REVIEW ARTICLE ISSN (ONLINE): 2321 - 8436

Role of lasers in periodontology: A Review

Aashima B Dang,1 Neelakshi S Rallan2

Abstract

Lasers were introduced into the field of clinical dentistry with the hope of overcoming some of the drawbacks posed by
the conventional methods of dental procedures. Since its first experiment for dental application in the 1960s, the use of
laser has increased rapidly in the last couple of decades. Because of their many advantages different types of lasers are
available for clinical and specific use. They are activated at different power setting modes, and pulse for soft and hard
tissues. This review discusses the applications in periodontics.

Key Words: - Laser, Periodontics, Implant

Introduction: the diode lasers were accepted for use only for oral soft
tissue procedures in periodontics.
Dentistry has changed tremendously over the past decade to
In 1997, the Food and Drug Administration cleared the first
the benefit of both the clinician and the patient. One
Er:YAG laser system, then in use for preparing dental
technology that has become increasingly utilized in clinical
cavities, for incisions, excisions, vaporization, ablation and
dentistry is that of the laser. Laser is an acronym for
hemostasis of soft and hard tissues in the oral cavity9.
Light Amplification by Stimulated Emission of
However, with the recent advances and developments of
Radiation.1 Laser is a device that utilizes the natural
wide range of laser wavelengths and different delivery
oscillations of atoms or molecules between energy levels
systems, researchers suggest that lasers could be applied for
for generating coherent electromagnetic radiation usually in
the dental treatments including periodontal, restorative and
the ultraviolet, visible, or infrared regions of the spectrum.
surgical treatments. Currently, numerous laser systems are
It is a device that produces high intensity of a single
available Ophthalmologists began using the ruby laser in
wavelength and can be focused into a small spot. Initially
the early 1960s and now the CO2 and the Nd: YAG
introduced as an alternative to the traditional halogen
(neodymium-doped yttrium aluminum garnet), Er,
curing light, the laser now has become the instrument of
Cr:YSGG, Diode and Er:YAG lasers are established and
choice, in many applications, for both periodontal and
most commonly used laser for the surgical procedures.
restorative care. Because of their many advantages, lasers
are indicated for a wide variety of procedures. Classification of Lasers:
Presently various laser systems have been used in Lasers can be classified according its spectrum of light,
dentistry. Among them Carbon dioxide (CO2), material used and hardness etc. They are also classified as
Neodymium-doped: Yttrium-Garnet (Nd:YAG), soft lasers and hard lasers.
Semiconductor diode lasers are used for soft tissue Classification based on light spectrum:
treatment. Recently Erbium doped: Yttrium-Aluminium-
Garnet (Er:YAG) laser has been used for calculus removal UV Light 100 nm – 400 nm Not Used in Dentistry
and decontamination of the diseased root surface in Most commonly used
Visible Light 400 nm – 750 nm in dentistry (Argon &
periodontal non-surgical, surgical and implant therapy. 2 Diagnodent Laser)
Review of literature: Most Dental Lasers
Infrared light 750 nm – 10000 nm
are in this spectrum
In 1917 Einstein published ideas on stimulated
emission radiation. Based on Albert Einstein’s theory of Classification According to material used:
spontaneous and stimulated emission of radiation, Maiman
Gas Liquid Solid
developed the first laser prototype in 19601 using a crystal
Diodes, Nd:YAG,
of ruby as a medium that emitted a coherent radiation light, Not so far in Er:YAG,
when stimulated by energy. In 1961, the first gas and Carbon Dioxide
clinical use Er:Cr:YSGG,
continuously operating laser was described by Javan et al 4. Ho:YAG
The application of a laser to dental tissue was reported by
Stern and Sognnaes5 and Goldman6 et al. in 1964, 1. Soft laser
describing the effects of ruby laser on enamel and dentine
with a disappointing result. Studies on the use of the Soft lasers are of cold (athermic) energy emitted as
neodymium-doped yttrium aluminium garnet (Nd:YAG) wavelengths; those are thought to stimulate cellular
laser for caries prevention have been published by activity. These soft lasers generally utilize diodes and the
Yamamoto and Sato7 and on the use of carbon dioxide manufacturers claim that these lasers can aid healing of the
(CO2) laser for dental caries treatment by Melcher 8et al. tissue, reduces inflammation, edema, and pain. Clinical
The first dental lasers approved by the US Food and application includes healing of localized osteitis, healing of
Drug Administration, namely the CO2, the Nd:YAG and aphthous ulcers, reduction of pain, and treatment of
gingivitis.

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The current soft lasers in clinical use are the:

1. Monochromatic: in which all waves have the
 Helium-neon (He-N) at 632.8 nm (red, visible). same frequency and energy.
 Gallium- arsenide (Ga-As) at 830 nm (infra-red, 2. Coherent: all waves are in a certain phase and are
invisible). related to each other, both in speed and time.
3. Collimated: all the emitted waves are nearly
2. Hard lasers (surgical) parallel and the beam divergence is very low.13
Hard lasers can cut both soft and hard tissues. Newer
Lasers can concentrate light energy and exert a strong
variety can transmit their energy via a flexible fiber optic
effect, targeting tissue at an energy level that is much lower
cable. Presently more common type clinically used, under
than that of natural light. The photon emitted has a specific
this category
wavelength that depends on the state of the electron’s
The Hard lasers are: energy when the photon is released. Two identical atoms
with electrons in identical states will release photons with
 Argon lasers (Ar) at 488 to 514 nm identical wavelengths.
 Carbon-dioxide lasers (CO2) at 10.6 micro-meter
 Neodymium-doped yttrium aluminum garnet Lasers can interact with their target material by either being
(Nd:YAG) at 1.064 micrometer. absorbed, reflected, transmitted, or scattered 14. Absorbed
 Holmiumyttrium-aluminum-garnet (Ho:YAG) at 2.1 light energy gets converted to heat and can lead to
micro-meter. warming, coagulation, or excision and incision of the target
 Erbium,chromiummyttrium-slenium-gallium-garnet tissue. Although the wavelength of the laser is the primary
(Er,Cr:YSGG) at 2.78 micro-meter. determinant of how much energy is absorbed by the target
 Neodymiummyttrium-aluminum-perovskite tissue, optical properties of the tissue, such as pigmentation,
(Nd:YAP) at 1,340 nm. water content, and mineral content, can also influence the
extent of energy absorbed.15
Types of lasers9
The term ‘waveform’ describes the manner in which laser
 On the basis of output energy power is delivered over time, either as a continuous or as a
o Low output, soft or therapeutic eg. Low-output pulsed beam emission. Continuous wave lasers deliver
diodes large amounts of energy in an uninterrupted steady stream
o High output, hard, or surgical eg. potentially resulting in increased heat production. Pulsed
CO2,Nd:YAG,Er:YAG wave lasers usually deliver smaller amounts of energy in
interrupted bursts, thereby countering the build-up of heat
 On basis of state of gain medium
o Solid state-eg.Nd:YAG, Er:YAG, Er,Cr:YAG in the surrounding tissues.16 The characteristic of a laser
o Gas- eg.HeNe, Argon,CO2 depends on its wave-length (WL), and wave-length affects
o Excimer-eg. ArF, KrCl both the clinical applications and design of laser. Different
o Diode- eg. GaAIAs wave lengths can be classified into three:
1. The UV range (ultra-spectrum approximately 400-
 On the basis of oscillation mode
700 nm).
o Continous wave eg. CO2, Diodes
o Pulsed wave eg. Nd:YAG, Er:YAG 2. The VIS range (visible spectrum approximately 400-
700 nm).
Mechanism of action of lasers:
3. The IR range (infra-red spectrum which is
The physical principle of laser was developed from
approximately 700 nm) to the microwave spectrum.
Einstein’s theories in the early 1900s, and the first device
was introduced in 1960 by Maiman.10 Since then, lasers Advantages and Disadvantages:
have been used in many different areas in medicine and
Advantages of laser treatment are greater hemostasis,
surgery. Laser light is a man-made single photon
bactericidal effect, and minimal wound contraction 17,18,19.
wavelength. The process of lasing occurs when an excited
Compared with the use of a conventional scalpel, lasers can
atom is stimulated to emit a photon before the process
cut, ablate and reshape the oral soft tissue more easily, with
occurs spontaneously. Spontaneous emission of a photon by
no or minimal bleeding and little pain as well as no or only
one atom stimulates the release of a subsequent photon and
a few sutures. The use of lasers also has disadvantages that
soon. This stimulated emission generates a very coherent
require precautions to be taken during clinical application. 20
(synchronous waves), monochromatic (a single
Laser irradiation can interact with tissues even in the
wavelength), and collimated form (parallel rays) of light
noncontact mode, which means that laser beams may reach
that is found nowhere else in nature.11
the patients eyes and other tissues surrounding the target in
Laser is a type of electromagnetic wave generator12. Lasers the oral cavity. Clinicians should be careful to prevent
are heat producing devices converting electromagnetic inadvertent irradiation to these tissues, especially to the
energy into thermal energy. The emitted laser has three eyes. Protective eyewear specific for the wavelength of the
characteristic features. laser in use must be worn by the patient, operator, and

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assistant. Laser beams can be reflected by shiny surfaces of Precautions and Risks Associated with Clinical use of
metal dental instruments, causing irradiation to other Lasers:20
tissues, which should be avoided by using wet gauze packs
Precautions before and during Irradiation
over the area surrounding the target. However, previous
laser systems have strong thermal side effects, leading to 1. Use glasses for eye protection (patient, operator,
melting, cracking, and carbonization of hard tissues. and assistants).
Current and potential applications of Lasers in 2. Prevent inadvertent irradiation (action in non-
Dentistry contact mode).
3. Protect the patient’s eyes, throat, and oral tissues
TYPE ACTIVE MEDIUM DENTAL APPLICATIONS outside the target site.
Excimer Argon –fluoride(ArF) Hard tissue ablation, dental calculus 4. Use wet gauze packs to avoid reflection from
Lasers Xenon-chloride (XeCl) removal shiny metal surfaces.
Argon (Ar)  Curing of composite materials, tooth 5. Ensure adequate high speed evacuation to capture
whitening, intraoral soft tissue surgery, the laser plume.
sulcular debridement (subgingival
curettage in periodontitis and Potential risks
periimplantitis) 1. Excessive tissue destruction by direct ablation and
Gas  Analgesia, treatment of dentin thermal side effects.
Lasers hypersensitivity, apthous ulcer treatment 2. Destruction of the attachment apparatus at the
Helium-neon (HeNe)  Intraoral soft tissue and soft tissue bottom of pockets.
surgery, aphthous ulcer treatment, 3. Excessive ablation of root surface and gingival
removal of gingival melanin tissue within periodontal pockets.
Carbon dioxide(CO2) pigmentation, treatment of dentin 4. Thermal injury to the root surface, gingival tissue,
hypersensitivity, analgesia pulp, and bone tissue.
Caries and calculus detection
Indium-gallium-
Intraoral general and implant soft tissue Applications of Lasers in Periodontal Treatment
arsenide-
surgery, sulcular debridement (subgingival
phosphorous(InGaAsP) The use of lasers in periodontal treatment has been well
Diode curettage in periodontitis and
Galium-aluminium- documented over the past 10 years. Lasers can be used for
Lasers periimplantitis), analgesia, treatment of
arsenide(GaAIAs) initial periodontal therapy and surgical procedures. When
dentin hypersensitivity, pulpotomy, root used in deep periodontal pockets with associated bony
Gallium-arsenide
canal disinfection, apthous ulcer treatment, defects, the laser not only removes the diseased granulation
(GaAs)
removal of gingival melanin pigmentation tissue and associated bacteria; it also promotes osteoclast
Selective ablation of dental plaque and and osteoblast activity, often resulting in bone regrowth.
calculus This usage becomes more complicated because the
Frequency-doubled
Intraoral soft tissue surgery, sulcular periodontium consists of both hard and soft tissues. Among
alexandrite
debridement (subgingival curettage in the many lasers available such as CO2, Nd:YAG and diode
Solid-state
periodontitis), analgesia, treatment of lasers can be used in periodontics because of their excellent
Lasers Neodymium:yttrium-
dentin hypersensitivity, pulpotomy, root ablation and hemostatic characteristics.
aluminium-
canal disinfection, removal of enamel
garnet(Nd:YAG) Initial Periodontal Therapy Scaling And Root Planing:
caries, aphthous ulcer treatment , removal
of gingival melanin pigmentation
Soft tissue lasers are a good choice in bacterial reduction
Caries removal and cavity preparation,
and coagulation. The erbium group of lasers has shown
significant bactericidal effect against porphyromonas
modification of enamel and dentin surfaces,
gingivalis and actinobacillus actinomycetemcomitans21.
Erbium group intraoral general and implant soft tissue
Reduction of interleukins and pocket depth was noted with
Erbium:YAG(Er:YAG) surgery, sulcular debridement (subgingival
laser therapy.
Erbium:yttrium(Er:YS curettage in periodontitis and
GG) periimplantitis), scalingof root surfaces, Soft Tissue Applications:
Erbium, osseous surgery, treatment of dentin Laser is effectively used to perform gingivectomies,
chromium:YSGG(Er:Y hypersensitivity, analgesia, pulpotomy, root gingivoplasties, free gingival graft procedures, crown
SGG) canal treatment and disinfection, aphthous lengthening, operculectomy and many more22. Gingival
ulcer treatment, removal of gingival depigmentation using laser ablation has been recognized as
melanin and metal-tattoo-pigmentation an effective, pleasant, and a reliable technique. In terms of
aesthetic dentistry, the use of the Erbium laser in crown
lengthening in the anterior has created an entirely new
dimension in smile design.

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LASER ASSISTED NEW ATTACHMENT field, reduced surgical time and the general experience of
PROCEDURE (LANAP): less postoperative swelling.
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