Dental Tribune U.S. Edition

Dental Tribune U.S. Edition | June 2013 A7iNDUStRY CLiNiCAL Er:YAG and Nd:YAG dual wavelength- optimized periodontal therapy protocol T his protocol involves using the Fotona Lightwalker/Powerlase (Lasers4Dentistry, www.T4Med. com, San Clemente, Calif.) fam- ily of lasers containing both Er:YAG and Nd:YAG laser wavelengths and the PIPS (photon-induced photoaccous- tic streaming) technology. PIPS6,11 is an Er:YAG photoaccoustic wave that enables removal of calculus, destruction of bio- film and detoxification of the cemental root surfaces in an atraumatic man- ner. This allows for bone regrowth and reattachment. History of lasers in dentistry The possibilities for laser use in den- tistry did not occur until 198910 with the production of the American Dental Laser for commercial use. This laser, us- ing an active medium of Nd:YAG, emit- ted pulsed light and was developed and marketed by Dr. Terry Myers.7,8 Though inappropriate for use on den- tal hard tissue, the availability of a dedi- cated laser for oral use gained popularity among dentists. In 1989, experimental work by Keller and Hibst using a pulsed Er:YAG (2,940 nm) laser, demonstrated its effectiveness in cutting enamel, den- tin and bone,9 and these then became commercially available soon after. Of the currently available hard-tissue lasers, Er:YAG lasers have a signifi- cantly higher affinity for water versus Er,Cr:YSGG lasers and are much more effective in most dental procedures.1,5 Er:YAG lasers have proved beneficial in the removal of granulation tissue and calculus and are an effective tool in peri- odontal therapy.4 Treatment with Nd:YAG lasers is effect- ive for connective tissue reattachment to cementum and periodontal regenera- tion.2 The Nd:YAG wavelength is able kill the bacteria that are a part of the patho- genesis of periodontal disease.3 The com- bination of the two wavelengths in a single treatment makes optimum use of the unique laser-tissue interaction char- acteristics of each wavelength. Nd:YAG laser energy is superior for co- agulation and deep disinfection, while Er:YAG is uniquely efficient at gently removing the infected tissue and calcu- lus from the root surface, along with its bactericidal effects. Combined, they can dramatically improve the outcome of laser-assisted treatments. Case study Patients who consented to treatment during this case study ranged from 40 to 80 years of age. The patients were not specifically selected, but represented the population typically treated in the of- fice, made up of approximately 75 per- cent adults. These patients had a variety of preex- isting health conditions, including high blood pressure, diabetes and coronary artery disease. Cases varied from single pockets to full-mouth treatments. Patients had pocketing ranging from 2 to 10 mm with moderate to severe horizontal and angu- lar bone loss. Pockets 6 mm deep had collagen placed while those more than 6 mm had Novabone™ (Novabone Products) placed with a liquid Atrisorb™ (Zila) membrane and sealed with Periacryl™ (Glustitch). Occlusal discrepancies were addressed in all cases, and full-mouth cases had full coverage orthotic appliances fab- ricated (Glidewell Comfort hard/soft). Patients were instructed to avoid brush- ing or flossing the area treated and avoid granular foods such as strawberries, poppy seeds and sesame seeds, etc., for one week. Patients were given Peridex™ (3M ESPE) rinse and doxycycline 100 mg for seven days. Follow-up appointments occurred at one and two weeks post-treatment for removal of Periacryl™ and biostimula- tion. In addition, de-epithelializing the pockets was completed based on the in- itial pocket depth during these one- and/ or two-week follow-up appointments. Patients were brought back for periodon- tal maintenance after two months. At all follow-up appointments, there were limitations on sub-gingival scaling. No probing was permitted for a min- imum of six months to avoid damage to the new attachment. Case No. 1 A 74-year-old female presented with no known allergies. The patient had no his- tory of significant medical conditions or habits and was taking no medications at the time of treatment. The patient had a Class I occlusion with significant crowd- ing. Her chief complaint was her swollen and bleeding gums. She presented with a 7 mm pocket on the mesial buccal of #7, 6 mm on the direct lingual and 6 mm on the distal lingual. Pre-operative ra- diographs showed a significant osseous defect. Eight months after “wavelength opti- mized periodontal therapy” (WPT) treat- ment, probings were 2 mm in the previ- ous locations; and after one year, they were consistent at 2 mm, which was a gain of 4 to 5 mm of attachment. Post- operative radiographs showed signifi- cant bone fill of the previous defect. Case No. 2 This 62-year-old male patient had a full- mouth case with pocketing ranging from 2 to 10 mm in multiple locations. The patient reported no known allergies and was taking prescription medica- tions that included Metropolol, Crestor, Ramipril and HCTZ. The patient’s chief complaint was his bleeding and pain- ful gums. The diagnosis was moderate to severe periodontal disease in all four quadrants and he consented to treat- ment. Two-year postoperative probings and radiographs showed significant pocket reduction, reattachment and osseous fill in defects. Unfortunately, Den- trix periodontal charting only goes to 9 mm so the charts were modified for 10 mm pockets as needed. Pre-operative pocketing (Fig. 4) was as high as 10 mm in two locations. Figure 5 shows signifi- cant improvement at the 22-month post- operative follow up. Harvey S. SHIffman, DDS, is in general practice at the Laser Dental Center in Boyn- ton Beach, Fla. He is a gradu- ate of Georgetown Univer- sity School of Dentistry and completed a general prac- tice residency at George- town University Medical Center with an emphasis on treating medically compro- mised patients. Shiffman completed certification with the Academy of Laser Dentistry (ALD) in three types of laser systems and was recently awarded a fel- lowship in the ALD. He is personally involved in the use and development of cutting-edge technology and has performed thousands of laser dental procedures dur- ing the last decade. Shiffman also lectured at the 2012 Yankee Dental Congress on advances in laser dentistry. Fig. 2: Case 1 pre-operative X-ray. Fig. 4: Case 2 pre-operative probings. Combination dramatically improves outcome of laser-assisted treatments By Harvey S. Shiffman, DDS Fig. 1: Case 1 during treatment. Photos/Provided by Dr. Harvey S. Shiffman Fig. 3: Case 1 post-operative X-ray at five months. Fig. 5: Case 2 post-operative probings at 22 months. ” See DUAL, page A8