Dent Clin N Am 48 (2004) 771–794

The biologic rationale for the use of

lasers in dentistry
Robert A. Convissar, DDS, FAGDa,b,*
a
Laser Dentistry, New York Hospital Medical Center of Queens, Flushing, NY, USA
b
Private Practice, General, Cosmetic and Laser Dentistry, 200 Park Avenue South,
Suite 1414, New York, NY 10003, USA

Whenever laser energy is applied to oral tissue, it is incumbent on the

dentist (or hygienist) to understand the biologic rationale for its use.
Dentists can choose from a variety of wavelengths to use in the oral cavity.
A complete understanding of the interaction between each of these different
laser wavelengths and the target tissues is essential to ensure optimal
treatment results. A separate article discussed the four different types of
tissue interaction—absorption, reflection, scatter, and transmission. From
that discussion, it is understood that optimal therapeutic effects result when
the wavelength best absorbed by the target tissue is selected for use;
however, the choice of the best laser for a certain procedure depends on
much more than just matching emission spectra of lasers to absorption
spectra of tissues. The type of delivery system best able to deliver the
wavelength to the target, the composition of the tissue surrounding the
target tissue, and the potential for necrosis of the surrounding tissue also
must be taken into account. Other articles in this issue discuss in detail the
use of lasers in the various disciplines of dentistry—prosthetics, periodon-
tics, pedodontics, endodontics, implantology, cosmetic and operative
dentistry, and oral and maxillofacial surgery. Those articles discuss how
lasers are best used in each discipline; this article discusses why specific lasers
should be used. Box 1 lists the uses of lasers in the various disciplines of
dentistry. This list is by no means complete; as the field of laser dentistry
expands, new uses are discovered on a regular basis.

* 200 Park Avenue South, Suite 1414, New York, NY 10003, USA.
E-mail address: [email protected]

0011-8532/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.06.004
Box 1. Laser use in dentistry

Periodontics
Initial (nonsurgical) pocket therapy
Nonosseous gingival surgery
 Frenectomy
 Gingivectomy
 Graft
Periodontal regeneration surgery
 De-epithelialization
 Removal of granulomatous tissue
 Osseous recontouring
Fixed prosthetics/cosmetics
Crown lengthening/soft tissue management around abutments
Osseous crown lengthening
Troughing
Formation of ovate pontic sites
Altered passive eruption management
Modification of soft tissue around laminates
Bleaching
Implantology

Second-stage recovery
Peri-implantitis
Removable prosthetics
Epulis fissurata
Denture stomatitis
Residual ridge modification
 Tuberosity reduction
 Torus reduction
 Soft tissue modification
Pediatrics/orthodontics
Exposure of teeth
Soft tissue management of orthodontic patients
Oral surgery/oral medicine/oral pathology
Biopsy
Operculectomy
Apicoectomy
Oral soft tissue pathologies
Operative dentistry
Deciduous teeth
Permanent teeth
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 773

Delivery systems
The field of lasers in general practice essentially began with the
introduction of the American Dental Laser (Birmingham, Michigan) dLase
300 neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in 1990. Before
the introduction of this instrument, most dental lasers used bulky articulated
arms for their delivery systems. These articulated arms were not conducive to
the practice of general dentistry, owing to the long learning curve needed to
master their use and the difficulty of delivering the laser energy to the entire
oral cavity. Articulated arm delivery systems consist of a series of rigid
hollow tubes with mirrors at each joint (called a knuckle) that reflect the
energy down the length of the tube. These joints exist to allow the delivery
arm to be bent and configured in such a way as to bring the handpiece close

Fig. 1. Articulated arm delivery system. (Courtesy of DEKA Laser Technologies LLC, Ft.
Lauderdale, FL.)
774 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

to the target tissue. The laser energy exits the tube through a handpiece
(Fig. 1). Strauss [1] described the intraoral use of an articulated arm delivery
system. He stated that it is a difficult way to remove discrete lesions within the
oral cavity because of the awkward three-dimensional maneuverability of the
arm. A second problem with the use of articulated arms is the alignment of
the mirrors. To transmit the laser energy efficiently, the mirrors at each
knuckle must be aligned precisely. A misalignment of the mirrors could cause
a drop-off in the amount of energy transmitted to the handpiece. The mirrors
could go out of alignment through the normal use of moving the articulated
arm for each new procedure or if the laser is moved from treatment room to
treatment room. Articulated arm delivery systems are noncontact systems
(ie, the handpiece or its attachments do not come into contact with the target
tissue). Dentists are familiar with contact technology: The fissure bur
contacts the enamel during tooth preparation. The curet contacts the root
surface during scaling and root planing. The scalpel contacts the soft tissue
when incising. Using a technology in which there is no contact between the
instrument and target tissue can be challenging at first. This is one major
reason for a longer learning curve with these instruments compared with
contact technology instruments.
The American Dental Laser dLase Nd:YAG system was the first such
instrument to use a fiberoptic delivery system. This fiberoptic technology
allows for contact with the target tissue. The fiberoptic cables are attached to
a small handpiece similar in size to a dental turbine and are available in sizes
ranging from 200 lm in diameter to 1000 lm in diameter. Fiberoptic cables
also are relatively flexible. This flexibility allows for easy transmission of the
laser energy throughout the oral cavity, including into periodontal pockets.
Fiberoptic delivery and articulated arm systems are not the only two delivery
systems currently on the market. One manufacturer has developed a hollow
waveguide delivery system. In contrast to an articulated arm system, this
waveguide is a single long, semiflexible tube, without knuckles or mirrors. The
laser energy is transmitted along the reflective inner lumen of this tube and
exits through a handpiece at the end of the tube (Fig. 2). This handpiece comes
with various attachments that the dentist may select, depending on the
procedure to be performed, and may be used either in contact or out of contact
with the target tissue. Fig. 3 illustrates fiberoptic cables of various diameters
and handpieces from a carbon dioxide (CO2) waveguide delivery system.
The final delivery system is the air-cooled fiberoptic delivery system. This
type of delivery system is unique to the erbium family of lasers. A con-
ventional fiberoptic delivery system cannot transmit the wavelength of the
erbium family of lasers, owing to the specific characteristics of the erbium
wavelength. These special air-cooled fibers terminate in a handpiece with
quartz or sapphire tips. These tips are used slightly (1–2 mm) out of contact
with the target tissue.
Since the introduction of the dLase 300, general practitioners have seen
the number of wavelengths and manufacturers available to them increase
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 775

Fig. 2. Waveguide delivery system. (Courtesy of Opus Dent, Santa Clara, CA.)

from one manufacturer of one wavelength to eight different manufacturers

offering six different wavelengths. Table 1 lists the wavelengths and
manufacturers currently marketed in the United States.

Incision, excision, ablation

Most soft tissue laser procedures can be categorized into one of three
simple processes: incision, excision, or ablation. Whether the dentist is
performing a soft tissue tuberosity reduction (excision) to enhance the
results of a removable prosthetic treatment plan, performing a small biopsy
of a large lesion on the palate (incision), or removing an area of lichen
planus from the buccal mucosa (ablation), the basic processes are the same,
no matter which wavelength is used. There is a difference in how the various
lasers interact with oral tissue, depending on the ability of the target tissues
to absorb the laser energy. The most significant differences among the
different types of oral soft tissues are the pigmentation, vascularity, and
water content. As an example of how these differences affect the selection of
a wavelength, imagine two patients who need a gingivectomy. The first
patient has light, coral pink gingiva; the second patient has dark, melanotic
gingiva. The chromophore for the CO2 laser is water. There would be no
difference in the cutting efficiency when using a CO2 laser on these patients.
776 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

Fig. 3. Fiberoptic cables of various diameters and handpieces from a CO2 waveguide delivery
system. (Courtesy of Robert Convissar, DDS, New York, NY.)

The coral pink and the melanotic gingiva would respond equally well to the
CO2 laser. Using the same patient models, gingivectomies performed with
the Nd:YAG and diode lasers would result in a significant difference in the
cutting efficiency. Diode and Nd:YAG lasers are absorbed preferentially by
tissue pigments, such as hemoglobin and melanin. The darker melanotic
gingiva would absorb the laser energy much more easily; it would cut more
quickly and easily than the coral pink gingiva. The melanotic tissue might
cut more rapidly than the clinician would like, possibly damaging the tissue
or creating a larger zone of thermal necrosis around the target tissue. In this
case, laser parameters (pulse duration, hertz, joules) would need to be

Table 1
Wavelengths currently available for sale in the United States
Wavelength Manufacturer Delivery system
Diode, 810–830 nm Biolase Fiberoptic cable
Hoya/Conbio Fiberoptic cable
Zap Lasers Fiberoptic cable
OpusDent Fiberoptic cable
Biolitec* Fiberoptic cable
Nd:YAG, 1064 nm Biolase Fiberoptic cable
Lares Research Fiberoptic cable
Millenium Dental Technologies Fiberoptic cable
Er:Cr:YSGG, 2780 nm Biolase Air-cooled fiberoptic/handpiece
Er:YAG, 2940 nm Hoya/Conbio Air-cooled fiberoptic/handpiece
OpusDent Hollow waveguide
CO2, 10,600 nm OpusDent Hollow wave guide
Deka Articulated arm
* The wavelength produced by the Biolitec laser is 980 nm; all other diode lasers produce
a wavelength of 810–830 nm.
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 777

modified from one patient to another. Laser parameters suggested by the

manufacturers are for the ‘‘average’’ patient. These parameters must be
modified based on many factors, with tissue pigmentation being one crucial
factor. This is an important fact that might be lost on new laser users.
Another case example can be used to illustrate the effect of tissue
vascularity and water content on the effectiveness of lasers. Imagine two
orthodontic patients wearing full bands and arch wires. The first ortho-
dontic patient has immaculate home care. The gingiva is firm, pink, and
stippled. The second patient’s home care is practically nonexistent. The
combination of poor home care and a foreign body (orthodontic appliance)
acting as a plaque trap has led to gingival hyperplasia. The gingiva is
hyperemic, red, and inflamed. Both patients need gingivectomies to increase
the gingivoincisal length of the teeth. Comparing the results of treatment
with a diode and an Nd:YAG laser would show large differences in
treatment outcomes. The chromophore that is absorbing the laser energy in
this case is the hemoglobin. The hyperemic, swollen tissue with more
vascularity cuts more quickly with the diode and Nd:YAG lasers than the
healthy pink tissue. In the case of the CO2 laser gingivectomies, the chro-
mophore is water. The swollen, hyperemic tissue would have more water
content and would absorb the CO2 laser energy more readily.
These examples illustrate that the laser user must consider the quality of
the target tissue. With proper training, a laser user is able to evaluate and
treat the above-described cases with any wavelength simply by adjusting the
laser parameters to suit the tissue. Selection of the correct wavelength is not
crucial to the success of these cases. Selection of the proper laser parameters
is crucial; this is precisely why laser training is so important. The new laser
purchaser must take into account the type of training offered by the
manufacturer. Will the training be at a sales seminar? Will the training be in
the purchaser’s office? Will it include live patient demonstrations? Will it
include a hands-on ‘‘wet lab’’? Alternatively, is the training nothing more
than a workbook with a CD-ROM? These are all critical issues that must be
discussed before the purchase of a laser is completed. The issue of training is
discussed in more detail in the article on practice management in this issue.

Gingival surgery
According to statistics compiled by the American Dental Association,
dentists spend more time in the delivery of prosthetic care than any other
field except operative dentistry. The 2000 Survey of Dental Practice [2]
showed that the average general dentist spent 35.7% of his or her time in the
delivery of operative dentistry and 19% of his or her time in the delivery of
prosthetic care. A review of the procedures listed in Box 1 shows that most
of the laser procedures in fixed, removable, and implant prosthetics are
variations of the simple gingivectomy. The same may be said about most
soft tissue procedures in pediatric dentistry and many minor oral surgical
778 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

procedures performed by general practitioners. Wigdor et al [3] described

the advantages of lasers over cold steel surgical procedures as follows:
1. Dry and bloodless surgery
2. Instant sterilization of the surgical site
3. Reduced bacteremia
4. Reduced mechanical trauma
5. Minimal postoperative swelling and scarring
6. Minimal postoperative pain
In his discussion of soft tissue surgery, Bader [4] listed the same
advantages and specified that when performing frenectomies in younger
patients, the laser is particularly benign compared with traditional surgery.
Parkins [5] stated that children and adolescents are among the best
candidates for laser use because they are particularly bothered by pain,
bleeding, and extra postoperative office visits. He believed that elimination of
hemorrhage and postoperative comfort are the two greatest benefits to
pediatric patients. His experience showed that any soft tissue laser may be
used for ankyloglossia, exposure of teeth to aid eruption, and treating the
effects of dilantin hyperplasia in a special needs patient. Every soft tissue
laser fulfills the advantages enumerated by Wigdor et al [3]. Every laser on
the market has the ability to perform incisions and excisions of soft tissue,
while destroying bacteria at the surgical site. Reduced mechanical trauma to
the tissue, less postoperative pain, swelling, and scarring are not unique to
any specific wavelength. For most laser dentistry procedures, the choice of
which wavelength is a matter of personal preference; for other procedures,
the use of the correct wavelength can make the difference between success
and failure. Some laser users prefer the CO2 wavelength because of its high
absorption in water and its lack of thermal penetration; others prefer
Nd:YAG because of its absorption by tissue pigments and its deeper depth of
penetration. Still other clinicians prefer diode units because of their compact
size and portability. Many dentists now are using the erbium family of lasers
for soft tissue due to their high absorption in water and lack of thermal
penetration. Arguments can be made for or against any of these wavelengths
for specific procedures. The fact is that any well-trained dentist who
understands the physics and emission characteristics of each of the lasers,
along with the absorption spectra of the target and surrounding tissues, can
be successful with most lasers. Rather than defending the use of specific lasers
for each procedure listed in Box 1, this article discusses only the procedures in
which use of a specific wavelength is crucial to the success of the procedure.

Nonsurgical periodontal therapy

It is a primary tenet of periodontics that periodontal disease is a bac-
terial infection. Nonsurgical periodontal therapy since the 1990s has focused
on bactericidal treatment. The use of systemically and locally delivered
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 779

antibiotics to fight periodontal disease is well documented. Doxycycline

[6–8] and metronidazole [9–11] are used systemically to fight periodontal
infections. Tetracycline-impregnated cords [12,13] and injection of minocy-
cline sphericals [14–17] are relatively recent additions to the armamentarium
of antibiotic therapies used in the treatment of periodontal disease. Many
patients who have chronic periodontal disease are given small maintenance
doses of tetracycline twice daily for 90 days or more in an effort to maintain
a constant antibacterial effect in the fight against periodontal disease [18,19].
All of these therapies have the same goal: the removal of bacteria from the
periodontium to improve the periodontal health of the patient. One essential
criterion for selection of an appropriate wavelength for nonsurgical
periodontal therapy is definitive proof of a bactericidal effect on periodontal
tissues. Another essential criterion is the delivery system. The practitioner
must be able to deliver a bactericidal wavelength to the tissue efficiently. If
a bactericidal wavelength is available, but the delivery system does not lend
itself easily to applications within the periodontal pocket, that wavelength is
therapeutically useless. A third criterion is the effect of the wavelength on
the surrounding tissue. In the case of nonsurgical periodontal therapy, the
surrounding tissue is the hard tissue of the root surface. A bactericidal
wavelength easily delivered into the periodontal pocket must not cause any
harmful effects to the root surface. The ideal properties of a wavelength that
can be used successfully for nonsurgical periodontal therapy are bacteri-
cidal, easy to deliver into the pocket, and safe enough to use in a periodontal
pocket so that it causes no harm to the root surface.
The previous section discussed the various delivery systems currently on
the market. The articulated arm delivery system does not meet the criterion
of easily delivering laser energy to the periodontal pocket. This is a
noncontact delivery system. The distance from the handpiece to the target
tissue can range from 1.5 cm to more than 6 cm. A focal distance of this
length would not allow for the laser energy to enter the periodontal pocket.
Waveguide delivery systems terminate in handpieces similar in size to
a dental turbine. These handpieces can accept various attachments, depend-
ing on the intended use of the laser. None of the attachments are small or
flexible enough to enter the periodontal pocket and effectively deliver laser
energy to the pocket lining. The only two soft tissue wavelengths that
currently meet the criterion of having a delivery system able to deliver laser
energy efficiently and effectively to the periodontal pockets for nonsurgical
periodontal therapy are Nd:YAG and diode.
The next criterion in evaluation of a wavelength for nonsurgical
periodontal therapy is the wavelength’s bactericidal ability. Both of these
wavelengths have been shown to be extremely effective against periodontal
pathogens in vivo and in vitro [20–24]. In a study by Moritz et al [21] using
diode lasers in vivo, bleeding index improved in 96.9% of the population
compared with a 66.7% improvement in the population that did not
undergo laser treatment. These investigators concluded that the diode laser
780 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

revealed a bactericidal effect, helped reduce inflammation, and supported

healing of the periodontal pockets through the elimination of bacteria. Neill
and Mellonig [23], in a double-blind, split-mouth study, assigned patients to
one of three treatment regimens: scaling and root planing alone, Nd:YAG
laser treatment with root planning, and control group with no laser
treatment or scaling. Their results showed that the laser-treated patients
exhibited significantly greater improvement in measurement of their gingival
index and gingival bleeding index. At 6 months postoperative, the laser-
treated group showed significant improvement in attachment gain.
Bader [4] described the advantage of laser curettage as enhanced bacterial
reduction with good hemostasis in a procedure that is less invasive than
open flap surgery. This procedure is technique sensitive and merits a brief
discussion. In this procedure, the laser energy is directed solely onto the soft
tissue lining of the periodontal pocket. The optical fibers used to deliver the
laser energy are only end-cutting fibers (ie, the energy comes out only from
the fiber tip, not along the length of the fiber). When the laser energy is
directed parallel to the root surface, the laser removes from the soft tissue
the bacteria and their exotoxins (eg, hyaluronidase, collagenase) that are
responsible for breakdown of the periodontium. When the laser energy is
directed onto the root surface rather than the soft tissue lining of the
periodontal pocket, the root surface can be damaged.
Schwartz et al [25] studied the effects of diode laser energy on root
surfaces. They concluded that when the laser energy is directed onto the root
surface, severe damage, including crater-like defects and grooves, occurred
on the root surface. Morlock et al [26] found similar results with Nd:YAG
lasers. These studies and others [27–31] led the American Academy of
Periodontology [32] to conclude that neither the diode laser nor the Nd:YAG
laser is an alternative to root planing. The key word in the American
Academy of Periodontology report is alternative. With diode and Nd:YAG
intrasulcular treatment protocols, as with most dental laser treatment
protocols, the laser is used as an adjunct to standard treatments rather than as
a replacement for standard treatments. Laser curettage of periodontal
pockets is unsuccessful unless it is combined with standard scaling and root
planing to remove bacteria and accretions from the root surface. Neill and
Mellonig [23] and Moritz et al [21] emphasized in their in vivo clinical studies
that the most significant improvement was found in the group of patients
who had conventional scaling combined with laser treatment. Conventional
instruments are used for standard scaling and root planing procedures, and
laser energy is used solely on the soft tissue lining the pocket.
Bader’s [4] description of his technique emphasizes the point that the laser
tip is moved circumferentially around the tooth rather than onto the root
surface and is followed by hand instrumentation. Neill and Mellonig [23]
emphasized that the tip of the fiberoptic makes light contact against the
pocket epithelium rather than the root surface and is kept in a sweeping
motion from the base of the pocket moving coronally. The conclusion to be
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 781

reached from this research is that diode and Nd:YAG lasers are safe and
effective wavelengths to be used in nonsurgical periodontal therapy when
used according to established protocols. As long as the laser energy is not
directed onto the root surface, wavelengths have been shown to be effective
instruments in nonsurgical periodontal therapy. This technique is discussed
in detail in the article on laser use for initial periodontal therapy. Fig. 4
illustrates a diode laser fiber being introduced into a periodontal pocket. The
fiber (slightly elongated for illustrative purposes) is parallel to the long axis of
the tooth, and the fiber tip does not come into contact with the root surface.

Regenerative periodontal surgery

The design and raising of a full-thickness mucoperiosteal flap for any
surgical procedure, whether for periodontal or oral surgery, is a relatively
straightforward procedure. Essentially the base must be wider than the crest
to ensure adequate blood flow to the flap. Most general practitioners have the
ability to raise and suture back into place a full-thickness mucoperiosteal
flap. For the purposes of this discussion, it is assumed that the flap is raised
by a conventional method (scalpel). The most difficult step in a typical
periodontal surgical procedure, and the step that ultimately determines the
success or failure of the surgical procedure, is the removal of the diseased
tissue from the surgical site. If the diseased soft tissue and calcified accretions
on the root surface are not removed, the surgical procedure is doomed to
failure. Many techniques and instruments have been available for removal of
this diseased tissue. Historically the instruments of choice have been curets
and other surgical steel instruments. Lasers now are being used for this
procedure. Whatever wavelength is used for regenerative periodontal surgery
must not cause any harmful effects on the root surfaces. As addressed in the
previous discussion of the use of lasers for nonsurgical periodontal therapy,
some wavelengths can cause harm to the root surface.

Fig. 4. Diode laser fiberoptic entering a periodontal pocket parallel to the long axis of the
tooth. (From Convissar RA. Lasers in general dentistry. Oral Maxillofac Surg Clin N Am
2004;16:165–79; with permission.)
782 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

Trylovich et al [27] evaluated the effects of the Nd:YAG laser on fibroblast

attachment to endotoxin-treated root surfaces. These investigators conclud-
ed that the laser alters the cementum surface in such a way that it makes it
unfavorable for fibroblast attachment. Spencer et al [28], Thomas et al [29],
and others [30,31] also found that when the Nd:YAG laser is used directly on
the root surface, the surface is altered unfavorably. Schwartz et al [33]
compared a diode laser, an erbium:YAG (Er:YAG) laser, and scaling and
root planing. The in vivo study selected teeth scheduled for extraction. The
teeth were assigned into one of three groups: scaling, Er:YAG treatment, or
diode treatment. The diode group had the highest mean number of craters on
the root surface (14.6 craters), the scaling and root planing group had a mean
of 3 craters per sample, and the Er:YAG group had no craters. The diode-
produced craters also were significantly deeper than the craters produced by
hand instrumentation. Schwartz et al [33] concluded that the diode laser was
unsuitable for calculus removal because it altered the root surface in an
undesirable way. This study reached the same conclusions as Kreisler et al
[34], in his evaluation of the effects of diode laser irradiation on root surfaces.
These results lead to the conclusion that diode and Nd:YAG lasers may be
used for initial periodontal therapy and soft tissue excision/ablation
procedures, but extreme caution must be taken to ensure that neither of
these wavelengths has a significant interaction with the root surface during
regenerative periodontal surgery.
The results of Schwartz’s in vivo study [33] warrant further attention. The
results showed that Er:YAG treatment left no craters on the root surface.
The conclusion regarding the use of Er:YAG laser on root surface was that
Er:YAG provided selective subgingival calculus removal on a level
equivalent to that provided by scaling and root planing. In vivo, Er:YAG
laser instrumentation produced nearly smooth root surfaces, with no cracks
or thermal effects. The results of this study are similar to two previous studies
using the Er:YAG wavelength on root surfaces. Both studies [35,36] showed
that Er:YAG lasers are excellent tools that can be used on root surfaces
safely and effectively. One of the most significant studies detailing the
potential for the use of Er:YAG for periodontal regeneration was performed
by Schwartz et al [37]. They studied the in vivo effects of the Er:YAG laser on
the biocompatibility of periodontally diseased root surfaces and periodontal
ligament fibroblasts. Their results showed that the Er:YAG laser promotes
the attachment of periodontal ligament fibroblasts on previously diseased
root surfaces and that the surface structure of Er:YAG laser instrumented
roots offers better conditions for the adherence of periodontal fibroblasts
than scaling and root planing. These studies, when taken together, show that
the Er:YAG laser can promote periodontal regeneration by removing
calculus from the root surface, leaving the root surface smooth and better
able to create an environment for successful attachment of new connective
tissue fibers. A distinction must be made here with respect to the erbium class
of dental lasers. There is a great deal of difference between the effectiveness
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 783

of the Er:YAG laser (2790 nm) and the erbium-chromium-yttrium-

scandium-gallium-garnet (Er:Cr:YSGG) laser (2940 nm) in regenerative
surgical periodontics. There are currently no peer-reviewed articles in the
literature that can defend the use of the Er:Cr:YSGG laser for periodontal
treatment of any kind. Dentists using Er:Cr:YSGG lasers have yet to report
in the scientific literature any use of this wavelength for osseous periodontal
surgery. The American Academy of Periodontology has stated that even
though the Er:Cr:YSGG wavelength has received US Food and Drug
Administration (FDA) safety clearance, there are neither reports in the
literature nor animal or human studies that may be used to defend its use
[32]. In comparison, the American Academy of Periodontology concluded
that ‘‘the Er:YAG laser demonstrated the best application of laser use
directly on hard tissue, leaving the least thermal damage and creating
a surface that suggests biocompatibility for soft tissue attachment. Studies
have shown the ability of the Er:YAG laser to remove lipopolysaccharides
from root surfaces, facilitate removal of the smear layer after root planing,
remove calculus and cementum’’ [32]. The Er:YAG laser is an excellent
choice to use in regenerative periodontal surgery to prepare the root surface
for new attachment of connective tissue. The problem is ensuring that the
connective tissue, rather than the epithelium, has an opportunity to grow
and create new attachment. Clinicians must ensure that the fibroblasts have
the opportunity to adhere to the root surface by preventing the epithelium
from growing faster than the connective tissue and creating a long junctional
epithelium.
The principle of epithelial exclusion has been in the periodontal literature
for more than 50 years [38]. Epithelium grows more quickly than connective
tissue. After a flap is raised, and the diseased tissue is removed from the
surgical site, an epithelial exclusion technique must be used to prevent the
epithelium from growing. When the epithelium is prevented from growing,
the connective tissue grows in its place. This connective tissue then
establishes new attachment to the root surface, provided that the root
surface has not been damaged from the surgical procedure, and the surface is
denuded of all bacteria and infected material. If the epithelium is not
prevented from growing as the surgical procedure heals, the result is a long
junctional epithelium, rather than a true connective tissue attachment. As
discussed earlier, the use of barrier membrane and epithelial exclusion
techniques is not new to regenerative periodontal therapy. The question to be
raised is whether there is any place in periodontics for the use of lasers to
retard epithelial downgrowth.
The answer to this question may be found in a series of publications. The
first article, by Rossmann et al [39], used monkeys to determine the ability of
the CO2 laser to prevent epithelial migration after flap surgery. In this split-
mouth study, periodontal defects were produced bilaterally. Both sides were
treated with open flap débridement. On one side, the epithelium was removed
with a CO2 laser. The other side served as the control. The results showed that
784 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

epithelialization of the CO2 irradiated side was delayed by at least 7 days,

allowing for new connective tissue to grow. Just as important, the results
showed that the healing of the connective tissue was not retarded at all. The
investigators concluded that the CO2 laser can be used to delay the apical
downgrowth of epithelium and that this technique was less technically
demanding and more time efficient than other currently known methods of
epithelial retardation. Israel et al [40] used the CO2 laser in a human study.
They performed open débridement and placed a notch on the teeth at the
crest of the alveolar bone before closure. At reentry 90 days later, every
nonlased tooth developed a long junctional epithelium the length of the root
to the base of the notch. On the lased side, the notch was filled with connec-
tive tissue and some repair cementum. Rossmann et al [41] refined this
technique with a study on beagles that found similar results. This tech-
nique subsequently was performed clinically [42]. The in vivo human results
showed that this CO2 laser de-epithelialization technique has the ability to
obtain new clinical attachment with bone fill in previously diseased sites. The
investigators concluded that this technique has shown significantly better
results than the results obtained through conventional osseous grafting alone.
The results of the CO2 de-epithelialization studies combined with the
Er:YAG studies of the effects on root surfaces lead to the conclusion that the
most effective method of regenerative periodontal surgical techniques would
be a double-wavelength technique. This technique would use the Er:YAG to
débride the open surgical site, clean and sterilize the root surface, and prepare
the root surface for the adhesion of fibroblasts. The CO2 laser would remove
the epithelium, which would allow the fibroblasts to adhere and proliferate,
creating new attachment. This double-wavelength technique shows tremen-
dous promise in the field of regenerative periodontal surgery. More
university-based or hospital-based, split-mouth studies involving a larger
number of patients are necessary before this technique can be considered
fully documented; however, there seem to be more than enough studies to
confirm that there is a biologic rationale for the use of this technique.
This technique is not the only technique that is advocated by laser
practitioners to regenerate lost periodontal structures. As noted earlier, diode
and Nd:YAG lasers have the ability to improve the gingival index, decrease
pocket depth, decrease bleeding on probing, decrease the bacterial content of
periodontal pockets, and improve the overall health of the periodontium.
The author has had a great deal of success treating molars with furcation
involvements and class II mobility nonsurgically with Nd:YAG and diode
lasers. To date, the only published studies suggesting that these wavelengths
can create regeneration of the periodontal apparatus are anecdotal [43–46]
and do not stand up to the scrutiny of the scientific method. Research of the
type needed to verify these claims is expensive and time-consuming. Neither
the laser companies nor dental schools have yet allocated precious resources
to study these wavelengths in sufficient detail to verify these claims. As more
research is performed, the field of laser dentistry will expand with more
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 785

peer-reviewed literature showing that many different wavelengths using

different techniques will be able to create regeneration of periodontal tissues.

Osseous resection
Many full-thickness mucoperiosteal flap procedures include osseous
resection. The only wavelengths cleared by the FDA for osseous surgery
are the erbium family of lasers. Er:YAG and Er:Cr:YSGG are the only
wavelengths that have the ability to ablate osseous tissue safely. There is
a great difference between FDA clearance for specific procedures, however,
and proof of efficacy when using lasers for those procedures. As addressed
earlier, the American Academy of Periodontology report [32] discusses the
fact that even though Er:Cr:YSGG has FDA clearance, peer-reviewed
literature defending its use for osseous procedures is lacking. In comparison,
the report does enumerate four articles in its discussion of the Er:YAG
wavelength, all of which led the American Academy of Periodontology to
state that the Er:YAG wavelength shows ‘‘the best application of laser use
directly upon hard tissue.’’ Four articles is hardly enough evidence to accept
unequivocally the role of this wavelength in osseous surgery. This is one area
of laser dentistry that needs more research. The role of lasers in osseous
surgery is discussed in more detail in the article on erbium lasers in this issue.

Endodontics
It is a well-accepted tenet of endodontic therapy that the cause of
periapical lesions and loss of tooth vitality is bacterial contamination.
Without the presence of bacteria, teeth do not lose vitality, and periapical
lesions do not develop. Spangberg [47] stated that the importance of infection
now is accepted as the major factor for the development of periradicular
inflammatory disease. Schilder [48] stated that the success of endodontic
treatment depends on the dentist’s ability to clean and disinfect the complex
canal system three dimensionally, then to fill and seal this space completely.
In a landmark study, Kakehashi et al [49] took normal rats and germ-free
rats and exposed their pulps. By day 8, all normal rats had nonvital, necrotic
pulps and periapical abscesses. The germ-free rats never lost pulp vitality. No
granulomas or abscesses formed. Dentinal bridges began to form by day 14,
with complete healing of the exposures by day 28, even with gross food
impaction in the endodontic access holes. Other studies have compared the
success rates of endodontically treated teeth with positive cultures with
endodontically treated teeth with negative cultures. Cultures were taken
immediately before obturation of the canals. The success rate of teeth with
negative cultures immediately before obturation was significantly higher
than the success rate of teeth with positive cultures [50,51].
Sundqvist et al [52] stated that most cases of endodontic failure are
thought to involve a continuing infection of the root canal system. Other
786 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

researchers, notably Nair et al [53] and Sjogren et al [54,55], concluded that

the most probable reason for failure of endodontic treatment is the presence
of a persisting infection. In 1957, it was known that intact teeth that became
devitalized as a result of trauma, rather than decay, harbored pathogenic
bacteria as a result of the trauma [56]. This early study by MacDonald et al
[56] has been substantiated by Wittgow and Sabiston [57]. These studies
illustrate the need for bacteria to be present to cause endodontic infections
and bony rarefactions at the apex of teeth. It also may be concluded from
these studies that when the root canal system is sealed properly after the
removal of bacteria, the endodontic treatment is successful. The criterion for
selection of an ideal wavelength for endodontic therapy is the ability to
deliver bactericidal energy to the root canal system. Every laser currently on
the market has been proved to be bactericidal. More specifically, lasers have
been shown to be bactericidal in root canals in vivo and in vitro. Moritz et al
[58] and Gutknecht et al [59] evaluated the diode and Nd:YAG lasers in root
canals. Both wavelengths were shown to be highly suitable for killing
bacteria in infected root canals. Schoop et al [60] subjected 220 extracted
human teeth to bacteriologic evaluation. Their results showed that there was
a decisive bactericidal effect when an Er:YAG laser was introduced into an
infected root canal. These investigators concluded that the Er:YAG laser
can be used to eliminate bacteria from root canals [60]. Mehl et al [61] in-
oculated 90 extracted anterior teeth with Escherichia coli or Staphylococcus
aureus. Their results after using Er:YAG laser in an attempt to sterilize the
canals showed that the Er:YAG laser exerts efficacious antimicrobial effects
in dental root canals.
Most laser delivery systems currently on the market have the ability to
deliver laser energy to the root canal system. Conventional fiberoptic cables
(Nd:YAG, diode) can be placed directly into root canals. Waveguide and
air-cooled fiberoptic delivery systems (Er:YAG, Er:Cr:YSGG, CO2) have
handpiece attachments that can deliver laser energy into the root canals.
Fig. 5 shows a variety of endodontic attachments available for the
Er:Cr:YSGG laser handpiece. Fig. 6 shows one of the Er:Cr:YSGG
attachments in a root canal.
If the sole purpose of using a laser for endodontic treatment is to sterilize
a root canal system, any wavelength would work. With the exception of the
articulated arm delivery system, every delivery system would work. If the
goal of using a laser in endodontic therapy is more than just sterilization of
the canal, the other steps in endodontic treatment must be addressed. The
goals of endodontic therapy may be summarized as follows:
1. Débridement of the canal
2. Instrumentation of the canal
3. Removal of the smear layer
4. Sterilization of the canal
5. Sealing of the main and all accessory canals
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 787

Fig. 5. Variety of endodontic attachments for the Er:Cr:YSGG laser handpiece. (Courtesy of
Biolase, San Clemente, CA.)

When endodontic access and initial débridement of the canal is completed,

the next critical steps are removal of the smear layer and sterilization of the
root canal system. When the bacteria are removed from the root canal
system, and the system is sealed off with gutta percha, the periapical
pathology heals. Removal of the smear layer is an important step in the
process of canal sterilization. It is important to remove the smear layer from
the root canal system because the smear layer occludes the dentinal tubules.
Fogel and Pashley [62] stated that the smear layer may harbor bacteria and
bacterial products. Bacteria may be multiplying within the dentinal tubules.

Fig. 6. Er:Cr:YSGG endodontic attachment in a root canal. (Courtesy of Biolase, San

Clemente, CA.)
788 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

If bacteria are not removed from the tubules, this could lead to failure of the
endodontic treatment. Smear layer removal allows for superior cleaning and
sterilization of the root canal. Takeda et al [63] compared 17% ethyl-
enediaminetetraacetic acid (EDTA), a chelating solution commonly used in
endodontics to enlarge canals and remove the smear layer, with 6%
phosphoric acid and Er:YAG laser energy. Sixty extracted human teeth were
used in their study. The results showed that the Er:YAG laser was the most
effective in removal of the smear layer from root canal walls [63]. In
a separate study, Takeda et al [64] used 36 extracted teeth in a study to
evaluate further the use of Er:YAG lasers inside root canals. Their results
showed the Er:YAG laser–treated walls were free of debris, with open
dentinal tubules. Takeda et al [64] concluded that the Er:YAG laser
irradiation efficiently cleaned the root canal walls. A further study concluded
that Er:YAG lasers are effective in removing debris and the smear layer from
root canal walls [65]. When Er:YAG lasers were compared with other lasers,
notably argon and Nd:YAG lasers, the results showed that the Er:YAG laser
was the most effective wavelength and more effective than 17% EDTA in
removal of smear layer from root canal walls [66]. The sole remaining step in
endodontic therapy is the obturation of the canal. Er:YAG lasers have
shown a remarkable ability to enhance the results of the obturation process.
Application of Er:YAG energy to the root canal walls has been shown to
increase the adhesion of epoxy-based root canal sealers (AH26, AH Plus,
Topseal, Sealer 26, and Sealer Plus) to the canal walls. Pecora et al [67] used
99 extracted maxillary molars with an Instron Universal testing machine.
Their results showed that there was a statistically significant difference
between laser-treated dentin and EDTA-treated dentin with respect to
adhesion of sealer to the dentin walls [67]. Sousa-Neto et al [68] used 40
extracted human molars with an Instron Universal testing machine. Their
results showed that laser application significantly increased the adhesion of
root canal sealers. Research also has attempted to respond to the concerns of
laser energy flowing outside the root canal. One major concern would be the
effect of laser energy on the periodontal ligament surrounding the tooth, just
beyond the apex of the tooth. Research to date has concluded that the effects
on the periodontal ligament when using Er:YAG laser energy is minimal, and
no discernible effects on the periodontal ligament have been noted. Kimura
et al [69] irradiated 20 extracted human teeth with Er:YAG laser energy.
With the use of thermocouples and scanning electron microscopy, they
discovered that the root surface temperature did not increase significantly,
and there was no evidence of carbonization or melting.
All of this research involves the use of the Er:YAG laser wavelength of
2940 nm. The manufacturer of the Er:Cr:YSGG wavelength of 2780 nm has
suggested the use of their unit for complete endodontic therapy, including
instrumentation of the canal. This manufacturer has developed a series of
thin, flexible endodontic tips that may be used to enlarge the root canal. This
wavelength has been cleared by the FDA for endodontic instrumentation
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 789

and débridement. There are many anecdotal reports of its use in

endodontic therapy; however, there are not yet any peer-reviewed articles
in the dental literature to substantiate the manufacturer’s claims. The
author is confident that in the near future, there will be peer-reviewed
literature to validate the use of this wavelength for endodontic therapy.
All wavelengths have been shown to be bactericidal. Conventional and
air-cooled fiberoptic delivery systems and waveguide delivery systems are
capable of delivering bactericidal energy to the root canals. If instrumen-
tation, removal of the smear layer, and sealing of the canals are the goal of
laser use in endodontic therapy, the erbium family is the only group of
wavelengths that can perform those tasks. Currently, Er:YAG lasers can be
recommended based on a review of the literature. Er:Cr:YSGG has been
approved and has many anecdotal reports, but as of this writing does not yet
have peer-reviewed research to validate its use.

Operative dentistry
Practically since the profession of dentistry began, dentists have been
seeking a method of removing decay painlessly and atraumatically without
affecting the surrounding healthy dental tissue. The field of laser operative
dentistry began with the FDA clearance of the Premier Laser Systems
Er:YAG laser for caries removal and cavity preparation in 1997. Since then,
three more erbium laser manufacturers have entered the market touting their
ability to remove diseased hard tissue without the need for anesthesia. These
lasers are indicated for all classifications of caries in enamel, dentin, and
cementum for deciduous and permanent teeth. Erbium lasers are capable of
removing not only decayed tooth structure, but also many nonmetallic
restorations. Defective composite, glass ionomer, and compomer restora-
tions may be removed quickly and easily without the use of analgesia. The
one limitation of use with erbium lasers is the removal of metallic and
porcelain restorations. Currently there is no laser that is able to remove
defective amalgam, gold, or porcelain restorations. These restorations must
be removed in a conventional manner before the laser may be used on the
tooth to remove the recurrent decay. It is beyond the scope of this article to
discuss in detail the process by which erbium lasers remove decay; this is
discussed in the article on erbium lasers elsewhere in this issue.
The erbium family of lasers are the only wavelengths that are indicated for
use in enamel, dentin, and cementum. For the sake of completeness, the
Nd:YAG laser was cleared for removal of first-degree caries in enamel in
1995; however, as a result of the limitations of its approval, its use in
operative dentistry is practically nonexistent today. The Nd:YAG laser has
been supplanted by the much more versatile erbium family. This family of
lasers consists of the Er:YAG laser with a wavelength of 2940 nm and the
Er:Cr:YSGG laser with a wavelength of 2780 nm. Although many dentists
790 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794

are familiar with the name ‘‘Waterlase,’’ used to describe the Er:Cr:YSGG
wavelength, this is actually a misnomer. The statement that water plays a role
in the cutting ability of this laser compared with Er:YAG lasers, used in
advertising for this company’s products for years, is scientifically invalid.
Although the concept of ‘‘accelerated water’’ was proposed in 1994 by Riziou
and DeShazer [70], scientific studies have shown this not to be the fact.
Research by Fried et al [71] into the mechanism of Er:YAG and Er:Cr:YSGG
concluded unequivocally that the mechanism proposed by Riziou and
DeShazer [70] was incorrect. Hibst [72], using high-speed photography, also
concluded that there was no scientific basis for any evidence of a ‘‘hydro-
kinetic effect.’’ Freiberg and Cozean [73] concluded from their study of the
erbium family of lasers that if a hydrokinetic effect exists, it is not effective on
hard materials and does not contribute to enamel ablation.
Another significant difference is the absorption rate of these two
wavelengths in water and hydroxyapatite. Coluzzi [74] stated that the
Er:YAG wavelength has a 20% higher absorption in hydroxyapatite than
Er:Cr:YSGG. Hibst [72] stated that the absorption of Er:Cr:YSGG in water
is only half that of Er:YAG. Hibst [72] also compared Er:YAG and
Er:Cr:YSGG with the same operating parameters, the same optical fiber,
and the same spot size. He concluded that mass removal of dentin is greater
and pulpal temperature increase is smaller during laser drilling with
Er:YAG. Hibst [72] and Gimbel [75] also described multiple clinical trials
detailing the need for anesthetic during operative procedures with the
Er:YAG laser is only 2% to 10%. The author could find no similar peer-
reviewed studies using the Er:Cr:YSGG wavelength. Does this mean that
Er:YAG is superior biologically to Er:Cr:YSGG? It seems that there is
a stronger biologic rationale for the use of Er:YAG over Er:Cr:YSGG in
operative dentistry. The fact that Er:YAG causes less of a pulpal
temperature increase and removes more dentin per pulse than Er:Cr:YSGG
would lead one to that assumption; however, ‘‘wet-fingered’’ dentists put
a great deal of stock in clinical results they can see. The clinical results
dentists achieve with the Er:Cr:YSGG laser are within the bounds of
clinically acceptable results. Research is ongoing with other wavelengths
for hard tissue ablation. A new CO2 wavelength of 9.6 l is in development.
The frequency-doubled alexandrite laser also is under development. The
processes of development and testing of the alexandrite laser for dental use is
discussed in the article on laser research in this issue. For the present, the
Er:Cr:YSGG and Er:YAG lasers are clinically acceptable for use on dental
hard tissue.

Summary
When selecting a laser for a specific procedure, the dentist must consider
the interaction between the wavelength, target tissue, and surrounding tissue.
For many dental procedures, most soft tissue lasers produce excellent results.
 R.A. Convissar / Dent Clin N Am 48 (2004) 771–794 791

For these procedures, in which the selection of wavelength is a matter of

personal preference, the selection of the correct operating parameters (joules,
hertz, pulse duration) is crucial to the success of the procedure. For certain
specific procedures, the choice of wavelength is crucial for the success of the
procedure. A biologic rationale for the use of specific wavelengths for certain
procedures has been outlined.

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