Application of Diode Lasers in

Periodontics and Peri-Implantitis

Basic Laser
Information
 Dental Lasers

Hard Lasers Soft Lasers

Hard tissue Soft tissue Germ reduction Germ reduction Biostimulation
Endo Perio PDT

Nd:YAG / Diode
Er:YAG Nd:YAG / Diode Nd:YAG KEY Laser III
Er:CrYSGG CO2 / Er:YAG Diode (Removal of calculus)
 Pulse frequency (Hz):
Number of pulses per sec.
Pulse power (W):
Power Power emitted per pulse

Pulse time Pause time Pulse time (s):

Time during which power
Pulse power P emission takes place
Pause time (s):
Pulse energy Mean CW
Time between two phases
power value
CW value (W):
1
Average power value in
reference to one second
0,5
Energie (J=Ws):
Energy Power emitted in one sec.
Dutycycle (%):
Time in seconds 1S Relation between pulse
and full on/off cycle

Source: Laser therapy in the dental practice; Prof. Dr. Norbert Gutknecht
 Normal Laser operation modes
Pulsed Mode
Laser beam interrupted at regular intervals (e.g. 50%
ON & 50% OFF)
Advantage: Better thermal control
PULSE MODE

DPL - Digital Pulse Lasering

Power
Very short treatment time (20 µs) at a very high
frequency (20 kHz)
Laser beam pulsed > higher peak (15 W) and longer
cooling time
Advantage: Quick treatment time with no
carbonisation of tissue

Continuous Wave (CW)

Laser beam not interrupted
Time
Use in sterilisation and bacterial reduction
Use should be at low power outputs only as
carbonisation will occur very quickly.
 Disruption:
Destruction caused by the
Power density release of plasma
W / cm2
Ablation:
10
16
Removal, smoothing
Photodisruption
Vaporization:
Conversion to vapor
1012 Energy density J/cm 2
Coagulation:
Photoablation 4
10 Hemostasis
108 Photodynamics:
10²
Vaporization Photochemical effects,
10 0
e.g. sunburn
Nonlinear
10 4
Coagulation
processes 10-2 Biostimulation:
Thermal Acceleration of metabolic
effect Photodynam.
100 Therapy
processes
Photochem. Transmission:
reaction Biostimulation Penetration without effect
Dispersion:
10-12 10-9 10-6 10-3 100 103 106 Exposure time s
Spreading/scattering of
radiation reflection
Source: Laser therapy in the dental practice; Prof. Dr. Norbert Gutknecht
 1/cm Nd:YAG Er:YAG
Ar+ Diode Er,Cr:YSGG CO2
105
Hemoglobin Water
104
Melanin
Absorption coefficient

103
102
101
100 Hydroxylapatite

10-1
10-2
10-3

100 514 810 980 1064 2780 2940 9600 10600 nm

Wave length
 The key to successful
periodontal treatment?
The most important aspect of
every periodontal treatment?

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BACTERIA MANAGEMENT!
 Biofilm

Our new enemy

in dentistry?

Michael Sedlacek, PhD, and Clay Walker, PhD, at the University of Florida
How do we normally manage bacteria

Medications What is it? Why is it used?

Prescription A prescription mouthrinse To control bacteria when treating gingivitis

antimicrobial containing an antimicrobial called and after gum surgery
mouthrinse chlorhexidine
Antiseptic chip A tiny piece of gelatin filled with To control bacteria and reduce the size of
the medicine chlorhexidine periodontal pockets

Antibiotic gel A gel that contains the antibiotic To control bacteria and reduce the size of
doxycycline periodontal pockets

Antibiotic Tiny, round particles that contain To control bacteria and reduce the size of
microspheres the antibiotic minocycline periodontal pockets

A low dose of the medication To hold back the body’s enzyme response —
Enzyme
doxycycline that keeps destructive If not controlled, certain enzymes can break
suppressant
enzymes in check down gum tissue
Oral antibiotics Antibiotic tablets or capsules For the short term treatment of an acute or
locally persistent periodontal infection
Are these the only treatments we can use?

Ask your self this question:

If I was having the treatment or treating a

member of my family,
would I use the same
method as I do on my patients?

Is Antibiotics always the answer?

What about Lasers?
 Dental Lasers

Hard Lasers Soft Lasers

Hard tissue Soft tissue Germ reduction Germ reduction Biostimulation
Endo Perio PDT

Nd:YAG / Diode
Er:YAG Nd:YAG / Diode Nd:YAG KEY Laser III
Er:CrYSGG CO2 / Er:YAG Diode (Removal of calculus)
Can Lasers be used in the management of Bacteria?

Hard tissue Laser

Yes
Technique sensitive/Non selective
High Equipment cost
Advanced laser users only

Very good clinical outcome

Can Lasers be used in the management of Bacteria?

Soft tissue Laser

Yes
Part of a combined treatment
Accessible equipment costs
Available to all clinical experiences

Very Good Clinical outcome

Can Lasers be used in the management of Bacteria?

Soft Laser
No, not with out additional materials
Part of a combined treatment
Low equipment costs
Available to all clinical experiences

Clinical outcome can be mixed

Could a diode laser be used by itself to treat
Periodontal and Peri Implant
disease on its own?
 NO
It is always part of the full treatment
Joined up Perio Treatment - Proposed Standard

Stage 1 - Scaling and Root Cleaning - Day 1

Stage 2 - Perio Green Treatment - Day 2-3

Stage 3 - Laser Assisted Perio Treatment -

Day 2-3 Also

Stage 4 - Review - 4-6 Weeks

Stage 5 - Retreat if required - 4-8 Weeks

Perio Treatment - Proposed Gold Standard

Stage 1 - Scaling and Root Cleaning - Day 1

Stage 2 - Sub Gingival Airflow— Day 2-3

Stage 3 - Perio Green- Day 4-5

Stage 4 - Laser Assisted Perio Treatment -

Day 4-5 Also

Stage 5 - Review - 4-6 Weeks

Stage 6 - Retreat if required - 6-8 Weeks

Lets Concentrate on diode lasers

2 treatment methods

Laser Assisted Chemically Assisted

Perio Treatment Laser perio
Treatment
1W 300mW
Continuous Wave Continuous Wave
810nm 810nm
the new focus
Laser Assisted Perio Treatment
Why would we do this after perio green?

•  Removal of granulation tissue

•  Bactericidal effect
•  Further reduction in bacterial population
•  Low level laser effect - biostimulation
•  Tightening of collagen
•  Synergistic effect
•  Duplication of effort
 What we already know;
Laser Assisted Perio Treatment

Periodontal pocket decontamination

“Bacterial reduction in periodontal pockets through irradiation with a

diode laser: a pilot study.” Moritz A, Gutknecht N, Doertbudak O,
Goharkhay K, Schoop U, Schauer P, Sperr W. J Clin Laser Med Surg.
1997 Feb;15(1):33-7.
“Treatment of periodontal pockets with a diode laser.”

Moritz A, Schoop U, Goharkhay K, Schauer P, Doertbudak O, Wernisch J,

Sperr W. Lasers Surg Med. 1998; 22(5):302-11.

Bacteria reduction significantly better in the diode laser group,

BOP reduction 97% compared to 67% in the control group (6 Months)
Chemically assisted laser perio treatment

What you may also know as:

PACT – photodynamic anti-microbial

chemotherapy.
PAD – photo-activated disinfection
PDD – photodynamic disinfection

aPDT – anti-microbial photodynamic therapy

This where elexxion is working

aPDT – anti-microbial photodynamic therapy

“Diode laser activated indocyanine green selectively kills bacteria”

Bohemia TK, Ciancio SG, J Int Acad Periodontal. 2011 Jul 13 (2): 58-63
pico lite - NEW

810nm Diode
Only for perio green use
100mw - LLLT
300mw - aPDT

Not able to “cut”

All elexxion lasers have
perio green settings
What is perio green?

Indocyanine green,
1,7-Bis(1,1-dimethyl-3-
[4-sulfobutyl]-1H-benz[e]indol-2-yl)
heptamethinium-betain-Na

Easy form - ICG

 Indocyanine green is an anionic photosensitiser
which is activated at 810 nm when dissolved in water

ICG bonds to the plasma proteins of the bacteria.

The overall effect of indocyanine green consists of 20

per cent photodynamics (PDT) as well as fluorescence
and, mainly, of its photothermal effect (PTT).

“Light Absorbing properties, Stability and spectral Stabilization of indocyanine green”

Landsman MJL, Kwant GA, Mook GA, Zijlstra WG. Journal of Applied Phys Vol 40, No 4 4/1976

“Plasma Proteins Binding of Indocyanine Green”

Buckle TJ Biochemical Medicine 15 17-21 1976

“Supplementary Periodontal Therapy with Photo Thermal Therapy”

John H-D, Laser Journal 2/2013 pp18-24

“Antimicrobial Photodynamic therapy of resistant bacterial strains by indocyanine green and 809nm diode laser”
Topaloglu N, Gulsoy M, Yuksel S. Photoed Laser Surg. 2013 Apr; 31(4): pp155-62
perio green® adheres to the
plasma proteins in the
membranes of bacterial cells
and dyes them.
Perio green® is activated by
laser with a wavelength of
780-820 nm. Each Elexxion laser
has preset functions for Perio
Green allowing quick and
simple selection and treatment
With just 300 mW, local,
imperceptible thermal heat
peaks are created and destroy
the bacteria.
Clinical application – Periodontology

Prerequisites for ALL laser

therapy:
Completed pretreatment
Oral hygiene instruction
Removal of calculus
The application in periodontal treatment

Non Surgical
 1-5 Min
wait

Application of perio green within Treatment site exposed to laser

periodontal pocket photonic energy. The 810 nm wavelength is
invisible (near-IR) and a red light is used as a
co-axial aiming beam

Application of laser on palatal

aspect of tooth. Note scatter of energy
within tissue

Pictures Courtesy; Dr S. Parker 2014 BDJ Publication

The application in periodontal treatment

With Surgical Combination

 Lateral sinus associated with periodontal Blunt-probe exploration of
lesion mesial UL first premolar tooth treatment site

Buccal mucoperiosteal flap raised

under local anaesthetic.
Interproximal bone
loss and associated granulation
tissue in situ

Pictures Courtesy; Dr S. Parker 2014 BDJ Publication

 Application of indocyanine green
Granulation tissue removed, root photosensitiser and exposure to 810
surface debrided nm lowlevel laser. Adjunctive benefit
of aPDT will help reduce
periopathogen contamination of
the surgical site

Pictures Courtesy; Dr S. Parker 2014 BDJ Publication

 Application of matrix graft mineral
Healing at 10 days
(Bio-oss. Geistlich Pharma AG., Germany)

Pictures Courtesy; Dr S. Parker 2014 BDJ Publication

Peri Implantitis Treatment

What are our treatment goals?

Removal of granulation materials -

Removal of Bacteria -
Sterilization of Implant in situ -
Re-Integration of Implant -
Suggested ADI Treatments

Note non surgical

treatment with
antibiotics

Are we killing all

the bacteria?
Suggested ADI Treatments

Note Surgical has a

consideration for
laser application.
Step By Step Treatment - Non Surgical
Scaling - Implant approved scaler

perio green - internal application

Laser assisted perio treatment

Antibiotics?
Limitations
Are we able to remove all
bacteria from the implant surface?
 Where possible all treatment should be
carried out in a non surgical manner.
With this in mind shouldn’t lasers and aPDT be
a serious consideration?
Step By Step Treatment - Surgical
Removal of restorations
Full flap surgery
Scaling - Implant approved scaler
perio green
Laser assisted perio treatment - implant surface*
Place replacement bone
Membrane
Close Flap
Low Level healing on surgery site

Limitations
Patient OH routine
*  Maximum irradiation time -14-18s
Implant Temperature Caution

We need be guided by the literature with

regards to exposure times of continuous laser
energy on implant surfaces
Thermodynamic effects of laser irradiation of implants placed in bone: an in vitro study
Leja C, Geminiani A, Caton J, Romanos GE. Laser Med Sci 2013 No; 28(6): 1425-40

Temperature change during non-contact diode laser irradiation of implant surfaces.

Geminiani A, Caton JG, Romanos GE. Lasers Med Sci, 2012 Mar; 27(2): 339-42

By using a high pulse rate, cooling with sterile liquid and

pausing during treatment we can ensure that we keep the
increase in surface temperature below the critical threshold
of 10oC
Should this stop us using lasers on implant surfaces?

NO
Under irradiation conditions known
not to alter zirconia implant surfaces
in vitro… the diode laser (150 J/cm2) effectively
reduced the viability of adhered S. sanguine
or P. gingivitis

Bactericidal effects of different laser systems on bacteria adhered to implant surfaces: an invert
study comparing zirconia with titanium
Hauser-Gerspach I, Stübinger S, Meyer J. Cin Oral Implants Res 2010 Mar; 21(3)
Should this stop us using lasers on implant surfaces?
Continuous irradiation for 20s* reduced bacteria counts by 99.67% at
810 nm… Repeating the 20 s exposure five times reduced counts by
99.98% at 810 nm.…A 98.86% reduction was seen after irradiation in
pulsed mode.

A further analysis in respect of different isolated bacteria revealed that

the streptococci group was reduced by 99.29–99.99%, while the
staphylococci group was reduced to a lesser extent in the range 94.67–
99.99%.

*note from previous, 20s should only be achieved by allowing pauses in

treatment to ensure the 10oC threshold isn’t reached.
Bactericidal effects of different laser systems on bacteria adhered to implant surfaces: an invert study
comparing zirconia with titanium
Sabine Sennhenn-Kirchner1, Sören Klaue1, Nadine Wolff1, Hamparsum Mergeryan2, Margarete Borg
von Zepelin3 andHans Georg Jacobs: Clin Oral Implants: 24 NOV 2006 DOI: 10.1111
Shouldn’t aPDT and
lasers be a serious
consideration in the
treatment of peri
implantitis?
Shouldn’t aPDT now be a
serious consideration in
the management of
bacteria in the oral
cavity?