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Lasers in periodontics

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Lasers in Periodontics*
Publicity about the use of lasers in dentistry has generated considerable interest in both professional and lay
audiences. The purpose of this report is to provide information for members of the dental profession about
the current and potential application of laser technology to periodontal practice. This report was prepared by
the Research, Science and Therapy Committee of the American Academy of Periodontology. J Periodontol
asers have become widely used in medicine and
surgery since the development of the ruby laser
by Maiman in 1960.1-8 Lasers designed for
surgery deliver concentrated and controllable energy
to tissue. For a laser to have biological effect, the
energy must be absorbed. The degree of absorption
in tissue will vary as a function of the wavelength
and optical characteristics of the target tissue. If the
peak emission of the laser matches the absorption
spectrum of one or more components of the target
tissue, a predictable and specific interactive effect
will occur. Since tissues all have more than one component, the overall effect will be a combination of the
effects on each tissue component. As the temperature increases at the surgical site, the soft tissues are
subjected to warming (37° to 60°C), welding (60° to
65°C), coagulation (65° to 90°C), protein denaturization (90° to 100°C), drying (100°C), or vaporization and carbonization (over 100°C). Vaporization of
tissue begins when cellular water is heated to its boiling temperature (100°C), while other components of
the tissue vaporize at higher temperatures.
Ophthalmologists began using the ruby laser in
the early 1960s, and now the CO2, Nd:YAG, Er:YAG,
Er,Cr:YSGG, Ho:YAG, and diode lasers are available
for dental and medical surgical specialties. The
CO24,7-21 and the Nd:YAG22-25 are the most commonly used lasers for surgical procedures performed
on oral soft tissues, and they were the first to have
handpieces adapted for intraoral use.
The characteristics of a laser depend on its wavelength (Table 1). Wavelength affects both the clinical
applications and design of the laser.24 The wavelength of lasers used in medicine and dentistry generally range from 193 nanometers (nm) to 10,600
nm, representing a broad spectrum from the ultraviolet to the far infrared range. The lasers most commonly used in dentistry, the CO2 and the Nd:YAG,
* This paper was developed under the direction of the Research, Science
and Therapy Committee and approved by the Board of Trustees of the
American Academy of Periodontology in August 2002.
J Periodontol • October 2002
have wavelengths of 10,600 nm (far infrared) and
1064 nm (near infrared), respectively. Since the
beams from both of those lasers are in the infrared
range, they are not visible. Therefore, these lasers
often use a quartz fiber incorporating a 630 nm (red)
coaxial helium-neon laser into the device to act as an
aiming beam, and thus facilitate use.
The 1064 nm Nd:YAG laser can be transmitted
through an optical fiber, allowing the laser delivery
device and the fiber to pass through an endoscope
or be delivered intraorally via a handpiece. This
allows the operator to work in a familiar setting and
use a contact mode for tactile sensation. In contrast,
the CO2 laser is absorbed by optical fibers and initially requires delivery through a series of mirrors in
an articulated arm. It also requires focusing by lenses
in an operating microscope or a handpiece.8,15 The
lack of a fiber optic delivery system and of a handpiece specifically designed for dental use initially
made the CO2 laser awkward for intraoral use.16,26
The development of a more versatile handpiece and
of a hollow wave guide technology that allows the
beam to be delivered through a flexible tube have
facilitated access to virtually all areas of the oral
cavity. Substantial data support the application of
both the CO2 and Nd:YAG lasers for oral soft tissue
surgery. The CO2 laser has been utilized for soft tissue surgery, including the oral tissues, since the early
1970s7-9,11-16,20,21,27 and received safety clearance
by the U.S. Food and Drug Administration (FDA) for
this purpose in 1976.
With the CO2 laser, the rapid rise in intracellular temperature and pressure leads to cellular rupture, as
well as release of vapor and cellular debris, termed
the laser plume. The debris arising from the site of
impact, the char, is carbonized tissue by the laser
beam. Char formation occurs more rapidly during the
continuous wave mode than with pulsed or gated
modes. If the char is allowed to accumulate and laser
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Table 1.
Laser Wavelengths
(in nanometers)
Argon (Ar)
Potassium Titanyl Phosphate (KTP/532)
Helium-Neon (He-Ne)
Neodymium: Aluminum-Yttrium-Garnet
Holmium:YAG (Ho:YAG)
Erbium:YAG (Er:YAG)
Erbium,Chromium:Yttrium-Scandium-GalliumGarnet (Er,Cr:YSGG)
Carbon Dioxide (CO2)
irradiation is attempted through it, there will be a
rapid jump in temperature to 1,500° to 2,000°C and
the irradiated site will begin to incandesce to an
orange glow, causing extensive thermal damage.17-21
Therefore, proper use of the laser requires removal
of the accumulated char layer during surgery to
reestablish a moist surface for absorption of the laser
The CO2 laser wavelength is readily absorbed by
water. As soft tissue is 75% to 90% water, about 98%
of the energy is converted to heat and absorbed at
the tissue surface with very little scatter or penetration. Thus, only a narrow zone of coagulation necrosis may surround the vaporization of a CO2 laser incision.4,17,18,28,29 In some systems, the laser beam is
focused by a lens to converge at a focal point. The
beam is smallest in the cross-sectional area at this
focal point and then grows larger as it diverges. In the
flexible waveguide delivery system, the smallest diameter of the beam is nearest the end of the handpiece
tip, beyond which it diverges. This corresponds to 3
to 5 mm from the target tissue.
Therefore, with this CO2 laser, no contact is made
with the tissue, and no tactile feedback occurs. Cutting is accomplished by vaporizing tissue along a
line, using a focused beam close to the focal point,
with a spot size of 0.1 to 1.0 mm. Divergence of the
beam beyond the focal point results in a rapid loss
Lasers in Periodontics
of power density and protects the underlying tissue,
causing only protein denaturation and coagulation.
Blood vessels in the surrounding tissue up to a diameter of 0.5 mm are sealed.4,17,18,28,29 Thus, a primary
advantage of CO2 laser surgery over the scalpel is
hemostasis and a relatively dry field for improved
The depth of the laser incision is proportional to
the power setting and the duration of exposure.4,15,17
CO2 laser surgery of the oral soft tissues is generally
performed with a power setting of 5 to 15 watts, in
either a pulsed or continuous mode. The higher
energy levels are required to vaporize and remove
tissue, while the lower energy levels are used for
hemostasis and photocoagulation.
The 1,064 nm Nd:YAG laser will penetrate water to
a depth of 60 mm before it is attenuated to 10% of
its original strength. Therefore, the energy is scattered in soft tissue rather than being absorbed on the
tissue surface as occurs with CO2 laser energy. However, since this wavelength is attracted to colors, in
heavily pigmented soft tissue such as skin, scattering is about twice as great as absorption. This heating effect with the Nd:YAG laser is ideal for ablation
of potentially hemorrhagic abnormal tissue, and for
hemostasis of small capillaries and very small venous
vessels. However, the scattering effect increases the
difficulty of judging the depth of penetration, particularly in pale colored tissue, since the surface appearance of the tissue is not a reliable indicator of thermal damage. The depth of penetration has been
estimated to be 2 ± 1 mm in soft tissue.29 A recent
study concluded that thermal damage may occur to
the underlying bone when the Nd:YAG laser is used
at appropriate energy levels during soft tissue ablation.30 A significant increase in intrapulpal thermal
damage has also been reported when the device was
used to remove the smear layer from tooth roots in
The ease of application of the Nd:YAG laser
through flexible quartz optical fibers has resulted in
its widespread use in endoscopy of the respiratory,
gastrointestinal, urinary, and gynecological systems,34-39 as well as its application to arthroscopic
temporomandibular joint surgery.40 Power of up to
100 watts is used for surgery in these applications,
with 10 to 20 watts used for photoablation.23 The
development of sapphire and ceramic tips for contact
use41 has allowed precise delivery at low wattage
settings (3 to 20 watts) and high power density using
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a small (0.2 to 1.2 mm) diameter tip. The advantage
of the contact tip is that the surgeon has tactile feedback not available with non-touch Nd:YAG or CO2
lasers.24 One study found that the least tissue damage occurred with the smallest tip at all power settings, and there was no bleeding with the contact tip.
However, the extent of tissue damage was still greater
than observed with a conventional scalpel.42
A Nd:YAG laser device, designed and promoted
for oral and dental applications, can deliver up to 3
watts of power in either a pulsed (20 pulses per second) or non-pulsed mode, utilizing a specially
designed handpiece with contact or non-contact
probes. It received FDA clearance for oral soft tissue
in 1990. However, the FDA has not permitted the
manufacturer of any laser to state that it can sterilize the field or that it is painless. Because of concerns about the claims for the use of the Nd:YAG
laser on dental hard tissues, the FDA convened an
expert panel in July 1990 to review submitted data.
The panel concluded that the data were not yet sufficient to substantiate claims of efficacy on hard tissues. To date this has not been revisited by the FDA
for the Nd:YAG laser.
The primary emphasis of utilizing lasers only on soft
tissues was changed in 1997 with FDA safety clearance for the use of the erbium:YAG laser on hard tissues such as enamel, cementum, and bone. The
Er:YAG laser has a wavelength of 2,940 nm, which
is ideal for absorption by hydroxyapatite and water,
making it more efficient in ablating enamel and dentin
than any previously introduced laser. This wavelength
corresponds to the absorption coefficient of water,
causing water to evaporate into steam in the tissues
being irradiated and resulting in a microexplosion of
the hard tissue. This process of ablation allows very
little heat generation into the underlying tissues and
minimal elevation of the pulpal temperature. The laser
energy produced at the 2,940 nm wavelength is
absorbed by water 15,000 times more than the
Nd:YAG laser wavelength of 1,064 nm. Therefore,
the tissue destruction caused by the Er:YAG laser is
probably not related to thermal effects as with other
types of lasers, but to the microexplosions associated with the water evaporation within the cementum and other dental hard tissues.43,44
The erbium:YAG laser utilizes a fiber optic delivery
system with an accompanying helium neon laser as
an aiming beam, since the wavelength is invisible. It
is essential to use a water spray to wet the surface
during laser radiation to achieve maximum efficiency
J Periodontol • October 2002
of tissue removal with minimal heat generation. The
surface is left with an acid-etched appearance microscopically, which enhances the bond strength when
used on enamel for cavity preparation.
The diode laser has also been introduced over the
past few years for dental use, obtaining FDA safety
clearance. It also can be delivered through a flexible
quartz fiber optic handpiece and has a wavelength of
819 nm. This energy level is absorbed by pigmentation in the soft tissues and makes the diode laser an
excellent hemostatic agent. It is used for soft tissue
removal in a contact mode, giving a tactile sensation
similar to electrocautery. The power output for dental use is generally around 2 to 10 watts and can be
either pulsed or continuous mode. The diode laser
has been shown to have similar tissue effects as the
Nd:YAG laser in comparable studies, with less thermal effects on the deeper tissues.45,46
Precautions should be observed when performing
laser surgery (Table 2). The CO2 laser beam may be
reflected from shiny metal surfaces such as retractors or mouth mirrors that may cause inadvertent
injury to adjacent tissues. Protective eyewear, specific to block the wavelength of the laser in use,
should be worn by operator and assistants.9 When
using the carbon dioxide laser, simple infection control lenses or normal eyeglasses are sufficient to
deflect the laser beam. However, all other lasers used
in dentistry require colored lenses specific to the
wavelength in use for proper eye protection. The
patient’s eyes, throat, and delicate oral tissues outside the surgical site should be protected from accidental beam impact through use of safety glasses
and wet towels or gauze packs.20 Adequate high
speed evacuation should be used to capture the laser
plume, which is a biohazard. Crater-like defects in
the underlying enamel and cementum have been
noted following experimental gingivectomy in dogs,
even when tinfoil was used as a shield between the
gingiva and the teeth.26 Clinicians experienced in
CO2 laser surgery have emphasized the need for an
adequate shield, such as a flat-bladed instrument or
silver foil, between the gingiva and teeth.9,11,20,47
However, with the newer delivery systems, this is less
of a concern since the focal distance from handpiece
to soft tissue target is only 3 mm.
Only a small number of periodontally directed reviews
and reports were published in refereed periodontal
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Table 2.
Lasers and Their Dental Applications
Carbon dioxide laser
Clinical applications: Removal of soft tissue by ablation.
Recommended for gingivectomy, frenectomy, and excision of soft
tissue pathology (both benign and malignant). Also used for laser
deepithelialization of flaps during and after surgery.59,68
Precautions: Avoid hard tissue contact by laser emission,
especially tooth structure. Use expanded margins when
performing a laser excisional biopsy to prevent fulguration of
diagnostic areas.74 Tissue penetration from laser irradiation will
be approximately 0.5 mm deep, depending on power density;
very little heat damage occurs below visual depth of wound.10
Neodymium:YAG laser
Clinical applications: Removal of soft tissue by ablation.
Recommended for gingivectomy, frenectomy, and excision of soft
tissue pathology, especially hemorrhagic lesions. Also used for
laser subgingival curettage procedure.97,103
Precautions: Avoid hard tissue contact by laser. Same precautions
as listed for CO2 laser.Tissue penetration from laser may cause
thermal damage 2 to 4 mm below surface wound, causing
underlying hard tissue damage.30,69
Diode laser
Clinical applications: Removal of soft tissue by ablation.
Recommended for gingivectomy, frenectomy, and excision of soft
tissue pathology, especially hemorrhagic lesions. Similar
applications as Nd:YAG laser.42,43 Used for laser-assisted
subgingival curettage and periodontal pocket disinfection.95,96
Precautions: Avoid contact with hard tissues. May damage root
cementum and bone during subgingival curettage.Tissue
penetration is less than comparable Nd:YAG effects, with
potential for heat damage to underlying bone reduced.43,103
Erbium:YAG laser
Clinical applications: Cavity preparation of incipient caries. Root
preparation similar to acid etching following root planing.40,54,55,64
Has not been studied extensively for soft tissue applications.
Precautions: Must use adequate water spray when cutting hard
tissues with laser. Minimal heat damage reported when used on
dental hard tissue at appropriate power densities.41,63
journals prior to 1995.9-12,48-61 However, several laser
related studies have appeared in the periodontal literature in the last few years.30,43,44,62-73 Earlier papers
advocated the utility of both the CO2 and the Nd:YAG
laser for soft tissue procedures.20,25,57,74,75 There is
abundant evidence to indicate that there is markedly
less bleeding,9,25,71 particularly of highly vascular
oral tissues during laser surgery.76-81 Anecdotal
remarks that suggest incising oral soft tissue with a
Lasers in Periodontics
laser is less painful than incising such tissue with a
scalpel and requires less local anesthesia have not
been scientifically validated.25 Reduced postoperative pain from oral and otolaryngological surgical procedures also has been claimed after laser tissue ablation.16 It is theorized that this pain reduction may be
due to the protein coagulum that is formed on the
wound surface, thereby acting as a biologic dressing82
and sealing the ends of the sensory nerves.16
Some reports suggest that laser-created wounds
heal more quickly and produce less scar tissue than
conventional scalpel surgery.7,82 However, contrary
evidence from studies in pigs,74 rats,17,83,84 and
dogs85 indicates that the healing of laser wounds is
delayed, that more initial tissue damage may result,
and that wounds have less tensile strength during the
early phase of healing.86 Ultimately, the tensile
strengths of scalpel and laser produced wounds are
comparable.86 The use of low-level laser irradiation
to improve wound healing has been suggested,87,88
but results to date are inconclusive.89-91 An experiment with cultured human skin fibroblasts showed
that collagen production and DNA synthesis were
delayed when the fibroblasts were exposed to Nd:YAG
laser radiation.92
Hard Tissue Applications
Lasers have been demonstrated to have an ablative
effect on dental hard tissues.54,55,93-98 However, there
is little evidence that lasers, either in contact or noncontact delivery, have any value in root debridement
in vivo. The application of the Nd:YAG laser to root
surfaces results in alterations in root surface protein
to mineral ratio, affects the ability of fibroblasts to
attach in vitro, and alters the nature of the smear
layer following conventional scaling and root planing.51-55,58 Neither the diode nor Nd:YAG laser was
effective in removing calculus from the root surface
and should not be seen as an alternative therapy for
root planing.
Several publications in the periodontal literature
have evaluated the affect on hard tissues and bone
when subjected to laser irradiation.55,65,68,73 Studies
have confirmed the negative effects of the Nd:YAG
and CO2 lasers when used directly on bone or root
surfaces. These negative effects include thermal damage to underlying bone when these lasers are used
on thin soft tissue to perform gingivectomies.30,64,69
In addition, the residual char formation that is produced during laser ablation of the hard tissues has
been shown to inhibit attachment of fibroblasts and
delay wound healing.54,70
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The erbium:YAG laser has demonstrated the best
application of laser use directly upon hard tissue,
leaving the least thermal damage and creating a surface that suggests biocompatibility for soft tissue
attachment.67,68 Studies have demonstrated 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, and leave a surface similar to an acid-etched
appearance with a scale-like texture.59,67,68 The
effects on the root surface from this laser show an
absence of melting, charring, and carbonization (char
formation) as seen with the Nd:YAG or CO2 lasers.68
However, any additional benefits of the Er:YAG laser
to root surfaces compared to root planing alone have
not been substantiated. Damage to the cementum
surface occurs from laser irradiation despite water
coolant, and no publication has shown attachment
of human gingival fibroblasts to a root surface previously treated by the Er:YAG laser.43
Recently the FDA has awarded safety clearance
for the use of the erbium, chromium:YSGG laser for
laser cutting, shaving, contouring and resection of
oral osseous tissues.99 However, there are no published reports of its use in periodontal surgical procedures, nor is there evidence from previous animal
or human studies to suggest that this methodology
is superior to conventional osseous surgical techniques.100
Preliminary evidence has been reported that the
laser may be useful for treatment of dentinal hypersensitivity.101 Also, root conditioning in periodontal
therapy may eventually be accomplished by laser
application,43,58 but this requires further investigation.
Soft Tissue Applications
Traditional use of lasers for soft tissue ablation includes
gingivectomy, frenectomy, removal of mucocutaneous
lesions (both benign and malignant), and gingival
sculpting techniques associated with implant therapy
and mucogingival surgery.9,13-15,20,21,25,48-50,62,78,79
Additionally, several authors have found the laser
removal of drug-induced gingival overgrowth to be an
advantage over other surgical techniques.11,12,74,102
Although the carbon dioxide laser is contraindicated for direct hard tissue application, it has been
shown to enhance periodontal therapy through an
epithelial exclusion technique in conjunction with traditional flap surgery procedures. It has been demonstrated that the CO2 laser can be used to deepithelialize the mucoperiosteal flap during surgery and
J Periodontol • October 2002
when repeated at 10-day intervals following surgery,
it has enhanced reduction in periodontal probing
depths.62,63,71,72 This technique requires further study
using controlled clinical trials with larger sample sizes
to substantiate its use as a recommended procedure
for enhancing periodontal regeneration.
Case reports have recommended the diode laser
(819 nm wavelength) along with the Nd:YAG for treatment of periodontal pockets by laser subgingival
curettage or excisional new attachment procedure.
However, these case reports offer no evidence to support the contention that these procedures are superior to conventional scaling and root planing. Furthermore, there are no evidence-based clinical trials
to substantiate the clinical benefits of laser-assisted
subgingival curettage. In addition, the presence of
root surface damage following laser-assisted subgingival curettage has been reported.61,103 The lack of
standardization with the laser curettage technique for
controlling the amount of laser energy produced is
also a concern.
From another perspective, since the diode and
Nd:YAG lasers are attracted to pigmentation, it was
hypothesized that the pigmented bacteria would
absorb the laser energy and be selectively killed. This
concept was evaluated in a pilot investigation104 and
a 6-month unblinded controlled study using the diode
laser in 50 patients.105 In the latter study, after initial
scaling of the teeth, individuals in the test group that
received multiple episodes of laser curettage demonstrated fewer periodontal pathogens than patients in
the control group.105 However, in these studies, the
results after scaling and laser therapy were not equivalent to the reduction in microbial flora reported following conventional scaling and root planing in other
Several controlled studies have assessed the use
of laser therapy combined with conventional scaling
and root planing. These investigations demonstrated
no benefit or only slightly improved treatment outcomes.110-113
Other Applications
Finally, in addition to their surgical applications, studies have indicated that lasers may be used to detect
caries, measure blood flow, and assess tooth mobility.49,114,115 These are areas of research that may
prove to have substantial diagnostic benefits.
The decision to use a laser for periodontal surgery
should be based on the proven benefits of hemosta-
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sis keeping in mind the claimed (but undocumented)
advantage of less postoperative pain with gingivectomy, frenectomy, or other procedures. Further peerreviewed, comparative clinical studies are required
to establish the potential of lasers in periodontal therapy. This is particularly true for subgingival applications, e.g., root debridement, soft tissue curettage,
and excisional new attachment. Furthermore, no longterm clinical studies have shown that laser therapy
alone can effectively be used to treat adult chronic
periodontitis. The public and general dental practitioners should realize that FDA safety clearance for
laser treatments, consisting primarily of soft tissue
removal, do not routinely apply to the treatment of
most periodontal diseases.
This paper was revised by Dr. Jeffrey A. Rossmann.
It replaces the paper titled Lasers in Periodontics,
which was authored by Drs. Robert E. Cohen and
William F. Ammons in 1996. Members of the 20012002 Research, Science and Therapy Committee
include: Drs. Terry D. Rees, Chair; Timothy Blieden;
Petros Damoulis; Joseph P. Fiorellini; William Giannobile; Gary Greenstein; Henry Greenwell; Vincent J.
Iacono; Angelo Mariotti; Richard Nagy; Robert J.
Genco, Consultant; Barry Wagenberg, Board Liaison.
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