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laserinternational magazine of laser dentistry1
2013
i s sn 2193-4665 Vol. 5 • Issue 1/2013
| overviewLaser versus conventional therapies
| researchPhotodynamic therapies – Blue versus Green
| industry reportLong-term treatment of peri-implant lesions in geriatric dentistry
LI-PB77691EN - A4 - for Laser Journal print.pdf 1LI-PB77691EN - A4 - for Laser Journal print.pdf 1 04.02.13 10:3304.02.13 10:33
Dr Georg Bach
editorial I
I 03laser1_2013
Dear readers of laser international magazine of laser dentistry,
I must confess that the headline of this editorial is a little presumptuous—and of course, notonly is Cologne in the focus of the dental community, but the whole dental family is watchingthe city on the Rhine. This time, for sure, it is not because of the carnival, but because of IDS, International Dental Show, which starts only shortly after.
Although we have experienced this dental trade show for decades, it still radiates a hard-to-describe mixture of curiosity, thirst for knowledge and fascination.
IDS has always been a special event for laser dentistry, if not even the motor of this incredi-ble and sometimes turbulent development this dental specialty has undergone since the early1990s.
Judging from the hype triggered by the first Nd:YAG lasers presented in Cologne as well asthe “all new” area of laser-supported hard tissue therapies and photodynamic therapy, laser den-tistry has brought about a multitude of both new and aspiring laser users: IDS has always provedto be the perfect place for laser dentistry!
As the dental laser industry is well aware of this fact, all important manufacturers and dis-tributors are represented with stands, staff and equipment and even with an entertaining pro-gramme.
Of course, dear reader, I am not yet able to predict if the time-honoured Cologne exhibitionhalls will witness a new laser hype, but you will certainly encounter state-of-the-art dental lasersat IDS. Therefore, I wish you as well as our editorial team much fun at IDS 2013!
Independently from whether or not you will be able to visit Cologne, I hope that all readers oflaser international magazine of laser dentistry will enjoy this issue!
Warm regards,
Georg Bach
Cologne in the eyes of laser dentistry
I content _ laser
04 I laser1_2013
page 34 page 44 page 46
page 06 page 10 page 26
I editorial
03 Cologne in the eyes of laser dentistry
| Dr Georg Bach
I overview
06 Laser versus conventional therapies
| Cristiane Meira Assunção et al.
I research
10 Photodynamic therapies – Blue versus Green
| Dr Michael Hopp et al.
I case report
26 Becoming kissable:
Laser-assisted haemangioma removal
| Dr Darius Moghtader
I industry report
30 Er:YAG Garnet in laser-assisted crown lengthening
| Dr Avi Reyhanian
34 Long-term treatment of peri-implant lesions in
geriatric dentistry
| Dr Georg Bach
38 X-Runner Er:YAG dental laser application
| Prof. Dr Carlo Fornaini
I education
44 1st International Congress of WALED and
GLOBAL 2013 in Istanbul
| AALZ Germany
I meetings
46 The next chapter in the IDS success story
| Koelnmesse
I news
42 Manufacturer News
48 News
I about the publisher
50 | imprint
Cover image courtesy of Fotona,
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_Introduction
In recent years, several studies have been con-ducted on the clinical applications of laser in den-tistry. At the same time, there has been a markedemergence of organisations in support of the use oflaser in dentistry. In the last decades, laser therapyhas been used in dentistry as an adjunct or alterna-tive to conventional approaches. In this paper, thefollowing topics will be reviewed: the application oflaser in caries prevention and diagnosis, hard- andsoft-tissue treatments, and periodontal and en-dodontic procedures. There is a large research effortinto new indications for laser in dentistry. It is ex-pected that laser will become an essential compo-nent of the dentist’s armamentarium.
While the technology was regarded as complexand of limited use in clinical dentistry in the past, agrowing awareness of the usefulness of laser in themodern dental practice has been observed. Laser canbe used as an adjunct or alternative to conventionalapproaches.1 When comparing the use of laser withconventional therapies, three important areas must
be considered: safety, efficacy and effectiveness.From an ethical standpoint, it is important to use thebest available evidence when making clinical deci-sions.2
_Diagnostic laser applications
The most common methods for caries detectionare visual and radiographic examination.3 However,visual examination is a subjective method that de-pends on the knowledge and clinical experience ofthe examiner.3-6 Several studies have demonstratedthat radiographic examination demonstrates poorsensitivity to non-cavitated lesions.3, 7-9 For this rea-son, fluorescence-based methods have been devel-oped, aiming at the detection of occlusal and ap-proximal carious lesions, for example DIAGNOdent2095 (KaVo; LF; Figs. 1a-c) and DIAGNOdent 2190 (LF pen; Figs. 2a & b). They rely on the same principle:a laser diode emits red light at 655 nm and a pho-todetector quantifies the reflected fluorescencefrom bacterial metabolites (fluorophores) in cariouslesions, showing values ranging from 0 to 99.3,9
A study that assessed the performance of a visualmethod, radiographic examination and fluores-cence-based methods in detecting occlusal caries inprimary teeth found that the visual method andVistaProof fluorescence camera (Dürr Dental; FC)exhibited better accuracy in detecting enamel anddentine carious lesions, whereas the visual methodcombined with LF, LF pen and FC better detected den-tine lesions on occlusal surfaces in primary teeth,with no statistically significant difference amongthem.3
Another study compared the performance offluorescence-based methods (FC, LF and LF pen), ra-diographic examination, and another visual
I overview
Fig. 1a_DIAGNOdent 2095.
Laser versusconventional therapiesAuthors_Cristiane Meira Assunção, Joanna Tatith Pereira, Renata Schlesner Oliveira &
Dr Jonas de Almeida Rodrigues, Brazil
06 I laser1_2013
Fig. 1a
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I overview
08 I laser1_2013
method called the International Caries Detectionand Assessment System (ICDAS) II on occlusal sur-faces. This study demonstrated that the combina-tion of ICDAS and bite-wing radiographs yieldedthe best performance for detecting caries on oc-clusal surfaces.9
_Caries prevention: Enhancing enamel resistance
In the past, several in vitro studies have shownthat enhancing enamel demineralisation resistancecan be achieved by irradiation with lasers. In a blindin vitro study, Ana et al. 20121 compared the effect ofprofessional fluoride application with that of laser ir-radiation with regard to the demineralisation ofenamel and fluoride formation and retention. Thestudy found that both methods enhanced enamel re-sistance, and no side-effects were found. A greaterconcentration of retained calcium fluoride-like ma-terial was found in the laser group. Formation and re-tention of calcium fluoride were also improved withlaser irradiation.
The wavelengths absorbed most strongly by den-tal enamel are the 9.3 and 9.6 µm carbon dioxide laserwavelengths. The reduction in acid dissolution ofenamel is said to be caused by a loss of the carbonatephase of enamel crystals due to the heat of irradia-tion. Rechmann et al. 201110 demonstrated thatshort-pulsed 9.6 µm carbon dioxide laser irradiationsuccessfully inhibited enamel caries without anyharm to the pulpal tissue of the teeth irradiated. Theefficacy of carbon C02 laser irradiation regarding itslong-term effect on caries resistances can be verifiedby further studies.
_Hard-tissue applications: Caries removal
There is limited evidence to support the effective-ness of dental lasers in the removal of caries com-pared with rotary burs. In order to evaluate this, a sys-tematic review of seven studies with adequatemethodologies was performed.8 Two of the studies
found that there was no difference with regard totime taken for caries removal and cavity preparation.Four of the studies found that the laser took up tothree times longer to perform these procedures. Fourof the studies found that there were no differencesbetween lasers and rotary burs with regard to pulpaleffects. One of the studies found that dentists pre-ferred the bur to the laser, and all the studies foundthat patients favoured the laser with respect to com-fort. The studies found that adult patients prefer thelaser, although the response from children was in-conclusive. The results are not surprising, consider-ing that local anaesthesia is often not needed whenusing a laser, making the overall dental experiencemore pleasant for the patient.10
_Endodontic laser procedures (disinfection)
The main causes of endodontic treatment failureare the presence of persistent micro-organisms andrecontamination of the root canal owing to inade-quate sealing.11 The long-term success rate of con-ventional endodontic treatment depends on severalfactors, such as the diverse and complex anatomy ofthe root-canal system that consists of small canalsdiverging from the main canal. This complex systemdoes not allow direct access during biomechanicalpreparation because of the canals’ positioning anddiameter.6 New antimicrobial approaches to disin-fecting root canals have been proposed; these in-clude the use of high-power lasers and photody-namic therapy, which works by dose-dependentheat generation. However, in addition to killing bac-teria, they have the potential to cause collateraldamage such as charred dentine, ankylosed roots,melted cementum, root resorption and periradicularnecrosis.2
In order to compare the effectiveness of antimi-crobial photodynamic therapy with standard en-dodontic treatment and combined treatment toeliminate bacterial biofilms present in infected rootcanals, a study was conducted on ten single-rootedfreshly extracted human teeth inoculated with sta-ble bioluminescent Gram-negative bacteria. Itfound that endodontic therapy alone reduced bac-terial bioluminescence by 90 %, while photody-namic therapy alone reduced bioluminescence by95 %. The combination reduced bioluminescence byup to 98 %, and, importantly, the bacterial regrowthobserved 24 hours after treatment was much less forthe combination group than for the treatmentgroups individually.12
Alternatives to conventional therapies to im-prove the disinfection of root canals are Nd:YAG andEr:YAG lasers. One study evaluated the bactericidal
Fig. 1b_Tip A for occlusal surfaces.
Fig. 1c_Tip B for smooth surfaces.
Fig. 1b Fig. 1c
overview I
I 09laser1_2013
Fig. 2a_Cylindrical tip for occlusal
surfaces.
Fig. 2b_Wedge-shaped tip for
proximal surfaces.
Fig. 3_Infra-red laser therapy for
treatment of a primary herpetic
infection in an adolescent patient
undergoing chemotherapy
(Therapy XT, DMC).
efficacy of Nd:YAG and Er:YAG lasers in experimen-tally infected curved root canals and concluded thatin the straight root canals the Er:YAG laser had abactericidal effect of 6.4 to 10.8 % higher than thatof the Nd:YAG laser. Conversely, the bactericidal ef-fect of the Er:YAG laser in the curved root canals was1.5 to 3.1 % higher than that of the Nd:YAG laser.13
These results suggest that further development ofthe endodontic laser tip and techniques are requiredto ensure its success.
_Periodontal laser procedures (disinfection)
Conventional periodontal therapy proceduresinclude mechanical scaling and root planing, whichhas some limitations, especially in reducing bacteriainside deep pockets. In order to overcome the limi-tations of conventional mechanical therapy, severaladjunctive protocols have been developed. Amongthese, laser has been proposed for its bactericidaland detoxification effects and for its ability to reachsites that conventional mechanical instrumentationcannot.14
Different lasers could be used in periodontaltherapy for calculus removal, periodontal pocketdisinfection, photoactivated dye disinfection ofpockets and de-epithelialisation to assist regenera-tion.15
Several studies have indicated that the diodelaser, with a wavelength of between 655 and 980 nm,can accelerate wound healing through the facilita-tion of collagen synthesis, promotion of angiogene-sis, and augmentation of growth factor release. Fur-thermore, the diode laser has in vitro bactericidaland detoxification effects and can prevent ablationof the root surface, which theoretically reduces therisk of removal of normal root tissue.13
Sgolastra et al. 201214 did not observe significantdifferences for any investigated outcome (clinicalattachment level, probing depth, and changes in theplaque and gingival indices) in their systematic re-view. These findings suggest that the use of thediode laser as an adjunctive therapy to conventionalnon-surgical periodontal therapy did not provideadditional clinical benefit. However, given that fewstudies were included in the analysis, the resultsshould be interpreted with caution. Important issuesthat remain to be clarified include the influence ofsmoking on clinical outcomes, the effectiveness ofthe adjunctive use of the diode laser on microbio-logical outcomes, and the effect of adverse events.Future studies are required to assess the effective-ness of the adjunctive use of the diode laser, as wellas the appropriate dosimetry and laser settings.
_Soft-tissue applications
There are numerous soft-tissue procedures thatcan be performed with laser. Two key advantages ofthis are reduced intra-operative bleeding and lesspost-operative pain compared with conventionaltechniques, such as electrosurgery. Certain proce-dures in patients with bleeding disorders are bettersuited to lasers with greater haemostatic capabili-ties.5
_Conclusion
Although the results of laser therapy are similar(in safety, efficacy and effectiveness) to those ob-tained with conventional methods, new techniquesand devices have been developed. Laser could thus bean evidence-based and well-supported treatmentoption for the dentist in daily dental practice._
Editorial note: A list of references is available from the pub-
lisher.
Dr Jonas de Almeida Rodrigues
School of DentistryFederal University of Rio Grande do SulAv. Paulo Gama, 110Porto Alegre – RGS 90000-000Brazil
_contact laser
Fig. 2a
Fig. 3
Fig. 2b
I research
Fig. 1_Structural formula of
methylene blue (MB).
Fig. 2_Structural formula of
toluidine blue (TBO).
Fig. 3_Structural formula of
indocyanine green (ICG).
_Introduction
After the successful introduction of antimicrobialphotodynamic therapy based on methylene and tolui-dine blue, a green medical colouring agent which is ac-tivated at 810 nm has become available. The followingarticle illustrates its indication, range of effects andtherapy efficiency in comparison to the classical blueagents. Photodynamic therapy (PDT) as a minimally in-vasive oncological method performed with injectedphotosensitisers has been advanced to a non-invasive,surface-oriented therapy in dentistry. Its main indica-tions are bacteria, which is why it has been marked “an-tibacterial”: antimicrobial photodynamic therapy(aPDT). aPDT entails a light-induced inactivation of cells,microorganisms or molecules without destroying thetissue. Therefore, aPDT or PDT in periodontology, en-dodontology, professional tooth cleaning, as well asperiimplantitis and mucosa treatment must be differ-entiated from invasive therapies such as hard-tissuetreatments in enamel, dentine and bone, surgery, peri-odontal treatment, endodontology and invasive peri-implantitis therapy.
In aPDT, two effects are brought together: the low-level, highly pervasive laser energy with the photody-namic effect resulting in high tissue efficiency and thecolouring agent activation resulting in a bactericidal ef-fect via singlet and triplet oxygen, which harms the un-saturated fatty acids in the colour-marked membranesand their organelles. In addition, they initiate the disin-tegration of the bacterial membranes and thereforecause the bacteria to die. These two effects are linked in-separably in aPDT. Parallelly to reducing bacteria, laserlight which has not been absorbed promotes healing.Even the application of laser light alone will reduce den-tal plaque1, thus leading to a reduced healing time. Inprevious years, aPDT has been associated with a multi-tude of synonyms: PACT—photoactivated chemother-apy, PDD—photodynamic disinfection, LAD—light-acti-vated disinfection, PAD—photoactivated disinfection,among others. These terms signify a principle ratherthan actually contributing to an enhanced insight intothe concept. They can therefore be seen as marketing-oriented neologisms.
Laser-, LED- und colouring agent systems have be-come available in larger quantities and can be inte-grated to other therapies. Possible combinations are:
– LED 630 nm—toluidine blue O—Fotosan/Fotosan 630– Laser 635—toluidine blue O—PACT system, R+J,
Two in one, MDL 10, among others– Laser 670 nm—methylene blue, HELBO system,
Periowave, among others– Laser 810 nm—methylene blue derivative—Photolase
system– Laser 810 nm—indocyanine green—EmunDo,
PerioGreen
_aPDT/PDT application in dentistry
Periodontology
Periodontology is the most prominent field of appli-cation for aPDT/PDT in dentistry to date. aPDT can be ap-plied specifically to target infected and contaminatedtissues or organic structures (periodontitis, periimplan-
Photodynamic therapies –Blue versus GreenAuthor_Dr Michael Hopp & Prof. Dr Reiner Biffar, Germany
10 I laser1_2013
Fig. 1
Fig. 2
Fig. 3
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AALZ_DGL_A4_laser113.pdf 1AALZ_DGL_A4_laser113.pdf 1 21.02.13 16:4321.02.13 16:43
Fig. 4_Intensity differences between
methylene blue (Blue Sensitizer,
HELBO, on the left) and toluidine
blue O (PACT, Cumdente,
on the right).
Case 1
Fig. 5_ Blue Sensitizer (HELBO)
applied to the sulcus.
Fig. 6_Laser light application
to the sulcus.
Case 2
Fig. 7_Measuring of progressing
bone resorption.
Fig. 8_Selective laser application
according to protocol.
Fig. 9_Inflammation-free condition
after 30 days.
Case 3
Fig. 10_Entrance to the inflamed
bone cavity after pus removal.
Fig. 11_Application of Blue
Sensitizer to the cavity.
Fig. 12_ TeraLite laser application.
Fig. 13_Removal of a bone
sequestrum from a bone cavity which
is almost completely epithelialised.
Fig. 13Fig. 12
Fig. 4 Fig. 5
Fig. 6 Fig. 7
Fig. 8 Fig. 9
Fig. 10 Fig. 11
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12 I laser1_2013
research I
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titis, infected mucosa or other areas of the patient’sskin).2-4 De Olivera et al.5 have reached comparable clin-ical results in their split-mouth investigations of aPDT incomparison to scaling and root planing (SRP). Wilson etal.6,7 have introduced the basics of low-level laser appli-cation with photosensitive substances in bacteria.
PDT treatment can be applied in dentition damagedby periodontitis:
1. As an immediate measure in acute gingivitis or peri-odontitis.
2. As a consecutive conventional periodontitis therapyin intervals of three days up to two weeks.
3. In unspecific prophylactic bacterial reduction in ex-tended professional tooth cleaning in intervals ofone to two years.3,8
aPDT applications have provided good results and asignificant reduction of the microbial load.9 In peri-odontitis caused by Porphyromonas gingivalis, a re-duced bone resorption in comparison to the controlgroup was observed in animal studies after colouringagent-activated laser treatment with toluidine blue.10
Comparing different laser systems with regard to theiradjuvant application, Brink and Romanos11,12 showedthat mechanical cleansing combined with aPDT re-sulted in the highest possible reduction of microbes inthe dental pockets. The highest reduction was verifiedafter three months. Actinobacillus actinomycetem-
comitans, now named Aggregatibacter actino-
mycetemcomitans, was eliminated after treatmentwith one of the systems (aPDT, 1,064 nm laser, 980 nmlaser). Investigations in patients of an open dental prac-tice showed a microbial reduction of 80,11 % after fourweeks and 91,37 % after twelve weeks compared to theinitial findings of aPDT in comparison to the above-mentioned laser systems. Sulcus bleeding index, pocketdepths and mobility of the teeth were significantly re-duced after treatment. In cases of minimal pocketdepths of three to four millimetres, aPDT can be the soletherapy. A fast recolonialisation of the periodontic tis-sue was minimised by PDT after two days.13They showedin their study that roughly 95 % of A. actinomycetem-
comitans and F. nucleatum and 99–100 % of the black-pigmented bacteria, such as P. gingivalis and P. inter-
medius and S. sanguis were eliminated. Rühling et al.14
did not note any advantages in PDT with regard to con-ventional treatment, but they admit that it can be an al-ternative. The initial treatment of periodontitis withamoxicillin and metronidazole (Winckelhoff cocktail) isfavoured by Griffiths et al.15 over an invasive treatment.An initial administration of antibiotics achieved betterresults than did subsequent treatment. A critical dis-cussion on the administration of metronidazole wasconducted only reluctantly. Procedures which arespecifically tropical (aPDT) and of a high selectivity aremore favourable in the aftercare of periodontally dam-
aged patients than broad-spectrum antibiotic treat-ments, which have various side effects and are often ac-companied with a limited compliance of the patients.16
Hägi & Sculean17 do not consider aPDT which is free from side effects and bactericidal a significant im-provement over antibiotic therapies, with the exceptionof severe and aggressive periodontitis.
The importance of pulpal temperature rise in peri-odontal treatments is described by El Yazami et al.18withan average temperature rise of roughly 0,5°C at 5,46 J/cm2 for 60 s with a diode laser of 660 nm (output:20 mW). Another advantage of aPDT is that it can be per-formed by a trained assistant if the patient has beentreated accordingly before. This kind of laser treatment(class 3B) is a physical, non-invasive therapy19which canbe delegated. Whereas the doctor is in charge of super-vision, control and overall responsibility of delegatedtasks with respect to a commission with single alloca-tion defined in concrete terms, he does not have to exe-cute the delegated tasks. Treatment is free of pain andnon-destructive on the tissues. However, its applicationin the bleeding dental pocket would neutralise its effectalmost completely. Therefore, a time-shift is recom-mended in this treatment. The activation of epitheliaand bone growth, vascularisation and an increase inphosphorylation are important for the production ofATP in the healing phase and their effects on mitochon-dria and enzymes of the respiratory chain have longbeen assumed.20,21 Bosatra22 showed that low-energylaser light induces the synthesis of fibres in the tissue in1984. Tocco et al.23 and Boulton et al.24 proved an in-crease in fibroblast growth by HeNe (630 nm) and IR laser application.
Implantology
In implantology, aPDT is applied in mucositis or man-ifested periimplantitis as a closed therapy or as an opentherapy in combination with surgical measures. An im-portant advantage of athermal laser applications is thelack of superficial changes of the titan and of ruptures.
Oral and maxillofacial surgery
In oral and maxillofacial surgery, photodynamic dis-infection of bone or soft tissue defects during the finalsurgical phase is an additional means of prevention. Lo-cal or systemic toxicity of the photosensitiser as well asdamage by the source of light can be excluded becauseof the low energy level. Lingohr et al.25 have describedadvantages with regard to apicoectomies. Neugebaueret al.26 have observed positive effects on the preventionof alveolar ostitis and the dolor post extractionem andConrad27 on the augmentation of infected alveoli. Na-gayoshi et al.28 have proved a complete sterilisation ofthe bone cavity via ICG with radiation for more than 60seconds at 810 nm in the periapical defect model. PDTcan be an alternative to lengthy and highly-dosed an-tibiotic therapies in the treatment and post treatment
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14 I laser1_2013
Case 4
Fig. 14_Injection of a surplus of TBO (Fotosan)
in the periodontal pockets.
Fig. 15_High transillumination in palatinal laser application.
Fig. 16_Laser light application in the mandible.
Case 5
Fig. 17_PDT disinfection of the tissue surfaces after periodontal
surgery.
Case 6
Fig. 18_Application of ICG solution.
Fig. 19_Transgingival laser application
with bare fibre.
Fig. 20_Laser application of the periodontal
pockets with bulb fibre.
Fig. 21_Removal of the inflamed pocket epithelium
at 300 mW.
Fig. 14 Fig. 15
Fig. 16 Fig. 17
Fig. 18 Fig. 19
Fig. 20 Fig. 21
research I
of bone defects induced by diphosphate. It can also becombined with surgery in the open operating site. A cru-cial side effect in laser therapy, however, is the stimula-tion of bone healing by photobiological effects of thelaser radiation. Guzzardella et al.29 have shown a signif-icant effect on bone defect healing by laser light of awavelength of 780 nm in their experiments. Laser irra-diation resulted in bone growth twice or three times theamount as compared to conventional treatment. Thesefindings have been confirmed by other studies30, whichhave also been published on red wavelengths of HeNelasers of low performance.31,32
Endodontics
Various low-consistent sensitisers and long slim ap-plicators are offered for the disinfection of the rootcanal. In addition to a possible discolouration of the rootdentine, there is the danger of a lack in in-depth mois-tening of the dentinal tubuli, which would limit the effect on the prepared pulp cavity. The application oftype-4 lasers must be considered with regard to safetyas well as material and time saving.
Cariology (dentine hardening)
In cariology, PDT procedures for dentine hardeningusually are time-dependent processes with blue colour-ing agents. Multiple applications are sensible and gen-
tle on the dentine, since carious dentine is disinfectedand removed layer-by-layer. Disinfection of the occlusalfissures is another possibility. A pulpal increase in tem-perature in the photodynamic treatment of deep cari-ous lesions results in a rise in temperature of 0,8 – 1°Cafter 30 seconds of irradiation.33 While a blue colouringagent only permits a disinfection of the carious dentine,ICG can also result in dentine removal. ICG-based cariesremoval was examined by Rodrigues de Sant’anna etal.34, who proved significant removal on the hard tissue.McNally et al.35 also describe erosive processes withoutany ruptures in the substance, whereas the temperaturerise in the pulpal area of extracted teeth depends on theICG concentration as well as the laser performance.Caries removal via ICG is more invasive and has hardlybeen examined to date. However, it suffices with onesingle application. It remains to be seen whether it posesa real alternative to Er:YAG and Er,Cr:YSGG lasers.
Skin und mucosa infections
Infections of mucosa or skin are a common oral orperiodontal phenomenon, resulting from bacterial orviral infections. Here, PDT can be performed by the den-tist as well as the dermatologist and other specialists.Zolfaghari et al.36have proved a photodynamic effect onStaph. aureus by the combination of methylene blueand laser light. In recent years, mycoses of the oral cav-
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I research
16 I laser1_2013
Fig. 30
Fig. 22 Fig. 23
Fig. 24 Fig. 25
Fig. 26 Fig. 27
Fig. 28 Fig. 29
Case 7
Fig. 22_Transgingival laser
application.
Fig. 23_Laser application in the
dental pockets with bulb fibre.
Fig. 24_Application of the ICG
solution in the periodontal pockets.
Fig. 25_Intrasulcular laser
application in the mandible.
Fig. 26_PDT/PTT treatment.
Fig. 27_Condition free from
inflammation and swelling
after two weeks.
Case 8
Fig. 28_Insertion of the ICG colouring agent
(EmunDo, ARC).
Fig. 29_Laser application with bulb fibre.
Fig. 30_Healing of the acute episode after
three weeks.
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ity have become a focal point of dental treatment. Here,photodynamic therapies are a new aspect in treating su-perficial mycotic infections. The target, which is the my-cotic cell, as well as other microorganisms are elimi-nated, since the colouring agents are unspecific. In der-matology and mycotic therapy, activation via conven-tional or LED light systems have been favoured so far,since they are simple, reasonably priced and easy to ap-ply on extensive surfaces. Malachite green, which is atriphenylmethan-based colouring agent activated at810 nm, has been used against Candida spp., whereasblue photosensitisers have been successfully applied inmycoses of mice in animal studies.37The colouring agentGreen 2 W, activated at 630 nm, has provided good re-sults in an in vitro study on Aspergillus fumingatus.38
Mucosa changes
The selective treatment of malign or semi-malignmucosa changes is often bound to special photosensi-tisers which are activated by differing wavelengths. Por-phyrin and its derivatives are often used for PDT in can-cer cells. 5-aminolaevuline acid (5-ALA) is applied in fluorescence diagnostics in urology, gynaecology anddermatology as well as in the therapy of malign degen-erations, such as urethral carcinomas in their initialstage. Methylene blue is applied as well, but its low in-sertion depth of less than 20 µm minimizes its effect.
Extended prophylaxis
PDT can prove an effective measure for an extensiveprophylaxis to maintain healthy, but reduced gingivawhich is unresponsive to further treatment after peri-odontitis.8 Generally speaking, low-level lasers are ap-plied more and more by trained assistants, especially inthe area of prophylaxis. If required, prophylaxis assis-tants can inform the patient on their own and performthe relevant tasks according to the therapy chosen bythe dentist. In addition to an increase in treatment effi-ciency, delegating these tasks will result in a motivationboost for the assistant, who can now work more au-tonomously.
_Photodynamic disinfection
Photodynamic disinfection auf prosthetics and im-pressions has been investigated in experiments. Vla-hova et al.39 have tested various Phthalocyanine photo-sensitisers, activated with an LED light at 635 nm, withregard to their performance in disinfection of MRSA,Staph. aeruginosa and C. albicans. The disinfection ofsilicones and composites by Ga-Phthalocyanine was100 % and 40 % in Alginates. Therefore, Phthalocyaninecan be seen as an alternative to other, specialised disin-fection methods.
Veterinary Medicine
In addition to human medicine and dentistry, veteri-nary medicine is another field in which photodynamic
therapies have proved to be successful treatment meth-ods. Toth et al.40 have given convincing results for thegentle treatment of infected extensive surface wounds,for instance eosinophil ulcerated dermatitis in horses.
_Photosensitisers in dentistry
In dental procedures, four photosensitisers are cur-rently applied. These are indocyanine green and threekinds of phenotiazines: methylene blue, toluidine blue,methylene blue derivatives. Whereas the effect of thesecolouring agents on bacteria can vary, their charge—an-ionic or cationic—seems to play a vital role in their bind-ing to bacteria (gram positive or negative), as dopreparatory medications or trypsinisation.41
1. Methylene blue
Methylene blue (MB), 3,7-bis(Dimethylamino)-phe-nothiazin-5-ium chloride (Fig. 1), was synthesised bychemist Henrich Caro (BASF, Germany) in 1876. Alreadyin 1885 did Paul Ehrlich realise its advantages with re-gard to selective colouring in histology. Methylene bluecan be applied as a vital colouring agent in the vitalstaining of live tissues. In the past, it was seen as an im-portant antidote in nitrite or aniline poisoning. Its appli-cation as an antiseptic, for example in malaria, enteritisand pyelitis cases, has become obsolete. Methylene bluetoday is used as an antirheumatic and as a means of di-agnosis. It has been considered a treatment option forAlzheimer’s disease for some time and several investi-gations were conducted. Its low toxicity makes it an un-problematic substance in medicine, which can be seenfrom its MAC (maximum workplace concentration)value of 1,180 mg/kg (rat, perorally). If larger quantities(0.5 ml and above) of methylene blue are swallowed,urine will assume a green colour.42Its absorption of max661 nm makes this cationic colouring agent an idealsensitiser for red laser applications.
2. Toluidine blue O
Toluidine blue O (TBO), also known as tolonium chlo-ride (Fig. 2), is a blue colouring agent (3-amino-7-[di-methylamino]-2-methylphenothiazine) which is usedfor histological and intravital dyeing or as an antidotein methemoglobin generator poisonings. In dentistryand maxillofacial medicine, it is used as a test to differ-entiate between benign and malign precancerousleukoplakia. However, the specificity of this test is toolow.
Similarly to methylene blue, toluidine blue has a lowantiseptic effect. Its low toxicity renders it an unprob-lematic medical substance: its LD50 in rats when ad-ministered intraperitoneally is 215 mg kg-1. If largerquantities of toluidine blue O are swallowed, urine willassume a green colour. An absorption of max 635makes this colouring agent ideal for red lasers of thiswavelength.43
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3. Methylene blue derivatives
Methylene blue derivatives are applied with wave-lengths of 810 nm. There are only a few case descriptionsin the literature. Balboaca et al.44 have proved a shift inthe activation wavelength to 810 nm in methylene bluederivatives. However, no exact description of the mole-cule applied in the Photolase system (Photolase Europe,Ltd., Hamburg), based on 810 nm lasers, was found.There was an attempt to explain the process by “changesin the colouring agent molecules based on pheno -thiazine causing a ‘long-waved flank’ which results inoptical activation and irradiation of 810 nm”. Since thenecessary light dose can be achieved faster, treatmenttime is said to be shortened considerably. In addition, anincrease in the output of reactive oxygen radicals (ROS)is said to result from the undiluted solution.45 Other de-rivatives, such as New Methylene blue (NMB, 556416-1G; Sigma) can reduce the activation wavelength simi-larly to toluidine blue O.37
4. Indocyanine green
Indocyanine green (ICG, Fig. 3), 1,7-Bis(1,1-di-methyl-3-[4-sulfobutyl]-1H-benz[e]indol-2-yl)hep-tamethinium-betain-Na, well-known in liver functiontests, ophthalmology and onkology46, is new in dentistrybut seems promising for periodontology.
Indocyanine green is an anionic photosensitiserwhich is activated at 810 nm and leads to photo-oxida-tion. Here, the intra- and extracellular ICG concentra-tion is vital and must comprise a temporal component.47
Its absorption depends on the dissolving medium,bonds to the plasma proteins and its concentration.48
The overall effect of indocyanine green consists of 20per cent photodynamics (PDT) as well as fluorescenceand, mainly, of its photothermal effect (PTT).49 Thethresholds in tissue coagulation are employed to makeuse of photothermal effects free from side effects intherapies of the ciliary body, which is a highly sensitivetissue.50 For this, the dose-effect graph must be takeninto account precisely. ICG in the form of sodium salt iscombined with sodium iodide of up to 5 % to improvesolutions for medical treatment.51 In dentistry, the ma-terial used is free from iodide (EmunDo, ARC) or con-tains normal quantities of iodide (PerioGreen, elexxion).There are no findings on how far material containing io-dide can trigger allergies or anaphylactic reactions indentistry. Most of the medical treatments consider aninjection of ICG and its concentration in the target cells.
The photothermal effect of injected ICG has been ap-plied in the therapy of telangiectatic leg veins in orderto obliterate tissue changes subcutaneously in an ele-gant manner.52 Laser energies of 100 – 110 J/cm2 are ap-plied. Mathematical Modellation and comparison withthe results of scientific experiments, ICG concentrationand laser performance can be optimised with regard tothe tissue. Thus, excessive heating of the tissue can be
prevented.53 The letal but selective effect of ICG on bac-teria is a well-established fact. While Staphyloccocus
aureus and Strep. pyogenes are eliminated by the pho-todynamic effect, P. aerugenosa remains intact. The en-ergy density applied was 411 J/cm2. An effective con-centration was reached already at 25 µg/ml.54 ICG lasersystems can advance acne treatments significantly insubstituting or accompanying conventional therapies,since the agents applied did not show any serious sideeffects.55
Szeimies et al.56 observed excellent effects in thetreatment of AIDS-associated Kaposi sarcomas on theouter skin, resulting in an almost complete remission ofthe sarcomas. Laser welding of wounds as described byKhosroshahi et al.57 can be performed with a relativelylow energy, avoiding in-depth tissues by topically ap-plied ICG. The future will show if this technique can beinvolved in welding neural tissue. An effective impactof ICG on squamous cancer of the oral mucosa wasproved by Lim & Oh.58 The percentage of apoptotic cellsincreased to 84 % six hours after ICG-PDT with 20 µMICG. The percentage of dead cells rose to 65 % in threehours of applying a solution of 200 µM ICG. Contrarilyto other studies, they activated ICG via LED of a wave-length of 785 nm. This procedure can advance mini-mally invasive cancer therapy in the oral cavity signifi-cantly. Urbanska et al.59 observed a high effectivenessof ICG in the pre-treatment of melanoma cells whichwas five to ten times higher than the effects of conven-tional laser treatment with diode lasers of a wavelengthof 700 – 800 nm. Experts are currently working on theimplementation of polyurethane composites in theproduction of intravenous catheters, since the antimi-crobial activity against gram-positive bacteria results ina reduction of 2 log10 units, such as methicillin-resist-ant Staphylococcus aureaus (MRSA) and Staphylococ-
cus epidermidis after 15 minutes of exposure at an en-ergy density of 31,83 J/cm2. Gram-negative bacteria (Es-
cherichia coli and Pseudomonas aeruginosa) showedonly little reaction under the same conditions: they werereduced by 0.5 log10-units.60
ICG is not resorbed by the intestinal mucosa, whichis why the danger of uncontrolled swallowing of thematerial is non-existent. The metabolization of indo-cyanine green occurs microsomally in the liver and is ex-creted only via liver and the pancreatic ducts.61 ICG is ofa low toxicity. LD50 values in animals were 60 mg/kg inmice and 87 mg/kg in rats.51 Restrictions of the visualfield with regard to the visual sense after intraocular ICGapplication have further enhanced the discussion aboutthe toxicity of the material. Engel et al.49 proved in cel-lular experiments that the material which disintegratesduring photo oxidation obtains a cell-inhibiting effectcaused by its fission and decomposition products. ICGis suitable for liver function diagnostics because of itscomplete metabolization and excretion by the liver. In
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addition, it can help differentiate between a normal,healthy liver, liver dysfunctions and drug- or medicinerelated liver anomalies because of its specific clearancerate.62 ICG which is administered intravenously has ahalf-life of three to four minutes, depending on theliver performance. During pregnancy, its administra-tion is not risk-free. Only few allergic reactions on ICGcontaining iodine have been described in the litera-ture.63
_Indocyanine green in dentistry
Only little published data is available on indocyaninegreen in dentistry, mostly in vitro studies, figures basedon experience and case studies. Its application in peri-odontology has been postulated after successful in vitro
tests with regard to periodontally pathogen germs byBoehm & Ciancio.64 This however has not yet beenproved by patient studies. More extensive studies arecurrently being conducted.
From the practitioner’s point of view, the integrationof PDT and ICG in aftercare and the long-term stabilisa-tion of periodontitis/periimplantitis have proved ofvalue.8 Combined with ICG photosensitisers, low laserperformance has a good effect on various bacteria ofthe biofilm as well as the periodontal pockets. Therefore,
it can be used in support of conventional mechanicalmethods.
McNally et al.35 evaluate the reduced hardware incolourant-based laser ablation of carious enamel anddentine as an advantage over Er:YAG lasers. In this re-gard, advantages postulated with respect to heat devel-opment, in-depth irradiation, pulpal damage, con-sumption of consumables and time must be discussedcritically, even if the authors conclude that the dentinetreated has no fissures and shows hardness similar tohealthy material. With regard to the colouring agent, itcan be argued that, in addition to various chemicalproperties, a differing quality and highly varying con-centration of active substances are currently being of-fered. Figure 4 gives a split-mouth depiction of MB(Helbo) and TBO (Cumdente) photosensitisers. Somemanufacturers do not declare the concentration of ac-tive substances in their colouring agents. The consis-tency of the solution has to match its application. Lowconsistencies are recommended for areas which arehard to moisten, such as root canals, while high viscosi-ties are more appropriate for surface defects or areas ofa long retention time such as the periodontal pockets.Each package is of a different user-friendliness and ap-plicability. While blue dyes are provided in a dissolvedform for direct application, the crystalline ICG has to be
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dissolved in a puncture vial first. The reason for this is itsshort shelf life of roughly four hours.48
Since photosensitisers are designed for one applica-tion (ICG) or one patient and thus are of a short shelf life(blue colouring agents), the packing quantities are de-cisive. Packages of 0.5 to 1 ml are optimal, while quan-tities of more than 1 ml are too large and result in a highproportion of waste and high costs. In addition, pricesdiffer significantly between the various providers andactive ingredients.
_Photoactivation
Light sources based on laser, LED or plasma lamps areappropriate for photoactivation. Conversely, the physi-cal and therapeutical differences resulting from thevariation in light sources are hardly known. Clinically,there are no differences in the results of identical pro-cedures, wavelengths and powers of the light sources.There are no experiments with regard to the possible dif-ferences of the photobiological effects on healing andstimulation of the tissues in the various light sources(laser or LED). It seemed more important to find outabout optical fibres and applicators appropriate to leadthe light to its site of action effectively and without loss.For this, the material of the optical fibre as well as thequality of the optical coupling points play an importantrole, as they decide about power losses and, finally, theprice. From a hygienic point of view, disposable applica-tors are preferable to permanent fibres.
In intrasulcular applications, the laser light reachesthe colouring agent immediately and thus is applied di-rectly to its site of action. A small percentage of the lightis emitted to the depths where it can trigger photobio-logical effects. Mucosal thickness, blood circulation,mucosal pigmentation, absorption in the tissue, lightparameters, remains of blood, secretions and colouringagents as well as absorption variations during treat-ment influence transgingival irradiation. It remains tobe discussed whether the concentration of the sensi-tiser and exposure time are corresponding with the ir-radiation parameters and whether the graphs of the ac-tion time are extrapolated with regard to unfavourableanatomic cases. Light plays a vital role in the photobio-logical effect. Fotosan (LOSER & CO, Leverkusen, Ger-many) is a system which works exclusively transgingi-vally. Due to the many still unknown components, thecurrent trend is directed towards intrasulcular light ap-plications or combined intrasulcular transgingival ap-plications.
_Clinical cases
Therapies based on blue colouring agents are rela-tively simple. The sensitiser is applied to the periodon-tal pocket which must be free from bleeding after dis-
infection. It is then put to effect by diffusion for a con-sistent colouration of the aquatic space and is finallyactivated by laser. Most of these systems work with ap-plicators which are injected in the periodontal pocket.Transgingival activation has become more and moreprominent, in which case laser parameters must be inaccordance with anatomical and physiological proper-ties.
Case 1: Consecutive periodontitis therapy
In the following case, a 49-year-old female patientis treated by the PDT system HELBO (Bredent, Senden,Germany). During her regular dental cleaning, a newperiodontal episode was noted after a successful laserperiodontitis treatment four years earlier. The systemused for this periodontal treatment included the TheraLite laser (660 nm, 100 mW), HELBO® 3-D pocketprobe and the light absorbing colouring agentsHELBO® Blue Photosensitiser (methylene blue). A timecontroller was used for an easy and controllable appli-cation of dye exposure and application times of thelaser light on the treatment site. aPDT should succeedthe professional dental cleansing after three to 14 dayswith respect to the degree of inflammation and latentbleeding tendency. A bleeding sulcus might have a re-ductive effect on the colouring agent penetration intothe pockets and thus on the final treatment result.However, immediate treatment is still an option. Treat-ment starts with the application of the colouring agentsolution (Fig. 5) circular around the teeth. The distribu-tion of the intensely blue colouring agent can be wellcontrolled. Exposure time is a minimum of three min-utes, since this step is determined by diffusion and themolecules of the colouring agent penetrate into thebiofilm, where they adsorb unspecifically and specifi-cally to the bacteria via forces of attraction caused byelectric charges. After the exposure, the colouringagent is sprayed off (Fig. 6) and the periodontal pock-ets are rinsed in order to avoid an unnecessary absorp-tion loss of the laser light in the free colouring agents.All steps of the procedure which depend on time arepaced by the time controller (Fig. 7). The tapered fibreapplicator of the activated laser can be injected easilyin the pockets and the activation energy (laser light) canbe applied (Fig. 8). Depending on the individual tooth,four to six points of the pockets are irradiated. Thetreatment success was monitored after about threeweeks, which showed a reduction in the depth of theperiodontal pockets of a minimum of three millimetres(Fig. 9). In severe and therapy-resistant cases, treat-ment can be repeated on a weekly basis.
Case 2: Periimplantitis therapy in the acute phase
An acute periimplant inflammation can be a dra-matic experience for the patient and a challenge forhis dentist. Inflammation, bleeding, pain, pocket for-mation and loss of the periimplant attachment de-fined the clinical picture of the 56-year old female pa-
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DGL | German Society for Laser Dentistry 22nd International Annual Congress
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Abstract: Please arrange the text in the order of:• Purpose: Give a brief overview of the topic and in this context state the main objective of the study.
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tient (Fig. 10) who presented 10 years post-op with il-iac crest bone which was applied via onlay procedureafter resorption. Probing depth (Fig. 11) and radiolog-ical bone loss are decisive parameters of the diagno-sis. In order to assess the severity of the damage andtreatment options, the CIST system by Lang et al.65 isan appropriate measure. The overall treatment proce-dure is conducted according to protocol: rinsing ofthe periodontal pockets, injection of the colouringagents (Fig. 12) and laser application according to theperimeters for single-rooted teeth for 20 seconds inall four sites (Fig. 13). Here, the applicator is placed onthe base of the pockets. After laser treatment, thepockets are rinsed and then dried to instill the CHX gel(Fig. 14) and insert the prosthesis. This procedure is re-peated weekly. Home care includes cleansing of theprosthesis and reciprocal instillation of CHX gel andDurimplant. After only a short amount of time, an in-flammation-free result was reached (Fig. 15).
Case 3: Osteonecrosis treatment after bisphospho-
nate therapy
The dramatic event of multiple osteonecrosis ofthe maxilla occurred in a 86-year-old male patient af-ter long-term bisphosphonate therapy. Bisphospho-nates have been administered for more than 20 yearsin multiple myelomas (plasmacytoma), mammarycarcinoma, kidney tumours, prostate carcinoma, os-teoporosis and rheumatism. In this case, a multiplemyeloma was diagnosed, but it was not confirmedlater. The initial OPG of the patient (Fig. 16) showed aremaining dentition in the maxilla, teeth 17, 22, weresituated in the devitalised bone and had to be re-moved. Markers of the devitalised bone are the lack inbleeding and hardly any resistance against extractiondue to the destruction of the periodontium. A surgi-cal revision of the maxilla was conducted INT with lossof the alveolar ridge and the maxillary sinus. Afterhealing, the maxilla was fitted with a telescope obtu-rator prosthesis (Fig. 17). Resulting from the follow-ing osteonecrosis episode, tooth 21 was lost and leftan persisting ulcerating defect in regio 22/23 (Fig. 18).After deciding against another surgical therapy, aconservative long-term treatment via PDT was pre-ferred over highly dosed antibiotics. Upon pus re-moval and rinsing, the entrance to an inflamed bonecavity with surrounding, highly reactive granulationbecame visible (Fig. 19). Blue Sensitiser (HELBO) wasapplied (Fig. 20) and left to take effect over a relativelylong amount of time of roughly ten minutes. The re-mains of the colouring agent were rinsed (Fig. 21) andlaser application (TeraLite laser, Fig. 22) followed. Af-ter several PDT applications during the following twoweeks and the reduction of inflammatory complica-tions, exposed bone became visible. This was removedas a bone sequestrum from an almost completely ep-ithelialized bone cavity (Fig. 23). The defect was againlased via PDT (Fig. 24) and then healed autonomously
(Fig. 25). Even three years later, an irritation-free alve-olar ridge without any signs of a relapse was diag-nosed (Fig. 26).
Case 4: Transgingival periodontitis treatment
A 68-year-old female patient presented with den-tures in urgent need for restoration. Periodontaltreatment was conducted in the form of PDT with TBOin the transgingival activation mode via the FotoSansystem. The special feature of this device is the lightsource with a 15-Watts LED. Photosensitiser was in-serted in the dental pockets after disinfection (Fig. 27)and left to take effect. The surplus of photosensitiserwas removed before laser application. Since only ashortened row of teeth existed, including the secondpremolars, the photosensitiser was applied in onestep at all teeth. The laminar applicator of the deviceis placed directly on the mucosa. The light is appliedsegmentally and tooth-by-tooth for activation. Fig-ures 28 and 29 show the high transillumination of thetissue, which is why there is sufficient activation en-ergy for the photosensitiser within the pockets. Afterirradiation, the remains of the sensitiser are sprayedof and CHX gel is placed in the pockets.
Case 5: Photodynamic Post treatment after periodontal
surgery
In the days following a surgical periodontal proce-dure, oral hygiene is limited. Pain, swelling, tendency to-wards bleeding and the danger of damage to the soft tis-sue structures are significant restrains to mechanicalcleansing. Some regenerative and augmentative proce-dures, such as the application of enamel matrix proteins(Emdogain, Straumann) requires only chemical clean-ing via a disinfecting rinsing in the first few days aftersurgery. An efficient bactericidal method without anymechanical intervention is the application of PDT on thesurfaces of mucosa, teeth and interdentally. Already inthe year 2000 did Frentzen et al.66 point out the possi-bility of a “laser tooth brush”. This principle was appliedsuccessfully in the following case of a female patientwith progressed aggressive periodontitis after surgicalperiodontal treatment via Emdogain. At the first follow-up two days after surgery, the postoperative conditioncorresponded with the healing process and a photody-namic cleaning of the teeth was conducted. Figure 30depicts the activation of the blue colouring agent witha laser by R+J (Berlin, Germany) and a therapeutic ap-proach which allows light application on the surface.
Case 6: Treatment of chronic periodontitis
A 46-year-old patient presented with chronic peri-odontitis caused by insufficient care. Bone loss andcrater-like irruptions became visible in the OPG. Aftercleaning the tooth necks (SRP), a combined PDT and PTTtreatment was conducted in a separate session. Super-ficial anaesthesia with Oraqix is sufficient for light casesof periodontitis. After rinsing the pockets with physio-
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logical saline, an ICG solution (EmuDo, ARC) is appliedand the first laser application is performed transgingi-vally with bare fibre (400 mW, 810 nm, Q 810, HenrySchein, Germany) for ten seconds per periodontal unitfrom vestibular to palatinal/lingual. Alternatively tobare fibres, the therapy, transgingival or bleaching handpiece can be used. The second step consists of laser ap-plication at and in the dental pockets with bulb fibresand, depending on the condition of the mucosa, with200 up to 300 mW. Depending on size and undercut,eight to twelve seconds of irradiation are estimatedtime frames. Constant movement is necessary since thephotothermal effect is significant already in low pow-ers and excessive burns must be avoided. The inflamedinner epithelium of the periodontal pocket can only beremoved efficiently with a power of 300 mW. The sameprocedure is conducted via a palatinal approach. Be-cause of the therapeutic character of the minimally in-vasive approach, the same principles that are applied tooperative laser-surgical procedures are adopted toPDTPTT with extended hygienic demands. For example,protective glasses have to be worn in any applicationsof type-4 lasers of a wavelength of 810 nm. When thePDT/PTT treatment is finished, the sulcus is rinsed andthe treatment result will show that a minimally invasiveprocedure was performed. After treating all five quad-rants, and after the periodontium has finished healing,only slight discolourations by the CHX rinsing solutionwere visible after four weeks. The development of theclinical parameters and the pocket depths indicate goodfinal results.
Case 7: Acute gingivitis/periodontitis treatment
Other than PDT with blue colouring agents, whichcan be applied without any tissue damage, ICG-basedmethods allow the selective removal of the inner ep-ithelia of the periodontal pocket from the sulcus at 300 mW and via bulb fibre. This is usually the standardin photothermal therapy (PTT).
The 64-year-old female patient presented with anacute inflamed periodontitis episode and a massive my-cotic infection by Candida albicans (CFU +++) in theoral cavity and on the lips five years after restoration ofthe dentures. The mycosis was treated with a combina-tion of Amphotericin B and Mikonazol. The periodontaltreatment was conducted after surface anaesthesiawith Oraqix by successive mechanical cleansing fol-lowed by PDT/PTT. Laser application was conductedwith the Q810 laser (Henry Schein) with universal fibreand disposable bare and bulb fibre attachments. Afterrinsing and application of the EmunDo photosensitiser,transgingival laser application with the bare fibre at400 mW was performed. Afterwards, the periodontalpockets were lasered with bulb fibre at 300 mW accord-ing to protocol. A light de-epithelialisation of the mar-ginal periodontium at 400 mW and rinsing ensued.Since only anterior dentures have remained, this case is
treated jaw-by-jaw and not quadrant-by-quadrant. Af-ter rising, the ICG solution is inserted in the periodontalpockets of the mandible. In addition, transgingival andintrasulcular laser application and de-epithelialisationare conducted. Finally, CHX gel is applied to the pocketsand the cone prosthesis as a reservoir. Only shortly afterPTT, the patient appears free from inflammation andswelling. The periodontal pockets depths showed con-vincing results and there are no periodontal inflamma-tions when the prosthesis is worn. Bleeding cannot beprovoked.
Case 8: Therapy of advanced periimplantitis
A 79-year-old patient presented with advancedperiimplantitis. In agreement with the patient, conser-vative, non-invasive maintenance measures are taken,preferably without any antibiotics. Home care involvesmechanical tooth cleaning, rinsing for disinfection, in-stillation of CHX gel in the periimplant sulcus andDurimplant application. Advanced bone loss becamevisible on the X-ray and was proved by the measuredpocket depths. There was neither block nor infiltrationanaesthesia, but an intrasulcular surface anaesthesiavia Oraqix. After careful cleansing, the ICG photosensi-tiser (EmunDo, ARC) is inserted and activated transgin-givally via bare fibre at 400 mW and 810 nm (Q810,Henry Schein) as well as bulb fibre at 300 mW. A singletreatment already resulted in immediate remission ofthe inflammation. A stable condition was achieved af-ter healing. However, this success should not blind us tothe fact that this is only a symptomatic treatment whichhardly contributes to the formation of new bone undmust be evaluated clinically as a dormant state of peri-implantitis.
_Economic aspects of PDT application
From an economic point of view, PDT methods aremore costly than laser treatments exclusively with type-4 lasers, due to the fact the colouring agents (photo-sensitisers) and sometimes disposable applicators haveto be used. Therefore, possible applications have to beexamined with regard to more efficient methods whichcan be used instead of photodynamic caries hardening,which has to be repeated on consecutive treatmentdays. Periodontal treatment of singular teeth which isbased solely on laser or selective caries removal viaEr:YAG laser is one possible alterantive.
_Conclusion
The integration of PDT has proved itself in the treat-ment and post-treatment with long-term stabilisationof periodontitis/perioimplantitis.8 Low laser powercombined with photosensitisers on various bacteria ofthe biofilm and in the periodontal pocket showed goodresults and can therefore be used in addition to con-ventional mechanical cleansing. Thus, PDT can already
research I
be found in a compilation of evidence-based laser-sup-ported treatment methods.67
All light-activated procedures have been viewed ascomparable to PDT treatment and were said to differonly in their colouring agents, their intrinsic effect andthe wavelength used for activation. This assessment,however, cannot be supported when the real modes ofaction are taken in consideration. Because of the goodadhesiveness of the colouring agents, depending on ex-posure time, photodynamic therapies with blue colour-ing agents encompass a photodynamic effect as well assolely disinfecting properties of the dyes along with anefficacy which exceeds the treatment. There is howeverno intrinsic disinfecting effect in photodynamic thera-pies based on indocyanine green. The therapeutical ef-fect is limited to the treatment time, which is theamount of time in which the colouring agent is acti-vated by laser. This effect consists of photodynamics(PDT) with a percentage of 20 %, fluorescence and,mainly, photothermal effects (PTT).49 These compo-nents of the therapeutical effect explain the limited de-struction of the pocket epithelium and minimisedbleeding. Another sensible application of the wave-length of 810 nm was added when ICG was introduced.In both of the two applications, a strict protocol whichincludes the abidance to the exposure and activationtimes of the colouring agents as well as rinsing and dry-ing procedures and the level of laser energy applied is vi-tal. While an extension of the activation time does notresult in tissue damages in PDT based on methylene ortoluidine blue, the specified treatment time must not beexceed in ICG. Moreover, the intrinsic effect of the pho-tosensitiser seems to be a philosophical problem, sincethe treatment success does not depend on the questionif the effect of the photosensitiser occurs when acti-vated or without activation. Both PDT and combinedPDT/PTT are gentle, yet efficient therapy methods foracute and chronic periodontal and periimplant defects.A separation between PDT und treatments with exten-sive bleeding are recommended, since the colouringagent could be rinsed or diluted in an invalid level by thebleeding. In addition, binding to plasma proteins orblood cells can also minimize the effect of the photo-sensitisers. PDT and PDT/PTT have increased the range oftreatment modalities for bisphononate-reduced necro-sis of the jaw and a multitude of infections. Economicaspects have to be taken into account in PDT or PDT/PTTapplication in single teeth, endodontics, caries harden-ing, and disinfection of the surgical site, among others.Because of the high efficiency of PTT when ICG is ap-plied, a singular therapy per cycle will be sufficient,whereas phenotiazine-based colouring agents will ne-cessitate the repetition of the treatment within short in-tervals. Both of the two procedures cannot necessarilysubstitute antibiotics, but they can contribute signifi-cantly to reduced antibiotic applications. The bacterialload in the periodontal pockets can be reduced consid-
erably, which is an advantage with regard to sluicingbacteria in immediately following periodontal surger-ies. ICG is more efficient because of its proved in-deptheffects which include PTT effects on microorganisms inbordering tissues. PTT is followed by healing of the de-fect in case of laser light applications beyond a thresh-old level causing tissue damages. This healing usuallyprocesses fast and does not cause retractions since thedefect is limited in size.
PDT and combined PDT/PTT cannot be comparedwith or replace each other. Although both of the twoprocedures can be applied equally, the wishes of patientand dentist as well as therapy goals determine their us-age. PDT alone cannot be applied in non-invasive dele-gation procedures, the treatment of tissue defects orpain-free conservational therapies. A maximum powerof 0.2 Watts must not be exceeded in ICG-based thera-pies. Further investigations with regard to these treat-ment areas are necessary. If the treatment can be of aninvasive character or more extensive, combined PDT/PTTtreatment must be preferred. In most cases, this will beperformed by the dentist. Combined PDT/PTT indocya-nine-green based treatment constitutes a new instru-ment for the dentist, which offers laser treatment at lowlaser energy levels of 200 up to 400 mW as well as a lowphotodynamic component for the sterilisation of peri-odontal pockets via oxygen radicals and a photobiolog-ical component to support the healing process. There-fore, PTT can result in an improved performance in mod-ified mechanisms of action in periodontal treatmentwhen compared to blue-based PDT procedures._
Editorial note: A complete list of references is available
from the publisher.
I 25laser1_2013
Dr Michael Hopp
Zahnarztpraxis am KranoldplatzKranoldplatz 512209 Berlin-Lichterfelde, Germany
Prof. Dr Reiner Biffar
Ernst-Moritz-Arndt-Universität Greifswald Zentrum für Zahn-, Mund- und Kieferheilkunde Abteilung für Zahnärztliche Prothetik und Werkstoffkunde Direktor: Professor Dr. Reiner Biffar Rotgerberstraße 8 17489 Greifswald, Germany
Tel.: +49 3834 [email protected]
_contact laser
Scan for the German version ofthis article, including a moreextensive image gallery.
I case report
Figs. 1a & b_Treatment example
with the 980 nm diode laser at 2.5 W
(continuous wave);
(a) Typical presentation of a
haemangioma;
(b) Six weeks after the third session.
_Introduction
This is the story of how an attractive youngwoman became kissable once again, thanks to lasertherapy.
There are a surprisingly high number of patientswith growths mostly in the area of the lip vermil-ion, and virtually every person affected by this con-dition reports suffering under it. Strangely, wedentists are hardly ever asked by patients whatthese growths could be or how they can be treated.The reasons for this will be discussed later on in thisarticle—I can certainly promise that it will be worthyour while to read on.
The lesion has a bluish colour, occurs in differingsizes and especially on the lip, but also on the mu-cosa of the cheek or on the tongue and—as you al-
ready guessed—goes by the name of haemangioma.Haemangiomas are benign blood-vessel tumoursthat are usually prominent and localised, and rangefrom crimson to greyish-blue in colour. The bloodfilling can often be pressed out (spatula test).
In this article, I will discuss the various non-in-vasive, minimally invasive and invasive laser treat-ment methods for haemangiomas and how arather rare exophytic haemangioma can be treatedquickly, painlessly and aesthetically.
_The proper addressee
We should first address the interesting issue ofwhy dentists are rarely asked about treatment op-tions for these unsightly lip spots. The answer is assimple as it is surprising: the patients have alreadyasked someone else: their GP. Generally their fam-
Becoming kissable:Laser-assistedhaemangioma removalAuthor_Dr Darius Moghtader, Germany
26 I laser1_2013
Fig. 1bFig. 1a
[PICTURE: ©DIEGO CERVO]
ily doctor, or perhaps their dermatologist, or an-other doctor who does not normally work withlasers will, correctly, tell the patient that it is a be-nign tumour and that he or she would recommendleaving it well alone, as removal can lead to copi-ous bleeding and potentially to ugly and disfigur-ing scars after removal of the sutures. And ofcourse, the doctor is right. It is better to leave thescalpel alone and refer the patient to a specialisedcolleague, who ideally also has experience in plas-tic surgery, or even better to a laser specialist!
If this last description applies to you anyway,first obtain the patient’s informed consent, thenfurnish the patient with a quotation and—after thestatutorily prescribed reflection period—performthe treatment using your diode laser in less thanfive minutes. The next section will detail thismethod and other more invasive methods.
_The methods—From non-invasive to invasive
Non-invasive therapyFirst, let’s talk about the non-invasive haeman-
gioma therapy developed by the laser pioneer, Prof.Georgios E. Romanos. The haemangioma is treatedby means of a contact-free diode laser through avery thin ice wafer. The cooling effect of the ice pre-serves the texture of the lip.
Place an extremely thin ice wafer on the vas-cular tumour (Fig. 1a) and, after administering lo-cal anaesthetic, irradiate the tumour through theice using the preset haemangioma programme ofthe elexxion claros or 2.5 W (continuous wave)until coagulation is achieved. As the ice wafermelts, the laser must constantly be moved in or-der to prevent direct contact between laser andtissue.
The blue spot shrinks and success of the therapyis evident by the greyish-white colour of the tissue.The constant cooling protects the surface of thetissue, and the lip structure is fully preserved. As arule, this therapy must be repeated several timesuntil the haemangioma has been completely elim-inated (Fig. 1b).
Romanos originally described this procedure inthe Atlas of Laser Applications in Dentistry1 withreference to the Nd:YAG laser, which is the idealwavelength for this method owing to its greaterdepth of penetration compared with the diodelaser.
How does it work? Laser light of the above-mentioned wavelengths has a high selective ab-sorption in haemoglobin and in certain pigments.This results in energy bundling in the tumour tis-sue and leads to coagulation and destruction of thevascular tumour.
What laser types are suitable? Lasers with agreater depth of penetration and high haemoglo-bin absorption are more advantageous for this application: argon, Nd:YAG, 980 nm diode and 810 nm diode lasers.
case report I
Figs. 2a–d_Minimally invasive
therapy (Photographs courtesy of
Dr Bach).
I 27laser1_2013
Fig. 2a Fig. 2b Fig. 2c Fig. 2d
I case report
Figs. 3a–f_(a & b) Invasive therapy,
(c) one, (d) two, (e) six and (f) twelve
weeks post-op.
Minimally invasive therapyIn Laser (German edition), Dr Georg Bach2 pre-
sented a modified method to optimise this proce-dure for the 810 nm diode laser. With the newmethod, the haemangioma is treated directly andin a minimally invasive manner (Fig. 2a) using acannula embedded in an ice block (Figs. 2b & c). Theadvantages of this method are good results whileprotecting the lip structure by means of coolingwith ice, as well as the possibility of completingthe treatment in just one session (Fig. 2d).
Invasive therapyThis female patient consulted me about her lip
problem. She told me how unhappy she was thatshe was no longer being kissed because of thegrowth on her lip. Her lip texture and structure hadbeen affected (Fig. 3a). In this case, invasive ther-apy was able to provide a good aesthetic result forthe exophytic haemangioma on her lip.
After administration of local anaesthetic, one-time, direct, contact-free irradiation was per-formed with the preset haemangioma programmeof the elexxion claros with the 600 µm fibre up tocomplete coagulation (Fig. 3b). In this programme,the elexxion claros operates at 25 W high peakpower with pulses of 15,000 Hz and a duration of10 µs and an average output of 3.75 W.
After one week (Fig. 3c), we saw wound healingwithout any complications. At every follow-upvisit, the elexxion claros was applied using thelow-level laser programme for one minute at 100 mW with the glass rod in order to optimisewound healing. A distinct improvement in the sit-
uation was seen after just two weeks (Fig. 3d).Slow and constant self-optimisation was ob-served in the further wound-healing process aftersix weeks (Fig. 3e) up to the desired final result atthe end of 12 weeks (Fig. 3f).
If one has performed the treatment correctly,there will be no bleeding, and the patient will haveno pain or discomfort. Only two weeks later, thispatient was kissable once again as she reportedwith a big smile on her lips.
This case report has demonstrated that inva-sive laser therapy can, in selected indications, leadto good aesthetic results with exophytic haeman-giomas of the lip quickly, safely and efficiently.
Editorial note: A complete list of references is availablefrom the publisher.
28 I laser1_2013
Fig. 3e Fig. 3f
Fig. 3b Fig. 3c
Fig. 3d
Fig. 3a
Dr Darius Moghtader
In den Weingärten 47
55276 Oppenheim
Germany
www.oppenheim-zahnarzt.de
_contact laser
1st International Congress of WALED and GLOBALJune 14-15, 2013 Istanbul, Turkey, Point Hotel Taksim Fees: 250 EUR, inclusive full day catering and 2 evening events
Congress Presidents: Prof Norbert Gutknecht, Dr Zafer Kazak
Preliminary List of Speakers:Prof Norbert Gutknecht Prof Aslihan Üsümez Prof Matthias Frentzen Prof Gerd Volland
Ass.-Prof Ilay Maden Ass.-Prof Jörg Meister Dr Iris Brader Dr Masoud Mojahedi
Dr Miguel Martins Dr Peter Fahlstedt Dr Zafer Kazak Dr Merita Bardoshi
Dr Stefan Grümer Dr René Franzen Dr Nasrin Kianimanesh Dr Alireza Fallah
Dr Dimitris Strakas Dr Gabriele Schindler-Hultzsch
Enjoy dental science and fun in Istanbul!
More Information: [email protected] © Sadik Gulec
AALZ_DGL_II_A4_laser113.pdf 1AALZ_DGL_II_A4_laser113.pdf 1 25.02.13 17:3925.02.13 17:39
I industry report
Fig. 1_Patient presentation.
Fig. 2_Insertion of five implants.
Fig. 3_Teeth #14 and 15
in occlusion.
Fig. 4_Use of the diode laser to mark
the border for incision of the
soft tissue.
Fig. 5_Incision border.
_Introduction
This article describes and demonstrates the useof the Erbium:YAG 2,940 nm laser system (Lite-Touch, Syneron Medical Ltd.) as a central tool in thetreatment of osseous crown lengthening, and theadvantages this wavelength offers versus the useof conventional methods.
_Objectives and methods
Crown lengthening is a surgical procedure em-ployed for the removal of periodontal tissue, in or-der to increase the clinical crown height. It is the
most frequently used and valuable periodontalsurgical procedure related to restorative treat-ment.1-4
The objectives of clinical crown lengthening in-clude
– Removal of subgingival caries– Preservation and maintenance of restorations– Cosmetic improvement– Enabling restorative treatment without imping-
ing on biologic width– Correction of the occlusal plane– Facilitation of improved oral hygiene
Er:YAG Garnet in laser-assisted crownlengthening Author_Dr Avi Reyhanian, Israel
30 I laser1_2013
Fig. 4 Fig. 5Fig. 3
Fig. 2Fig. 1
industry report I
There are two methods of crown lengthening:– Orthodontic—coronal extension– Surgical—apical extension.
Clinical considerations– Importance of the tooth– Subgingival caries– Clinical crown/root ratio– Root length and morphology– Residual amount of bone support– Furcation involvement– Tooth mobility– Aesthetic demands– Post-op maintenance and plaque control.
_Biologic width and aesthetic dentistry
The clinician must create a symmetrical andharmonious relationship between lips, gingival ar-chitecture and positions of the natural dentateforms. Spear et al.5 have referred to this diagnosticmethodology as facially generated treatmentplanning, where the maxillary central incisal edgesdetermine where the soft tissue, i.e., gingiva, andbone should be positioned.6
To utilize crown lengthening, it is important forthe restorative dentist to understand the conceptof biologic width, indications, technique and otherprinciples.7-9 To maintain healthy periodontal tis-sue, the attached gingival and biologic width mustbe considered. Biologic width is measured from thebottom of the gingival sulcus to the alveolar crestand is maintained by homeostasis.10,11 This widthconsists of the epithelial attachment to the tooth
surface and its connective tissue. The averagewidth is 2.04 mm. Impinging biologic width maycause periodontal tissue destruction; therefore, incrown lengthening, the position of the margin isimportant.
_Methods of clinical crown lengthening
As mentioned above, there are two methods tolengthen a crown: coronal extension and apical ex-tension. Apical extension of the crown is achievedby surgery, with or without osseous resection. Inapical extension there are two methods:
– Open technique—patients who exhibit asym-metrical gingival levels, those with greater than3 to 5 mm of maxillary gingival display, or bothmay be candidates for surgical gingival and/oralveolar bone repositioning to improve their aes-thetics.
– Closed technique—for minor localized biologicwidth and/or aesthetic gingival zenith correc-tions. Can be used in lieu of a flap procedure tomake the correction and complete the restora-tive process without the necessary healing timerequired for open crown lengthening surgeries.12
_Case presentation
This clinical report describes a situation inwhich a crown lengthening procedure was suc-cessfully performed with the Er:YAG laser (Lite-Touch, Syneron Medical Ltd.) as a principal auxil-iary tool, and the advantages of the 2,940 nmwavelength versus conventional methods.
Fig. 6_Incision.
Fig. 7_Lifting the mucoperiosteal.
Fig. 8_Bone ablation.
Fig. 9_Bone level after ablation.
Fig. 10_Immediately post-op.
Fig. 11_One week post-op.
I 31laser1_2013
Fig. 6 Fig. 7 Fig. 8
Fig. 9 Fig. 10 Fig. 11
I industry report
Fig. 12_Four months post-op.
Fig. 13_Nine months post-op.
Fig. 14_Nine months post-op X-ray
image.
32 I laser1_2013
Fig. 13 Fig. 14Fig. 12
ExaminationClinical examination of a 57-year-old male re-
vealed missing teeth at the locations #17, 36, 44,45 and 46 with overeruption of teeth # 14 and 15(Fig. 1). Radiographic examination of the areashowed overeruption of teeth 14 and 15 with thealveolar bone.
Treatment optionsThe treatment options available in this case
were:
– Insertion of implants and metal-ceramic crownsat the locations of teeth #17, 36, 44, 45 and 46.
– In addition to option one above: crown length-ening for teeth #14 and 15 and covering themwith metal-ceramic crowns.
Following discussion with the patient and eval-uation of the possibilities for success, it was de-cided to perform crown lengthening. Treatmentwould involve the use of the Er:YAG laser to per-form the following steps, based upon accepted re-search:
– Flap incision13-15
– Ablation of soft tissue around the teeth afterraising a flap16-18
– Remodelling, shaping and ablating of thebone.13,15,19,20
TreatmentAll five implants were placed in one sitting (Fig.
2). Crown lengthening was performed three weekspostop (Fig. 3). Laser operating parameters em-ployed for the various surgical stages were as fol-lows:
– Flap Access: Wavelength: 2,940 nm (Er:YAG),600-micron sapphire tip, contact mode; 200 mJper pulse at 35 Hz. Total power: 7 Watts.
– Soft Tissue Removal: Wavelength: 2,940 nm(Er:YAG), 1,300-micron sapphire tip, non-con-tact mode; 400 mJ per pulse at 20 Hz. Totalpower: 8 Watts.
– Bone Surgery: Wavelength: 2,940 nm (Er:YAG),
1,300-micron sapphire tip, non-contact mode;300 mJ per pulse at 20 Hz. Total power: 6 Watts.
With the assistance of a diode laser operatingat a power setting of 2.4 W in contact mode, thelocation of the incision was marked (Figs. 4 and 5).An incision was made with the laser (after anaes-thesia) at the buccal and palatal side of teeth #14and 15 (Fig. 6) and a vertical incision was not re-quired. The buccal and palatal flaps were lifted andthe area was explored (Fig. 7); there was soft tis-sue around the neck of the teeth. The soft tissuewas ablated using the laser. Vaporization ofsoft/granulation tissue (if any exists) after raisinga flap is efficient with the Er:YAG laser, offering alower risk of overheating the bone than that posedby the diode or CO2 lasers23 and often obviates theneed for hand instruments. Results from bothcontrolled clinical and basic studies have pointedto the high potential of the Er:YAG laser and its excellent ability to effectively ablate soft tissuewithout producing major thermal side effects toadjacent tissue have been demonstrated in nu-merous studies.16-18
The Er:YAG laser was aimed at the surface of theexposed bone which was ablated in non-contactmode (Fig. 8). Studies have shown that Er:YAGlaser energy effects on bone include bacterial re-duction.22 Following this, all accessible bone sur-faces were exposed to laser energy to ablatenecrotic bone and to shape and remodel the sur-face in accordance with established clinical proto-cols.13,15,20
The bone level around teeth #14 and 15 fits tothe bone level of teeth #13 and 16 (Fig. 9). The mu-coperiosteal flap was re-positioned and suturedwith silk 3-0, paying particular attention to pri-mary closure of the flap (Fig. 10).
Postoperative instructionsThe patient was prescribed antibiotics to avoid
infection and painkillers for pain. Instructions weregiven to rinse with Chlorhexidine 0.2 %, startingthe next day for two weeks, three times per day.
Management of complications and follow-upThe following day the patient reported moder-
ate pain and moderate swelling. There was no tis-sue bleeding and the site was closed. The flap wasshowing signs of attachment and was healingnicely. At seven days post-op, the patient returnedfor inspection and removal of sutures. The swellinghad resolved and healing was progressing well (Fig.11). After five months, the soft tissue was healedcompletely without complications (Fig. 12). Thesoft issue had healed over the bone and there wereno bony projections observed under the soft tissue.The prognosis is excellent. An impression for twometal-ceramic crowns was taken five monthspost-op (Fig. 10). An aesthetic result was achieved(Figs. 13 & 14).
_Conclusion
The Er:YAG laser system (LiteTouch, SyneronMedical, 2,940 nm) can be employed as an auxiliarytool for the purpose of crown lengthening and hasbeen shown to be effective and safe. The use of theLiteTouch wavelength for these procedures pres-ents many advantages as opposed to conventionalmethods, including enhancement of the surgicalsite and less bleeding during the operation, provid-ing the surgeon with a better field of visibility andreducing patient discomfort during use. In addi-tion, anecdotal claims have been made that post-operative effects such as pain and swelling are lesspronounced. Finally, the laser offers the dental sur-geon enhanced ease of use with the hand piece's360° swivel capability._
Editorial note: A complete list of references is availablefrom the publisher.
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Dr Avi Reyhanian
Private Clinic
1 Shaar Haemek St.
Netanya 42292, Israel
Tel.: +972 9 8338825
Fax: +972 9 8339890
www.dentallaser.co
_contact laser
I industry report
Long-term treatment of peri-implant lesions in geriatric dentistryAuthor_Dr Georg Bach, Germany
34 I laser1_2013
_Introduction
In recent years, photodynamic therapy hasgained many new users in laser dentistry, giving it anenormous push forward. This therapy is minimallyinvasive and long-lasting. A multitude of scientificstudies on the therapy have been conducted and ithas a uniform nomenclature, established during thelast meeting of the DGL (German Association forLaser Dentistry). During this meeting, the differencebetween “real” photodynamic therapy and onewhose sensitiser has its own (antibacterial) proper-ties was established. The following case report de-scribes the minimally invasive use of a photody-namic therapy system with a green sensitiser ingeriatric dentistry (treatment of peri-implant le-sions).
_Real photodynamic therapy: Sensitiser with intrinsic effect
In treatments with real photodynamic therapy,cell death of the pathogenic bacteria is achieved ex-clusively by the interaction between sensitiser andlaser light, which generates oxygen, resulting in de-struction of the pathogenic cell. A further differen-tiation can be made with regard to sensitisers thatuse blue (usually with antibacterial properties) andthose that use green (usually without antibacterialproperties) dyes. Systems with green sensitisers areundoubtedly the focal point of current interest. Theyare generally indocyanine green (ICG) based and ac-tivated with an 810 nm (diode) laser (near infrared).
_Indocyanine green-based sensitisersfor photodynamic therapy
ICG is a recognised active substance that hasbeen standard in ophthalmology, as well as in on-cology, dermatology and veterinary medicine, foryears. If irradiated with a low-energy laser of awavelength of 810 nm, it promises a successfultherapy for periodontitis and peri-implantitis.
_Case report
Eleven years ago, the now 79-year-old femalepatient had received implants in the mandible. Af-ter several years of total satisfaction with the im-plant provision, she experienced the first compli-cations. While initially limited to the superstruc-ture (small chips on the ceramic and loosening ofthe superstructure), problems with the actual im-plants had increased in the past three years and re-curring infections, sometimes painful, and bleed-ing when brushing her teeth, etc. arose. Local andsystemic antibiotics only yielded short-lived im-provement, and she was then referred to our prac-tice.
The first superficial intra-oral examination re-vealed clinical findings clearly indicative of a diag-nosis of peri-implantitis:
– massive peri-implant bone loss;– bowl-shaped defect; and– pain on probing the soft-tissue sleeve.
[PICTURE: ©PRIVILEGE]
industry report I
Fig. 1_Within the scope of a
full-mouth disinfection, both of the
implants affected by peri-implantitis
and the remaining teeth of the
mandible were treated with
ICG-based photodynamic therapy.
I 35laser1_2013
Fig. 1jFig. 1i
Fig. 1a Fig. 1b
Fig. 1c Fig. 1d
Fig. 1e Fig. 1f
Fig. 1g Fig. 1h
I industry report
Fig. 2_Mixing of sensitiser: the kit contains all the
components required for preparing the sensitiser solution
by dissolving the dye tablet in the liquid provided,
which can then be used for approximately 30 minutes
and is applied intra-orally.
36 I laser1_2013
Fig. 2b Fig. 2cFig. 2a
Fig. 2h Fig. 2i
Fig. 2j
Fig. 2g
Fig. 2m Fig. 2n
Fig. 2d Fig. 2e Fig. 2f
Fig. 2k Fig. 2l
industry report I
The X-ray confirmed the initial clinical diagnosis:it was a case of full peri-implantitis. One implant inthe left half of the mandible had loosened from thebone to the extent that no more than half of the ti-tanium surface that had originally been covered bythe implant was still osseointegrated. An explanta-tion with subsequent augmentation and re-implan-tation later could have been considered for this ar-tificial abutment tooth.
Already at this early stage of decision-making,the family doctor and internal medicine specialistvetoed any procedures with increased risk of bleed-ing, increased risk of bacteraemia and a high degreeof invasiveness owing to the patient’s highly com-promised physical condition. With these justifiedrestrictions, photodynamic therapy was the obviouschoice for treatment.
An ICG-based sensitiser (Perio Green, elexxion) incombination with an 810 nm diode laser (100 mW,pulsed) was used (Fig. 1). This is a photodynamictherapy system with matched components. Thesensitiser is made up immediately prior to treatmentby dissolving a dye tablet in the liquid included in thekit and then applied intra-orally (Fig. 2). The appli-cation of a low-viscosity light-green sensitiser,which requires a directed droplet-flow technique, isquite demanding compared with high-viscosityblue sensitisers. After application and a period of ex-posure, the laser fibre is inserted into the target areaand the tissue is then irradiated with a low-energydiode laser (810 nm). The persistent colouring of thegingiva that is often observed when using othersensitisers does not occur after completion of treat-ment. No residue of the dye is visible intra-orally af-ter rinsing several times.
An intra-oral follow-up examination was carriedout at one and four weeks. The patient was, and is todate, without any symptoms. To maintain this situ-ation, she is scheduled for recalls every threemonths, with every recall entailing a professionalcleaning and photodynamic therapy for every sec-ond recall (Fig. 3).
Since, the patient is now almost completelywithout symptoms for the first time in years, but noimprovement is to be expected with regard to hergeneral health, we decided on this minimally inva-sive maintenance therapy. Regarding the commit-ments associated with it, the patient concluded verymatter-of-factly, “To me, it is worth it”.
_Conclusion
In my opinion, photodynamic therapy is a mini-mally invasive option compared with conventional
methods. It is ideally and most effectively used witha verified treatment protocol and a sensitiser with-out an intrinsic effect. Photodynamic therapy hasbecome my treatment of choice for patients withcompromised health, for whom more invasive ther-apy options would be more difficult or impossible toimplement, and for patients with a risk of bact -eraemia._
Fig. 3_Treatment regimen of
ICG-based photodynamic therapy
using Perio Green.
I 37laser1_2013
Pretreatment
Aim: reduction of the inflammation parameters
Information
(Perio Green motivation)
Application ofPerio Green
Success monitoring
Decision on
further measures
Aim achieved?No effect?
Individual decision
Recall phase
YES
YES
NONODecision on
further measures
Dr Georg Bach
Rathausgasse 36
79098 Freiburg/Breisgau
Germany
_contact laser
_Introduction
The notion of utilising laser technology in conser-vative dentistry was proposed in 1990 by Hibst andKeller, who introduced the possibility of using anEr:YAG laser as alternative to conventional instru-ments such as the turbine and micro-motor.1,2 Wide-spread interest in employing this new technologystems from a number of significant advantages, as de-scribed in several scientific studies. Thanks to theaffinity of the Er:YAG laser wavelength to water andhydroxyapatite, laser technology allows for efficientablation of hard dental tissues without the risk of mi-cro- and macro-fractures, as have been observed with
the use of conventional rotating instruments.3-5 Thedentin surface treated by laser appears clean, withouta smear-layer, and with the tubules open and clear.6
Thermal elevation in the pulp, recorded duringEr:YAG laser irradiation, is lower than that recorded byusing a turbine and micro-motor with the same con-ditions of air/water spray.7,8 This wavelength also hasan antimicrobial decontamination effect on thetreated tissue, which destroys both aerobic and anaer-obic bacteria.9 The most interesting aspects of this newtechnology are related to the goals of modern conser-vative dentistry, i.e. minimally invasive treatments andadhesive dentistry. Er:YAG lasers can reach spot di-mensions smaller than 1 mm, which enables a selec-tive ablation of the affected dentin while preservingthe surrounding sound tissue to produce highly effi-cient restorations.10 Several in vitro studies havedemonstrated that the preparation of enamel anddentine by Er:YAG laser, followed by orthophosphoricacid-etching, enhances the effectiveness in terms ofreduced microleakage and increased bond strength.11
To understand the role that a scanner can performin dental treatments, it is useful to take a comparativelook at the field of aesthetic medicine. The Er:YAG laserhas been used for many years in the field of dermatol-ogy, where it is employed for the vaporisation of le-sions such as condyloma, naevi, warts, mollusca con-tagiosa, as well as for the treatment of keloid scars andwrinkles with so-called laser “resurfacing”.12 For manyyears, scanners have proven highly effective in derma-tological treatments, enabling high-precision surfacetreatments without overlapping or under-coverage ofthe laser treatment area.
The aim of our study, which began several years ago,has been to evaluate the possibility of transferring thesame type of scanner technology that is widely utilised
I industry report
Fig. 1_Tooth sample for optical
microscope and SEM observation.
Fig. 2_LightWalker AT dental laser.
Fig. 3_X-Runner handpiece.
Fig. 4_X-Runner settings screen.
38 I laser1_2013
X-Runner Er:YAG dental laserapplicationAuthor_Prof. Dr Carlo Fornaini, Italy
Fig. 1
Fig. 2
Fig. 3 Fig. 4
industry report I
in dermatology to the dental field. The first in vitro testswere performed on extracted teeth by using a scannerand a dermatological Er:YAG laser. Because of the factthat this particular dermatological device operateswithout water, it was necessary to modify it by addinga double external pipeline in order to deliver an air/wa-ter spray at the point of the laser’s impact on the tooth.
The results of this first sequence of tests were verypromising and convinced the manufacturer Fotona toinvest in a major research and development effort toconstruct a scanner handpiece of reduced size, able tobe employed intra-orally. Once developed, the newdental-optimised scanner was given another series of“in vitro” tests, and after the safety of its utilisation wasdemonstrated via K-thermocouple records, opticalmicroscope (Fig. 1) and SEM observation, it was subse-quently applied to in vivo tests on human subjects.
_Material and method
The laser appliance used was a LightWalker (Fo-tona, Fig. 2). The scanner handpiece is similar to theusual non-contact Er:YAG laser handpiece. The scan-ning mechanism is integrated inside an ergonomic boxthat lies on the operator’s hand, with a supplementaryelectrical cable delivering the digital information fromthe laser device to the scanning mirrors (Fig. 3). Its ap-plication is the same as with the usual non-contacthandpiece; the only difference is that it covers a big-ger area than the standard handpiece. However, it isuseful because it can cover a larger area, or, by press-ing the button on the screen, it can be used as a clas-sical one-spot laser handpiece. The scanner handpiececan thus be used for all kinds of treatments by switch-ing from the scanner modality to classic handpiecemodality, without swapping handpieces.
The following settings are available for the scannerhandpiece on the touch screen (Fig. 4):– scanning of the area shape (circular, rectangular,
hexagonal), – size of the scanning area (width and length of the
rectangle, diameter of circle and hexagon), – number of scan passages (a function of the re-
quested ablation depth),
– delay between consecutive scans (duration of thepause between scans).
Moreover, all parameters available with the classichandpiece (energy, frequency, mode, spray) are alsoused with the scanner handpiece. By reducing one ofthe sides of the rectangular shape, it is possible to ob-tain a linear cut without moving the handpiece, for in-stance to cut the root apex during endodontic surgeryor to perform an incision in soft tissues surgery.
In this preliminary study, clinical applications areshown below which illustrate this new Er:YAG lasertechnology.
_Case 1: Enamel laser conditioning fororthodontic bracket bonding
The employment of an Er:YAG laser to prepare theenamel for improving the strength of adhesion ofcomposite resins has been proposed by several au-thors in conservative dentistry as well as for bracketbonding in orthodontics.13 Several studies, based bothon traction and microleakage tests, have shown thatthe best values were obtained with samples irradiatedby an Er:YAG beam before acid etching.14 Additionally,an “in vitro” study on extracted human teeth demon-
Fig. 5_a) During laser-scanner
conditioning; b) After the enamel
preparation for brackets with the
scanner; c) Brackets bonding
completed.
Fig. 6_a) Enamel lesions in the right
upper lateral incisor, canine, and the
first premolar; b) During scanner
treatment; c) After the scanner
ablation of enamel lesions;
d) After the complete treatment.
I 39laser1_2013
Fig. 5a Fig. 5b Fig. 5c
Fig. 6a Fig. 6b
Fig. 6c Fig. 6d
I industry report
Fig. 7_a) Damaged frontal teeth
crowns; b) During scanner ablation
of enamel; c) After the scanner
ablation of dental tissue; d) After
bonding a coat of composite resin.
strated that preparation by Er:YAG laser alone alsogives a stronger adhesion than orthophosphoric acidalone.15 Moreover, other authors have underscoredthese results when using lasers to prepare enamelsurfaces to make them more resistant to decay.16 Thisis possible because of the modification of hydroxya-patite crystals, which is important in the preventionof decalcification zones around brackets, particularlyin patients with scanty oral hygiene.17 Another ad-vantage of laser utilisation is the ability to prepare avery small surface area of enamel, exactly of the samedimension of the bracket. We initially proposed atechnique based on the use of a plastic template withrectangular windows designed to limit the irradiatedarea. Now, by using the scanner handpiece, the pro-cedure is faster, easier and more precise.
The case described presents a 14-year-old femalereceiving orthodontic fixed treatment of the upperarch. The parameters used were determined by SEMobservation in order to give the best enamel condi-tioning coupled with the minimal ablation: 55 mJ, 8 Hz,MSP mode, 4/6 air/water spray. The dimension of theablation area was 2.5 x 3 mm and the number of passeswas 10, once for each tooth.
_Case 2: Treatment of amelogenesis imperfecta spots on permanent incisors
The term amelogenesis imperfecta is defined as adiverse group of hereditary disorders that primarily af-fects the quantity, structure, and composition ofenamel.18 In the hypomature type, the affected teethexhibit mottled, opaque white-brown or yellowishdiscoloured enamel, which is softer than normal. Thehypocalcified type shows pigmented, softened, and
easily detachable enamel, while in the hypoplastictype, the enamel is well mineralised but the amount isreduced.19
In our daily practice, we have worked with severalyoung patients exhibiting zones of discoloration in theirfrontal teeth and who needed treatment to improve theaesthetics of their smile. Due to the impossibility oftreating these cases with classical bleaching tech-niques, it was necessary to ablate the affected zones andto fill the cavities produced with composite resins. Wehave already described the use of the Er:YAG laser in thistype of case as a good example of minimally invasivedentistry20 but the use of the scanner improves the pre-cision of the ablation even further by programming theextent and depth of the zone in advance.
The case presented concerns an 18-year-old male who had enamel lesions in the right upper lat-eral incisor, canine, and the first premolar. The treat-ment was performed without anaesthetics, with atotal laser irradiation time of 186 sec. For this case weused the following parameters: 250 mJ, 10 Hz, MSP mode, 4/6 air/water spray. The ablation area wasa 3.5 mm diameter circle and the number of passeswas 15.
_Case 3: Direct composite veneering ofpermanent incisors
In cases concerning damage to the frontal teethcrowns from a number of possible causes, i.e. traumasor bruxism, and if the patient does not wish to choosea prosthetic option, the solution is to ablate a portionof the enamel and to directly bond a coat of compos-ite resin. The role of the Er:YAG laser in improving the
40 I laser1_2013
Fig. 7a Fig. 7b
Fig. 7c Fig. 7d
industry report I
adhesion of resin to enamel has been well demon-strated21,22 and the advantage with the use of a scan-ner handpiece is the possibility to limit the volume ofablated dental tissue. The case presented regards a 64-year-old male who needed repair of his upper incisors.The treatment was performed without anaesthetics,with a total laser irradiation time of 253 sec. The pa-rameters used were: 300 mJ, 10 Hz, MSP mode, 4/6air/water spray. The ablation area was a 4.5 mm diam-eter circle, the number of passes was 15.
_Case 4: Aesthetic re-treatment of anaging composite restoration
In some cases, composite restorations may presentdiscolorations and spots after a number of years, par-ticularly in patients who do not observe an adequatelevel of oral hygiene. The vestibular face of the frontalteeth or the cervical area of the premolars may pose aproblem, from an aesthetical point of view, and this isthe reason why several patients have come to our of-fices to regain a pleasant smile. The Er:YAG laser maybe very helpful in this situation; in fact, because of itswavelength (2,940 nm) it is well absorbed by Glycidylmethacrylate (GMA) and Silicon Dioxide, two impor-tant components of composite. It is very effective inthe ablation of old restorations without thermal ele-vation23 and can produce a rough surface, very diffi-cult to obtain with orthophosphoric acid, which is ableto bond the new coat of resin.
The case presented here involves a 55-year-old fe-male with an aging infiltrated and spotted cervicalrestoration on tooth 34. The treatment was performedwithout anaesthetic. The parameters used were: 250 mJ, 10 HZ, MSP mode, 4/6 air/water spray. The ab-
lation area was a 4 mm diameter circle and the num-ber of passes was 15 for two times.
_Discussion and Conclusion
Laser technology was introduced in dentistry byGoldman in 1967.24 Since that time, a continuing ef-fort has been made by clinicians, researchers and com-panies to improve the results of clinical treatments.The introduction of Er:YAG in 1990 provided the op-tion to also treat hard tissues, and this technology wasfurther improved through greater control of pulse du-ration (VSP—variable square pulse technology).
The recent introduction of a scanner handpiece en-abled a higher precision of irradiation and depth of ab-lation as well as reduced treatment time, allowing lasertechnology to more fully realise the vision of “mini-mally invasive” conservative dentistry._
Editorial note: A list of references is available from the
author.
Fig. 8_a) Old composite on tooth 34;
b) During scanner ablation; c) Imme-
diately after scanner treatment;
d) After the complete treatment.
I 41laser1_2013
Fig. 8a Fig. 8b
Fig. 8c Fig. 8d
Prof. Dr Carlo Fornaini
MD DMD MSc
Via Varini, 10
29017 Fiorenzuola d'Arda, PC, Italy
Tel.: +39 0523 982667
Fax: +39 0523 242109
www.fornainident.it
_contact laser
CHEESE dental laser is a good assistance for dentistsin the treatment of periodontics, conservative den-tistry, endodontics, oral surgery as well as teethwhitening. The good performance of laser technologycomprising with conventional treatments makes thepatients smile, it sounds like “CHEESE”. With the ad-vantage of battery-operated design, the fully chargedbattery can support about three hours of treatment inCW mode.
GBOX dental laser with repetition rate up to20 kHz makes the pulse-pause-ratio (PPR technology) available.PPR technology is a treatment forsoft tissue cutting and coagula-tion in a high repetition rate withless or no carbonization. As aresult, the patients will feel less
pain and recover quickly. Gigaa isa leading developer and manu-
facturer of diodelaser systems forthe dental areaas well as othersurgery areas,such as vascular surgery,ENT surgery, lipolysis, and urology surgery and lasertherapy. It is our mission to provide reliable diode lasersystems to increase patients’ health.
Wuhan Gigaa
Optronics Technology Co., Ltd
5-6/F, Unit A-B, Building B8, Hi-Tech Med-
ical Device Industrial Park,
#818 Gaoxin Avenue, East Lake Develop-
ment Zone, Wuhan 430206, China
www.gigaalaser.com
GIGAA LASER
Professional medical diode lasersystems supplier
I manufacturer _ news
42 I laser1_2013
With the new photodynamic active ingredient PerioGreen, elexxion AG based in Radolfzell, Germany, isbringing colour into laser-assisted periodontal andperi-implantitis treatment.The new class IIa medicaldevice, which is based onthe clinically proven PDTdye indocyanine green andreacts specifically to thelight frequency of elexxionlasers, provides highly ef-fective and painless adjuvanttreatment of periodontitis and peri-implantitis –with no risk to hard dental and soft tissue and with-out causing discolouration or systemic effects.
If the active ingredient is irradiated by a diode laserwith a wavelength of 810 nm, active oxygen is re-leased. This singlet oxygen changes the micro-or-ganisms so that they are no longer able tometabolise and are killed. The treatment is virtuallypainless for patients because it causes no thermal
or mechanical effects; anaesthesia is usually un-necessary.
The actual Perio Green treatment,which can be repeated any timein recall appointments, takesabout an hour. If the method isused during a professional oralhygiene session, the time is re-duced to only about 30 minutes.Furthermore, as this type of
laser-assisted therapy is non-invasive, itcan be delegated to a suitably trained dental nurse.
elexxion AG
Schützenstraße 84
78315 Radolfzell, Germany
www.periogreen.com/en
IDS: Hall 10.1, booths J030-K031
elexxion
Antimicrobial periodontal and peri-implantitistreatment
Informing themselves about the latest develop-ments and methods in laser applications and tak-ing part in the respective trainings is mandatoryfor all laser users. Therefore, Biolase has beensupporting WCLI (World Clinical Laser Institute) formany years, thus operating in laser education onan international scale. In order to be able to offercertified high-level courses worldwide, Biolasehas also recently started a new cooperation withAALZ (Aachen Dental Laser Center) in Aachen,Germany, presided by Prof. Norbert Gutknecht.
In addition, train-the-trainer seminars will be heldfor international training practices. For the firsttime, a workshop will be conducted which com-bines periodontology and aesthetic surgery/der-matology. Every laser user can gain further quali-fication in a certification course starting January2013.
Moreover, the release of the new 10-Watts diodelaser Epic is eagerly awaited by laser users. A goodprice-performance ratio, its appealing design andeasy handling have already led to such a high de-mand that it has become hardkeep pace with on the pro-duction side, resultingin delivery delays.Now, finally, themodern diode-lasersystem Epic with 25years of Biolase expe-rience in development ismade available worldwide.
All training activities in the German-speakingcountries can be found atwww.nmt-muc.de.
Biolase Europe GmbH
Paintweg 10
92685 Floss, Germany
www.biolase.de
IDS: Hall 4.2, botth N060
Biolase
Laser training andnew diode laser
Manufacturer News
I 43laser1_2013
A team of office workers from HenrySchein UK, subsidiary of the US-basedHenry Schein, Inc. (NASDAQ: HSIC),the world’s largest provider ofhealth care products and servicesto office-based dental, medicaland animal health practitioners,swapped their pens for paintbrushesto give one of EllenorLions Hospices’local charity shops a make-over.
Henry’s Angels—a troupe of volun-teers from Henry Schein in Gilling-ham, UK—took time out of their busyschedules to give Gravesend’s KingsStreet store a face life. Armed with paintpots and oodles of enthusiasm, the dedi-cated team set to work on Thursday, 23 August 2012.The Angels brightened the walls with lashings ofwhite emulsion and gave the woodwork a beautifulglossy finish. All of the materials were also paid fordonations raised by the Angels at a car-wash projectheld at a local car wash centre in July. The team alsobrought in donations of pre-loved clothes, household
items and other goodies, to be sold in theshop. Henry’s Angels was formed in Janu-
ary 2011 with the goal of providingHenry Schein employees an opportu-nity to help local causes in practicalways. Henry Schein’s global corpo-
rate social responsibility programme,Henry Schein Cares, stands on four pil-
lars: engaging Team Schein Members toreach their potential, ensuring account-ability by extending ethical businesspractices to all levels, promoting envi-ronmental sustainability, and expand-
ing access to health care for under-served and at-risk communities.
Henry Schein UK
Centurion Close
Gillingham Business Park
Gillingham ME8 0SB, England
www.henryschein.co.uk
IDS: Hall 10.2, booths M048-N049
Henry Schein
Henry’s Angels brighten EllenorLions Hospices’ charity shop
Syneron Dental Lasers, provider of innovative dentallaser technologies, is pleased to announce thelaunch of its global LiteTouch™ Training Academy,with a new concept that opens more than eight aca-demic institutions around the globe offering practi-cal LiteTouch™ training and insight into the Laser-in-the-Handpiece™ technology.
Syneron Dental Lasers has partnered in educationwith world-class leading laser dentistry institutions,including the International Society for Oral Laser Ap-plications (SOLA) in Vienna, the University ofBarcelona, the Hebrew University and HadassahMedical Center in Jerusalem, the University of Nice-Sophia Antipolis, the University of Plovdiv, the facultyof Medical Sciences, General Stomatology Univer-
sity “Goce Delcev” Stip, R. Macedonia, the Universityof Geneva and the Asia Pacific Laser Institute. TheLiteTouch™ training programs include instructor-led classroom lectures as well as hands-on ses-sions. The Academy offers training programs led bykey opinion leaders and targets two main groups:new entrants to laser dentistry and practitionerslooking to extend their clinical knowledge. In addi-tion, the program will provide a first-of-its-kind edu-cation program for specialists seeking to under-stand best practices and clinical solutions for spe-cific procedures in their area of specialty (e.g., endodontics, periodontics, paediatric dentistry,restorative and oral Surgery, aesthetic dentistry).
Syneron Dental Lasers
Tavor Building, Industrial Zone
20692 Yokneam Illit, Israel
www.synerondental.com
IDS: Hall 4.2, booth N050
Syneron Dental Lasers
LiteTouch™ Training Academy Goes Global
[PICTURE: ©BOULE]
Please contact Claudia Jahn
[PIC
TUR
E: ©
SU
KIY
AKI]
AD
I education
From 14-15 June 2013, the 1st International Con-gress of WALED and GLOBAL 2013 will be held at PointHotel Taksim in Istanbul, Turkey. We are planning an ex-citing programme with evidence-based and state-of-the art laser dentistry. Meet international experts in theirfields, e.g. laser diagnostics, paediatric dentistry, aes-thetics and oral surgery.
The programme is separated between the two or-ganisers on the first day. The WALED programme is re-served only for WALED members. Members of this acad-emy are Master of Science and Mastership/ Fellowshipgraduates from the Aachen Dental Laser Center (AALZ)and RWTH Aachen University. WALED (World Academyfor Laser Education in Dentistry) is the academic and ed-ucational worldwide network of AALZ and has been es-tablished to realise an international academy of excel-lence for postgraduate education and research in laserdentistry. The goal of WALED is to standardise educationconcepts based on evidence-based research as well as
treatment protocols based on evidence-based preclini-cal and clinical research.
On the second day, the programme is open for every-body. Simultaneous translation in Turkish will be pro-vided. Workshops will complete the lecture and the con-gress will be closed by the great “International Night”.The Congress Fees are 250 Euro and include, in additionto the scientific sessions, the full day catering as well asthe evening events!
We also established a WALED page on www.face-book.com/groups/123005997774948/
Please have a look from time to time for any updatesand news. We sincerely hope you will be able to attendour congress, that your visit will be an enriching experi-ence both academically and culturally, and that, aboveall, you will have fun! We look forward to welcoming youat our congress and to Istanbul. _
1st International Congress of WALED andGLOBAL 2013 in IstanbulSource_AALZ Germany
44 I laser1_2013
[PICTURE: ©ILKER CANIKLIGIL]
AEEDC_A4_2014.pdf 1AEEDC_A4_2014.pdf 1 14.02.13 12:0314.02.13 12:03
I meetings
46 I laser1_2013
_IDS 2013 will continue a positive
tradition that began 90 years ago, whenthe first dental show took place in Germany.More than 1,900 exhibitors from over 55 countriesare expected to be in Cologne from 12–16 March 2013for the world’s largest trade show for dentistry anddental technology. Thanks to the tremendous de-mand for space, the fair will also occupy Hall 2.2 in ad-dition to Halls 3, 4, 10 and 11. Altogether, 150,000 m²of gross exhibition space will be covered.
The International Dental Show will once again bethe global meeting point for the international dentalsector in 2013. Around 68 per cent of the exhibitingcompanies will come to Cologne from abroad. Fol-lowing Germany, the nations that will be the moststrongly represented include Italy, the USA, the Re-public of Korea, the People’s Republic of China,Switzerland, France and Great Britain. In addition,there will again be a large number of joint participa-
tions from abroad in March 2013. These are organisedin conjunction with state or private export promotionorganisations and associations. At present, 13 jointparticipation groups have registered. These comefrom Argentina, Brazil, Bulgaria, The People’s Repub-lic of China, Great Britain, Israel, Italy, Japan, the Re-public of Korea, Pakistan, Russia, Taiwan and the USA.
Once again in 2013, the International Dental Showwill stick to its time-tested recipe for success. The con-cept of the event will continue to focus on business atthe stands and product information provided by theexhibitors. Correspondingly and according to tradi-tion, 12 March 2013, the first day of the show—alsoreferred to as Dealer’s Day—will concentrate on den-tal trade and importers. This special focus will provideparticipants with an appropriate atmosphere for
undisturbed and intensive sales negotiations.Another well-established part of the IDS pro-
gramme—the Speakers’ Corner—will takeplace in Hall 3.1, right next to the EntranceSouth. Here, IDS exhibitors will presentnew product information, services and
process techniques every day. In addition,speakers will report on the latest findings
from the worlds of science and research.
A number of digital services are available to helpvisitors plan the optimal trade show visit. These serv-ices contribute to goal-oriented trade show prepara-tions and help make the visit more effective. In orderto ensure optimal support, the update for the tradeshow’s own IDS app for iPhone, Blackberry and otheroperating systems is available since December. Theapp can be downloaded free of charge from the IDSwebsite.
Travel arrangements, hotels and admission ticketsfor the trade fair can be booked quickly and easily on-line, thanks to a number of services on the IDS web-site. Registration and ticket sales are available nowthrough the online ticket shop._
The next chapter in theIDS success storySource_Koelnmesse
[PICTURES: ©KOELNMESSE GMBH]
New research from the US provides evidence thatPorphyromonas gingivalis, the main agent of thechronic inflammatory disease periodontitis, alsomanipulates the human immune system. In a num-ber of laboratory tests, scientists observed that thepathogen inhibits the body's defense processesthat would normally destroy it.
In order to determine the manner in which P. gingi-valis influences the immune system, the re-searchers treated cells from mice with an inhibit-ing antibody against Interleukin-10 (IL-10), an anti-inflammatory protein, while leaving a different por-tion of the same cells untreated. Afterwards, theytested whether the cells produced interferon-gamma (IFN-γ), a protein that has an immunostim-ulatory and antiviral effect.
According to the study, P. gingivalis stimulated theproduction of IL-10, which in turn inhibited the ac-tivity of T-cells and macrophages, and repressedthe immune response. The researchers observedincreased production of IFN-γ in the treated cells,while no such growth was seen in the untreatedcells.
The study highlighted the mechanism by which thepathogen establishes a chronic infection. "Thesebacteria go beyond merely evading our body's de-fense and actually manipulate our immune systemfor their own survival," the researchers said. Thefindings suggested that the damage done by thebacterium occurs when the immune cells of thehost are first exposed to the pathogen. With regardto successful treatment, the results demonstratedthe importance of a very early intervention.
Gingivitis bacteria
Manipulate immunesystem
Of the estimated 700 bacterial species foundin the oral cavity, only 11 are known to causeperiodontitis. The detection of the relevantpathogens, however, has been very time-consuming to date. Now scientists from Ger-many hope that a newly developed diagnos-tic device will allow dentists and medical labsto conduct bacterial analysis in less than halfan hour.
Conventionally, bacterial analyses are car-ried out in external contract laboratories us-ing microbial cultures. This method bears therisk of bacteria being killed as soon as theycome into contact with oxygen and the analysis cantake up to four to six hours. Therefore, ParoChip, aninitial lab-on-a-chip device, was designed by re-searchers at the Fraunhofer Institute for Cell Ther-apy and Immunology (IZI) to speed up the timeneeded for identification.
The new mobile diagnostic unit consists of a disk-shaped microfluidic card that is about 6 cm in di-ameter. The card has eleven reaction chambers,each containing the dried reagent for one of theeleven periodontal pathogens.
Using ParoChip, many manual steps involved inbacterial analysis can be avoided, Kuhlmeier said.In addition, the synthetic disks can be producedcheaply and are disposable, just like a single-useglove, he added.
To date, there is only a prototype of the device,which will be tested in clinical laboratories first.However, the researchers believe that it could alsobe used by dentists to carry out in-house analysesof patient samples in their practice in the future.
New chip accelerates
Detection of periodontal bacteria
Councilman Dan Halloran, Philips, and Dr Bernard Fialkoff DDS presented the Partnership for HealthyMouths, Healthy Lives and the Ad Council’s“Healthy Mouths, Healthy Lives” campaign at a
free oral health care event for 20 elementary agedQueens children at the Colonial Church’s after-school program in Bayside, NY, this past week.
Dr Fialkoff, founder of the Fialkoff Dental StudyClub, a dental educational group in Queens,learned about the Partnership for Healthy Mouths,Healthy Lives’ campaign earlier this year which theAd Council recently released to Capitol Hill andAmerican dentists.
Dr Fialkoff encouraged all dentist members to dolikewise at the group’s October meeting. Mike Caliaof Philips Oral Healthcare donated 20 “Sonicare forKids” electronic toothbrushes.
Victor Mimoni, staff representative of CouncilmanDan Halloran, instructed the children on properdental health.
Oral Health Care
“Healthy Mouths, Healthy Lives”
NEWS
48 I laser1_2013
[PICTURE: ©MICHAELJUNG]
[PICTURE: ©BOTAZSOLTI]
[PICTURE: ©MOTOROLKA]
I 49laser1_2013
The Eco-Dentistry Association, an internationalassociation of dental professionals that promotesearth-friendly dentistry, has announced that it willbe holding the first conference devoted to high-tech, environmentally sound dental practices. Theevent will take place on 3 and 4 May at the RedfordConference Center in Provo, Utah.
The conference will showcase the information andproducts needed to create and maintain state-of-the-art green practices. In this regard, it will fea-ture a number of lectures about branding and mar-keting a green dental practice, as well as a pres-entation about how dental technologies can re-duce waste and save energy. Participants mayearn continuing education credits, the EDA an-nounced. During the meeting, panel discussionswill be held on various topics, from building and fi-nancing to creating a successful green hygieneprogram. Participants will have the opportunity toattend small-group hands-on courses for dental
technology such as laser andCAD/CAM systems.
In order to promote the overallhealth and well-being of the at-tendees, optional morning yogaand meditation courses will beheld, in addition to presentationsfocusing on the importance ofwork-life balance. After the confer-ence, participants can join a hiking tourin the 6,000 acres of pristine wildernessadjacent to the Sundance Resort on May 5.
Anyone interested can register for the event on theEDA’s website, www.ecodentistry.org/confer-ence. However, attendance is limited to the first100 registrants, the association said.
The EDA was founded by Dr Fred Pockrass and hiswife Ina Pockrass, who created the model for eco-
friendly dentistry, which includes methods such asreducing waste and pollution, as well as savingenergy, water and money. Their practice in Berke-ley, CA, was the first in the country to be certifiedas a green business.
Eco-Dentistry Association to hold
First Green Dentistry Conference
New research has provided evidence that blackberryextract could be used to control the growth of oralpathogens on dental and mucosal surfaces. In anumber of tests, the researchers foundthat it inhibited the metabolic activ-ity of the causative agents of peri-odontal disease and dental caries inparticular. In the study, researchers from theUniversity of Kentucky tested the antimicro-bial effects of blackberry extract on ten differ-ent oral bacteria. Among others, they observedthat the extract significantly reduced the metabolicactivity of Porphyromonas gingivalis and Fusobac-terium nucleatum, two pathogens known to cause pe-riodontal diseases, by about 40 per cent, and that it in-hibited Streptococcus mutans, the primary agent ofdental caries, by approximately 30 per cent. In addi-tion, they found that at higher concentrations the ex-tract had the ability to kill oral bacteria.
To date, mouth rinse containing chlorhexidine, achemical antiseptic, has been one of the most effec-tive antimicrobial agents against the colonization oforal bacteria responsible for gingivitis and periodonti-
tis. However, its side effects, such as staining andabrasion, limit its prolonged use as antimicrobial agentby the general population. Thus, blackberry extractmight be a promising adjunct for prevention and treat-ment of periodontal infections, the scientists con-cluded.
Although the mechanisms underlying the antimicro-bial effects are not fully understood, the researcherssuggested that berry-derived polyphenols, which canbe found in red wine, citrus and black tea too, could beinvolved the process. The study will be published in theFebruary issue of the Journal of Periodontal Research.
Blackberries: possible treatment for
Oral bacterial diseases
According to recent news reports, Australian dentistshave had to remove all the teeth from the mouth of a25-year-old owing to overindulgence in soft drinks.The man had apparently drunk up to eight litres of softdrink each day for the last three years. As reported byonline newspaper adelaidenow, William Kennewell ishighly addicted to sugary drinks and ignored dentists’repeated warnings about the possible danger to hisoral health. He said he drank six to eight litres a day.His addiction had not only led to severe tooth decay,leaving him with only 13 teeth, but also caused bloodpoisoning, which improved after his teeth were re-moved and replaced with dentures, the newspaperreported. Only recently, a study among 16,500 Aus-tralian children revealedthat more than half of thechildren in the country con-sume at least one soft drinkper day. Health experts haveconsequently called fortooth-decay warnings onsugar-sweetenedbeverages.
Complete tooth loss after
Extensive consumeof soft drinks
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I about the publisher _ imprint
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Copyright Regulations _laser international magazine of laser dentistry is published by Oemus Media AG and will appear in 2013 with one issue every quarter. The
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Lutz V. [email protected]
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Editorial BoardMarcia Martins Marques, Leonardo Silberman,Emina Ibrahimi, Igor Cernavin, Daniel Heysselaer,Roeland de Moor, Julia Kamenova, T. Dostalova,Christliebe Pasini, Peter Steen Hansen, Aisha Sul-tan, Ahmed A Hassan, Marita Luomanen, PatrickMaher, Marie France Bertrand, Frederic Gaultier,Antonis Kallis, Dimitris Strakas, Kenneth Luk, Mukul Jain, Reza Fekrazad, Sharonit Sahar-Helft,Lajos Gaspar, Paolo Vescovi, Marina Vitale, CarloFornaini, Kenji Yoshida, Hideaki Suda, Ki-Suk Kim,Liang Ling Seow, Shaymant Singh Makhan, Enri-que Trevino, Ahmed Kabir, Blanca de Grande, JoséCorreia de Campos, Carmen Todea, Saleh GhabbanStephen Hsu, Antoni Espana Tost, Josep Arnabat,Ahmed Abdullah, Boris Gaspirc, Peter Fahlstedt,Claes Larsson, Michel Vock, Hsin-Cheng Liu, SajeeSattayut, Ferda Tasar, Sevil Gurgan, Cem Sener,Christopher Mercer, Valentin Preve, Ali Obeidi,Anna-Maria Yannikou, Suchetan Pradhan, RyanSeto, Joyce Fong, Ingmar Ingenegeren, Peter Klee-mann, Iris Brader, Masoud Mojahedi, Gerd Volland, Gabriele Schindler, Ralf Borchers, StefanGrümer, Joachim Schiffer, Detlef Klotz, HerbertDeppe, Friedrich Lampert, Jörg Meister, ReneFranzen, Andreas Braun, Sabine Sennhenn-Kirch-ner, Siegfried Jänicke, Olaf Oberhofer, ThorstenKleinert
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international magazine of laser dentistryis published in cooperation with the World Federa-tion for Laser Dentistry (WFLD).
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University of Aachen Medical FacultyClinic of Conservative DentistryPauwelsstr. 3052074 Aachen, GermanyTel.: +49 241 808964Fax: +49 241 [email protected]
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