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Laser Dentistry 101: An Introduction to Wavelengths and

Laser-Tissue Interaction

Robert A. Convissar D.D.S.

PII: S1073-8746(20)30016-5
DOI: https://doi.org/10.1053/j.sodo.2020.06.001
Reference: YSODO 600

To appear in: Seminars in Orthodontics

Please cite this article as: Robert A. Convissar D.D.S. , Laser Dentistry 101: An Introduc-
tion to Wavelengths and Laser-Tissue Interaction, Seminars in Orthodontics (2020), doi:
https://doi.org/10.1053/j.sodo.2020.06.001

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Laser Dentistry 101: An Introduction to Wavelengths and Laser-Tissue Interaction

Robert A. Convissar, D.D.S.

Diplomate, American Board of Laser Surgery

Director, Laser Dentistry

New York Presbyterian Hospital, Queens

200 Park Avenue South

Suite 1414

New York, New York 10003

212-255-5730

LaserBobDDS@gmail.com

No grant money was involved in this paper

Abstract:

Lasers are excellent devices that can add significant value to orthodontic practices.

Orthodontists can now perform many procedures quickly, efficiently, and

bloodlessly in their offices, instead of referring them back to the general

practitioner, oral surgeon or periodontist. Many different laser devices are currently

on the market, with purchase prices that vary from $5000 to well over $100,000. In

order to understand how to use a laser, how a laser works on oral mucosa, and how

to maximize use of this device in an orthodontic practice, it is critically important

that the dentist understands the basics of laser-tissue interaction and the role a

good laser education program plays in selection of the best device for their

practices.
What is a laser? The word laser is actually an acronym – it stands for Light

Amplification by Stimulated Emission of Radiation. A laser therefore is simply a

more powerful (amplified) beam of light energy. The textbook definition of a laser

is: a device that produces a beam of collimated, coherent, monochromatic light 1.

Light energy has been used as a therapeutic modality since the time of the ancient

Greeks 2. How is a more powerful beam of light energy produced? Simply stated,

energy is put into a material. The electrons in the outermost electron shell of the

material absorb the energy. Since everything in the universe tends towards entropy,

the electrons will then release that absorbed energy in the form of energy known as

a photon. A photon is the basic unit of light energy. When the electrons give back

that energy, the photons will stimulate more electrons to release more photons in a

cascading effect until a sufficient number of photons are produced – creating a beam

of photonic (light) energy. The material within the laser that is stimulated to create

the beam of photons is known as the active medium. The active medium both gives

the laser its name, and provides the electrons that will absorb and then emit the

energy. Lasers can have active media that are solid (such as Erbium lasers), liquid

(such as pulsed dye lasers used in medicine), gas (such as CO2 lasers), or electronic

circuits – such as semiconductor diode lasers, more commonly known as diode

lasers.
How do lasers work? To answer that question, we must ask two other questions:

First, why do people wear light colors in the summer, and dark colors in the winter?

The answer is light (and heat) absorption from the Sun. In the summer, light colors

are worn to reflect light/heat energy, and keep us cool. In the winter, when there is

less heat and light from the Sun, dark colors are worn to absorb as much of the

feeble sunlight as possible. Second: why do we place lead shields on patients before

taking radiographs? The answer, once again, is absorption. The lead apron absorbs

the x-rays (ultra short wavelength invisible light energy), which prevents them from

hitting our bodies. The key word, therefore, when discussing how lasers (light

energy) work is: absorption. One definition that must be discussed is: chromophore.

The definition of a chromophore is: a light absorbing compound or molecule that

absorbs specific wavelengths of light energy 3. Everything in laser-tissue interaction

is based on one concept: absorption of the laser energy into the target tissue by the

chromophores of the target tissue. The light energy is either absorbed by the target

tissue, resulting in a therapeutic effect, or not absorbed, in which case there will be

no therapeutic effect. Each laser wavelength is absorbed preferentially by different

chromophores in the oral cavity. Figure One shows the four types of laser-tissue

interaction:
Figure 1. Four types of laser-tissue interaction: Reflection Absorption-Transmission-

Scatter

A) Reflection – the laser (light) energy is not absorbed at all by the target tissue.

The energy is reflected off of the surface. An example of this would be

wearing light colored clothing in the summer to reflect the sun’s rays.

Reflection is why all personnel in the room must wear laser wavelength-

specific safety glasses.

 B) Absorption – the laser (light) energy is absorbed by the target tissue. An

example of this would be wearing dark clothes in the winter to absorb the

Sun’s rays, or the use of a lead apron to absorb harmful x-rays (ultraviolet

light energy). Absorption is responsible for performing a therapeutic effect. If

the light energy is not absorbed by the tissue, there will be no therapeutic

effect.

C) Transmission – the light energy penetrates through the tissue with no effect

whatsoever. There is no therapeutic effect during transmission. An example

of this would be using a diode laser non-initiated, out of contact with oral

mucosa. There will be no effect because diodes are not absorbed by the main

chromophore of oral mucosa. The diode laser wavelength goes through the

tissue with no effect on the tissue.

D) Scattering – the light energy is partially absorbed and partially reflected. An

example of this would be using a laser to cure composite restorations.

An easy mnemonic device to remember the four types of laser tissue interaction is:

RATS…..Reflection…Absorption….Transmission…Scatter
Figure 2. Both Erbium and CO2 laser energy is absorbed by water. The corneal

tissue of the eye has high water content. Both Erbium and CO2 lasers are ABSORBED

by the cornea.

Both Nd.YAG and Diode lasers are absorbed by the chromophores of the retina. The

Nd.YAG and Diode wavelengths are TRANSMITTED through the cornea, lens, iris,

anterior chamber, posterior chamber, with no effect on those tissues because those

tissues do not have the correct chromophores for those wavelengths. Those

wavelengths are then ABSORBED by the retina, because the retinal tissue has the

correct chromophores for those wavelengths

Table 1 lists the most common surgical laser available and their chromophores.
Table 1. COMMON DENTAL LASERS, THEIR WAVELENGTHS AND THEIR
CHROMOPHORES
CO2 10,600 nm Water

CO2 9300/9600 nm Water,

Hydroxyapetite,

Phosphate

Diodes 810/940/980/1064

A) In Contact Not Applicable

B) Out of Contact Melanin,

Hemoglobin,

Oxyhemoglobin

Erbiums 2740/2980 nm Water,

Hydroxyapetite

Nd.YAG 1064 nm

A) In Contact Not Appliable

B) Out of Contact Melanin,

Hemoglobin,

Oxyhemoglobin

The 9300/9600 nm CO2 and both of the Erbium lasers are primarily hard tissue

lasers; that is, they are used for operative dentistry and osseous surgery. They are

quite expensive units when compared with the other wavelengths, and in the
author’s opinion are ill suited to an orthodontic practice due to their expense, their

large size, and their high operating cost. Though they are on casters and can be

moved from operatory to operatory, their weight and bulk make it impractical to

wheel them around the office all day long. These units can weigh as much as 135

pounds or more. The Nd.YAG laser, though it may be used for general soft tissue

treatment, including orthodontic therapy is marketed primarily for periodontal

pocket reduction. The remainder of this paper will deal with the most common soft

tissue devices, the 10,600 nm CO2 and Diode lasers.

The first question that needs to be addressed is: how do lasers work? How does the

light energy remove tissue? The CO2 and Diode devices work by two totally

separate mechanisms. Lasers are optical devices: that is, the photons produced by

the laser are absorbed by the chromophores of the target tissue, and perform the

therapeutic effect. Lasers are, generally speaking, non-contact device. The photons

leave the handpiece, are absorbed by the chromophores of the contact tissue

without touching the tissue, and perform the therapeutic procedure. When an

ophthalmologist performs retinal surgery, he/she does not take the laser fiber and

thrust it through the eyeball, pushing the fiber to the back of the eye until it touches

the retina; the laser energy is emitted from the laser out of contact from the eye, and

is absorbed by the chromophores of the retina, thereby producing a therapeutic

effect.
Figure 3. When a diode laser is used for certain retinopathies, it is used non-

initiated, out of contact, like a true optical device.

In medicine when a laser is used in contact it is usually to coagulate tissue or melt

tissue, rather than optically ablate tissue. Lasers are never initiated in order to

perform a therapeutic procedure. The purpose of initiation is to place a black

material (never articulating paper or cork!) on the tip of the laser handpiece in

order to prevent the photons from coming out of the laser handpiece. Remember

that black absorbs all light energy; therefore, when placing something black on the

tip of a laser, the photons do not come out of the laser handpiece. The photons are

absorbed by the black material, which causes the tip of the laser to heat up. Diode
lasers, therefore, when used with initiated tips, are not used as lasers – they are not

used as optical (photon-emitting) devices, they are used as thermal devices. Diode

lasers, when initiated, are nothing more than hot glass tips. Diode lasers are

classified as lasers because they produce a beam of collimated, coherent,

monochromatic light; however, they are not used as true optical devices, because

they prevent the light energy from leaving the tip of the handpiece. How hot is the

tip of a diode laser? The peer-reviewed literature shows that the initiated tip of a

diode laser is between 750-1200 degrees Celsius 4-5. Erbium and CO2 lasers, which

are never initiated and never touch tissue, work optically. Their chromophore,

generally speaking, is water; more specifically the water in oral mucosa. Oral

mucosa is 70% or more water 6. These lasers heat up the water in the tissue until

the water evaporates, and the tissue is vaporized. The boiling point of water is 100

degrees Celsius. Erbium and CO2 lasers, therefore, work optically and only need to

heat up tissue to 100 degrees in order to vaporize tissue. Diodes melt tissue at a

minimum of 750 degrees. Diode users are quite familiar with the material that

accumulates at the end of the fiber – that’s simply melted tissue. Some practitioners

familiar with diode lasers don’t bother initiating lasers – they just touch the tissue

and start to melt the tissue; however, what those practitioners do not realize is that

as soon as the hot glass tip touches the tissue, it becomes initiated with a glob of

superheated, melted tissue – a very poor conductor of heat that vastly increases the

width of the incision. When properly initiated with a black substance, such as black

acrylic ink or black waterproof mascara, a laser will melt tissue approximately the

size of the laser tip used. A 300-micron tip will melt a swath of tissue approximately
300 microns in width. A 400-micron tip will melt a swath of tissue approximately

400 microns in width, and so on. If a laser tip is not initiated properly, and a large

ball of melted superheated tissue accumulates on the laser tip, that ball of tissue is

much wider than the laser tip, and will result in a much wider incision. This does not

mean that diode lasers should not be used; it just means that a diode user must be

educated on how to use a hot glass tip at 750-1200 degrees Celsius on oral mucosa.

A review of Table One shows that when diodes are used in contact with tissue,

chromophores are irrelevant. Why is that? When diodes are used in contact, they

are simply hot glass tips that will remove any tissue in its path by heating up that

tissue, no matter the chromophore content of the tissue. Diodes may be used as

actual photon-emitting optical devices in certain circumstances. Note that the

chromophores of these devices are melanin and hemoglobin/oxyhemoglobin. If a

patient has a venous lake or a hemangioma, or an aphthous ulcer, diodes can be

used like optical devices: non-initiated, out of contact, to treat these lesions;

however, for the bulk of orthodontic procedures, diodes will be used as

chromophore-irrelevant hot glass tips that melt tissue.

Figure 4. Note the laser uninitiated, one millimeter out of contact, treating an

aphthous ulcer

Education is one of the most important criteria when deciding on which laser to

purchase. If one looks around the typical orthodontic operatory, it’s easy to see all of

the high-tech devices. Dentists just don’t purchase cone beam or digital x -ray

devices, have them installed and start using them immediately. Those devices come

with training on image acquisition, software use, sterilization of the appropriate

parts of the devices, and much more. Orthodontists don’t simply purchase digital

scanning devices and start scanning immediately. Hours of training is critical in

order to efficiently and effectively use the device and maximize the dentists’ return

on investment (ROI). A webinar and CD, in the author’s opinion, is not sufficient to

maximize use of lasers. Training is critically important when using any high-tech

device. One of the most critical criteria for deciding which laser to purchase is the

amount of training that comes with the device. In the author’s opinion, any laser

device that does not come with two full days of didactic and hands-on participation

training utilizing pig mandibles to perform certain basic procedures (gingivectomy,

frenectomy, tooth uncovering, gingival zenith adjustment, etc.) followed by a full day

of training in the dental office conducted by a dentist (not a salesperson who has

never used the laser, yet makes a commission on its sale) is a very poor choice for

purchase.

Another important criterion when deciding on which laser to purchase is operating

expense. Many dentists make the mistake of looking at a laser’s purchase price,

rather than operating expense. This is a large and expensive mistake. The best

analogy for describing operating cost vs. purchase price is this: tomorrow I will be

purchasing a new car. My choice is between Car A and Car B. Both cars have the

same exact sticker price (purchase price). Both cars get the exact same miles per

gallon (mpg). The only difference between the cars is that Car A uses regular gas and

Car B uses premium gas. If the difference in price between regular and premium gas

is 50 cents/gallon, and I drive 10,000 miles/year, even though the purchase price

of both cars is the same, the operating expense of Car B is $5000/year more than

Car A (10,00 miles x 50 cents = $5000). Over a 3-year period, Car B will cost
$15,000 more in operating expense. The same is true of lasers. Assume I purchase a

diode laser for $6000. The purchase price is $6000. The diode laser has disposable

tips. Assume the tips are $8 each. If I use the laser ten times/day, my operating cost

is $80/day. If I work a 4 -day week, my operating cost is $320/week, or

$1280/month. If I work ten months/year (taking off a week for Christmas, a week

for Easter, a summer vacation, a winter vacation, a few national holidays, etc.,

leaving me with essentially 10 months/year of actual production), my operating

expense is $12,800 plus the cost of the laser, for a total of $18, 800. After two years,

my operating expense is $18,800 plus the cost of a year’s worth of tips for a 2 year

operating cost of over $30,000. Instead of a diode laser, if I were to purchase a CO2

laser with a purchase price of $30,00 but with zero disposable tips and zero

operating expense, after two years, the operating cost of the CO2 laser is slightly less

than a diode. After 3 years, the CO2 is significantly less expensive than a diode. This

scenario is based on the assumption that an orthodontist would use a laser ten

times per day. Many readers of this paper might think that unrealistic. Those

readers that think this number is unrealistic are, unfortunately, orthodontists that

have not been properly trained in how to use a laser, what a laser can do, and how it

can impact their practice financially. The following papers in this issue of Seminars

will more than adequately illustrate the many uses of lasers in an orthodontic

practice. This issue, however, is no substitute for a hands-on participation course,

which the author strongly urges both for orthodontists thinking of purchasing a

laser, and for those orthodontists who already have a laser, but do not use it to its

maximum.
The other consideration when purchasing a laser - or any hi-tech device – is the

amount of chair time the device saves you. At the end of the day, the only thing

dentists sell to our patients is chair time. Anything that saves chair time will save

money. Since CO2 lasers are true optical devices, rather than hot glass tips (diodes),

CO2 devices are significantly faster and more efficient than diodes. This increased

speed and efficiency results in less chair time per patient, which results in increased

income. None of this discussion is meant to dissuade an orthodontist from

purchasing a diode; rather it is meant to alert the orthodontist that there are many

different lasers on the market and an educated decision, based on facts, is surely

better than a gut reaction formed by speaking with a laser sales company

representative, or colleagues that do not use their device to the fullest degree

possible.

Lasers are excellent additions to an orthodontist’s armamentarium; these devices

allow the dentist to perform many of their current procedures more quickly, saving

valuable chair time. They also allow the dentists to perform many procedures in-

office that they previously would have sent out to specialists. The most important

factors when thinking of purchasing a laser are:

A) The type and amount of training supplied to the dentist.

B) A complete understanding of the difference in operating expense among the

different units

C) The amount of support in the form of continuing education, including a

generous amount of practice management advice.

A final word about training: many excellent training courses are available for

dentists interested in learning about laser dentistry. There are also many laser

organizations that support laser dental education. It is imperative that the course be

non-biased. It is imperative that the course is supported by an organization that has

no financial ties to any laser company. It is imperative that the organization not

accepts any money from any laser company. Many of the better-known laser

organizations, such as the Academy of Laser Dentistry, are supported by the dues of

its corporate sponsors – laser companies. This has the potential to skew the

education towards the devices manufactured by its corporate members. An

organization with no ties whatsoever to any laser company would be an ideal

organization to sponsor a non-biased laser dentistry course.

References:

1) Convissar, R: Principles and Practice of Laser Dentistry 2nd ed. St. Louis;

Elsevier, 2016

2) Sulewski, J: Einstein’s “Splendid Light”: Origins and Dental Applications. In:

Principles and Practice of Laser Dentistry 2nd ed. St. Louis, Elsevier, 2016

3) Convissar, R: Principles and Practice of Laser Dentistry 2nd ed. St. Louis;

Elsevier, 2016
4) Weiss, R Comparison of endovenous radiofrequency versus 810 nm diode

laser occlusion of large veins in an animal model Dermatologic Surg 28 (1)

56-61, 2002

5) Romanos G, Belikov A, Skrypnik A, et. al. Uncovering dental implants using a

new thermo-optically powered (top) technology with tissue air coolong

Lasers Surg Med 47:411-420, 2015

6) Rossmann, J (ed) Lasers in Periodontics J Periodontal 2002:73:1231-1239