use of a diode laser for soft tissue management …...use of a diode laser for soft tissue...

• A Tribute to Dr. Theodore Maiman

• Essays from ALD 2009 Award Winners

• Adjunctive CO2 and Nd:YAG Laser Use for Severe Periodontitis

• Scientific Review: Erbium Laser Fundamentals

• An Update on U.S. FDA Marketing Clearances

• Guest Editorial: Education in Laser Dentistry

The Official Journal of the Academy of Laser Dentistry 2009 • Vol. 17 No. 2The Official Journal of the Academy of Laser Dentistry 2009 • Vol. 17 No. 2

Use of a Diode Laser for Soft Tissue ManagementBefore Employing CAD/CAM to Fabricate a Restoration

See article on page 100.

Academy of Laser Dentistry3300 University Drive, Suite 704

Coral Springs, FL 33065

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TA B L E O F CO N T E N T SThe official journal of the

Academy of Laser Dentistry

Editor-in-ChiefDonald J. Coluzzi, DDSPortola Valley, CA [email protected]

Managing EditorGail S. Siminovsky, CAE, Executive DirectorCoral Springs, FL [email protected]

Consulting EditorJohn G. Sulewski, MA Huntington Woods, MI [email protected]

Associate EditorsCraig Gimbel, DDS, Denville, NJAlan J. Goldstein, DMD, New York, NYPeter Pang, DDS, Sonoma, CADonald E. Patthoff, DDS, Martinsburg, WVSteven P.A. Parker, BDS, LDS RCS, MFGDP,

Harrogate, United KingdomPeter Rechmann, Prof. Dr. med. dent.,

San Francisco, CADavid Roshkind, DMD, Gainesville, FLWayne Selting, DDS, Colorado Springs, COMichael D. Swick, DMD, Conneaut Lake, PA

PublisherMax G. MosesMember Media

1844 N. Larrabee • Chicago, IL 60614312-296-7864 • Fax: 312-896-9119

[email protected]

Design and LayoutDiva Design

2616 Missum Pointe • San Marcos, TX 78666512-665-0544 • Fax 609-678-0544

[email protected]

Editorial Office3300 University Drive, Suite 704

Coral Springs, FL 33065

954-346-3776 Fax 954-757-2598

[email protected]

The Academy of Laser Dentistry is a not-for-profitorganization qualifying under Section 501(c)(3) ofthe Internal Revenue Code. The Academy of LaserDentistry is an international professional member-ship association of dental practitioners and sup-porting organizations dedicated to improving thehealth and well-being of patients through theproper use of laser technology. The Academy isdedicated to the advancement of knowledge,research and education and to the exchange ofinformation relative to the art and science of theuse of lasers in dentistry. The Academy endorsesthe Curriculum Guidelines and Standards forDental Laser Education.

Journal of Laser Dentistry

E D I TO R ’ S V I E WDental Lasers – Where We’ve Been, Where We Are, and Where We’re Going ......................................................................................73Donald J. Coluzzi, DDS, Portola Valley, California

T R I B U T EThe Laser Man … The Laser Story: A Tribute to Dr. Theodore H. Maiman ....................................................................................74Kathleen Maiman, Vancouver, British Columbia, Canada

P R AC T I C E M A N AG E M E N T E S S AYThank You, Doctor, How Much Do I Owe You? ..........................................76Stuart Coleton, DDS, Valhalla, New York

H I STO R I C A L E S S AYNineteen Years and Counting............................................................................79Dennis R. Pietrini, DDS, Franklin Park, Illinois

R EG U L ATO R Y U P DAT EClearing the FDA Hurdle, from Initial Device Application through Regulatory Approval to the Clinical Operatory: An Update on Dental Laser Marketing Clearances ....................................81John G. Sulewski, MA, Bloomfield Hills, Michigan

SC I E N T I F I C R E V I E WFundamental Erbium Laser Concepts: Part I ................................................87Wayne Selting, DDS, Colorado Springs, Colorado

C L I N I C A L R E V I E WThe Pending Zone: Managing the Compromised Periodontal Patient ..............................................................................................94Mary Lynn Smith, RDH, McPherson, Kansas

COV E R F E AT U R ESC I E N T I F I C A N D C L I N I C A L R E V I E WDiode Lasers and Computer-Aided Design and Manufacturing (CAD/CAM) Dentistry: A Perfect Marriage of Two Advanced Technologies....................................................100Eugene L. Antenucci, DDS, Huntington, New York

G U E ST E D I TO R I A LEducation in Laser Dentistry: A Necessity, an Optional Extra, or an Irrelevance?....................................................................................104Steven Parker, BDS, LDS, RCS, Harrogate, United Kingdom

R E S E A R C H A B ST R AC T SThe Use of Lasers for Tissue Retraction for Impression ........................106

The Journal of Laser DentistryThe mission of the Journal of Laser Dentistry is to provide a professional journal that helps tofulfill the goal of information dissemination by the Academy of Laser Dentistry. The purpose ofthe 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 oflasers 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 safetyand efficacy of the devices, and articles about future and experimental procedures. In addition,featured columnists offer clinical insights, and editorials describe personal viewpoints.

Journal of Laser Dentistry: Guidelines for AuthorsThe Academy of Laser Dentistry Welcomes Your Articles for Submission

The Journal of Laser Dentistry publish-es articles pertaining to the art, science,and practice of laser dentistry. Articlesmay be scientific and clinical in naturediscussing new techniques, research,and programs, or may be applications-oriented describing specific problemsand solutions. While lasers are our pre-ferred orientation, other high-technolo-gy articles, as well as insights into mar-keting, practice management, regula-tion, and other aspects of dentistry thatmay be of interest to the dental profes-sion, may be appropriate. All articlesare peer-reviewed prior to acceptance,modification, or rejection.

These guidelines are designed tohelp potential authors in writing andsubmitting manuscripts to the Journalof Laser Dentistry, the official publica-tion of the Academy of Laser Dentistry(ALD). Please follow these instructionscarefully to expedite review and process-ing of your submission. Manuscriptsthat do not adhere to these instructionswill not be accepted for consideration.The Academy of Laser Dentistry and theeditors and publisher of the Journal ofLaser Dentistry endorse the “UniformRequirements of Manuscripts Submittedto Biomedical Journals” (www.icmje.org).The Journal reserves the right to reviseor rescind these guidelines.

Authors are advised to read the morecomprehensive Guidelines for Authorsand required forms available by mail oronline at www.laserdentistry.org.

Manuscript EligibilitySubmitted manuscripts must be writtenclearly and concisely in AmericanEnglish and appropriate for a scholarlyjournal. Write in active voice and usedeclarative sentences. Manuscripts willbe considered for publication on the con-dition that they have been submittedexclusively to the Journal, and have notbeen published or submitted for publica-tion in any part or form in another publi-cation of any type, professional or lay, orin any language elsewhere, and with theunderstanding that they will not bereprinted without written consent fromboth the managing editor and the author.

PermissionsDirect quotations of 100 or more words,and illustrations, figures, tables, orother materials (or adaptations thereof)that have appeared in copyrightedmaterial or are in press must be accom-panied by written permission for theiruse in the Journal of Laser Dentistryfrom the copyright owner and originalauthor along with complete informationregarding source, including (as applica-ble) author(s), title of article, title of

journal or book, year, volume number,issue number, pages. Photographs ofidentifiable persons must be accompa-nied by valid signed releases indicatinginformed consent. When informed con-sent has been obtained from anypatient, identifiable or not, it should benoted in the manuscript. The appropri-ate Permission Letters must be submit-ted with the manuscript. Suggestedtemplate letters are available online.

CopyrightAll manuscript rights shall be trans-ferred to the Journal of Laser Dentistryupon submission. Upon submission ofthe manuscript, authors agree to sub-mit a completed Copyright TransferAgreement form, available online. If themanuscript is rejected for publication,all copyrights will be retained by theauthor(s).

CommercialismALD members are interested in learn-ing about new products and serviceofferings, however ALD stresses thatsubmitted manuscripts should be edu-cational in nature. The emphasis is onscientific research and sound clinicaland practical advice, rather than pro-motion of a specific product or service.

Disclosure of Commercial RelationshipsAccording to the Academy’s Conflict ofInterest and Disclosure policy, manu-script authors and their institutions areexpected to disclose any economic orfinancial support, as well as any per-sonal, commercial, technological, aca-demic, intellectual, professional, philo-sophical, political, or religious interestsor potential bias that may be perceivedas creating a conflict related to thematerial being published. Such condi-tions may include employment, consul-tancies, stock ownership or other equityinterests, honoraria, stipends, paidexpert testimony, patent ownership,patent licensing arrangements, royal-ties, or serving as an officer, director, orowner of a company whose products, orproducts of a competitor, are identified.Sources of support in the form of con-tracts, grants, equipment, drugs, mate-rial donations, clinical materials, specialdiscounts or gifts, or other forms of sup-port should be specified. The roles of thestudy or manuscript sponsor(s), if any,are to be described. Disclosure state-ments are printed at the end of the arti-cle following the author’s biography.This policy is intended to alert the audi-ence to any potential bias or conflict sothat readers may form their own judg-ments about the material being pre-sented. Disclosure forms are to be

signed by each author. Manuscripts willnot be reviewed without the Journalhaving this form on file.

The Academy of Laser Dentistry alsorequires that authors disclose whetherany product discussed in their manu-script is unlabeled for the use discussedor is investigational.

The Disclosure Statement form isavailable online and must be submittedwith the manuscript.

Manuscript TypesSubmissions to the Journal should belimited to one of the types indicatedbelow.• 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

Manuscript Preparation andSubmissionFormatAll submitted manuscripts should bedouble-spaced, using 12 pt. font sizewith at least 6 mm between lines.Submit manuscripts in Microsoft Word(.doc), using either the Windows orMacintosh platform. Manuscripts mustbe submitted electronically in this for-mat. Hard copy-only submissions willnot be accepted.

Unacceptable FormatsThe following submission formats areunacceptable 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 ComponentsTitle PageThe title page of the manuscript shouldinclude a concise and informative titleof the article; the first name, middle ini-tial(s), and last name of each author,along with the academic degree(s), pro-fessional title(s), and the name andlocation (city, state, zip code) of currentinstitutional affiliation(s) and depart-ment(s). Authors who are private practi-tioners should identify their location(city, state, and country). Include allinformation in the title that will makeelectronic retrieval of the article sensi-

tive and specific. Titles of case studiesshould include the laser wavelength(s)and type(s) utilized for treatment (forexample, “810-nm GaAlAs diode”).

Identify the complete address, busi-ness and home telephone numbers, faxnumber, e-mail address, and Web siteaddress (if any) for all authors. Identifyone author as the corresponding author.Unless requested otherwise, the e-mailaddress is published in the Journal.

AbstractA self-standing summary of the text ofup to 250 words should precede theintroduction. It should provide an accu-rate summary of the most significantpoints and be representative of theentire article’s content. Provide the con-text or background for the article, basicprocedures, main findings and conclu-sions. Emphasize new or importantaspects. Do not use abbreviations (otherthan standard units of measurement) orreferences in the abstract.

Author(s) BiographyProvide a brief, current biographicalsketch of each author that includes pro-fessional education and professionalaffiliations. For authors who hold teach-ing positions, include the title, depart-ment, and school. For authors who arein federal service, include rank or titleand station.

ReferencesReferences are to be cited in the text bynumber in order of appearance, withthe number appearing either as asuperscript or in brackets. The refer-ence list should appear at the end of themanuscript with references in order offirst appearance in the text of the man-uscript. The reference list must betyped double-spaced on a separate pageand numbered in the same sequence asthe reference citations appear in thetext. Prior to submission, all referencesare to be properly prepared in the cor-rect format, checked for completeness,carefully verified against their originaldocuments, and checked for accuratecorrespondence between referencescited in the text and listed in theReferences section.• For journal citations, include sur-

names and all initials of all authors,complete title of article, name of jour-nal (abbreviated according to the U.S.National Library of Medicine(www.nlm.nih.gov/services/lpabbrev.html), year of publication,volume, issue number, and completeinclusive page numbers. If abstractsare cited, add the abstract numberafter the page number.

• For book citations, specify surnamesand initials of all authors, chapternumber and title (if applicable), edi-tors’ surnames and initials, book

title, volume number (if applicable),edition number (if applicable), cityand full name of publisher, year ofpublication, and inclusive page num-bers of citation.

• For government publications or bul-letins, identify the author(s) (if given);title; department, bureau, agency, oroffice; the publication series, report,or monograph number; location ofpublisher; publisher; year of publica-tion; and inclusive page numbers.

• For articles published online but notyet in print, cite with the paper’sDigital Object Identifier (DOI) addedto the end of the reference.

• For Web citations, list the authorsand titles if known, then the URLand date it was accessed.

• For presentations, list the authors,title of presentation, indication thatthe reference is a lecture, name ofconference or presentation venue,date, and location.

Illustration Captions and LegendsAll illustrations must be accompanied byindividual explanatory captions whichshould be typed double-spaced on a sepa-rate page with Arabic numerals corre-sponding to their respective illustration.

TablesTables must be typewritten double-spaced, including column heads, data,and footnotes, and submitted on sepa-rate pages. The tables are to be cited inthe text and numbered consecutively inArabic numerals in the order of theirappearance in the text. Provide a con-cise title for each table that highlightsthe key result.

IllustrationsIllustrations include photographs, radi-ographs, micrographs, charts, graphs,and maps. Each should be numbered andcited in the text in the order of appear-ance and be accompanied by explanatorycaptions. Do not embed figures withinthe manuscript text. Each figure andtable should be no larger than 8-1/2 x 11inches. Digital files must measure atleast 5 inches (127 mm) in width. The

image must be submitted in the size itwill be printed, or larger. Illustrationsare to augment, not repeat, material inthe text. Graphs must not repeat datapresented in tables. Clinical photographsmust comply with ALD’s Guidelines forClinical Photography, available online.Authors are to certify in a cover letterthat digitized illustrations accuratelyrepresent the original data, condition, orimage and are not electronically edited.

Publisher and Copyright HolderThe Journal of Laser Dentistry is pub-lished by Max G. Moses, MemberMedia, 1844 N. Larrabee, Chicago, IL60614, Telephone: (312) 296-7864; Fax:(312) 896-9119. The Journal of LaserDentistry is copyrighted by TheAcademy of Laser Dentistry, 3300University Drive, Suite 704, CoralSprings, FL 33065, Telephone: (954)346-3776; Fax: (954) 757-2598.

Articles, Questions, IdeasQuestions about clinical cases, scientificresearch, or ideas for other articles maybe directed to Donald J. Coluzzi, Editor-in-Chief, by e-mail: [email protected].

Submission of Filesby E-mail:Send your completed files by e-mail(files up to 10 MB are acceptable). Iffiles are larger than 10 MB, they maybe compressed or sent as more than onefile, with appropriate labels. Filesshould be submitted to: Donald J.Coluzzi, Editor-in-Chief, by e-mail:[email protected].

By Federal Express or OtherInsured Courier:If using a courier, please send the file asa CD-ROM, include a hard copy of yourmanuscript and also send a verificationby e-mail to Gail Siminovsky ([email protected]).Gail SiminovskyAcademy of Laser Dentistry3300 University Drive, Suite 704Coral Springs, FL 33065Phone: (954) 346-3776.

Summary of Illustration Types and Specifications

IllustrationType

Definition and ExamplesPreferredFormat

RequiredResolution

Line Art andVector Graphics

Black and white graphic with noshading (e.g., graphs, charts, maps)

EPS or JPG 1200 DPI

Halftone Art

Photographs, drawings, or paint-ing with fine shading (e.g., radi-ographs, micrographs with scalebars, intraoral photographs)

TIFF orJPG

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

CombinationArt

Combination of halftone and lineart (e.g., halftones containingline drawing, extensive lettering,color diagrams)

EPS or JPG 1200 DPI

Editorial PolicyThe Journal of Laser Dentistry is devoted to providing the Academy and its members with comprehensive clinical, didactic andresearch information about the safe and effective uses of lasers in dentistry. All statements of opinions and/or fact are publishedunder the authority of the authors, including editorials and articles. The Academy is not responsible for the opinions expressedby the writers, editors or advertisers. The views are not to be accepted as the views of the Academy of Laser Dentistry unlesssuch statements have been expressly adopted by the organization. Information on any research, clinical procedures or productsmay be obtained from the author. Comments concerning content may be directed to the Academy’s main office by e-mail [email protected]

SubmissionsWe 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 RelationshipsAccording to the Academy’s Conflict of Interest and Disclosure policy, authors of manuscripts for JLD are expected to discloseany economic support, personal interests, or potential bias that may be perceived as creating a conflict related to the materialbeing published. Disclosure statements are printed at the end of the article following the author’s biography. This policy isintended to alert the audience to any potential bias or conflict so that readers may form their own judgments about the materialbeing presented.

Disclosure Statement for the Academy of Laser DentistryThe Academy of Laser Dentistry has no financial interest in any manufacturers or vendors of dental supplies.

Reprint Permission PolicyWritten permission must be obtained to duplicate and/or distribute any portion of the Journal of Laser Dentistry. Reprints maybe obtained directly from the Academy of Laser Dentistry provided that any appropriate fee is paid.

Copyright 2009 Academy of Laser Dentistry. All rights reserved unless other ownership is indicated. If any omission or infringementof copyright has occurred through oversight, upon notification amendment will be made in a future issue. No part of this publica-tion may be reproduced or transmitted in any form or by any means, individually or by any means, without permission from thecopyright 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 memberprospects and dentists requesting information on lasers in dentistry.

Advertising Information and RatesDisplay rates are available at www.laserdentistry.org/press.cfm and/or supplied upon request. Insertion orders and materials shouldbe sent to Bill Spilman, Innovative Media Solutions, P.O. Box 399, Oneida, IL 61467, 877-878-3260, fax: 309-483-2371, [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 membersreceive 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 dis-play 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 educationalcourses are recognized by the Academy of Laser Dentistry. ALD as an independent professional dental organization is concerned that coursesmeet the stringent guidelines following professional standards of education. Readers are advised to verify with ALD whether or not specificcourses are recognized by the Academy of Laser Dentistry in their use of the Curriculum Guidelines and Standards for Dental Laser Education.

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As you know, the Academy held its16th Annual Conference in LasVegas at the end of April. A myriadof courses and interactive sessionsfeatured many clinicians andresearchers who shared theirknowledge about the use of lasersin dentistry. The next three issuesof the Journal will contain articlesfrom some of those presenters atthe Conference. Their manuscriptsgive those of us who were in atten-dance a chance to remember theirdiscussions, and enable all of ourmembers to read their topics.

The flow of the articles in thisissue gives an overview of the past,present, and future of thewonderful technology of lasers.

Looking at the past, from theinvention of the first laser to howlaser dentistry and the Academyhave affected three of our authors,we have the following:• Our keynote speaker at Las Vegas

was Mrs. Kathleen Maiman, thewife of the late Dr. TheodoreMaiman, inventor of the firstlaser. Kathleen presents a shorttribute to “Ted, the laser man,” asshe affectionately calls him.

• Dr. Stuart Coleton was the 2009winner of the Academy’s LeonGoldman Award for clinical excel-lence. Stu writes a rather uniquearticle on how his clinical proce-dures have affected hisrelationship with his patients.

• Dr. Dennis Pietrini received theDistinguished Service Awardfrom the ALD this year. Amonghis many accomplishments ofdedication is his attendance atevery Conference since the incep-tion of the Academy. Dennisoffers some wonderful thoughtson our history.

Three articles connect our pastknowledge and principles to thepresent clinical applications:• Mr. John Sulewski offers an

overview on how dental lasersprogress through the regulatoryprocesses. John describes themechanisms of the U.S. Food andDrug Administration and givesan update on the marketingclearances that provide the direc-tion and confidence for our use oflasers.

• Dr. Wayne Selting writes partone of a two-part manuscriptdescribing some fundamentalconcepts on how to use erbiumlasers more efficiently. Wayne’sbackground as an electrical andbiomedical engineer augmentsthe practical clinical applicationsof these wavelengths.

• Mrs. Mary Lynn Smith presentsfour case descriptions of patientswith advanced periodontaldisease and how their treatmentprogressed. Mary Lynn concludesthat her adjunctive use of certainlasers can be of benefit to eventhose compromised patients withtheir cooperation.Two other articles continue our

laser journey:• Dr. Eugene Antenucci demon-

strates how relatively simple andtime-tested diode laser procedurescan be employed with one of thenewest dental technologies,computer-aided design and manu-facturing. Gene offers clinicalexamples of how the laser is anecessary addition to the future ofdigital impressions to ensure theaccuracy and clinical excellence ofthe fabricated restorations.

• Dr. Steven Parker offers hisviews on the future direction of

laser education. Steven, as chairof ALD’s Education Committee, isworking with that group to studynew approaches to offeringStandard Proficiency certificationto all laser users.I hope you enjoy this first

segment of the ‘replay’ of LasVegas.

A U T H O R B I O G R A P H YDr. Donald Coluzzi, a 1970 grad-uate of the University of SouthernCalifornia School of Dentistry, is anassociate clinical professor in theDepartment of Preventive andRestorative Dental Sciences at theUniversity of California SanFrancisco School of Dentistry. He isa charter member and past presi-dent of the Academy of LaserDentistry, and is currently theEditor-in-Chief of the Journal ofLaser Dentistry. He has used dentallasers since early 1991. He hasAdvanced Proficiency in Nd:YAGand Er:YAG laser wavelengths. Heis the 1999 recipient of the LeonGoldman Award for ClinicalExcellence and the 2006Distinguished Service Award fromthe Academy of Laser Dentistry, aFellow of the American College ofDentists, and a Master of theAcademy of Laser Dentistry. Dr.Coluzzi has presented about lasersworldwide, co-authored two books,and published several peer-reviewed articles. Dr. Coluzzi maybe contacted by e-mail [email protected].

Disclosure: Dr. Coluzzi is a past andpresent presenter at various local,state, and national dental meetings.He has no financial interest in anycompany. nn

Coluzzi

Dental Lasers – Where We’ve Been, Where We Are, and Where We’re GoingDonald J. Coluzzi, DDS, Portola Valley, CaliforniaJ Laser Dent 2009;17(2):73

The Laser Man…The Laser Story:A Tribute to Dr. Theodore H. MaimanKathleen Maiman, Vancouver, British Columbia, CanadaJ Laser Dent 2009;17(2):74-75

When I first encountered TedMaiman, what attracted me wasthe smile on his face. He had thenicest smile I had ever seen.

That was February 13, 1984.Just that weekend Ted had beeninducted into the NationalInventors Hall of Fame, joiningluminaries like Thomas Edison,Alexander Graham Bell, and theWright Brothers. When we startedtalking I felt an immediate comfortas if I had known Ted all my life. Itwas magical, and as I later learned,Ted conveyed the same naturalease, warmth, and modesty toothers.

It was a pleasure to feel thewelcome of a large family at yourannual Academy of Laser Dentistryconference last April. I appreciatedyour interest and could sense thepioneering spirit of ALD members.That encouraged me in sharingTed’s personality and the laserstory with you.

I had the joy of being Ted’s wifefor 23 years. We were seldom sepa-rated since our fateful meeting of1984 (Figure 1). It was always easyto be with Ted as he was a kind,generous, and gentle man. Throughthe years I got to better understandwhy Ted was successful—to under-stand why he had won thetechnological Olympics by realizingAlbert Einstein’s vision of coherentlight with the world’s first laser in1960.

Several competitor groupsaround the world including BellLaboratories had already set out todevise an apparatus to createcoherent light. They had the topscientists and far more resources.

But they didn’t have TedMaiman.

Ted’s family was intellectuallyvigorous, placing great value oneducation and independentthinking. Ted’s father Abe was anelectrical engineer and gave Tedthe love of science and invention asa small boy. Together they exploredmany creative ideas and oftencompeted on such projects as whocould build the best hi-fi amplifier.Ted found his father’s electronicslaboratory in their basement a funplace to be.

In the home lab Ted saw hisfather invent the first DC-to-DCconverter, known later as thevibrator, which made car radiosfeasible. Abe’s colleagues did nothave the vision to appreciate theconverter, discouraging him frompatenting his invention. Abe hadalso developed an electronic stetho-scope. Upon showing his prototypeto a cardiologist, the response was,“Yes I can hear more information,but who knows what to do with it?”

Ted was witness to his father’screative genius being ridiculed andrejected. That turned out to be aprofound and positive influence onTed’s lifelong bent not to give up on

anything that seemed right to him.And give up, Ted wouldn’t.Ted would not give up at age 12,

when he wanted to work repairingelectrical appliances. Told that hewas too young for that job, heaccepted a job of sweeping floors toget in and then moved on to repairwork. Later in life, wanting workas an electronics engineer beforeearning any formal degrees, Tedhad to convince an employer thathe was worth trying out.

Getting into Stanford’s physicsdepartment was much the same—having first to persuade ProfessorWillis Lamb. Dr. Lamb later receivedthe Nobel Prize in physics after Tedfinished his doctoral thesis provingthe Lamb Shift by detailing finestructure splitting in excited heliumatoms. This important finding led tothe development of the laser.

Exit Stanford University, enterHughes Research Laboratories,Ted’s first important job. AtHughes he was determined toextend the electromagnetic spec-

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Maiman

Editor’s Note: This article is a condensation of the presentation that Mrs.Maiman gave at the Academy’s 16th Annual Conference in Las Vegas. Shediscussed many details of Dr. Maiman’s scientific life from his early yearsthrough the development of the first laser, highlighting the various chal-lenges he faced. She always refers to him by his shortened first name, Ted.

Figure 1: Ted and Kathleen

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trum beyond microwaves by afactor of 10,000 times. Hughesmanagers admonished Ted to workon something important likecomputers, as prevailing wisdomwas that coherent light was nottechnically possible.

Ted would not follow the crowdthat was trying to devise a cryo-genically cooled potassium-vapormodel endorsed by the gurus of thetime. The direction Ted wanted togo had been discarded; he wascondescendingly advised by leadingscientists that a ruby-based laserwas not workable. Ted believedthem wrong, as his theories and

calculations told him that his ideasshould work.

Still, making that quantum leapin the radiation spectrum frommicrowave to laser (LightAmplification by StimulatedEmission of Radiation) would bevery difficult. He ultimatelysucceeded in 1960 (Figure 2).

Ted’s unusual blend of inventive,engineering, and scientific skillsworked to his advantage, but theywould not have sufficed without hispersonal strengths. Ted had thatextra drop of courage to listen tohimself when everyone else toldhim he was wrong.

The laser’s advent in 1960 hasrapidly revolutionized manyaspects of consumer enjoyment,industrial processes, technologicaladvances, and medical procedures.Welcome to the age of the photon.The possibilities of lasers arelimited only by our imaginations!

I can still see that mavericksmile on Ted (Figure 3).

Kathleen Maiman

For Theodore Maiman’s detailedautobiography and account of hislaser invention, see The LaserOdyssey (www.laserinventor.com).

A U T H O R B I O G R A P H YWhen I met Ted I had just finishedan Emergency Medical Techniciansprogram with the interest ofbecoming a physician’s assistant.Today it is my joy to have theknowledge of a myriad of laserdevelopments to share. It is thekind of laser applications that yougive to your patients, oftenimproving their quality of lifedramatically, that was Ted’sgreatest satisfaction.

Ms. Maiman may be contactedthrough the Academy of LaserDentistry. nn

Maiman

Figure 2: A young Ted Maiman with hislaser, early 1960s

Figure 3: Dr. Maiman at his desk

Thank You, Doctor, How Much Do I Owe You?Stuart Coleton, DDS, New York Medical College, Valhalla, New York, and Westchester University

Medical Center, Valhalla, New YorkJ Laser Dent 2009;17(2):76-78

Treating dental emergencies are asmuch a part of everyday practice astaking radiographs and returningtelephone calls to patients anddental colleagues. As dentists wehave formed the habit of catego-rizing just about everything in ouroffices, from paper clips to surgicalinstruments. Such is the case withorganizing the emergency treat-ment we provide to our patients.

In general, emergencies can besubdivided into four groups:bleeding, pain, cosmetic discomfort,and referrals. Treatment of painand bleeding conditions necessitatea rapid response, but cosmeticdiscomfort and referrals require alittle bit of additional explanation.Cosmetic discomfort is usually theresult of an accident necessitatingmedical or dental treatment. Themid-day referral may not requiremuch time to treat but it still canwreak havoc with a carefullyplanned daily treatment schedule.

Many of the factors that deter-

mine the cost of preplanned dentalcare do not hold true for emergencytreatment. This essay will discussthree typical examples of emer-gency care from a practicemanagement standpoint. The firstcase, though cosmetic in nature,was not the result of an accident;nevertheless, it requires someconversation with the patient aboutetiology and treatment. The secondcase involving the treatment ofpainful oral lesions cannot factor inthe cost of time, medicaments, or

postoperative visits. The third casehas such serious sequelae thattrying to determine a fee immedi-ately after treatment almost putsthe dollar ahead of the patient’sneed for immediate follow-up treat-ment and a careful explanation ofwhat problems might lie ahead.

The first patient is a 42-year-oldfemale Caucasian with 90% of herbuccal gingiva pigmented verydarkly (Figure 1). This pigmenta-tion was not present at birth butbecame evident at age 22 when shebecame pregnant with her firstchild. Now she is 42 and herdaughter is getting married in onemonth. She was referred by hergeneral dentist to see whether thepigmentation could be removed.Since the melanin pigment is foundin the melanocytes in the basementlayer of the epithelium, it stood toreason that if I could lift theepithelium off the connective tissueof the gingiva, I could eliminate thepigmentation. In other words, alaser peel was in order.

A carbon dioxide (CO2) laser wasused at a low power setting of 2Watts, continuous wave. With thelaser tip in a highly defocusedmode, I could create a bulla whichcould be easily peeled away fromthe underlying connective tissue. Astrong topical anesthetic was usedto keep the patient comfortable.The procedure was completed in 2half-hour visits. Healing wascomplete in 17 days and hergingival tissue returned to normalcolor and tone (Figures 2-3).

To say the least, the patient wasabsolutely thrilled with the resultand as I expected asked the usualquestion, “Thank you, Doctor, howmuch do I owe you?” I’ll hold my

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P R AC T I C E M A N AG E M E N T E S S AY

Coleton

Editor’s note: Dr. Coleton, a periodontist, is the 2009 recipient of the LeonGoldman award for Clinical Excellence from the Academy of LaserDentistry. While he has written many clinical articles about his specialty,this one offers a unique perspective on practice management.

SY N O P S I S

As dental practitioners, we answer a myriad of questions from our

patients about treatment from initial diagnosis to continuing care. For

the emergency patient, the discussions should be shorter so that crit-

ical care can begin. After the remedial treatment, one question likely

remains—“What’s the fee?” This article presents three different case

scenarios and is intended to help answer that query.

Figure 1: Preoperative view of buccalpigmentation

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response until the end of thisarticle.

The second patient, a 72-year-old female, was referred to ouroffice mid-day by her dentist. Shewas in severe pain and could noteat or drink even the blandest offoods. Although the clinical appear-ance of the lesions in her mouthappeared similar to that of aph-thous ulcers (Figure 4), the historyof her problem was a tissue reac-tion to the placement of aperiodontal dressing containingzinc oxide and eugenol. In anyevent, the goal of treatment was todenature the protein on the surfaceof the lesions, causing them tocollapse onto the underlyingconnective tissue thereby forming abiologic bandage which wouldprotect the nerves in the connectivetissue from noxious stimuli.

Once again, the CO2 laser wasset on 2 Watts, continuous wave,and placed in a highly defocusedmode. With a circular motion, thetip of the laser handpiece wasbrought close to the surface of thelesion. Since there was no change

in the texture of the surface tissue,the tip of the laser was reposi-tioned as before and the power wasincreased to 3 Watts. The procedurewas repeated and as the laser tipapproached to within 1 cm of thetissue surface, a graying andmatting of the surface tissueoccurred. Close examination of themost forward of the palatal lesions,compared it to its posteriorneighbor, revealed that the poste-rior lesion had a shinier surfacethan the anterior one (Figure 4). Ofcourse the procedure wasperformed without any anestheticwhatsoever so the patient couldindicate any discomfort at eitherpower setting. If any pain were feltat either setting, the procedurewould have been aborted. If wewere to proceed any further therewould be danger of perforating thesurface of the lesion, therebyexposing the underlying tissue andcausing even more pain. The proce-dure was completed inapproximately 12 to 15 minutesand the patient was able to toleratechewing soft white bread dipped inmilk. The silence in the operatoryas she chewed was unbelievablebut no more so than the smile onher face. I advised the patient notto keep testing the result andremain on a liquid or semi-soliddiet for one week. She wasinstructed to call for anotherappointment if the symptomsreturned. Once again the dreadedquestion was asked: “How much doI owe you, Doctor?” What do youcharge for 15 minutes of your time,

in the middle of a busy day andobtaining such a dramatically posi-tive result? Once again, I’ll hold myresponse for later.

The third case involved apatient who was referred some sixyears ago to my office by herdentist who had recently finishedthe placement of a full crown ontooth #13. The dentist reportedthat 3 weeks after permanentcementation was completed, thepatient returned to his office with achief complaint of mild discomfortand bleeding upon brushing in theupper left part of her mouth. Hisclinical examination revealed whatappeared to be granulation tissuebetween teeth #12 and 13. Usinglocal anesthetic, he had curettedthe area, suspecting that theremight be some excess cementsubgingivally. The patient returnedwith the same complaint and clin-ical picture in 10 days. It was thenthat he decided to make thereferral.

Upon close examination of this55-year-old Caucasian female, Inoted that the full extent of thegingival lesion was from the mesialaspect of tooth #11 to the buccalaspect of #13 (Figure 5), but thislarge affected area could not be dueto the placement of the crown. Thesurface of the tissue was erythema-tous and granulated. The speed atwhich the tissue re-grew afterinitial removal aroused my suspi-cions so I decided to biopsy thearea. I discussed my suspicionswith the patient, advising her thatmy procedure would most likely

Coleton

Figure 2: Full-mouth view of tissue, 17days postoperative

Figure 3: View of tissue above maxillarycentral incisors, 17 days postoperative

Figure 4: View of maxillary left posteriorarea showing lesions

Figure 5: View of maxillary left bicuspidarea showing granulation tissue

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result in significant tissue reces-sion and the possible need foradditional restorative dentistry.The patient agreed to the biopsy.

The CO2 laser was set at 6Watts, continuous wave, in afocused mode and a buccal spec-imen of tissue was removed andsent for histologic examination(Figure 6). The patient returned fora postoperative evaluation in 1week. The clinical picture showedunusual healing of a granuloma-tous nature (Figure 7). The biopsyreport was delivered by phone in 2days, a departure from the usualwritten report in 7 to 10 days, andthe diagnosis was squamous cellcarcinoma. Histologic specimensclosely followed (Figure 8). I calledthe patient immediately afterreceiving the phone report andasked her to come in to see me thenext day. At that visit I explainedthe findings to her and advised herthat most if not all of her questionscould only be answered after

further examination by an oralsurgeon. The proper referrals weremade while she was still in myoffice, and her state of mind did notgenerate any questions about fees.However, every year atThanksgiving I receive a card witha handwritten note, “Thank you forsaving my life.” I have received sixcards so far.

While in graduate school Iattended the closest thing to apatient management lecture I hadin four years. This doctor was farahead of his time. He told us thatthere were two ways to be paid forour work, in shekels or in warmfuzzies; and when we felt betterreceiving the warm fuzzies thanthe scheckles, we were truly profes-sionals. Well, every Thanksgiving,when I receive that card, I feelthose warm fuzzies running up anddown my arm, very much as I doright now as I write this.

So how do I answer my patients’question as to fees? As I stand withthe patient at the reception desk, Ipalm a few of my professional cardsand hand them to the patients. Iask them to put them in theirpurse or wallet and should a familymember or friend have need of myservices, please remember me andgive them one of my cards. I can

guarantee that by using thismethod in 38 years of treatingpatients, I have never lost one cent.On the contrary, I’ve practiced myprofession proudly.

A U T H O R B I O G R A P H YDr. Stuart Coleton is a Diplomateof the American Board ofPeriodontology and the AmericanBoard of Oral Medicine. He is chiefattending periodontist atWestchester Medical CenterUniversity Hospital and holds therank of assistant professor indental medicine at New YorkMedical College. He is a past presi-dent of the Academy of LaserDentistry and is a RecognizedCourse Provider. He has been certi-fied as having AdvancedProficiency, Educator, andMastership status in lasers by theAcademy of Laser Dentistry. Hisareas of special expertise are perio-dontal diagnosis and treatment aswell as oral medicine. He hastaught didactic and clinical lasertherapy to both dental and medicalgeneral practice residents. Dr.Coleton may be contacted by e-mailat [email protected].

Disclosure: Dr. Coleton is a stock-holder in Lantis Laser, Inc. nn

Coleton

Figure 6: Immediate postoperative viewof biopsied area

Figure 7: One-week postoperative view oftissue

Figure 8: Histologic specimens showingpathology

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H I STO R I C A L E S S AY

Nineteen Years and CountingDennis R. Pietrini, DDS, Franklin Park, IllinoisJ Laser Dent 2009;17(2):79-80

President John F. Kennedy oncestated, “There is always inequity inlife. Some men are killed in a war,and some men are wounded, andsome men never leave the country,and some men are stationed in theAntarctic and some are stationed inSan Francisco…” After graduatingfrom the University of IllinoisCollege of Dentistry in 1970, asluck would have it, I spent twoyears active duty with the U.S.Naval Reserve in San Francisco,while many of my friends weredeployed to less desirable placeslike Vietnam.

Twenty years later, fortuneshone upon me again when Iattended my first course on usinglasers for dental care. The coursewas presented by Dr. Jerry Kohenin Windsor, Ontario just across theborder from Detroit. Dr. TerryMyers dropped in at Jerry’s officeto greet us and answered ournumerous questions about what heperceived would be the impact oflasers on dental care. I refer toTerry as the godfather of lasers indentistry. As most of you know heand his late brother Bill, anophthalmologist, adapted anNd:YAG laser as the first devicededicated for use in dentistry.

I questioned Terry about whatplans were in place for additionaltraining and possible certification in

the clinical use of lasers. Heinformed me of a study club that hadmet on two previous occasions andwould be meeting again in October1990 in Boston. That October, Ipurchased my first Nd:YAG laserand three days later I left for Bostonto attend the meeting. At thatsession, sponsored by AmericanDental Laser (ADL), a commercialcompany, several significant eventsoccurred. Terry challenged the groupto consider organizing as an inde-pendent entity free of unilateralcommercial support. Because therewere other laser companies in themarketplace and surely many moreto come in the future, it behooved usto form our own Academy. Iremember suggesting that perhapswe could come up with an amount ofseed money to start the organizationand we would be acknowledged asCharter Members. Someoneproposed that two organizations beformed—an international group anda North American group. Thus, at ameeting in Puerto Vallarta, Mexicoin February 1991, the groundworkwas laid for the InternationalAcademy of Lasers in Dentistry andthe North American Academy ofLaser Dentistry. At this time I beganmy commitment to organized laserdentistry, when I was elected to beSecretary of the North AmericanAcademy.

One of my most memorableexperiences occurred in July of1992, when a group of dentists,academicians, and manufacturer’srepresentatives met at theUniversity of California SanFrancisco School of Dentistrywhere we created the CurriculumGuidelines and Standards forDental Laser Education. Dr. Myers’desire for a certification programwas set in place. In April of 1993, Ireceived my Category II (StandardProficiency) certification in theNd:YAG laser wavelength.

In the late 1980s and early1990s a group of dentists who wereusing CO2 lasers formed theAmerican Academy of LaserDentistry. It was not long before allthe academies determined it wouldbe best to merge—forming theAcademy of Laser Dentistry (ALD)in 1993. About this time, I wasasked to serve as a member of theBoard of Directors. By October1993, we had our first conference inChicago. At that conference, Ireceived my Mastership (AdvancedProficiency), again in Nd:YAG. I amproud to say that my wife, Elaine,and I have been in attendance atevery conference since.

The first educator course wasgiven in San Francisco in October1998. That weekend a group of usalso revised the CurriculumGuidelines. One of the most grati-fying aspects of my associationwith ALD has been participating inits mission of educating and certi-fying dental professionals. Throughmy involvement in teaching lasercourses as well as assisting in thecertification process, I have had theopportunity to train and meetpeople from around the world.

Pietrini

SY N O P S I S

Dr. Pietrini is the 2009 recipient of the Distinguished Service Award

from the Academy of Laser Dentistry. In this essay, he describes his

almost two decades of involvement with dental lasers and the

Academy.

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H I STO R I C A L E S S AY

These experiences have returnedbig dividends. Not only do I learn alot from these colleagues, Elaineand I have become friends withpeople from all over the UnitedStates and internationally.

After working my way up thechain of command in the Academy,it was my privilege to serve asPresident in 2000. I feel fortunateto have had some great mentorspreside before me. At the lastconference in Las Vegas, I was sopleased that so many of the PastPresidents were in attendance,where we participated in a PastPresidents panel. One notableexception was our late friend Dr.Eugene Seidner (1997 President).During the discussion Dr. AlanGoldstein commented that thefuture of ALD is in our youngpeople. Several years ago, a studentscholarship was established inGene’s name. I would like to chal-lenge all Academy members tomake a contribution toward this

important program.I want to thank the members

and the Board of ALD for the honorof receiving the DistinguishedService Award. To be included in thecompany of so many accomplishedpeople is truly flattering. Like theloyal Chicago Cubs fan that I am,each year I look forward to the nextbaseball season and the next ALDconference with much optimism.Every ALD conference has exceededmy expectations. At the end of eachof the annual sessions, I think aboutthe phrase most quoted by Cubsfans, “Wait until next year.” Ofcourse, what I mean is that I knowwhere I’m going with lasers nextyear; the beloved Chicago baseballfans are only hoping.

A U T H O R B I O G R A P H YDr. Dennis Pietrini is a 1970 grad-uate of the University of IllinoisCollege of Dentistry. He served onactive duty with the U.S. NavyDental Corps from 1970 to 1972 at

Hunter’s Point Naval Shipyard inSan Francisco. In 1972, he started aprivate general dentistry practice inRiver Grove, Illinois, moving to hiscurrent location in Franklin Park in1978. He has been on the active staffof Gottlieb Memorial Hospital since1972, serving as Chairman of theDepartment of Oral Medicine, amember of the CredentialsCommittee, and as the Chairman ofthe hospital’s Laser SafetyCommittee. Dr. Pietrini hasAdvanced Proficiency in Nd:YAG, isa Certified Dental Laser Educator,and a Recognized Standard CourseProvider. He is the past president ofthe Academy of Laser Dentistry andthe co-founder of the former MidwestLaser Dental Study Club. Dr.Pietrini may be contacted by e-mailat [email protected].

Disclosure: Dr. Pietrini has no stock,teaching assignments, or activecommitments with any lasercompany. nn

Pietrini

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R EG U L ATO R Y U P DAT E

Sulewski

Clearing the FDA Hurdle, from Initial DeviceApplication through Regulatory Approval tothe Clinical Operatory: An Update on DentalLaser Marketing ClearancesJohn G. Sulewski, MA, The Institute for Advanced Dental Technologies, Bloomfield Hills, MichiganJ Laser Dent 2009 17(2):81-86

This article presents a briefoverview of the role of the U.S. Foodand Drug Administration (FDA) asit relates to dentistry, and describeshow medical devices, includinglasers, enter the U.S. marketplace;presents a timeline of milestones indental laser marketing clearances;examines how one can search theFDA Web site for marketing clear-ance information; discusses theconcepts of off-label use, adverseevents, and risk management; andsummarizes other national regula-tory agencies and worldwide effortstoward harmonizing regulations.

R O L E O F T H E U . SF O O D A N D D R U GA D M I N I ST R AT I O NThe history of the FDA dates from1906 when Congress passed themodern food and drug law whichmade it illegal to distributemisbranded or adulterated foods,drinks, and drugs. Over the yearsadditional legislation expanded theresponsibilities of the agency. Overall,its mission is to promote and protectthe public health by helping safe andeffective products reach the U.S.market. It also monitors products forcontinued safety once they are in use,and helps the public get accurate,science-based information needed toimprove health.

The FDA is mandated to conducta number of activities in fulfillmentof its mission. It reviews new prod-ucts, monitors safe manufacturingand handling and new risks, usesstandards and regulations to define

requirements, conducts research toprovide the basis for regulatorydecisions, corrects problems, andenforces the law.

The FDA has a number of regu-lated product areas under itspurview, ranging from foods andmedicines, biologics (such asvaccines and blood products) andmedical devices, electronic devicesthat emit radiation (such asmicrowave ovens and cellularphones), to animal drugs anddevices, cosmetics, and productlabels. This article will concentrateon one of those areas, medicaldevices.

Legislation has added new defi-nitions to and requirements of theFederal Food, Drug and CosmeticAct since its inception in 1906. Ofspecial note are the Medical DeviceAmendments of May 28, 1976which defined a medical device forthe first time from a regulatorystandpoint, specified 1700 generictypes of devices and 19 medicalspecialties, and required premarketreview of devices.

Under Section 201(h) of theFood, Drug and Cosmetic Act, amedical device was defined as adevice that:• is used for diagnosis, cure, miti-

gation, treatment, or preventionof disease or condition

• affects the structure or functionof the body

• does not achieve its intended usethrough chemical reaction

• and is not metabolized to achieveeffect.

A number of products fit thatdefinition, including dental floss,endoscopes, replacement heartvalves, examination gloves, and, ofcourse, lasers.

F DA’ S R O L E I N T H ER EG U L AT I O N O FM E D I C A L D E V I C ESThe FDA’s Center for Devices andRadiological Health (CDRH) is thebranch of the agency charged withoversight of medical devices. TheCenter helps ensure that medicaldevices are “reasonably” safe andeffective, regulates what manufac-turers can claim about theirproducts, requires manufacturersto abide by defined GoodManufacturing Practices andQuality System legislation. TheFDA does not control the practiceof medicine or dentistry.

Good Manufacturing Practice(GMP) requirements of the Food,Drug and Cosmetic Act specify thatdomestic or foreign manufacturershave a quality system for thedesign, manufacture, packaging,labeling, storage, installation, andservicing of finished medicaldevices intended for commercialdistribution in the United States.

Also relevant for entry into themarketplace is the ISO 13485 stan-dard, published in 2003, that hasbeen adopted by many countries.The ISO standard specifies therequirements for a comprehensivequality management system for thedesign and manufacture of medicaldevices.

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PAT H WAYS TO T H E U . S .M A R K ETUnder FDA regulation, three path-ways to the U.S. marketplace existfor medical devices: A so-calledPremarket Notification 510(k), whichapplies to virtually all medical anddental lasers in the commercialmarketplace. This designation is fordevices deemed to be “substantiallyequivalent” to predicate devices thatwere legally marketed prior to theMedical Device Amendments of1976. Other pathways includePremarket Approval or PMA, incases where no predicate devicesexist, and the De Novo Process forlow-risk in vitro diagnostic devicesfor which no predicate exists.

Substantial Equivalence meansa device has the same intended useand has the same technologicalcharacteristics of a predicate device,or it has the same intended use andhas different technological charac-teristics, but does not raise any newquestions of safety and effective-ness, and is at least as safe andeffective as the predicate device.

The FDA requires 510(k) appli-cations be submitted when a deviceis introduced to the market for thefirst time, when a significant modi-fication is made to a previouslycleared device, and when the indi-cations for use are changed for apreviously cleared device.

Considerable information isrequired when submitting a 510(k)application, including the submitterand contact information, the commonand proprietary name of the device,a listing of the indications for useand identification of the marketeddevices to which equivalence isclaimed, and proposed labels,including promotional material.

If the device is not identical to apredicate device, then additionalinformation must be submittedrelated to performance data thatmay be bench, animal, and/or clinicalin nature, as well as sterilization,software and hardware information.

The FDA requires clinical dataaccompany approximately 10% of all

510(k) submissions when there is animportant difference with a predi-cate device, such as a newindication for use or new technology.The data must be collected underrigorous Investigational DeviceExemption (IDE) regulations.

An IDE permits the investiga-tional device to be used in a clinicalstudy in order to collect requiredsafety and effectiveness data.Additionally, investigational useincludes clinical evaluation ofcertain modifications or newintended uses of legally marketeddevices. Clinical evaluations ofinvestigational devices, unlessexempt, must have an approvedIDE before the study is initiated.

Clinical evaluation of medicaldevices that have not been clearedfor marketing requires:• an IDE approved by an institu-

tional review board (IRB). If thestudy involves a significant riskdevice, the IDE must be approvedby FDA as well;

• informed consent from allpatients included in the study;

• labeling for investigational useonly;

• monitoring of the study;• required records and reports.

M I L ESTO N ES I ND E N TA L L AS E RM A R K ET I N G C L E A R A N C ESWith this background in mind, atimeline of milestones in laserdentistry can be constructed bylisting significant 510(k) marketingclearances for specific devices andclinical indications for use. May 3,1990 is chosen as the starting point,the date when the first laserdesigned specifically for generaldentistry was cleared by the FDA forintraoral soft tissue surgery. Otherlasers had been used previously byotolaryngologists and oral surgeons,but the dLase 300 pulsed Nd:YAGdental laser system, manufactured bySunrise Technologies and distributedby American Dental Laser, was thefirst laser instrument in dentistry.

Other clearances followed. AnHGM argon ion laser was cleared forcuring of composite materials onJune 24, 1991; an ILT Genesis carbondioxide laser for tooth whitening onDecember 18, 1995; American DentalTechnologies’ PulseMaster Nd:YAGlaser for sulcular debridement onMarch 10, 1997.

Premier achieved the first hardtissue clearance on May 5, 1997 forits Centauri Er:YAG laser devicefor caries removal, cavity prepara-tion, and enamel roughening. Adifferent Premier device, thePegasus Nd:YAG laser, was clearedfor removal of coronal pulp as anadjunct to root canal procedures onAugust 23, 1998. One year later, onMay 13, 1999, American DentalTechnologies received clearance forselective removal of enamel carieswith its PulseMaster Nd:YAG laser.

KaVo received clearance for itsDIAGNOdent device to aid in thediagnosis of dental caries onFebruary 22, 2000. A BiolaseTechnologies device, the Waterlase,was cleared for tooth preparation toobtain access to the root canal(January 18, 2002), and for cuttingof oral osseous tissue (bone)(February 12, 2002).

One year later, on February 3,2003, the Biolase Waterlase receivedclearance for apicoectomy, and theMillennium Dental TechnologiesPerioLase device was cleared forlaser-assisted new attachmentprocedure on July 26, 2004.

On February 12, 2008, Biolasereceived clearance for its Waterlasefor root canal disinfection, and theKaVO KEY Laser III device wascleared for removal of subgingivalcalculi in periodontal pockets onJuly 10, 2008.

S E A R C H I N G F O RM A R K ET I N G C L E A R -A N C E I N F O R M AT I O NHow does one find out about FDAmarketing clearances for lasers? Asimple way is to search the onlinedatabase “510(k)s – PremarketNotifications (PMN)” on the FDA

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Web site, www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm.

To search for most surgical laserdevices, one can enter the “GEX”product code in the searchable fieldin the database. “NBL” is a productcode used for certain diagnosticdevices used for caries detection.

Clicking the “search” buttondisplays a listing of 510(k) clear-ances for GEX devices, listed bydevice, applicant, 510(k) number,and decision date. Not all of thedisplayed devices have dental indi-cations for use, of course. It bearsmentioning that the applicant isnot necessarily a manufacturer, butcould be a consulting firm acting onbehalf of a manufacturer.

Additionally, it is not necessaryfor an actual device to exist in orderto achieve clearance. Submission ofengineering drawings may be suffi-cient in some cases. It also shouldbe mentioned that just because adevice has been cleared to enter theU.S. market does not necessarilymean that the manufacturer willchoose to sell the device in theUSA. It just means that thecompany is allowed to do so.

Closer examination of thedisplayed results reveals thatnumerous devices have beencleared for a variety of indicationsfor use, for example, in derma-tology, plastic surgery, generalsurgery, as well as dentistry. Suchwide-ranging indications for useare rather common. Some deviceshave been cleared for intraoralapplications only.

The accompanying chart listssignificant marketing clearances byindication for use and by laserwavelength, from 1990 throughFebruary 24, 2009.

To be clear, the Code of FederalRegulations (21 CFR 807.97) isvery explicit in the proper use ofterminology. Determination ofsubstantial equivalence to a predi-cate device “does not in any waydenote official approval of thedevice. … Any representation thatcreates an impression of official

approval of a device because ofcomplying with the premarket noti-fication regulations is misleadingand constitutes misbranding.”

“ C L E A R E D ” V S . “ O F F - L A B E L” U S EIf a medical or dental practitionerchooses to use a device for an appli-cation that is not named in the“Indications for Use” statement,what does this mean? What are theimplications of performing “cleared”vs. “off-label” procedures?

According to the FDA, goodmedical practice and the best inter-ests of the patient require thatphysicians use legally availabledrugs, biologics, and devicesaccording to their best knowledgeand judgment. If physicians use aproduct for an indication that is notin the approved labeling, they havethe responsibility to be wellinformed about the product, to baseits use on firm scientific rationaleand on sound medical evidence,and to maintain records of theproduct’s use and effects. Use of amarketed product in this mannerwhen the intent is the “practice ofmedicine” does not require thesubmission of an InvestigationalDevice Exemption, InvestigationalNew Drug Application, or review byan Institutional Review Board(IRB). Nevertheless, the institutionat which the product will be usedmay, under its own authority,require IRB review or other institu-tional oversight.

Another source, the Physician’sDesk Reference or PDR, refers tooff-label use of pharmaceuticals.The PDR states in part:

“…The FDA has also recognizedthat the FD&C Act does not,however, limit the manner inwhich a physician may use anapproved drug. Once a producthas been approved formarketing, a physician maychoose to prescribe it for uses intreatment regimens or patientpopulations that are notincluded in approved

labeling…The FDA alsoobserves that accepted medicalpractice includes drug use thatis not reflected in approved druglabeling…”The PDR does NOT indicate

what should happen should some-thing go wrong under suchcircumstances.

A DV E R S E E V E N TSIn FDA terms, the “something wentwrong” is known as an “adverseevent” which is defined as death, orserious injury or illness that is life-threatening, results in permanentimpairment of a body function orpermanent damage to a body struc-ture, or necessitates medical orsurgical intervention to precludepermanent damage or impairment.

A key phrase in the adverseevent regulatory language is“caused or contributed to.” Thismeans that the medical device mayhave been a factor in death orserious injury because of devicefailure, malfunction, improper orinadequate device design, manufac-ture, labeling, or user error.

The Safe Medical Devices Act of1990 specified the procedures forreporting adverse events. By law,user facilities and manufacturersmust report deaths and seriousinjuries to the FDA. A user facilityis defined in the legislation as ahospital, an ambulatory surgicalfacility, a nursing home, an outpa-tient treatment facility, or anoutpatient diagnostic facility thatis not a physician’s office. By exten-sion, one can also presume that theterm “physician’s office” includes“dental operatory.”

When it comes to adverse eventreporting, the FDA requires manu-facturers to report deaths andserious injuries to the FDA; theagency requires distributors toreport deaths and serious injuriesto the FDA and to the manufac-turer. The FDA requires userfacilities to report deaths to theFDA, and serious injuries to the manufacturer. Meanwhile,

individual private practices areencouraged to voluntarily reportadverse events to the FDA and arestrongly recommended to reportadverse events to the manufacturer.

U S E R S ’ R O L E I N R I S KM A N AG E M E N TAnother way of looking at the topic ofAdverse Events is “RiskManagement.” A 2003 World HealthOrganization publication outlined theuser’s role in risk management.Foremost among the list of responsi-bilities is for the user to secure andfollow adequate training. The user isalso responsible for monitoring safetyand performance of the device on acontinuous basis, ensuring regularcalibration and maintenance, sharinginformation and problems, andassuring appropriate waste disposal.

OT H E R R EG U L ATO RYAG E N C I ESThe preceding discussion dealtexclusively with the U.S. Food andDrug Administration. Of course,similar regulatory agencies exist inother countries, for example:• Canada – Health Canada (Device

License)• European Community – Medical

Devices Sector (CE Mark)• United Kingdom – Medicines and

Healthcare products RegulatoryAgency (MHRA)

• Australia – Therapeutic GoodsAdministration (ARTG Number)

• Japan – Pharmaceutical andMedical Safety Bureau (Approvalor Notification).The common theme of each of

these agencies is protection of thepublic health. Each of them regu-lates how a medical device isbrought into the marketplace.

In general, like the FDA, each ofthe agencies mentioned requires astatement of indications for use fora medical device. However, theextent of supporting data differsfrom one agency or region toanother. At times, published litera-ture is sufficient, at other timesclinical studies are required.

Over the past several decades,any company wishing to sell medicallasers in these regions had tocomply with a dizzying array ofgovernmental regulations before itwas allowed entry into the market-place. A need was recognized tominimize regulatory barriers, facili-tate trade, and improve access tonew technologies. In 1993, an effortwas initiated to achieve greateruniformity between national medicaldevice regulatory systems, with thegoal of enhancing patient safety andincreasing access to safe, effective,and clinically beneficial medicaltechnologies. That year, the GlobalHarmonization Task Force (GHTF)was founded with representationfrom the European Union, UnitedStates, Canada, Australia, andJapan. The effort continues today.

R E F E R E N C ES1. Numerous sources were consulted

for information relating to the U.S.Food and Drug Administration,including several derived from theFDA’s Web site, www.fda.gov. Amongthe sources are:

a. “The United States Food & DrugAdministration, Overview ofRegulatory RequirementsMedical Devices, William (Bill)M. Sutton, Deputy Director,Division of Small Manufacturers,International and ConsumerAssistance, Center for Devicesand Radiological Health,”www.fda.gov/MedicalDevices/ResourcesforYou/Industry/ucm126245.htm

b. “510(k) Overview, HeatherRosecrans, Director, 510(k) StaffCenter for Devices &Radiological Health, FDA,”www.fda.gov/MedicalDevices/ResourcesforYou/Industry/ucm126288.htm

c. “Off-Label” and InvestigationalUse of Marketed Drugs, Biologicsand Medical Devices, www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/GuidancesInformationSheetsandNotices/ucm116355.htm

Accessed April 19, 2009 and July 31,2009.

2. PDR® 63 Edition 2009. Montvale,NJ: Physicians’ Desk Reference,Inc.: 2008:Foreword to the 63rdedition.

3. Office of Health and IndustryPrograms. Medical Device Reportingfor User Facilities. Rockville,Maryland: U.S. Dept. of Health andHuman Services, 1996.

4. Cheng M. Medical device regula-tions. Global overview and guidingprinciples. Geneva: World HealthOrganization, 2003.

A U T H O R B I O G R A P H YA graduate of the University ofMichigan, Mr. John Sulewskiserves as the director of educationand training for The Institute forAdvanced Dental Technologies. Asa consulting editor for the Journalof Laser Dentistry, he is also amember of the Academy of LaserDentistry’s scientific sessions, certi-fication, conference, ethics,communications, safety, science andresearch, and awards committees.Having been involved in the laserdentistry field since 1989, Mr.Sulewski is a past recipient of theAcademy’s distinguished serviceaward, has obtained AdvancedProficiency in Nd:YAG and diodelasers as a Laser Safety Officer,and is a University of CaliforniaCertified Dental Laser Educator.He is a member of the Academy ofLaser Dentistry, the AmericanSociety for Laser Medicine andSurgery, and SPIE – TheInternational Society for OpticalEngineering. Mr. Sulewski may becontacted by e-mail [email protected].

Disclosure: Mr. Sulewski is directorof education and training of TheInstitute for Advanced DentalTechnologies. He has served as aconsultant for American DentalTechnologies; Continuum Biomedical;Incisive, LLC; and Millennium DentalTechnologies. nn

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Intraoral Soft TissueSurgery (Ablating,Incising, Excising,Coagulating)• Carbon Dioxide• Nd:YAG• Argon• Ho:YAG• Er:YAG• Nd:YAP• Er:YSGG• Diode• Frequency-Doubled

Nd:YAG• Diode-Pumped 2.01-

micron

Curing of CompositeMaterials• Argon

Aphthous UlcerTreatment• Er,Cr:YSGG• Carbon Dioxide• Nd:YAG• Diode• Er:YAG• Frequency-Doubled

Nd:YAG

Tooth Whitening• Carbon Dioxide• Argon• Diode• Frequency-Doubled

Nd:YAG

Sulcular Debridement• Nd:YAG• Diode• Er:YAG• Er:YSGG• Carbon Dioxide

Caries Removal, CavityPreparation, EnamelRoughening• Er:YAG• Er:YSGG

Illumination for CariesDetection• Argon

Illumination forEndodontic OrificeLocation• Argon

Soften Gutta Percha• Argon• Frequency-Doubled

Nd:YAG

Removal of CoronalPulp, Adjunct to RootCanal Procedures• Nd:YAG• Diode

Pulpotomy as Adjunctto Root CanalProcedures• Diode• Nd:YAP• Nd:YAG• Er,Cr:YSGG• Er:YAG

Selective Removal ofEnamel (First Degree)Caries• Nd:YAG

Removal of FillingMaterials as AdjunctiveTreatment during RootCanal Retreatment• Nd:YAP• Nd:YAG

Aid in Diagnosis ofDental Caries• Diode

Treatment of HerpeticLesions• Er,Cr:YSGG• Nd:YAG• Frequency-Doubled

Nd:YAG• Diode• Er:YAG

Blood FlowMeasurements• Diode

Tooth Preparation toObtain Access to RootCanal, PulpExtirpation, RootCanal Debridementand Cleaning, RootCanal Preparationincluding Enlargement• Er,Cr:YSGG• Er:YAG

Cutting, Shaving,Contouring andResection of OralOsseous Tissues (Bone)• Er,Cr:YSGG• Er:YAG

Apicoectomy Surgery• Er,Cr:YSGG• Er:YAG

Coagulation ofExtraction Sites• Diode• Carbon Dioxide

Osteotomy, OsseousCrown Lengthening,Osteoplasty• Er,Cr:YSGG• Er:YAG

Laser-Assisted NewAttachment Procedure(cementum-mediatedperiodontal ligamentnew-attachment to theroot surface in theabsence of long junc-tional epithelium)• Nd:YAG• Carbon Dioxide

Reduction of BacterialLevel(Decontamination) andInflammation• Diode

Aid in Detection andLocalization ofSubgingival DentalCalculus• Diode

Root CanalDisinfection afterEndodonticInstrumentation• Er,Cr:YSGG

Removal ofSubgingival Calculi inPeriodontal Pockets• Er:YAG

U . S . F DA M A R K ET I N G C L E A R A N C ES BY I N D I C AT I O N F O R U S E(Applies to Certain Models Only)

The Institute for Advanced Dental Technologies – February 27, 2009Copyright 2009 The Institute for Advanced Dental Technologies. All Rights Reserved. Reprinted with permission.

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Carbon Dioxide• Intraoral Soft Tissue

Surgery (Ablating,Incising, Excising,Coagulating)

• Aphthous UlcerTreatment

• Tooth Whitening• Sulcular Debridement• Coagulation of

Extraction Sites• Laser-Assisted New

Attachment Procedure(cementum-mediatedperiodontal ligamentnew-attachment to theroot surface in theabsence of long junc-tional epithelium)

Nd:YAG• Intraoral Soft Tissue



• Sulcular Debridement• Removal of Coronal

Pulp, Adjunct to RootCanal Procedures

• Selective Removal ofEnamel (First Degree)Caries

• Pulpotomy as Adjunct toRoot Canal Retreatment

• Removal of FillingMaterials as AdjunctiveTreatment During RootCanal Retreatment

• Treatment of HerpeticLesions

• Laser-Assisted NewAttachment Procedure(cementum-mediatedperiodontal ligamentnew-attachment to theroot surface in theabsence of long junc-tional epithelium)

Argon• Intraoral Soft Tissue


• Curing of CompositeMaterials

• Tooth Whitening• Illumination for Caries

Detection• Illumination for

Endodontic OrificeLocation

• Soften Gutta Percha

Ho:YAG• Intraoral Soft Tissue


Er:YAG• Intraoral Soft Tissue


• Caries Removal, CavityPreparation, EnamelRoughening


• Sulcular Debridement• Pulpotomy as Adjunct to

Root Canal Retreatment• Tooth Preparation to

Obtain Access to RootCanal, Pulp Extirpation,Root Canal Debridementand Cleaning, RootCanal Preparationincluding Enlargement

• Cutting, Shaving,Contouring andResection of OralOsseous Tissue (Bone)

• Treatment of HerpeticLesions

• Apicoectomy Surgery• Osteotomy, Osseous

Crown Lengthening,Osteoplasty

• Removal of SubgingivalCalculi in PeriodontalPockets

Er,Cr:YSGG• Intraoral Soft Tissue



• Cavity Preparation,Caries Removal, ToothEtching

• Sulcular Debridement• Treatment of Herpetic

Lesions• Pulpotomy as Adjunct to

Root Canal Retreatment• Tooth Preparation to

Obtain Access to RootCanal, Pulp Extirpation,Root Canal Debridementand Cleaning, RootCanal Preparationincluding Enlargement

• Cutting, Shaping,Contouring andResection of OralOsseous Tissues (Bone)

• Apicoectomy Surgery• Osteotomy, Osseous

Crown Lengthening,Osteoplasty

• Root Canal Disinfectionafter EndodonticInstrumentation

Diode• Intraoral Soft Tissue



• Sulcular Debridement• Removal of Coronal

Pulp, Adjunct to RootCanal Procedures


• Tooth Whitening• Aid in Diagnosis of

Dental Caries• Blood Flow

Measurements• Treatment of Herpetic

Lesions• Coagulation of

Extraction Sites• Reduction of Bacterial

Level (Decontamination)and Inflammation

• Aid in Detection andLocalization ofSubgingival DentalCalculus

Nd:YAP• Intraoral Soft Tissue



• Removal of FillingMaterials as AdjunctiveTreatment During RootCanal Retreatment

Frequency-DoubledNd:YAG• Intraoral Soft Tissue


• Tooth Whitening• Aphthous Ulcer

Treatment• Treatment of Herpetic

Lesions• Soften Gutta Percha

Diode-Pumped 2.01-micron• Intraoral Soft Tissue


U . S . F DA M A R K ET I N G C L E A R A N C ES BY WAV E L E N GT H(Applies to Certain Models Only)

The Institute for Advanced Dental Technologies – February 27, 2009Copyright 2009 The Institute for Advanced Dental Technologies. All Rights Reserved. Reprinted with permission.

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SC I E N T I F I C R E V I E W

Fundamental Erbium Laser Concepts: Part IWayne Selting, DDS, Colorado Springs, ColoradoJ Laser Dent 2009;17(2):87-93

I N T R O D U C T I O NClinical lasers aid us in providingoptimal treatment for our patients.As with any device, they workeffectively only if basic principles ofuse are followed meticulously. Forexample, when using a high-speedhandpiece, we ensure that the airpressure is set correctly, water flowis adequate, the bur is sharp, andour manipulation does not stall burrotation or cause overheating of thetooth. Similar considerations, suchas water spray, beam placement,and laser parameters, are neces-sary to use a dental laser efficientlywithout causing tissue damage.

The erbium family of lasers(Er,Cr:YSGG at 2780 nm andEr:YAG at 2940 nm) ablate bothenamel and dentin efficiently underroutine clinical situations.However, ablation efficiency is

dramatically affected by a complexinteraction of several parametersincluding proximity of the laser tipto the tissue surface, beam diver-gence, irrigation flow rate, laserenergy level, pulse repetition rate,tip angulation, and tip condition. Aseries of studies was conducted toexplore the relative importance ofeach of these factors.

M ET H O D S A N D M AT E R I A LSRecently extracted third molarswere subjected to laser ablationusing an Er:YAG laser (DELight,HOYA ConBio, Fremont, Calif.)with a wavelength of 2940 nm. An80-degree, 600-micron diameterquartz tip was used with air andwater spray. Tip-to-tissue distancewas precisely controlled with acustom spacer as shown in Figure1. A series of studies wereconducted over the last four yearson at least 100 different tooth spec-imens.

Suction was placed at approxi-mately 1 cm from the surface toremove excess water during abla-tion without causing the surface tobecome dehydrated. Specimenswere washed, dried, and weighedbefore and after treatment on aprecision analytical balance(Sartorius CP64, Sartorius AG,

Goettingen, Germany) with anaccuracy of 0.1 milligram. Weightloss due to ablation was recorded,and mean and standard deviationswere calculated.

Ablation of enamel wasperformed on the facial or lingualsurface where the enamel structureis predictable. Root dentin wasablated, avoiding the apical thirdwhere dentin might not be fullyformed. Dentin and enamel wereablated for 30 seconds under avariety of conditions in differentstudies.

F U N DA M E N TA LCO N C E P TSThe information here will be

Selting

A B ST R AC TThe use of erbium lasers fordental hard tissue procedures iswell into its second decade. Basiclaser concepts proposed in pastresearch have been used toformulate clinical protocols. As ourknowledge has increased, some ofthe techniques used in these olderstudies are no longer appropriate.More importantly, lasers anddelivery systems have evolvedfrom laboratory setups tocommercial devices, deservingnew analysis.

The ideas presented here arelargely extracted from landmarkstudies conducted over the last 20years and from laboratory experi-ments as outlined below. Part oneof this paper deals with character-istics of the erbium laser and itsenergy beam while part two in afuture issue will explore theerbium wavelengths’ interactionwith dental hard tissues.

SY N O P S I S

This article is the first of a two-part manuscript, and will offer some

basic understanding of how erbium lasers interact with dental hard

tissue. The points covered below include discussions about the

thermal events, energy and power calculations, and how the laser

radiation is delivered to the target tissue.

Figure 1: Custom adjustable specimenspacer maintains precise tip-to-tissuedistance.

presented in the form of funda-mental concepts describing theerbium laser’s interaction withdental hard tissues. While thestudies discussed here wereconducted with the aforementionederbium:YAG laser, in the author’sexperience, most of the conclusionscan be generally applied to allerbium lasers. Although thefollowing concepts are discussedindividually for clarity, they arestrongly interrelated.

1. Er:YAG and Er,Cr:YSGGlaser wavelengths interactwith biological tissues in asimilar fashion but withsignificant differences.The basic laws of physics apply

to all erbium lasers. Ablation ofenamel, dentin, and bone occursthrough the explosive removal oftissue in a thermomechanicalevent.1-4 Because laser energy oferbium wavelengths is very highlyabsorbed by water, the target tissueis rapidly superheated. When thesteam pressure within the tissueexceeds the structural strength ofthe overlying material, micro-explo-sions occur, ejecting particles offractured material, as shown inFigure 2. Considerable pressure isneeded to fracture enamel anddentin so temperatures muchhigher than water’s normal boilingpoint of 100° C must be generated,a fact confirmed by Hibst andKeller.1 Ablation of enamel hasbeen reported to occur at tempera-tures of 300° to 400° C usingEr:YAG and 800° C for Er:YSGG.5

(Note: A number of articlescompare two erbium wavelengths,but many of those laboratorystudies use an Er:YSGG laser witha wavelength of 2790 nm. Thecommercially available equivalent,manufactured by BiolaseTechnologies in Irvine, Calif., usesan Er,Cr:YSGG active mediumwith a wavelength of 2780 nm. Inthis author’s opinion, the 10-nmdifference is insignificant for theconcepts presented here.)

While explosion is dependent onthe total amount of energydeposited in the tissue, it is criti-cally dependent on energyabsorption and pulse width.Although absorption coefficients forwater are commonly used in abla-tion discussions (Er:YAG = 13,000cm-1 and Er:YSGG = 5,250 cm-1,approximately),6 water is only apart of enamel (3% by weight, 12%by volume) and dentin (12% byweight, 25% by volume).7 Majaronet al. found an absorption coeffi-cient for the Er:YAG laser of 150mm-1 for enamel and 200 mm-1 fordentin.8 Perhavec and Diaci foundthe corresponding coefficients forthe Er,Cr:YSGG laser were aboutthree times lower. Therefore, theycalculated Er:YAG energy penetra-tion of 7 µm in enamel and 5 µm indentin. Similarly, Er,Cr:YSGGenergy penetrates 21 µm in enameland 15 µm in dentin.9 Otherauthors report absorption coeffi-cients for enamel at 480 cm-1 forEr:YSGG and 800 cm-1 for Er:YAG

with corresponding absorptiondepth of 25 µm for Er:YSGG and12 µm for Er:YAG.10

It is apparent from these widelyvarying numbers that no consensushas been reached on values forabsorption coefficient or the resultantenergy penetration depth at the twocommonly used erbium wavelengths.What is important is the concept ofsignificantly higher absorption and,therefore, lower penetration depth forthe Er:YAG laser compared to theEr,Cr:YSGG laser.

The impact of these values onablation is borne out in clinical appli-cation. Dispersing the energythrough a larger volume creates aless vigorous explosion and morethermal diffusion. Two studies thatused extracted teeth show Er:YAG tobe more efficient than Er,Cr:YSGGin ablation rates and speed.11-12 Whileefficiency is not necessarily the mostimportant determining factor inlaser ablation, it minimizes the nega-tive effects of thermal diffusion asdiscussed in the next concept.

2. Diffusion of thermal energyis harmful and inefficient.Thermal relaxation is a very

important factor to consider in softtissue ablation but is detrimentalin hard tissue applications. Theconcept of thermal relaxationasserts that energy will diffuse intosurrounding tissue, moderatingtemperature changes at the targetsite and, thus, minimizing harmfuleffects. It assumes that the energywill be carried away to somenoncritical location. In fact, fordental hard tissue, the oppositeeffect – thermal confinement – isboth desirable and necessary.

All infrared laser radiationentering hard tissue is convertedinto heat or thermal energy and,ideally, most of that heat causesablation. In a tooth, heat must notdissipate toward the pulp sinceeven a small temperature rise cancause cell death. Zach and Cohenfound that an increase in pulpaltemperature of 5.6° C caused

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Selting

Figure 2: Ultraspeed microphotography ofEr:YAG laser energy interaction with anenamel surface. (Photo by the author,using an Olympus E-10 camera with +8diopter closeup lens linked to a precisionmicrosecond timing circuit [The TimeMachine™, Mumford Micro Systems,Santa Barbara, Calif.] controlling a 500-nsec flash [Strobotac Type 1531, GeneralRadio Co., Concord, Mass.]. The camerawas operated at f8, 125 msec, in ablackout environment.

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necrosis in 15% of teeth and anincrease of 16.7° C caused necrosisin 100% of them.13 If thermalenergy diffuses into surroundingenamel or dentin, it leads to dehy-dration and lowered ablation.Osseous tissue can also be damagedby heat; the collagen tissue beginsto denature and coagulate attemperatures above 60-80° C.4

The concept of thermal confine-ment14 asserts that, if incidentenergy is completely contained in asmall volume of enamel, explosiveablation will occur. During thisprocess, energy is ejected in thevapor and exploded particles, leavinglittle to affect the surrounding toothstructure. The shorter the pulse, theless the energy will diffuse beforebeing ejected. Water coolant causesrapid diffusion of the remainingenergy out of the tooth.

Table 1, compiled from data inthe study of Perhavec and Diaci,illustrates the thermal effects ofpulse width employed by the twodifferent erbium wavelengths.15 Aspulse width increases, surface

temperature, residual heat (thermalenergy remaining after the ablationevent), and the depth to which thethermal energy penetrates increase.The percentage of incident energythat remains in the tooth after abla-tion more than triples as the pulsewidth increases from 150 µsec to1400 µsec. Of course, the two erbiumdevices in the study have inherentlydifferent pulse durations; neverthe-less, while these are different lasers,the trend is strongly suggested bydifferent pulse widths within theEr,Cr:YSGG laser.

3. Hydroxyapatite does notcontribute to ablation whenerbium lasers are used.While hydroxyapatite is a

major secondary absorber oferbium energy, in the author’sopinion, it does not contribute toablation; in other words, theprimary erbium laser-tissue inter-action is with water, as mentionedabove. The mineral can absorbenergy4 and then transfer the heatinto the enamel or dentin,

promoting dehydration and struc-tural change. If sufficient energyis absorbed to raise the tempera-ture to about 1100° C16 melting ofthe enamel will occur. It should bepointed out that erbium lasers arenot indicated for enamel meltingand their proper use will preventthat from occurring; moreover,some experimental carbon dioxidelasers are being studied for thera-peutic enamel melting andrecrystallization.10

A simple experiment illustratesthis point. Directing Er:YAG laserenergy at a dried extracted toothwith no water spray using 240 mJ at25 pps from a distance of 10 mmresults in subablative irradiation.After about 10 seconds the toothbecomes too hot to hold, havingreached approximately 200° C (meas-ured with an infrared pyrometer[Model MS6530, Precision MastechEnterprises Co., Ltd., ShenzhenHuayi, Kowloon, Hong Kong, China]).No ablation has occurred but a signif-icant amount of energy has beenabsorbed. Moving even closer (5 mm)causes melting, charring, and over-heating of the enamel, but still notrue explosive ablation.

4. Emitted fluence is notuniform over the surface ofthe tip.The spatial profile of the laser

beam is not well understood. It isoften, erroneously, assumed to behomogeneous with energy outputuniform across the entire laser tip,commonly referred to as a “TopHat” output. While this beamprofile can be achieved with lenses,it is not the normal output from anoptical resonator.

Most lasers emit in the “funda-mental transverse mode” also calledthe “TEM00 mode.” This output isGaussian in cross section (asymmetric “bell curve” shape) as itleaves the resonator. By the time thelight is emitted, imperfections in thelaser tip and the fiber-optic deliverysystem cause variation from thistheoretical output, as shown in

Selting

Table 1: Surface Temperature and Residual Heat During Ablation with Er:YAG and Er,Cr:YSGG Lasers

Tooth Substance

Laser Type

SurfaceTemperature

Change(°C)

Residual Heat(% of pulse

energy)

PenetrationDepth of

Residual Heat(µm)

Enamel

Er:YAG 150 µsec

104 4 15

Er,Cr:YSGG 500-700 µsec

176 9 25


200 13 30

Dentin

Er:YAG 150 µsec

64 3 7


236 7 19


251 9 22

This table shows that as pulse width increases, all three variables also increase signifi-cantly. Results are compiled from data by Perhavec and Diaci.15

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Figure 3. The tip surface is furtheraltered by damage during use.17

Significant amounts of subabla-tive energy are deposited intotissue on the fringes of the output,causing heating and dehydrationinstead of the desired ablation.

5. As the distance between thelaser tip and the targettissue increases, the fluencedecreases precipitously.One of the most important

concepts to understand is the effectof beam divergence on laser-tissueinteraction. Erbium laser energy istransported efficiently from aresonating chamber, through a fiber-optic delivery system bundle, andfinally through a quartz or sapphire

tip to be delivered directly to thetooth surface. Once the energyleaves the application tip, it divergesrapidly, as seen in Figure 4a.

Beam divergence for the laserused in this study is reported inthe manufacturer’s specificationsas 230 mrad or 13.2 degrees (26.4-degree beam spread). Simplemathematical calculations (fluence= total energy/area, where areachanges as a function of the squareof the radius) show that fluence orenergy density decreases precipi-tously in a very short distance, asseen in Table 2. At 2 mm tip-to-tissue distance, fluence hasdecreased by 68% from its level atthe tip surface. At 3 mm, it has

decreased by 78%, making tip-to-tissue distance a critical factor inlaser use.

Manipulation of laser beamdivergence is routinely done inindustry to achieve a desired effect.In laser pointers, a focusing lens isused to collimate the output, mini-mizing divergence and allowingspot size to remain largelyunchanged at long distances, asseen in Figure 4b. While this isessential to pointer function, it israrely done with clinical lasers. Afocused beam with constant spotsize could cause as muchdamage/ablation at 2 meters as itdoes at 2 millimeters – an undesir-able outcome. Instead,manufacturers use divergence tocreate a safe working environment.

Laser beams can be more exten-sively focused with optics, creatinga small spot size at a single pointwith a diverging beam beyond, asshown in Figure 4c. The result issimilar to starting a fire with amagnifying glass by focusing thesun’s energy on paper. The enor-mous energy densities produced areideal for melting, cutting, andfusing metals but are not appro-priate for biological tissues wherethe intention is to remove a rela-tively broad swath of tissue byexplosive ablation.

Selting

a: Beam from an erbium laser divergesrapidly after it leaves the tip

c: Focused beam creates very highfluence at one spot

d: “Soft-focused” beam creates a zone ofmoderate fluence

b: Beam from a laser pointer is colli-mated to prevent divergence

Figure 4: Types of laser emission beams

Table 2: Decrease in Energy Density with Increased Tip-to-Tissue Distance

Tip-to-Tissue Distance(mm)

Spot Area

(mm2)Fluence

(% of contact value)

0.0 (contact) 0.2827 100

0.5 0.4012 70

1.0 0.5424 52

2.0 0.8860 32

3.0 1.3134 22

This table shows the theoretical decrease in energy density (fluence) with distance at acommonly stated beam divergence of 13.2°.

Figure 3: Actual 3-dimensional outputprofile of an Er:YAG quartz tip analyzedwith an Ophir Spiricon beam analyzer(Model SP503U, Ophir-Spiricon Inc.,Logan, Utah). The vertical axis indicatesrelative energy density while the whitering represents an ideal Top Hat output.(Photo courtesy of Frank Yung, DDS)

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In a variation on this concept,some dental laser manufacturers(Fotona d.d., Ljubljana, Slovenia,EU; and Biolase Technology, Irvine,Calif.) now offer a noncontact“tipless” handpiece which focusesthe laser beam in a zone about 2mm long, located a few millimetersfrom the tip. An example is shownin Figure 4d.

Were it not for the next conceptof ablation threshold, beam diver-gence would be of littleconsequence. If the spot area istripled, as occurs at 2 mm tip-to-tissue distance vs contact (seeTable 2), the fluence would be one-third but the total energy would bethe same. Therefore, ablation wouldbe one-third as deep but coverthree times the area for the sametotal ablation. Ablation threshold isthe primary reason that this doesnot hold true.

6. Energy is needed to reachthe ablation threshold.Ablation threshold is defined as

the minimum energy densityrequired to initiate an explosiveremoval process.18 Below this level,all energy is absorbed as heat anddissipated into surrounding areas.As mentioned above, there is anamount of energy needed to bringthe water contained in the tissue toa boil and further energy isrequired to create the pressurenecessary for fragmentation of theenamel or dentin particles.

Apel et al. found a fluence of 9-11 J/cm2 using the Er:YAG laserand 10-14 J/cm2 using the Er:YSGGlaser as the ablation threshold ofenamel.18

For purposes of our discussion athreshold value for enamel of 10J/cm2 will be assumed. Measuringenergy in joules/cm2 has littlemeaning in our dental context with600-micron diameter tips. A moreappropriate measurement systemtranslates 10 J/cm2 into 100mJ/mm2. With a 600-µm tip (0.2827mm2), the total threshold energyrequired per pulse would be 28

millijoules if the tip were placed incontact with the enamel.

In contact: Threshold energy =100 mJ/mm2 x 0.2827 mm2 = 28.27mJ.

At a 3-mm distance, the totalthreshold energy has increased to131 millijoules per pulse.

At 3 mm: Threshold energy =100 mJ/mm2 x 1.31 mm2 (spot areaat 3 mm) = 131 mJ.

Table 3 shows the effect of tip-to-tissue distance on total energythat must be supplied before abla-tion can begin.

When water spray interposes,absorption and scattering willoccur, significantly modifying thebeam profile and affecting theenergy density actually reachingthe tooth surface. Any part of thebeam that does not exceed thelevels in Table 3 will not causeablation.

7. Tip-to-tissue distance has aprofound effect on ablation.As a result of the previous two

fundamental concepts, actual clin-ical ablation of any tissue by anyerbium laser is highly dependenton tip-to-tissue distance. Onlyenergy above that needed to reachthreshold can be used for ablation.As tip-to-tissue distance increases,spot size also increases throughbeam divergence and totalthreshold energy increases asdescribed above. If the energy illu-minates twice the area, twice asmuch energy must be expended to

reach the threshold.Majaron et al.19 showed in their

in vitro study that having a gapbetween the tip and tissueincreased enamel ablation signifi-cantly. They suggest an optimal gapof 0.3 to 0.6 mm for enamel.Theoretically, this would allowdebris to exit the gap and allowmore water in to flush accumulateddebris. As the distance exceeds 1mm, decreases in energy density aswell as absorption by and refrac-tion from interposed water willexceed the advantages of debrisclearance.

The theoretical calculations inTable 2 and Table 3 suggest signifi-cant effect on ablation byincreasing tip-to-tissue distance.This theory is supported by empir-ical results as shown in Figure 5.Beyond 3-mm tip-to-tissue distanceall ablation ceases. A deceptive“popping sound” still occurs but itonly represents explosion of inter-vening water.

8. Peak power is more impor-tant than average power.One watt of average power is

one joule of energy delivered overone second. The energy may bedelivered evenly throughout thatsecond or turned on and off anynumber of times. The term “peakpower” creates an image of an ulti-mate level that is rarely achieved.It is, in fact, the power emitted anytime that the laser pulse is on.

The currently available erbium

Selting

Table 3: Energy Required to Overcome Ablation Threshold at VariedTip-to-Tissue Distance

Tip-to-Tissue Distance (mm) Total Threshold Energy (mJ)

0.0 (contact) 28

0.5 40

1.0 54

2.0 88

3.0 131

This table shows the theoretical total ablation threshold energy per pulse in enamel atdifferent tip-to-tissue distances based on a threshold of 10 J/cm2 per Apel et al.18

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lasers offer pulse durations rangingfrom 50 µsec to several hundredµsec.

These short pulse widths createhigh peak power, since the calcula-tion divides the energy per pulse bythe pulse duration. This “peakpower” can be in the hundreds orthousands of watts, although theaverage power may be in singledigits. For example, in a 250-µsecpulse at 25 pulses per second and240 mJ/pulse that is commonlyused to ablate enamel with anEr:YAG laser, the average powerwould be 6 watts (0.24 J/pulse x 25pulses/sec = 6.0 J/sec = 6 watts).Since 240 mJ is delivered duringthe pulse “on time” of 250-µsecduration, peak power is 960 watts(0.24 J / 0.000250 sec = 960 watts).If pulse width were narrowed to100 µsec, peak power with thesame 240 mJ of energy would beincreased to 2,400 watts (0.24 J /0.0001 sec = 2,400 watts).

9. Ablation is directly propor-tional to pulse repetitionrate.Currently available dental lasers

offer the ability to adjust the pulserepetition rate from as few as 3 to asmany as 50 pulses per second. If bothpulse width and energy per pulse arekept constant, increasing the pulserepetition rate will increase total

energy and, thus, ablation rate.Figure 6 shows a linear increase inablation with increased pulse rate.These results suggest that there is no“optimal” pulse rate. However, thepulse duration as well as the pulserepetition rate must be kept in mindso that ablation proceeds efficientlyas well as safely.10

CO N C LU S I O NThe fundamental conceptsdiscussed here provide a basis formaking scientifically supportedclinical decisions. The next part ofthis paper will explore the effect ofcommonly encountered clinicalvariables on ablation efficiencythrough practical experiments.

A U T H O R B I O G R A P H YDr. Wayne Selting holds a bach-elor’s degree in electricalengineering and a Master’s degreein biomedical engineering fromMarquette University, as well as aDoctor of Dental Surgery degreefrom Creighton University. He isthe former chief of biomedical engi-neering for the U.S. Army Instituteof Dental Research in Washington,DC and a former consultant onBiomedical Engineering to theArmy Medical Research andDevelopment Command. Dr. Seltinghas been a special lecturer on thefaculty of the U.S. Army Dental

Postgraduate School and theGeorge Washington University. Henow maintains a laser and cosmeticpractice in Colorado Springs,Colorado and conducts independentresearch on dental lasers. Dr.Selting may be contacted by e-mailat [email protected].

Disclosure: Dr. Selting has nocommercial relationships relative tothis paper.

R E F E R E N C ES1. Hibst R, Keller U. The mechanism of

Er:YAG laser induced ablation ofdental hard substances. In: Gal D,O’Brien SJ, Vangsness CT, WhiteJM, Wigdor HA, editors. Lasers inorthopedic, dental, and veterinarymedicine II, January 16-18, 1993,Los Angeles, Calif. Proc. SPIE 1880.Bellingham, Wash.: SPIE – TheInternational Society for OpticalEngineering, 1993:156-162.

2. Farrar SR, Attril DC, Dickinson MR,King TA, Blinkhorn AS. Etch rateand spectroscopic ablation studies ofEr:YAG laser-irradiated dentine.Appl Opt 1997;36(22):5641-5646.

3. Niemz MH. Investigation and spec-tral analysis of the plasma-inducedablation mechanism of dentalhydroxyapatite. Appl Phys B1994;58(4):273-281.

4. Parker SPA. The use of lasers inbone surgery. J Laser Dent2007;15(1):9-13.

Selting

0.0

5.0

10.0

15.0

20.0

25.0

0 1 2 3 4

Ab

lati

on

(m

g/3

0 se

c)

Tip-to-tissue distance (mm)

Enamel

Figure 5: Er:YAG laser ablation of enamel as a function of tip-to-tissue distance. This graph shows that tip-to-tissue distance has adramatic effect on ablation efficiency. The vertical axis showsamount of ablated material, measured in mg per 30 seconds; thehorizontal axis is the distance from the tip to the enamel in mm.

0

5

10

15

20

25

30

0 5 10 15 20 25 30 35

Ab

lati

on

(m

g)

Pulse repetition rate (pulses per second)

Enamel

Dentin

Figure 6: Er:YAG laser ablation of enamel and dentin as a func-tion of pulse repetition rate. This graph shows that ablation isdirectly proportional to pulse rate. The vertical axis shows theamount of ablated material, measured in mg per 30 sec; thehorizontal axis is the pulse rate.

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5. Fried D. IR laser ablation of enamel.In: Featherstone JDB, Rechmann P,Fried D, editors. Lasers in dentistryVI, January 23-24, 2000, San Jose,Calif. Proc. SPIE 3910. Bellingham,Wash.: SPIE – The InternationalSociety for Optical Engineering,2000:136-148.

6. Walsh JT Jr, Cummings JP. Effect ofthe dynamic optical properties ofwater on midinfrared laser ablation.Lasers Surg Med 1994;15(3):295-305.

7. Meister J, Franzen R, Forner K,Grebe H, Stanzel S, Lampert F, ApelC. Influence of the water content indental enamel and dentin on abla-tion with erbium YAG and erbiumYSGG lasers. J Biomed Opt2006;11(3):034030-1-7.

8. Majaron B, Sustercic D, Lukac M,Skaleric U, Funduk N. Heat diffu-sion and debris screening in Er:YAGlaser ablation of hard biologicaltissues. Appl Phys B Lasers Opt1998;B66(4):479-487.

9. Perhavec T, Diaci J. Comparison ofEr:YAG and Er,Cr:YSGG dentallasers. J Oral Laser Appl2008;8(2):87-94.

10. Featherstone JDB, Fried D.Fundamental interactions of laserswith dental hard tissues. Med LaserAppl 2001;16(3):181-194.

11. Perhavec T, Gorkic A, Bracun D,Diaci J. A method for rapid meas-urement of laser ablation rate ofhard dental tissue. Opt LaserTechnol 2009;41(4):397-402.

12. Perhavec T, Diaci J. Comparison ofEr:YAG and Er,Cr:YSGG lasers. JOral Laser Appl 2008;8(2):87-94.

13. Zach L, Cohen G. Pulp response toexternally applied heat. Oral SurgOral Med Oral Pathol1965;19(4):515-530.

14. Vogel A, Venugopalan V.Mechanisms of pulsed laser ablationof biological tissues. Chem Rev2003;103(2):577-644.

15. Perhavec T, Diaci J. Comparison ofheat deposition of Er:YAG andEr,Cr:YSGG lasers in hard dentaltissue. J Laser Health Acad2009;2(1):1-6. [Editor’s note: TheJournal of the Laser and HealthAcademy is published by Fotonad.d., Ljubljana, Slovenia, EU.]

16. Wu C-C, Roan R-T, Chen J-H.Sintering mechanism of the CaF2 onhydroxyapatite by a 10.6-µm CO2laser. Lasers Surg Med2002;31(5):333-338.

17. Selting WJ. The effect of tip wear onEr:YAG laser ablation efficiency. JLaser Dent 2007;15(2):74-77.

18. Apel C, Meister J, Ioana R, FrazenR, Hering P, Gutknecht N. The abla-tion threshold of Er:YAG andEr:YSGG laser radiation in dentalenamel. Lasers Med Sci2002;17(4):246-252.

19. Majaron B, Prosen T, Sustercic D,Lukac M. Fiber-tip drilling of harddental tissues with Er:YAG laser. In:Featherstone JDB, Rechmann P,Fried DS, editors. Lasers indentistry IV, January 25-26, 1998,San Jose, Calif. Proc. SPIE 3248.Bellingham, Wash.: SPIE – TheInternational Society for OpticalEngineering, 1998:69-76. nn

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The Pending Zone: Managing the Compromised Periodontal PatientMary Lynn Smith, RDH, McPherson, KansasJ Laser Dent 2009;17(2):94-99

I N T R O D U C T I O NPatients with advanced periodontaldisease often find themselves in a“pending zone.” Restorative or pros-thetic treatment is postponedbecause the patient has not chosento take the next step of treatmentor the next step may be clinicallyunclear. Periodontal infectiontherapy during the interim is valu-able and could change the course oftreatment. How the patient’s oralhealth is managed in the “pendingzone” is determined by the patient’sdesires and commitment to treat-ment, the treatment options andpossible results, and continuedevaluation throughout treatment.

Open communication will helpdefine success for both the patientand clinician. Most patients knowtheir dental condition is compro-mised by the time they come for anevaluation. Some have a precon-ceived idea of needed treatment buthave little understanding of otherpossible options. The periodontallycompromised patient in particularneeds treatment goals clarified.Because the bone loss is severe,treatment may be a progression ofsteps. Periodontal therapy, as one ofthe steps, is meant to stabilize thecurrent disease by reducing theinflammatory processes and elimi-nating active infection. Preservingcomfort and function, as well as

providing time to determine thedesired course of treatment, arealso essential objectives. Thefollowing critical areas should beconsidered when shaping treat-ment: esthetics, quality of life,compromised health issues, func-tion, treatment prognosis, patientcompliance/motivation, andrequired treatment time. Invitinghonest discussion about dentalconcerns, hopes, and fears beginsbuilding the relationship neededbetween the patient and clinician.When expectations are matched,trust and harmony result.

Excellent treatment planningbuilds on the foundation of compre-hensive clinical evaluation yet pivotson the patient’s ideas of successfultreatment. Components of thecomprehensive evaluation are:• Radiographs• Periodontal charting (pocket

depths, recession, clinical attach-ment loss, hemorrhaging,furcations, and mobility)

• Restorative charting• Temporomandibular joint and

occlusal relationship evaluation• Risk assessment for caries and

periodontal disease• Pathogenic testing• Systemic health issues that may

require collaboration with thepatient’s physician and addi-tional testing (HbA1C [glycated

hemoglobin, for diabetes], CRP[C-reactive protein assay, forinflammation], genetic testing).Additional considerations for

designing treatment include:• What are the patient’s physical

tolerances (i.e., length of appoint-ments, pain threshold, anxieties)?

• Is sedation desired (i.e., IV seda-tion, conscious sedation, nitrousoxide)?

• What kind of anesthetic isneeded (i.e., local anesthesia,topical anesthesia)?

• How can scheduling be accommo-dated by the patient andpractice?Nonsurgical periodontal infec-

tion therapy may occur as a seriesof appointments coordinated withrestorative treatment or in a sepa-rate treatment phase with anexpanded treatment design or full-mouth debridement within 24hours. The severity of periodontaldisease and the amount and

A B ST R AC TPatients with severe periodontaldisease often pose a dilemma forboth themselves and their dentistsand dental hygienists. On the onehand, the patient may haveresigned him/herself to losingteeth that the practice can savewith continued therapy; on theother hand, the dental team maynot be able to treat the diseaseadequately either because of thepatient’s compromised conditionor because of an incomplete treat-ment plan. This article discussesseveral factors that must beconsidered when treating a patientwith advanced periodontitis andgives an overview of the treatmentof four different clinical cases.

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Editor’s Note: In this article, Ms. Smith briefly describes using a carbondioxide laser for sulcular debridement in 2005. The reader should beaware that, at that time, the particular laser did not have an U.S. FDA510(k) clearance for the procedure, although a similar instrument fromanother company did. Last year, the FDA did grant the manufacturer ofher instrument a marketing clearance for sulcular debridement.

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quality of calculus affect the treat-ment planning as well.

The following cases illustratevarious treatment paths chosen bypatients. Each case was discussedthoroughly in a consultation.Patients were counseled that theyhad the option to stop or changethe course of treatment at anytime. The dentist, hygienist, andpatient continually evaluated andqualified success according tocriteria discussed in the consultprior to treatment. The resultsindicated the next treatment phase.

C AS E 1The first patient had a general atti-tude of “get ‘em out and get ondown the road!” He is a 57-year-oldwho presented with a missingmaxillary anterior bridge andwanted upper teeth replaced by theweekend. He was not interested inperiodontal therapy, yet he wantedto maintain his lower teeth as longas possible. He chose to have themaxillary arch restored withimplant-supported bridges (Figure1). The plan was for him to returnfor hygiene care every 3 months.

He returned sporadically over thenext 2 years (Figure 2). Withfurther deterioration, he was readyfor treatment of the mandibulararch—extractions and implantswith an abutment-supporteddenture (ANKYLOS® SynCone®,Dentsply Friadent, Mannheim,Germany) (Figure 3). He falls intothe “Mr. Noncompliant” categoryand comes every so often for dentalvisits.

C AS E 2The second patient, 54 years old,wanted to know her options. Shefelt sure she would have to weardentures but was hesitant. Herconcerns were centered around thefact she is a performing artist anda denture is likely to change herspeech as well as resonance whensinging. There were immediatetreatment needs to address prior toconsidering periodontal treatmentif she were to opt for delayingdentures (Figure 4). Challenges ofher case were numerous. The poste-rior teeth were in bilateralcrossbite and the anterior teeth inan open bite (Figure 5); the amountof bone loss was extensive; herdaily care was fair; and she smokesapproximately 1/4 to 1/2 pack per

day. Her stress was elevated due tounemployment. The patient wantedto try to saving her teeth and wasundaunted by the proposed treat-ment plan.

Teeth #2 and 18 were extracted,and even though several teeth werefractured, the next priority was tobegin minimizing the inflammationand infection of soft tissues ratherthan undertake restorative treat-ment. The patient agreed tononsurgical laser-assisted peri-odontal therapy followed bymaxillary surgery after primaryresolution. The pretreatment peri-odontal chart is shown in Figure 6,and therapy was completed in oneday for a total treatment time of 5hours. The following month, teeth#6-11 were splinted prior tosurgery. The flap surgery and opendebridement employed a laser,manual and ultrasonic instrumen-tation. The lower arch wasdebrided with manual and powerinstrumentation and decontami-nated with a laser. A micropulsed10,600-nm CO2 laser (SmartUS20D, DEKA Laser Technologies,Inc., Carlsbad, Calif.) was usedthroughout treatment. A 400-micron ‘periodontal tip’ was usedwith parameters of 50 Hz and an

Figure 1: Anterior view of Case 1 at initialpresentation

Figure 2: Anterior view of Case 1 twoyears later showing almost total deterio-ration of the mandibular dentition.

Figure 3: Case 1: Implant fixtures placed.Patient continued with mandibular pros-thesis

Figure 5: Anterior, right, and left lateral views of Case 2 at initial presentation

Figure 4: Panoramic radiograph of Case 2at initial presentation

time with future plans being madeas function changes (Figures 8-9).This patient is not a stranger toperiodontal treatments. He hadperiodontal surgery in the 1980s,several rounds of scaling and rootplaning, extractions of variousteeth due to periodontal disease—he would just rather not do more.When presented with treatmentoptions, he flatly refused surgery,but liked the idea of laser-assistednonsurgical periodontal therapy.This treatment began in 2003. An

Nd:YAG laser (PulseMaster 600IQ,American Dental Technologies,Corpus Christi, Texas) was usedwith a 400-micron fiber. Laserbacterial reduction was accom-plished at parameters of 30 mJ and60 Hz (1.8 W) followed by coagula-tion with parameters of 100 mJand 20 Hz (2.0 W).

Prior to laser-assisted therapy,data showed improved parameters,as shown in Table 2.

Supportive care continuedapproximately every 10 to 12

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Table 2 (Case 3)

BleedingPeriodontal

Pockets (> 4 mm)Number of Teeth

Involved

Initial 89 13125 of 25 (all teethpresent affected)

4 Months Later 43 90 25 of 25

average power range of 1.7-2.0 W.Follow-up biofilm removal andlaser decontamination followed atintervals of 10-14 days untilcomplete. After 12 weeks full perio-dontal assessment was charted.Areas of redebridement and addi-tional laser decontaminationfollow-up were needed. Supportivecare consisted of 8-week intervalsto provide evaluation of dailybiofilm removal, professional ultra-sonic biofilm removal, and laserdecontamination.

This case began with 81 bleeding-on-probing sites, 107 pocketsmeasuring 4 mm or greater, and all23 teeth exhibiting pocketing. At oneyear, the patient experiencedimprovements of 88% in bleeding,57% in pocketing, and 17 of 23 teethwith pocketing. See Table 1.

The patient is pleased she hasgained better health with therapy.When considering the currentpanoramic radiograph (Figure 7) andother imaging data (not shown), themaxillary arch still seems hopeless.The patient’s choice is to continueshort-interval hygiene appointmentsand pursue upper extractions and adenture as the next step.

C AS E 3The third patient is one whoseteeth have been extracted one at a

Figure 6: Periodontal probe chart of Case2 at initial presentation (pocket depthson first line, next to tooth icons) andone-year postoperative results (pocketdepths on second line)

Figure 7: One-year post-treatmentpanoramic radiograph of Case 2. Notemolars with hopeless prognosis (teeth#2, 14, 15, 18, and 31) have beenextracted and with good osseous repair.There is some radiographic evidence ofbone fill in some of the existing pockets,compared to Figure 4.

Figure 9: Initial radiographs of Case 3 atinitial presentation

Figure 8: Anterior view of Case 3 at initialpresentation

Table 1 (Case 2)

BleedingPeriodontal


Involved

Initial 81 107 24 of 24


% Improvement 88% 57%

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weeks. A year later, another toothhad been extracted and full retreat-ment using a different laserwavelength was completed.Dataimproved, as seen in Table 3.

Supportive care continuedapproximately every 10-12 weeksfor a total of 7 months of laser-assisted treatment. Fifteen monthsafter the start of treatment,another tooth had been extractedand full re-treatment using adifferent laser wavelength (the CO2described above) was completed.Eighteen months after initial treat-ment, the CO2 was used again.Data improved.

Even more interesting is how thepocket depths were changing. Pocketsdepths changed (see Table 4).

He continues supportive care atapproximately 10 weeks and iscurrently maintaining fairly well(Figures 10-11). An implant hasbeen placed in the tooth #13 area.Tooth #12 is the next plannedextraction. Other areas showingadvanced compromise are beingtreated periodontally and beingmonitored. Implants are beingstrategically placed in order toeventually support a maxillarydenture.

C AS E 4The last case is one motivated bythe patient’s immediate healthconcerns and emotional dread ofmoving into dentures. She knewher dental health was extremelychallenged with significant disease,but she was hoping for “just onemore year.” At 63 years old, sheoriginally presented with pain ontooth #10, which was extracted. Agraft was placed in preparation foran implant, but failed. Her generalhealth was showing compromisethrough repeated sinus infections,urinary tract infections, andchronic fatigue. Antibiotics almostalways caused a yeast infection.With her return visit, radiographswere taken (Figure 12); the surgicalsite of tooth #10 was examined, andshe agreed to an evaluative

hygiene visit. She was able todiscuss her dental future andwanted options. She wanted to buytime, even if it were only 12months, if there were a possibletreatment option. Esthetics werenot as much of a concern as herhealth and function. She chosemaxillary full-flap surgery anddebridement using manual andultrasonic instrumentation andlaser decontamination. Her treat-

ment was scheduled in 3 sessions—upper right, upper left, and lowerarch. The previously describedmicropulsed CO2 laser was usedthroughout her treatment.Continued home care refinement,ultrasonic biofilm removal, andlaser decontamination werecompleted every week for 4 weeks.Figure 13 shows her smile at thispoint. Then 6-week appointmentintervals were scheduled for thenext year. These appointment serv-ices alternated a reinfectionassessment appointment type(plaque management evaluation

Table 3 (Case 3)

BleedingPeriodontal


Involved

15 Months Later 53 8724 (one tooth

extracted)


Table 4 (Case 3)

4-mm sites 5-mm sites 6-mm sites 7-mm sites 9-mm sites

From: 40 18 12 11 1

TO: 38 13 4 5 0

Figure 11: Current (approximately 5years) post-treatment panoramic radio-graph of Case 3. Teeth with hopelessprognosis (#1, 2, 13, 18, and 31) wereextracted. Tooth #13 has been replacedwith an implant and there is some radio-graphic evidence of bone fill in some ofthe existing pockets shown in Figure 9.

Figure 13: Anterior view of Case 4 atinitial periodontal examination appoint-ment

Figure 12: Initial radiographs of Case 4

Figure 10: Current (approximately 5years) post-treatment anterior view ofCase 3. The tissue tone has improved,compared to the initial photo in Figure 8.

and ultrasonic biofilm removal withlaser decontamination) and asupportive care appointment type(complete periodontal maintenanceincluding laser decontamination).At one year, appointmentscontinued with supportive care at10-week intervals.

After 2.5 years, the improvementhas been significant. She statesthat her health has improved withno urinary tract infections, only 1sinus infection, and a return ofnormal energy. Esthetics are lessthan ideal in this case; however, thepatient’s lip line shows minimalcrown length, and the tissue tone isacceptable (Figure 14). She has nosensitivity and minimal mobility onlocalized teeth. The maxillary perio-dontal chart is shown in Figure 15and the mandibular arch in Figure16. Periodontal data showsimprovements, as seen in Table 5.

Plans are being made forrestorative treatment, beginning onthe lower right. She continues hersupportive periodontal care at 12-week intervals. She has absolutelyno regrets for pursuing this treat-ment path.

CO N C LU S I O NPeriodontally compromised patientsmay or may not have to pursuerestorative or prosthetic treatmentright away. Varying levels of caremay be provided while other treat-ment is pending. It is critical thatthe patient be educated on peri-odontal treatment options andprognosis. The dentist, hygienist,and patient need to continuallyevaluate, qualify, and quantify

success according to criteriadiscussed in the consult prior totreatment. The results indicate thenext treatment phase. Identifyingwhat is success in the patient’s eyesis significant. Success is not alwaysresolving pocket depths. Sometimessuccess is bringing the patient to a

healthier state in order for them totake the next step. The hygienist isan integral part of this transition.Patients who understand the treat-ment options and related prognosisprior to beginning therapy usuallycontinue with recommended treat-ment.

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Table 5 (Case 4)

BleedingPeriodontal


Involved

Initial 56 95 22 of 23 (96%)

30 Months Later 4 8 8 of 21 (38%)

% Improvement 93% 92%

Figure 15: Maxillary periodontal chart of Case 4. Initial pocket depths at presentation areon the first line, next to tooth icons, and 2.5-year post-treatment measurements are onthe second line. Significant pocket reduction has taken place, and almost all of thebleeding and inflammation areas have been eliminated.

Figure 14: Two-and-one-half-year post-treatment view of Case 4

Figure 16: Mandibular periodontal chart of Case 4. Initial pocket depths at presentationare on the first line, next to tooth icons, and 2.5-year post-treatment measurements areon the second line. Similar to the maxillary arch shown in Figure 15, all pockets havebeen reduced; and the bleeding areas are almost all eliminated.

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A U T H O R B I O G R A P H YMs. Mary Lynn Smith is a regis-tered dental hygienist, workingclinically for more than 14 years.She achieved Standard Proficiencyfor the Nd:YAG (1,064 nm) anddiode (810 nm) laser wavelengthsin 2003 and Advanced Proficiency

in Nd:YAG in 2007. Ms. Smith hascontributed to the dental commu-nity through articles and speakingto fellow hygienists on care ofimplants, periodontal therapies,and laser-assisted hygiene tech-niques and principles. Shecurrently resides in McPherson,

Kansas, and is employed by JonJulian, DDS and Brian Kynaston,DDS. Ms. Smith may be reached bye-mail at [email protected].

Disclosure: Ms. Smith receives hono-raria from DEKA Lasers. nn

Smith

Diode Lasers and Computer-Aided Design and Manufacturing (CAD/CAM) Dentistry: A Perfect Marriage of Two AdvancedTechnologiesEugene L. Antenucci, DDS, FAGD, Huntington, New YorkJ Laser Dent 2009;17(2):100-103

I N T R O D U C T I O NDiode lasers have proven to be ahighly successful technology withnumerous applications in dentistry,providing practitioners and patientswith a wide range of soft tissuesurgical procedures.1-2 Duringrestorative dentistry, soft tissuelasers can be used for gingivalperiodontal tissue management,providing good hemostasis and areduction of bacteria.3-5 As withother soft tissue lasers, it has beenreported that the diode laser offersprecision during gingival contouringand that healing usually occursuneventfully.6-7 For example, thediode laser wavelengths areroutinely used for sulcular prepara-tion prior to an impression. In theauthor’s experience, the soft tissuecan be expected to heal unremark-ably, and without postoperative painand discomfort or postoperative lossof gingival margin height.

The majority of dental impres-sions taken are physicalimpressions which utilize traysfilled with materials that areinjected around the prepared andunprepared teeth, and whichharden following a chemical reac-tion after several minutes. Theimpressions require a laboratory

procedure to create a set of hardmodels and a second procedure toarticulate the models. Once anarticulated set of models is avail-able, the lab technician can thenfabricate the desired restorationfrom the prescribed materials –commonly with metallic copingsand a ceramic veneer. The entirerestorative process from the date ofpreparation and impression tocompletion averages 2 weeks withmost laboratories, during which thepatient is temporized.

The introduction of chairside andlaboratory-based Computer-AidedDesign / Computer-Aided-Manufacturing (CAD/CAM)technology in dentistry has radi-cally changed the paradigm andhas significantly altered themanner in which dentists are ableto approach the restorative work-flow. It has also allowed for theintroduction and utilization ofnonmetallic copings which can thenbe veneered with ceramics, as wellas monolithic ceramic restorationswhich are milled.

F U N DA M E N TA LS O FC A D / C A MThe CAD/CAM process involvesacquiring an image with a digital

scanning device that is linked to acomputer. In restorative dentalapplications, the digital imagereplaces traditional impression-taking techniques, with theacquired image serving as the basisfor designing various types ofrestorations. After the restorationis designed, computer softwareconverts the information into datathat is used by a milling machineto create restorations from theselected materials.

CAD/CAM has been clinicallyutilized in restorative dentistrysince 1985 with the introduction ofCEREC I by Drs. Mörmann andBrandestini.8 They coined the termCEREC, which stands for“computer-assisted CERamicREConstruction.” CAD/CAM,however, realized a very slow startin restorative dentistry. Laboratorystandards of impressions, wax-ups,castings, and ceramics were familiarand accepted by dentists and techni-cians. CEREC I, though an excitingconcept, required a high degree oftechnical knowledge regarding theuse of computers. Unfortunately, thetechnology was relatively difficult touse, and the results were notcomparable to what was availableby laboratories at the time.Moreover, computers were not incommon use, and dentists and labo-ratory technicians saw nocompelling reason to seriouslyconsider CAD/CAM as a viablealternative for commonly used tech-niques in restorative dentistry.

Over the past several years arevolution has quietly occurred.

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Antenucci

SY N O P S I S

This article describes the adjunctive use of a diode laser with computer-

aided design and manufacturing technology. The laser helps to create a

clean, bloodless area for an accurate digital optical impression.

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Computers have become widelyused for dental imaging, diagnosis,education, and management; anddentists have increasingly becomefamiliar with the use of computersand digital photographic tech-niques. Today the speed, memory,and capacity of computers today ishigh, and the relative cost is low;and that has allowed for sophisti-cated CAD/CAM software which isrelatively simple to use.

Meanwhile, some patients areplacing a high degree of value onesthetics, while trying to assess thecontinued controversy regardingmercury content in amalgam fill-ings. For practitioners, adhesivetechnology has matured to thepoint where restorations can bebonded to enamel and dentinrapidly, predictably, and with theexpectation of long-term service.

The confluence of these factorshas contributed to CAD/CAM’s riseto acceptance in dentistry, both inchairside restorative- and labora-tory-based applications. Chairsidedesign and in-office fabrication ofrestorations allows doctors to enjoycomplete control over the restora-tive and laboratory process, withvery efficiently produced, high-quality esthetic restorations.

There are several types ofCAD/CAM systems in use inrestorative dentistry today:1. In-office imaging and fabrica-

tion systems which allow for thefabrication and delivery ofsingle-visit restorations.Examples of these systems areCEREC AC (Sirona DentalSystems GmbH, Bensheim,Germany) and E4D (D4DTechnologies, LLC, Richardson,Texas).

2. In-office imaging-only systemsthat allow dentists to replaceimpression materials by takingdigital impressions, which arethen transmitted to a commer-cial laboratory. The laboratorymay or may not use a computermilling system for the restora-tions. Examples of these systems

are iTero™ (Cadent, Carlstadt,N.J.) and the Lava™ ChairsideOral Scanner C.O.S. (3M ESPE,St. Paul, Minn.). CEREC AC isalso marketed as an imaging-only system.

3. Laboratory-based and central-ized manufacturing facilityCAD/CAM systems. Examplesare inLab-System by Sirona,Procera® (Nobel Biocare HoldingAG, Zürich-Flughafen,Switzerland), and Lava by 3MESPE. There are many labora-tory-based systems in use inlaboratories around the world.

C L I N I C A L WO R K F LOWThe clinical workflow forCAD/CAM imaging and fabricationsystems uses a plan similar toconventional indirect restorations,and is illustrated in Figure 1. Thepatient is anesthetized, the tooth isprepared with the carious lesionand/or defective restorationremoved. The next step is to

capture an optical image of thepreparation. The author uses theCEREC system which requires alight spray of imaging powder tomake the teeth optically reflective.(The ED4 system does not requirethe use of powder.) After the digitalimpression is completed, a biteregistration is taken with conven-tional material and then it iscaptured. The optical images aredisplayed on the computer screenand a virtual model and die isavailable for custom design of therestoration. Once designed, thedigital restoration is transmitted toa milling chamber. A ceramic mate-rial is selected and is then milled.The finished restoration isprepared for bonding and luted tothe tooth. Adjustments to occlusionare made intraorally, and finalpolishing and finishing completethe process. Single restorationstypically take 60 to 75 minutesfrom the time the patient is seatedto the time the patient is

Figure 1: A photo montage of the clinical steps for fabrication of a CAD/CAM porcelaininlay restoration. Clockwise, photo 1 shows the preoperative view of the first bicuspid.Photo 2 depicts the preparation completed. Photo 3 shows the area powdered. Photo 4displays a polyvinyl siloxane bite registration. Photo 5 shows the finished CAD imagefrom the computer screen. Photo 6 portrays the restoration luted in place. Photo 7shows the completed restoration. The total time taken for the procedure was one hour.

dismissed.

T H E R O L E O F T H ED I O D E L AS E RFor CAD/CAM to be optimallyutilized, tissue and moisture at thepreparation margins must becontrolled. If the system employs apowder, blood and saliva will alsobe coated. In addition, the cameradoes not distinguish debris andgingiva from sound tooth structure.At this point, a diode laser is indis-pensible for retracting the softtissue and managing bleeding toensure a predictably accurateoptical impression. Figures 2 and 3

illustrate the difference between anunacceptable and inaccurateimpression and a usable one.

The author uses an 810-nm diodelaser (Odyssey 3Watt, IvoclarVivadent, Amherst, N.Y.) at a powersetting of 0.5 to 1.0 W at a contin-uous wave setting for approximately30 seconds total time. The lasercreates a circumferential trough atthe restoration’s margin whileproviding hemostasis. Figures 4-7illustrate the laser’s ability toprovide good visibility of the marginsof the preparation with excellenthemostasis in the soft tissue.

The laser can also be used forcontouring the marginal tissue in acrown lengthening procedure.Figures 8-12 show the laserremoval of facial gingival tissue toimprove the esthetics of the lateralincisor. After the veneer prepara-tion is completed, the laser is again

used to ensure hemostasis so thatan accurate digital impression canbe taken. The laser parametersdescribed above were used for bothprocedures. The restoration is fabri-cated with the CAD/CAMtechnology and delivered. A one-year post-treatment view (Figure12) illustrates the good-fittingrestoration with healthy perio-dontal tissue.

S U M M A RYThe use of a soft tissue laser isessential for the success ofCAD/CAM technology in managingsoft tissue around the margins ofpreparations. The author prefersusing a diode laser as illustrated inthis article. The utility of the laserto provide excellent hemostasis andeasy contouring and troughing ofthe gingival tissue provide a cleanand clearly visible site for an accu-rate digital optical impression. Thecomputer fabrication can then

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Figure 2: An optical image of a full-crownpreparation without laser soft tissuemanagement. Note the shoulder prepara-tion has an indistinct marginal finish line.This is an unacceptable digital impression.

Figure 3: An optical image of the samepreparation shown in Figure 2, but after alaser was used to create a trough in themarginal gingiva. Now the preparationmargins can be easily detected.

Figure 4: Preoperative intraoral and(inset) radiographic views of maxillaryright second bicuspid treatment plannedfor a porcelain inlay restoration to replacethe existing amalgam.

Figure 5: Preparation completed. Theinterproximal gingival margins wereplaced slightly below the free gingivalmargin and the soft tissue is inflamed.

Figure 6: Immediate postoperative viewafter diode laser use to create a trough,exposing the mesial and distal marginswith excellent hemostasis.

Figure 7: Optical powder placed in thearea just prior to using the CEREC opticalcapture device. Note the excellent visi-bility of the margins of the preparation.

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confidently proceed and theresulting restoration should be clin-ically successful.

A U T H O R B I O G R A P H YDr. Eugene Antenucci is a 1983graduate of the New YorkUniversity College of Dentistry. Heserved as a clinical instructor at theNew York University College ofDentistry in the Department ofProsthodontics and Occlusion, andas an assistant clinical professor atthe School of Dental Medicine at theState University of New York StonyBrook in the Department of GeneralDentistry. Currently, he serves as anattending dentist at MontefioreHospital and Medical Center. Dr.Antenucci maintains a full-timeprivate practice in Huntington, New

York, where his state-of-the-artdental facility serves the patients ofHuntington, and also is home to acontinuing dental educationtraining center for dentists as wellas a commercial dental laboratory.Dr. Antenucci is a certified CERECbasic and advanced traininginstructor, and has conductedtraining seminars throughout theUnited States. He has worked withdental lasers since 1990, and withCEREC technology since 1996. Dr.Antenucci may be contacted by e-mail at [email protected].

Disclosure: Dr. Antenucci is a certi-fied advanced and basic CERECtrainer for Patterson Dental.

R E F E R E N C ES1. Roshkind DM. The practical use of

lasers in general practice. AlphaOmegan 2008;101(3):152-161.

2. Parker S. Lasers in dentistry.London: BDJ Books, 2007:29-49.

3. Coluzzi DJ, Convissar RA. Atlas oflaser applications in dentistry.Chicago: Quintessence PublishingCo., Inc.: 2007:6.

4. Moritz A, Schoop U, Goharkhay K,Schauer P, Doertbudak O, WernischJ, Sperr W. Treatment of periodontalpockets with diode laser. LasersSurg Med 1998;22(5):302-311.

5. Fornaini C, Rocca JP, Bertrand MF,Merigo E, Nammour S, Vescovi P.Nd:YAG and diode laser in thesurgical management of soft tissuesrelated to orthodontic treatment.Photomed Laser Surg2007;25(5):381-392.

6. Pang P. Lasers in cosmetic dentistry.Gen Dent 2008;56(7) 663-670; quiz671-672, 767.

7. Romanos G, Nentwig G-H. Diodelaser (980 nm) in oral and maxillo-facial surgical procedures: Clinicalobservations based on clinical appli-cations. J Clin Laser Med Surg1999;17(5):193-197.

8. Mörmann WH. The evolution of theCEREC system. J Am Dent Assoc2006;137(Suppl):7S-13S. nn

Figure 8: Preoperative view of maxillaryright cuspid with an existing discoloredresin veneer. Soft tissue crown length-ening is indicated to establish a moreesthetic gingival architecture.

Figure 9: Immediate postoperative viewafter the diode laser was used to removeand recontour the facial gingival tissue toimprove esthetics.

Figure 10: Immediate postoperative viewof the completed preparation and thediode laser tissue retraction. The nextstep is the optical impression.

Figure 12: One-year postoperative viewshowing a good restorative result andhealthy soft tissue.

Figure 11: Immediate postoperative viewof the luted restoration that was fabri-cated with CAD/CAM.

Education in Laser Dentistry: A Necessity, an Optional Extra, or an Irrelevance?Steven Parker, BDS, LDS, RCS, MFGDP, Harrogate, United KingdomJ Laser Dent 2009;17(2):104-105

There is a quintessentially egocen-tric comfort in the recollection ofhaving graduated in dentistry – orto be more precise, successfullycompleted the undergraduateuniversity curriculum in dentistry– in that there was no further needfor study or examination! Sadly, orcorrectly, the process of learning topractice dentistry begins with grad-uation. Far from further study orqualification, there is the require-ment of ongoing revalidation of ourpracticing rights and privileges, thecompliance with a whole range ofregulations pertaining to the phys-ical provision of dentistry ingeneral practice, not to mention thepersonal election of postgraduateeducation chosen to further areasof specialty or interest.

The real test of the value of certi-fication in laser dentistry has yet tobe determined; possibly throughadoption of a university-basedcurriculum and graduation (at leastone Master of Science degree inlaser dentistry program is availableat RWTH Aachen University inGermany1), or the consequence of ahigh-drama lawsuit, such valueremains to be formally assigned.Until then, except currently in theStates of Nevada, Arizona, andLouisiana, a dentist can purchaseand use a laser for patient carewithout any educational require-ments of licensure.

The prime tenet of theHippocratic Oath (a possiblyanachronistic declaration formedical graduates) remains “do noharm.” This may be similarlyadopted by other areas of primaryhealth care, as we all owe ourpatients the right to expect treat-ment that is within our level of

competence and our scope of prac-tice, and that is provided as anevidence-based “best option” for thepresenting condition. One way inwhich harm can be avoided in laseruse is to achieve and be able todemonstrate a meaningful level ofcertification.

Of course, there remains thequestion “what level of competenceis sufficient?” Whether it is thethoughtful, expert manipulation oftechnique and materials thatresults in an exquisite dentalrestoration, or the compassionateexpertise in treating a nervouspatient, there is rightful celebra-tion and applause for the clinicianwho demonstrates “mastery” ofdentistry. The maxim “to know is touse – to understand is to empower”provides the distinction that sets“excellence” apart from inferiorcomparatives.

The use of lasers in dentistryand the development of dentalimplants are two modern examplesof clinical practice that have chal-lenged the hitherto conventionalundergraduate curriculum. Bothareas of treatment have essentiallydeveloped “outside” mainstreamuniversity teaching, both may betechnically challenging, and bothare best represented in the handsof the clinician who both knowsand understands all aspects of thetreatment modality.

One of the commonest areas offirst exposure to laser use is seenin the currently popular “weekend”course on the provision of “make-over,” minimal-preparation veneers.Notwithstanding the value of suchtreatment, the course may presenta step-by-step guide to the method-ology of treatment and marketing.

Often, some consideration ofsurgical gingival management maybe presented, for which a laser isoften suggested as the best instru-ment. From such, audienceenthusiasm may result in increasedsales of soft-tissue laser units, theuse of which is often relegated to agingivoplasty procedure in thehands of a possible novice practi-tioner. And yet, nowhere could theconsequence of lack of under-standing and expertise be moreexposed than in the poor outcomeof ill-chosen parameters in such animportant cosmetic exercise.

Equally, is it acceptable for us toglibly accept that our personal“learning curve” toward self-taughtexpertise should be littered with aseries of errors in judgment orability, or the realization ofpatients who have suffered? Thebusiness of dentistry is sustainedthrough the attraction and prof-itable treatment of patients, yet ourcore responsibility is to uphold ourpracticing license through theprovision of competent, ethical, andproportionate treatment for ourpatients, within an area ofexpertise – not “experimentation.”An acceptable level of competencecan therefore be justified andperhaps best defined as one thatemploys objectivity and a core ofknowledge, and is measurable.

Historically, the single expres-sion of the attempt to apply suchcompetence has been theCurriculum Guidelines andStandards for Dental LaserEducation.2 The first two lines ofthe document’s Statement ofPurpose provide unequivocalevidence as to its importance andapplication: “This document

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Parker

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Parker

provides guidelines to assure safeand efficacious use of lasers for thehealth and welfare of the patient.It establishes the standards ofeducation in the use of lasers indentistry and defines standards forthe demonstration of competency.”

This document was adopted bythe Academy of Laser Dentistry(ALD) and has been endorsed bymore than 100 dental and healthorganizations, universities, andmanufacturers worldwide. It hasformed the backbone of the ALD’sthree main educational levels:Introductory, Standard, andAdvanced. The latter two levels ofcompetence are measurablethrough examinations and recog-nized through certification. TheAcademy has prided itself in itsStandard Proficiency course as thestandard of care in treatingpatients.

Other organizations have offeredcertification, with or without recog-nition of the CurriculumGuidelines, and individual lasermanufacturers have provideddevice-specific training courses tosupplement their laser products.

With multiple educationalvenues available, the new or inex-perienced laser user may not beable to choose the best option.Moreover, standards of competenceshould be able to be applied tothose offerings to determine theirvalue so that the clinician can beassured of an equivalent and recip-rocal certification.

The primary focus in this discus-sion must be the patient receivinglaser therapy. That person must be

assured of the dedication of his orher practitioner to the use of lasersin general and of that particularlaser for a particular procedure.

The practitioner must acknowl-edge his or her responsibility to thepatient; there must be an accumu-lation of appropriate knowledgepertaining to laser use in dentalpractice and the opportunitygrasped to integrate the specificinstrument within a broader rangeof devices / laser wavelengths.Commensurate with the require-ments of continuing education, thepractitioner is entitled to theopportunity to associate lasereducation with ContinuingEducation requirements or affilia-tion with other organizations, e.g.,the Academy of General Dentistry.Additionally, there should be adedicated, structured educationpathway leading to appropriatecertification.

Key to a beneficial relationshipbetween a laser company and clini-cian is the metaphoricaltriumvirate of an excellent product,appropriate sustainable support,and evidence-based grounding intheoretical and applied knowledgeof laser use. Laser manufacturersstrive to temper the desire forinstrument sales with responsibletraining, and the successful firmsachieve this. However, what betterendorsement of a given laser isthere than the approval of a clini-cian who deduces excellencethrough detailed, science-basedcomparison? Correspondingly,manufacturers’ training in device-specific laser use should be ideally

complemented by a broader level ofbackground knowledge.

The Academy of Laser Dentistryhas been accused of being too rigid,too dogmatic, elitist, and out oftouch in a dental world that isdriven by material gain. It remainsone of the few organizations world-wide that offers multilevel,objective education that is designedto provide competence in laserdentistry as a whole, as opposed tosingle laser machines or wave-length. The Academy will continueto develop new opportunities forlaser dentists and hygienists tosource their education throughdiffering routes; to eventuallyqualify for a measured level ofcompetence as part of a progres-sive, positive framework, ultimatelydesigned to make laser dentistrysafer and more effective for thepatient.

It is hoped that all clinicallyoriented stakeholders in laserdentistry will acknowledge theirindividual responsibilities withinthe collective need to protect thepatient, and work toward thisessential goal.

R E F E R E N C ES1. Master of Science in “Lasers in

Dentistry.” AALZ Aachen DentalLaser Center.http://aalz.prographics-server.de/en/masterstudien/mos.php.Accessed August 8, 2009.

2. Certification. CurriculumGuidelines. ALD Academy of LaserDentistry. www.laserdentistry.org/certification/guidelines.cfm.Accessed August 8, 2009. nn

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In his discussion of the role of diode lasers in computer-aided design and manufacturing in restorativedentistry (pages 100-103), Dr. Eugene Antenuccidescribes his use of an 810-nm diode laser to preparegingival margins and manage bleeding to achievepredictably accurate optical impressions.

As Myers and Sulewski point out, the use of a laserto circumferentially remove a portion of the insideborder of the gingival-free margin of a prepared toothfor crown and bridge impressions in lieu of retractioncord can save both time and money. However, the laser-assisted tissue retraction for impression procedure istechnique-sensitive. The authors indicate that some newlaser dentists may become frustrated in their initialattempts at creating smooth, bloodless, open surgicalareas ready for impression; they may find the marginsto be rough while the sulcular area exhibits bleeding.

Myers and Sulewski continue:Assuming they used correct laser settings,the clinicians were probably moving thehandpiece too slowly and applying too muchforce toward the gingival margin. The slowerthe movement, the more likely one willcreate small tissue tags (the roughness),and, the more force or pressure that isapplied to the gingival margin with theglass or sapphire tip of the laser, the morelikely that hard tip will scrape open whatthe laser energy just coagulated. The propertechnique employs light, sweeping motionsof the laser handpiece, similar to dustingfine china.

Proper adjustment of technique should enable satis-factory results (bloodless, fairly dry, and smooth) in 60seconds or less per tooth, according to the authors.1

In their study abstracted below, Abdel Gabbar andAboulazm employ a pulsed Nd:YAG laser techniqueusing constant and steady circular movement of thefiber, emphasizing a “light and sweeping motion.” Theyalso suggest cooling the area by using the central evac-uation system a few millimeters from the surgical site.While Abdel Gabbar and Aboulazm do not identify theirlaser settings, Barr used a pulsed Nd:YAG laser at 30mJ, 60 to 70 Hz, 1.8 to 2.1 W with a 320-µm fiber forhis tissue retraction procedure.2

In their gingival retraction study abstracted below,the Gherlone group use a 980-nm diode laser at 2.5 to3.5 W continuous-wave and a pulsed Nd:YAG laser at2.5 to 4.0 W, 25 to 40 Hz, and 100 mJ.

Kutsch described the use of an argon laser, 1.0 Wcontinuous-wave, for gingival retraction whileemploying suction without accessory water spray.3

While utilizing an 810-nm diode laser for pre-impression gingival troughing, Lee recommends that“thermal energy generation and transfer must becontrolled by using the laser beam in a pulsed modewhenever possible” (compared to Dr. Antenucci whouses continuous-wave mode at 0.5 to 1.0 W), “as well asimplementing the use of cooling methods such asrunning an air current or incorporating a water spraythroughout the procedure.”4 Of course, care must betaken to avoid inducing subcutaneous emphysemawhile using pressurized air during such procedures.Lee does not specify the power settings he used.

When using an Er,Cr:YSGG laser for troughing,Scott (abstracted below) advises the use of short,brushing strokes, and indicates that the chance forbleeding increases when the wattage and/or percentageof air or water are increased beyond recommendedparameters. For his case, Scott used a 6.0-mm T-4, 400-µm tapered sapphire tip and laser settings of 0.50 Wand 20 Hz with 7% water and 11% air. In contrast,Colonna and colleagues used an Er,Cr:YSGG laser at0.75 to 1.0 W, a pulse rate of 50 Hz, 30% water and 60%air, with a 600-µm quartz tip for a “marginationprocess” during full-mouth rehabilitation withCAD/CAM technology to create smooth, readablemargins.5

In short, while the suggested specific operationalparameters or delivery mode for laser-assisted tissueretraction may vary from clinician to clinician,depending on the instrument employed, practitionersrecommend using light, brushing strokes of the fiberwhile keeping the power settings within the prescribedlimits.

For U.S. readers, various carbon dioxide, Nd:YAG,argon, Ho:YAG, Er:YAG, Nd:YAP, Er,Cr:YSGG, diode,and frequency-doubled Nd:YAG lasers have beencleared by the U.S. Food and Drug Administration forintraoral soft tissue surgery. The literature generally

Editor’s Note: The following three 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.

T H E U S E O F L AS E R S F O R T I SS U E

R ET R AC T I O N F O R I M P R ESS I O N

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presents tissue retraction cases involving fiber-opticdelivered laser systems.

As always, clinicians are advised to review thespecific indications for use of their lasers and to reviewtheir operator manuals for guidance on operatingparameters before attempting similar techniques ontheir patients.

R E F E R E N C ES1. Myers TD, Sulewski JG. Evaluating dental lasers: What

the clinician should know. Dent Clin North Am2004;48(4):1127-1144.

2. Barr RE. Nd:YAG laser gingival crown lengthening andtissue retraction for impressions. Wavelengths2000;9(2):17.

3. Kutsch VK. Argon-laser assisted gingival retraction.Wavelengths 1995;3(3):4.

4. Lee EA. Laser-assisted gingival tissue procedures inesthetic dentistry. Pract Proced Aesthet Dent2006;18(9):Suppl 2-6.

5. Colonna MP, DiVito E, Wiater G. Minimally-invasive, full-mouth rehabilitation using an Er,Cr:YSGG laser andCAD/CAM technology. Pract Proced Aesthet Dent2008;20(1):59-63.

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Purpose: The aim of the present study was to evaluatethe tissue retraction and gingival healing in pulsedlaser (diode 980 nm and Nd:YAG 1064 nm lasers)gingival retraction in comparison with the conventionalmechanical or surgical techniques (double cord andelectrosurgery). Materials and Methods: A group of 103adult patients, 45 women, 58 men (mean age 42, range19 to 52 years) scheduled for fixed and implant pros-thetic rehabilitation was recruited, and four impressiontechniques were compared: the double cord technique,the electrosurgery technique, the 980-nm diode and the1064-nm Nd:YAG laser technique. Patient[s] wererandomly placed into four groups according to impres-sion-taking technique. Thirty impressions were takenin each group, for a total of 110 elements each. Thepreferred impression materials were addition silicones

(polyvinyl siloxanes) (2nd generation). The outcome wasmeasured by the bleeding index (during the impressiontaking and after 15 days) and gingival [recession] (after15 and 30 days). Results: Compared to the conventionaltechniques, both laser techniques proved to be lessaggressive in terms of absence of gingival bleeding(99.2% vs. 92.7%). There were also fewer cases ofgingival [recession] than with the conventional tech-nique (2.2% vs. 10%). Conclusion: This study suggeststhat the laser technique can be valuable for implantprosthetic rehabilitation. While both the conventionaland laser techniques are satisfactory in achievinggingival retraction, the laser technique may be lesstraumatic to the periodontal tissue.

Copyright 2004 Quintessence Publishing Co., Ltd.

T H E U S E O F 9 8 0 - N M D I O D E A N D 10 6 4 - N M N D : YAG L AS E R F O R G I N G I VA L R ET R AC T I O N I N F I X E D P R O ST H ES ES

Enrico F. Gherlone,a Carlo Maiorana,b Roberto F. Grassi,c

Riccardo Ciancaglini,b Francesca CattoniaaVita-Salute University, Milan, Italy; bUniversity of Milan, Italy; cUniversity of Bari Dental Clinic, Bari, Italy

J Oral Laser Appl 2004;4(3):183-190

The aim of the present study was to study the tissuereaction and gingival healing in pulsed laser gingivalretraction in comparison with chemico-mechanicalgingival retraction technique. This work was applied onsix patients recommended for orthodontic extraction offirst premolars upper and lower. The patients weredivided into three groups (two patients each), one groupwith laser tissue retraction, another group with ferricsulphate (13.3%), and a third group with aluminiumchloride (25%). The present histologic findings revealed

that with the application of pulsed Nd:YAG laser thegingival tissues showed faster healing with less hemor-rhage and less inflammatory reaction in comparisonwith the other two groups. In conclusion it was evidentthat pulsed laser is a surgical device increasinglyimportant to dentistry. The present study can supportwith the clinical application of laser in gingival retrac-tion as a simple convenient, painless method.

Copyright 1995 Egyptian Dental Association

CO M PA R AT I V E ST U DY O N G I N G I VA L R ET R AC T I O N U S I N G M EC H A N O C H E M I C A L P R O C E D U R E A N D

P U LS E D N D : YAG L AS E R I R R A D I AT I O N

Fatma Abdel Gabbar, Cairo University, Cairo, Egypt

Sanaa F. Aboulazm, Alexandria University, Alexandria, EgyptEgypt Dent J 1995;41(1):1001-1006

109


The two-cord retraction technique is used for troughingaround a crown to achieve biologic width. This tech-nique can cause significant discomfort for the patientand offers several potential clinical disadvantages forthe dentist, of which unpredictable tissue recession isthe most significant. The clinical case presented in thisarticle compares the use of the standard two-cordretraction technique with that of an 2,780-nm erbium-class dental laser to determine which method achieves

an accurate, easily readable impression whilerespecting the biologic width. Using an erbium laser toachieve the trough prior to placing an indirect restora-tion results in little or no postoperative discomfort forthe patient; in addition, the erbium laser reduces intra-operative complications related to tissue recession andpatient discomfort while providing consistently accu-rate impressions.

Copyright 2005 Academy of General Dentistry

U S E O F A N E R B I U M L AS E R I N L I E U O F R ET R AC T I O N CO R D : A M O D E R N T EC H N I Q U E

Arthur Scott, DDSMetairie, Louisiana

Gen Dent 2005;53(2):116-119

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Rudy Project Sports Frame

Revolution Frame

Titanium Frame

Filters are available for the most popular laser wave lengths used in the dental industry including:

800-830 nm940-980 nm1064 nm2780-2940 nm

2780-2940 nm10,600 nm

JLD_Aug09_LaserLine_hlfPg.indd 1 7/9/09 1:14 PM

use of a diode laser for soft tissue management …...use of a diode laser for soft tissue...

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