We have all seen the chart showing the absorption coefficient of different wavelengths in water.

This is important for us to understand since water is a main component of dental tissues.  The CO2 laser is absorbed very well in water, but there is a tendency to see charring and thermal effects in soft tissue, as well as melting of hard tissues.  This does not make it very friendly for periodontal therapy where cementum and roots are involved, although a newer pulsed CO2 laser does improve on this problem.

Diode and Nd:YAG penetrate deep into tissue and may cause unseen thermal effects.  Currently, they seem to be positive as adjuncts in periodontal therapy, as long as laser energy applied to the roots is kept minimal and controlled.

Erbium lasers have an excellent ablative potential in soft tissues, do not penetrate deep, and do not show the same thermal damage as the other wavelengths.  They seem to be ideally suited for comprehensive soft tissue periodontal treatment, as well as calculus removal and root treatment.

There are 2 different Erbium lasers: Er:YAG and Er, Cr:YSGG.  Both have a very similar absorption spectrum.  There are few studies that compare their physical properties.  As one study shows, it is difficult to analyze different systems because of the different manufacturer parameters.

For all intents and purposes, and to facilitate a meaningful discussion, going forward we will assume that all Erbium laser studies are reasonably interchangeable.  Literature reviews will follow very soon.

MS

Materials and Methods

First and foremost, only 6 pairs of teeth were analyzed in this study – hardly a big sample size.

While not necessarily a major issue, it is worth noting that all experimental teeth received “occlusal adjustment and were splinted to neighboring teeth with an extracoronal bond”.  Why do I bring this up?  This is part of the LANAP protocol, but I highly doubt it is even being done in private practice.

Additionally, all teeth received an unspecified  “triple antibiotic ointment” and a “light cured dressing”.  Again, definitely not routine measures taken in private practice, and undoubtedly they play some role in the treatment outcome.  However, since all teeth received this treatment, a comparison of control vs. experiment is fair.

Discussion

Cementum mediated new attachment was evident on 4 lased teeth, but Yukna himself states that “similar periodontal healing in humans has been shown with other surgical techniques”.

How much new cementum was actually seen?  An average of 1.2mm.  Repeat, just 1.2mm.

By no means would I consider this a good result.  As Yukna clearly states in the beginning, “regeneration of the supporting tissues of the teeth is a primary goal of periodontal therapy”.  Numerous studies demonstrate superior results when regenerative materials, such as grafts, membranes, Emdogain or rhBMP are used.

How can any clinician justify lowering the bar for periodontal therapy?  How is this an advancement in patient care?

This study does clearly demonstrate “new attachment” and new cementum.  The fibrin clot in the lased pocket apparently acts as an effective barrier to epithelium advancement, thereby allowing periodontal healing to proceed favorably.  But it does not empower dentists to offer superior treatment to patients.

Closing Comments

One may ask, why not use regenerative products with a proven record, in combination with Nd:YAG therapy? Nd:YAG, being so efficient in hemorrhagic tissues, promotes a fibrin clot that prohibits the use of regenerative material simply because there is no space to place the materials.  The patient is robbed of the ability for an even better regenerative outcome.

The Case for Erbium Lasers in Periodontal Therapy

Erbium lasers (Er:YAG or YSGG) offer the same apparent periodontal benefits as the Nd:YAG: bactericidal effect and ablation of inflamed and diseased pocket epithelium.  Additionally, a space is maintained in the pocket, allowing the concomitant use of regenerative products to further enhance the healing.  De-epithelialization can then be performed with an Erbium or CO2 laser to inhibit epithelium downgrowth and prevent the formation of a long junctional epithelium.  De-epithelialization can be done at post-op visits for as long as needed to help achieve the desired results.

Doesn’t that make more sense, fellow Laser Dentists?

The Nd:YAG and LANAP seem great in mild or moderate cases, but where intrabony defects are involved or where a higher level of regenerative predictability is desired, comprehensive laser periodontal therapy with an Erbium laser is the way to go.  More Lit Reviews to follow.

Comments?  Thoughts?

I decided to research lasers independently.  I read countless studies, spoke to laser users around the world, attended seminars, and even had various lasers in my practice to evaluate.  My goal was to get a laser that would best assist me with periodontal procedures, regeneration, hard tissue grafting, cosmetic surgeries, implant dentistry, extractions and the occasional treatment of pathological lesions.  With regards to periodontal treatment, the laser had to be kind to diseased cementum.

A diode laser is very nice – but it is not meant to be a workhorse.   Its uses are limited.  The remaining options were: CO2, Nd:YAG, Er:YAG and YSGG.

Based on my findings, the CO2 would not suit my needs.  CO2 is not designed for hard tissue, and it can char tissues if not used properly.  Healthy root surfaces can literally melt.

Here’s where things get interesting.  The Periolase Nd:YAG laser, manufactured by Millenium, is loaded with all sorts of fantastic claims.  There are 100′s of dentists out there who are believers in the LANAP procedure, a proprietary treatment protocol.  There are other Nd:YAG manufacturers, but Millenium is the “big guns”.  I opted out of this laser.  I will address all of the Periolase’s shortcomings in a separate, probably controversial, post.  I am looking forward to intelligent comments and a scholarly discussion.

The most intriguing lasers, in my mind, were the Er:YAG, manufactured by several companies; and the Er,Cr:YSGG, a.k.a. Waterlase MD, manufactured exclusively by Biolase who holds the patent.  The Erbium lasers generate much less heat than the other dental lasers.  Both the Er:YAG and YSGG have very similar wavelengths and probably only differ slightly based on machine settings and calibration.  The Waterlase has a greater variety of interchangeable tips for various procedures.

Numerous studies clearly show that the Erbium lasers are safe when used on roots and cementum.  They ablate tissue effectively without a char.  They are also FDA cleared for cutting bone and teeth.  The YSGG was the choice that I made, for my practice, for my patients.

Having used it now for many months and seeing the results and patient experiences, I felt obligated to share my journey.  In the coming months, I will document dozens of studies and provide insightful commentary from the perspective of a periodontist.  My hope is to make the dental community more aware of the benefits of laser dentistry.  Dentistry must move forward with better patient care.  This is my contribution.

Sincerely,

Mark Schlesinger, DDS

Diplomate, American Board of Periodontology

President, NY Academy of Collaborative Dentistry

Clinical Assistant Professor, NYU College of Dentistry

NYImplantDentistry.com

I’m still waiting to see the studies that clearly demonstrate this, because I have tried removing calculus with the YSGG on freshly extracted teeth and it doesn’t come off easily.  Granted, intra-orally with the presence of saliva it might work, but????

______________________
EXCERPT: BIOLASE Announces FDA 510(k) Clearance of Its Waterlase MD^TM Laser for Removing Calculus in Patients With Periodontal Disease Minimally-Invasive Treatment for Condition Impacting Over Half of Americans Over 55

IRVINE, CA–(Marketwire – December 9, 2009) – BIOLASE Technology, Inc. (NASDAQ: BLTI), the world’s leading dental laser company, today announced that it has received 510(k) clearance from the U.S. Food and Drug Administration (FDA) to market its Waterlase MD™ laser system for removal of subgingival calculi to prevent and treat periodontitis, the greatest cause of tooth loss for adults over 35 and a condition impacting more than half of Americans over the age of 55, as reported by the American Academy of Periodontology (AAP).

“…As an example, we should have determined the feasability, yes or no, of using lasers.  We should have been involved as a profession.  We looked the other way, and now we’re down on the food chain.”

No kidding, doc.  So what are you going to do about it?  Is it just me or does it seem that the AAP is all talk, no action.