Tobin AM. Oral cancer in a blue spotlight as
more dentists buy screening devices. The Cana-
dian Press;October 22, 2007.
15. Attrill DC, Ashley PF. Occlusal caries detection in
primary teeth: A comparison of DIAGNOdent
with conventional methods. Br Dent J 2001;190
(8):440-443.
16. Lane PM, Gilhuly T, Whitehead P, Zeng H, Poh
CF, Ng S, Williams PM, Zhang L, Rosin MP,
MacAulay CE. Simple device for the direct visu-
alization of oral-cavity tissue uorescence. J
Biomed Opt 2006;11(2):024006.
17. Otis LL, Everett MJ, Sathyam US, Colston BW Jr.
Optical coherence tomography: A new imaging
technology for dentistry. J Am Dent Assoc 2000;
131(4):511-514.
18. Photodynamic therapy with photofrin for treat-
ment of dysplasia, carcinoma in situ and Stage I
of the oral cavity and the larynx: A pilot study.
Available at: http://www.roswellpark.org/
Patient_Care/What_Is_a_Clinical_Trial/
ClinicalTrialsOnlineSearch/ClinicalTrialsOnline
SearchDisplay?trial=221&search_for=BodyPart
&search_string=HeadNeck&search_for2=
&Active=&program_search=false. Accessed
September 2, 2008.
19. Mang TS, Sullivan M, Cooper M, Loree T, Rigual
N. The use of photodynamic therapy using 630
nm laser light and pormer sodium for the
treatment of oral squamous cell carcinoma.
Photodiag Photodynam Ther 2006;3(4):272-
275.
20. Walsh LJ. Safety issues relating to the use of
hydrogen peroxide in dentistry. Aust Dent J
2000;45(4):257-269.
21. Dougherty TJ. An update on photodynamic ther-
apy applications. J Clin Laser Med Surg 2002;
20(1):3-7.
22. Anderson R, Loebe N, Hammond D, Wilson M.
Treatment of periodontal disease by photodisin-
fection compared to scaling and root planing. J
Clin Dent 2007;18(2):34-38.
Published with permission by the Academy of
General Dentistry. Copyright 2009 by the
Academy of General Dentistry. All rights reserved.
www.agd.org General Dentistry January/February 2009 59