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Frank A. Licht, RDH, BSDHUniversity of Tennessee Health Science Center

MDH 706Capstone

Dr. Nancy Williams

Application of Lasers in Dentistry

CE Course

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Frank Licht, RDH, BSDHClinical Supervisor

Tennessee State University

The University of MichiganGraduated in 2004

CertificationsLocal Anesthesia

Nitrous Oxide AdministrationNitrous Oxide MonitoringPeriodontal Laser Therapy

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• Brief History and Science of Lasers

• Lasers and their use in Dentistry

• Lasers in the Treatment of Periodontal Disease

• LBR and LAPT Procedures• What else you can do with

this knowledge

Course Overview

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History of Lasers in Dentistry

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First Laser Developed by:

Theodore Maiman

A ruby based laser

He called it “Maser”

1960

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Lasers in Dentistry 1965 Gold used Ruby and CO2 Lasers1970’s CO2 and Nd:YAG tooth Prep 1980’s Emphasis switched to incision of soft tissue with CO21990’s Introduction of Diode and Er:YAG and pulsed Nd:YAG

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Common Lasers In Dentistry

Diode – 810, 940, 980 nmNd:YAG – 1064 nmEr:YAG – 2780 nm CO2 – 10,000 nm

A Nanometer (nm) equals 10 to the -9th Power

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Einstein’s Theory

Light Amplification by Stimulated Emission

of Radiation was developed by

ALBERT EINSTEIN

1916

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Laser PhysicsStimulated Emission

• Atoms of the active medium are stimulated to a higher energy level

• This energy is released as a photon as the atom returns to a more stable energy level

• Released photons can go on to stimulate more atoms in the crystal thus producing more photons (Amplification)

Single Photon Enters Atom

Two Photos Exit Atom

External Stimulus

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Spectrum

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Frequency ofLasers

(Wavelength)

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Wavelength

The Distance from Wave Crest to Wave Crest

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Wavelength

The overall effect of Laser Light on it’s target is dependent on it’s wavelength

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L.A.S.E.R

Monochromatic Light

Collimated

Coherent

Light Amplified by Stimulated Emission of Radiation

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More Laser Information…

Laser Mediums – Gas, Liquid or Solid

Medium determines Wavelength (Frequency)

Wavelength Absorbed Differently by H2O and Tissue

Absorption Depth Determined by Wavelength

Pulse and Duration focus and concentrate Energy

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Tissue Penetration

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Pulsed vs ContinuousContinuous emission of laser energy will non-selectively ablate tissue

Pulsed Energy increases Wattage to area and reduces Duty Cycle (time laser on) by ½

Generally Nd:YAG runs 0.2% of time. This reduces thermal effects on tissue

Varying the Pulse Duration can provide additional benefits such as ablating tissue and hemostasis

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Are you Still Awake…

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Laser Effects On Tissue

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Laser Effects on TissueAbsorption Affects infected tissue

**** Most Important Affect***

Reflection: Dissipates quickly

Scattering: May Harm Surrounding Tissue

Transmission May Harm Surrounding Tissue

Hemostasis Blood Coagulation

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Bio-Stimulation

What is accomplished while performing Bio-Stimulation?

1. Increase Collagen Formation

2. Increase Circulation

3. Increase Fibroblastic Activity – Tissue Regeneration

4. Increase Osteoblastic Activity – Bone Regeneration

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Bio-Stimulation

What is accomplished while performing Bio-Stimulation?

1. Reduce or Eliminate Bacteremias

2. Reduce or Eliminate Cross-Contamination

3. Kill Periodontal Infections before loss of attachment occurs

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Specific Types of LasersCO2

Diode

Erbium

Neodymium

Argon

Holmium

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CO2 Laser10,000 nm mostly continuous wave (millisecond pulsing offered in some)

Non contact.

Absorbed by Water and Hydroxyapatite.

Excellent for cutting soft tissue and surface ablation

Hollow tube Delivery

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Diode Laser940nm (810nm and 980nm also)Produced from a Solid Medium

Absorbed by: WaterHydroxyapetiteHemoglobinMelanin

Continuous wave with programmable pulsed setting

Disposable fiber-optic Delivery

940nm creates a cleaner cut and less char than other wavelengths.

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Er:YAG = BioLase2780 nm Wavelength

Absorbed by water and Hydroxyapatite

High Surface absorption

Excellent for hard tissue removal

Non-Selective for Soft tissue removal

Fiberoptic Delivery

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Periolase MVP 7

Nd:YAG 1064Nm

Fiber-optic Delivery 200u 300u 450u size

7 Variable Pulse Settings

Absorbed by Hemoglobin and pigmented tissue

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Effects of Exposure DurationThe Zone of Necrosis is the area of tissue affected by the laser’s energy and heat.

***The Diode laser’s Zone of Necrosis is smaller than that of other Electro-Surgical Devices.***

The Zone of Necrosis is affected by the length of exposure

and the powerSetting of the Laser.

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Laser ProceduresFrenectomy

GingivectomyCaries Detection

Periodontal Disease Treatment - L.B.R. – L.A.P.T.Tooth Preparation

Bio-StimulationUncovering implants

Cutting TeethGingival Sulcus Debridement

Biopsy Curettage

Apthous Ulcer TreatmentTeeth Desensitizing

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Hygiene Procedures

• Herpetic Lesion Treatment• Aphthous Ulcer Treatment• Teeth Desensitizing• L.B.R – Laser Bacterial Reduction• L.A.P.T – Laser Assisted Periodontal Therapy

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Increase patient comfort

Increase effectiveness of treatment

Improve patient acceptance of care

Increase reparative and regenerative healing

Increase types of procedures available

Improve office image

Benefits of Laser Treatment

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Advantages of Laser TreatmentHigh Bactericidal effect

Reduce Post-op Inflammation & Edema

Increased productivity – Less wait time

Greater Hemostasis

Minimal wound contraction – skin shrinkage

Retard epithelial proliferation apically along healing root surface to enhance periodontal tissue

regeneration

Reduce Noise factor

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Disadvantages Of Laser Treatment

Laser irradiation can interact with tissues even in the non-activated mode. Meaning laser beams can reach the client’s eye and other tissues surrounding the target in the oral cavity

You need specific eyewear according to wavelength for client and clinician

Cost and size will constitute an obstacle for clinical application in Dental Hygiene.

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Medically Compromised

Patients on Blood Thinners are not required to stop medication… Why?

High BP – Epinephrine is contraindicated

Client allergic or hypersensitive to Epinephrine.

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Contraindications

Dental lasers can NOT be implemented in the following clients.

Patient suffers from a skin disease, and is allergic to light

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Laser SafetyGlasses

Each laser must have several pairs of protective eyewear related to its wavelength. You and your patient MUST wear protective eyewear to avoid any possible retinal damage.

SignageIt is recommended that signs are posted

in the cubicle where laser therapy will be performed. Make sure other employees know not to enter when the sign is posted.

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Prevalence Of Periodontal Disease

200 Million US Adults and nearly 95% have some form of Periodontal disease with 30% having

Moderate to Severe Periodontitis

Only 3% of the Moderate to Severe actually get treatment!

When Detected and Treated Early this Disease Does not have to be as Destructive regarding,

Function, Phonetics, Esthetics or Systemic Implications!

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Treatment OptionsProphylaxis

Scaling & Root Planing

Anti-mocrobial Medications

Antibiotics

Flap Surgery

Bone Graft

Tissue Graft

Laser Therapy

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Traditional Surgery

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Disadvantages of Traditional Surgery

• Surgical manipulation of tissue with consequences

• Increased sensitivity and risk of root decay• Cost of Procedure• Fear of Surgical Procedure• Must have Patients Cleared of Any Medical

Issues i.e. clotting concerns

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• Recession • Sensitivity• Morbidity• Cost• Long Junctional

Epithelium Loss

Consequences of Traditional Therapy:

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Why Laser is best for Periodontal Disease?

Periodontal Disease Manifests Clinically as Red Inflamed Tissue.The Disease is initiated by Anaerobic Bacteria

that invade tissue and cementum

Porphyromonas Gingivalis Tannerella forsythiaMutans streptococciStreptococcus mutansStreptococcus sobrinusStreptococcus IntermediusPrevotella intermediaTreponema denticolaLactobacilliAggregatibacter actinomycetemcomitans

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Histological Effects of Lasers

Ultrasonic debridement results in a smooth surface which still contains debris, bacteria, contaminated root

cementum and sub-gingival plaque.

Laser Treatment roughens the root surface enhancing adhesion of fibroblasts…

Leads to greater periodontal attachment

Laser treatment initially blocks the growth of epithelium which in effect enhances periodontal attachment.

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Diode LaserUses heat to “Melt” TissueExcellent for Hemostasis and effective clottingCan penetrate 2 – 3 mm in depthONLY indicated for soft tissue applicationsElectromagnetic energy from the laser beam is

absorbed by the carbonized tip. The molecules in the tip are converted to heat energy, then the tip emits visible infrared light.

Has been shown to regenerate cementum

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Recommendations to use Laser for Periodontal Treatment

Want to Destroy Quantity and Quality of Bacteria

Want to De-Epithelialize (Infected tissue)

Want to Penetrate into cementum and gingival tissue

Want to Minimize damage to healthy tissue

Want to Stimulate Regeneration

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Bio-Film Disruption• Laser irradiated surfaces removed bacteria from

biofilm and hard surfaces

• Abrupt decrease in bacterial ATP = cell mortality

• Effective bacterial ablation and slower rate of recolonization

• 55% bacterial reduction from laser alone, independent of heat or wavelength

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Why Laser over Traditional Approach?

Addresses all Treatment Objectives

Better Decontamination of Pocket

Bio-Stimulatory and Regenerative

Shorter Treatment - weeks vs. months or years

Less Invasive and Lower risk than Surgery

Not Necessary to Go Off Anti-Coagulants

Better Patient compliance

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Laser Function

The laser functions in such a way that it can cut or affect soft tissue and cut it with precision.

It can Coagulate blood in the treatment area

It can reduce Post-op inflammation and edema

These area all desired effects of Laser Treatment.

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Clinical Goals ofPeriodontal Treatment:

• Decrease Bacterial Levels• Reduce Inflammation• Eliminate Infected tissue• Reduce Pocket Depths• Gain Clinical attachment

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L.A.P.T.Laser Assisted Periodontal Therapy

What is accomplished while performing L.A.P.T.?

• Laser Bacterial Reduction – Reduction in Bacterial Load

• Bio-Stimulation – Stimulation of bone and tissue

Growth

• Guided Tissue Regeneration – Gingival Contouring

• Laser Curettage – Removing diseased tissue

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L.A.P.T. Protocol

• Full Mouth Treatment completed in several visits

• Diode laser used to Reduce Bacterial Load (LBR)• Ultrasonic Instrumentation of roots• SRP Per Quads• Laser Curettage with Activated Tip. • Diode laser used to Bio-stimulate Bone and Gingival

Tissue

• LBR Recommended at all recall appointments 4 months or greater.

Laser Assisted Periodontal Therapy

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Post-Op Care• One Day liquid / soft diet• Soft food for one month – Nothing real crunchy• Two weeks Q-tip cleaning of area (No Brushing)• Chlorhexidine on Q-tip or rinse two weeks.• Soft toothbrush for one month – then sonic brush• No flossing for two weeks • Flossing after two weeks to gum line only

– one month• Maintenance visit one to two months after last

session of LAPT

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Hygiene Post LAPT

• No Probing for three months• No sub-gingival scaling for three months • Hand scalers and coronal polish – Supra

Only• Ultrasonic on low power just to gingival

margin• Fluoride treatment OK• Low level laser treatment OK for LBR

- 1 to 2 mm Subgingival only.

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http://www.youtube.com/watch?feature=player_embedded&v=l5rOvglzjD0

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CertificationYou must be certified to provide laser therapy to your patients. The StateOf Tennessee requires that you be taught by someone who has had lasertraining.

Over 30 states currently allow hygienists to use lasers in the course of their duties.

You can get certification through the following site.• You must also perform hands on prior to becoming certified*

Advanced Laser Training Inc.2651 Quarry LaneFayetteville, AR 72704(877) 527-3766(479) 361-8853

mowens@advancedlasertraining.com

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What can you do with this knowledge…???

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980 n

m 940 nm

Operculectomy - 980 nm

Operculectomy - 940 nm

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Clean Removal around Implant

You can use Diode lasers to work around around metal

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Contouring

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Gingivectomy

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Aphthous Ulcer Treatment

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Curettage

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ContouringGingivectomy

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1 year Post Treatment

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14 months Post Treatment

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6 months Post Treatment

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Initial Presentation

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First Laser Treatment

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Second Laser Treatment

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2 week and 4 week Post Treatment

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Advanced Periodontitis

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Probing depths 5-10mm

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90% Bone loss #27

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Laser First Treatment

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10mm to 3mm #27

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Anterior bone loss7-8mm pocketing max anterior

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Six months laterPocketing 3-4mm!

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One Year Post Treatment

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Two Year Follow Up

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Six months Post Treatment

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Course Evaluations

Please remember to fill out course evaluations and sign your name on the

attendance sheet.

This course presentation is the final requirement for my Masters Capstone.

Thank you for attending!!!

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Thank You…Frank Licht, RDH, BSDHTennessee State UniversityClinical Supervisor

flicht@tnstate.edu

(615) 963-1475

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References Aykol, G., Baser, U., Maden, L., Kazak, Z., Onan, U., Tanrikulu-Kucuk, S., ... Yalcin, F. (2011,

March 2011). The Effect of Low-Level Laser Therapy as an Adjunct to Non-Surgical Periodontal Treatment. Journal of Periodontology, 82, 481-488. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20932157

Blayden, J., & Mott, A. (2013). Soft-Tissue Lasers in Dental Hygiene. Ames, Iowa: Wiley-Blackwell.

Christodoulides, N., Nikolidakis, D., Chondros, P., Becker, J., Schwarz, F., Rossler, R., & Sculean, A. (2008, September 2008). Photodynamic Therapy as an Adjunct to Non-Surgical Periodontal Treatment: A Randomized Clinical Trial. Journal of Periodontology, 79, 1638-1644. Retrieved from http://www.helbo.de/fileadmin/docs/wissenschaft/Christodoulides_et_al._PDT_JP_0908.pdf

Goldstep, F. (2009). Diode Lasers for Periodontal Treatment: The Story So Far. Retrieved from http://www.oralhealthgroup.com/news/diode-lasers-for-periodontal-treatment-the-story-so-far/1000349901/

Infective Endocarditis. (2014). Retrieved from http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/TheImpactofCongenitalHeartDefects/Infective-Endocarditis_UCM_307108_Article.jsp

Kamma, J. J., Vasdekis, V. G., & Romanos, G. E. (2006). The Short-Term Effect of Diode Laser (980 nm) Treatment on Aggressive Periodontitis. Evaluation and Clinical Microbiological Parameters. The Journal of Oral Laser Applications, 2, 111-121. Retrieved from www.ncbi.nlm.nih.gov/pubmed/19196111

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Lui, J., Corbett, E. F., & Jinn, L. (2011). Combined Photodynamic and Low-Level Laser Therapies as an Adjunct to Nonsurgical Treatment of Chronic Periodontitis. Journal of Periodontal Research, 46, 89-96. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20860592

Moritz, A., Schoop, U., Goharkay, K., Schauer, P., Doertbudak, O., Wernisch, J., & Sperr, W. (1998). Treatment of Periodontal Pockets With a Diode Laser. Lasers in Surgery and Medicine, 22, 302-311. Retrieved from www.ncbi.nlm.nih.gov/pubmed/9671997

Qadri, T., Miranda, L., Turner, J., & Gustafsson, A. (2005). The Short-Term Effects of Low-Level Lasers as Adjunct Therapy in the Treatment of Periodontal Inflammation. Journal of Clinical Periodontology, 32, 714-719. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15966876

Qadri, T., Poddani, P., Javed, F., Turner, J., & Gustafsson, A. (2010, August 2010). A Short-Term Evaluation of Nd:YAG Laser as an Adjunct to Scaling and Root Planing in the Treatment of Periodontal Inflammation. Journal of Periodontology, 81, 1161-1166. Retrieved from http://www.joponline.org/doi/pdf/10.1902/jop.2010.090700

Ustun, K., Erciyas, K., Sezer, U., Gundogar, H., Ustun, O., & Oztuzcu, S. (2014). Clinical and Biochemical Effects of an 810 nm Diode Laseras an Adjunct to Periodontal Therapy: A Randomized Split-Mouth Clinical Trial. Photomedicine and Laser Surgery, 32, 61-66. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24444428

References Continued