93557_LaserDentistry:Laser Dentistry - Academy of Laser Dentistry

17 downloads 26 Views 5MB Size Report
use of lasers in dentistry. The Academy ... the Journal of Laser Dentistry is to present information about the use of lasers in dentistry. .... PowerPoint presentations.

The Official Journal of the Academy of Laser Dentistry

2008 2008 •• Vol. Vol. 16 16 No. No. 33

In This Issue CE Credits Available

The Use of Laser Energy in Implantology See the review article on page 117

Case Reports: • Treatment of Venous Lake with a Diode Laser • Gingival Depigmentation with an Er:YAG Laser • Diode Laser Therapy for the Patient Who Smokes • Diode Laser Treatment of Drug-Induced Gingival Enlargement

Academy of Laser Dentistry 3300 University Drive, Suite 704 Coral Springs, FL 33065

Journal of Laser Dentistry

Consulting Editor John G. Sulewski, MA Huntington Woods, MI [email protected] Associate Editors Craig Gimbel, DDS, Denville, NJ Alan J. Goldstein, DMD, New York, NY Peter Pang, DDS, Sonoma, CA Donald E. Patthoff, DDS, Martinsburg, WV Steven P.A. Parker, BDS, LDS RCS, MFGDP, Harrogate, United Kingdom Peter Rechmann, Prof. Dr. med. dent., San Francisco, CA David Roshkind, DMD, Gainesville, FL Wayne Selting, DDS, Colorado Springs, CO Michael D. Swick, DMD, Conneaut Lake, PA Publisher Max G. Moses Member Media 1844 N. Larrabee • Chicago, IL 60614 312-296-7864 • Fax: 312-896-9119 [email protected] Design and Layout Diva Design 2616 Missum Pointe • San Marcos, TX 78666 512-665-0544 • Fax 609-678-0544 [email protected] Editorial Office 3300 University Drive, Suite 704 Coral Springs, FL 33065

Onward and Upward ................................................................................115 Donald J. Coluzzi, DDS

I N T H I S I S S U E ..............................................................................116 C O V E R F E AT U R E CLINICAL REVIEW The Use of Laser Energy in Implantology ..........................................117 Steven P. A. Parker, BDS, LDS RCS, MFGDP

CLI N ICAL CASES Noncontact Venous Lake Treatment Using a 980-nm Diode Laser 126 David Burt, DDS, Center Valley, Pennsylvania Gingival Depigmentation with an Er:YAG Laser: A Clinical Case with Three-Year Follow-Up ........................................130 Grace Sun, DDS, Los Angeles, California “The Good, the Bad, and the Ugly”: 810-830-nm Diode Laser Therapy for the Periodontal Patient Who Smokes ..........................133 Nora Raffetto, RDH, Los Altos Hills, California Gingivoplasty Using an 810-nm Diode Laser to Treat Drug-Induced Gingival Enlargement ....................................136 John J. Graeber, DMD, MAGD, FICD, Master of the Academy of Laser Dentistry

R ESEARCH ABSTR ACTS Laser Treatment of Gingival Hyperplasia............................................140 954-346-3776 Fax 954-757-2598 www.laserdentistry.org [email protected] The Academy of Laser Dentistry is a not-for-profit organization qualifying under Section 501(c)(3) of the Internal Revenue Code. The Academy of Laser Dentistry is an international professional membership association of dental practitioners and supporting organizations dedicated to improving the health and well-being of patients through the proper use of laser technology. The Academy is dedicated to the advancement of knowledge, research and education and to the exchange of information relative to the art and science of the use of lasers in dentistry. The Academy endorses the Curriculum Guidelines and Standards for Dental Laser Education. Member American Association of Dental Editors

G U E S T E D I TO R I A L LASERMIND ................................................................................................143 Alan Goldstein, DMD, New York, New York

20 0 8 VO L 16 , N O . 3

Managing Editor Gail S. Siminovsky, CAE, Executive Director Coral Springs, FL [email protected]

E D I TO R ’ S V I E W

C O N T I N U I N G E D U C AT I O N ..............................................145 CE Program ................................................................................................145 CE Questions ..............................................................................................145 CE Registration Form & Answer Sheet ................................................147

The Journal of Laser Dentistry The mission of the Journal of Laser Dentistry is to provide a professional journal that helps to fulfill the goal of information dissemination by the Academy of Laser Dentistry. The purpose of the Journal of Laser Dentistry is to present information about the use of lasers in dentistry. All articles are peer-reviewed. Issues include manuscripts on current indications for uses of lasers for dental applications, clinical case studies, reviews of topics relevant to laser dentistry, research articles, clinical studies, research abstracts detailing the scientific basis for the safety and efficacy of the devices, and articles about future and experimental procedures. In addition, featured columnists offer clinical insights, and editorials describe personal viewpoints.

|

Editor-in-Chief Donald J. Coluzzi, DDS Portola Valley, CA [email protected]

TA B L E O F C O N T E N T S

J O U R N A L O F L AS E R D E N T I ST RY

The official journal of the Academy of Laser Dentistry

Journal of Laser Dentistry: Guidelines for Authors The Academy of Laser Dentistry Welcomes Your Articles for Submission The Journal of Laser Dentistry publishes articles pertaining to the art, science, and practice of laser dentistry. Articles may be scientific and clinical in nature discussing new techniques, research, and programs, or may be applicationsoriented describing specific problems and solutions. While lasers are our preferred orientation, other high-technology articles, as well as insights into marketing, practice management, regulation, and other aspects of dentistry that may be of interest to the dental profession, may be appropriate. All articles are peer-reviewed prior to acceptance, modification, or rejection. These guidelines are designed to help potential authors in writing and submitting manuscripts to the Journal of Laser Dentistry, the official publication of the Academy of Laser Dentistry (ALD). Please follow these instructions carefully to expedite review and processing of your submission. Manuscripts that do not adhere to these instructions will not be accepted for consideration. The Academy of Laser Dentistry and the editors and publisher of the Journal of Laser Dentistry endorse the “Uniform Requirements of Manuscripts Submitted to Biomedical Journals” (www.icmje.org). The Journal reserves the right to revise or rescind these guidelines. Authors are advised to read the more comprehensive Guidelines for Authors and required forms available by mail or online at www.laserdentistry.org. Manuscript Eligibility Submitted manuscripts must be written clearly and concisely in American English and appropriate for a scholarly journal. Write in active voice and use declarative sentences. Manuscripts will be considered for publication on the condition that they have been submitted exclusively to the Journal, and have not been published or submitted for publication in any part or form in another publication of any type, professional or lay, or in any language elsewhere, and with the understanding that they will not be reprinted without written consent from both the managing editor and the author. Permissions Direct quotations of 100 or more words, and illustrations, figures, tables, or other materials (or adaptations thereof) that have appeared in copyrighted material or are in press must be accompanied by written permission for their use in the Journal of Laser Dentistry from the copyright owner and original author along with complete information regarding source, including (as applicable) author(s), title of article, title of

journal or book, year, volume number, issue number, pages. Photographs of identifiable persons must be accompanied by valid signed releases indicating informed consent. When informed consent has been obtained from any patient, identifiable or not, it should be noted in the manuscript. The appropriate Permission Letters must be submitted with the manuscript. Suggested template letters are available online.

signed by each author. Manuscripts will not be reviewed without the Journal having this form on file. The Academy of Laser Dentistry also requires that authors disclose whether any product discussed in their manuscript is unlabeled for the use discussed or is investigational. The Disclosure Statement form is available online and must be submitted with the manuscript.

Copyright All manuscript rights shall be transferred to the Journal of Laser Dentistry upon submission. Upon submission of the manuscript, authors agree to submit a completed Copyright Transfer Agreement form, available online. If the manuscript is rejected for publication, all copyrights will be retained by the author(s).

Manuscript Types Submissions to the Journal should be limited to one of the types indicated below. • Scientific / Technology / Clinical Review • Case Reports and Clinical Case Studies • Scientific / Clinical Research • Randomized Clinical Trials • Advances in Dental Products • Trends • Practice Management • Guest Editorials and Essays • Letters to the Editor • Book Reviews

Commercialism ALD members are interested in learning about new products and service offerings, however ALD stresses that submitted manuscripts should be educational in nature. The emphasis is on scientific research and sound clinical and practical advice, rather than promotion of a specific product or service. Disclosure of Commercial Relationships According to the Academy’s Conflict of Interest and Disclosure policy, manuscript authors and their institutions are expected to disclose any economic or financial support, as well as any personal, commercial, technological, academic, intellectual, professional, philosophical, political, or religious interests or potential bias that may be perceived as creating a conflict related to the material being published. Such conditions may include employment, consultancies, stock ownership or other equity interests, honoraria, stipends, paid expert testimony, patent ownership, patent licensing arrangements, royalties, or serving as an officer, director, or owner of a company whose products, or products of a competitor, are identified. Sources of support in the form of contracts, grants, equipment, drugs, material donations, clinical materials, special discounts or gifts, or other forms of support should be specified. The roles of the study or manuscript sponsor(s), if any, are to be described. Disclosure statements are printed at the end of the article following the author’s biography. This policy is intended to alert the audience to any potential bias or conflict so that readers may form their own judgments about the material being presented. Disclosure forms are to be

Manuscript Preparation and Submission Format All submitted manuscripts should be double-spaced, using 12 pt. font size with at least 6 mm between lines. Submit manuscripts in Microsoft Word (.doc), using either the Windows or Macintosh platform. Manuscripts must be submitted electronically in this format. Hard copy-only submissions will not be accepted. Unacceptable Formats The following submission formats are unacceptable and will be returned: • Manuscripts submitted in desktop publishing software • PowerPoint presentations • Any text files with embedded images • Images in lower than the minimum prescribed resolution. Manuscript Components Title Page The title page of the manuscript should include a concise and informative title of the article; the first name, middle initial(s), and last name of each author, along with the academic degree(s), professional title(s), and the name and location (city, state, zip code) of current institutional affiliation(s) and department(s). Authors who are private practitioners should identify their location (city, state, and country). Include all information in the title that will make electronic retrieval of the article sensitive and specific. Titles of case studies

should include the laser wavelength(s) and type(s) utilized for treatment (for example, “810-nm GaAlAs diode”). Identify the complete address, business and home telephone numbers, fax number, e-mail address, and Web site address (if any) for all authors. Identify one author as the corresponding author. Unless requested otherwise, the e-mail address is published in the Journal. Abstract A self-standing summary of the text of up to 250 words should precede the introduction. It should provide an accurate summary of the most significant points and be representative of the entire article’s content. Provide the context or background for the article, basic procedures, main findings and conclusions. Emphasize new or important aspects. Do not use abbreviations (other than standard units of measurement) or references in the abstract. Author(s) Biography Provide a brief, current biographical sketch of each author that includes professional education and professional affiliations. For authors who hold teaching positions, include the title, department, and school. For authors who are in federal service, include rank or title and station. References References are to be cited in the text by number in order of appearance, with the number appearing either as a superscript or in brackets. The reference list should appear at the end of the manuscript with references in order of first appearance in the text of the manuscript. The reference list must be typed double-spaced on a separate page and numbered in the same sequence as the reference citations appear in the text. Prior to submission, all references are to be properly prepared in the correct format, checked for completeness, carefully verified against their original documents, and checked for accurate correspondence between references cited in the text and listed in the References section. • For journal citations, include surnames and all initials of all authors, complete title of article, name of journal (abbreviated according to the U.S. National Library of Medicine (www.nlm.nih.gov/services/ lpabbrev.html), year of publication, volume, issue number, and complete inclusive page numbers. If abstracts are cited, add the abstract number after the page number. • For book citations, specify surnames and initials of all authors, chapter number and title (if applicable), editors’ surnames and initials, book title, volume number (if applicable),









edition number (if applicable), city and full name of publisher, year of publication, and inclusive page numbers of citation. For government publications or bulletins, identify the author(s) (if given); title; department, bureau, agency, or office; the publication series, report, or monograph number; location of publisher; publisher; year of publication; and inclusive page numbers. For articles published online but not yet in print, cite with the paper’s Digital Object Identifier (DOI) added to the end of the reference. For Web citations, list the authors and titles if known, then the URL and date it was accessed. For presentations, list the authors, title of presentation, indication that the reference is a lecture, name of conference or presentation venue, date, and location.

Illustration Captions and Legends All illustrations must be accompanied by individual explanatory captions which should be typed double-spaced on a separate page with Arabic numerals corresponding to their respective illustration. Tables Tables must be typewritten doublespaced, including column heads, data, and footnotes, and submitted on separate pages. The tables are to be cited in the text and numbered consecutively in Arabic numerals in the order of their appearance in the text. Provide a concise title for each table that highlights the key result. Illustrations Illustrations include photographs, radiographs, micrographs, charts, graphs, and maps. Each should be numbered and cited in the text in the order of appearance and be accompanied by explanatory captions. Do not embed figures within the manuscript text. Each figure and table should be no larger than 8-1/2 x 11 inches. Digital files must measure at least 5 inches (127 mm) in width. The image must be submitted in the size it

will be printed, or larger. Illustrations are to augment, not repeat, material in the text. Graphs must not repeat data presented in tables. Clinical photographs must comply with ALD’s Guidelines for Clinical Photography, available online. Authors are to certify in a cover letter that digitized illustrations accurately represent the original data, condition, or image and are not electronically edited. Publisher and Copyright Holder The Journal of Laser Dentistry is published by Max G. Moses, Member Media, 1844 N. Larrabee, Chicago, IL 60614, Telephone: (312) 296-7864; Fax: (312) 896-9119. The Journal of Laser Dentistry is copyrighted by The Academy of Laser Dentistry, 3300 University Drive, Suite 704, Coral Springs, FL 33065, Telephone: (954) 346-3776; Fax: (954) 757-2598. Articles, Questions, Ideas Questions about clinical cases, scientific research, or ideas for other articles may be directed to Donald J. Coluzzi, Editor-inChief, by e-mail: [email protected] Submission of Files by E-mail: Send your completed files by e-mail (files up to 10 MB are acceptable). If files are larger than 10 MB, they may be compressed or sent as more than one file, with appropriate labels. Files should be submitted to: Donald J. Coluzzi, Editor-in-Chief, by e-mail: [email protected] By Federal Express or Other Insured Courier: If using a courier, please send the file as a CD-ROM, include a hard copy of your manuscript and also send a verification by e-mail to Gail Siminovsky ([email protected]). Gail Siminovsky Academy of Laser Dentistry 3300 University Drive, Suite 704 Coral Springs, FL 33065 Phone: (954) 346-3776.

Summary of Illustration Types and Specifications Illustration Type

Definition and Examples

Preferred Format

Required Resolution

Line Art and Black and white graphic with no EPS or JPG 1200 DPI Vector Graphics shading (e.g., graphs, charts, maps)

Halftone Art

Photographs, drawings, or painting with fine shading (e.g., radi- TIFF or ographs, micrographs with scale JPG bars, intraoral photographs)

Combination Art

Combination of halftone and line art (e.g., halftones containing EPS or JPG 1200 DPI line drawing, extensive lettering, color diagrams)

300 DPI (black & white) 600 DPI (color)

Editorial Policy The Journal of Laser Dentistry is devoted to providing the Academy and its members with comprehensive clinical, didactic and research information about the safe and effective uses of lasers in dentistry. All statements of opinions and/or fact are published under the authority of the authors, including editorials and articles. The Academy is not responsible for the opinions expressed by the writers, editors or advertisers. The views are not to be accepted as the views of the Academy of Laser Dentistry unless such statements have been expressly adopted by the organization. Information on any research, clinical procedures or products may be obtained from the author. Comments concerning content may be directed to the Academy’s main office by e-mail to [email protected] Submissions We encourage prospective authors to follow JLD’s “Instructions to Authors” before submitting manuscripts. To obtain a copy, please go to our Web site www.laserdentistry.org/press.cfm. Please send manuscripts by e-mail to the Editor at [email protected] Disclosure Policy of Contributing Authors’ Commercial Relationships According to the Academy’s Conflict of Interest and Disclosure policy, authors of manuscripts for JLD are expected to disclose any economic support, personal interests, or potential bias that may be perceived as creating a conflict related to the material being published. Disclosure statements are printed at the end of the article following the author’s biography. This policy is intended to alert the audience to any potential bias or conflict so that readers may form their own judgments about the material being presented. Disclosure Statement for the Academy of Laser Dentistry The Academy of Laser Dentistry has no financial interest in any manufacturers or vendors of dental supplies. Reprint Permission Policy Written permission must be obtained to duplicate and/or distribute any portion of the Journal of Laser Dentistry. Reprints may be obtained directly from the Academy of Laser Dentistry provided that any appropriate fee is paid. Copyright 2008 Academy of Laser Dentistry. All rights reserved unless other ownership is indicated. If any omission or infringement of copyright has occurred through oversight, upon notification amendment will be made in a future issue. No part of this publication may be reproduced or transmitted in any form or by any means, individually or by any means, without permission from the copyright holder. The Journal of the Academy of Laser Dentistry ISSN# 1935-2557. JLD is published quarterly and mailed nonprofit standard mail to all ALD members. Issues are also mailed to new member prospects and dentists requesting information on lasers in dentistry. Advertising Information and Rates Display rates are available at www.laserdentistry.org/press.cfm and/or supplied upon request. Insertion orders and materials should be sent to Bill Spilman, Innovative Media Solutions, P.O. Box 399, Oneida, IL 61467, 877-878-3260, fax: 309-483-2371, e-mail [email protected] For a copy of JLD Advertising Guidelines go to www.laserdentistry.org/press_advguide_policy.cfm. The cost for a classified ad in one issue is $50 for the first 25 words and $2.00 for each additional word beyond 25. ALD members receive a 20% discount. Payment must accompany ad copy and is payable to the Academy of Laser Dentistry in U.S. funds only. Classified advertising is not open to commercial enterprises. Companies are encouraged to contact Bill Spilman for information on display advertising specifications and rates. The Academy reserves the right to edit or refuse ads.

Editor’s Note on Advertising: The Journal of Laser Dentistry currently accepts advertisements for different dental laser educational programs. Not all dental laser educational courses are recognized by the Academy of Laser Dentistry. ALD as an independent professional dental organization is concerned that courses meet the stringent guidelines following professional standards of education. Readers are advised to verify with ALD whether or not specific courses are recognized by the Academy of Laser Dentistry in their use of the Curriculum Guidelines and Standards for Dental Laser Education.

E D I TO R ’ S V I E W

Onward and Upward Donald J. Coluzzi, DDS Portola Valley, California J Laser Dent 2008;16(3):115

I am honored to serve as your Editor for the Journal of Laser Dentistry. For those of you who don’t know me, I am a charter member of the Academy of Laser Dentistry (ALD); was president of the organization in 1998; and, along with Dr. Steven Parker, coedited Wavelengths, the predecessor to the Journal. I have also served on various committees, especially Certification and Communications. Together with my team of Associate Editors, I intend to continue with the Journal’s mission to provide you with the best and most useful information about dental lasers from clinical and research perspectives. I do need your help: please consider writing an article. Your submission can range from a clinical case to a scientific paper derived from a study; from a new technique to a review of common procedures; from a literature review to clinical

problem solving; and from an insight into practice management to safety issues. All manuscripts will be peer-reviewed and the “Guidelines for Authors” are published in each issue to help you. This year has been remarkable for the ALD. Celebrating its fifteenth anniversary, it has grown into a strong international organization. It has fostered relationships with the American Dental Association, Academy of General Dentistry, and the American Dental Education Association. The upcoming Annual Conference in Las Vegas has an outstanding preliminary program, and the Academy’s committees are involved in important tasks to help the leadership in its governance. I will persevere in my role to produce a worthy publication for you, the ALD membership. A preview of this edition's content appears on the next page. I hope you enjoy this issue.

Disclosure: Dr. Coluzzi is an occasional presenter and trainer for Hoya ConBio, and receives an honorarium for that service. ■■

|

and describes the contents of this issue.

J O U R N A L O F L AS E R D E N T I ST RY

Donald J. Coluzzi, the new editor-in-chief, welcomes your articles

Dr. Donald Coluzzi, a 1970 graduate of the University of Southern California School of Dentistry, is an associate clinical professor in the Department of Preventive and Restorative Dental Sciences at the University of California San Francisco School of Dentistry. A charter member and past President of the Academy of Laser Dentistry, he has used dental lasers since early 1991. He has Advanced Proficiency in Nd:YAG and Er:YAG laser wavelengths. He is the 1999 recipient of the Leon Goldman Award for Clinical Excellence and the 2006 Distinguished Service Award from the Academy of Laser Dentistry, and is a Fellow of the American College of Dentists. Dr. Coluzzi has presented about lasers worldwide, co-authored two books, and published several peerreviewed articles.

20 0 8 VO L 16 , N O . 3

AU T H O R B I O G R AP H Y

S YN O P S I S

Coluzzi

115

In This Issue…

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

J Laser Dent 2008;16(3):116

116

This edition of the Journal features a scientific review of the use of lasers for implant dentistry as well as four examples of soft tissue procedures using two laser wavelengths. Clearly, all available dental lasers can perform a variety of soft tissue procedures; however, the two highlighted here, diode and Er:YAG, possess fundamentally different tissue interactions, but both are effective. Your scrutiny of these articles will hopefully enhance your understanding of how these lasers can produce the results indicated. Supplemental reading materials and suggestions appear below and in the Research Abstracts section. In addition, the guest editorial sums up how we can think with our “lasermind.” Readers are invited to examine the following additional references to enhance their understanding of the clinical cases. Previous issues of the Journal and its predecessor publications have featured similar applications. Noncontact Venous Lake Treatment Using a 980-nm Diode Laser David Burt, DDS Center Valley, Pennsylvania ADDITIONAL READING: VENOUS LAKES AND VASCULAR LESIONS 1. del Pozo J, Peña C, García Silva J, Goday JJ, Fonseca E. Venous lakes: A report of 32 cases treated by carbon dioxide laser vaporization. Dermatol Surg 2003;(3):308-310. 2. Kotlow LA. Elimination of a venous lake on the vermilion of the lower lip via 810-nm diode laser. J Laser Dent 2007;15(1):20-22. 3. Rice JH. Removal of venous laser using a diode laser (810 nm).

Wavelengths 2004;12(1):20-21. 4. Research abstracts. Laser treatment of vascular lesions of the lip. J Laser Dent 2008;16(1):48-50. Gingival Depigmentation with an Er:YAG Laser: A Clinical Case with Three-Year Follow-Up Grace Sun, DDS Los Angeles, California ADDITIONAL READING: GINGIVAL DEPIGMENTATION 1. Díaz, M. CO2 laser treatment of pigmented lesion – Focal melanotic macule. Wavelengths 1999;7(3):22-23. 2. Gartner LP, Hiatt JL. Color textbook of histology. 3rd edition. Philadelphia: Saunders, 2007:332-334. 3. Luk K. Clinical application of a digital pulsed diode laser in depigmentation therapy. J Acad Laser Dent 2005;13(4):18-21. 4. Nanci A. Ten Cate’s oral histology. Development, structure, and function. Philadelphia: Mosby, 2008:333-335. 5. Research abstracts. Wavelengths 1999;7(3):8. 6. Research abstracts. Wavelengths 2004;12(1):30-32. 7. Takahashi K. Removal of gingival melanin hyperpigmentation with an Er:YAG laser. J Acad Laser Dent 2005;13(3):1819. 8. Umemoto H. Melanin pigmentation removal assisted with an Nd:YAG laser. Wavelengths 2004;12(1):14-16. 9. Young B, Lowe JS, Stevens A, Heath JW. Wheater’s functional histology. A text and colour atlas. 5th edition. Philadelphia: Elsevier, 2006:172-173.

“The Good, the Bad, and the Ugly”: 810-830-nm Diode Laser Therapy for the Periodontal Patient Who Smokes Nora Raffetto, RDH Los Altos Hills, California ADDITIONAL READING: PERIODONTITIS AND SMOKING, SULCULAR DEBRIDEMENT 1. Bergström J, Eliasson S, Dock J. Exposure to tobacco smoking and periodontal health. J Clin Periodontol 2000;27(1):61-68. 2. Fisher S, Kells L, Picard J-P, Gelskey SC, Singer DL, Lix L, Scott DA. Progression of periodontal disease in a maintenance population of smokers and non-smokers: A 3year longitudinal study. J Periodontol 2008;79(3):461-468. 3. Heitz-Mayfield LJA. Periimplant diseases: Diagnosis and risk indicators. J Clin Periodontol 2008;35(8 Suppl):292-304. 4. Johnson GK, Hill M. Cigarette smoking and the periodontal patient. J Periodontol 2004;75(2):196-209. 5. Maestas LB. Nd:YAG laser curettage as an adjunctive treatment of type III moderate periodontitis. Wavelengths 2001;9(3):19. 6. Martinelli E, Palmer RM, Wilson RF, Newton JT. Smoking behaviour and attitudes to periodontal health and quit smoking in patients with periodontal disease. J Clin Periodontol 2008;35(11):944-954. 7. McMahon JL. Nd:YAG laserassisted treatment of acute periodontal disease: Case 2. J Acad Laser Dent 2005;13(2):2528. 8. Mott AS. Nd:YAG laser-assisted treatment of chronic periodontal disease: Case 1. J Acad Laser Dent 2005;13(2):13-16. ■■

C O V E R F E AT U R E

The Use of Laser Energy in Implantology Steven P. A. Parker, BDS, LDS RCS, MFGDP Harrogate, North Yorks, United Kingdom

This article discusses how lasers can be used during various

Laser use in dentistry is wellfounded. The emergence of many laser wavelengths in commercially available machines has allowed evidence-based application of photonic energy in aspects of oral and dental surgery. In addition, the prime benefits of incisional hemostasis, precision, and pathogen reduction have enabled the surgical manipulation of both hard and soft tissue within clinical dentistry.

dental implant procedures, including assisting in the osseous site preparation, second stage exposure, and the treatment of peri-

Introduction The use of laser photonic energy has been shown to be effective in many aspects of clinical dentistry. The benefits of laser use include precision, hemostasis, pathogen reduction, and interaction with both hard and soft oral and dental tissue, depending on the laser wavelength employed.1 In consideration of the breadth of application of laser therapy with oral tissue and bacteria, the areas of implantology in clinical dental practice that might be applicable to the use of laser photonic energy are the possible preparation of osteotomy sites for placement, together with bone modification procedures, soft

tissue manipulation in assisting the second-stage recovery of healed implants, and in the treatment of peri-implantitis.

Laser-Assisted Osteotomy Site Preparation Bone is a connective tissue derived from hyaline cartilage whose matrix, under the influence of calciferol, has been hardened by the deposition of calcium and phosphate to form a carbonated hydroxyapatite-like mineral.2 Erbium:YAG (2940 nm) and erbium,chromium: YSGG (2780 nm) are the two lasers in current clinical practice that are used for osseous procedures. Erbium laser energy is absorbed by chromophores (naturally occurring substances) found in bone tissue — water and the hydroxyl groups of the hydroxyapatite mineral. Ablation occurs through vaporization of water and explosive dislocation of mineralized tissue.3-4 The nature of the ablaFigure 1: Scanning electron micrographs of animal specimen tive process achieved with bone showing ablation crater prepared with an Er:YAG laser. commercially availKey: Upper left specimen x20 magnification, lower right able microsecond specimen further magnified to x100 power. Laser paramepulse emission, ters used: 400 mJ per pulse / 10 Hz / Average Power 4.0 together with the Watts / Beam size 600 µm / Water spray

Dental implantology demands well-defined protocols to ensure the osseointegration of rootform titanium abutments is predictable and maintainable. Early stability of the fixture within the osteotomy site appears necessary to ensure approximation of osseous tissue, and the proportionate loading of the integrated implant, together with appropriate maintenance, are protocols to ensure longterm survivability. With the introduction of dental laser therapy, a growing interest in the application of this therapy in implantology has allowed laser-assisted treatment to be investigated in the areas of implant placement, second-stage recovery, and treatment of periimplantitis. The purpose of this paper is to examine how photonic energy

inherently low absorption of these wavelengths in pigmented blood proteins, offers limited opportunity for conductive thermal rise; consequently, there is minimal hemostasis with the use of these wavelengths and their emission parameters, which is a desired effect in bone surgery procedures (Figure 1).

Parker

|

ABSTR ACT

J O U R N A L O F L AS E R D E N T I ST RY

S YN O P S I S

20 0 8 VO L 16 , N O . 3

J Laser Dent 2008;16(3):117-125

117

With laser energy, it is possible to cut bone which allows graft harvesting and sinus-lift procedures to be carried out. The fundamental concern in any bone surgical procedure is to limit thermal rise to within 47 °C and for less than one minute,5 in order to avoid damage to cellular components of bone metabolism and delayed healing.6 With regard to this limit, studies have been carried out to investigate the physical and thermal effects of rotary instrumentation and Er:YAG and CO2 laser wavelengths on bone tissue.7-8 Conclusions have been drawn as to the benefits of the erbium laser wavelengths with water spray in limiting the thermal rise,9-11 and one study alluded to the possible promotion of osteogenic biochemical agents that might induce accelerated healing of the bone tissue.12 The conventional protocol of osteotomy site preparation involves the use of burs, which may be internally irrigated and which are operated at an appropriate speed in order to minimize thermal rise in the hard tissue.13 Such preparation

allows the implant to be either tapped into position or threaddriven using a torque wrench or low-ratio handpiece. Although laser use is considered precise for many procedures, the mode of action of the emerging photonic beam is end-cutting and does not allow for a measured development of a fixed diameter three-dimensional preparation of the bone.14 In addition, the delivery of adequate water spray that is necessary when using erbium lasers may be difficult in deep preparations (Figure 2). In a study of tissue healing by Kesler and colleagues, a 2-mm diameter osteotomy was performed and titanium implants were placed. The measured parameter of boneimplant contact demonstrated greater value in the sites prepared with an Er:YAG laser compared to the control.15 In practice, there are anecdotal reports of site preparation in bone prior to implant placement, where an Er,Cr:YSGG laser is used with specially designed, lengthened delivery tips to allow adequate water irrigation of the target site.16 Although success has been demonstrated, there remains concern as to the accuracy of the preparation when compared to conventional bone drilling.

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

C O V E R F E AT U R E

118

Figure 2: Light micrograph of demineralized, sectioned, and stained osteotomy preparations in animal specimen bone. Key: Left specimen shows preparation with conventional internally irrigated implant osteotomy bur. Right specimen shows similar preparation with an Er:YAG laser, with evidence of marginal irregularities and charred residues, indicative of poor water cooling. Laser parameters used: 400 mJ per pulse / 10 Hz / Average Power 4.0 Watts / Beam size 600 µm /

Parker

Laser-Assisted Second-Stage Recovery of Implants In some cases, the implant site may be subject to immediate loading, although the majority of sites are allowed to heal for at least a 3-month period, prefer-

ably with a closed soft tissue layer.17-19 The restorative phase requires the exposure of the implant cover screw and at this time a decision is made as to how much modification of the soft tissue is needed. In an ideal case, or where aesthetics is not a prime consideration, the simple exposure of the cover screw involves a mucoperiosteal flap, a soft tissue punch, or the use of a suitable laser to ablate the overlying epithelium. All laser wavelengths commercially available in dentistry are capable of positive interaction with target soft tissue, although the longer wavelengths (erbium family at 2780 and 2940 nm or CO2 at 10,600 nm) preferentially react with the water content of that tissue.20 Where the tissue is pigmented or liable to bleeding, a shorter laser wavelength, such as the frequency-doubled Nd:YAG or KTP (potassium titanyl phosphate) (532 mm), diode (810 to 980 nm), or Nd:YAG (1064 nm), may be preferable.21 Each tissue element is capable of absorbing incident photonic energy, dependent on the laser wavelength. The consequent conversion of this laser energy into thermal energy will result in tissue change.22 The benefits of laser use include precision, hemostasis (which can be varyingly effective depending on the wavelength), and immediate postoperative protection through a coagulum surface.23-24 It is essential to accurately assess the position of the implant site relative to the edentulous ridge. This may be done through Xray, model mapping, and using natural landmarks; exposure of the cover screw allows an impression to be taken from which the prosthetic superstructure can be made. Further assessment must be made of the soft tissue emergence profile, to establish whether augmentation is required to support the aesthetic appearance or whether modification is required to reduce the soft tissue peri-implant collar to allow

C O V E R F E AT U R E

Figure 6: Case as in Figure 5, showing abutment placement and final pros-

correct maintenance. The use of lasers in the harvesting of distant connective tissue grafts has been reported through case reports and anecdotal accounts.25-26 Specifically, however, it is the subject of this review to examine the use of varying laser wavelengths to remove the tissue immediately overlying the implant site. Local anesthetic may or may not be used, depending on patient and operator preference. Some analysis of the form, thickness, and vascularity of the tissue should be made, which will define a choice of laser wavelength or, if not possible, the operating parameters. By use of a minimal power value commensurate with tissue ablation, a small cone of tissue is removed until

near-contact with the screw is made. From this, the tissue opening is extended to a point within the diameter of the cover screw. Typical laser average power values should be in the range of 1 to 1.5 Watts to assess the ablation efficiency and increased slightly as required. However, care should be exercised to avoid the buildup of any carbonized material.27 In the author’s experience, at the stage of near-contact with the cover screw any remaining tissue tags should be removed with a sharp curette; the screw is removed and a suitable healing cap placed. The immediate post-surgery phase can be suitably managed through the topical application of a chlorhexidine mouthwash. With correct laser power settings, the choice of laser wavelength may be viewed as often irrelevant to the

Figure 8: Case as in Figure 7, showing abutment placement and final pros-

predictability of healing of the soft tissue collar (Figures 3-8). The management of excessive soft tissue may be addressed in the same way as any laser-assisted debulking procedure – pedunculated overgrowths can be excised immediately above the base, and less-defined excess tissue can be incised under tension or, in the case of longer laser wavelengths, reduced by surface ablation. Where the objective is to reduce the thickness of the gingival collar around the transmucosal element, a technique similar to gingivoplasty / gingivectomy can be employed, using either a provisional crown or custom-made acrylic abutments to protect the metal surface of the transmucosal element (TME). In those cases where a more radical adjustment of overlying soft tissue

Parker

20 0 8 VO L 16 , N O . 3

Figure 7: Second-stage recovery of implant using a CO2 (10,600 nm) laser. Key: Upper left showing laser ablation of soft tissue, lower right showing healed collar at 10 days. Laser parameters used: 1.5 Watts pulsed / Beam size 600 µm / Noncontact mode

Figure 5: Second-stage recovery of implant using an Er:YAG laser. Key: Upper left showing laser ablation of soft tissue, lower right showing healed collar at 10 days. Laser parameters used: 250 mJ per pulse / 10 Hz / Average Power 2.5 Watts / Beam size

|

Figure 3: Second-stage recovery of implant using a diode (810 nm) laser. Key: Upper left showing laser ablation of soft tissue, lower right showing healed collar at 10 days. Laser parameters used: 1.4 Watts CW / Beam size 320 µm / Contact mode

J O U R N A L O F L AS E R D E N T I ST RY

Figure 4: Case as in Figure 3, showing abutment placement and final pros-

119

C O V E R F E AT U R E

Figure 9: Use of a diode (810 nm) laser in gingival margin modification associated with three upper right quadrant implants. Key: Upper left – Preoperative view with acrylic temporary crowns in place to provide protection to the TME and allow accuracy of the gingivectomy. Lower left – Immediately post-laser use with crowns removed. Right – Healing at 3 months with final restorations in place. Laser parameters used: 1.4 Watts CW / Beam size 320 µm / Contact

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

is required, careful dissection of the tissue should be carried out using the laser with minimal power levels to avoid any heat buildup or pitting in the abutment (Figures 9-10).

120

Laser-Assisted Therapy in PeriImplantitis According to the 1st European Workshop on Periodontology, periimplantitis is defined as the “term for inflammatory reactions with loss of supporting bone in the tissues surrounding a functioning implant.”28 Associated definitions exist to identify the nontissue nature of the metal fixture — the American Academy of Implant Dentistry has noted “implant histoclasia” or “peri-implantoclasia” as appropriate terms to denote conditions around the implant and these terms are published in the 1974 Current Clinical Dental Terminology’s glossary of terms.29 Nonetheless, the term peri-implantitis has persisted, and as a rapidly progressive failure of osseo-integration, the condition is due to bacterial toxins and yeasts disrupting the bone homeostasis.30

Parker

Figure 10: Use of a CO2 (10,600 nm) laser to correct gingival contour. Original second-stage exposure of two implants, using scalpel and flap procedure has led to inappropriate gingival contour. Key: Upper left – Post-scalpel excision at three weeks. Lower left – Laser used to ablate excess soft tissue. Right – Healing cap exposure and healing at 10 days. Laser parameters used: 2.0 Watts pulsed / Beam size 600 µm / Noncontact mode

The condition occurs irrespective of implant type,31-32 and is part of the etiology of implant loss, along with associated phenomena such as occlusal overloading and poor emergence profiles of the restoration.33-34 A review of 26 articles mapping the survivability of implant-supported single crowns showed that 9.7% of treatment sites had evidence of peri-implantitis and 6.3% showed greater than 2 mm of crestal bone loss over a 5year observation period.35 The distinction must be made as to whether the implant site exhibits essentially treatable periimplantitis (the “ailing” implant), or whether the loss of the fixture is inevitable (the “failing” implant). Wherever possible, the implant should be isolated; and, if it is not mobile, reparative treatment could be undertaken.36 The underlying bacterial involvement in cases of peri-implantitis — overt signs of infection and inflammation, marked infiltration of the periimplant connective tissue by inflammatory cells, ulceration and proliferation of the junctional

epithelium — has been demonstrated. However, microflora associated with infective failure are those that also cause periodontitis.37 Attempts to establish treatment protocols for the treatment of periimplantitis include the application of an antimicrobial agent,38-40 local and systemic antibiotics,41 air- or abrasive-polishing,42 guided tissue regeneration,43-44 combination techniques using detoxification, tetracycline, citric acid, and guided bone regeneration.45 A review of published literature concluded that “most of the information accessible at this time derives from case reports … Several uncertainties remain regarding the treatment of peri-implantitis.”46 Early investigations into the effects of Nd:YAG laser photonic energy on a range of pathogens showed significant results, but in the early 1990s two studies concluded that the thermal effects of an Nd:YAG laser resulted in damage to the titanium surface.47-48 The effects of such thermal rise may be seen in site defects (pitting,

C O V E R F E AT U R E

supports the relatively safe use of a continuous-wave diode laser on titanium. In their work with carbon dioxide lasers, Fried and colleagues explain that thermal relaxation is inversely related to the thermal diffusivity of the tissue (material) exposed to photonic energy, assuming that absorption of the energy occurs.56 One in vitro study with a continuous-wave 809-nm diode laser considered that the conditioning effect of local cooling measures (exposure of implants to laser energy within a body-temperature water bath) might approximate those found in vivo and concluded that this laser could be used on titanium implant surfaces, provided that exposure be limited in time and power to allow the implant and bone to cool to avoid tissue damage.57 On zirconia implants, one study using 810-nm diode, Er:YAG, and CO2 lasers, the Er:YAG wavelength was transmitted through the material and may cause damage to adjacent tissues, and CO2 altered the surface.58 The author’s own clinical experience has shown a number of important factors to consider when

Parker

20 0 8 VO L 16 , N O . 3

and absorption of titanium, two studies yielded different results. Rechmann showed the metal to be more reflective of long (CO2) wavelengths compared to visible (532-nm) light, but indicated no damage with the CO2 wavelengths.53 As previously stated, Kreisler’s investigation showed damage with Nd:YAG, Ho:YAG, Er:YAG, and CO2 lasers.50 Power density effects relate to emission of photonic energy and the radiated beam (spot) size. The power density values of microsecond pulses may be several thousand Watts/cm2, compared to few hundred found with continuous-wave emission. Power density may be viewed as the concentration of laser energy over an area, and (assuming some absorption occurs) this will lead to greater temperature rise with decreasing spot size. Boulnois54 and Niemz55 provide models that associate power density and exposure time in terms of tissue effects and allow deduction to be made that with lower power density values there is a longer exposure time before damaging effects may occur. Within such theoretical consideration, this

|

melting craters), and local conductive effects into the bone. Furthermore a study using a CO2 laser showed possible distant transportation of metal substrates to organs such as the liver, spleen, and kidney.49 A comparative in vitro study undertaken by Kreisler of most commercially available laser wavelengths used without water cooling concluded that Nd:YAG and Ho:YAG lasers should not be used irrespective of the power output; CO2 and Er:YAG laser should be used at low powers; and only the 809-nm diode group appeared to not cause any surface alterations.50 Kreisler also showed the high bactericidal potential of the Er:YAG laser on the implant surface.51 Another study demonstrated that the Er:YAG laser at approximately 1 W (which is “low” power) with a water spray could effectively remove plaque and calculus from the implant surface without damage.52 In consideration of the above studies, other factors will be discussed, such as reflectance from the implant fixture, power density, and thermal relaxation. In analyses of the reflectance

Figure 12: Treatment case as in Figure 11. Key: Upper left and right – Use of laser fiber tip to decontaminate implant surface prior to application of bone matrix and barrier membrane; Lower – Healing at six months and radiograph of postoperative bone regrowth at six months. Laser parameters used: 810 nm / 0.7 Watt CW / Beam size 320 µm / Contact mode

J O U R N A L O F L AS E R D E N T I ST RY

Figure 11: Use of a diode (810 nm) laser in the treatment of peri-implantitis. Key: Upper left – pretreatment; Upper right – Surgical exposure through scalpel-assisted flap procedure, showing granulation tissue; Lower – Preoperative radiograph showing marginal bone loss and extent of bone defect, and photography showing granulation tissue removed

121

C O V E R F E AT U R E

selecting parameters for laser use in implant surgery: • Power density • Exposure duration • Thermal relaxation potential, including the local cooling effect of circulating blood • Use of coaxial water spray, if available • Reflectance from the implant fixture • Presence of energy-absorbing organic debris on the ailing implant surface • Type of implant material. The potential for all laser wavelengths to exert a bactericidal effect and the wish to define a more predictable protocol for treating peri-implantitis have prompted a number of studies into some of those wavelengths,59-62 but not all have been shown to be positively conclusive. This has prompted concerns as to the effects of biofilm.

A biofilm is “a structured community of microorganisms encapsulated within a self-developed polymeric matrix and adherent to a living or inert surface. Biofilms are also often characterized by surface attachment, structural heterogeneity, genetic diversity, complex community interactions, and an extracellular matrix of polymeric substances.”63 Some studies have examined the effect of applying photonic energy to biofilm on implant surfaces.64-66 As such, lowlevel laser photoactivated disinfection (PAD) technique, used for endodontic canal disinfection as well as treatment of carious lesions,67-68 might allow inaccessible areas of infected implant surfaces to be adequately decontaminated. The author suggests the treatment protocol shown in the accompanying table.

Suggested Protocol for Laser-Assisted Treatment of Peri-Implantitis Step

J O U R N A L O F L AS E R D E N T I ST RY

122

Considerations Etiological factors – oral hygiene, occlusion, host local and general response factors, smoking. Establishment of cause of infection or trauma. Determination of whether the

Access / surgical technique

Debridement of granulation tissue – curette / laser-assisted

Disruption of biofilm

Examples: sodium lauryl sulfate, chlorhexidene, polyhexamethylene biguanide (PHMB), triclosan

Pathogen reduction (part 1)

Laser wavelength of choice. Minimal power levels – Average power 0.7 to 1.0 Watt. Use of water spray. Exposure of treatment site (10 to 15 seconds, repeated with intervals as required (maximum 3 passes)

Pathogen reduction (part 2), if available*

PAD (proprietary tolonium chloride solution used with the 670-nm PeriowaveTM (Oraldent Ltd., Kimbolton, Cambs, UK), diffuser tip, 60 sec. expo-

Reestablishment of biocompatibility / new bone growth

Guided bone regeneration procedure / membrane

Continuing care / maintenance

Professional review / radiographs / hygienist / home care

|

20 0 8 VO L 16 , N O . 3

Pretreatment assessment

*Editor’s Note: The Periowave™ device has not received U.S. Food and Drug Administration marketing clearance in the United States.

Parker

Conclusion Modern implantology is based on strict protocols of pretreatment assessment, placement, and considerate functional force dissipation. The success of integration of laserassisted surgical therapy with hard and soft oral tissue manipulation has led to an understandable wish to bring such advantages within the placement and recovery stages of implant therapy. Apart from the evidence-based ability of erbium laser wavelengths to cut bone tissue, they are only in the developmental stage for use as the sole instrument to produce the osteotomy site. The second-stage recovery and any associated soft tissue manipulation can be usefully and predictably accomplished with any of the currently commercially available laser wavelengths used in dentistry. The extensive investigations into the possible use of laser photonic energy in the treatment of peri-implantitis have acknowledged the inherent dangers of such energy on metal and have been modified with greater understanding of the multifactorial aspects of laser use and the in vivo conditions that accompany the majority of peri-implantitis cases. A protocol that may address these factors and prompt greater research has been suggested. It remains the responsibility of the clinician to employ lasers within one’s level of competence and understanding of laser-tissue interaction and the added respect for the demands of implant placement, function, and maintenance.

AU T H O R B I O G R AP H Y Dr. Steven Parker is in private practice in Harrogate, UK. He has been involved in the use, investigation, education, and examination of all aspects of laser dentistry since 1990. He holds Advanced Proficiency in four laser wavelengths, is an Educator and Recognized Course Provider with the Academy, and a past editor of

C O V E R F E AT U R E

1. Ishikawa I, Sculean A. Laser dentistry in periodontics. In: Gutknecht N, editor. Proceedings of the 1st international workshop of evidence based dentistry on lasers in dentistry, February 2006, Vaals, the Netherlands. London: Quintessence Publishing Co., 2007:115-128. 2. Parker SPA. The use of lasers in bone surgery. J Laser Dent 2007;15(1):9-13. 3. Rechmann P, Goldin DS, Henning T. Er:YAG lasers in dentistry: An overview. In: Featherstone JDB, Rechmann P, Fried DS, editors. Lasers in dentistry IV, January 2526, 1998, San Jose, Calif. Proc. SPIE 3248. Bellingham, Wash.:SPIE – The International Society for Optical Engineering. 1998:2-13. 4. Hibst R. Mechanical effects of erbium:YAG laser bone ablation. Lasers Surg Med 1992;12(2):125130. 5. Eriksson AR, Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury. A vital microscopic study in the rabbit. J Prosthet Dent 1983;50(1):101-107. 6. Fernández-Tresguerres-HernándezGil I, Alobera Gracia MA, del Canto Pingarrón M, Blanco Jerez L. Physiological bases of bone regeneration. I. Histology and physiology of bone tissue. Med Oral Patol Oral Cir Bucal 2006;11(1):E47-E51.

9. Wang X, Zhang C, Matsumoto K. In vivo study of the healing processes that occur in the jaws of rabbits following perforation by an Er,Cr:YSGG laser. Lasers Med Sci 2005;20(1):21-27. 10. Sasaki KM, Aoki A, Ichinose S, Ishikawa I. Ultrastructural analysis of bone tissue irradiated by Er:YAG laser. Lasers Surg Med 2002;31(5):322-332. 11. Wang X, Ishizaki NT, Suzuki N, Kimura Y, Matsumoto K. Morphological changes of bovine mandibular bone irradiated by Er,Cr:YSGG laser: An in vitro study. J Clin Laser Med Surg 2002;20(5):245-250. 12. O’Donnell RJ, Deutsch TF, Flotte TJ, Lorente CA, Tomford WW, Mankin HJ, Schomacker KT. Effect of Er:YAG laser holes on osteoinduction in demineralized rat calvarial allografts. J Orthop Res 1996;14(1):108-113. 13. Sharawy M, Misch CE, Weller N, Tehemar S. Heat generation during implant drilling: The significance of motor speed. J Oral Maxillofac Surg 2002;60(10):1160-1169. 14. Stübinger S, Kober C, Zeilhofer H-F, Sader R. Er:YAG laser osteotomy based on refined computer-assisted presurgical planning: First clinical experience in oral surgery. Photomed Laser Surg 2007;25(1):37. 15. Kesler G, Romanos G, Koren R. Use of Er:YAG laser to improve osseointegration of titanium alloy implants – A comparison of bone healing. Int J Oral Maxillofac Implants 2006;21(3):375-379.

17. Crespi R, Capparé P, Gherlone E, Romanos GE. Immediate versus delayed loading of dental implants placed in fresh extraction sockets in the maxillary esthetic zone: A clinical comparative study. Int J Oral Maxillofac Implants 2008;23(4):753758. 18. Schropp L, Kostopoulos L, Wenzel A. Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: A prospective clinical study. Int J Oral Maxillofac Implants 2003;18(2):189-199. 19. Turkyilmaz I, Avci M, Kuran S, Ozbek EN. A 4-year prospective clinical and radiological study of maxillary dental implants supporting single-tooth crowns using early and delayed loading protocols. Clin Implant Dent Relat Res 2007;9(4):222-227. 20. Niemz MH. Laser-tissue interactions. Fundamentals and applications. 3rd enlarged ed. Berlin: Springer-Verlag, 1996:65. 21. Coluzzi DJ, Convissar RA. Atlas of laser applications in dentistry. Chicago: Quintessence Publishing Co, Inc, 2007:5. 22. Knappe V, Frank F, Rohde E. Principles of lasers and biophotonic effects. Photomed Laser Surg 2004;22(5):411-417. 23. Goharkhay K, Moritz A, WilderSmith P, Schoop U, Kluger W, Jakolitsch S, Sperr W. Effects on oral soft tissue produced by a diode laser in vitro. Lasers Surg Med 1999;25(5):401-406. 24. Wilder-Smith P, Dang J, Kurosaki T. Investigating the range of surgical effects on soft tissue produced by a carbon dioxide laser. J Am Dent Assoc 1997;128(5):583-588. 25. Visser H, Mausberg R. Free gingival grafts using a CO2 laser: Results of a clinical study. J Clin Laser Med Surg 1996;14(2):85-88. 26. Finkbeiner RL. Free autogenous soft

Parker

20 0 8 VO L 16 , N O . 3

REFERENC ES

8. Lewandrowski K-U, Lorente C, Schomacker KT, Flotte TJ, Wilkes JW, Deutsch TF. Use of the Er:YAG laser for improved plating in maxillofacial surgery: Comparison of bone healing in laser and drill osteotomies. Lasers Surg Med 1996;19(1):40-45.

16. Berna N, Crudo V, inventors and assignees. Shape and depth template for incisions with laser tips, particularly usable in bone surgery. European Patent EP1477126. 2004 Nov 17.

|

Disclosure: Dr. Parker has no company affiliation.

7. Pourzarandian A, Watanabe H, Aoki A, Ichinose S, Sasaki KM, Nitta H, Ishikawa I. Histological and TEM examination of early stages of bone healing after Er:YAG laser irradiation. Photomed Laser Surg 2004;22(4):342-350.

J O U R N A L O F L AS E R D E N T I ST RY

Wavelengths. He is the 1998 recipient of the Leon Goldman Award for Clinical Excellence in Laser Dentistry and the 2005 President of the Academy of Laser Dentistry. His publications include a chapter on laser use in fixed prosthodontics in Dental Clinics of North America, peer-reviewed papers on laser use with hard tissue in the Journal of Laser Dentistry and a nine-part (peer-reviewed) series “Lasers in Dentistry,” published in the British Dental Journal in 2007. Dr. Parker may be contacted by e-mail at [email protected]

123

C O V E R F E AT U R E

tissue graft with the argon laser. J Clin Laser Med Surg 1995;13(1):1-5. 27. Wyman DR, Whelan WM, Wilson BC. Interstitial laser photocoagulation: Nd:YAG 1064 nm optical fiber source compared to point heat source. Lasers Surg Med 1992;12(6):659-664. 28. Albrektsson T, Isidor F, editors. Consensus report Session IV. In: Lang NP, Karring T, editors. Proceedings of the 1st European workshop on periodontology, February 1-4, 1993, Thurgau, Switzerland. London: Quintessence Publishing Co., Ltd., 1994:365-369. 29. Boucher CO, compiler and editor. Current clinical dental terminology: A glossary of accepted terms in all disciplines of dentistry. 2nd ed. St. Louis, Mo.: The C.V. Mosby Company, 1974:189, 292.

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

30. Leonhardt Å, Renvert S, Dahlén G. Microbial findings at failing implants. Clin Oral Implants Res 1999;10(5):339-345.

124

31. Martins MC, Abi-Rached RS, Shibli JA, Araujo MWB, Marcantonio E Jr. Experimental peri-implant tissue breakdown around different dental implant surfaces: Clinical and radiographic evaluation in dogs. Int J Oral Maxillofac Implants 2004;19(6):839-848. 32. Shibli JA, Martins MC, Lotufo RFM, Marcantonio E Jr. Microbiologic and radiographic analysis of ligatureinduced peri-implantitis with different dental implant surfaces. Int J Oral Maxillofac Implants 2003;18(3):383-390. 33. Kourtis SG, Sotiriadou S, Voliotis S, Challas A. Private practice results of dental implants. Part I: Survival and evaluation of risk factors – Part II: Surgical and prosthetic complications. Implant Dent 2004;13(4):373-385. 34. Oh T-J, Yoon J, Misch CE, Wang HL. The causes of early implant bone loss: Myth or science? J Periodontol 2002;73(3):322-333. 35. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5-year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res

Parker

2008;19(2):119-130. 36. Meffert RM. How to treat ailing and failing implants. Implant Dent 1992;1(1):25-33. 37. Shibli JA, Melo L, Ferrari DS, Figueiredo LC, Faveri M, Feres M. Composition of supra- and subgingival biofilm of subjects with healthy and diseased implants. Clin Oral Implants Res 2008;19(10):975-982. 38. Mombelli A, Lang NP. Antimicrobial treatment of peri-implant infections. Clin Oral Implants Res 1992;3(4):162-168. 39. Mombelli A. Etiology, diagnosis, and treatment considerations in periimplantitis. Curr Opin Periodontol 1997;4:127-136. 40. Zablotsky MH. Chemotherapeutics in implant dentistry. Implant Dent 1993;2(1):19-25. 41. Sbordone L, Barone A, Ramaglia L, Ciaglia RN, Iacono VJ. Antimicrobial susceptibility of periodontopathic bacteria associated with failing implants. J Periodontol 1995;66(1):69-74. 42. Behneke A, Behneke N, d’Hoedt B. Treatment of peri-implantitis defects with autogenous bone grafts: Six-month to 3-year results of a prospective study in 17 patients. Int J Oral Maxillofac Implants 2000;15(1):125-138. 43. Grunder U, Hürzeler MB, Schüpbach P, Strub JR. Treatment of ligature-induced peri-implantitis using guided tissue regeneration: A clinical and histologic study in the beagle dog. Int J Oral Maxillofac Implants 1993;8(3):282-293. 44. Schüpbach P, Hürzeler M, Grunder U. Implant-tissue interfaces following treatment of peri-implantitis using guided tissue regeneration: A light and electron microscopic study. Clin Oral Implants Res 1994;5(2):55-65.

47. Romanos GE, Everts H, Nentwig GH. Effects of diode and Nd:YAG laser irradiation on titanium discs: A scanning electron microscope examination. J Periodontol 2000; 71(5):810-815. 48. Block CM, Mayo JA, Evans GH. Effects of the Nd:YAG dental laser on plasma-sprayed and hydroxyapatitecoated titanium dental implants: Surface alteration and attempted sterilization. Int J Oral Maxillofac Implants 1992;7(4):441-449. 49. Deppe H, Greim H, Brill T, Wagenpfeil S. Titanium deposition after periimplant care with the carbon dioxide laser. Int J Oral Maxillofac Implants 2002;17(5):707-714. 50. Kreisler M, Götz H, Duschner H, d’Hoedt B. Effect of the Nd:YAG, Ho:YAG, Er:YAG, CO2, and GaAlAs laser irradiation on surface properties of endosseous dental implants. Int J Oral Maxillofac Implants 2002;17(2):202-211. 51. Kreisler M, Kohnen W, Marinello C, Götz H, Duschner H, Jansen B, d’Hoedt B. Bactericidal effect of the Er:YAG laser on dental implant surfaces: An in vitro study. J Periodontol 2002 73(11):1292-1298. 52. Matsuyama T, Aoki A, Oda S, Yoneyama T, Ishikawa I. Effects of the Er:YAG laser irradiation on titanium implant materials and contaminated implant abutment surfaces. J Clin Laser Med Surg 2003;21(1):7-17. 53. Rechmann P, Sadegh HM, Goldin DS, Hennig T. Zur oberblachenmorphologie von implantaten nach laserbestrehlung [Surface morphology of implants after laser irradiation.] Dtsch Zahnärztl Z 2000;55(5):371-376. German. 54. Boulnois J-L. Photophysical processes in recent medical laser developments: A review. Lasers Med Sci 1986;1(1):47-66.

45. Meffert RM. Periodontitis vs. periimplantitis: The same disease? The same treatment? Crit Rev Oral Biol Med 1996;7(3):278-291.

55. Niemz MH. Laser-tissue interactions. Fundamentals and applications. 3rd enlarged ed. Berlin: Springer-Verlag, 2007:46.

46. Roos-Jansåker A-M, Renvert S, Egelberg J. Treatment of periimplant infections: A literature review. J Clin Periodontol 2003;30(6):467-485.

56. Fried D, Ragadio J, Akrivou M, Featherstone JDB. Dental hard tissue modification and removal using sealed transverse excited atmospheric-pressure lasers oper-

C O V E R F E AT U R E

59. Miller RJ. Treatment of the contaminated implant surface using the Er,Cr:YSGG laser. Implant Dent 2004;13(2):165-170. 60. Deppe H, Horch H-H, Neff A. Conventional versus CO2 laserassisted treatment of peri-implant defects with the concomitant use of pure-phase β-tricalcium phosphate: A 5-year clinical report. Int J Oral Maxillofac Implants 2007;22(1):79-86.

63. Wikipedia contributors. Biofilm. Wikipedia, The Free Encyclopedia [Internet]. San Francisco, Calif.: Wikimedia Foundation Inc.; [Updated 23 Oct 2008; Accessed 2008 Nov 23]. Available from: http://en.wikipedia.org/wiki/Biofilm. 64. Sennhenn-Kirchner S, Klaue S, Wolff N, Mergeryan H, von Zepelin MB, Jacobs HG. Decontamination of rough titanium surfaces with diode lasers: Microbiological findings on in

65. Araki ÂT, Ibraki Y, Kawakami T, Lage-Marques JL. Er:YAG laser irradiation of the microbiological apical biofilm. Braz Dent J 2006;17(4):296-299. 66. Schwarz F, Nuesry E, Bieling K, Herten M, Becker J. Influence of an erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser on the reestablishment of the biocompatibility of contaminated titanium implant surfaces. J Periodontol 2006;77(11):1820-1827. 67. Bonsor SJ, Nichol R, Reid TMS, Pearson GJ. Microbiological evaluation of photo-activated disinfection in endodontics (An in vivo study). Br Dent J 2006;200(6):337-341. 68. Williams JA, Pearson GJ, Colles MJ, Wilson M. The photo-activated antibacterial action of toluidine blue O in a collagen matrix and in carious dentine. Caries Res 2004;38(6):530-536. ■■

20 0 8 VO L 16 , N O . 3

58. Stübinger S, Homann F, Etter C, Miskiewicz M, Wieland M, Sader R. Effect of Er:YAG, CO2 and diode laser irradiation on surface properties of zirconia endosseous dental implants. Lasers Surg Med 2008;40(3):223-228.

62. Giannini R, Vassalli M, Chellini F, Polidori L, Dei R, Giannelli M. Neodymium:yttrium aluminum garnet laser irradiation with low pulse energy: A potential tool for the treatment of peri-implant disease. Clin Oral Implants Res 2006;17(6):638-643.

vivo grown biofilms. Clin Oral Implants Res 2007;18(1):126-132.

|

57. Kreisler M, Al Haj H, D’Hoedt B. Temperature changes induced by 809-nm GaAlAs laser at the implant-bone interface during simulated surface decontamination. Clin Oral Implants Res 2003;14(1):91-96.

61. Takasaki AA, Aoki A, Mizutani K, Kikuchi S, Oda S, Ishikawa I. Er:YAG laser therapy for periimplant infection: A histological study. Lasers Med Sci 2007;22(3):143-157.

J O U R N A L O F L AS E R D E N T I ST RY

ating at α=9.6 and 10.6 µm. J Biomed Optics 2001;6(2):231-238.

Parker

125

CLI N ICAL CASE

Noncontact Venous Lake Treatment Using a 980-nm Diode Laser David Burt, DDS, Center Valley, Pennsylvania J Laser Dent 2008;16(3):126-129

S YN O P S I S This case report is one of treatment of a vascular lesion, a venous lake, that was performed using a diode laser in a noncontact mode, without a surgical incision.

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

INTRO D U C TIO N

126

While a majority of the procedures performed using soft tissue lasers are surgical in nature, venous lakes and related angiomas represent a class of lesions which do not always respond well to traditional vascular surgery, and hence, are avoided. First described in 1956 by Walsh and Bean,1 venous lakes have been reported only in the adult population and on patients 50 years or older with the average age being approximately 65. While considered to be biologically harmless and asymptomatic, they can exhibit tenderness, pain, and excessive bleeding when traumatized. The negative cosmetic implications of these lesions are obvious. The methods of treatment have ranged from electrosurgery, cryosurgery, and sclerotherapy to the use of argon, Nd:YAG, and carbon dioxide lasers. Although a laser can have some advantages, all of these modalities can achieve successful results. However, since

Figure 1: Preoperative view of three venous lake lesions on lower lip

Burt

they all involve surgical methods that are invasive in nature, prolonged healing and scarring can result. Those potential complications have kept many dental clinicians from attempting to treat a venous lake. This clinical case study will examine the use of a 980-nm diode laser in a nonsurgical setting to achieve results considered acceptable to the patient as well as the clinician. It is hoped that the demonstrated beneficial outcome would allow dentists to feel more comfortable in providing this service to their patients.

P R E T R E AT M E N T A. Outline of Case Clinical Description A 75-year-old male presented with a chief complaint of a blue-colored swelling on his lower lip. He had noticed it for quite some time, but reported that it recently had gotten

Figure 2: Preoperative measurement of the lesions

larger and become a nuisance when eating. His medical history was noncontributory and his only medication is Eldepryl which is used to impede the onset of Parkinson’s disease. Dentally, he presented with a good periodontal condition, and excellent general oral health. A clinical exam revealed a group of three ovoidshaped, raised papules on his lower vermillion border measuring approximately 6 mm x 5 mm, 4 mm x 3 mm, and 6 mm x 3mm, as shown in Figures 1 and 2. The areas were dark blue in color, raised approximately 2-3 mm, and felt soft and compressible to the touch. These areas were fairly well demarcated and had a smooth surface. All other soft tissue was within normal limits and no other tests were performed. He did state that his mother had had the same condition and that he remembered it being more extensive than his. B. Diagnosis and Treatment Plan 1. Provisional Diagnosis A tentative diagnosis would include blue nevus, melanoma, basal cell carcinoma, and venous lake. The test used for differentiating venous lakes from other lesions is diascopy. This involves direct pressure on the lesion using a glass microscope slide. Since it is highly vascular, the site will blanch due to the emptying or shifting of the contents (Figures 3 and 4). In some occasions, the area will not completely empty of the blood but there will be a distinct color change noted. 2. Final Diagnosis A final diagnosis of venous lake

CLI N ICAL CASE

Figure 5: Topical anesthetic in place

surgical intervention or other therapy. No treatment is also an option. 6. Informed Consent Written and verbal consents were obtained after a lengthy discussion of the treatment objectives and the realistic variability of the potential outcomes. The patient was enthusiastic about achieving success without having to be subjected to injections, sutures, and a lengthy healing phase.

T R E AT M E N T 4. Indications, Contraindications, and Precautions Remediation of this lesion would have functional as well as cosmetic indications. The potential for trauma to the area was becoming more significant as per the patient’s original complaint. The contraindications to this procedure are excessive bleeding or frank hemorraghage, scarring, and inability to eat or speak due to pain. The patient’s age is significant but not a contraindication to the procedure due to his robust health. The main precaution is to avoid the possibility of heat buildup in the surrounding tissue. The tissue will be cooled with ice between laser exposures. 5. Treatment Alternatives Treatment alternatives include referral to a dermatologist or plastic surgeon to evaluate for

A. Treatment Objectives Strategy Use of a diode laser would potentially achieve the results desired due to its affinity for blood proteins. The lesion will be reduced in size by coagulation and sclerosing the vessels surrounding it. The laser energy will penetrate into the lesion but will be controlled to avoid damage to the underlying dermis. The noncontact mode of the laser fiber allows flexibility in controlling the amount of energy being transmitted to the target area by simply adjusting the distance from the tissue surface. B. Laser Operating Parameters A 980-nm diode laser (SIROLaser, Sirona Dental Systems, LLC, Charlotte, N.C.) was used for the treatments. The 320-micron fiber delivered the energy through a stock handpiece modified to accept a 19-gauge disposable tip

C. Treatment Delivery Sequence The laser safety officer verified that protective eyewear was worn by the patient, the doctor, and attending staff. She also informed the remaining staff, via walkie-talkie, to not enter the treatment room. The local anesthetic was applied to the lip and allowed to remain for 15 minutes (Figure 5). EMLA cream, which is a eutectic mixture of lidocaine and prilocaine, was used initially but TAC 20% (lidocaine 20%, tetracaine 4%, phenylephrine 2%) was found to have a better and faster onset of anesthesia, requiring only five minutes of application. (These products are available from Professional Arts Pharmacy, Lafayette, La., or a local compounding pharmacy.) During this time, the patient was instructed to raise his hand to notify the doctor of any discomfort or sensation of warmth during the treatment. The laser settings were confirmed, then the laser was test-fired outside the mouth. The target area then had ice applied for one minute and the first “pass” was started by using a constant motion of the tip to create small overlapping circles until the target area had been covered.

Burt

20 0 8 VO L 16 , N O . 3

3. Treatment Plan Outline The treatment approach, because of the size of the area and the potential for excessive bleeding, was to use a 980-nm diode laser in a noncontact mode, allowing the laser energy to penetrate into the vascularized area. The lack of an incision reduces the risk of hemorrhage. Varied power settings would be used to determine the most effective treatment based on time, optimum visual results, and patient comfort.

(Ultradent Products, Inc., South Jordan, Utah) which was curved to approximately 60 degrees. The laser fiber was not initiated. The power settings for the first and second treatments were 2 W continuous wave (CW), followed by 1 W CW for the third. The fiber was used in noncontact mode, 1-2 mm away, with the tip being kept perpendicular to the tissue.

|

was determined by diascopy and blanching.

Figure 4: Direct pressure from a glass slide shows the blanching of the lesion area, confirming the diagnosis of venous lake

J O U R N A L O F L AS E R D E N T I ST RY

Figure 3: The lesion area of the lip is stretched tightly

127

CLI N ICAL CASE

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

Figure 6: Immediate postoperative view, first treatment

128

Figure 7: Immediate postoperative view, second treatment

Figure 9: Three-month postoperative

Figure 10: Six-month postoperative

Distance of the tip to the surface was kept at approximately 1-2 mm. This was continued until the patient registered a warm feeling. The ice was reapplied for one minute and the second “pass” started with attention paid to the change in color of the lesion, particularly near the borders. After the patient again informed us of a warm sensation, ice was applied for the requisite time and a third “pass” was undertaken. A definite lightening of the dark blue color was noted after each pass and was verified when compared to the pretreatment pictures. The immediate postoperative view is shown in Figure 6. A total of three treatments was performed over a period of eight weeks and a gradual resolution was achieved, even though a regression of the color was noted before the start of each treatment session and was most prominent before the second treatment. Figure 7 shows the view after the second treatment and Figure 8 shows the view after the third treatment.

nonsteroidal anti-inflammatory drugs (NSAIDs) for any discomfort he might have. He was also informed that there may be some transient swelling of the area for up to 24 hours and to be careful when eating so as not to traumatize the site. The patient was further instructed to monitor the color of the site and to call to report any untoward reactions.

D. Postoperative Instructions Postoperatively, the patient was instructed to use over-the-counter

F O L LO W- U P C AR E

Burt

E. Complications No complications of any type were noted by the patient in the days following the treatments. F. Prognosis The short- and long-term prognosis for this type of lesion is good. Recurrence has not been noted at this point and the patient is happy with the results. G. Treatment Records All pertinent data along with the informed consent and intraoral photos have been recorded and retained.

Assessment of Treatment Outcome and Long-Term Results

Figure 8: Immediate postoperative view, third treatment

The 3-month (Figure 9) and 6month (Figure 10) checks of the site revealed a smaller total area of the lesion as well as reduced height. The lesion now measures approximately 3 mm x 2 mm and the dark blue color has also lightened significantly to the point where the patient stated that it is not nearly as visible to himself or another person. A clinical exam showed smooth tissue with no visible signs of scarring or traction. A very pale blue color is still present at the site and most likely will not resolve unless further treatments are undertaken.

C O NC LU SIO N Although vascular lesions make most clinicians nervous when considering remediation, lasers can accomplish lesion resolution through methods which allow the practitioner to safely treat such lesions via radiant energy in a noncontact mode. The resultant sclerosing and coagulation of the vessels of a venous lake, without damaging the surface of the tissue, showcases some of the exquisite abilities of lasers in dental care.

REFERENC E 1. Bean WB, Walsh JR. Venous lakes. AMA Arch Derm 1956;74(5):459-463.

AU T H O R B I O G R AP H Y Dr. David Burt is a graduate of Temple University School of Dentistry and is currently co-owner of Castle Dental PC with his wife, Dr. Lorri Burt, as well as owner of the Lehigh Valley Dental Education

CLI N ICAL CASE

20 0 8 VO L 16 , N O . 3

Disclosure: Dr. Burt has previously worked as a trainer for Deka and is currently a post-purchase trainer for the 980 SIROLaser by Sirona Dental Systems as well as a basic and advanced trainer for CEREC CAD/CAM technology. He receives an honorarium for his services. ■■

|

the International College of Dentists. Dr. Burt’s personal passion is the sport of skydiving which he has enjoyed for more than 18 years. He is a licensed freefall instructor and has logged more than 1700 skydives to his credit as well as participated in a world record. Dr. Burt may be contacted by e-mail at [email protected]

J O U R N A L O F L AS E R D E N T I ST RY

Center where he teaches advanced CEREC and laser technologies. He has been using both CO2 and diode lasers for more than five years and has performed many soft tissue applications with the 810-, 980-, and 10,600-nm laser wavelengths. He is also a member of the International Society of Computerized Dentistry, the Academy of Laser Dentistry, and

Burt

129

CLI N ICAL CASE

Gingival Depigmentation with an Er:YAG Laser: A Clinical Case with Three-Year Follow-Up Grace Sun, DDS, Los Angeles, California J Laser Dent 2008;16(3):130-132

S YN O P S I S This clinical case study describes the removal of gingival hyperpigmentation using an Er:YAG laser. This benign condition was an esthetic concern for the patient, and the laser procedure produced good results. While the prognosis is good, the patient’s smoking can stimulate melanin production and the coloration can reap-

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

P R E T R E AT M E N T

130

A. Case Outline A 43-year-old African American male presented with normal medical, oral, and dental health. The patient reported that his four upper incisors had a history of trauma, but he would not supply any details. A clinical examination revealed that those four teeth had received endodontic therapy and were then restored with porcelain-fused-to-metal crowns. A panoramic radiograph showed good dental health (Figure 1). The patient had been a cigarette smoker for 20 years, but had since quit smoking for 10 years. The patient had recently finished adult orthodontic therapy and was happy with the results; but he expressed concern about the darkened color of his gingival tissue on both arches, as seen in Figure 2. He was informed that pigmentation can

Figure 1: Panoramic radiograph

Sun

be a normal benign condition, but he revealed that he was unhappy with the esthetics. Furthermore, he described the coloration to have had a negative psychological impact on him for the past 20 years. B. Diagnosis The diagnosis is hyperpigmentation due to excessive melanin in the basal layer of the epithelium. This condition exists among all races, but is more prevalent among the African and South Asian population. It can be exacerbated by smoking, since chemicals such as nicotine can activate melanocytes to produce melanin. In fact, this benign increase in melanin has been termed “smoker’s melanin.”1 The metal substrate of his crowns appeared to be a precious alloy, and this finding was important since some nonprecious metals can

cause marginal gingival discoloration. It was then determined that the metal composition was not a factor in the soft tissue coloration on the maxilla and had no effect on the mandibular arch. Periodontal probing showed adequate biologic width around all teeth, with normal pocket depth and healthy tissue. C. Treatment Options, Precautions, and Informed Consent As per the patient’s request, removal of the excessively pigmented portion of the gingival tissue will be performed. The options for this elective treatment were discussed, including scalpel surgery, rotary abrasion, cryotherapy, electrosurgery, and laser ablation. The patient chose the laser option. Multiple wavelengths of dental lasers could be utilized to ablate the basal epithelial layer containing the melanin. Since prime absorption of melanin and other pigments occurs in the near-infrared portion of the electromagnetic spectrum, diode or Nd:YAG laser wavelengths would be good choices for efficiency.2 Erbium and carbon dioxide lasers could also be used, since they are also effective for soft tissue surgery.3-5 The chief precaution is to control the energy delivered to the tissue to avoid potential collateral damage. Depending on which laser wavelength is chosen, underlying connective tissue, periosteum, and bone could suffer from the heat of ablation if it were to extend beyond the target tissue. The second precaution is to preserve as much of the thin marginal tissue as possible, partic-

CLI N ICAL CASE

(2.1 W), and some of the laser energy will absorbed by the water spray. The total treatment time was 2 hours and the laser exposure was approximately 20 minutes.

T R E AT M E N T A. Treatment Objective The objective was de-epithelization to remove the melanin principally located in the basal layer of the epithelium. B. Laser Operating Parameters An Er:YAG laser (DELight, Hoya ConBio, Fremont, Calif.), 2940-nm wavelength with a fiber delivery system was used with a 600-micrometer 80-degree tip. The parameters were 30 Hz, 70 mJ, with a water spray. This is a low power setting

C. Treatment High-volume evacuation was in place, and all laser safety precautions were used. Visualization was enhanced with 3.5x magnification. Periodontal probing showed adequate attached gingival width. Only topical anesthetic (TAC 20% alternate gel – tetracaine 4%, phenylephrine 2%, lidocaine 20%) (Professional Arts Pharmacy, Lafayette, La.) was used. This topical cream is applied for 5 minutes onto an area of tissue. After that time, good anesthesia is obtained for 20-30 minutes. The treatment area on the maxillary arch extended from the right first bicuspid to the left first bicuspid and consisted of a 5-mmwide band of excessive pigmentation on thick gingival tissue. On the mandible, the area extended from cuspid to cuspid, and the pigmented width varied from 2 to 7 mm, within thin marginal tissue. The first site selected was the tissue above the upper right cuspid, where the tissue thickness was greatest. The laser energy was directed at the tissue with very light contact of the tip. The epithelium was gradually ablated in very thin layers. Ultimately, the basal layer was exposed and carefully ablated, and the pigmentation was removed. When this area was completed, the same parameters and procedures continued toward the left cuspid

D. Postoperative Assessment and Instructions The patient did not experience any discomfort during or after the procedure, and there were no complications. The postoperative instructions were to eat a soft diet and take over-the-counter medications such as Motrin®, Advil®, or Tylenol® if necessary.

F O L LO W- U P C AR E A. Treatment Assessment, Prognosis, and Long-Term Results The healing was uneventful and the early prognosis was good. The patient returned for follow-up visits at 1 week, 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and 3 years. Figures 4-9 show various postoperative periods. The gingival tissues have remained healthy, and the patient liked the absence of the darkened gingiva. At the 3-year-postoperative visit, some slight repigmentation appeared (Figure 9). Comparison of photographic records confirmed this reappearance. The patient reported that he started smoking cigars, and he was reminded that smoking can contribute to excessive pigmentation. B. Long-Term Prognosis and Conclusion The long-term prognosis is good. As noted above, it is partially

Sun

20 0 8 VO L 16 , N O . 3

ularly on the mandibular arch. The author chose a fiber-delivered Er:YAG laser because its free-running pulse emission mode provides some degree of thermal relaxation, and it has a relatively shallow depth of penetration. As with other lasers with flexible delivery systems, it permits accurate placement of the tip. The instrument can also be used with a water spray for soft tissue surgery to help cool the tissue and flush the site of debris. While the Er:YAG laser has limited hemostatic ability on soft tissue, especially when coincidental water spray is used, it was felt that whatever bleeding might occur in this moderately vascular area could be readily controlled via conventional means such as compression. Moreover, efficient high-volume evacuation and enhanced visualization with magnification will aid in the precision of the procedure. The patient gave his consent for the procedure.

|

Figure 3: Intraoperative view of maxillary arch

J O U R N A L O F L AS E R D E N T I ST RY

Figure 2: Preoperative full-smile view of excessive pigmentation

area. Figure 3 shows an intraoperative photograph, and the ablation areas are apparent. The mandibular tissue was treated with the same parameters and protocol, once again moving from right to left. Some bleeding occurred in various areas after the pigmentation was removed. Hemostasis was achieved by compression with wet gauze and no complications arose. The immediate postoperative view is shown in Figure 3. Upon completion of the procedure in both arches, adequate free gingival marginal tissue remained, and bleeding was absent on the ablated surfaces.

131

CLI N ICAL CASE

Figure 4: Two-week postoperative view of maxillary arch

dependent on the patient’s smoking habits. Moreover, he has a genetic tendency to produce melanin. The gingival depigmentation procedure using the Er:YAG laser was successful, with good patient comfort, predictable healing, and satisfaction.

REFERENC ES 1. Brown FH, Housten GD. Smoker’s melanosis. A case report. J Periodontol 1991;62(8):524-527. 2. Coluzzi DJ, Convissar RA. Atlas of laser applications in dentistry. Chicago: Quintessence Publishing Co., Inc., 2007:1-8. 3. Nakamura Y, Hossain M, Hirayama K, Matsumoto K. A clinical study on

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

Figure 7: Three-month postoperative full-smile view

132

Sun

Figure 5: Two-week postoperative view of mandibular arch

Figure 6: Six-week postoperative fullsmile view

Figure 8: One-year postoperative fullsmile view

Figure 9: Three-year postoperative fullsmile view

the removal of gingival melanin pigmentation with the CO2 laser. Lasers Surg Med 1999;25(2):140-147.

AU T H O R B I O G R AP H Y

Clinics of North America. Dr. Sun is also certified as Advanced Proficiency and was awarded Educator status by the Academy of Laser Dentistry where she was a member of the Board of Directors. She had lectured internationally on the subjects of laser and cosmetic dentistry. Dr. Sun is an accredited Fellow with the American Academy of Cosmetic Dentistry, a Fellow of the International Congress of Oral Implantologists, and is a Master of the Academy of General Dentistry. Dr. Sun may be contacted by e-mail at [email protected]

Dr. Grace Sun routinely utilizes multiple wavelengths of dental lasers. Her articles on dental lasers have been published in Dental

Disclosure: Dr. Sun has no commercial relationships relative to this article. ■■

4. Tal H, Oegiesser D, Tal M. Gingival depigmentation by erbium:YAG laser: Clinical observations and patient responses. J Periodontol 2003;74(11):1660-1667. 5. Rosa DSA, Aranha ACC, Eduardo Cde P, Aoki A. Esthetic treatment of gingival melanin hyperpigmentation with Er:YAG laser: Short-term clinical observations and patient follow-up. J Periodontol 2007;78(10):2018-2025.

CLI N ICAL CASE

“The Good, the Bad, and the Ugly”: 810-830-nm Diode Laser Therapy for the Periodontal Patient Who Smokes Nora Raffetto, RDH, Los Altos Hills, California J Laser Dent 2008;16(3):133-135

The diagnosis was Chronic Moderate Periodontitis.

were poor due to insufficient patient compliance, and the prognosis is

INTRO D U C TIO N

C AS E P R E S E N TAT I O N

The pathogenesis of periodontal disease and the methods of treating it have undergone radical changes in the past 30 years. The contemporary model for periodontal disease includes microbial components, host-inflammatory responses, and host risk factors that contribute to the disease progression.1 The pathogenic bacterial plaque in the susceptible host triggers an immune response that results in inflammation and subsequent pathology of the connective tissue and bone.2-3 Periodontal disease can have periods of intense activity and periods of dormancy. Initial periodontal therapy now includes nonsurgical debridement of the tooth structure, local delivery of antimicrobial agents, host modulators, and laser reduction of sulcular bacteria with laser coagulation of the periodontally inflamed areas.4-6 The dental hygienist generally is the provider of this initial nonsurgical treatment. During treatment and post-therapy the most unpredictable element the clinician will face is the “human factor,” which refers to a patient’s compliance with home care and other treatment modulators such as smoking.1-2, 7 Continued tobacco use can severely compromise the success of periodontal therapy.

The patient is a 58-year-old Caucasian male with good general health. He was taking over-thecounter seasonal allergy medication (CLARITIN®, ScheringPlough Corporation, Kenilworth, N.J.) for seasonal allergies. The patient reported that he smoked two packs of cigarettes daily. The periodontal examination included a full-mouth X-ray, complete periodontal probing, oral cancer screening, and an evaluation of occlusion. The results of this exam showed inflammation, supra- and subgingival calculus, recession from 1 to 6 mm due to occlusal trauma, bone loss in all quadrants, and a perio/endo abscess on tooth #13. Figure 1 is the radiograph of tooth #13. Figures 2 and 3 show pretreatment probing of the maxillary posterior areas. Figure 4 depicts the pretreatment periodontal probe chart.

Figure 1: Radiograph of a perio/endo abscess of tooth #13

Short-Term Goals • Initiate good plaque control with an oral hygiene program tailored to the patient’s needs. • Treat the perio/endo abscess on tooth #13. • Adjust occlusal interferences for more balanced contacts. • Work with the patient on smoking cessation. • Debride all hard tissue followed by laser treatment of the soft tissues. Long-Term Goals • Continue support with smoking cessation.

20 0 8 VO L 16 , N O . 3

therapy for a patient with a long-standing smoking habit. The results

|

This article describes one-and-a-half year laser-assisted periodontal

Figures 2 & 3: Pretreatment probing of upper right and left quadrants

Raffetto

J O U R N A L O F L AS E R D E N T I ST RY

S YN O P S I S

133

CLI N ICAL CASE

Figure 5: Laser fiber in lingual pocket

Figure 6: Laser fiber in facial pocket

Figure 7: Laser fiber with debris from bacterial reduction procedure

Figure 8: 3-month post-treatment assessment, upper left.

Ariz.) injected and Oraqix® 2.5% (lidocaine and prilocaine topical periodontal gel, DENTSPLY Pharmaceutical, York, Pa.). After scaling, the laser was used in the pockets to a calibrated depth to achieve bacterial reduction and coagulation. Figures 5, 6, and 7 show the laser procedure, which has been described for diode and Nd:YAG lasers by a number of clinicians.4-5, 8-10

The 9- and 12-month appointments showed improved tissue health with some gain in clinical attachment levels. The patient reported that he had again stopped smoking. Figure 10 shows probing of the lower right, and Figure 11 depicts the 12-month post-treatment periodontal chart. At the 15-month appointment after the initial therapy the patient was again smoking and home care techniques were not being employed. The clinician noted several areas of calculus and plaque with many areas of inflammation (Figure 12). These areas were debrided and treated with the laser and home care was stressed. The patient reported at the 18month appointment that he was still smoking and not very regular with his home care. Areas of inflammation were treated with the laser, home care instruction was again stressed, and the need for smoking cessation was discussed. Figure 13 shows the upper right area with accumulated plaque and inflammation, a result of the patient’s poor oral hygiene and continued smoking habit.

Figure 4: Pretreatment perio chart

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

• Improve periodontal condition with a gain in clinical attachment levels. • Help patient maintain a high level of oral hygiene.

134

Treatment Plan • Complete debridement of the hard tissues using ultrasonics followed by hand scaling. • Perform laser bacterial reduction followed by laser coagulation of the site. • The treatment laser is an 810830-nm diode laser (DioDent, Hoya ConBio, Fremont, Calif.) • The fiber for this treatment is a 400-micron fiber • Bacterial reduction settings are 500 mW CW for 15-20 seconds per site • Coagulation settings are 700 mW CW for 10 seconds per site • Conduct oral hygiene instruction tailored for the patients needs. • Start the patient on Fluoridex® (Discus Dental, Culver City, Calif.) 1.1% sodium fluoride daily topical application. Treatment Sequence The patient was treated in a splitmouth design, with the upper and lower left quadrants treated first, followed 8 days later by the upper and lower right quadrants. Anesthesia used for treatment included Septocaine™ (Articaine hydrochloride 4% with epinephrine, 1:100,000, SmartPractice, Phoenix,

Raffetto

Treatment Assessment Assessments of the treated areas were done at 1, 3, 6, 9, 12, 15, and 18 months post-treatment. During the initial treatment phase the patient stopped smoking. Figure 8 shows light pressure probing of the upper left area, with some pocket depth reduction. At the 6-month follow-up appointment the patient reported that he was smoking again, but was making an effort to stop. The home care evaluation showed considerable plaque so time was spent adjusting the home care for the patient and retreating areas of bleeding and inflammation with the laser. Figure 9 shows probing of the upper left quadrant.

CLI N ICAL CASE

Figure 9: 6-month post-treatment assessment, upper left

Figure 10: 12-month post-treatment assessment, lower right

Figure 11: 12-month post-treatment assessment, perio chart Garcia RI. Risk of tooth loss after cigarette smoking cessation. Prev Chronic Dis 2006;3(4):A115:1-8.

C O NC LU SIO N An excellent treatment plan executed flawlessly with the latest technology does not guarantee a good result unless the patient is ready to participate completely with the clinician. Sometimes it is the human factor of a case that is the most difficult to treat. Good assessment intervals will be helpful to keep the patient involved in his treatment and allow the clinician to adjust the home

REFERENC ES 1. Kim J, Amar S. Periodontal disease and systemic conditions: A bidirectional relationship. Odontology 2006;94(1):10-21. 2. Offenbacher S, Barros SP, Singer RE, Moss K, Williams RC, Beck JD. Periodontal disease at the biofilmgingival interface. J Periodontol 2007;78(10):1911-1925. 3. Pradeep AR, Manjunath SG, Swati PP, Shikha C, Sujatha PB. Gingival crevicular fluid levels of leukotriene B4 in periodontal health and disease. J Periodontol 2007;78(12):2325-2330. 4. Raffetto N. Lasers for initial periodontal therapy. Dent Clin North Am 2004;48(4):923-936. 5. Coluzzi DJ. Using lasers for phase one periodontal therapy. Dent Today 2007;26(4):124, 126-129. 6. Assaf M, Yilmaz S, Kuru B, Ipci SD, Noyun U, Kadir T. Effect of the diode laser on bacteremia associated with dental ultrasonic scaling: A clinical microbiological study. Photomed Laser Surg 2007;25(4):250-256. 7. Krall EA, Dietrich T, Nunn ME,

10. Smith ML. Nd:YAG laser-assisted treatment of moderate chronic periodontitis. J Laser Dent 2008:16(1):23-29.

AU T H O R B I O G R AP H Y Nora Raffetto has Advanced Proficiency in Nd:YAG and diode laser wavelengths and has completed the Educators Course. She has written articles on lasers, has had a chapter published in Dental Clinics of North America, and taught courses on lasers for hygiene application. Ms. Raffetto is the recipient of ALD’s 2001 Leon Goldman Award for Clinical Excellence and has been active in the Academy of Laser Dentistry since 1992, having served two terms on the Board. She has been practicing for 33 years in a general practice setting in Redwood City, California. Ms. Raffetto may be contacted by e-mail at [email protected] Disclosure: Ms. Raffetto has no commercial relationships relative to this article. ■■

Raffetto

20 0 8 VO L 16 , N O . 3

care and laser therapy to achieve the best result.

9. Casper PJ. Peaks and valleys: A three-year case study examining the use of diode laser-assisted periodontal therapy. J Acad Laser Dent 2004;12(4):17-19.

|

Prognosis The long-term prognosis for this patient is guarded. The clinician notes that the patient must participate wholeheartedly in his treatment to have a good outcome. To date the patient has been unable to quit smoking cigarettes for longer than six months at a time. Regular removal of the dental plaque is a must for this patient, but removal has been irregular resulting in hard deposits and inflammation. An ongoing effort to help the patient quit smoking and be invested in his oral health through good home care is the goal of the clinician.

Figure 13: 18-month post-treatment assessment, upper right

J O U R N A L O F L AS E R D E N T I ST RY

Figure 12: 15-month post-treatment assessment, lower right

8. Maddox SD. Treatment of class IV periodontal disease using a 820-nm diode laser. Wavelengths 2003;11(3):22-24.

135

CLI N ICAL CASE

Gingivoplasty Using an 810-nm Diode Laser to Treat Drug-Induced Gingival Enlargement John J. Graeber, DMD, MAGD, FICD, Master of the Academy of Laser Dentistry East Hanover, New Jersey J Laser Dent 2008;16(3):136-139

S YN O P S I S This article describes a clinical technique for recontouring gingival tissue hypertrophy due to the patient’s medication. The author discusses how different wavelengths have been used, and highlights his protocol that employs a diode laser.

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

INTRO D U C TIO N

136

Prescription drug-induced gingival hyperplasia is a form of periodontal disease affecting many patients. This condition can be chronic and can require repeated surgical interventions to remove the excessive tissue.1 Calcium channel blockers and anticonvulsant medications, as well as immunosuppressant drugs, are known to promote gingival hypertrophy.2-3 This drug-induced form of hyperplasia most often manifests as papillary hyperplasia, with anterior areas being the most commonly affected.2 Today, the term “gingival enlargement” or “gingival overgrowth” has been adopted by the American Academy of Periodontology to describe medication-related gingival lesions previously termed “gingival hypertrophy” or “gingival overgrowth.”2 Gingival overgrowth is first seen as localized papillary enlargement, as shown in Figure 1. However, its severity can range from minor variations to complete coverage of teeth, leading to functional and esthetic problems for the patient.4 Histological assessment suggests that the overgrowth is a combination of epithelial and connective tissue neoplasia, which often results in deepening of the normal sulcular depth. This is usually

Graeber

Figure 1: Preoperative view of gingival enlargement

considered a “pseudo pocket” because the epithelial attachment typically has not migrated apically due to periodontal tissue breakdown. As a result, some authors have advocated a multiphasic approach to treating gingival hyperplasia that includes mechanical and chemical plaque control, as well as removal of the hyperplastic tissue.5 Traditional Removal Approaches Traditional techniques for removing hyperplastic gingival tissue include thinning the underlying connective tissue using a sulcular surgical approach, or using the scalpel or similar knives to thin the tissue from the exterior side. These techniques leave the connective tissue exposed to the oral

environment, cause hemorrhage, and expose nerve endings, all of which may result in delayed healing and postoperative pain. With the latter surgical approach, it is usually necessary to cover denuded tissues with periodontal dressings. However, the author has found that applying periodontal dressings is timeconsuming and is met with less-than-favorable acceptance by the patient. There is also a small possibility that bacterial pathogens can be entrapped against the denuded surgical site.6 The Evolution of Laser Removal Techniques Lasers have been employed for more than 20 years for the excision of hyperplastic oral tissues. Since at least 1985, the carbon dioxide laser has been used for various soft-tissue procedures in the oral cavity, including – but not limited to – gingivectomies, gingivoplasties, incisional and excisional biopsies, frenectomies, and removal of certain soft tissue lesions.7-10 The benefits of its use in such procedures include lack of hemorrhage that results in a dry working field, significant bacterial reduction in the surgical area, minimal postoperative discomfort, and reduced time to perform the procedure.7-10 Compared to the use of a scapel, the laser gingivoplasty is easy to perform, although specific training with lasers is required.11 As reported by some studies,8, 10 the early CO2 laser soft tissue surgery usually resulted in a charred or eschar layer on the surface of the wound, as shown in

CLI N ICAL CASE

the potential for char on the soft tissue. Although both the CO2 and Nd:YAG lasers could be used successfully for a variety of softtissue procedures, the CO2 laser was thought to be faster for most procedures. In time, however, many astute laser clinicians found that the charred layer that resulted from both devices led to increased postoperative pain and affected the predictability of the resultant tissue level. In both Figures 2a and 2b, the charring results from reheating already coagulated tissue and/or from excessively high energy levels. This excess fluence also causes increased edema in the underlying connective tissue. Users of the Nd:YAG laser learned that the optical fiber could be held in the same orientation relative to the tooth as a knife or scalpel.11 The same concept was applied when the 810-nm diode laser was introduced; that is, the energy was delivered parallel to the tissue instead of perpendicular. This orientation helped to reduce deep penetration of the laser beam into the underlying soft tissue, and continued heating and thermal damage would be decreased. In this way, the amount of charring could be held to a minimum. Additionally, these optical fiber-delivered lasers have been considered as an appropriate substitute for the scalpel for periodontal surgery because the

Diode Laser Gingivoplasty Technique A 38-year-old female patient presented with gingival enlargement as a result of many years of Dilantin® (phenytoin) therapy for epilepsy. She desired a veneer restoration to reposition the labial surface of the upper right lateral incisor. The clinical finding was that of excessive labial gingival tissue including an enlarged papilla, and the treatment was a laser gingivoplasty. The protocol and results of that procedure are described below. For the typical gingival surgery, attention to anesthesia is required. Many patients will benefit from only the application of topical agents. These include transdermal lidocaine patches; eutectic mixtures of local anesthetics (e.g., lidocaine 20%, prilocaine 20%, and phenylephrine 4%) that are custom-

Graeber

20 0 8 VO L 16 , N O . 3

Figure 2a. This was mainly unavoidable with the first CO2 lasers because they were essentially only slightly modified medical lasers that achieved surface absorption only and provided no – or only low – pulse rates. Additionally, those lasers must be used parallel to the long axis of the tooth to avoid any absorption by and damage to the hard dental tissues, since the CO2 wavelength has a high affinity for hydroxyapatite. The first designed-for-dentistry laser was the Nd:YAG (neodymium:yttrium, aluminum, garnet) (dLase 300, American Dental Laser, Birmingham, Mich.). In contrast to the aforementioned older CO2 laser concept, the removal of tissue with the Nd:YAG laser is accomplished by holding the laser tip perpendicular to and in contact with the tissue being ablated. Similarly, however, charring was a natural outcome of the technique, as shown in Figure 2b, especially if higher power settings, inordinately slow technique, or reapplication of laser energy to the previously ablated / surgerized site were employed. The same outcome is evident when diode lasers are used under similar conditions. There are currently available CO2 and diode lasers with pulse durations as small as a few ten-thousandths of a second. That emission mode on those instruments should significantly reduce

|

Figure 2b: An example of charred gingival in an immediate postoperative view of a gingivectomy performed with an Nd:YAG laser. Photograph courtesy of the Academy of Laser Dentistry

J O U R N A L O F L AS E R D E N T I ST RY

Figure 2a: An example of charred gingival in an immediate postoperative view of a gingivectomy performed with a continuous-wave CO2 laser. Photograph courtesy of Stuart Coleton, DDS, Chappaqua, N.Y.

clinician can work in a familiar setting, using a contact mode for tactile sensation and to facilitate the lasers’ insertion into the depth of the periodontal pocket.12 Instead of a char layer, the resulting surface consists of denatured protein. This layer will usually remain in place for several days – protecting the underlying connective tissue, nerve endings, lymphatics, and blood vessels – before sloughing off.13 The author refers to this as the “laser bandage.” This covering is usually adequate and protects against possible postoperative pain and infection. After 3 days, the author has observed that normal masticatory function and tooth brushing will remove the “laser bandage,” leaving exposed connective tissue. During this time re-epithelialization begins, and the wound is covered. During the denuded phase, patients often report being sensitive to acidic foods (e.g., tomato products), abrasive foods (e.g., snacks), and oral hygiene techniques.

137

CLI N ICAL CASE

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

Figure 3: Bare fiber tip of the diode laser in the recommended orientation

138

formulated in local pharmacies or available commercially (e.g., Oraqix®, DENTSPLY Pharmaceutical, York, Pa.); or benzocaine 20%, which is applied subgingivally. The depth of the pockets must be measured using the six-point probing scheme. The starting point for the beveled incision, as it relates to the end result, must be predetermined. To accomplish this, the clinician uses a periodontal probe, records the depth of the pocket to be treated, and notes and evaluates its condition (e.g., acute or chronically inflamed). If there is no apparent exudate present, the probe is used to define the height of contour that should be established when reducing the pocket depth. The laser can be used to place a line or a series of small dots along the facial aspect of the gingiva to create a reference for the laser incision path. The author uses an 810-nm diode laser (Odyssey® 3Watt, Ivoclar Vivadent Inc., Amherst, N.Y.) with an initiated 400-micron fiber, utilizing a power setting of between 1.0 and 1.4 Watts, in the continuous-wave mode. The fiber is angled slightly toward the occlusal or incisal aspect of the tooth and the excess tissue is removed down to the previously marked incision line, as shown in Figures 3 and 4. Figure 4: Laser surgery begins. The power setting in this excision was 1.0 W continuous wave. Care was taken to maintain papillary height while reducing the pocket depth to 2 mm. The blue arrow

Graeber

Figure 4: Laser surgery begins. The power setting in this excision was 1.0 W continuous wave. Care was taken to maintain papillary height while reducing the pocket depth to 2 mm. The blue arrow indicates the direction of laser fiber’s movement. The clinician needs to remove approximately 1 mm of additional tissue to allow for the regrowth of the epithelial layer

indicates the direction of laser fiber’s movement. The clinician needs to remove approximately 1 mm of additional tissue to allow for the regrowth of the epithelial layer. As noted earlier, the optical fiber of both the diode and Nd:YAG lasers can be substituted for a periodontal scapel or knife.14 As the operator proceeds incisally, tooth structure may be encountered. Care should be taken to avoid prolonged contact, and the use of low power settings is advised, as suggested above.15 Once the majority of hypertrophic tissue has been removed, the remaining tissue should be contoured and blended into the surrounding area. This phase of the procedure is termed “laser festooning” by the author. The crestal gingiva is contoured as needed using powers of 1.5 Watts or less, then any excess epithelium remaining near the root is quickly removed (Figure 5). The operator should remember to move quickly, and to avoid touching the root with the laser fiber whenever possible. Immediate postoperative results, subsequent to wound cleansing, are shown in Figure 6. The beneficial biostimulatory effects of soft-tissue diode laser procedures have been studied but

Figure 5: Gingival tissue “festooned” for normal physiologic contour. The sulcus is then flushed with warm saline solution or hydrogen peroxide. The immediate postoperative result is

Figure 6: Clinical appearance immediately postoperative after cleansing the wound with 3% hydrogen peroxide. Any loose fragments of tissue are easily removed with a minimal scrubbing motion, using a cotton pellet. The 810-nm laser wavelength produces enough depth of coagulation to prevent post-treatment hemorrhage

not clearly understood. Moreover, the laser parameters mentioned by Karu16 are well below those used by the author. It is known, however, that the inflammatory responses are muted;13 and, in the author’s experience, healing appears at an accelerated rate and most patients report little to no postoperative pain. The appearance of normal tissue color with stippling has been observed to return within a 14-day period in most cases. Figures 7 and 8 depict postoperative healing at 7 and 21 days, respectively.

C O NC LU SIO N Soft-tissue lasers are increasingly being utilized, and newer, more efficient and effective methods of employing lasers for the benefit of

CLI N ICAL CASE

REFERENC ES 1. Seymour RA, Ellis JS, Thomason JM. Risk factors for drug-induced gingival overgrowth. J Clin Periodontol 2000;27(4):217-223.

dental patients are being reported Figure 8: Twenty-one-day healing of gingivoplasty sites. There is complete clinical healing with stippling

with greater frequency. This article has demonstrated one such technique for performing a gingivoplasty procedure more predictably and safely than conventional methods when treating a patient with medication-induced gingival enlargement. Moreover, the recurrence is lessened when a laser is used.17

AU T H O R B I O G R AP H Y Dr. John Graeber is a graduate of the University of Medicine and Dentistry of New Jersey, and maintains a private dental practice in East Hanover, New Jersey. He joined the Academy of Laser Dentistry (ALD) at its inaugural conference in 1993, and has taught laser courses since 1996. He has earned Advanced Proficiency,

2. Dongari-Bagtzoglou A; Research, Science and Therapy Committee, American Academy of Periodontology. Drug-associated gingival enlargement. J Periodontol 2004;75(10):1424-1431. 3. Ciancio SG. Medications’ impact on oral health. J Am Dent Assoc 2004;135(10):1440-1448. 4. Hallmon WW, Rossmann JA. The role of drugs in the pathogenesis of gingival overgrowth. A collective review of current concepts. Periodontol 2000 1999;21:176-196. 5. Silverstein LH, Garnick JJ, Szikman M, Singh B. Medicationinduced gingival enlargement: A clinical review. Gen Dent 1997;45(4):371-376. 6. Powell CA, Mealey BL, Deas DE, McDonnell HT, Moritz AJ. Postsurgical infections: Prevalence associated with various periodontal surgical procedures. J Periodontol 2005;76(3):329-333. 7. Pick RM, Pecaro BC, Silberman CJ. The laser gingivectomy. The use of the CO2 laser for the removal of phenytoin hyperplasia. J

10. Pick RM, Colvard MD. Current status of lasers in soft tissue dental surgery. J Periodontol 1993;64(7):589-602. 11. Russo J. Periodontal laser surgery. Dent Today 1997;16(10):80-81. 12. White JM, Goodis HE, Rose CL. Use of the pulsed Nd:YAG laser for intraoral soft tissue surgery. Lasers Surg Med 1991;11(5):455-461. 13. Parker S. Lasers in dentistry. London: British Dental Association, 2007:19, 31. 14. Stabholz A, Zeltser R, Sela M, Peretz B, Moshonov J, Ziskind D, Stabholz A. The use of lasers in dentistry: Principles of operation and clinical applications. Compend Contin Educ Dent 2003;24(12):935940, 942-948, Quiz 949-950. 15. Theodoro LH, Haypek P, Bachmann L, Garcia VG, Sampaio JEC, Zezell DM, Eduardo Cde P. Effect of Er:YAG and diode laser irradiation on the root surface: Morphological and thermal analysis. J Periodontol 2003;74(6):838-843. 16. Karu TI, Pyatibrat LV, Kolyakov SF, Afanasyeva NI. Absorption measurements of a cell monolayer relevant to phototherapy: Reduction of cytochrome c oxidase under near IR radiation. J Photochem Photobiol B 2005;81(2):98-106. 17. Mavrogiannis M, Ellis JS, Seymour RA, Thomason JM. The efficacy of three different surgical techniques in the management of drug-induced gingival overgrowth. J Clin Periodontol 2006;33(9):677-682. ■■

Graeber

20 0 8 VO L 16 , N O . 3

Disclosure: Dr. Graeber is a current consultant and trainer for Ivoclar Vivadent, and receives honoraria for those services.

9. Pick RM, Powell GL. Lasers in dentistry. Soft-tissue procedures. Dent Clin North Am 1993;37(2):281296.

|

Figure 7: Seven-day postoperative view of tissue. Epithelialization is

Periodontol 1985;56(8):492-496. 8. Pick RM, Pecaro BC. Use of the CO2 laser in soft tissue dental surgery. Lasers Surg Med 1987;7(2):207-213.

J O U R N A L O F L AS E R D E N T I ST RY

Educator status, and Mastership in the Academy, and is an ALD Recognized Course Provider. A current ALD Board Member, he serves on the Ethics and Education committees. This is his tenth published article. Dr. Graeber may be contacted by e-mail at [email protected]

139

R ESEARCH

Editor’s Note: The following four abstracts are offered as topics of current interest. Readers are invited to submit to the editor inquiries concerning laser-related scientific topics for possible inclusion in future issues. We’ll scan the literature and present relevant abstracts.

L AS E R T R E AT M E N T

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

O F G I N G I V AL H YP E R P L AS I A

140

In his case study of laser treatment of drug-induced gingival enlargement, (136-139), Dr. John J. Graeber uses an 810-nm diode laser to perform gingivoplasty – removing the hypertrophic tissue and contouring the remaining tissue to optimize the esthetic and functional result. Silverstein and colleagues1 outline the types of medications identified as possible causative agents. They include anticonvulsants (to control epileptic seizures), immunosuppressants (to prevent rejection in human organ tranplants and to treat diseases of cellmediated autoimmune origin such as Type I diabetes mellitus and rheumatoid arthritis), and calcium channel blocking agents (to manage certain cardiovascular conditions). Enlargement of oral mucosal tissue may also occur during or as a result of hormonal changes (during pregnancy, at puberty, and with the use of oral contraceptives), orthodontia, localized sites of chronic irritation such as illfitting dentures, poor oral hygiene, system diseases such as leukemia, and other conditions. Esmeili and colleagues2 review the etiology of many of the common soft tissue masses, and emphasize the need for conducting a definitive diagnosis to determine treatment.

For additional background on the use of lasers in the treatment of gingival hyperplasia, readers are referred to clinical cases and research abstracts in previous issues of the Journal of the Academy of Laser Dentistry and Wavelengths. 1. Cecchini SCM. Clinical case study #1: Removal of a benign focal reactive hyperplasia with a pulsed Nd:YAG laser. Wavelengths 1998;6(4):4-5. 2. Gilio DA. Adjunctive orthodontic treatment: Hyperplastic tissue removal using the Nd:YAG laser with contact tip. Wavelengths 2001;9(3):20. 3. Graeber JJ. Nd:YAG laser reduction of drug-induced gingival hyperplasia. Wavelengths 2001;9(2):18.

Lasers have been used to effect treatment of such conditions for more than two decades, as indicated in Dr. Graeber’s article and a previous review of this subject in the Research Abstracts section of the Journal of the Academy of Laser Dentistry 2005;13(3):33-35. The additional abstracts below illustrate how a variety of lasers may be used to facilitate treatment. For U.S. readers, certain carbon dioxide, Nd:YAG, argon, Ho:YAG, Er:YAG, Nd:YAP, Er,Cr:YSGG, diode, and frequency-doubled Nd:YAG lasers have been cleared by the U.S. Food and Drug Administration for intraoral soft tissue surgery. As always, clinicians are advised to review the specific indications for use of their lasers and to review their operator manuals for guidance on operating parameters before attempting similar techniques on their patients.

REFERENC ES 1. Silverstein LH, Garnick JJ, Szikman M, Singh B. Medication-induced gingival enlargement: A clinical review. Gen Dent 1997;45(4):371-376; Quiz 379-380. 2. Esmeili T, Lozada-Nur F, Epstein J. Common benign oral soft tissue masses. Dent Clin North Am 2005;49(1):223-240.

4. Greider WA. Er,Cr:YSGG laser removal of hyperplastic tissue in the maxillary frenum. Wavelengths 2002;10(2):24. 5. Griffin G. Nd:YAG laser reduction of dilantin hyperplasia. Wavelengths 2001;9(3):21. 6. Neckel CP. Diode laser treatment of medication-induced gingival hypertrophy in a medically compromised patient. Wavelengths 2000;8(4):18. 7. Research abstracts. J Acad Laser Dent 2005;13(3):33-35. 8. Research abstracts. Wavelengths 2002;10(3):22-23. 9. Rosenberg SP. Laser treatment of cyclosporine hyperplasia. Wavelengths 1995;3(2):6.

R ESEARCH ABSTR ACTS

AT YP I C AL PAL ATAL PAP I L LO MATO S I S T R E AT E D B Y E XC I S I O N AN D F U L L-T H I C K N E S S G R AF T I N G

Alan R. Brown, DDS, Charles M. Cobb, DDS, PhD, Charles L. Dunlap, DDS, Jean N. Manch-Citron, PhD University of Missouri, Kansas City, Missouri Compend Contin Educ Dent 1997;18(7):724, 726, 728-732, 734

Papillary lesions of the oral cavity are extremely common, and inflammatory palatal hyperplasia is well known to dental practitioners. Advanced sophistication in viral laboratory technologies makes it apparent that various forms of the human papilloma virus are often causative. However, this is not true for inflammatory palatal hyperplasia. This article describes a patient with anatomically well-demarcated, multiple squamous cell papillomas of the palate that could not be classified as inflammatory palatal hyperplasia, nor could a viral etiology be ascertained, despite exhaustive laboratory

studies. The lesion recurred despite numerous surgical ablation attempts, including CO2 laser therapy. Eradication was achieved only after applying free softtissue grafts over the areas of excision. The differential diagnosis of papillary lesions with an emphasis on viral etiology, laboratory studies associated with their identification, and a hypothesis that explains why grafting was the only successful means of treatment are also discussed. Copyright 1997 Dental Learning Systems ■■

R E MO V AL O F H YP E R P L AS T I C L E S I O N S O F T H E O R AL C AV I T Y. A R E T R O S P E C T I V E S T U D Y O F 1 2 8 C AS E S

Meritxell Tamarit Borràs, Esther Delgado-Molina, Leonardo Berini-Aytés, Cosme Gay-Escoda University of Barcelona

Copyright 2005 Medicina Oral S.L. ■■

|

(51.9%). Fibrous hyperplasia was the most common histological diagnosis (49 cases; 63.6%). Percentage relapse following removal was 9.1%, of which 5 cases corresponded to fibrous hyperplasia. Only one malignancy was identified, corresponding to infiltrating squamous cell carcinoma. On the other hand, of the 51 treated cases of fibromatous hyperplasia, 58.8% were located in the upper jaw. These were histologically confirmed to be fibrous hyperplasia, with relapse in 19.6% of the cases. Conclusions: Although the different surgical techniques used for removal of epulis of the oral cavity are appropriate, we consider the CO2 laser to be the treatment of choice, since it offers a number of both intra- and postoperative advantages. On the other hand, all oral lesions require histological study to establish a firm diagnosis.

J O U R N A L O F L AS E R D E N T I ST RY

Aims: Based on our accumulated experience, the present study evaluates and discusses the indications, advantages, and inconveniences of oral cavity epulis resection using the carbon dioxide laser (CO2) versus the erbium:YAG laser (Er:YAG), diode laser, and surgical scalpel. Materials and Methods: A retrospective study has been made of 120 patients involving the removal of 128 epulis lesions with the CO2 laser, Er:YAG laser, diode laser, and surgical scalpel. Postoperative controls were carried out after 7, 15, and 30 days to evaluate healing and wound evolution, and after 3, 6, and 12 months to assess possible relapse. Results: Two groups were defined, based on the clinical and etiopathogenic characteristics of the excised lesions: gingival hyperplastic lesions (77 cases) and fibromatous hyperplasia (51 cases). The lower jaw was the most frequent location of gingival hyperplasia

20 0 8 VO L 16 , N O . 3

Med Oral Patol Oral Cir Bucal 2005;10(2):151-162. English, Spanish

141

R ESEARCH

U S E O F T H E C O 2 L AS E R O N O R T H O D O N T I C PAT I E N T S S U F F E R I N G F R O M G I N G I V AL H YP E R P L AS I A

Sabrina K.C. Gama, DDS; Telma Martins de Araújo, PhD; Daniel Humberto Pozza, PhD; Antonio Luiz B. Pinheiro, PhD Photomed Laser Surg 2007;25(1):214-219

Objective: The present study aimed to assess the effect of the use of the CO2 laser on the treatment of gingival hyperplasia in orthodontic patients wearing fixed appliances. Background Data: Gingival hyperplasia is a condition very frequent in patients undergoing fixed orthodontic treatment. Amongst the treatments available for this is the use of surgical lasers. Methods: Ten patients entered this study and signed an informed consent. Seventy-five anterior teeth with gingival hyperplasia were selected for laser surgery. Prior to surgery, the length of the crowns were measured using a digital caliper, and depth of the

pocket was probed. The hyperplasic gingiva was removed with a CO2 laser under local anesthesia. Immediately after surgery, measurement of the length of the crowns and probing were carried out and were repeated. Results: The results were statistically analyzed and significant differences were detected regarding the length of the crown (p = 0.000) and depth of the gingival sulcus (p = 0.000). Conclusion: It is concluded that the use of the CO2 laser was effective in the treatment of gingival hyperplasia. Copyright 2007 Mary Ann Liebert, Inc. ■■

I N F L AM MATO R Y PAP I L L AR Y H YP E R P L AS I A O F T H E PAL AT E : T R E AT M E N T WI T H C AR B O N D I O XI D E L AS E R , F O L LO WE D B Y R E S TO R AT I O N WI T H AN I M P L AN T- S U P P O R T E D P R O S T H E S I S

P. Infante-Cossio,1 R. Martinez-de-Fuentes,2 E. Torres-Carranza,1 J.L. Gutierrez-Perez1

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

1Virgen del Rocio University Hospital, Sevilla, Spain

142

2University of Seville, Seville, Spain Br J Oral Maxillofac Surg 2007;45(8):658-660

Inflammatory papillary hyperplasia of the palate is a persistant non-neoplastic lesion that is normally caused by poorly fitting dentures and Candida infection. We describe a case that was managed primarily with topical miconazole, and complete removal of the old acrylic denture. A multidisciplinary approach between surgeon and prosthodontist was used that combined carbon dioxide laser followed by substitution

of the old removable denture for a new implantsupported screw-retained prosthesis. This avoided direct support of the prosthesis by the palatal mucosa and made oral hygiene easier. The treatment has resulted in complete remission and there has been no recurrence during 3 years of follow-up. Copyright 2007 The British Association of Oral and Maxillofacial

G U E S T E D I TO R I A L

LASERMIND Alan Goldstein, DMD, New York, New York

to bring acceptance to living situations.” – Chogyam Trungpa, The Myth of Freedom and the Way of Meditation

Recently, the Wall Street Journal ran a piece on obesity control. Obesity, as I am sure you are aware, is one of the major pubic health challenges of our time. The Journal reported a unique and promising approach to the problem using the Buddhist concept of mindfulness and described the approach as mindful eating. Mindfulness methodology is the brilliantly simple idea that says one can only do one thing at a time. How novel a concept during this era when multitasking is frighteningly held in such high esteem. The idea as it relates to eating, and borne out by research, revealed an unexpected finding. Overweight and obese people can barely remember what it is they ate just a few minutes after finishing a meal. This, of course, points up the distinction between eating food in a mindless manner and actually tasting and appreciating it. Think about the notion of placing one raisin in your mouth, chewing, then tasting, and then swallowing it. There will be an appreciation of that raisin that is often missed in our rushed lives. But we miss far more than raisins when we laud the so-called benefits of multitasking and efficiency in the modern and often hysterical world. Maggie Jackson,

author of a disturbing and important new book, Distracted, observes, as we move at warp speed from one task to another, from one conversation to another, or from one relationship to another: “Attention is the building block of intimacy, wisdom and cultural progress. If we squander our powers of attention, our technological age could ultimately slip into cultural decline.” This was first discussed by William James, the American psychologist and philosopher, who wrote at length about the varieties of human attention in The Principles of Psychology (1890). He outlined the differences among “sensorial attention,” “intellectual attention,” “passive attention,” and the like, and noted “gray chaotic indiscriminateness” of the minds of people who were incapable of paying attention. As laser dentists we have a wonderful metaphor at our disposal. The idea of a lasermind is one that focuses absolutely and with full attention and awareness. A lasermind will provide us with a tool for both superb care for our patients and learning and growth for ourselves. Like many tools our lasers have learning curves. Learning about laser-tissue interactions, learning about the details of laser safety, and learning the

Goldstein

|

Mindfulness is the vanguard of awareness … [Both] work together

requisite laser physics that distinguish these devices from most of the instruments in our operatories provide us with fertile ground for intellectual growth. All of these areas can be entered with the full focus of our laserminds. If we sit with this concept of mindfulness we will see that it has the capacity to transform our professional and personal lives. Slowing down, we can pay attention not only to the broad array of details that require our careful attention, but perhaps more importantly, the myriad relationships that provide the human cement that make us a part of our community. And as we pay attention to these things our skills improve and our efficiency increases. Imagine, for a moment, suggesting to our patients that they brush and floss mindfully. At first they might look at you in a funny way, but when you explain that their tooth brushing and flossing activities could have intention attached to them so that when they were doing these chores they weren’t daydreaming about this thing or that, but they were focused on where the bristles landed or where the floss was placed. Again the Buddhist and other Eastern teachings provide some guidance in these matters. The metaphor that they use to teach the concept of intentionality uses the activity of washing dishes, seemingly the most mindless of activities. “One should wash the dishes when one is washing the dishes,” they suggest. This is different than thinking about something else while washing the dishes. What could be more beautiful, clear, or self-

J O U R N A L O F L AS E R D E N T I ST RY

“Mindfulness and awareness always complement each other …

20 0 8 VO L 16 , N O . 3

J Laser Dent 2008;16(3):144-145

143

G U E S T E D I TO R I A L

evident? I can only add: as it goes with dishes, so it goes with teeth! Only please trade the Cascade for some Crest…

AU T H O R B I O G R AP H Y

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

Born and raised in the Bronx, Dr. Alan Goldstein graduated from the City College of New York before receiving his dental degree from the University of Pennsylvania School of Dental Medicine in 1968. He is a frequent contributor to the dental literature as well as a lecturer in a variety of venues. He was certified as a Professional Integral Coach in 2001 and has a coaching practice in New York City. He often addresses audiences on topics of personal effectiveness,

144

Goldstein

fulfillment, and leadership as well as dental practice management and use of lasers. He is a past president of the Academy of Laser Dentistry and a former editor of Wavelengths. He serves on the Dental Advisory Board of Dentistry Today and the Journal of Laser Dentistry and is a Fellow in the American College of Dentists. Dr. Goldstein may be contacted by e-mail at [email protected] Disclosure: Dr. Goldstein has provided educational services for a number of laser manufacturers and received honoraria for these services. Presently, he has no commercial financial relationships.

REFERENC ES 1. Trungpa C. The myth of freedom and the way of meditation. Boston: Shambhala Publications, Inc., 2005. 2. Beck M. Putting an end to mindless munching. Wall Street Journal May 13, 2008. http://online.wsj.com/public/ article/SB121062985377986351L2sPVaRuoMPJ_RQV6vkIKsr5AA8 _20080611.html?mod=tff_main_tff_t op. Accessed December 12, 2008. 3. Jackson M. Distracted: The erosion of attention and the coming Dark Age. Amherst, N.Y.: Prometheus Books, 2008. 4. James W. The principles of psychology. New York: Henry Holt and Company, 1890. ■■

C O N T I N U I N G E D U C AT I O N

J O U R N AL O F L AS E R D E N T I S T R Y

Continuing Education Program The Journal of Laser Dentistry’s Continuing Dental Education Program offers readers an opportunity to earn one CE self-instructional credit for one of the articles in this issue. Read the specified article and then select the most correct answer to each of the questions. If you correctly answer 7 of the 10 questions on the test (for a score of 70%), you earn one credit hour. The answer form must be completed as directed in the instructions; otherwise, it will not be processed. This program is developed by representatives of the Academy of Laser Dentistry’s Science and Research committee and is provided as a benefit to ALD members at no additional charge. Nonmembers are also eligible to participate for a $20

administrative fee per issue. Answers to this exercise will be published in a future issue. Please photocopy and complete the registration form as well as the answer sheet and evaluation form on pages 147-149 for the test and mail them (along with the $20 administrative fee if you are not an ALD member) to: The Journal of Laser Dentistry Department of Continuing Education P.O. Box 8667 Coral Springs, FL 33075 Payment may be by check drawn on a U.S. bank, money order, or VISA or MasterCard. Please keep a copy of

your answers for your records. Your test is graded by representatives of the Academy of Laser Dentistry, an ADA CERP recognized provider.

You will be notified by mail of your test score and the number of credits awarded. You must then forward the information to your state dental board or agency for licensure purposes. Individuals who score less than 70% will receive a letter. Answers to these tests are due on or before March 31, 2009. Please call the Academy of Laser Dentistry (954) 346-3776 if you have any questions about this program. ■■

AC AD E MY O F L AS E R D E N T I S T R Y • S E L F - I N S T R U C T I O N P R O G R AM N O . 1 6 3 1

• Define peri-implantitis and specify considerations in the treatment of this condition. Test Questions 1. The currently available laser wavelength(s) that have clinical indications for use in performing osseous surgery is (are): a. all diodes b. Nd:YAG c. carbon dioxide d. Er,Cr:YSGG and Er:YAG 2. The wavelengths utilized for osseous surgery are absorbed by the chromophores in bone, including: a. hemoglobin and oxyhemoglobin

b. water and the hyrdroxyl group of hydroxyapatite c. phosphate and nitrate groups d. melanin and xanthophyll 3. When an osteotomy for the placement of an implant fixture is performed with a laser, which of the following statements is true? a. the laser has an advantage because it can much more rapidly prepare the site than size-matched burs b. the water spray used for cooling the tissue is easily directed into even the deepest preparations with conventional tips c. the end-cutting laser beam does not allow for a measured development of a threedimensional preparation

|

Educational Objectives Upon successful completion of this module, you will be able to: • Identify which laser types may be used safely for osseous surgery, and specify the chromophores that are absorbed by the laser’s energy. • Describe the parameters under which a laser may be used for osseous surgery, and enumerate the laser’s advantages and limitations in such a procedure. • Identify which laser types may be used safely for second-stage recovery of implants. • Describe the procedure and precautions for using a laser for second-stage uncovering of an implant.

J O U R N A L O F L AS E R D E N T I ST RY

The Use of Laser Energy in Implantology Steven P.A. Parker, BDS, LDS RCS, MFGDP

20 0 8 VO L 16 , N O . 3

Subject Code: 690

145

C O N T I N U I N G E D U C AT I O N

d. studies have shown significant disrupted healing of laser-prepared osteotomies compared to the control group 4. To avoid damage to osseous tissue with a laser, the maximum temperature to which bone should be raised during osseous surgery is: a. 47 degrees Celsius b. 42 degrees Celsius c. 80 degrees Celsius d. 57 degrees Celsius

J O U R N A L O F L AS E R D E N T I ST RY

|

20 0 8 VO L 16 , N O . 3

5. The application of laser energy on the metal implant should be accomplished under which of the following considerations: a. Use a laser with a power density of several thousand Watts per pulse b. Use a laser with a high peak power per pulse without a water spray c. Use a laser in continuouswave mode with an average power of approximately 1.0 W d. Use a laser that causes detectable disruption of the coated implant surface

146

6. Which of the following statements applies to second-stage uncovering of an implant fixture? The procedure:

a. should not be performed with a laser because of the laser’s potential to harm the fixture b. can be performed with any commercially available laser wavelength c. should not be performed with a laser because of the laser’s potential to damage the periodontium d. can be performed only with fiber-delivered lasers with water spray 7. According to the author, secondstage uncovering of the implant with a laser: a. can be performed without regard to the thickness and vascularity of the soft tissue b. should be performed at a starting average power of 4-5 Watts c. starts with removing a small cone of tissue until nearcontact with the implant is made d. should produce rapid buildup of carbonized material on the soft tissue surface and the tip of the laser 8. Which of the following was demonstrated in the article’s accompanying clinical case examples of second-stage uncovering of the implant fixture?

a. the choice of laser wavelength is irrelevant, as long as the proper parameters are utilized b. the laser clearly damaged the periodontium c. excessive soft tissue must not be removed with a laser d. a laser cannot be used to contour the gingival tissue after uncovering the implant 9. The generally accepted definition of the term peri-implantitis is: a. the acute inflammation of only the marginal gingival tissue adjacent to a functional implant b. inflammatory reactions with loss of supporting bone in tissues surrounding a functional implant c. the loosening of the implant abutment d. disintegration of the restorative material on the abutment crown 10. In the treatment of peri-implantitis, which of the following is true? a. the presence of biofilm on the implant surface causes no concern b. removal of granulation tissue is not recommended by the author c. occlusal loading is never analyzed d. pathogen reduction is a primary step

C O N T I N U I N G E D U C AT I O N C O N T I N U I N G E D U C AT I O N C R E D I T R E G I S T R AT I O N F O R M Please print or type clearly. The certificate will be issued from the information given. First Name

Initial

Last Name

Degree

Social Security Number

Street Address

Suite

City

State or Province

Postal Code

Daytime Telephone Number with Area Code

Fax Number with Area Code

E-mail Address

Nonmembers only: I wish to pay the $20 administrative fee by the following method: ❑ Check #__________________

❑ VISA

❑ MasterCard

Credit Card #

Expiration Date

Name on Card

Signature

The Use of Laser Energy in Implantology Steven P.A. Parker, BDS, LDS RCS, MFGDP Subject Code: 690

Poor = 1 to Excellent = 5

Clarity of the questions

_____

Relevance of the questions

_____

The article presented new information

_____

B

C

D

1.









Clarity of objectives

_____

2.









Usefulness of the content

_____







_____

3.



Program achieved its educational objectives

4.









Benefit to your clinical practice

_____

5.









Quality of the manuscript

_____

How many minutes did it take you to read the article and complete the test?

_____

6.









7.









8.









9.









10.









Usefulness of the references _____ Quality of the illustrations

_____

Relevance of the illustrations_____

Please list future CE topic preferences:

|

A

J O U R N A L O F L AS E R D E N T I ST RY

Program Evaluation — Test 1631 Please evaluate this article.

Place an X in the box corresponding to the answer you believe is most correct.

20 0 8 VO L 16 , N O . 3

AN S WE R S H E E T F O R T E S T 1 6 3 1

147