Han Sol Kim
Year V, Group16Efficacy of laser in Periodontal treatment
Master’s ThesisRenata Šadzevičienė
Gyd. periodontologė
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY CLINIC (Periodontics)
Efficacy of laser in Periodontal treatment Master’s Thesis
The thesis was done
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Abstract
Objective: Laser has been introduced to dentistry for decades. Aim of this review is to analyze and evaluate the efficacy efficacy of laser in Periodontal treatment
Material and Methods: For this review, articles were searched by using PMC, PubMed and google scholar search. Keywords used for searching is : laser, dental, laser in perio, CO2 laser, Er:YAG, Er, Cr:YSGG, Low level laser therapy, periodontal laser, laser healing.
Conclusion: Research on laser for periodontal treatment is expected to increase and effective lasers will be developed, Laser therapy is expected to gradually expand into an additional and alternative treatment for periodontal treatment.
Keywards: Laser, dental, periodontal treatment.
SELECTION CRITERIA OF THE STUDIES. SEARCH METHODS AND STRATEGY Protocol of systemic review
Selected protocol : Year, language, publication condition
Articles were selected by protocol, articles published in 10 year (2007~2017) and language with English.
Information sources
Articles were searched and found in internet. By using PMC, PubMed and google scholar search Articles were searched in year 2016,2017. And last time of search was in March of 2017
Key words used for searching was laser, dental, laser in perio, CO2 laser, Er:YAG, Er, Cr:YSGG, Low level laser therapy, periodontal laser, laser healing.
Total 56 article were selected.
Inclusion criteria for the selection were: Methods were useful nowadays.
Contents are related with laser and medicine Contents are related with laser and dental Contents are related with laser and periodontics Contents are related with laser and implant Contents are related with laser and tissue healing Exclusion criteria for the selection were:
Contents are related with laser and making implant Contents are related with laser and making dental tools
CONTENTS
1 Summary 2 Introduction
3 The Basics of Lasers 3.1 Introduction
3.2 History and use of laser in medicine 3.3 Use of laser in dentistry
3.4 Clinical application after knowing penetration depth 3.5 Factors affecting tissue absorption of laser light 4 Types and characteristics of laser used in periodontics
4.1 Introduction
4.2 Characteristics of the main lasers used in dentistry 4.2.1 CO2 laser
4.2.2 Nd:YAG laser
4.2.3 Er:YAG, Er,Cr:YSGG 4.2.4 Diode laser
4.2.5 Argon laser
5 Uses of laser in periodontal treatment
5.1 Non-surgical periodontal treatment using laser 5.2 Surgical periodontal treatment using laser 5.3 Periodontal surgery using laser
5.4 Implant using laser
6 Low level laser therapy in periodontal disease 6.1 History of low level laser therapy 6.2 Effect of low level laser therapy 6.3 Clinical use of low level laser therapy 6.4 Treatment and management after surgery
6.5 Use of low level laser therapy in periodontal disease 7 Conclusion
1. SUMMARY
Lasers have long been introduced into dental clinics.[1] In the past, lasers in the dental field have mainly been mainly used for area of conservation such as polymerization of composite and in-office bleaching. But recently, Erbium-based lasers such as Er: YAG, Er, Cr: YSGG, which can be used to incise tissue without causing any thermal damage to the surrounding tissues, have been introduced. into soft tissues as well as soft tissues.[2] As a result, the laser can be used not only for hard tissue surgery such as teeth and alveolar bone but also for soft tissue surgery.[1] Therefore, the current research on laser application in dentistry is proceeding in almost all dental fields including oral surgery, prosthodontics as well as preservation area such as apical surgery, endo treatment, treatment of hypersensitivity by fluid movement through dentinal tubules.[2,3,4] In this paper, the latest papers on the types of lasers used in periodontics and laser applications in periodontics were searched and sorted by themes, and understanding of them would be especially useful for those interested in periodontics.
2. INTRODUCTION
It has been only about 30 years since the laser was commonly used in dentistry.[1] The first lasers used in dentistry were CO2 laser and Nd: YAG laser, which can be applied only to the soft tissues and low efficiency on hard tissue removal and causes thermal damage to tissue. But nowadays Erbium series lasers that cans be used on hard tissue of the teeth with little heat damage to the surrounding tissues, is being produced.[5,6] And also there are ultraviolet lasers that is capable of selectively removal of only calculus.[5,6] Research on the application of laser in the field of periodontics will develop with the development of laser technology. Therefore, the usefulness and necessity of clinical application for this will be also increased. At this point it is very important to understand the current status of the use of laser in the field of periodontal science.
3. The Basics of Lasers 3.1 Introduction
The theoretical background for lasers was established 100 years ago, the laser was first applied to the extraction teeth 60 years ago, and the laser was commercialized in dental clinics for 30 years.[1] In dentistry, lasers are not used as the sole remedy, but as an adjunct to other existing therapies. In most dental treatments, patient co-operation is important. The noise from handpieces, bleeding during treatment, and edema of the skin that interferes with normal pronunciation and mastication are factors that interfere with the cooperation in dental treatment.[1] The laser used in the dentistry has an effective cutting ability on the tooth hard tissue, and also it has a bleeding-free incision on the soft tissue, as well as a disinfection effect which removes the bacteria. In addition, the low level
laser with low output increases cell activity and is used to activate biochemical factors related to tissue healing, and it is also used for polymerize composite resin.[50]
3.2 History and use of laser in medicine
Lasers emit light of a single wavelength with strong intensity. The first laser, developed by Maiman of IBM lab, used ruby crystals pumped with electrical energy as the activation medium. Various lasers have been developed since solid ruby lasers. In 1961, a H2-Ne laser was developed in a bell lab, and in 1962, the first diode laser was developed in the GE lab. In 1964, neo-dymium-doped yttrium aluminum garnet lasers and CO2 lasers were developed at the bell lab.[1]
After the laser was developed, scholars such as Dr. Leon Goldman started a clinical study of the action and coherence of the laser on living systems including humans. Initially, there was a variety of problems such as power control and energy delivery. However, in the mid-1960s, ruby lasers were used for retinal surgery. In 1964, Argon lasers were developed that were easy to manipulate and absorbed by hemoglobin and successfully used in retinal surgery.[1]
In 1964, Nd: YAG lasers and CO2 lasers were developed in a bell lab in the United States. The CO2 laser emits a continuous wave of 10,600nm wavelength that is well absorbed in water, the near infrared region. Because the soft tissue is mostly composed of water, it is expected to be used for soft tissue incision without bleeding. In the early 19th century, clinicians such as Dr. Tomas Polanyi and Geza Jako successfully established ENT and Gynecologic surgery using CO2 laser, but they were used only in university hospitals.[1]
In the early 1980s, more powerful and miniaturized lasers were used. Most of them were CO2 lasers used for tissue dissection and Argon lasers used in ophthalmology. These second generation lasers were all continuous wave systems and required long laser treatment experience to prevent non-selective thermal damage.
A remarkable improvement in the medical use of lasers is the introduction of the concept of pulsing into the laser beam. This allows selective treatment of abnormal and pathological tissues without spreading to surrounding normal tissues.[1] The first laser with this concept of selective thermolysis was a pulsed dye laser used in the treatment of port wine stains in children in the late 1980s and an ultra short pulsed laser used for tattoo removal.[1]
3.3 Use of laser in dentistry
Maiman's Ruby laser was used on the extraction tooth in 1960, but until 1989 when the first dental laser was introduced in the United States, the laser was not used in dentistry.[1] The first commercially available dental laser in 1989 was a Nd: YAG pulsed laser produced by the American dentist Dr. Terry Myers. It was not available to use for tooth hard tissues because of its low power,
but it was used in oral soft tissues and became popular among dentists.[4] In the early 1990s, various lasers commercialized in the field of medical surgery were modified and introduced into dentistry.[1] Lasers such as Nd: YAG, CO2, semiconductor diodes lasers, those used as dental lasers had many problems such as low deletion efficiency and lethal effects on surrounding tissues in application of dental hard tissue removal, which was the main purpose of dentists.
In 1989, Keller and Hibst confirmed that they were able to successfully remove enamel, dentin, and alveolar bone in an experimental study using an Er: YAG laser. The laser was first marketed in the UK in 1995. Er, Cr: YSGG lasers, which have similar effects, were developed in 1997.[1]
3.4 Clinical application after knowing penetration depth
Each lasers have different wavelength and penetration depth to tissue. It is a dangerous idea to get into clinical practice without even understanding basic knowledge like this.Because of the different penetration depths of the lasers, the response to the tissue as well as the reflection of the laser beam from the tissue should be properly prepared. Therefore, both the patient and the surgeon are
encouraged to wear safety goggles, and it is also important to control access to unnecessary objects or persons in the area of the procedure.
Particularly, in the case of a diode laser or a Nd: YAG laser, the penetration depth to the tissue is several times larger than that of other lasers, and therefore, the reflected light can be increased. Therefore, when using these lasers, special care should be taken with special care. .
3.5 Factors affecting tissue absorption of laser light
There are several factors affecting tissue absorption of laser light. Laser wavelength Tissue composition Tissue thickness Surface wetness Angle of beam Exposure time
Contact mode of laser
4. Types and characteristics of laser used in periodontics 4.1 Introduction
Laser systems are divided into different types depending on the activation mass to activate the photons. There are solid, gas, diode, excimer, and dye lasers.[1] Depending on the output of the emitted energy, it may be classified as soft if it has low output and hard if it has high output.[4] Depding on emission mode it can be differed in to continues wave and pulse wave, and the laser
which generates pulse waves due to the nature of the laser is free-running pulse laser there are ND: YAG, Er: YAG, Er, Cr: YSGG. Also, there is a gated or chopped pulse that artificially generates pulses by putting an opening / closing device at the front of a laser such as a diode laser or a Co2 laser that generates a continuous wave.[1,4] diode In the case of diode lasers, a very high frequency pulse can be produced by adjusting the current applied to the diodes in a very short time period.[4] When laser light reaches tissue, there are four phenomena: reflection, scattering absorption, and transmission. Absorption occurs mainly through water, proteins, pigments and other macromolecules.[4] Er:YAG and CO2 lasers are known to be safe and easy to use because most of the energy is absorbed to the skin surface in response to moisture by having a long wavelength range of far infrared rays in the middle infrared ray. They can be used for soft tissue, periodontal treatment, and implant treatment.
Periodontal disease is a chronic inflammatory disease caused by bacterial infection. Therefore, using a laser with a bactericidal, detoxicifying effect is very useful for the treatment of periodontal disease.[4,6] The laser used for periodontal therapy functions to sterilize, remove infected tissues without bleeding, and stimulate normal healing by biologically stimulating and activating cells and tissues.[4,6] Therefore, it has advantages such as reduction of the depth of the periodontal pouch and promotion of regeneration of the periodontal tissue, compared with the mechanical treatment.[3,8] The laser also has little noise and vibration, which reduces pain during and after surgery and result increasing patient satisfaction with treatment.[3] The clinical use of lasers for periodontal therapy began in the 1980s using CO2 lasers and in the 1990s Nd: YAG laser was stated to used.[3] With the development of erbium lasers, it became possible to use lasers in hard tissue.
4.2 Characteristics of the main lasers used in dentistry Table 1. Characteristics of Dental Lasers
Laser Type Wavelength Mode Application
Carbon Didoide 10 600 nm Pulse or
continuous-wave
1. Soft tissue ablation
2.Gingival contouring for esthetic purposes
3.Treatment of oral ulcerative lesions 4.Frenectomy and gingivectomy
tissue during regenerative periodontal surgeries
Neodymium:Aluminu m-Yttrium-Garnet (Nd:YAG)
1064 nm Pulse 1. Root canal therapy: Helps eliminate pathogenic microorganisms and debris from the root canal
2. Extensive periodontal surgery and scaling to eliminate necrotic tissues and pathogenic microorganisms 3. Caries removal Erbium:YAG (Er:YAG) 2940 nm Pulse 1. Caries removal
2. Cavity preparation in enamel and dentin
3. Root canal preparation
Eriubm,Chromium:Yt trium-Scandium-Gallium-Garnet (ER,CR:YSGG)
2780 nm
Pulse 1. Enamel etching 2. Caries removal 3. Cavity preparation
4. Bone ablation without over-heating, melting or changing the calcium and phosphorus ratios
5. Root canal preparation
Argon 572 nm Pulse or
continuous-wave
1. Polymerization of restorative resin materials
2. Tooth bleaching
3. Elimination of necrotic tissue and gingival contouring
4.Treatment of oral lesions such as recurrent aphthous ulcers or herpetic lesions
5.Frenectomy and gingivectomy
nm continuous-wave
enhancing the healing of oral lesions or surgical wounds
2.Frenectomy and gingivectomy
3. Correcting the gingival contouring for esthetic purposes
Holmium:YAG (Ho:YAG)
2100 nm Pulse 1. Gingival contouring 2. Treatment of oral lesions 3. Frenectomy and gingivectomy J Lasers Med Sci. 2015 Summer; 6(3): 96–101.
Published online 2015 Jun 28. doi: 10.15171/jlms.2015.01
4.2.1 CO2 laser
The co2 laser emits a wavelength of 10,600 nm and has two modes: pulse wave and continuous wave.[6,9] CO2 laser is far infrared ray that has long wavelength. It's characteristic is that it is absorbed by water which is composed in living tissue.[6,9] Because it has a high extinction coefficient for water, it is very effective for soft tissue incision with high water content. Compared to scapel assisted surgery, CO2 laser allows for bloodless sterilization and fast tissue dissection while minimizing tissue contraction and scar formation.
However, when the co2 laser is applied to the hard tissue, the temperature rises rapidly and many carbides are generated with dissolved root and bone surfaces Thus, the healing of periodontal tissue will be delayed and the hard tissue will not removed well. When the CO2 laser is used on the tooth hard tissue, hydroxy apatite absorbs more energy of the wavelength of co2 laser than moisture, so more energy is absorbed by hydroxy apatite and heat accumulates and does not cut-out hard tissue. Therefore, Co2 lasers cannot be used for hard tissue.[4]
4.2.2 Nd:YAG laser
The Nd: YAG laser emits near-infrared wavelengths of 1,064 nm in FRP mode and is used for soft tissue incision and soap disinfection of the periodontal pouch.[4,6] Nd:YAG laser is in infrared region but because it is close to visible ray heat reaches deep inside, so it is known that they have a potential danger of being exposed to heat, but they are easy to apply in the field of surgery. Unlike CO2 laser or Er:YAG laser, the Nd: YAG laser has a low extinction coefficient for water and penetrates deeply into the tissue, resulting in a haemostatic effect.[6] Therefore, when it is incident on a living tissue, it is scattered rather than absorbed or transmitted to the deep layer. Because of this high permeability, thermal stimulation may be given below the laser irradiation site, causing heat damage to the dimensions or bone tissue. However, using low power can penetrate the deep
part of the skin compared with the other lasers are absorbed mostly on the surface, and can enhance the tissue healing ability through the physiological phototactic activity of the deep part of the periodontal tissue and the surrounding tissue. Nd: YAG lasers are strongly absorbed selectively in certain pigments such as melanin and hemoglobin. Therefore, germs and becterica containing most of these pigments can be removed.[6]
4.2.3 Er:YAG, Er,Cr:YSGG
Erbium lasers in use are Er: YAG, Er, and Cr: YSGG, both of which operate in FRP mode. Er:YAG laser is known to be safe and easy to use because most of the energy is absorbed to the skin surface in response to moisture by having a long wavelength range of far infrared rays in the middle infrared ray. Er: YAG, Er, and Cr: YSGG lasers have excellent incision ability for both soft and hard tissues while minimizing heat damage to tissues and are used for tartar removal, cavity formation, and pathological root surface and alveolar bone It is the most widely used laser for dental treatment including periodontal treatment.[11,12]
Er: YAG and Er, Cr: YSGG lasers have highly absorbed by water and hydroxyapatitie.[6,11,12 ] This property makes these lasers good in cutting bone as well as soft tissue. And also because of it penetrate tissue shallow, it's risk of giving thermal damage is minimal[13]
4.2.4 Diode laser
Most frequently used diode laser is Gallium-Aluminum-Arsenide(GaAlAs) laser that has 810nm and Indium-Gallium-Arsenide(InGaAs) laser that was 980nm.[4] Because wavelength of diode laser is short it is poorly absorbed by water and hard tissue.[15] This characteristic of penetrating tissue is similar to Nd:YAG. Also diode laser can be produced in really small size with high power and high frequency.[1] Diode lasers are capable of continuous wave and pulsed wave modes and have hemostatic, coagulation, and incisional effects.
4.2.5 Argon laser
Argon laser uses argon ion gas as its lasing medium. Light emitted from an argon laser has a very low absorbance to water.[4,15] The laser emits visible light at two wavelengths: 488 nm of blue and 514 nm of blue green.[15] On the other hand, it is well absorbed in pigmented tissues and
pigmented bacteria containing haemoglobin or melanin.[4,15] Argon lasers are used more
conservatively than periodontics, that it is used for polymerization of restorative resin materials and in office teeth bleaching. Argon laser is also used for blood control in gingival surgery and
5. Uses of laser in periodontal treatment
5.1 Non-surgical periodontal treatment using laser
The pathogenesis of periodontal disease and the method of treating it have rapidly developed in recent 40 years. The contributing factors of periodontal disease are host pathogens, host immune responses, and host risk factors that affect disease progression.[17] Pathogenic bacterial plaques accumulated in susceptible hosts cause immune response and affect the inflammatory response, connective tissue and bone metabolism.[17] Initial periodontal therapies include non-surgical debridement of dental tissues, topical application of antimicrobials, host modulators, and laser-assisted reduction of periodontal bacteria.
Risk factors affect both the onset and progression of periodontal disease and the depth of periodontal disease. Periodontal disease is now known to be an infectious disease caused by the presence of pathogenic bacteria, and host response to pathogenic bacteria also has a significant impact.[17] Therefore, the treatment of periodontal disease should proceed with minimal side effects and risks to the patient.
Soft tissue lasers are very useful for bacterial reduction and hemostasis during periodontal treatment.[18] Soft tissue lasers include argon lasers, diode lasers, and Nd: YAG lasers, and the light emitted by these lasers is absorbed by melanin, haemoglobin, or other pigments in tissues affected by periodontal disease.[4] Because of the nature of these soft tissue lasers, soft tissue lasers can be used as tools for periodontal pouches with periodontal tissue with pigmented bacteria and dark implanted tissue.[4] In addition, since the laser energy is transferred to a flexible optical fiber having a thin diameter of about 300 to 400 μm, the periodontal disease can be easily applied to the affected periodontal pouch.[37] Laser light energy emitting short wavelengths is mostly transmitted through the fluid in the periodontal pouch and is mainly absorbed by inflammatory tissues and stained bacteria.
Another laser used for soft tissue treatment is Er, Cr: YSGG. The laser energy of the erbium series is absorbed very well in water. Therefore, when using this laser, a large amount of energy is
absorbed by the moisture of the tissue surface.[37] Therefore, in order to apply energy to the tissue, the optical fiber to which the laser is incident must be adhered to the target tissue. Er, Cr: YSGG lasers have a remarkable bactericidal effect against P. gingivalis and A. actinomycetemcomitans, which are important causative bacteria of periodontitis.[37]
The application of Nd: YAG laser to the periodontal pouch can be used as an adjunctive therapy after mechanical debridement with currettes or ultrasonic scaler. One of the advantages of laser-based periodontal therapy is the ability to debridement soft tissue surfaces that were not possible with conventional mechanical debridement. [4] The Nd: YAG laser can be delivered by a very thin and flexible optical fiber, so that the poket-lining epithelium in the periodontium can be vaporized
and decontaminated without causing carbonization or necrosis of the underlying connective tissue.[37] Since the Nd: YAG laser is well absorbed by the pigment, it can effectively remove pigmented bacteria such as Porphyromonas gingivalis, which cause periodontal disease [4,37]
5.2 Surgical periodontal treatment using laser
If the periodontal disease is severe, periodontal surgery should be used to debridement the tooth surface, remove the pathological granulation tissue of the bone defect, correct the contour of the alveolar bone, and sterilize the surgical site. Eliminating all pathological granulation tissue is a necessary process for the regeneration of new bone tissue. [4] However, the instrument approach to the floor and root apices of narrow infrabony defects is very difficult, inefficient, and time
consuming. [4] Hand chisels and handpieces used to alveolar bone can cause noise and vibration, which can increase patient discomfort. [4] These instruments are also difficult to access over the posterior teeth. [4]
Most surgical lasers significantly reduce the bacterial population at the surgical site, which is because laser energy is absorbed by pigmented bacteria found in the oral tissues.[38] In addition, the operation with laser is superior in the hemostatic function, and the need for wound closure is reduced.
Erbium-based lasers are very useful for bone surgery. Other lasers can not remove bone tissue because they have low absorbance to water. CO2 laser has a relatively high absorbance to water, but it has more absorbance to inorganic crystal structures that make up bone than water. Which can induce bone grafting and produce carbides.[4] However, erbium-based lasers are selectively
absorbed in water and can accurately eliminate bone tissue without microbio-explosion. In addition, the erbium laser can accurately and effectively mold the osseous tissues in areas that are difficult to access with conventional equipment, with little heat damage to the surrounding tissues, and the postoperative healing process is also histologically advantageous.[4,39]
Firoozmand Reported that the Er: YAG laser was less heat-damaged than the handpiece when used for the removal of teeth and alveolar bone during surgical periodontal surgery. [39] For the
incisions of 30 cows in which the thickness of the dentin was reduced to 2.0 mm using three
equipment, high speed high torque handpiece, high spped low torque handpiece and Er: YAG laser, Class V cavity was formed under water cooling and then thermocouple is placed inside the pulp chamber, which is connected to the computer to measure the temperature rise in the pulp chamber. [39] The results were analyzed by using ANOVA and Turkey statistical method. Average
temperature rise was 1.92 0.80℃, 1.34 .86℃,0.75 0.39℃ in low-torque handpiece, high-torque handpiece and Er: YAG laser. All three devices did not exceed the temperature-rising
threshold of 5.5 ° C, which would impair the dimensions. [39] It was also confirmed that the increase of temperature was lowest when Er: YAG laser was used.[39]
Erbium lasers can be used to remove the granular tissue attached to the bone during conventional periodontal procedures. There is little noise and vibration, and the post-operative healing process is more beneficial. [4] A follow-up study of 3 years after Er: YAG laser treatment of chronic
periodontal disease showed that the depth of the periodontal ligament was decreased and the clinical attachment level was higher than conventional widman flap surgery.[40]
Erbium-based lasers can be used to accurately cut soft tissue. [4] The incision is as sharp as using a surgical knife and the healing rate is also very fast. [4] The Er: YAG laser can remove tartar and lipopolysaccharides without dissolving the root and forming a carbonized layer on the root surface. The Er: YAG laser removes pathological soft tissues and hard tissues of the root surface, as well as removes pathological tissue of the root crown and infrabony pockets without damaging the tooth surface. [4,40] Nd: YAG, Co2 lasers leave a layer of carbonation on the tooth surface that interferes with the adhesion of fibroblasts. Er: YAG lasers form a smooth tooth surface with no carbonized layer on the tooth surface, no smear layer, and form collagen matrix exposed root surface.
5.3 Periodontal surgery using laser
The laser is useful for securing the visual field of the surgical site by closing the soft tissues of the oral cavity through an easy dissection and hemostatic action through blood coagulation and instantaneously depriving the microvasculature through peripheral protein denaturation.[41] In addition, the laser is more effective because it reduces the pain and swelling at the surgical site with the sterilization effect, the tissue heals fast, and because the oral tissues, especially the gingivae, are complex and narrow, making it difficult to access traditional scapel blades laser is more effective. Laser-induced wounds are more advantageous in terms of histology than wound caused by surgical knives. Most importantly, there are few myofibroblasts that cause tissue contraction and
hemorrhage during wound healing, Therefore it is very advantageous for restoration of the normal function of the post-operative tissue, which is very important for active soft tissues such as labial mucosa or platelets in esthetic dentistry.
A laser destroys all of the bacteria in a very low energy level. In addition, the possibility of
bacteremia after surgery is greatly reduced due to the closure of vessels and lymphatic vessels after laser treatment.
Electrosurgery has a very rapid rate of soft tissue dissection and a too severe hemorrhage due to hear at the site of application. In addition, when the depth of anesthesia is low, contacting with the root surface will results in severe pain, and contact with the bone can cause osteonecrosis due to
heat. On the other hand, lasers can be used better in soft tissue surgery, reducing the risk of tissue injury compared to electrosurgery.[41]
If the depth of the surgery is not deep, the laser can be used without local anesthesia to perform painless surgery. There will be almost no pain by using Er: YAG or Er: Cr: YSGG laser with water spray at the same time.[42] In addition, the laser can be used to heal even after the operation without any suture or dressing after opening.[42]
Lasers can be used for a variety of soft tissue surgeries. The first is gingiva. In the case of gingival hyperplasia such as epulis fissuratum due to gingival hyperplasia caused by use of calcium channel blockers or poorly fitting dentures, an erbium-based laser can be used for clean incision without hemorrhage and carbonization without anesthesia. The second is frenectomy. Excessive frenum causes excessive tension in the organization, interferes with accurate pronunciation, and is not aesthetic. The use of a laser also has the same advantages as gingival resection. The third is crown enlargement. More accurate and delicate gingival formation is possible with laser than with electro-surgical instruments. Er: YAG lasers can precisely cut soft tissues using a variety of delicate contact tips, thus enabling safe and precise treatment of periodontal soft tissue aesthetics.[43] In addition, incision of the alveolar bone may be included in case of simple incision of the gingiva. Since the erbium-based laser can be incised to both the soft tissue and the hard tissue, it is possible to expand the crown by removing the gingival and alveolar bone.[4]
Diodes, including Co2 lasers, and Nd: YAG lasers are used to effectively treat melanin pigment. [44]However, because the lasers penetrate deeply into the light and have a large thermal effect, gingival ulcers and gingival recession can occur when the gingiva is weakened. On the other hand, Er: YAG laser can safely remove pigments such as metal tatto caused by metal components penetrating into connective tissues during melamine and preprocessing of metal prostheses.
5.4 Implant using laser
The laser can be useful for everything from implant placement, to the treatment of oral soft tissue incision, which is the second implant implant, and to the treatment of periplasmic implants, as well as the entire period of implant placement and post-implant periodontal tissue management.[4] The most important consideration in implant placement is that the temperature of the osteotomy site for implant placement should not exceed 47 ℃. When the laser beam is irradiated to the bone tissue, the light energy is converted into thermal energy at the irradiation site, so how much the
temperature of the irradiation site is increased is a very important factor in using the laser for implant removal of the implant.[45] In addition, the possibility of damage to the implant surface caused by laser irradiation should be confirmed.[45] Co2 and Nd: YAG lasers, which are the first dental lasers, have low bone removal efficiency as well as excessive heat when applied to the
implantation process. Therefore, it damages the implant's bone tissue, destroys the viability of the bone, and does not cause osseointegration between the bone and the implant.[4, 45] Making hole for implant fixture on bone by using Er: YAG laser and Er,Cr:YSGG, compared with the conventional method using drilling burs, was possible to obtain better osseointegration because there was not much heat generated with less mechanical stress on the bone tissue.[46] Animal experiments have shown that better tissue healing and stronger osseointegration occurs for implant fixture placement with an erbium-based laser than traditional methods using drills.[46] Using a laser in the second implant surgery has several advantages over the conventional scalpel method. The use of laser in the second implant surgery allows painless surgery without anesthesia. There is no hemorrhage at the surgical site, and there is little inconvenience to the patient after the operation.[45] The use of an erbium-based laser can prevent both ambient heat damage and the formation of carbonized layers.[4] Sohn reported the case of laser application in the maxillary sinus lift in 2009.[47] Twelve sinus bone grafts were performed in ten patients through bone window osteotomy using Er:Cr:YSGG.[47] Of the 12 patients, 8 did not puncture the sinus membrane (perforation rate 33.3%), and the mean time taken for bony window osteotomy was 3.4 1.4 min, and all implanted implants were reported to be successful.[47]
Implant periostitis is summarized as implant failure due to production of bacterial toxins causing rapid destruction of osseointegration, inflammatory changes of periodontal tissue, and alveolar bone loss.
A method of decontamination of the peri-implant pocket using a laser has been proposed for the treatment of peri-implantitis. Utra sonic scalers, metallic hand scalers, and Nd: YAG lasers will cause damage to the titanium surface of implants and should not be used in the treatment of peri-implantitis. Co2, diode, and Er: YAG lasers can safely and effectively treat peri-implant diseases such as mucositis and peri-implantitis.[4,48] Co2 lasers do not damage the surface of implants or interfere with the attachment of osteoblasts. In the study, it was reported that the implant periostitis is well healed with the bone regeneration after co2 laser treatment.[49]
7. Low level laser therapy in periodontal disease
Low level laser therapy, also known as therapeutic laser treatment, has a number of advantages. As a nonsurgical method, it promotes tissue healing, reduces edema, inflammation, and pain.[50]
7.1 History of low level laser therapy
The healing effects of sunlight on a variety of diseases have long been recognized, and the current treatment is referred to as heliotherapy. In 1903, Finsen received the Nobel Prize for his treatment of lupus vulgaris using a carbon arc lamp. The first laser was developed by Theodore Maiman in
1960, in the late 1960s, Mester found that low-power ruby lasers and He-Ne lasers were not carcinogenic and animal wounds healed more when used with this laser.[51] In the 1980s, clinical applications for Low Level Laser Therapy began. Low Level Laser Theraphy has gained popularity in Europe, Asia and South America, and cheap, high power GaA1As or GaAs lasers have been used.[50]
6.2 Effect of low level laser therapy
Photobiostimulation of Low Level Laser Therapy uses red visible light and near infrared light to reduce pain and promote healing.[51] Near infrared rays penetrate the skin several millimeters and are used to stimulate deep tissue cells. Light energy is absorbed by the cellular photo receptors present in cytochromophores, and the initial light energy is used to produce ATP in mitochondria inside the cells.[52] As a result, the increased amount of ATP promotes the activity of cells such as bifroblast, which helps to heal tissue. In addition, some of the incident light is converted to thermal energy and promotes local bicro blood circulation through vasodilation. The effect of Low Level Laser Therapy will be listed below.
Proliferation of fibroblasts Proliferation of lymphocytes Proliferation of endothelial cells Proliferation ofkeratinocystes Proliferation ofmacrophages Increased cell respiration Increased ATP synthesis
Transformation of fibroblasts into myofibroblasts Collagen synthesis
Release of growth fators and other cytokines
In addition, Low Level Laser Therapy has been reported to increase the synthesis of endorphin and bradykinin, reduce the activity of C-fibers involved in pain transmission and also induce an increase in pain thresholds.[52]
6.3 Clinical use of low level laser therapy
It can be applied to dermatologic conditions such as wounnds, inflammations and neural ailments at various sites. It can also be used for degeneration of various sites and for bone trauma with
pain.[53,54] Table 2.
Soft Tissue Application Hard Tissue Application
Herpetic Lesions Temporomandibular Disorders
Aphthous/ Traumatic Ulcers Orthodontic Treatment Post Oncology Mucositis Dentinal Hypersensitivity Post Extraction Socket/ Post trauma Sites Bone Remodelling
Trigeminal Nueralgia Erosion
Periodontal Pocket Disinfection/Periodontitis Stimulatory effect on root development
Edema Implants
Sinusitis
Gag Reflex/ Nausea Postsurgical Pain
Laser Ther. 2015 Oct 2; 24(3): 215–223.
doi: 10.5978/islsm.15-RA-01
Copyright 2015, Japan Medical Laser Laboratory [55]
6.4 Treatment and management after surgery
One method of postoperative therapy can provide the best health care for patients by using Low Level Laser Therapy. Low Level Laser Therapy minimizes discomfort and pain after dental treatment and shortens healing time.[50] In addition, use of low-level laser therapy for post-operative treatment, Can be applied in for all dental treatments including conservative treatment, prosthetic treatment, surgical/non-surgical neurology, surgical/non-surgical periodontal therapy, implant treatment, oral surgery.[50]
6.5 Use of low level laser therapy in periodontal disease
Low-level laser therapy can be used to control the symptoms and condition of periodontal disease. Anti-inflammatory action can slow or prevent periodontal damage and can help to maintain oral hygiene by reducing edema by root planning, scaling, surgical flap, and curretage. Therefore, healing is promoted and postoperative discomfort can be reduced.[51] In some studies, fibroblasts were stimulated and the immune system became active.[51]
Herpes Simplex is a major lesion that is induced by human herpes virus type 1 and type 2 and prone to recurrence and latency. Symptoms may include painful vescicles or erosions involving gingiva and tongue mucosa, heat and mucous membranes in the mouth accompanied by painful lymph nodes. Helium-Neon Low-energy laser or diode lasers have proven effective in reducing analgesic
and inflammation in vesicle patches. Laser radiation has been suggested to support the interpretation of laser radiation in the treatment of herpes simplex labialis by promoting the formation of blood vessels in regenerated tissues that are secreted into inflammatory tissues along with reproductive chemical agents.[55]
Low level laser therapy is recommended for the treatment of aphthous or traumatic ulcers because of analgesic effects and shortened healing times. This can interfere with Na-K pump in cell
membrane and serotonin releas. Diode laser is considered an effective and safe treatment for oral ulcers.[55]
Mucositis is reported to be an inevitable aftereffect of radiation therapy or chemotherapy regimens. It has been demonstrated that Low level laser therapy can be used effectively in these cases and can reduce the incidence of inflammation and pain. It has been shown that He-Ne lasers or infrared lasers are beneficial in providing immediate symptom relief to patients.[55]
Diode lasers have been used extensively in periodontal treatments to remove diseased pocket lining epithelium and disinfect periodontal pockets with low levels of energy. Fiber optic delivery systems with 200-320μm diameters allows easy access to periodontal pockets. The anti-inflammatory effects of Low level laser therapy slow or stop the deterioration of periodontal tissue and reduce the swelling of hygiene with other scaling, root planning, curettage or surgical treatment. Some studies show that diode lasers have better healing power because they are more effective at removing bacteria.[55]
7. CONCLUSIONS
Since the introduction of dental lasers, lasers have been used for preserving and curing complex resin in areas, photo activated in office bleaching, and fluoroscopic examination of adjacent caries. However, the development of Erbium-based lasers capable of removing hard tissues as well as soft tissues has made it possible to perform soft tissue surgery, alveolar bone formation, gingival
associations, and by irradiating the inside of the periodontal pouch with a laser beam through a thin optical fiber, it is possible to remove dental plaque and sterilization toxin inside the periodontal pouch. Since the purchase price of lasers is high and most of the periodontal treatments are available with mechanical treatments, there is not much use for periodontal treatment. However, research on the practical effect of periodontal treatment of lasers is expected to increase and effective lasers will be developed, Laser therapy is expected to gradually expand into an additional and alternative treatment for periodontal treatment.
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