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Radially Firing Laser Tip: A New Perio Treatment John A. Handy, DDS; Gregory T. Miller, PhD; Diedre Krupp, Dept. of Chemistry & Physical Science,

Chronic periodontitis is triggered by pathogenic bacteria comprising a dynamic subgingival biofilm. The endotoxins, or toxic waste products, released by these bacteria trigger the immune response of the host, leading to more tissue damage than repair. The treatment of periodontal disease presents a number of challenges for the clinician on a clinical level as well as on a patient management level. Effective removal of subgingival calculus deposits without root surface damage; pain management; control of bacteria and endotoxins; and reattachment of connective tissue pose clinical challenges. Case acceptance of long and often expensive procedures poses an additional patient management challenge.

Laser assisted periodontal therapy was introduced in the early 1990s, and today, a new prototype of a radially firing periodontal laser tip (only used for research and development and not currently commercially available) used on a Er,Cr:YSGG laser (Biolase Waterlase MD) is being introduced. It has the potential to deliver laser energy to diseased root surfaces and the periodontal supporting structures more efficiently and effectively. The new tip delivers radial laser energy in a 360-degree “halo” around the laser tip, as well as the usual incident laser energy penetrating through the end of the tip. In the author’s opinion this new radial firing laser allows for more effective root surface coverage, especially in difficult to reach area like furcations (Figs. 1, 2 & 3). Radial laser energy is simultaneously being delivered in front of a moving tip, to the root surface, to the soft tissue pocket lining, and behind the tip.

This new laser technique for periodontal treatment may reduce the hardness of calculus without damaging the root surface and eliminate subgingival bacteria and endotoxins. Evidence suggests a more coronal tissue attachment in cases treated with this new laser technique, and radiographs appear to have significant bone defect resolution.
More About the New Laser Tip
The new radially firing periodontal tip ranges in diameter from 0.6mm-1.2mm diameter with a tapered and circumferential bevel at a 55- to 60-degree angle. The last 100 micron diameter at the tip is flat in the center. The end result looks like a sharpened pencil with the lead flat at the tip. When this tapered tip is inserted into the pocket the radial energy bathes the entire pocket and root with a band of energy approximately 1mm wide or more. The radial energy footprint produced by this application of the laser is shown on thermal paper tests (Figs. 3 & 4).

The incident beam at the tip provides more concentrated energy in a small surface area, which is very useful for dislodging ledges of calculus on root surfaces. It will also deliver energy to the bone at the depth of the pocket eliminating bacteria, and producing degranulation. It also creates a halo of low level energy (cold laser therapy), completely surrounding the laser tip which stimulates faster healing and regrowth by photobiomodulation. When the tip is held parallel to the root surface or up to 15-20 degrees from parallel, the incident energy is delivered at a tangent to the curvature of the root, as it slopes toward the apex. This technique prevents any harmful deep ablation lines on the root surface, which have been reported when using standard tips.

Effects on Calculus
To test this laser tip on bacteria and calculus, the radially firing tip laser was used at a power level of 2 watts which delivers a radial energy pattern lateral to the center incident light energy pattern (Figs. 3, 4 & 5). This energy output was at 20 Hz. and was applied for the present studies at a slow deliberate rate (1-2 mm/sec) over samples of calculus, bacterial culture samples, endotoxins and tooth root surfaces for a 20-second exposure. The radial energy footprint is displayed in thermal paper studies as the tip continued in its development (Fig. 5).

Calculus samples were gathered from a patient who had not been treated in more than 10 years. These calculus pieces were embedded in methylmethacrylate (Fig. 6) and tested for compression hardness with a Wilson Tukon 2100B (Fig. 7) that measures hardness in Vickers units. Applying direct or incident laser energy to the calculus would vaporize it, only radial energy was used. Surface hardness is measured by pressing a diamond tip into the surface of the calculus sample. The indentation mark is then measured in length and width as a function of the hardness of the sample.

The initial tests were difficult to read because the exterior surfaces of the calculus samples were less calcified compared to the deeper layers of the more mature calculus. The results for tests for hardness could not be measured accurately because the surface was too soft to measure linearly. The calculus samples were then cut with a high-speed carbide bur to expose the middle of the sample and then retested. The new test area was found to have a penetration from the diamond tester of 3-5 microns, which is 206,000 Vickers units. After radial laser irradiation with the Er,Cr:YSGG laser the depth of the indentation was 8- 9 microns, which is 28,968 Vickers units (Fig 8). These results show the surface was weakened significantly by softening the calculus composition with the radial energy of the laser.
This softening may ease the removal by power scalers or the incident beam in the center of the laser tip.

In another test, a tooth with calculus on the crown and root was exposed to the Er,Cr:YSGG laser at two watts, 24 percent air and 16 percent water for 20 seconds. Only the effects of radial energy of the laser were evaluated, including surface preparation, calculus removal and depth of ablation. To measure the depth of ablation on the root surface, a scanning electron microscope (SEM) was also used. Measurements of the effect of the radial energy of this new laser tip on dentinal surfaces and root surfaces are approximately 10-15 microns, which is minimal (Fig. 9) compared to reports of up to 500 microns seen
from aggressive root planing with curettes and power scalers. Minimally invasive root surface removal with the least damage to cementum but leaving a favorable surface texture was shown to be very beneficial for fibroblast reattachment. Changes to enamel after exposure to radial energy were also minimal (Fig 10).

Effects on Periodontal Pathogens
To measure the effect of the new radially firing Er,Cr:YSGG laser tip on bacteria associated with periodontal disease, comparisons were made of bacterial culture growths for control and irradiated samples of periodontal bacteria. Subgingival bacterial samples were taken from diseased periodontal pockets, then divided into two groups. The control group of bacterial samples was inoculated directly onto culture mediums. The laser treated group of bacterial samples was irradiated with two watts at 20 Hz for 20 seconds. Air alone was used since an air/water spray could potentially wash the bacteria from the sample probe. The samples were then inoculated on culture mediums, incubated at 37 degrees, and read for cell growth at 24, 48 and 72 hours (Fig. 11).

The culture testing demonstrated complete elimination of the bacteria following a 20 second exposure to the Er,Cr:YSGG laser radial energy (Fig. 12). The control plates showed a wide variety of bacteria while the test plates showed no colonies were formed anytime within the 72-hour incubation test period (Figs. 13 & 14). Previous studies have shown the bactericidal effects of the incident light due to the ablation effect on the bacteria. The bactericidal effect of the radial energy from this new laser tip was shown to be very effective for stopping bacterial growth. Multiple samples were tested on different dates a variety of culture mediums including blood agar and the culture tubes from Carifree (Albany, Oregon) (Fig. 15). Further studies show that the radially firing laser will denature endotoxins by effectively cleaving molecules (in as many as six or more locations). Bacteria and their endotoxins are the agents that trigger periodontal disease, and as such are key targets for laser therapy (Fig 16).

Effect of radially firing Er,Cr:YSGG
laser clinically The new radially-firing Er,Cr:YSGG laser tip was used on several patients with moderate to severe periodontal disease. Data collection included radiographs, photographs, and probing depths. Following prophylaxis and oral hygiene instructions, patients were scheduled for laser assisted root planning of all pockets greater than 3mm. The root planning protocol included subgingivally applied topical anesthetic (Profound, Glidewell Labs Newport Beach, CA) for approximately 20 seconds (Fig. 17) followed by de-epithelialize the lining of the periodontal pocket (Fig 18). The Waterlase MD laser was used with a 1.0 mm diameter radially firing periodontal tip at two watts, 24 percent air, and 16 percent water at 20 Hz. for approximately 20 seconds for each root surface (ie. buccal or lingual). The movement of the tip is in a slow and deliberate “crown down” fashion. This starts at the crest of the gingival pocket and sweeps in a mesial to distal movement as the tip is moved slowly in an apical direction. More of the 20 second exposure is spent in deeper areas of the pocket and slowly progressing deeper with the tip (Fig. 19).

Next, an ultrasonic scaler was used for 20 seconds per surface (Fig. 20) followed by retreatment with the laser at the same settings for 20 seconds to be sure the laser reaches the root surfaces that were covered with calculus, prior to ultrasonic instrumentation.

A different laser was used again at weeks one, two and three in progressively deeper pockets. At the one-week visit, pockets measuring 6mm and greater were treated with a diode laser at 810nm (Biolase, Irvine, California) at .7-1 watts in both a continuous and pulsed mode (30/30) for approximately 20 seconds per root surface as was done previously with the Er,Cr:YSGG laser (Fig. 22). This was to disinfect the pocket, remove any residual granulation tissue and de-epithelialize the pocket lining and 3mm past the crest on the exterior of the pocket. At the two-week visit, all pockets measuring 7mm and over were irradiated again in the same manner. At three weeks, all pockets measuring 8mm or greater were irradiated.

Healing was evaluated at six weeks and again at 12 weeks. Periodontal maintenance retreatment followed at each three month intervals with standard prophylaxis, any needed subgingival scaling and root planning and a diode laser was used in any residual pockets measuring 4mm or greater with bleeding on probing. After five years and more than 2,000 quadrants of therapy, results have been very predictable. Generally all pockets are reduced to 3mm or less and with adequate oral hygiene, there is no bleeding on probing. The very few times 3mm pockets were not obtained, invariably residual calculus or an endodontic drainage point was found. These pockets then reduced to 3mm once corrected.

This new tip delivers radial energy in overlapping bands with each pass within the pocket. The efficient and complete exposure of the root surface provides an advantage over other lasers tips, which requires a zig-zag motion to cover the complete root surface using only incident light. The efficient energy transfer of 40 joules of energy in a radial band of energy in addition to an incident energy produces tremendous tissue results (Figs. 23-30).

Conclusion
Periodontal disease and its treatment can be a frustrating experience for both the clinician and the patient. The current standard of care treatment, using non-laser root planing and curettage, followed by aggressive and sometimes painful respective surgery may discourage patients from accepting treatment. The cosmetic results can be very damaging and often can never be adequately corrected. The new prototype (not currently commercially available) radially firing Er,Cr:YSGG laser tip presented in this report demonstrated several characteristics that make it a desirable tool to treat periodontal disease. It can soften calculus with minimal damage to surrounding root surfaces. It effectively kills bacteria associated with periodontal disease, as well as breaking up the molecular structure of the tissue-damaging endotoxins produced by periodontal pathogens. Clinical findings suggest significant healing following treatment with a radially firing laser tip Er,Cr:YSGG laser with absolutely no accompanying root sensitivity. The minimally invasive nature of this laser therapy is exciting and encourages patient acceptance of therapy.





















Further References
  1. Haffajee AD, Socrausky SS:Microbial etiological agents of destructive periodontal diseases. Periodontal 2000 1994 June; 5: 78-111
  2. Listgarten MA: Nature of periodontal disease: Pathogenic mechanism. J Periodont. Res. 22: 172-178 1987.
  3. Adriaens PA, De Boeuer JA, Loesche WJ: Bacterial invasions in root cementum and radiclar dentin of periodontally diseased teeth in humans. A reservoir of periodontopathic bacteria. J Periodontology 59(4): 222-230, 1988
  4. Van Strijp AJ, Van Steenbergen TJ, Ten Cate JM: Bacteria colonization of mineralized and completely demineralized dentin in situ. Caries Res 31 (5): 349- 355, 1997.
  5. Love RM, McMillan MD, Jenkinson HF: Invasion of dentinal tubules by oral streptococci is associated with collagen recognition mediated by the antigen I/II family polypeptides. Infect Immun 65 (12): 51.57- 51.64, 1997.
  6. Love RM: Adherance of Streptococcus gordonii to smeared and nonsmeared dentin. Int. Endod J 26(2): 108-112, 1996.
  7. Effects of Irradiation of an Erbrium YAG Laser on Root Surfaces. Yamaguchui, Kobayashi, Osada, et al. Journal of Periodontalogy; 68: 1151,1997
  8. Kelbauskiene, S: A pilot study of ER, CR:YSGG laser therapy used as an adjunct to scaling and root planning in patients with early and moderate periodontitis.; Clinic of Dental and Oral Pathology, Kaunas University of Medicine, Kaunas, Lithuania, March 2007.
  9. Schoop U, Kluger W, Moritz A, Nedjelik N, Georgopoulous A, Sperr W. Bactericidal effect of different laser systems in deep layers of dentin. Laser surg Med 2004; 35(2): 111-116.
  10. GordonW, Atabarhsh V, Meza F, Doms A, Nissan R, Rizoru I, Stevens R. The antimicrobial effecency of the erbium, chromium: yttrium scandium –gallium garnet laser with radial emitting tips on root canal dentin walls infected with Enterococcus faecalis. J Am Dent Assoc. 2007; 138; 992-1002
  11. Ting, F. Effects of Er, Cr:YSGG Laser Irradiation on the Root Surface: Morphologic Analysis and Efficiency of Calculus Removal. Et. Al. J Periodontology Dec. 2007, Vol 78, No 12, pgs 2389-2394.
  12. Schoop U., Kluger W., Moritz A., Nedjelik N., Georgopoulos A., Sperr W.: Bactericidal Effects of Different Laser Systems in the Deep Layers of Dentin, Lasers in Surgery and Medicine. Aug 2004, Vol. 35, Issue 2, pgs 111-116.
  13. Crispi, Romanos, Cassinelli, and Gherlone: Effects of Er:YAG Lasers and Ultrasonics Treatment on Fibroblast Attachment to Root Surfaces: An In Vitro Study. J. Periodontology, July, 2006. Page 1217-1222.
Acknowledgments: For their assistance, the authors wish to thank the collaboration of Dr. Graeme Milicich, Dr. Miller, Dr. Quainoo, and Diedre Krupp for their dedication and efforts contributing to the study.

Author for correspondence: John A. Hendy, DDS, 1873 Williams Hwy Suite 1A, Grants Pass, OR; phone: 541-479-5505,
fax: 541-479-7891, e-mail: drjohnhendy@charter.net
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