Cap 3

3
Laser-Assisted Nonsurgical Periodontal

Therapy
MARY LYNN SMITH AND ANGIE MOTT
Periodontal disease affects 80% of the adult population in Periodontitis is defined as follows: “the presence of gingival
the United States.1 Recent research suggests that bacteria inflammation at sites where there has been a pathologi-
associated with periodontal disease have been linked to an cal detachment of collagen fibers from cementum and the
increased risk of heart disease, diabetes, stroke, premature junctional epithelium has migrated apically.”7 In addition,
birth,2,3 and respiratory infection in susceptible persons.4,5 inflammatory events associated with connective tissue
Although periodontal disease should be one of the most fre- attachment loss also lead to the resorption of coronal por-
quently treated conditions in dentistry, traditional therapies tions of tooth-supporting alveolar bone.
have been poorly received, even feared, and viewed by many Similar definitions are recognized for periimplant muco-
patients as “bad experiences.” Patients are reluctant to pur- sitis and periimplantitis, respectively. The disease process is
sue initial periodontal treatment and are even more reluctant disrupted and controlled by host resistance through therapy
to have further treatment when disease progression occurs. or natural defenses.8
This chapter discusses the use and benefits of lasers in The organization and activity of biofilm are important
treatment planning and delivery of nonsurgical periodon- because biofilm is the first component of periodontal disease–
tal procedures, as well as the efficiency and efficacy of these targeted in therapy. Biofilm is a complex community of micro-
laser-assisted procedures. The use of lasers is widely accepted organisms protected by a secreted extracellular polymeric
and is the standard of care in ophthalmology, dermatology, substance. As it becomes more mature, the microbes use a
plastic and vascular surgery, and many other medical spe- molecular communication, quorum sensing, to create a highly
cialties. Dentistry also should embrace laser technology as a organized and adaptable infrastructure. The various microbes
proven method to treat patients safely and effectively, with within the biofilm behave so as to preserve the entire commu-
excellent results. nity, in essence becoming a discrete, living organism.9
In many states, hygienists are permitted to perform laser- As the biofilm responds to its environment, its adapta-
assisted nonsurgical periodontal therapy. In other states, tion provides resistance to such factors as ultraviolet (UV)
only dentists are permitted to use lasers. Some state dental light, bacteriophages, biocides, antibiotics, immune system
practice acts require certification of dentists and hygien- responses, and environmental stresses.10 Manor et al.11
ists through successful completion of an Academy of Laser found that biofilm penetrates epithelium and underlying
Dentistry Standard Proficiency Certification Course or connective tissue, possibly to a depth of 500 μm. Biofilm
similar educational program before practicing laser-assisted has been observed penetrating tissues along the path of cap-
procedures. Other states have no educational requirements illaries. Through various means, including stimulating the
for clinicians to perform laser treatments. Procedures pro- host’s inflammatory pathways, biofilm may control transu-
vided by health care professionals, whether the dentist or date production to supply its nourishment.12 These findings
the hygienist, must be within the clinician’s scope of prac- demonstrate the parasitic nature of biofilm in tissue.
tice according to the dental practice laws of the particular As the body responds to biofilm invasion, proinflamma-
state or country. tory cytokines, prostanoids, and proteolytic enzymes are
synthesized and released. Fluids increase within the tissues,
Periodontal Diseases circulation becomes stagnant, swelling occurs, and meta-
bolic products become backlogged. Enzymes such as col-
Periodontal diseases are biofilm-initiated inflammatory con- lagenase, gelatinase, elastase, and fibrinolysin,3 which are
ditions that affect susceptible persons.6 Gingivitis, the first instrumental in the initial healing stage, remain at the site,
stage of periodontal disease, is defined as “gingival inflam- destroying the developing strands of healing matrix needed
mation without loss of connective tissue attachment.”7 to form connective tissue. The inflamed tissue is unable
27
28 CHA P T E R 3 Laser-Assisted Nonsurgical Periodontal Therapy
to progress from the granulation phase of healing into the consequent direct, increased effect on the red and orange–
remodeling phase because of the continued insult, with complex bacteria associated with periodontitis.23 The CO2
pathogenic processes and further biofilm proliferation.13 laser also has excellent bactericidal properties.24,25 Both
The site is now a biofilm-infested chronic wound14; without CO2 and erbium lasers act on pathogens by heating intra-
treatment, progression to localized destruction is likely, with cellular fluids, causing the microbes to collapse.26,27 The
associated adverse effects on systemic health. absorption of laser energy by tissues produces a photo-
All of the following terms used throughout this chapter thermal effect. With use of the appropriate settings, most
refer to treatment of the soft tissue wall of the periodontal nonsporulating bacteria, including anaerobes, are readily
pocket: deactivated at 50° C.28,29
• Nonsurgical periodontal therapy In laser-assisted active phase I periodontal infection ther-
• Sulcular debridement apy, the diseased biofilm-infested tissues of periodontal
• Active phase I periodontal infection therapy pockets are debrided. With laser techniques that involve
• Laser decontamination—refers specifically to reducing working close to the recommended parameter of 60° C,30
the biofilm of the pocket, usually meaning what is con- the healthy tissue beneath the nonhealing granulation
tained within diseased tissue layer is not affected by the low energy. As noted earlier,
• Laser coagulation—refers specifically to sealing of capil- biofilm can penetrate soft tissues. Localized removal of
laries and lymphatics after laser decontamination of the “bioburden” has a significant beneficial effect on wound
tissue bed preparation and wound healing.31 Steed et al.32
showed that more frequent debridement resulted in better
Benefits of Laser Therapy healing than that obtained with debridement performed
less frequently. Moritz et al.19 reported that the bleed-
Lasers have a direct deleterious effect on bacteria, which ing index improved in 96.9% of the patients treated with
supports the body’s healing response. Incorporating lasers laser-assisted periodontal therapy after conventional ther-
into conventional therapies helps accomplish treatment apy, compared with 66.7% of patients treated convention-
objectives. Conventional nonsurgical periodontal therapy ally without laser. These investigators concluded that “the
entails debriding the affected area of bacteria, endotoxins, diode laser assisted periodontal therapy provided a bacteri-
and hard deposits from the tooth structure to restore gingi- cidal effect, reduced inflammation, and supported healing
val health.8 Instrumentation is focused on the tooth struc- of periodontal pockets through elimination of bacteria.”19
ture, and debridement most often is accomplished by means Administering laser energy to the affected tissues at spe-
of manual and power scaling. In the future, lasers also will cific, repeated intervals is key in targeting biofilm during
be used for root debridement. periodontal therapy.
To date, the U.S. Food and Drug Administration (FDA) Lasers also have the ability to seal capillaries and lym-
has not yet cleared the use of lasers for removal of deposits phatics, thereby reducing swelling at the treated site and
and biofilm from tooth structure. However, Aoki et al.15 minimizing postoperative discomfort.33
determined that deposits and biofilm are more thoroughly Another benefit of laser-assisted procedures is the heal-
removed and that a more biocompatible surface is created ing stimulated at the cellular level.34 Medrado et al.35
for reattachment with use of an erbium laser than with con- found that low-level laser treatment depresses the exu-
ventional methods.16 The alexandrite laser also has been in dative phase while enhancing the proliferative processes
development for selective removal of calculus from the root during acute and chronic inflammation. Laser photobio-
structure.17 The carbon dioxide (CO2) laser has been shown modulation can activate the local blood circulation and
to increase adherence of fibroblasts to root surfaces, and the stimulate proliferation of endothelial cells.36,37 Wound
fibroblast adherence is superior to conventional techniques healing is supported, with reduced edema and polymor-
both in quantity of fibroblasts attached and in the quality of phonuclear (leukocyte) neutrophil (PMN) infiltrate,
the attachment.18 increased fibroblasts, and more and better-organized col-
Regardless of the instrument used, it is essential that con- lagen bundles.38 Karu39 suggested that these effects are
taminants be thoroughly removed from the tooth structure caused by an increase in mitochondrial synthesis. The
in any periodontal therapy. Current laser-assisted methods slight scattering that occurs with more deeply absorbed
focus on the biofilm of the pocket wall, supplementing con- energy of certain lasers may have photobiomodulation
ventional methods that debride the tooth structure itself. effects beyond the direct application. The aiming beams
A critical point in this context is that laser treatment is an of the lasers also may have a photobiomodulation effect
addition to, not a replacement for, conventional periodontal (see Chapter 15). More research needs to be conducted
therapy. in this area.
Both in vitro and in vivo studies show that lasers are
bactericidal.19–22 Although not specific to certain bacteria, Laser Types
the argon (Ar), neodymium-doped yttrium-aluminum-
garnet (Nd:YAG), and diode laser wavelengths show Laser wavelengths used to treat active phase I periodontal
strong absorption in darkly pigmented bacteria, with a infection include the diodes, Nd:YAG, CO2, and erbium
CHAPTER 3 Laser-Assisted Nonsurgical Periodontal Therapy 29
lasers. Chapter 2, on laser fundamentals, provides further Neodymium:Yttrium-Aluminum-Garnet Laser

information on each wavelength.
The Nd:YAG is a free-running pulsed laser. The laser energy
Argon Laser is produced in bursts of photonic energy, rather than as a
continuous beam. This laser also uses a fiberoptic delivery
The argon laser, emitting a 514-nm wavelength, was FDA- system for contact or noncontact procedures. The 1064-
cleared for sulcular debridement in 1991. The energy is nm wavelength is most highly absorbed in melanin, less
delivered through a fiberoptic system in contact or noncon- absorbed in hemoglobin, and slightly absorbed in water.
tact mode, depending on the procedure. These wavelengths The Nd:YAG laser also is bactericidal20 and provides good
are highly absorbed in hemoglobin and melanin, and have hemostasis. Because it is a free-running pulsed laser, the
demonstrated bactericidal properties, particularly for Pre- Nd:YAG emits high peak powers but allows for tissue cool-
votella and Porphyromonas.23,40 However, argon lasers are no ing during the off time. In choosing settings for treatment,
longer being marketed to dentists. the combination of higher millijoules (mJ) with fewer
repetitions per second (i.e., hertz [Hz]) aids in coagula-
Diode Lasers tion, whereas lower mJ with higher Hz typically is used for
decontamination.
The semiconductor diode lasers are available in four differ-
ent wavelengths, as follows:
• 810–830 nm CLINICAL TIP
• 940 nm A joule (J) is a measurement of energy available to do work in
• 980 nm dentistry; dental professionals work in millijoules (mJ).
• 1064 nm
Both the 810- to 830-nm and the 980-nm wave- Micropulsed CO2 Lasers
lengths may be used for nonsurgical periodontal therapy,
with good results well supported by the literature. As yet, The micropulsed 10,600-nm CO2 lasers incorporate the
few published studies have examined the use or advan- newest technology available in producing CO2 laser energy.
tages of the 940-mn wavelength or the 1064-nm diode Delivery by an articulated arm or waveguide in noncontact
wavelength. mode facilitates treatment. A 250-μm tip (the diameter of a
Like argon lasers, diode lasers also use fiberoptics for #25 endodontic file) is used for administering laser energy
energy delivery in contact or noncontact mode, depending into the periodontal pocket. This wavelength interacts with
on the procedure. With diodes in this wavelength range, water and hydroxyapatite and has a depth of penetration on
energy is absorbed in hemoglobin and pigment (e.g., mela- the order of micrometers. Inflamed tissue has an increased
nin). These chromophores, or organic compounds that absorb water content and is therefore preferentially affected by the
light at a specific wavelength, are present in high concentra- laser energy, as are crevicular fluids and intracellular fluids.
tions within the diseased periodontal pocket, making these Fluids are photothermally heated and then vaporized, with
wavelengths applicable for sulcular debridement. consequent collapse of the cell membranes. The bacteria are
The 980-nm wavelength exhibits greater absorption in inactivated,24,25 and dehydration occurs as energy is applied.
water than for the other three diode wavelengths, which Earlier CO2 lasers emitted energy in continuous-wave
may be an added benefit to the laser interaction within mode and, with later improvements, also could be gated,
the pocket. However, no definitive studies yet show that but only with longer pulses and higher mJ. The less sophisti-
the increased absorption in water leads to clinical results cated technology of those units was associated with increased
superior to those obtained with use of other diode wave- thermal damage in surrounding tissue, often resulting in
lengths. Diode lasers are bactericidal19,41,42 and aid in charring, and they could not be used within the periodontal
coagulation. pocket. The newest micropulsed CO2 lasers provide greater
Diode lasers may be operated in continuous-wave mode control of the energy, making application safe and effective
(with energy emitted as a constant beam), with low settings within the periodontal pocket. These lasers allow higher
and short application time, or in gated-pulse mode (with peak power for ultrashort pulse durations, with longer off
energy emitted as a constant but interrupted beam, or times. This improvement provides for maximum thermal
pulsed at specific intervals), with higher settings and lon- relaxation, decreasing collateral damage and discomfort.
ger application time. Some diode lasers offer specific pulse The mJ settings are greatly reduced in sulcular debride-
duration on–off time controls, allowing higher power to ment compared with previous gated-pulse CO2 technolo-
be applied to the tissue for shorter periods of time, which gies. Technique requires the same care as for any other soft
allow the tissues to cool adequately before receiving another tissue laser application: The laser energy must be directed
pulse of energy. This energy pattern limits accumulation of away from the tooth structure. A new-wavelength CO2 laser,
heat, which decreases thermal collateral damage. Less col- emitting at 9300 nm, has recently been FDA-cleared for
lateral damage means less postoperative discomfort for the clinical use. To date, there have been no published studies or
patient. reports of its use in periodontal pocket therapy.
Erbium Lasers Typically this combination of parameters will improve

hemostasis. If lower mJ is selected with more Hz, there is
Erbium lasers are FDA-cleared for both hard and soft tis- less energy in each repetition but also less thermal relaxation
sue applications, and some erbium lasers are FDA-cleared time, because more pulses are emitted into the tissue every
for sulcular debridement. It is important to check with the second. With these settings, more even thermal absorp-
manufacturer of the specific laser device to ensure that it is tion may be achieved. Diode lasers are operated in either
FDA-cleared for its intended use. The erbium-doped YAG continuous or gated mode; continuous operation does not
(Er:YAG) 2940-nm and erbium plus chromium–doped allow any thermal relaxation. Lower-power settings should
yttrium-scandium-gallium-garnet (Er,Cr:YSGG) 2780-nm be chosen to prevent temperature increase beyond the treat-
instruments are free-running pulsed lasers with wavelengths ment goal of decontamination or coagulation. If gated
that are most highly absorbed in water, followed by good (pulsed) mode is selected, a higher energy may be required
absorption in hydroxyapatite and poor absorption in hemo- to raise the tissue temperature with each pulse. The gated
globin. Thermal rise in the superficial tissue layers is minimal mode allows the tissue to cool before the succeeding pulse.
and even less with concurrent water spray during the laser All tissues have an absorption threshold; tissue can absorb
procedure. This effect limits achievement of hemostasis and only so much energy before it is overloaded by the energy and
coagulation within the pocket. Although some clinicians view becomes painful and is damaged. Think of sitting on a beach
the associated bleeding as a hindrance when working with and getting a nice suntan. To achieve that look, your tissue
these lasers, a benefit of this wavelength is almost complete (skin) absorbs a certain amount of energy (sunlight). Think
absence of operative or postoperative discomfort. Quicker again of sitting on a beach for many hours, with prolonged
healing also is another advantage reported with these wave- exposure to the sun’s rays. Your skin will then be overloaded
lengths.16,43 Studies have demonstrated significant popula- with too much energy (sunlight), and the result will be a sun-
tion reduction of the periodontal pathogens Porphyromonas burn, with pain and charring of the tissue. The pain occur
gingivalis and Actinobacillus (Aggregatibacter) actinomycetem- when more energy reaches the target tissue than it can absorb.
comitans, as well as positive long-term clinical results in attach- When the patient feels discomfort during laser treatment,
ment gain.16,21,26 With the 9300-nm CO2 laser, recently the following adjustments can be made without changing
cleared for hard tissue applications, the energy is absorbed by the mJ or Hz settings:
the carbonate of hard tissue, rather than the hydroxyapatite. • Move the laser fiber more quickly (adjust hand speed),
To date, there have been no studies or peer-reviewed pub- decreasing total energy exposure.
lished reports of its effects or use in pocket therapy. • Move the suction closer to the operative site so that the
circulating air decreases the accumulating temperature.
Fundamentals of Laser Physics • Add a light spray of water to dissipate heat.
These adjustments work well with all wavelengths.
Understanding basic laser physics is important to make Of note, however, because the CO2 wavelength is highly
needed adjustments while administering laser treatment. absorbed in water, a high tissue fluid content (too much
In laser-assisted procedures, laser energy is absorbed by water) will inhibit tissue interaction, whereas a lower fluid
the chromophores within the pocket and transformed into content (not enough water) will increase discomfort.
photothermal energy. Observing laser–tissue interaction is Conversely, if the tissue is not responding, alterations are
critical. Tissues containing different concentrations of the needed. First, check the settings; then inspect the aiming
wavelength-specific chromophore will require different beam, ensuring patency of the optics. If parameters are cor-
parameters. rect, test-fire the laser on an appropriate chromophore, mov-
The patient’s comfort also is important. Often a treating the laser more slowly. If results are still negative, increase
ment area is fully anesthetized during the initial appoint- the settings incrementally until interaction occurs. If a large
ment for debridement and laser decontamination but may increase is necessary, a technical problem is likely, and the
require only topical or no anesthetic for laser therapy at laser instrument should be serviced by a certified technician.
repeat visits. Making adjustments will improve the patient’s The clinician must understand the properties of the selected
comfort while accomplishing the treatment goal. wavelength to provide optimal, beneficial laser treatment.
The treatment goal for nonsurgical periodontal therapy is
decontamination and coagulation, rather than incising. Pro-
cedures are accomplished through control of tissue tempera- Treatment Objectives with Soft Tissue
ture. The factors that affect tissue temperature are the mJ and Lasers
Hz settings, speed at which the laser beam moves over the
target tissue (hand speed), and cooling factors such as pulse The objective of active phase I periodontal infection therapy
“off” time, high-volume evacuation, and water application. is to remove biofilm and deposits found above the gumline
Some lasers allow more control of these parameters than and within the periodontal pocket, whether on the tooth
that provided by others. For a free-running pulsed laser such structure, on the pocket wall, or in the crevicular fluids. Such
as the Nd:YAG, high mJ with low Hz means more energy therapy assists the body’s healing response. This aspect of
per pulse but more thermal relaxation time between pulses. treatment is accomplished through conventional scaling and
root debridement as well as laser-assisted sulcular debride- coronally (Figure 3-2). The edge of the cannula indicates
ment. Sulcular debridement addresses the pocket wall for the treatment depth of the pocket being reached. Use a
profound decontamination and seals the capillaries and lym- gliding, multidirectional motion with the tip of the fiber in
phatics through coagulation. constant contact with the pocket wall. The strokes should
address small sections and should be systematically over-
Sulcular Debridement with Fiberoptic Laser lapping. The motion is somewhat analogous to sweeping
Delivery a floor with a broom. It is helpful to mentally divide the
pocket into affected sections, such as interproximal to the
Preprocedural Decontamination line angle, the direct buccal or lingual surface, and the line
Preprocedural decontamination is a laser application done angle to the interproximal area. Continually inspect the
before any instrumentation, even probing. The objectives are fiber tip and remove any accumulated debris (Figure 3-3)
to eradicate the bacteria within the sulcus, thereby reducing with water-moistened gauze.
the risk of bacteremia from instrumentation, and to lower the
microcount in aerosols created during ultrasonic instrumenta-
tion.44 The technique uses very low energy. The fiber is placed
within the sulcus and is swept vertically and horizontally
against the pocket wall, away from the tooth, with a smooth,
flowing motion, for 7 to 8 seconds on the lingual aspect and
then on the buccal surface of each tooth’s tissue wall. The ben-
efits of preprocedural decontamination are seen in the reduced
microbial translocation through the circulatory system.
Decontamination
Just as conventional root debridement removes biofilm and
accretions from the hard tooth surface, laser decontamina-
tion removes biofilm within the necrotic tissue of the pocket • Figure 3-1 Calibrating optimal laser fiber length using a periodontal
wall. The laser energy interacts strongly with inflamed tissue probe.
components (owing to preferential absorption by chromo-
phores, which are more abundant in diseased tissues) and
less strongly with healthy tissue. This nonsurgical therapy
uses very low settings and decontaminates rather than cuts
the tissue.28 Canula
The administration of laser decontamination requires an
understanding of current periodontal pocket topography,
proficiency in technique, and recognition of laser–tissue
interaction to determine the end point of therapy. An updated
Fiber
periodontal chart is needed for reference throughout therapy.
With conventional root debridement provided just before
laser decontamination, the pocket depths may need to be rep-
robed for accuracy of laser treatment. Laser therapy should
address sites manifesting with inflammation and/or pocket
depths of 4 mm or greater. It is helpful to visualize the extent
of surface area being treated. For example, the diseased pocket • Figure 3-2 Laser fiber in periodontal pocket.
lining requiring treatment in a patient with 50% genera
lized bone loss has an estimated tissue surface area of 40 cm2
(6.2 in2), and with 4 to 5 mm of generalized pocketing, this
area is 20 cm2 (3.1 in2).45 Knowing the depth and shape of
pockets and the area to be addressed enables the clinician to
be thorough with decontamination technique.
With fiberoptic technique, the fiber tip engages every
millimeter of the diseased tissue–wall that corresponds to
the indicated sites marked on the periodontal chart. Before
initiation of the laser treatment, calibrate the amount of
fiber exposed to measure 1 mm less than the pocket depth
(Figure 3-1). Begin the procedure with the fiber placed just
inside the gingival margin, progressing apically, or place
the fiber 1 mm short of the depth of the pocket, working • Figure 3-3 Small amount of granulomatous tissue debris on fiber tip.
When exiting the pocket, take care to inactivate the laser, EXERCISE: To illustrate laser technique, try this simulation
preventing overexposure of the gingival margin’s thin tis- exercise. On paper, draw an area measuring 20 cm2 (3 × 1–inch
sue. If the fiber tip becomes irreversibly coated (Figure 3-4), rectangle). Use a mechanical pencil with fine lead (0.5 mm) to color
cleave the fiber, calibrate the length of the fiber, and con- the area using flowing, methodical, overlapping, multidirectional
strokes, leaving no areas uncolored. The laser fiber is actually only
tinue the procedure. 0.4 or 0.3 mm, but this activity reflects the time and thoroughness
Completion of laser decontamination is determined needed for treatment within the pocket.
by laser parameters used, delivery time, and clinical signs.
Decontamination is accomplished with less mJ and more
Hz than for coagulation. A more inflamed pocket may Coagulation
require less average power because of increased concentra- When biofilm has been removed, the second objective in
tion of the laser’s preferred chromophores. With use of an active phase I periodontal infection therapy is coagula-
initiated fiber and lower settings in continuous-wave mode, tion, sealing the capillaries and lymphatics of the healthy
interaction is concentrated and will require less treatment tissue. As previously noted, biofilm tends to continue its
time than with use of a noninitiated fiber with higher set- invasion of the host tissue through the vessels. Coagulation
tings in pulsed mode. A deeper pocket will require longer may inhibit the biofilm’s progression. It also counteracts the
treatment time because of increased surface area. As laser swelling that occurs with the inflammatory process. Coagu-
treatment progresses in an area, less and less debris should lation is accomplished with increased mJ and decreased Hz
collect on the fiber. Fresh bleeding will occur, however, compared with decontamination. Coagulation also requires
when the pocket wall is fully decontaminated and debrided less time within the pocket and does not address every mil-
(Figure 3-5). Keep in mind the laser parameters and appli- limeter of tissue.
cation time. Observing tissue interaction is essential in For this procedure, a newly cleaved fiber is moved back
determining the duration of laser exposure for the diseased and forth through the pocket, administering laser energy
site being treated. beyond the end of the fiber into the tissue. The applica-
tion raises the temperature within the pocket slightly, to
promote protein denaturation and sealing of the vessels.
If continued hemorrhaging occurs on exiting the pocket,
a freshly cleaved fiber may be used in noncontact mode to
coagulate at the gingival margin, keeping the laser energy
directed away from the tooth surface.
After coagulation, application of firm digital pressure to
areas with deep pockets will support the re-adaptation of the
tissue to the tooth and further enhance reattachment. Coag-
ulation assists the first stages of healing after debridement.
Sulcular Debridement with Carbon

Dioxide Laser
Whereas the argon, diode, and Nd:YAG lasers employ a con-
tact technique for sulcular debridement, the micropulsed
• Figure 3-4 Excessive amount of debris on fiber. At this stage of
treatment, the fiber should be cleaved and recalibrated.
10,600-nm CO2 laser uses a defocused, noncontact tech-
nique. Marginal dehydration and pocket decontamination
are two steps applied in CO2 laser therapy. Because the CO2
laser’s wavelength is absorbed by the crevicular fluids and water
content in the diseased tissue wall, it is important to direct the
energy parallel to the tooth surface and toward the tissue.
Begin the debridement procedure by directing laser
energy to the coronal edge of the marginal gingiva. Hold
the tip perpendicular to the tissue crest at a distance of
approximately 1 mm. Tissue interaction is observed as a
slight “frosting” of the surface (Figure 3-6). Marginal dehy-
dration will improve entry of the tip by drawing the tissue
slightly away from the tooth structure. Epithelial growth
will be inhibited by this application. This is the first step
before pocket decontamination.
The technique for decontamination involves placement
• Figure 3-5 Gingiva immediately after fiber-based laser treatment, of the laser’s defocusing tip 1 to 2 mm into the pocket (only
showing fresh bleeding from the pocket. 1 mm for pockets up to 6 mm in depth; only 2 mm for
pockets greater than 6 mm in depth). Treatment should and working in a single direction will enhance the laser’s effi-
include the complete circumference of each tooth presenting ciency. Vertical, up-and-down movements or pushing the tip
with disease. Activate the laser as the tip is drawn through toward the tissue can cause the tip to clog. If the tip becomes
the crevicular space in an even, slow motion, working from occluded, both the tip and detritus inside will continue
the distal aspect to the mesial aspect on the buccal and again absorbing the energy, with consequent excessive heating of
on the lingual side of the tooth. The laser tip is kept parallel the tip. Coagulation occurs simultaneously with decontami-
to the long axis of the tooth (Figure 3-7). nation. No additional steps are necessary in using the CO2
Treatment time is a maximum of 16 seconds per buccal or laser. Figure 3-8 shows the gingiva after laser treatment.
lingual surface. The length of application time depends on
the extent of disease and the surface area; larger teeth such Postoperative Care
as molars are treated longer than smaller teeth such as lower
anteriors.46 The tip must be kept open and free of coagulum The therapeutic appointment concludes with several steps
for efficient energy flow. Keeping the tissue slightly moist in professional postoperative care. After the laser treatment,
allow the patient to rinse with water or with a non–alcohol-
based rinse to freshen and moisten the mouth. A topical
soothing agent such as vitamin E oil or aloe vera may be
applied with a gloved finger or sterile cotton swab to the
areas treated. Firm adaptation of tissue to the tooth with
digital pressure may assist adhesion of fibrin between the
tissue and tooth, particularly for deeper pockets.
Postlaser irrigation is a subject of debate. Although irriga-
tion with chlorhexidine or other solutions is used in conven-
tional treatment as a final step in disinfecting periodontal
pockets, the authors believe that postlaser irrigation is unnec-
essary. In fact, Mariotti and Rumpf47 found that solutions of
chlorhexidine (0.12% or less) in contact with wound sites for
• Figure 3-6 Laser marginal dehydration of gingival tissue immedi- even a short time could have serious toxic effects on gingival
ately before pocket debridement and decontamination with CO2 laser. fibroblasts. Other studies report that subgingival irrigation
has no significant additive effects on periodontal healing.48–50
When the laser procedure is completed, all the ben-
efits of profound decontamination and coagulation are in
place. Further manipulation of the tissues will reintroduce
contaminated instruments into the pocket and disrupt the
fibrin clot.
The final step in postoperative care is advising the patient
on what to expect, addressing further concerns, and dis-
cussing continued self-care. Counsel the patient that mild
discomfort is possible the first 24 to 48 hours. With laser-
assisted nonsurgical periodontal therapy, discomfort is asso-
ciated more often with root debridement than with the
laser treatment. Excessive pain may indicate another issue
• Figure 3-7 Tip of CO2 laser in periodontal pocket. Note parallel
and warrants investigation. The patient should avoid spicy,
orientation of tip to root surface. sharp, and crunchy foods for 24 hours to help prevent dis-
comfort and trauma. Seeds and husks may become lodged
between the gum and the tooth and should be avoided. The
risk of impaired healing from presence of a foreign object is
highest in the first few postoperative days, but risk may per-
sist if the periodontal disease is more severe. Encourage the
patient to be diligent in supporting the healing process by
consistent and thorough daily cleaning. Patients appreciate
instructions in written form for reference as well as in verbal
form (Box 3-1).
Healing and Tissue Rehabilitation

Healing typically occurs without complications as the body
• Figure 3-8 Gingiva immediately after CO2 laser treatment. responds to laser therapy. Through the first 24 to 72 hours,
the patient may feel tenderness and experience light bleeding pocket depth, all are desired indications of tissue healing.
when eating or cleaning; after tooth debridement and tis- Figure 3-9 shows initial periodontal probing before treat-
sue decontamination, epithelium begins to regenerate after ment and periodontal probing 6 months after treatment.
24 hours and then progresses 1 mm per day, protecting the Figure 3-10 shows data for three sets of probings: initial
pocket wall. Within 1 week, the wound surface is covered. probing, 8 weeks after treatment, and 5 months after treat-
Connective tissue begins proliferation by day 5. Because ment. Analysis of the probing results shows a resolution of
laser decontamination procedures are repeated at 10-day 86% of the bleeding sites, a decrease in 86% of the pocket-
intervals, the epithelium is impaired during laser biofilm ing sites, and a 58% decrease in the number of teeth exhibit-
reduction. This allows the fibroblasts to continue organizing ing periodontal disease.
into a connective tissue attachment apparatus. The attach-
ment will continue to mature for 12 months.8 This attach- Complications and Adverse Reactions
ment is easily disrupted, so only light-pressure probing is
recommended after several months, with resumption of Healing may be complicated by microbiologic, immuno-
normal probing after 6 months of postoperative therapy.51 logic, and traumatic factors. Rapid pocket reinfection will
Classic signs of tissue rehabilitation include improved occur with insufficient removal of subgingival biofilm, with
color, consistency, texture and stippling, and contour. These inadequate supragingival biofilm control, or with uncor-
signs, as well as a decrease in or elimination of hemorrhag- rected poor restorative conditions. Patients with a compro-
ing during gentle tissue manipulation and a reduction of mised immune system often exhibit a delayed or less optimal
healing response; with the assistance of laser benefits, how-
ever, such patients could recover better than expected.
• BOX 3-1 Patient Care Instructions after Traumatic injury, such as from excessive instrumentation
Laser-Assisted Periodontal Therapy or increased collateral damage from overexposure of laser
energy, may result in prolonged tissue discomfort and sore-
1. Do not eat until numbness is gone. ness. Systemic diseases such as diabetes are associated with
2. For patients who smoke: Smoking compromises the delayed healing. Evaluation for excessive occlusal stress,
healing processes; refrain from smoking for as long as
possible (or preferably, take opportunity to stop smoking). which may impair healing, also is important.
3. Avoid spicy, sharp, crunchy foods for 24 hours. In states in which hygienists are allowed to perform laser
4. Avoid alcohol-containing products for 24 hours. therapy, it is incumbent on the hygienist to make certain
5. Avoid seeds or husks for 3 to 5 days (or as directed). that the dentist has performed a complete occlusal evalua-
6. Rinse with salt water (1 tsp in 8 oz of warm water) three tion and correction/equilibration of the dentition. Occlu-
times daily until tissues are comfortable.
7. Any over-the-counter pain reliever may be taken as sion is a risk factor for periodontal breakdown, so occlusal
directed to manage mild discomfort. treatment needs to be considered as a part of the compre-
8. More severe pain should be evaluated by the dentist. hensive treatment of periodontal disease.52 Trauma from
9. Thorough but gentle cleaning is essential to the healing occlusal problems constitutes an additional risk factor for
process. In treated areas, use an extra-soft toothbrush the progression and severity of periodontal disease. An
for 1 or 2 days, and floss gently. Regular brushing and
flossing may be done in all other areas. understanding of the effect of trauma from occlusal loading
10. Oral irrigation may begin after 24 hours. Use a medium on the periodontium is useful in the clinical management of
to low power setting, directing the water stream at a periodontal problems.53
90-degree angle to the tooth—not into the pocket. Adverse reactions are a result of inappropriate laser appli-
Subgingival irrigation is contraindicated until further cation: The wavelength is incorrect for the target site, the
evaluation.
parameters are incorrect, or the duration of application is
incorrect. Some lasers interact with metal, resulting in a
A B C D
• Figure 3-9 A, Periodontal pocket probing before CO2 laser treatment. B, Periodontal pocket probing
6 months after CO2 laser treatment. C, Periodontal pocket probing before fiber-based laser treatment. D,
Periodontal pocket probing 6 months after fiber-based laser treatment.
percussive reaction and immediate heat generation. This Written references concerning laser use should include the
heat could transfer to the nerve or surrounding tissue. following:
Therefore the laser energy must not be directed toward • The wavelength and type of laser (e.g., 980-nm diode)
metallic crown margins or metallic restorations at the gin- • The spot size (size of fiber, tip, or aperture of tip)
gival margins. Laser energy directed toward the tooth may • The settings (e.g., mJ, Hz, W of average power)
cause irreversible damage to the tooth, such as cracking, pit- • Mode of application (continuous or pulsed wave)
ting, melting, or charring. Excessive heat accumulation can • Duration of application
cause damage to underlying bone. Intense overexposure of • Application with or without water spray
laser energy on tissue results in carbonized tissue. • Type of anesthesia used (topical or injection, number of
Complications in healing and adverse reactions are mini- carpules)
mized with adherence to appropriate treatment protocols. Documentation also should (1) confirm that wave-
Understanding the laser settings and observing the laser–tissue length-specific laser safety glasses were worn, (2) describe
interaction during application are crucial. The clinician must any adverse reactions and how they were managed, and (3)
have adequate knowledge and proficiency whenever provid- state that postoperative instructions were given. Complete
ing treatment with any instrument, whether ultrasonic, hand, documentation should include content that serves to answer
or laser. All of these treatment modes are extremely beneficial any question that a patient might ask about the treatment
when used properly. (Box 3-2).
Documentation Adjunctive Chemotherapeutics

Documentation in the patient’s chart serves to describe The rationale for adding antibiotics in some cases is better
the conditions, diagnosis, and specific treatment rendered. biofilm suppression with concomitant therapies. If treatment
• Figure 3-10 Periodontal charting showing pocket depths initially and at 8 weeks and then 5 months
after laser treatment.
requires multiple strategies, chemotherapeutics may be used how long it should be administered, and whether a second
in conjunction with lasers and conventional treatment. Anti- phase with testing is needed. Chronic wounds should never
biotics such as doxycycline, tetracycline, and metronidazole be controlled merely with antibiotic therapy.
are prescribed for systemic control of pathogens. Low-dose
levels of oral doxycycline hyclate (Periostat) suppress the Laser Safety
enzymatic activity of collagenase associated with the disease
processes. Topical preparations of minocycline hydrochlo- The designated laser safety officer is responsible for educat-
ride (Arestin), doxycycline hycylate (Atridox), and chlorhex- ing the dental team in the safe use of the laser, as well as for
idine gluconate (as the Periochip) may be placed to control enforcing safety practices, as follows:
localized growth of pathogens. 1. Securing the operatory by limiting access to the room
Biofilm is most susceptible to chemotherapeutics when and posting “laser in use” signs
it has been disrupted aggressively through debridement of 2. Using safety features of the laser, such as placing the laser
both the tooth and the tissue. A systemic antibiotic should in standby mode when not in use
begin early in the treatment to assist the body as treatment 3. Enforcing mandatory use of wavelength-specific protec-
progresses. A local antibiotic may be placed in an affected tive eyewear within the treatment area
site after the last session of laser treatment; in this way, with- 4. Evacuating with high-volume evacuation to remove
out disturbance, the effectiveness of the drug is maximized, aerosols and laser plume
because it works for several weeks. Locally administered 5. Using a high-efficiency particulate filtration mask (par-
antibiotics should not be used between lasing appointments. ticle filtration efficiency of 99.75% at 0.1 μm)
It is prudent to assess the biofilm’s composition and the Test firing the laser before the patient’s procedure is
susceptibility of pathogens before administration of che- another important step in safety and procedure prepara-
motherapeutics. Many types of culturing do not test the tion. Test firing proves the laser energy is being delivered as
antibiotic against the protective mechanisms in the bio- expected. For this procedure, with safety measures in place,
film and thus do not reflect the in vivo environment. Poly- position the terminal end of the laser away from the patient.
merase chain reaction (PCR) assay, 454 sequencing, and Select a suitable chromophore (for argon, Nd:YAG, and
other molecular tests give a better view of what organisms diode lasers: dark material; for CO2 lasers: moist paper; and
are cohabitating within the biofilm. This information may for erbium lasers: water) and activate the laser while holding
determine which medication(s) would be most beneficial, it 1 to 2 mm from the material chosen. As energy is absorbed,
an interaction will be observed, such as a mark and plume or
water bubbling or evaporating. This test step is not the same
• BOX 3-2 Example of Charting and as “initiating” the fiber but simply constitutes an assessment
Documentation for Laser Periodontal of interaction between the laser and an appropriate chromo-
Therapy phore, to ensure the laser is working as anticipated.
10-11-2012: Pt presented for PIT [periodontal infection
therapy] UR. Laser Plume
Health history reviewed, no contraindications to treatment.
Administered 20% topical benzocaine followed by 2% Although no set standard exists, strong recommendations
lidocaine, with epi 1:100,000, 1.8 mL for local anesthesia (such as those from the Occupational Safety and Health
of teeth #2-5.
Disclosed #5-8 and instructed on specific daily biofilm removal Administration [OSHA], the Centers for Disease Control
techniques. Recommended: Bass toothbrush technique and Prevention [CDC], and the American National Stan-
twice daily and adding floss to current routine. Review floss dards Institute [ANSI]) address evacuation of the laser
technique further at next appointment. plume. High-volume evacuation is indicated for aerosol
Preprocedural laser decontamination with 980-nm diode, reduction during ultrasonic instrumentation,54 as well
uninitiated 300-μm fiber, power of 0.4 W [watt] in CW
administered approx 16 sec/tooth throughout. as for plume removal during laser treatment. The plume
Supragingival ultrasonic biofilm removal throughout. Manual is composed of 95% water and 5% particulate matter,
and ultrasonic definitive debridement of #2-5. organic and inorganic chemicals, and microorganisms.55
Laser decontamination of #2-5 with same laser and fiber, 2.0 Organic chemicals such as benzene, toluene, formalde-
W in PW on 25 msec/off 50 msec for an average power of hyde, and cyanide have been isolated within the plume;
0.7 W administered approx 20 sec/site. Laser coagulation
followed with power of 0.8 W in CW administered approx inorganic chemicals include carbon monoxide, sulfur,
10 sec/site. and nitrogen compounds.56 The microorganism analysis
Laser-specific glasses were worn by patient and clinician shows bacteria, microbacteria, fungi, viruses, and DNA
during laser procedures. No adverse reactions. Postop from intact viruses of human immunodeficiency virus
instructions given in both written and oral forms. (HIV), hepatitis B virus (HBV), and human papilloma-
Next visit: PIT for UL area.
virus (HPV).57 Most particles are 0.3 to 0.5 μm in size,
CW, Continuous wave [mode]; epi, epinephrine; PW, pulse width; UL, upper 90% of which are likely to be inhaled and deposited on
left; UR, upper right.
the alveolar lung tissue.58 Therefore the common mask
that filters only 5.0-μm particles provides inadequate
filtration. Use of a mask filtering 0.1-μm particles is 400-μm fiber. With the same setting, a 400-μm fiber delivers
recommended.55 only 64% of the power density delivered with a 320-μm fiber.
The combination of high-volume evacuation and a high- The concentration of chromophore present in the tar-
efficiency filtration mask decreases the exposure risk associ- get tissue also will affect settings. Diseased tissue has an
ated with ultrasonic and laser procedures. These masks are increased amount of hemoglobin and responds well to cer-
available in tie-on and ear-loop styles through dental supply tain wavelengths, requiring less energy. Fibrotic tissue, with
companies. decreased vascularization and hemoglobin, comparatively
needs more energy.
Printed parameters from laser manufacturers are only
CLINICAL TIP guidelines for treatment. Observed tissue interaction is the
As an alternative to high-efficiency filtration masks, tuberculosis key to knowing if the settings are adequate or need adjust-
(TB) masks may be worn. ment. A rule of thumb is to use the minimum amount of
energy to achieve the therapy needed. Reference sources
for settings have been added, for convenience, to the sug-
Technical Aspects of Laser Settings gested parameters in Table 3-1.59–61 Although each of the
listed lasers may be used in nonsurgical periodontal pro-
The treatment objective, fiber size, and existing chromophore cedures, some are more efficient than others. One laser
concentration should be considered in choosing the settings used for therapy may require more or less treatment time
for a nonsurgical periodontal procedure. For laser-assisted than another, which affects treatment planning. Table 3-2
hygiene applications, lower settings are required for thorough contrasts the time investment required with three types
decontamination of the tissues. The fiber size can directly of lasers. The patient undergoing treatment exhibited 87
affect the amount of energy the target receives with a spe- “bleeding on probing” sites, 106 sites of 4-mm depth or
cific setting. A 320-μm fiber has a smaller spot size, which greater, and 20 involved teeth. Because of treatment pro-
increases the power density at the target, compared with a tocol, the Nd:YAG and diode lasers reflect treatment of
TABLE
3-1 Suggested Laser Parameters for Nonsurgical Periodontal Therapy*
Fiber/Tip Diameter/ Preprocedural

Laser Type Aperture Decontamination Debridement Coagulation
Argon Fiber diameter: 300 μm No suggested parameters 0.5 W, 0.05-sec pulse 0.7–0.8 W, 0.05-sec
in literature duration, 0.2 sec pulse duration, 0.2
between pulses† sec between pulses†
Diode (810 nm) Fiber diameter: 300 μm, 1.0 W, uninitiated fiber, 0.4 W, continuous wave, 0.8 W, continuous
initiated gated 50% duty cycle, 20 sec/site† wave, 10 sec/site†
15 sec/tooth43
Nd:YAG (1064 nm) Fiber diameter: 300 μm No suggested parameters 30 mJ and 60 Hz, 1.8 W, 100 mJ and 20 Hz, 2.0
in literature applied 40 sec/site† W, 20 sec/site†
Diode (980 nm) Fiber diameter: 300 μm No suggested parameters 2.0 W, pulsed 25 msec 0.8 W, continuous
in literature on/50 msec off for avg applied 10 sec/site
power of 0.7 W, applied
20 sec/site or 0.4–0.6 W,
continuous applied 20
sec/site57
Micropulsed CO2 Periotip aperture: 0.25 mm No suggested parameters 80 mJ, 50 Hz, N/A
in literature 1.8–2.0 W; avg of
24 sec/tooth47
28 mJ, 30 Hz, 1 W, 350-
μsec pulse width, 0.31
msec off; avg of
24 sec/tooth60
Er:YAG Tip diameter: 0.6 mm No suggested parameters 80 mJ, 30 Hz, 2.4 W avg N/A
in literature power with water spray21
No suggested parameters
Er,Cr:YSGG Tip diameter: 0.6 mm in literature 1.0 W (50 mJ/pulse)61 N/A
avg, Average; N/A, not applicable.

*This chart provides only suggested parameters. Check the owner’s manual for the specific laser being used for more complete information regarding settings.
†Data from Raffetto N: Lasers for initial periodontal therapy. In Coluzzi DJ, Convissar RA: Lasers in clinical dentistry, Philadelphia, 2004, Saunders.
each site exhibiting disease, whereas the CO2 laser reflects occur while working in the pocket. If a metal cannula is
treatment per tooth. used, the side of the fiber may rub against the cannula’s
edge, inadvertently scoring the fiber and leading to break-
Fiber age. If such breakage goes undetected, unwanted exposure
to laser energy may result. Loss of fiber integrity can waste
The fibers used with argon, diode, and Nd:YAG lasers are valuable treatment time, diminish power needed for treat-
constructed similarly and are manufactured in a variety of ment, and constitute a hazard.
diameters, with the 300- to 400-μm fiber most often used
for laser-assisted hygiene procedures. The fiber has four parts: Initiating the Fiber
the jacket, cladding, fiber, and coupler. The jacket is a thick, Initiating the fiber is helpful with some laser-assisted hygiene
flexible, clear or translucent, latex-like covering, or in some procedures but is not desired in others. Initiation of the fiber
models, a thin, tougher plastic, that protects the fiber. The tip is accomplished by activating the laser while touching
cladding is a coating on the outside of the fiber that is inwardly the fiber to a dark chromophore. Though many practitio-
reflective, collimating the laser beam completely to the fiber’s ners use articulating fiber or cork, neither produces a satis-
terminal end. The fiber itself is made of quartz and is crystal- factory, complete or thorough initiation. The best initiation
line in structure. The coupler connects the fiber to the laser. is performed by using black ink suitable for painting onto
Proper handling of these parts is critical for optimal power glass surfaces (available at any art supply or hobby store)
delivery. The extra length of fiber should be loosely coiled and a good quality, very thin paintbrush. The paintbrush is
and secured away from rolling chairs or sources of entangle- dipped into the ink and painted onto the tip of the laser fiber
ment. Manufacturers produce accessories to help manage and allowed to dry for 30 seconds. The purpose is to con-
the extra length of fiber. When preparing the fiber for the centrate heat energy at the fiber’s tip, increasing the thermal
handpiece, strip away as little of the jacket as possible. The interaction with the tissue and accelerating debridement.
fiber should be bare through the cannula but not at the point Initiation is used with lasers of lower fluence, particularly
at which the collet nut in the handpiece tightens. Damage diode lasers, in the decontamination procedure. Because
to the cladding can occur with use of an improperly sized an initiated fiber concentrates the laser energy at the point
stripping tool. Overclosing on the fiber during stripping will of tissue contact, heat can accumulate within the tissues
nick the cladding. Should the cladding become scratched, quickly. Application time should be limited to minimize
laser energy will be lost from that site, decreasing the power collateral damage in surrounding tissue. Lower settings are
at the working end. Inspect the fiber for light leaks of the used in continuous-wave mode for a shorter duration to
aiming beam before inserting it into the handpiece. If light accomplish decontamination of the pocket wall. Also, in
leaks are present, strip the fiber farther back, and cleave the working with fibrotic tissue exhibiting less chromophoric
fiber just behind the point where visible light is detected. concentration, initiation is helpful.
Fiber breakage may occur if the fiber is coiled too tightly If the objective is penetration of the laser energy into the tis-
or retracted repeatedly in a cassette. Breakage may also sue beyond the fiber, the fiber is not initiated. An uninitiated
fiber is used for preprocedural decontamination and coagu-
lation. The Nd:YAG, a free-running pulsed laser, does not
CAUTION require initiating because of its high peak powers and immedi-
ate interaction with the tissue. Argon and diode lasers may be
If the cladding is damaged but the fiber is not broken, the
aiming beam will still be visible at the terminal end, but the used in pulsed or continuous-wave mode, with an uninitiated
power of the working beam will be lessened, sometimes fiber used for preprocedural decontamination and coagula-
significantly. tion. Continuous-wave mode requires less energy and shorter
application time, which will minimize heat accumulation
TABLE
3-2 Example Case of Time Investment with Three Lasers
Laser (wavelength) Duration of Application Number of Sites Treated Laser Application (minutes)
Nd:YAG (1064 nm) 40 sec/site* 106 71
20 sec/site* 106 35
Total: 106
Diode (810 nm) 20 sec/site* 106 35
10 sec/site* 106 18
Total: 53
CO2 (10,600 nm) 26 sec/tooth 20 teeth Total: 8.6
*Data based on suggested parameters from Raffetto N: Laser for initial periodontal therapy. In Coluzzi DJ, Convissar RA: Lasers in clinical dentistry, Philadelphia,
2004, Saunders.
within the tissue. The pulsed-wave mode may use higher be mastered both to conserve fiber length and to provide
settings with slightly longer treatment times. The off time efficient laser energy delivery during treatment.
between pulses allows heat dissipation within the tissue. Observe laser safety precautions. Never look directly at
The clinician must have a clear understanding of the laser the laser light. Do not activate the laser when assessing the
effects with an initiated or uninitiated fiber and must be fiber’s cleave, even though it may be in ready mode. The
proficient in reading tissue–laser interaction. cleaved portion of the fiber, whether contaminated or not,
is considered a “sharp,” and disposal in an appropriate con-
Cleaving the Fiber tainer is required.
Fiberoptic systems require cleaving for maximum energy
delivery. Cleaving refers to creating a flat, 90-degree surface CLINICAL TIP
at the terminal end of the fiber. This “clean cut” ensures
Cleaving tools are basically nothing more than knives used to
maximum energy delivery from the fiberoptics. Types of cut (score) a glass fiber. One secret of a good chef is to have
cleaving tools include carbide or diamond “pens” held at sharp knives at all times. Chefs are constantly sharpening their
90 degrees, 1-inch serrated ceramic tiles held at a 45-degree knives to obtain the best possible cutting efficiency. Dull knives
angle, and scissors, all used to score the fiber, not cut through don’t cut well, leading to less-than-ideal results. A cleaving tool
it (Figure 3-11). must be replaced periodically to ensure creation of cleaves that
are always as clean as possible.
To cleave a fiber, lay the fiber down on a firm, flat surface
and secure with the nondominant hand. Orient the cleaver Fiber Handpieces
appropriately at 2 mm from the end of the fiber. Move the
cleaver across the fiber one time to score the quartz. When A variety of handpieces may be used with fiberoptic delivery
using the scissors design, place the fiber at 90 degrees systems; however, it is important that they be compatible
between the blades, allowing the fiber to scoot along the with the selected fiber. Just as with hand scalers, handpiece
blades while closing them. With a proper score created by designs include different barrel sizes, textures, and weights
any one of these devices, a “light leak” should be visible and (Figure 3-13). The clinician should consider these factors
the fiber can be easily snapped away or pulled off. for comfort and working ergonomics.
When checking the fiber for an optimal cleave, hold Properly sized components inside the handpiece will pre-
the fiber perpendicular 1 cm from a flat, light-colored sur- vent the fiber from slipping during treatment. Most handpieces
face (Figure 3-12). The aiming beam should show a well- are designed with a collet nut or chuck that tightens around
defined, solid circle. A poor “cleave” creates an uneven or an inner bushing. The bushing grips the fiber jacket, holding
diffuse margin and may have a “comet tail.” With an imper- the fiber in place. Some bushings accept only a certain size of
fect cleave, the amount of laser energy being delivered to jacket, whereas others may be adjusted. If the jacket is stripped
the target tissue is diminished, and trauma is induced away, allowing the bushing to tighten against the bare fiber,
when it contacts tissue. The technique for cleaving should the cladding may be damaged, resulting in loss of laser power.
Cannulas
Because the crystalline structure of the fiber will not allow
sharp bends in the fiber, the cannula is essential for guiding
the fiber to the treatment site. Many different designs of
cannula are available: Some are metal and others clear or
• Figure 3-12 Example of optimal cleave. Note well-defined, solid

• Figure 3-11 Three styles of cleaving tools. From top, Scissors, circle of light. A less-than-ideal cleave would show an oval or “comet
glass-cutting pen, and ceramic tile. tail” appearance of the light.
during procedures. The internal aspect should be cleaned

with tufted floss or a slightly smaller-diameter cleaning tool
Cannulas and very warm water, then sterilized. Protect metal cannu-
las from damage when not in use. Proper sterilization and
handling of the fiber, handpiece, and cannula will elimi-
nate related cross-contamination and increase longevity of
components.
Handpieces
Treating Periimplant Mucositis
and Periimplantitis
Treatment of periimplant mucositis and periimplantitis is
similar to that discussed earlier for gingivitis and periodon-
titis. The objective is to preserve attachment or to promote
its regeneration by removing pathogens and supporting
• Figure 3-13 Various handpieces and cannulas. healing. The attachment of tissue to the implant is a glyco-
protein matrix that adheres to the titanium. When the bio-
translucent plastic (see Figure 3-13). Some screw onto the logic seal is disrupted by inflammation or trauma, the result
handpiece, whereas others are tension-retained. Some can- is an open pathway to the bone supporting the implant.
nulas are multiuse and sterilizable; others are single-use and In periimplant mucositis, the implant often is described
disposable. Some can be shaped into a gentle arc, whereas as “ailing,” with inflammation but no bone loss. The condi-
others have a predefined shape. Selecting the best cannula to tion warrants therapy to reverse the inflammatory process,
provide access to the treatment site effectively and efficiently with preservation of as much attachment of tissue and bone
will facilitate periodontal therapy. as possible. As discussed in gingivitis therapy, it is essential
to remove biofilm on the implant collar and crown using
Fiber Patency specialized instruments for implant care. The periimplant
tissue is then decontaminated by laser treatment using the
Before connecting the sterilized fiber to the laser, check previously recommended settings. Therapy should involve
the fiber’s patency, or openness. Hold the terminal end of at least two sessions 10 days apart. Reappoint at the same
the fiber to a light source and look at the connector end. It interval until conditions resolve.
should show a bright light representing the full diameter of If the implant is diagnosed as “failing,” when half of
the fiber at the connector. Several conditions may prevent the implant is still supported with bone and no mobility
patency. The fiber at the connector may be occluded with is detected, other treatment is necessary. Laser therapy can
oils from sterilization or handling. This can be corrected provide immediate decontamination of the surrounding
by cleaning the connector according to the manufacturer’s tissue as preparation for a surgical procedure. Nonsurgical
guidelines. Also, the fiber may be broken. Check by install- therapy is limited because of the inability to fully address
ing the fiber and using the aiming beam to locate the “light the biofilm on the complex implant structure.
leak.” Strip away the jacket, and cleave the fiber. Lasers with soft tissue applications can accomplish treat-
ment of periimplant mucositis or periimplantitis. The tech-
CAUTION nique of nonsurgical application with most wavelengths
does not aim the laser energy directly toward the implant.
Do not install and activate the laser fiber until criteria for
Only the soft tissue is treated for decontamination. The
patency are met.
laser settings used for nonsurgical therapies are much lower
than in surgical procedures. Some wavelengths require more
Sterilization attention than others; for example, a wavelength absorbed
in dark chromophores has the potential to cause greater
Ensuring fiber, handpiece, and cannula integrity through- thermal rise and heat transfer. When coated with blood, the
out the sterilization and installation procedures requires implant surface could accumulate heat, which would radiate
specific care. Manufacturer recommendations should be fol- through the implant body to the bone. An implant coated
lowed for processing. Avoid sterilizing fibers in autoclaves with hydroxyapatite could absorb another wavelength,
used for sterilizing oiled handpieces. Oil may accumulate on resulting in a modified surface.62 High risk of surface altera-
the connector, causing damage to the laser when activated. tion is recognized for the Nd:YAG laser. Much lower risk
Handpieces require minimal maintenance beyond cleaning has been documented with use of the CO2, Er:YAG, and
and sterilizing. Occasionally, plastic bushings break down Er,Cr:YSGG wavelengths. CO2 laser use in periimplant
with heat or chemical processing and must be replaced. treatment is well documented in the literature.63,64 Effec-
Sterilizable cannulas may become occluded with debris tiveness of treatment with the erbium family of lasers is
variable, with contradicting results reported. Effectiveness and debris present supragingivally and subgingivally, with
with diodes also is variable as reported for all four diode mobility and furcation involvement
laser wavelengths (see Chapter 7). CO2 laser energy is not Type V: Refractory periodontitis—inflammation and pocket
absorbed at all by implants, so it may be directed toward the depths of 4 mm or greater in a periodontium previously
implant to remove the biofilm from the implant. treated for periodontal disease
Early detection of disease and good planning with appro-
priate treatment can result in excellent resolution of inflam- Severity also is based on clinical attachment loss, graded
mation in periimplant tissue. The goal of treatment should as follows:
be clear to achieve expected outcomes. Even when more • 1 to 2 mm = slight
advanced care is required, the nonsurgical laser therapy can • 3 to 4 mm = moderate
prepare the site by reducing the inflammatory process and • 5 mm or greater = severe
pathogenic load. Laser-assisted periimplant tissue therapy is
a valuable treatment. Treatment Planning
Diagnosis Treatment planning may encompass many different strat-
egies based on the patient’s needs. Because each case is
Diagnosis and classification of periodontal disease in a given unique, the following considerations and guidelines are
patient depends on accurate assessment. The initial clinical used to develop a customized treatment design rather than
appointment includes the general health history; screening fitting each case into a strict, predefined protocol.
for oral cancer; assessment of hard tissues, occlusion, and Treatment needs are discovered during the process of
the temporomandibular joint (TMJ); complete periodon- data collection and the diagnostic workup. Planning should
tal and radiographic evaluation; and bacterial testing. Risk address all issues, ranging from obvious signs of periodontal
assessments from data collected at this appointment help disease to occlusal problems, and incorporate keys for behav-
determine the diagnosis of disease and its severity or can ior modification. Factors such as the wavelength being used in
serve to confirm periodontal health. therapy and the clinician’s level of training and expertise also
Once periodontal disease is detected, classification and influence treatment planning. The following treatment plans
case type are needed for treatment planning. The classifica- are suggestions based on our own experiences using Nd:YAG,
tion categories as presented at the 1999 World Workshop diode, and CO2 lasers in periodontal care since 1999.
on Periodontics include the following:
• Gingivitis Considerations in Planning Treatment
• Chronic periodontitis*
• Aggressive periodontitis* 1. What are the patient’s tolerances concerning physical
• Periodontitis as a manifestation of systemic disease conditions limiting treatment time, such as temporo-
• Necrotizing periodontal diseases mandibular disease (TMD) or back problems?
• Abscesses of the periodontium 2. Does the patient have moderate or severe anxiety?
• Periodontitits associated with endodontic lesions 3. Will the appointment be conducted with the patient
These classification categories are used for diagnosis and under conscious or intravenous sedation?
third-party billing of insurance, along with the following 4. Will local anesthesia or only topical gel be required?
American Dental Association (ADA) case types65: 5. Are there any points of data to be reevaluated (e.g.,
periodontal charting, radiographs)?
Healthy—pocket depths of 3 mm or less and no bleeding or 6. Will restorative treatment be accomplished during the
inflammation same appointment?
Type I: Gingivitis—pockets 3 mm or less, bleeding on prob- 7. What is the severity of disease? Is it localized or
ing, inflammation, and possibly some debris present generalized?
supragingivally 8. Are the biofilm and deposits slight, moderate, or heavy,
Type II: Mild periodontitis—pockets 4 to 6 mm with slight and what is the tenacity?
bone loss, bleeding on probing, inflammation, and de- 9. How large is the surface area to be debrided and decon-
bris present subgingivally taminated (both tissue surface and tooth surface)?
Type III: Moderate periodontitis—pockets 6 to 7 mm with 10. How motivated and skilled is the patient with daily
bone loss, bleeding on probing, inflammation, and de- care?
bris present subgingivally, with some mobility and pos- 11. Are there occlusal problems exacerbating the periodon-
sible furcation involvement tal disease that need to be addressed?
Type IV: Advanced periodontitis—pockets 7 mm or greater, Each treatment session involves much more than instru-
heavy bleeding on probing, inflammation and suppuration, mentation. The answers to the previous questions will influence
the time allowed for treatment, as well as the arrangement of
* Further defined as localized (<30% teeth affected) and generalized (>30% appointments needed for therapy. It must be emphasized that
affected) the laser will not overcome poor daily biofilm management.
Regardless of the degree of periodontal disease, home care is 3. Assessment of oral health
still an essential element of the treatment plan. • Oral cancer screening
• Evaluation of the TMJ
Guidelines for Planning Appointments • Occlusal evaluation
• Radiographic survey as needed
1. Address only those clinical goals that can be completed • Periodontal charting (six-point probing, recession,
in the scheduled appointment time. Issues to be included mobility, furcations)
are patient motivation and skill refinement, complete • Assessment of existing debris, biofilm, and calculus
and thorough debridement, laser treatment, and postop- • Description of patient’s daily dental care routine
erative instructions. • Evaluation of restorative needs
2. The more severe the disease, the more time required per 4. Diagnosis
tooth for treatment. 5. Treatment
3. Include time for patient management. 6. Supportive care, retreatment, or referral
4. The amount of time needed to perform laser treatment of
the pocket tissue depends on the laser used, the extent of
disease, and the laser–tissue interaction. Gingivitis
5. For each millimeter of optimal attachment gain desired, General Approach
a session of laser treatment is needed after the original
debridement. Gingivitis involves only the gingival tissues, without bone

loss. The tissues may exhibit classic signs of erythema, swell-
Example: A 6-mm pocket should be decreased to 3 mm.
ing, hemorrhage, blunted papillas, and pseudopocketing. The
• Appointment 1: tooth debridement and laser tissue
objective of therapy is to coach the patient in daily cleaning
treatment
skills and to professionally remove localized factors initiating
• Appointment 2: ultrasonic biofilm removal on the
the inflammatory response. This latter step includes scaling to
cervical one third and laser treatment
thoroughly remove biofilm and deposits on the tooth struc-
• Appointment 3: ultrasonic scaling and laser treatment
ture and laser decontamination of the sulcus.
• Appointment 4: ultrasonic scaling and laser treatment
At least two appointments are needed in the gingivitis
6. Begin therapy in the deepest pockets.51 This approach series (Case Study 3-1). The first appointment allows diag-
allows retreatment of the deepest pockets as the shallow nosis, development of patient skills for daily dental care
pockets are being treated in successive appointments. using appropriate tools and techniques to manage biofilm
7. In subsequent appointments, areas previously treated plus nutritional counseling, scaling, and laser decontami-
will be revisited, with ultrasonic biofilm removal at each nation. The second appointment continues refinement of
tooth’s cervical area, and relased. As the patient’s daily care daily cleaning skills, scaling, and laser decontamination.
improves, less time is spent on biofilm assessment and skill
refinement and, typically, more time on laser treatment. Full-Mouth Debridement
Repetitive therapy is designed to address localized bio-
film infection and to promote the regeneration of a strong Full-mouth debridement is indicated when heavy calculus
connective tissue attachment. By decontamination of the prevents access for probing, or when inflammation with dis-
periodontal infection site at frequent intervals, the biofilm’s comfort prevents assessment of the periodontal tissues. This
community structure is continually weakened, with fewer procedure provides gross removal of calculus but is not con-
remnants left to rebuild each time. This strategy optimizes sidered a definitive treatment. The patient should be sched-
the body’s ability to respond. The body will begin to heal uled for a follow-up appointment in 2 to 4 weeks for thorough
when the host is no longer challenged with the inflamma- periodontal evaluation and determination of further therapy.
tory response initiated by biofilm. (A refractory case will not
respond because the host is impaired.) Epithelium covers
the surface of a wound in 7 to 10 days.8 Connective tissue Periodontitis
begins regenerating at approximately day 5,8 maturing for General Approach
12 weeks and continuing even up to 1 year.
Assisting the body in balancing the proliferation of these Periodontitis is the inflammatory process initiated by the
tissue types is the foundation for the following protocols. presence of biofilm, with destruction of the tooth’s support-
ing structures, including bone. Clinical attachment loss is
Basic Elements of All Appointments apparent with pocketing and with no gingival recession, or
recession with no pocketing, or both pocketing and reces-
The following basic elements should be included in all sion. Again, the objective of therapy is to coach the patient
appointments: in daily techniques to prevent or minimize accumulation of
1. Health history review biofilm in the mouth. Professional therapy must address the
2. Concerns of the patient depth of disease in both the tooth structure and the tissue
CASE STUDY 3-1 disinfection or an expanded periodontal infection therapy

approach may offer the best treatment for certain patients.
Moderate/Severe Gingivitis With any treatment program, ongoing attention to current
severity of and susceptibility to disease is essential in determin-
Diagnosis of conditions: Negative findings on oral cancer ing intervals of active therapy, evaluation, and continued care.
screening; TMJ function is normal; radiographs show no bone
loss, and there is no evidence of decay. There is no mobility,
and the occlusion is without interferences. Periodontal tissues Full-Mouth Disinfection Therapy
show moderate to severe gingivitis, moderate generalized
hemorrhaging, pseudopocketing, supra- and subgingival Full-mouth disinfection therapy consists of complete
plaque, and calculus. debridement with extensive subgingival irrigation within
Appointment 1 24 hours (Case Study 3-2). This treatment program also
1. Manage patient discomfort with topical or local
includes biofilm reduction in the entire oral cavity with a
anesthesia, if needed. specific twice-daily regimen of flossing, brushing the teeth
2. Address daily cleaning needs with use of appropriate as well as all accessible oral mucosa, scraping the tongue,
tools and technique recommendations. rinsing the mouth, and spraying the throat with chlorhexi-
3. Begin debridement of tooth structures, completing as dine.66 The full-mouth disinfection treatment design
much as possible at this appointment.
4. Floss to remove additional biofilm and loose calculus.
requires fewer appointments with longer treatment times.
5. Perform laser decontamination of areas that exhibit
signs of inflammation. Advantages
6. Give postoperative instructions, and schedule next • Quicker reduction of overall microbial load
appointment for 10 days later. • Completion of the most difficult part of treatment
Appointment 2 • More efficient for sedation appointments
1. Manage patient discomfort.
• Restorative concerns may be addressed at the same visit
2. Review the daily cleaning routine, and refine according
to the needs presented. Disadvantages
3. Complete debridement, or provide biofilm removal • Limited opportunity to work with the patient on daily
throughout if debridement has already been completed. care skills (with sedation-appointment patients, such
4. Floss.
5. Perform laser decontamination of areas with continued
opportunity is lacking)
inflammation. • Patient fatigue
6. Review postoperative instructions. • Psychologically overwhelming for the patient
Continue to schedule subsequent appointments at 10-day • Postoperative discomfort increased because all areas are
intervals until daily skills support health and inflammation is treated
resolved. If systemic health issues are a concern, referral to a
physician may be indicated.
• Clinician fatigue and decreased instrumentation effec-
tiveness
Continued Care • Follow-up appointments are needed to address recurring
This patient is susceptible to recurrence of disease. Once biofilm at about 10-day intervals
inflammation is resolved, schedule appointments for 3-month • Loss of a large amount of production time if the appoint-
intervals to monitor and maintain health. As health is stabilized ment is broken
for an extended time, intervals may be lengthened 2 to 4
weeks more at each visit, as long as health is maintained. If
reinfection occurs, the intervals should be shortened. CLINICAL TIP
Necrotizing ulcerative gingivitis (NUG) may be managed with Full-mouth treatment would employ the same basic treatment
the same therapy as just outlined. It is important to recognize design without adding an antimicrobial, such as chlorhexidine.
that the patient with NUG may be experiencing intense
discomfort; accordingly, it may not be possible to perform
periodontal charting or instrumentation at this appointment. Expanded Periodontal Infection Therapy
Radiographic survey and visual evaluation for diagnosis followed
by instruction for daily cleaning at home may be all that is The expanded-therapy design for management of peri-
accomplished at this visit. The patient may require systemic odontal infection takes into consideration the severity of the
antibiotic therapy, as well as analgesics. An appointment to begin disease to be treated. The treatment plan has the flexibility
gingivitis therapy should be scheduled for within 5 to 10 days.
to treat all diseased teeth in a beginning or localized case,

or very small sections of teeth in an advanced case. This
strategy is structured with more appointments with shorter
wall forming the pocket. This is accomplished through treatment times (Case Study 3-3).
supragingival and subgingival definitive debridement of
tooth structure, followed by sulcular debridement. Advantages
The series of appointments may be designed in vari- • Repeated reduction of microbial load within the pocket
ous ways. Some cases can be effectively treated with tradi- • Supports the healing process by retarding epithelium and
tional half-mouth or quadrant therapy; however, full-mouth allowing connective tissue growth
CASE STUDY 3-2

Type IV Periodontitis
Diagnosis of conditions: Negative findings on oral cancer 3. Remove biofilm with ultrasonic scaling throughout.
screening; TMJ function is normal; radiographs show horizontal 4. Debride tooth structure definitively with manual and
bone loss, no decay. ultrasonic scaling and extensive irrigation.
Periodontal condition: Chronic periodontal disease, 5. Floss.
generalized moderate bone loss (case type III) with moderate
to severe gingivitis; moderate generalized hemorrhaging;
supra- and subgingival plaque and calculus, horizontal bone
loss in posterior with vertical bone loss on #4 and furcation
involvement on #2 and 19. Class I mobility of anterior teeth. The
occlusion exhibits interferences (Figures 3-14 and 3-15).
Treatment Plan for Full-Mouth Disinfection within 24 Hours
(Figure 3-16)
• 5 hours planned for tooth debridement and laser
decontamination
• 2 hours for laser decontamination (four 30-minute
appointments)
• 30 minutes for reinfection assessment (optional)
• 60 minutes for reevaluation (definitive therapy)
Appointment 1: Upper/Lower Left (UL/LL)

(2.5 hours)
1. Administer local anesthesia for left side. • Figure 3-15 Panoramic radiograph obtained as part of the initial
2. Apply disclosing agent in area of left side and periodontal evaluation.
recommend tools and techniques for daily care.
• Figure 3-14 Initial periodontal probing for baseline evaluation.

CASE STUDY 3-2—cont’d

Type IV Periodontitis
UR UL
Appt 6
Appt 1 Appt 2 Appt 3 Appt 4 Appt 5 Laser
decontamination
9 10 Appt 1
7 8
6 11 All UL/LL Areas Areas Areas
5 12 UL/LL Areas 7 mm
pockets 4mm 5mm 6mm
4 13 debridelase
3 14 Appt 2
All UL/LL
UR/LR
2 15 pockets
debridelase
1 16
Appt 3 lase 4mm
32 17
31 18 Appt 4 lase 5mm

30 19
29 20
Appt 5 lase 6mm
28 25 23 21
27 22
26 24
Appt 6 lase 7mm
LR LL
• Figure 3-16 Graphic representation of treatment plan for full-mouth nonsurgical periodontal laser treat-
ment. Colors in chart at right correspond to those in the tooth chart at left.
6. Perform laser decontamination. 3. Remove biofilm at the cervical portion of each tooth.
7. Provide postoperative palliative care (e.g., vitamin E oil). 4. Floss.
8. Give postoperative instructions. 5. Repeat laser treatment of all areas previously noted with
9. Confirm appointment for next day. disease.
6. Provide postoperative care and instructions.
Appointment 2: Upper/Lower Right (UR/LR) 7. Confirm next appointment in 10 days.
(2.5 hours) The laser decontamination appointments continue until the
1. Administer local anesthesia for right side. deepest pockets have been treated enough times to minimize
2. Apply disclosing agent in area of right side and reinforce biofilm and inflammatory activity and support connective tissue
daily care from the previous day. reattachment.
3. Remove biofilm with ultrasonic scaling throughout.
4. Debride tooth structure definitively with manual and Appointment 7
ultrasonic scaling and extensive irrigation. Perform reinfection assessment 6 weeks after laser
5. Floss. decontamination (optional).
6. Perform laser decontamination (on the right side only,
because 7 days have not passed). Appointment 8
7. Provide postoperative palliative care (e.g., vitamin E oil). Provide definitive therapy 8 to 12 weeks after laser
8. Give postoperative instructions. decontamination.
9. Confirm next appointment in 10 days.
Appointment 9
Appointments 3 to 6: Laser Decontamination
Provide supportive periodontal therapy, retreatment, or
1. Plan 60 minutes to address all areas; less time may be referral.
required for fewer treatment sites.
2. Apply disclosing agent in one area to demonstrate need
for improved daily care or in another area to highlight
good management.

• Continued assessment and refinement of daily care skills • Less patient fatigue
(working to form good habits in self-care) • Restorative concerns may be addressed at same visit
• Decreased postoperative discomfort because smaller • Repeated biofilm removal at the cervical portion of the
areas are treated. tooth
• Increased effectiveness of instrumentation (less clinician • Less production time lost if the appointment is
fatigue) broken
CASE STUDY 3-3

Treatment Plan for Expanded Periodontal Infection
(Figure 3-17) Appointment 4: LR Teeth #28–31

• 5 hours planned for tooth debridement and laser 1. Repeat steps 1 to 6 above.
decontamination 2. At this appointment, repeat laser treatment of #9, 10 to
• 30 minutes for final laser decontamination 12, 14, 15 and 2, 4, 14, 15, 18, 19.
• 30 minutes for reinfection assessment (optional)
• 60 minutes for definitive therapy Appointment 5: LR/LL Teeth #22–27
Appointment 1: UR Teeth #2, 4–8 1. Repeat steps 1 to 6 above.
2. At this appointment, repeat laser treatment of #28–31
1. Administer local anesthesia for selected area. and 2, 14, 15, 18, 19.
2. Apply disclosing agent in an area and recommend tools
and techniques for daily care. Appointment 6: Laser Decontamination
3. Remove biofilm with ultrasonic scaling throughout.
4. Debride tooth structure definitively with manual and 1. Plan 30 minutes to address remaining sites needing care.
ultrasonic scaling. 2. At this appointment, repeat laser treatment of #22–27
5. Floss. and any areas exhibiting inflammation.
6. Perform laser decontamination. The laser decontamination appointments continue until the
7. Provide postoperative palliative care (e.g., vitamin E oil). deepest pockets have been treated enough times to minimize
8. Give postoperative instructions. biofilm and inflammatory activity and to support connective
9. Confirm next appointment at approximately 10 days. tissue reattachment.
Appointment 2: LL Teeth #18–21 Appointment 7

1. Repeat steps 1 to 6 above. Perform reinfection assessment 6 weeks after laser
2. At this appointment, repeat laser treatment of #2, 4, 5, 6, decontamination (optional).
7, and 8.
Appointment 8
Appointment 3: UL Teeth #9, 10–12, 14, 15 Provide definitive therapy 8 to 12 weeks after laser
1. Repeat steps 1 to 6 above. decontamination.
2. At this appointment, repeat laser treatment of #18–21
Appointment 9
and 2, 4, 5 of UR.
Provide supportive periodontal therapy, retreatment, or referral.
UR UL
9 10
7 8 11
6
5 12
Appt 6 Appt 7
4 13 Appt 1 Appt 2 Appt 3 Appt 4 Appt 5 Laser Laser
3 14 decontamination decontamination
Appt 1 UR Areas Areas Areas Areas
2 15 #2,4–8
debridelase 4mm 5mm 6mm 7mm
1 16
Appt 2 LL
#18–21 4mm 5mm 6mm 7mm
debridelase
32 17 Appt 3 UL #9–12,
4mm 5mm 6mm 7mm
debridelase 14,15
31 18
Appt 4 LR
30 19 #28–31 4mm 5mm
debridelase
29 20 Appt 5 LR/LL
28 25 23 21 #22–27 4mm 5mm
debridelase
27 22
26 24
LR LL
• Figure 3-17 Graphic representation of treatment plan for full-mouth nonsurgical periodontal laser treat-
ment. Colors in chart at right correspond to those in the tooth chart at left.

Disadvantages selected and time allowed for each debridement appoint-

• More visits, requiring coordination of patient and prac- ment depend on the case severity and treatment design.
tice schedules
• Not practical for sedation appointments Laser Decontamination Appointment
Apatzidou and Kinane67 found that both expanded treat-
ment and full-mouth treatment strategies were effective and The laser decontamination appointment is provided after
suggested selecting the treatment modality on the basis of thorough debridement of tooth structure, when continued
practical considerations related to patient preference and decontamination of the tissue wall, impairment of epithelium,
clinical workload. and maturation of connective tissue are required. Laser decon-
tamination appointments continue until each pocket has had
sufficient therapy to support healing to ideal resolution.
Sedation Appointment (Intravenous Again, for each millimeter of attachment gain desired,
or Conscious) an additional laser decontamination session should be pro-
vided. These sessions are scheduled approximately 10 days
Sedation appointments require variation in the treatment apart after the last debridement plus lasing session. Sessions
design, according to the procedures scheduled during the may be 30 to 60 minutes in length, depending on the num-
sedation. Patients receiving sedation often will have restor- ber of sites and pocket depths to be treated. At completion
ative and periodontal procedures accomplished in the same of the last laser decontamination appointment, the defini-
visit. Because periodontal disease affects the supporting tive therapy appointment should be scheduled for 6, 8, or
structures of the teeth, it is prudent to give it a high priority 12 weeks (a longer interval allows attachment to mature).
in the treatment sequence.
Active periodontal infection therapy with sedation
focuses only on definitive debridement of the teeth and Reinfection Assessment Appointment
decontamination of tissues. Treatment planning must con- (Optional)
sider the time required for thorough treatment within the
practical time available. The clinician should work to com- The purpose of the reinfection assessment appointment is
pletion in sections, so that if an unforeseen complication to evaluate tissue rehabilitation, reinforce biofilm removal
forces treatment to conclude, each treated section has full skills, and maintain patient motivation. It does not include
benefit of therapy. probing or instrumentation, unless an area presents with
Active periodontal infection therapy also involves inflammation. The patient’s daily cleansing skills are
coaching the patient with customized techniques and assessed, and further coaching and motivation are directed
recommended tools for removing biofilm effectively on at prevention of reinfection. Biofilm removal at the cervical
a daily basis. Because this cannot be addressed with the portion of each tooth is provided with ultrasonic scaling.
patient in a sedated state, it is helpful to have an appoint- Should an area need further instrumentation, laser decon-
ment concentrating on biofilm management techniques tamination is indicated as the last step of disinfection.
before the sedation appointment, as well as additional The reinfection assessment appointment should be
“coaching” appointments at intervals after the sedation. scheduled as a 30-minute appointment and should follow
Tissue rehabilitation is optimal if the patient can undergo the last laser decontamination appointment by approxi-
“laser decontamination” procedures, including ultrasonic mately 6 weeks. The patient should be seen for the definitive
biofilm removal and continued laser treatents, at 10-day therapy appointment after another 6 weeks.
intervals. If the patient cannot tolerate these appoint-
ments, the next option is to schedule several appoint-
ments at 2-week intervals until effective biofilm control CLINICAL TIP
is demonstrated. Reinfection assessment at a separate appointment is indicated
The treatment that follows the sedation appointment(s) when the definitive therapy appointment is scheduled for 12
depends on patient tolerance. If the biofilm is not continu- or more weeks later and the patient is at moderate risk for
reinfection.
ally controlled and the healing processes are not supported,
rehabilitation of the tissues will not be as effective as with
repetitive therapy.
Reevaluation (Definitive Therapy)
Debridement Appointment
The definitive therapy appointment marks the comple-
The debridement appointment includes definitive removal tion of active phase I periodontal infection therapy and
of calculus and endotoxins on the tooth surfaces, along with is the occasion for providing evaluative and therapeutic
the first application of laser decontamination of the diseased services. This appointment follows the last laser decon-
pocket walls. The objective is to greatly reduce the micro- tamination appointment by 6 to 12 weeks and includes
bial load in the instrumented area. The number of teeth continued evaluation of daily care. Periodontal disease
status is reevaluated, with documentation of six-point

probing, recession, and mobility. These data are compared
with pretreatment charting to determine the extent of reha-
bilitation. Occlusal stresses and restorative needs also are Daily care Professional
evaluated, providing important information for indicated care
treatment recommendations. Maintained
Healthy sites are supported with appropriate care as
well during this appointment. Treatment includes biofilm
removal throughout, instrumentation of areas where calcu-
lus is present, and in unresolved areas, further debridement
with manual and ultrasonic instruments. Laser decontami-
nation in areas of inflammation and persistent pocketing Host immune
completes the process for the definitive therapy (reevalua- support
tion) appointment.
The clinician must determine whether management of • Figure 3-18 Venn diagram depicting health maintenance with daily
unresolved areas can be addressed during the appointment and recommended care.
or if periodontal needs are more extensive. This decision will
depend on the number of areas manifesting with inflamma-
tion and pocketing, in addition to the contributing factors. additional therapy is needed, as discussed for the reevalua-
With a limited number of unresolved sites, the root surfaces tion appointment.
can be debrided again and continued laser decontamination Determine whether the patient’s needs can be addressed
provided. Subsequent appointments for continued support- during the supportive therapy appointment. If additional
ive periodontal therapy should be scheduled at an appropri- treatment is required, keep in mind that a single ses-
ate interval. sion of retreatment usually is insufficient to control bio-
More extensive needs may include another series of root film within the pocket or to promote connective tissue
debridement and laser decontamination appointments, reattachment.
moving ahead with restorative treatment, or pursuing sur-
gery (conventional or laser-assisted). Some patients may Conclusions
require medical referral for systemic evaluation. At any time
during the patient’s care, it is the clinician’s judgment, based Few contraindications to laser treatment exist. There are
on personal knowledge and skill, whether to continue with no concerns regarding development of resistant bacteria
active phase I periodontal infection therapy or to refer the or allergic reactions. Lasers may be used in children, preg-
patient to a specialist. nant women, immunocompromised patients, and patients
with pacemakers or defibrillators or other implanted med-
Supportive Periodontal Therapy ical devices. When used within appropriate parameters,
lasers provide gentle, yet highly effective decontamination
Supportive periodontal therapy appointments maintain the at the target site, thereby promoting healing. Laser wave-
body’s stabilization in oral health by eliminating or reducing lengths are bactericidal, with associated improvement in
local microbiologic factors.8 Clinically, this strategy involves indices related to periodontal health. Laser treatment is an
preserving clinical attachment level, maintaining alveo- excellent adjunct to thorough root debridement and tissue
lar bone height, eliminating inflammation, and ensuring rehabilitation. Understanding applications and safe tech-
comfortable function. The patient in whom a satisfactory niques of laser-assisted therapy provides a higher standard
level of maintenance has been achieved can be treated as of care.
previously discussed for the reevaluation (definitive therapy) In keeping with various trends in dental health, such as
appointment, and subsequent appointments for continued an aging population retaining teeth longer, an increase in
follow-up can be scheduled at an optimal interval. diabetes and other chronic diseases in all age groups, and
The Venn diagram in Figure 3-18 reinforces the concept diets of poor nutritional value among the general popu-
that periodontal health is maintained when daily (home) lation, the prevalence of periodontal disease is likely to
care and recommended professional care are implemented. increase. Unless patients are better educated and experi-
If either daily care or professional care is lessened, periodon- ence more positive therapies, increasing periodontal disease
tal health may decline. prevalence will continue. Laser therapy is an improvement
Often, patients believe that their periodontal disease is on traditional therapeutic modalities. It is less invasive and
“fixed,” like a healed broken arm. They should be coun- more efficient, decreasing the time spent in treatment and
seled on the chronic nature of the disease, with episodes reducing the need for surgery. As research and clinical study
of activity and remission, and requiring consistent evalu- reveal more aspects of periodontal disease, treatment modal-
ation at shorter intervals and treatment as indicated by ities will continue to evolve to provide more successful pre-
activity level. When a patient presents with reinfected sites, vention and healing.
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combination periodontitis therapy, Pract Periodont Aesthet Dent
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Laser-Assisted Nonsurgical Periodontal

lasers. Chapter 2, on laser fundamentals, provides further Neodymium:Yttrium-Aluminum-Garnet Laser

Erbium Lasers Typically this combination of parameters will improve

Sulcular Debridement with Carbon

Healing and Tissue Rehabilitation

Documentation Adjunctive Chemotherapeutics

Fiber/Tip Diameter/ Preprocedural

avg, Average; N/A, not applicable.

• Figure 3-12 Example of optimal cleave. Note well-defined, solid

during procedures. The internal aspect should be cleaned

CASE STUDY 3-1 disinfection or an expanded periodontal infection therapy

CASE STUDY 3-2

Appointment 1: Upper/Lower Left (UL/LL)

• Figure 3-14 Initial periodontal probing for baseline evaluation.

CASE STUDY 3-2—cont’d

31 18 Appt 4 lase 5mm

Appt 6 lase 7mm

CASE STUDY 3-3

(Figure 3-17) Appointment 4: LR Teeth #28–31

Appointment 2: LL Teeth #18–21 Appointment 7

Disadvantages selected and time allowed for each debridement appoint-

status is reevaluated, with documentation of six-point

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31 18 Appt 4 lase 5mm

Appt 6 lase 7mm