1282_IPC_AAP_553172 11/8/02 9:50 AM Page 1292
Volume 73 • Number 11
Bactericidal Effect of the Er:YAG Laser on
Dental Implant Surfaces: An In Vitro
Study
Matthias Kreisler,* Wolfgang Kohnen,† Claudio Marinello,* Hermann Götz,‡ Heinz Duschner,‡
Bernd Jansen,† and Bernd d’Hoedt*
Background: The aim of the in vitro study was to examine
the bactericidal effect of an Er:YAG laser on common dental
implant surfaces.
Methods: Seventy-two titanium platelets with 3 different sur-
faces—sandblasted and acid-etched (SA), titanium plasma-
sprayed (TPS), and hydroxyapatite-coated (HA)—were incu-
bated with a suspension of Streptococcus sanguinis (ATCC
10556). Irradiation at pulse energies of 60 and 120 mJ and a
frequency of 10 pps was performed on a computer-controlled
XY translation stage. After laser treatment the specimens were
sonicated and the bacterial growth examined by counting colony
forming units on blood agar plates. Temperature elevations dur-
ing irradiation were investigated using K-type thermocouples.
Laser treated implant surfaces were analyzed by means of elec-
tron microscopy.
Results: Compared to non-irradiated specimens, mean bac-
terial reductions of 99.51% (SA), 98.39% (HA), and 99.6% (TPS)
at a pulse energy of 60 mJ and 99.92% (SA), 99.85% (HA), and
99.94% (TPS) at 120 mJ were calculated. At these laser param-
eters, no excessive temperature elevations or morphological
implant surface alterations were detected.
Conclusions: Even at low energy densities, the Er:YAG laser
has a high bactericidal potential on common implant surfaces.
Clinical studies are justified to evaluate the applicability and effi-
cacy of the Er:YAG laser in the treatment of peri-implantitis. J
Periodontol 2002;73:1292-1298.
KEY WORDS
Lasers/therapeutic use; dental implants/microbiology; peri-
implant diseases/prevention and control.
* Department of Oral Surgery, Johannes Gutenberg University, Mainz, Germany.
† Department of Hygiene and Environmental Medicine.
‡ Institute for Applied Structure and Microanalysis.
1292
P
eri-implant infection results in inflam-
mation of the surrounding soft tissues
and can induce a breakdown of the
implant-supporting bone (Figs. 1 and 2).
Bacterial adherence to implant surfaces is
a complex process not yet fully under-
stood.1,2 Several physical and biological
factors seem to influence the adhesion
process. Surface roughness plays a major
role in the colonization process, sheltering
the microorganisms from removal by sali-
vary flow and oral hygiene procedures.3-5
The surface-free energy of the bacterium,
the ionic strength of the surrounding liquid
medium, and the distance of the bacterium
from the surface affect non-specific elec-
trostatic interaction between the cells and
the colonized substratum.4,6,7 Further stud-
ies indicate that different strains have dif-
ferent affinities to implant surfaces and that
the type of organism, concentration, and
growth phase together with surface char-
acteristics influence the colonization
process.8-13 Compared to biofilms on other
biomaterials, such as indwelling catheters
and contact lenses, the communities of
organisms on implant surfaces are very dif-
ficult to eradicate. Several treatment regi-
mens have been proposed for cleaning and
decontamination of implant surfaces. Plas-
tic curets are probably best for manual
removal of peri-implant plaque,14 as metal
curets and the application of ultrasonic
scalers induce surface alteration in implants
and are, therefore, contraindicated.15 Bac-
tericidal chemicals such as chlorhexidine
digluconate or iodine as well as local and
systemic administration of antibiotics are a
1282_IPC_AAP_553172 11/8/02 9:50 AM Page 1293
J Periodontol • November 2002
Figures 1 and 2.
Severe peri-implant inflammation with pronounced bone loss. Note the partly exposed Ti plasma-sprayed implant surface and the massive bacterial
contamination.
useful adjunct in the treatment of peri-implantitis.16
Sterilization and cleaning of implant surfaces using
lasers has been suggested.17,18 However, the bacteri-
cidal potential of some laser systems on roughened
surfaces requires considerable scientific investigation.
Since its 2940 nm wavelength is highly absorbed in
water, the Er:YAG laser is useful in various dental appli-
cations. It has been mainly studied for hard tissue
removal and for various indications in oral surgery.19,20
Other studies demonstrated its applicability in the treat-
ment of periodontal diseases and endodontics.21,22 It
is feasible that the sterilizing effects of the Er:YAG laser
might be useful in the treatment of ailing implants.
This study is part of a research program investi-
gating the possibilities and hazards of laser application
in implant dentistry. The aim was the examination of
the bactericidal effect of Er:YAG laser irradiation on
common implant surfaces.
MATERIALS AND METHODS
Titanium Discs
Test platelets§ made from commercially pure (CP)
titanium (grade 4) with a thickness of 1.5 mm and a
diameter of 10 mm with 3 different surfaces (sand-
blasted and acid etched, SA; titanium-plasma sprayed,
TPS; and hydroxyapatite-coated, HA) served as sub-
strates. Surface roughness as indicated by the man-
ufacturer was SA: Ra = 2.2 µm; TPS: Ra = 3.41 µm;
and HA: Ra = 2.0 µm with a standard deviation of
approximately 20%.
Target Microorganisms and Culture Conditions
Streptococcus sanguis (ATCC 10556) was obtained
commercially
and cultured on blood agar plates.¶ The
bacterial cells were washed 3 times with phosphate-
buffered saline (PBS, pH = 7.2) and afterwards sus-
Kreisler, Kohnen, Marinello, et al.
pended in PBS. The viable bacterial colony counts
were determined for quantification of bacterial cell
numbers present in suspensions of known optical den-
sity (625 nm). The mean concentration was 8 × 108
cells/ml prior to specimen inoculation. The solution
was sonicated to disperse cell clumps.
Colonization Model
Preliminary experiments were performed to determine
optimal test conditions. To ensure that only the respec-
tive surface on the upper side and no other parts of
the discs were contaminated, the discs were embed-
ded between 2 aluminum plates, 1 with 12 perfora-
tions for the upper side of the specimens. The space
between the plates and the discs was isolated with flow
impression paste. This mounting and the platelets were
incubated with the cell suspension for 1 hour at 37°C.
Discs with similar surfaces were incubated simultane-
ously. After incubation the 12 discs were removed from
the mounting and washed with PBS to remove non-
adherent cells. Four specimens served as controls; 4
were irradiated at 60 mJ and 4 at 120 mJ. Except for
the irradiation process, all specimens were treated
equally.
Laser
An Er:YAG laser# with a wavelength of 2940 nm and
a variable pulse frequency (1 to 15 pps) and pulse
energy (60 to 250 mJ) was used. Frequency was kept
constant at 10 pps. Pulse energy was set alternatively
at 60 and 120 mJ. The light was delivered by an optic
fiber and a 540 micron application tip. Irradiation was
performed without water cooling.
§ Friadent GmbH, Mannheim, Germany.

German Collection of Microorganisms and Cell Cultures, Braunschweig,
Germany.
¶ Heipha Dr. Müller GmbH, Heidelberg, Germany.
# Key II, KaVo, Biberach, Germany.
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Bactericidal Effect of Er:YAG Laser on Implants Volume 73 • Number 11

Irradiation
Subsequent to incubation, the discs were affixed on
an XY translation stage.** The movement of the
handpiece and, therefore the parameters relevant to
the irradiation of the discs (distance from the tip of
the handpiece to the specimen, irradiation time, and
working angle), were controlled by a computer pro-
gram. The tip of the handpiece was moved to the
center of each disc at a distance of 0.5 mm from the
surface. The optic fiber was positioned perpendicu-
larly to the specimen. After laser activation, the
movement was performed in concentric circles from
the center to the periphery of the disc. The radius of
the circles was successively enhanced by 540 µm,
corresponding to the diameter of the fiber, to ensure
an equal exposure of the entire specimen. The over-
all irradiation time of the entire disc was 60 seconds.
Bactericidal Efficacy
After laser irradiation the discs were placed into 10 ml Figure 3.
of sterile PBS and sonicated†† for 2 × 45 seconds at Streptococcus sanguis after 48-hour incubation on blood agar plates.
75 watts. After serial 10-fold dilution, aliquots of each
dilution (100 µl) were spread on Columbia blood agar
plates¶ (Fig. 3). Colony forming units were counted

after 48 hours incubation. A total number of collected
bacteria from the control and irradiated samples was
estimated and the bactericidal efficacy of the laser
treatment was calculated.
Scanning Electron Microscopy
Subsequent to standard specimen preparation, single
discs of the laser and the control groups were placed
in the vacuum chamber of a scanning electron micro-
scope‡‡ and micrographed at different magnifications.
Secondary electrons were detected by means of a stan-
dard SE detector.
Temperature Measurements
Prior to irradiation, temperature rises of the titanium
discs during a 1-minute irradiation at various pulse
energies were measured with a thermocouple system§§
at room temperature (24.0°C). Three 0.5 mm probes
(K-type) were attached to the border of the specimens.
The sensitive tip of the probes was covered with a ther-
moconductive paste.
Statistical Analysis
The statistical analysis was performed with a spread
sheet

and a statistic package.¶¶ For each implant
surface, 8 samples served as control, 8 were irradiated
at 60 mJ, and 8 at 120 mJ. The median, mean, and
standard deviation of the bacteria concentration of the
control and the 2 laser groups were calculated. Dif-
ferences between the groups were analyzed by means
of the Mann Whitney-U test and differences consid-
ered to be significant at P <0.05. The bacterial reduc-
tion was quoted in “log kills” in accordance with the
work of Rooney et al.23 and calculated as follows:


a
log kill = log


b
with a = mean bacteria concentration in the control
group, b = mean bacteria concentration in the laser
group, and log = decimal logarithm.
RESULTS
Bactericidal Efficacy
Table 1 presents the bacterial counts on the SA, HA,
and TPS specimens. The mean bacterial count in the
non-irradiated specimens was 6.38 × 104 in the SA
group 2.73 × 105 in the HA group, and 6.25 × 105 in
the TPS group. The application of the Er:YAG laser
resulted in a highly significant reduction of colony
forming units in all irradiated specimens at both
energy levels (P <0.001). The best bactericidal effect
was achieved irradiating the TPS surface followed by
the SA and HA surfaces. The mean reduction in the
TPS group expressed in log steps was 2.4 at a pulse
energy of 60 pps and 3.21 at 120 mJ correspond-
ing to a bacterial reduction of 99.60% and 99.94%,
respectively. The values were slightly lower in the SA
group: 2.31 (99.51%) at 60 mJ and 3.11 (99.92%)
at 120 mJ and in the HA group: 1.79 (98.39%) at
60 mJ and 2.82 (99.85%) at 120 mJ. The differ-
ence in bacterial counts between the 2 energy lev-
els was significant in all groups (P <0.001) and
** HBM, Langen, Germany.
†† Branson Ultrasonics Corp., Danbury, CT.
‡‡ LEO 435 VP, Zeiss-Leica Corp., Oberkochen, Germany.
§§ Omega Engineering, Stanford, CT.


Excel 97, Microsoft, Richmond, VA.
¶¶ SPSS for Windows, Release 10.0.5, SPSS Inc., Chicago, IL.

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J Periodontol • November 2002 Kreisler, Kohnen, Marinello, et al.

Table 1. the cells partly forming a monolayer. The attached

bacteria, however, were not uniformly distributed. Cell
Bacterial Counts on Control and Irradiated clumps were found in surface depressions. An asso-
Discs (pulse energy: 60 and 120 mJ) ciation of cell orientation and surface pattern was
clearly discernible. A tendency to form chains was
Disc Control 60 mJ 120 mJ obvious, in particular along the edges of elevations.
The microscopy findings were comparable to data
SA
Mean 6.38E+04 3.13E+02 5.00E+01 published earlier.1,24,25 Figures 6 and 7 show the SA
Median 7.50E+04 2.50E+02 5.00E+01 surface after incubation and laser irradiation at 120
SD 2.92E+04 2.10E+02 2.51E+01 mJ. Only a sparse distribution of cells could be
Max 9.00E+04 7.00E+02 8.00E+01 detected and cluster formations were not widely pre-
Min 2.00E+04 1.00E+02 2.00E+01 sent. Typical laser-induced surface alterations, such as
melting, cracking, and crater formations, were not
HA
observed.
Mean 2.73E+05 4.38E+03 4.12E+02
Median 3.00E+05 4.00E+03 3.50E+02
SD 1.85E+05 2.45E+03 2.10E+02 Temperature Elevations
Max 6.00E+05 9.00E+03 8.00E+02 Table 2 presents the mean temperature elevations mea-
Min 3.00E+04 1.00E+03 2.00E+02 sured at the border of the specimen after 60 seconds of
irradiation. At both 60 and at 120 mJ, temperature ele-
TPS vations were significantly higher in the HA specimens
Mean 6.25E+05 2.50E+03 3.88E+02
than in the TPS (P <0.001, Mann-Whitney U test) and
Median 6.00E+05 3.00E+03 2.00E+02
SD 1.75E+05 1.31E+03 2.90E+02
SA discs (P <0.001). Differences between the 2 titanium
Max 9.00E+05 4.00E+03 8.00E+02 surfaces were not significant (P = 0.95). The tempera-
Min 4.00E+05 1.00E+03 1.00E+02 ture did not exceed 47°C, irrespective of the surface.

ranged between 0.8 and 1.03 log steps. Complete
bacterial reduction could not be achieved.
Scanning Electron Microscopy
Figures 4 and 5 show the microscoping appearance
of Streptococcus sanguis on the SA surface after incu-
bation. A dense colonization was predominant with
DISCUSSION
Beside undisturbed osseointegration and an adequate
prosthetic design, maintenance is crucial for long-term
implant prognosis. Clinical success can be jeopardized
by bacterial infection inducing mucositis or peri-implan-
titis. Elimination of pathogenic microorganisms from
implant surfaces is a prerequisite for successful treat-
ment of ailing implants. Several in vitro studies demon-
strated a sterilizing effect of various laser systems on

Figures 4 and 5.
Scanning electron micrograph of a sand-blasted and acid-etched implant surface after incubation with a suspension of S. sanguis (original
magnification ×2,000 and ×5,000).

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Bactericidal Effect of Er:YAG Laser on Implants Volume 73 • Number 11

Figures 6 and 7.
Scanning electron micrograph after laser irradiation at 120 mJ (original magnification ×1,000 and ×2,000).

Table 2. described by Haas et al.31 Due to the numerous vari-

Temperature Elevations [°C] After
Continuing Irradiation for 60 Seconds at
Room Temperature (24°C)
60 mJ
Mean SD Mean
SA 5.4 0.2 11.0
HA 7.8 0.2 16.4
TPS 5.7 0.2 11.9
Note the significantly greater heating of the HA specimens.
periodontitis and peri-implantitis-associated bacte-
ria.26-30 The potential applicability of lasers in the treat-
ment of peri-implant infections has been investigated
in in vitro, animal, and in vivo studies.31-34 Block et
al. reported that the Nd:YAG laser was not able to ster-
ilize Ti-plasma and hydroxyapatite-coated surfaces
under in vitro conditions.35 Since the high bactericidal
effect of this laser has been described earlier, this phe-
nomenon might be attributed to the particular surface
morphology. Moreover, this laser system induces severe
surface alterations in implants such as melting and
loss of porosity even at minimal power settings.35-37
Its application in the treatment of peri-implantitis is
therefore contraindicated. Deppe et al. demonstrated
that application of the CO2 laser in treating ailing
implants may favorably influence new osseous regen-
eration.34 A high bactericidal effect of the combined
application of a low intensity laser and a photosensi-
tizer on contaminated implant surfaces has been
able parameters, such as the wavelength of the laser
system, power output, mode, time of irradiation, dis-
tance of the fiber from the specimen, and working
angle, it is difficult to compare results from different
investigations.
120 mJ The wavelength of a laser system is crucial for its
biological effect. The coherent and collimated light of
SD
the Er:YAG laser with a wavelength of 2940 nm is
0.2 highly absorbed in water.38 With microorganisms, the
light is primarily absorbed by cell water resulting in
0.3
rapid evaporation and cell death. Ando et al. reported
0.2 that the Er:YAG laser was equally efficient in killing
pigmented and non-pigmented bacteria on culture
plates.27 We, therefore, decided to not to experiment
with technique-sensitive anaerobic bacteria as P. gin-
givalis and P. intermedia in favor of simple and repro-
ducible test conditions with an aerobic bacterium.
Streptococcus sanguis is a primary intraoral colonizer
of enamel and implant surfaces which leads to coag-
gregation of pathogenic bacteria.39,40 It can, therefore,
be associated with peri-implant infection.
The microbiological and microscopy results of the
present study indicate that the Er:YAG laser has a high
bactericidal potential on common implant surfaces.
The application of high energy lasers in dentistry, how-
ever, requires special consideration of potential risks
of inadvertent tissue and material damage. With regard
to the treatment of peri-implantitis, this refers to pos-
sible implant surface alterations and excessive heat
generation in the peri-implant bone. Temperature rises
over 47°C have been reported to induce damage to
bone structures and must be avoided during laser
decontamination.41 The energy densities and the time
of irradiation applied in this investigation were deter-

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J Periodontol • November 2002
mined subsequent to temperature measurements by
means of an in vitro bone model as well as by an SEM-
and energy dispersive spectrometry-investigation of
laser treated implants at various pulse energies.37,42
Er:YAG laser irradiation at pulse energies over 120 mJ
may cause visible alterations in the implant surfaces
investigated.37 This critical temperature threshold of
47°C is not exceeded even during a continuous 2-
minute irradiation period. Er:YAG irradiation of implants
at the energy settings applied in this study can there-
fore be considered safe. It seems that the application
of lasers might be an adequate treatment alternative
for cleaning the surface of ailing implants. Clinical
studies are justified to evaluate the applicability and
efficacy of the Er:YAG laser in the treatment of peri-
implantitis.
ACKNOWLEDGMENTS
The authors express their appreciation to Friadent
GmbH, Mannheim, Germany for providing the titanium
discs and to Mrs. Susanne Teske-Kaiser for her kind
support in the laboratory work.
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