Journal of the International Academy of Periodontology 2008 10-1: 22-30

Clinical Application of Erbium:YAG Laser in Periodontology

Isao Ishikawa1, Akira Aoki2, and Aristeo Atsushi Takasaki2
1

Professor Emeritus, Tokyo Medical and Dental University, Visiting Professor, Institute of Advanced Biomedical Engineering and Science, Tokyo Womens Medical University; 2Division of Periodontology, Department of Hard Tissue Engineering, Graduate School, Tokyo Medical and Dental University
Abstract Various lasers have been introduced for the treatment of oral diseases and their applications in dental clinics have become a topic of much interest among practitioners. Technological advances and improvements have increased the choices of the available laser systems for oral use. Among them, a recently developed erbium-doped:yttrium aluminum garnet (Er:YAG) laser system possesses suitable characteristics for oral soft and hard tissue ablation. Due to its high absorption in water, an effective ablation with a very thin surface interaction occurs on the irradiated tissues without any major thermal damage to the irradiated and surrounding tissues. In the eld of periodontics, the application of Er:YAG laser for periodontal hard tissue has begun with studies from Japanese and German researchers. Several in vitro and clinical studies have already demonstrated an effective application of the Er:YAG laser for calculus removal and decontamination of the diseased root surface in periodontal non-surgical and surgical procedures. However, further studies are required to better understand the various effects of Er:YAG laser irradiation on biological tissues for its safe and effective application during periodontal and implant therapy. Randomized controlled clinical trials and more basic studies have to be encouraged and performed to conrm the status of Er:YAG laser treatment as an adjunct or alternative to conventional mechanical periodontal therapy. In this paper, the advantages and current clinical applications of this laser in periodontics and implant dentistry are summarized based on current scientic evidence. Key words: Erbium YAG, neodymium YAG, periodontics, laser, dental implant

Introduction Periodontal disease is a chronic bacterial infection that results from an inammatory response to dental plaque that affects the gingiva and periodontium supporting the teeth. In periodontal pockets, the root surfaces are contaminated with an accumulation not only of plaque, but also of calculus, as well as inltration of bacteria and bacterial endotoxins into cementum. Based on its various characteristics, such as ablation or vaporization, hemostasis, and sterilization effect, laser treatment is expected to serve as an adjunct or alternative to the current conventional mechanical periodontal therapy (Frame, 1985; Romanos, 1994; White et al., 1998; Ishikawa et al., 2003; Aoki et al., 2004b; Ishikawa et al., 2004). FDA approved the pulsed Er:YAG (erbium:yttrium aluminum garnet) laser for hard tissue treatment such as caries removal and cavity preparation in 1997, for soft
Correspondence to: Isao Ishikawa, DDS, PhD, Institute of Advanced Biomedical Engineering and Science, Tokyo Womens Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 1628666 JAPAN. E-mail: ishikawa@abmes.twmu.ac.jp
International Academy of Periodontology

tissue surgery and sulcular debridement in 1999 and for osseous surgery in 2004. The excellent ablation effect of the Er:YAG laser for both soft and hard tissues has received a lot of attention in the eld of periodontal therapy, and has been extensively investigated (Aoki et al., 1994; Aoki et al., 2000a; Schwarz et al., 2001a; Sasaki et al., 2002a; Sasaki et al., 2002d). The high absorption of the Er:YAG laser into water and in combination with water irrigation minimizes thermal inuences on the surrounding tissues during irradiation. When the Er:YAG laser was used for incision of pigskin in a non-contact mode, it showed formation of a thermally changed layer of only 10 - 50 m (Walsh et al., 1989). Er:YAG laser irradiation using water irrigation has been reported to produce an altered layer of width 5 - 15 m on cementum and dentin surfaces (Aoki et al., 1998; Fujii et al., 1998; Aoki et al., 2000a). Pioneer work In the eld of periodontics, the application of Er:YAG laser for periodontal hard tissue application started in the early 1990s with studies from Japanese researchers

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(Aoki et al., 1994) and German researchers (Keller et al., 1995; Keller et al., 1997) demonstrating effective calculus removal and decontamination of the diseased root surface. Watanabe et al. reported the rst clinical study for scaling and soft tissue surgery (Watanabe et al., 1996), Schwarz et al. used the laser for pocket treatment (Schwarz et al., 2001b; Schwarz et al., 2003e; Schwarz et al., 2003f), and Schwarz et al. and Sculean et al. reported its application for surgery (Schwarz et al., 2003g; Sculean et al., 2004b). In the current periodontal clinic, the Er:YAG laser is applied for non-surgical scaling treatment due to its excellent ability to easily remove calculus, and detoxify and kill the bacteria from the contaminated cementum. Surgical treatment for removal of infected granulation tissue and bone ablation, minor surgical soft tissue management that requires delicate handling, and esthetic results and implant maintenance therapy are also procedures that show exciting and interesting clinical results using Er:YAG laser irradiation in periodontics. Non-surgical periodontal scaling therapy Complete removal of bacterial deposits and their toxins from the root surface and within the periodontal pockets is still difcult and not necessarily achieved with conventional mechanical therapy. Sometimes the root anatomy renders it difcult to achieve a biologically compatible root surface: inter-proximal areas, furcations, the cemento-enamel junction, multi-rooted teeth and distal sites of molars are most likely to exhibit residual plaque and calculus following treatment. Therefore, Er:YAG laser scaling was recently introduced as an alternative to conventional scaling procedures because of excellent tissue ablation performance with strong bactericidal and detoxication effects (Aoki et al., 2004b; Ishikawa et al., 2004). Removal of subgingival calculus and root substance during Er:YAG laser scaling Dental calculus contains water in its structural micropores as well as in its intrinsic components. Since the Er:YAG laser has the ability of ablating dental hard tissues such as enamel and dentin, the laser is also capable of dental calculus removal at much lower energy levels (Aoki et al., 1994). Stock et al. (1996) introduced a newly developed contact tip (chisel type) suitable for root surface treatment within periodontal pockets. Used at an angle of 20 degrees to the root surface, it was found that the maximum depth of ablation traces was approximately 100 m after Er:YAG laser scaling. They also reported that the threshold for both calculus and cementum ablation was 0.8 J/cm2 (Stock et al., 1996). Keller et al. tried Er:YAG laser scaling under water irrigation using a rotatory ber tip with a chisel-shaped prole. They demonstrated that Er:YAG laser scaling

using a chisel type tip could remove calculus on the root surface effectively without thermal alteration of the root surface (Keller and Hibst, 1997). Folwaczny et al. (2000) examined root substance removal with the Er:YAG laser while irradiating root surfaces with or without calculus. From the ndings they concluded that the root substance removal with the Er: YAG laser at lower energy densities up to 100 mJ/pulse was comparable to that after conventional root surface instrumentation with curettes, and that selective calculus removal may be feasible using lower radiation energies (Folwaczny et al., 2000). However, the power output should be decided with caution, considering a balance of effectiveness and unnecessary tissue removal. Improvement of the effectiveness of laser scaling should rely on other variables, such as pulse repetition rate and pulse duration, rather than only on an increase of energy output (Ishikawa, 2002). In another study, Aoki et al. evaluated the effectiveness of Er:YAG laser scaling compared to conventional ultrasonic scaling, and reported that the level of calculus removal by laser scaling was similar to that by ultrasonic scaling, although the efciency of laser scaling was a little lower (Aoki et al., 2000a). Schwarz et al. (2003d) reported that the Er:YAG laser treatment provided selective subgingival calculus removal to a level equivalent to that provided by scaling and root planing. Recently, Schwarz et al. (2001a) reported that the clinical use of the Er:YAG laser resulted in smooth root surface morphology, which was not comparable to the marked morphological changes that were produced in vitro, and they suggested calculus removal can be done selectively in vivo, contrary to the in vitro condition. However, in subgingival scaling, not only the removal of calculus but also removal of contaminated cementum may be clinically acceptable to some extent. In order to avoid excessive removal of sound root substance during Er:YAG laser subgingival scaling, further in vitro and in vivo studies are required to determine a suitable combination of laser irradiation parameters, such as energy output and pulse rate in conjunction with the irradiation manner and type of contact tip used. Root surface alteration following Er:YAG laser irradiation Several studies have described a characteristic morphological change of root surface after Er:YAG laser irradiation observed by histological and scanning electron microscope (SEM) examination (Aoki et al., 1994; Israel et al., 1997; Fujii et al., 1998; Folwaczny et al., 2000; Gaspirc et al., 2001; Sasaki et al., 2002a; Sasaki et al., 2002d). It has been demonstrated that the ablated surface becomes chalky after drying due to micro-ir-

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regularities on the lased surface (Aoki et al., 1994; Israel et al., 1997; Aoki et al., 2000a; Gaspirc and Skaleric, 2001). The surface lased by Er:YAG laser showed slight melting with cluster formation of enlarged microparticles of inorganic components in SEM observation at ultra-high magnication. Also, the laser-treated root surface under water coolant has been reported to have a micro-irregular appearance without cracks or thermal side effects, such as signicant melting and microfractures, which are usually observed after CO2 or neodymium:YAG (Nd:YAG) laser irradiation (Israel et al., 1997; Fujii et al., 1998; Aoki et al., 2000a; Sasaki et al., 2002a). In a contact irradiation, Fujii et al. (1998) showed a micro-structured root surface with denaturation of collagen bers up to a depth of 15 m in cementum. Also, Aoki et al. reported that numerous rounded or sharp pointed projections were evident on the root surface after Er:YAG laser scaling used with water spray, and that the supercial layer of the root surface ablated by Er:YAG laser irradiation presented minimal change with characteristic staining (Aoki et al., 2000a). Sasaki et al. (2002d) demonstrated that the Er:YAG laser did not cause major compositional changes or chemically deleterious changes of the root cementum and dentin under water irrigation using Fourier-transformed infrared (FTIR) spectroscopy analysis. Schwarz et al. (2003a) performed in vivo Er:YAG laser irradiation with water spray or scaling and root planing (SRP) with hand instruments on periodontally diseased roots of teeth that were deemed suitable for extraction due to severe periodontal destruction, and cultured broblasts on the treated teeth following extraction. They observed signicantly greater cell attachment in vitro in the laser treatment group than in the SRP treatment group (Schwarz et al., 2003a). Feist et al. performed in vitro Er:YAG laser irradiation with water spray or scaling and root planing with curettes on periodontally diseased roots of teeth. They reported that the surfaces treated with 35 mJ/pulse Er:YAG laser irradiation promoted faster adhesion and growth than those treated with either root planing or 59 mJ/pulse Er: YAG laser irradiation (Feist et al., 2003). These positive results may be due to the disinfection and detoxication effects of Er:YAG laser irradiation on the diseased root surface and the absence of a smear layer on the treated root surface after irradiation (Aoki et al., 2004b). Further in vitro and animal experiments are required to clarify the biocompatibility of the root surface prepared by Er:YAG laser. In addition, whether supplementary treatment, using chemical or mechanical methods, is required to remove the supercially altered layer to better understand the periodontal connective tissue attachment to the Er:YAG lased root surface remains to be determined. Regarding the thermal damage caused during Er: YAG laser treatment of the root surface, the importance

of water irrigation to keep the irradiated root surface from exposure to major thermal change has already been claried. It has been demonstrated that the use of water coolant effectively prevents thermal generation during laser scaling while not compromising the efciency of laser scaling (Keller & Hibst, 1997). There are no histological studies of pulp tissue response after Er:YAG laser scaling of subgingival calculus. However, it was reported that no major damage occur in the pulp tissue under water irrigation after cavity preparations that use much higher energy levels than those employed in laser scaling (Aoki et al., 2004b). Therefore, it may be presumed that Er:YAG laser subgingival scaling at a low energy level, especially with the contact tip directed obliquely to the root surface, does not produce any major deleterious outcomes in the pulpal tissue. Disinfection and detoxication Er:YAG laser irradiation has been reported to exhibit high bactericidal properties (Ando et al., 1996; Folwaczny et al., 2002; Kreisler et al., 2002b). It has been proven that conventional methods for treatment of periodontal disease are not equally effective in eliminating all types of bacteria. Actinobacillus actinomycetemcomitans, a periodontopathogen important in the development of periodontal disease, is known to be difcult to eliminate with usual mechanical means (Renvert et al., 1990; Takamatsu et al., 1999). These limitations have led to a shift in emphasis from a purely mechanical approach to other methods that include the use of adjunctive antimicrobial procedures. Ando et al. (1996) reported that the Er:YAG laser exhibits a high bactericidal potential against periodontopathic bacteria such as Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans at a low energy level of 0.3 J/cm2. Folwaczny et al. (2002) reported that Er:YAG laser irradiation causes reduction in bacteria on root surfaces in vitro. In 1997, Yamaguchi et al. showed in vitro that the infrared spectrum of bacterial lipopolysaccharide had a peak at 2,940 nm, which also corresponded to the wavelength of the Er:YAG laser, and that the Er:YAG laser could effectively and rapidly remove most of the lipopolysaccharide that had been coated on the extracted root surfaces. It has been reported that no smear layer was produced on the Er:YAG laser-irradiated surface. This suggests a possible advantage of laser therapy, because the presence of a smear layer has been reported to be detrimental to periodontal tissue healing by potentially inhibiting or slowing reattachment of cells to the root surface. Also, Sasaki et al. (2002d) showed that root cementum and dentin treated with the Er:YAG laser used with water coolant was free of toxic substances such as cyanate (NCO-) and cyanamide (NCN2-) that were observed on

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surfaces irradiated by CO2 and Nd:YAG (neodymium: yttrium aluminum garnet) lasers. Therefore, improved disinfection and detoxication may be expected on the Er:YAG laser-treated root surface. Clinical applications Based on the results of in vitro studies, several clinical studies were conducted reporting the usefulness of Er: YAG laser for periodontal therapy. In 1996, Watanabe et al. suggested that laser scaling was safe and effective, and clinically useful. Recently, Schwarz et al. (2001b) reported interesting clinical data of non-surgical periodontal treatment comparing Er:YAG laser irradiation with conventional scaling and root planing in a randomized, controlled clinical study using a split-mouth design. At a six-month post-treatment evaluation, the laser treatment showed similar or better results than the scaling and root planing treatment in terms of reduction of bleeding on probing, pocket depth and clinical attachment level (Schwarz et al., 2001b). In particular, the laser treatment group presented a signicantly greater reduction of bleeding on probing and improvement of clinical attachment level compared to the scaling and root planing group. The researchers concluded that the Er:YAG laser may present a suitable alternative to conventional mechanical debridement in non-surgical periodontal treatment. Furthermore, Schwarz et al. investigated the necessity of adjunctive scaling and root planing after Er:YAG laser treatment. They performed a clinical study similar to the above-mentioned study, and found no additional improvement in clinical outcomes for the laser treatment followed by scaling and root planing compared to laser treatment alone (Schwarz et al., 2003e). Schwarz et al. (2003f) also reported that the clinical attachment gain obtained following Er:YAG laser nonsurgical periodontal treatment was maintained over a 2-year period. Most recently, Sculean et al. compared the effectiveness of an Er:YAG laser to that of ultrasonic scaler for non-surgical periodontal treatment. Twenty patients with moderate to advanced periodontal destruction were randomly treated in a split-mouth design with a single episode of subgingival debridement using either an Er:YAG laser or an ultrasonic instrument. At six months following treatment, mean values of bleeding on probing, probing pocket depth and clinical attachment level improved statistically signicantly in both groups. However, no statistical or clinical differences in the improvement of investigated parameters were observed between the treatment modalities (Sculean et al., 2004a).

Summary of non-surgical laser periodontal therapy Research has suggested that the Er:YAG laser irradiation is safe and effective for periodontal pocket treatment, including root surface debridement (Aoki et al., 1994; Watanabe et al., 1996; Israel et al., 1997; Fujii et al., 1998; Aoki et al., 2000a; Gaspirc and Skaleric, 2001; Schwarz et al., 2001a; Schwarz et al., 2001b; Sasaki et al., 2002a; Schwarz et al., 2003a; Schwarz et al., 2003d; Schwarz et al., 2003f; Aoki et al., 2004b; Ishikawa et al., 2004). Er: YAG laser irradiation may be a promising and useful adjunctive or alternative method to the conventional technique for root preparation and pocket curettage. However, the effects of the Er:YAG laser need to be demonstrated in further randomized controlled trials and a subsequent meta-analysis needs to be performed. Also, further studies are necessary to clarify the histological attachment of periodontal tissues to the irradiated root surface in vivo. For clinical application in periodontal pockets where the operator cannot visualize the irradiated target, special tips should be designed to facilitate insertion into the periodontal pocket and detection of the presence of dental calculus on the surface (Keller and Hibst, 1997; Watanabe et al., 2001). Recently, as a novel application of laser irradiation, the use of diode laser uorescence spectroscopy for detection of dental calculus has been suggested (Hibst et al., 2001). This work has already resulted in the development of a commercial device (Sculean et al., 2004a). Er:YAG laser treatment combined with an automatic calculus-detecting system may be a novel technical modality for pocket therapy in the near future. Periodontal surgery Since most forms of periodontal disease are plaque-associated disorders, surgical access to the infected sites can be important to facilitate the removal of subgingival deposits under direct visualization and thereby enhance the long-term preservation of the periodontium. The root surface has been the area of focus for mechanical debridement. However, in order to obtain the fast and complete healing of the inamed site, not only removal of root surface debris, but also removal of infected granulation tissue has to be performed. Some difculties can be associated with conventional therapy, such as those caused by tooth anatomy, localization of the surgical site and the time consumed by conventional instrumentation. The Er:YAG laser seems to be a potential tool for removal of granulation tissue due to its excellent capacity to ablate soft tissues, and, thus, is expected to promote healing of periodontal tissues by ablating the inamed lesions and the epithelial lining of the soft tissue wall within periodontal pockets (Watanabe et al., 1996; Schwarz et al., 2003g; Sculean et

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al., 2004b; Mizutani et al., 2006). Concerning the bone treatment, Sasaki et al., using Er:YAG laser irradiation at 100 mJ/pulse energy output and 10 Hz, demonstrated the bone cutting ability of the Er:YAG laser, with results comparable to that of conventional steel burs (Sasaki et al., 2002c). In an animal study using dogs, effective and safe granulation tissue removal using Er:YAG laser during ap surgery was demonstrated, showing both clinically and histologically that no major thermal damage occurred to the irradiated bone surface. Also, the amount of newly formed bone was signicantly greater in the laser-treated group than in the conventional surgery control group after 12 weeks, as demonstrated in the histological observation of this study (Mizutani et al., 2006). Furthermore, effective granulation tissue removal from periodontal bone defects after full-thickness mucoperiosteal ap elevation using Er:YAG laser in contact mode at parameters set at energy output of 160 mJ/ pulse and 10 Hz was clinically demonstrated (Schwarz et al., 2003g; Sculean et al., 2004b). Regarding the application of Er:YAG laser for bone ablation, Nelson et al. reported that this laser could ablate bone effectively with minimal thermal damage to the adjacent tissues (Nelson et al., 1989). Also, the ability to remove bone tissue with minimal chemical and morphological changes to the irradiated and surrounding surfaces was demonstrated previously. A typical irregular pattern, which consisted of biological apatites surrounded by organic matrix, was observed in the irradiated bone and this might have aided in uneventful healing. Lewandrowski et al. (1996) reported that the healing rate following Er:YAG laser irradiation may be equivalent or even faster than that following bur drilling. Sasaki et al. (2002b) showed, histologically, a thin altered layer produced by Er:YAG laser at 100 mJ and 10 Hz on irradiated rat calvaria bone surface. The irregular bone morphology after irradiation and absence of toxic substances may have promoted the adhesion of plasma proteins during the initial stages of healing. On the other hand, bone ablated using CO2 laser showed extensive thermal effects (Sasaki et al., 2002b). In another study, Pourzarandian et al. (2004) demonstrated that the initial bone healing following Er:YAG laser irradiation occurred faster than that after mechanical bur drilling and CO2 laser irradiation in rats, as observed by light and transmission electron microscopy (TEM). The laser irradiation was performed with an energy output of 100 mJ/pulse at 10 Hz. This laser system has been demonstrated to be useful and to be a promising tool for granulation tissue removal in periodontal pocket sites and infra-bony defects. Also, it seems to be an important apparatus for bone ablations and osseous re-contouring during periodontal surgery. Furthermore, there is a possibility that the bone is biostimulated after Er:YAG laser irradiation. Further

experiments have to be carried out to elucidate the exact mechanism of Er:YAG laser irradiation of bone tissue and to demonstrate the efcacy of granulation tissue removal without any thermal damage to the adjacent tissue, including alveolar bone and root surfaces. Soft tissue management Recently, the Er:YAG laser has been effectively applied for periodontal soft-tissue management without causing major thermal side effects (Aoki et al., 2000b; Kawashima et al., 2002; Aoki et al., 2003; Aoki et al., 2004a; Aoki et al., 2004b). Due to its superior qualities, this laser has extremely low thermal side effects and has become one of most promising lasers for periodontal therapy. It would be very useful and safe for periodontal minor soft tissue management, especially for delicate esthetic procedures. The application of the Er:YAG laser, sometimes in combination with a surgical microscope, renders some esthetic procedures more feasible. It becomes possible to deal with the soft tissues more delicately, thus yielding more satisfactory results compared to those obtained by conventional methods. Esthetic management of periodontal soft tissues is a focus in the current periodontal clinic, especially cases of removal of melanin hyperpigmentation, metal tattoos, and gingival enlargement ablation (Aoki et al., 2000b; Kawashima et al., 2002; Aoki et al., 2003; Aoki et al., 2004a; Aoki et al., 2004b). Complaints of black gums are common, and depigmentation is usually performed for esthetic reasons. The efciency of gingival melanin hyperpigmentation removal with laser was evaluated by several researchers (Atsawasuwan et al., 2000; Sharon et al., 2000; Yousuf et al., 2000; Tal et al., 2003). The Er:YAG laser is capable of excellent soft tissue ablation, which makes it suitable for this kind of pigmentation removal (Aoki et al., 2000b; Kawashima et al., 2002). In our previous study, the width of the thermally changed layer in gingival connective tissue was 5-20 m after Er:YAG laser melanin removal in dogs (Aoki et al., 2000b). Clinically safe and effective procedures are performed without causing any major thermal side effects or delayed wound healing for gingival melanin pigmentation ablation. Kawashima et al. demonstrated safe and effective pigmentation removal with complete and fast wound healing within two weeks without any side effects or complications, using parameters of an energy output of 27-54 mJ/pulse and pulse rate of 20-30 Hz under water spray using 600 m diameter 80 curved tip. Also, a surgical microscope was used during irradiation at approximately 20-30x magnication for detection of any slight pigmentation remaining and careful laser manipulation (Kawashima et al., 2002).

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The Er:YAG laser is utilized for removal of darkcolored gingiva containing foreign metal, namely metal tattoos, which is unaesthetic (Aoki et al., 2004a; Ishikawa et al., 2004). It is suspected that dental treatment procedures or restorative materials cause this kind of discoloration. A recent report indicated that this kind of discolored gingiva contained silver sulfate, tin sulfate, and pieces of iron, as observed by electron probe microscopy (Sato et al., 1997). Apparently, the iron can originate from cut restorative material, and, without surgical removal of the gingival tissues containing the fragments, the discoloration will remain. Aoki et al. demonstrated effective removal of gingival tissue with metal debris using an Er:YAG laser (at 24-48 mJ/pulse, 600 m diameter tip at 10-30 Hz under water spray) in contact mode under topical and local anesthesia, showing cases with ideal wound healing with no post-surgical pain or gingival recession (Aoki et al., 2004a). Implant therapy The utility of Er:YAG laser for soft tissue applications and root debridement procedures is well established. In the eld of implant therapy, the use of this laser for the second stage of implant surgeries has already been reported (Arnabat-Dominguez et al., 2003). The use of Er:YAG laser diminishes the need for local anesthesia, minimizes postoperative pain and edema, with tissue showing complete healing by day 5, thus facilitating more rapid prosthetic rehabilitation when compared with conventional procedures. However, the most interesting application of Er:YAG laser in the implantology eld is for treatment of peri-implant tissue inammation and maintenance of a healthy peri-implant tissue environment. Peri-implant infection results in inammation of the surrounding soft tissues and can induce a breakdown of the implant-supporting bone. It is associated with the presence of a subgingival microora, which is quite similar to that in periodontal pockets and contains a large variety of Gram-negative anaerobic bacteria (Sanz et al., 1990). It is well known that adherent bacterial plaque and calculus develop on the surface of implant abutments, as on natural teeth. Maintenance treatment is required to keep the peri-implant tissue healthy, but mechanical instruments such as metal curettes and ultrasonic scalers are not recommended for decontamination of titanium implants, since they easily damage the titanium surface. Recently, the Er:YAG laser was proposed for implant maintenance (Matsuyama et al., 2003; Schwarz et al., 2003b; Schwarz et al., 2005), taking advantage of its bactericidal effect, technical simplicity and absence of postoperative pain and edema. Lasers may be used for decontamination of implant surfaces and treatment of peri-implantitis without damaging the titanium surface (Bach et al., 2000). Kreisler et al. (2002b)demonstrated in

vitro the high bactericidal potential of Er:YAG laser on titanium implants with different surface characteristics without major laser surface alteration using energy output at 60 and 120 mJ and 10 Hz during 60 seconds of irradiation. Matsuyama et al. (2003) also observed that the Er:YAG laser causes damage on the titanium surface at a high energy level, such as 100 mJ/pulse, but does not result in any morphological change or major temperature elevation at a low energy level (under 50 mJ/pulse and 30 Hz) with water coolant, which is suitable for periodontal treatment. Schwarz et al. (2003c) observed that the Er:YAG laser at 100 mJ/pulse and 10 Hz under water irrigation does not damage titanium surfaces and does not affect the attachment of osteoblast-like cells. Their preliminary clinical results (Schwarz et al., 2005) have also shown that non-surgical treatment of peri-implantitis with an Er:YAG laser at 100 mJ/pulse and 10 Hz under water spray led to a statistically signicant pocket depth reduction and clinical attachment level gain. Effective decontamination of the implant surface without excessive temperature elevation and any morphological changes by Er:YAG lasers has been reported in vitro (Kreisler et al., 2002a, 2002b). Laser treatment of peri-implantitis may also be a promising eld. However, further studies are required for application of lasers in implant maintenance therapy. Discussion Laser treatment is expected to serve as an alternative or adjunct to conventional mechanical therapy in periodontics due to various advantages, such as easy handling, short treatment time, hemostasis and decontamination and sterilization effects. With conventional mechanical instruments, complete access and disinfection may not be achieved during the treatment of periodontal pockets. The effectiveness of instrumentation may vary with the skill and experience of the practitioner, and therefore the technique is sensitive. Among all the lasers, the Er: YAG laser possesses characteristics particularly suitable for oral treatment, due to its dual ability to ablate soft and hard tissues with minimal damage. Also, its bactericidal effect (with elimination of bacterial lipopolysaccharide), its ability to easily remove plaque and calculus, an irradiation effect limited to an ultra-thin layer of tissue, promotion of comparable or faster bone repair after irradiation than conventional bur drilling, and its use in implant maintenance make it a promising tool for periodontal treatment. Er:YAG laser is capable of effectively removing dental plaque and calculus from the root surface with extremely low mechanical stress and no formation of a smear layer on the treated root surface. Furthermore, potential biostimulation effects of scattering and penetrating lasers on the cells surrounding the target tissue during irradiation might be helpful for the heal-

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ing of periodontal tissues. Considering these various advantages that Er:YAG laser irradiation can offer, the use of laser irradiation in combination with conventional treatment or laser irradiation alone for periodontal treatment has the potential to improve post-operative healing in comparison to conventional therapy alone. However, to obtain the desired success of periodontal treatment without damage to the surrounding tissue, the appropriate laser parameters, such as power energy, energy density and time of irradiation, have to be used. Even though successful experimental results have been reported so far with the Er:YAG laser, further studies are required to better understand the effects on biological tissues for its safe and effective application during periodontal therapy. The ultimate applicability and benets of a novel treatment modality must be strictly evaluated based on scientic evidence and critical review of existing literature (AAP, 1999). Recently, in an AAP-commissioned review, Cobb (2006) wrote as follows: Based on this review of the literature, one must conclude that there is a great need to develop an evidence-based approach to the use of lasers for the treatment of chronic periodontitis. Simply put, there is insufcient evidence to suggest that any specic wavelength of laser is superior to the traditional modalities of therapy. Current evidence does suggest that use of the neodymium:YAG (Nd:YAG) or Er:YAG wavelengths for treatment of chronic periodontitis may be equivalent to scaling and root planing (SRP) with respect to reduction in probing depth and subgingival bacterial populations. However, if gain in clinical attachment level is considered the gold standard for non-surgical periodontal therapy, then the evidence supporting laser-mediated periodontal treatment over traditional therapy is minimal at best. Lastly, there is limited evidence suggesting that lasers used in an adjunctive capacity to SRP may provide some additional benet. Establishment of a sound evidence base for laser usage in treatment of chronic periodontitis will require randomized, blinded, controlled, longitudinal, clinical trials. Given the inherent expense, requirements of time, and number of clinicians required to conduct such studies, this may require multicenter collaborative studies. The Nd:YAG laser has characteristics completely different from the Er:YAG laser (Ishikawa et al., 2004). Briey, the wavelength (1064 nm) of Nd:YAG penetrates into water to a depth of 60 mm, and the energy is scattered in soft tissues rather than being absorbed on the tissue surface. It is highly absorbed by the color black, and therefore this laser is commonly used for cutting and coagulation of oral soft tissues with good hemostasis. However, due to its scattering effect, it is difcult to judge the depth of penetration of this laser. It was shown that the Nd:YAG laser did not provide satisfactory root surface debridement because of insufcient calculus removal, and cementum alteration by heat

generation (Cobb et al., 1992; Spencer et al., 1996). There is a specic potential risk in the treatment of pockets with the Nd:YAG laser, as the laser beam is released to surfaces with very different absorbent properties (subgingival calculus, epithelium, periodontal membrane, root element, bone), without any optical control. There is also real risk with inexpert use, including laser-induced pulpitis, gingival necrosis and sequestration. There have even been cases of laser-induced osteomyelitis. The Nd: YAG laser should be considered as adjunctive to conventional mechanical treatment if it is necessary. Also, in order to use lasers safely in a clinic, the practitioner should have precise knowledge of the characteristics and effects of each laser system and their applications as well as a full understanding of the conventional treatment procedures, and, nally, should exercise appropriate caution during their use. Due to its high absorption by water, less tissue degeneration with very thin surface interaction occurs after Er:YAG laser irradiation. Also, the temperature rise is minimal in the presence of water irrigation, which makes hard tissue preparations and scaling treatment easily possible with this laser. In summary, the Er:YAG laser shows promise as an effective tool for periodontal therapy, and may emerge as a new technical modality for non-surgical periodontal therapy in the near future. Randomized controlled clinical trials and more basic studies have to be encouraged and performed to determine the most optimal and safest parameters for laser treatment. References
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Lewandrowski, K.U., Lorente, C., Schomacker, K.T. et al. Use of the Er:YAG laser for improved plating in maxillofacial surgery: comparison of bone healing in laser and drill osteotomies. Lasers in Surgery and Medicine 1996; 19:40-45. Matsuyama, T., Aoki, A., Oda, S., Yoneyama, T. and Ishikawa, I. Effects of the Er:YAG laser irradiation on titanium implant materials and contaminated implant abutment surfaces. Journal of Clinical Laser Medicine & Surgery 2003; 21:7-17. Mizutani, K., Aoki, A., Takasaki, A.A. et al. Periodontal tissue healing following ap surgery using an Er:YAG laser in dogs. Lasers in Surgery and Medicine 2006; 38:314-324. Nelson, J.S., Orenstein, A., Liaw, L.H. and Berns, M.W. Mid-infrared erbium:YAG laser ablation of bone: the effect of laser osteotomy on bone healing. Lasers in Surgery and Medicine 1989; 9:362-374. Pourzarandian, A., Watanabe, H., Aoki, A. et al. Histological and TEM examination of early stages of bone healing after Er:YAG laser irradiation. Photomedicine and Laser Surgery 2004; 22:342-350. Renvert, S., Wikstrom, M., Dahlen, G., Slots, J. and Egelberg, J. Effect of root debridement on the elimination of Actinobacillus actinomycetemcomitans and Bacteroides gingivalis from periodontal pockets. Journal of Clinical Periodontology 1990; 17:345-350. Romanos, G.E. Clinical applications of the Nd:YAG laser in oral soft tissue surgery and periodontology. Journal of Clinical Laser Medicine & Surgery 1994; 12:103-108. Sanz, M., Newman, M.G., Nachnani, S. et al. Characterization of the subgingival microbial ora around endosteal sapphire dental implants in partially edentulous patients. International Journal of Oral & Maxillofacial Implants 1990; 5:247-253. Sasaki, K.M., Aoki, A., Ichinose, S. and Ishikawa, I. Morphological analysis of cementum and root dentin after Er:YAG laser irradiation. Lasers in Surgery and Medicine 2002a; 31:79-85. Sasaki, K.M., Aoki, A., Ichinose, S. and Ishikawa, I. Ultrastructural analysis of bone tissue irradiated by Er:YAG Laser. Lasers in Surgery and Medicine 2002b; 31:322-332. Sasaki, K.M., Aoki, A., Ichinose, S. et al. Scanning electron microscopy and Fourier transformed infrared spectroscopy analysis of bone removal using Er:YAG and CO2 lasers. Journal of Periodontology 2002c; 73:643-652. Sasaki, K.M., Aoki, A., Masuno, H. et al. Compositional analysis of root cementum and dentin after Er:YAG laser irradiation compared with CO2 lased and intact roots using Fourier transformed infrared spectroscopy. Journal of Periodontal Research 2002d; 37:50-59. Sato, A., Ukon, S., Hamano, M. and Miyoshi, S. Gingival pigmentation due to prolonged retention of metal fragments. Japanese Journal of Oral Biology 1997; 39:565-571. Schwarz, F., Putz, N., Georg, T. and Reich, E. Effect of an Er:YAG laser on periodontally involved root surfaces: an in vivo and in vitro SEM comparison. Lasers in Surgery and Medicine 2001a; 29:328-335. Schwarz, F., Sculean, A., Georg, T. and Reich, E. Periodontal treatment with an Er: YAG laser compared to scaling and root planing. A controlled clinical study. Journal of Periodontology 2001b; 72:361-367. Schwarz, F., Aoki, A., Sculean, A. et al. In vivo effects of an Er:YAG laser, an ultrasonic system and scaling and root planing on the biocompatibility of periodontally diseased root surfaces in cultures of human PDL broblasts. Lasers in Surgery and Medicine 2003a; 33:140-147. Schwarz, F., Rothamel, D. and Becker, J. [Inuence of an Er:YAG laser on the surface structure of titanium implants]. Schweizer Monatsschrift fur Zahnmedizin 2003b; 113:660-671. Schwarz, F., Rothamel, D., Sculean, A. et al. Effects of an Er:YAG laser and the Vector ultrasonic system on the biocompatibility of titanium implants in cultures of human osteoblast-like cells. Clinical Oral Implants Research 2003c; 14:784-792. Schwarz, F., Sculean, A., Berakdar, M., Georg, T. and Becker, J. In vivo and in vitro effects of an Er:YAG laser, a GaAlAs diode laser and scaling and root planing on periodontally diseased root surfaces. A comparative histologic study. Lasers in Surgery and Medicine 2003d; 32:359-366.

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Schwarz, F., Sculean, A., Berakdar, M. et al. Clinical evaluation of an Er:YAG laser combined with scaling and root planing for nonsurgical periodontal treatment. A controlled, prospective clinical study. Journal of Clinical Periodontology 2003e; 30:26-34. Schwarz, F., Sculean, A., Berakdar, M. et al. Periodontal treatment with an Er:YAG laser or scaling and root planing. A 2-year follow up split-mouth study. Journal of Periodontology 2003f; 74:590-596. Schwarz, F., Sculean, A., Georg, T. and Becker, J. Clinical evaluation of the Er:YAG laser in combination with an enamel matrix protein derivative for the treatment of intrabony periodontal defects: a pilot study. Journal of Clinical Periodontology 2003g; 30:975-981. Schwarz, F., Sculean, A., Rothamel, D. et al. Clinical evaluation of an Er:YAG laser for nonsurgical treatment of peri-implantitis: a pilot study. Clinical Oral Implants Research 2005; 16:44-52. Sculean, A., Schwarz, F., Berakdar, M. et al. Periodontal treatment with an Er:YAG laser compared to ultrasonic instrumentation: a pilot study. Journal of Periodontology 2004a; 75:966-973. Sculean, A., Schwarz, F., Berakdar, M. et al. Healing of intrabony defects following surgical treatment with or without an Er:YAG laser. Journal of Clinical Periodontology 2004b; 31:604-608. Sharon, E., Azaz, B. and Ulmansky, M. Vaporization of melanin in oral tissues and skin with a carbon dioxide laser: a canine study. Journal of Oral and Maxillofacial Surgery 2000; 58:1387-1393; discussion 1393-1384. Spencer, P., Cobb, CM., McCollum, MH. and Wieliczka, DM. The effects of CO2 laser and Nd:YAG with and without water/air surface cooling on tooth root structure: correlation between FTIR spectroscopy and histology. Journal of Periodontal Research 1996; 31: 453-462 Stock, K., Hibst, R. and Keller, U. Er:YAG removal of subgingival calculi: efciency, temperature and surface quality. Proceedings of the Society of Photo-Optical Instrumentation Engineers 1996; 2922:98-106.

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Presented at the 10th International Biennial Congress of the International Academy of Periodontology, Salvador, Bahia, Brazil, 27 - 29 October, 2005