QLF Review Caries

8/22/2019 QLF Review Caries

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Scientific Report: Er,Cr:YSGG Laser Effects on Dentin and Collagen

Case Reports: Treatment of Moderate Chronic Periodontitis;

Gingivoplasty, Frenectomy, and Second-Stage Implant

Recovery; Establishing a Gingival Smile Line; Treatment

of Lip Hemangiomas

The Official Journal of the Academy of Laser Dentistry 2008 Vol. 16 NThe Official Journal of the Academy of Laser Dentistry 2008 Vol. 16 No

Caries Detection by Quantitative Light-Induced Fluorescence

See the technology review article on page 6

Academy of Laser D3300 University Drive, Su

Coral Springs, FL


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TA B LE OF CONT ENTSThe official journal of the

Academy of Laser Dentistry

Editor in ChiefJohn D.B. Featherstone, MSc, PhDSan Francisco, CA [email protected]

Managing EditorGail S. Siminovsky, CAE, Executive DirectorCoral Springs, FL [email protected]

Consulting EditorJohn G. Sulewski, MAHuntington Woods, MI [email protected]

Associate EditorsDonald J. Coluzzi, DDSPortola Valley, CA [email protected] P.A. Parker, BDS, LDS RCS, MFGDPHarrogate, Great Britain

[email protected]

Editorial BoardJohn D.B. Featherstone, MSc, PhDGail S. Siminovsky, CAEJohn G. Sulewski, MADonald J. Coluzzi, DDSSteven P.A. Parker, BDS, LDS RCS, MFGDPAlan J. Goldstein, DMDDonald E. Patthoff, DDSPeter Rechmann, Prof. Dr. med. dent.

PublisherMax G. MosesMember Media

1844 N. LarrabeeChicago, IL 60614

312-296-7864Fax: 312-896-9119

[email protected]

Design and LayoutDiva Design

2616 Missum PointSan Marcos, TX 78666

512-665-0544Fax: 512-392-2967

[email protected]

Editorial Office3300 University Drive, Suite 704

Coral Springs, FL 33065

954-346-3776Fax 954-757-2598

[email protected]

The Academy of Laser Dentistry is a not-for-profitorganization qualifying under Section 501(c)(3) ofthe Internal Revenue Code. The Academy of LaserDentistry is an international professional member-ship association of dental practitioners and sup-porting organizations dedicated to improving thehealth and well-being of patients through theproper use of laser technology. The Academy is

dedicated to the advancement of knowledge,research and education and to the exchange ofinformation relative to the art and science of theuse of lasers in dentistry. The Academy endorsesthe Curriculum Guidelines and Standards forDental Laser Education.

Member American Association of Dental EditorsThe Journal of Laser DentistryThe mission of theJournal of Laser Dentistry is to provide a professional quarterly journalthat helps to fulfill the goal of information dissemination by the Academy of Laser Dentistry.The purpose of theJournal of Laser Dentistry is to present information about the use of lasersin dentistry. All articles are peer-reviewed. Issues include manuscripts on current indicationsfor uses of lasers for dental applications, clinical case studies, reviews of topics relevant tolaser dentistry, research articles, clinical studies, research abstracts detailing the scientificbasis for the safety and efficacy of the devices, and articles about future and experimentalprocedures. In addition, featured columnists offer clinical insights, and editorials describepersonal viewpoints.

ED I TOR S V I EWUnderstanding Our Laser Tools to Better Serve Our Patients ..................5

John D.B. Featherstone, MSc, PhD

COVER FEATUREC L I N I C A L R E V I E WSupplementary Methods for Detection and Quantificationof Dental Caries........................................................................................................6Lena Karlsson, RDH; Sofia Tranus, DDS, PhD

SC I ENT I F I C R EPOR TEffect of Er,Cr:YSGG Laser on HumanDentin Collagen: A Preliminary Study ......................................................... ...15Eleftherios-Terry Farmakis, DDS, MDSc, PhD; Konstantinos Kozyrakis,DDS, PhD; Evangelos G. Kontakiotis, DDS, PhD; Kouvelas Nikolaos

DDS, PhD

A DVA NC ED PR OF I C I ENC Y C A SE STUD I ESIntroduction .......................................................... ..................................................22

Nd:YAG Laser-Assisted Treatment ofModerate Chronic Periodontitis........................................................................23

Mary Lynn Smith, RDH; McPherson, Kansas

Use of an 810-nm Diode Laser in a Combined Gingivoplasty,Frenectomy, and Second-Stage Implant Recovery Procedure ................30Steven Parker, BDS, LDS RCS, MFGDP;

Harrogate, North Yorks, Great Britain

Establishing a Maintainable Esthetic GingivalSmile Line with an Er:YAG Laser ..................................................... .................37Charles R. Hoopingarner, DDS, Houston, Texas

Use of an 810-nm Diode Laser in the Treatmentof Multiple Hemangiomata of the Lip............................................................43Steven Parker, BDS, LDS RCS, MFGDP;Harrogate, North Yorks, Great Britain

R ESEA R C H A B STR A C TSLaser Treatment of Vascular Lesions of the Lip ..........................................48

JournalofLaser Dentistry


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Journal of Laser Dentistry: Guidelines for AuthorsThe Academy of Laser Dentistry Welcomes Your Articles for Submission

TheJournal of Laser Dentistry publish-

es articles pertaining to the art, science,

and practice of laser dentistry and

other relevant light-based technologies.

Articles may be scientific and clinical in

nature discussing new techniques,

research, and programs, or may be

applications-oriented describing specific

problems and solutions. While lasers

are our preferred orientation, other

high-technology articles, as well as

insights into marketing, practice man-

agement, regulation, and other aspects

of dentistry that may be of interest to

the dental profession, may be appropri-

ate. All articles are peer-reviewed prior

to acceptance, modification, or rejection.

These guidelines are designed to

help potential authors in writing and

submitting manuscripts to theJournal

of Laser Dentistry, the official publica-

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(ALD). Please follow these instructionscarefully to expedite review and process-

ing of your submission. Manuscripts

that do not adhere to these instructions

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CommercialismALD members are interested in learn-

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information in the title that will make


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electronic retrieval of the article sensi-

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Identify the complete address, busi-

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Provide a brief, current biographical

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Publisher and Copyright HolderTheJournal of Laser Dentistry is pub-

lished by Max G. Moses, Member

Media, 1844 N. Larrabee, Chicago, IL

60614, Telephone: (312) 296-7864; Fax:

(312) 896-9119. TheJournal of Laser

Dentistry is copyrighted by The

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346-3776; Fax: (954) 757-2598.

Articles, Questions, Ideas

Questions about clinical cases, scientificresearch, or ideas for other articles may

be directed to John D.B. Featherstone,

Editor-in-Chief, by e-mail: [email protected].

Submission of Filesby E-mail:

Send your completed files by e-mail

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Gail Siminovsky

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3300 University Drive, Suite 704

Coral Springs, FL 33065

Phone: (954) 346-3776.

Summary of Illustration Types and SpecificationsIllustration

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Line Art and

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EPS or JPG 1200 DPI


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Editorial PolicyTheJournal of Laser Dentistry is devoted to providing the Academy and its members with comprehensive clinical, didactic andresearch information about the safe and effective uses of lasers in dentistry. All statements of opinions and/or fact are publishedunder the authority of the authors, including editorials and articles. The Academy is not responsible for the opinions expressedby the writers, editors or advertisers. The views are not to be accepted as the views of the Academy of Laser Dentistry unlesssuch statements have been expressly adopted by the organization. Information on any research, clinical procedures or productsmay be obtained from the author. Comments concerning content may be directed to the Academys main office by e-mail to

[email protected]

SubmissionsWe encourage prospective authors to follow JLDs Instructions to Authors before submitting manuscripts. To obtain a copy,please go to our Web site www.laserdentistry.org/press.cfm. Please send manuscripts by e-mail to the Editor at [email protected].

Disclosure Policy of Contributing Authors Commercial RelationshipsAccording to the Academys Conflict of Interest and Disclosure policy, authors of manuscripts forJLD are expected to discloseany economic support, personal interests, or potential bias that may be perceived as creating a conflict related to the materialbeing published. Disclosure statements are printed at the end of the article following the authors biography. This policy isintended to alert the audience to any potential bias or conflict so that readers may form their own judgments about the materialbeing presented.

Disclosure Statement for the Academy of Laser Dentistry

The Academy of Laser Dentistry has no financial interest in any manufacturers or vendors of dental supplies.

Reprint Permission PolicyWritten permission must be obtained to duplicate and/or distribute any portion of theJournal of Laser Dentistry. Reprints maybe obtained directly from the Academy of Laser Dentistry provided that any appropriate fee is paid.

Copyright 2008 Academy of Laser Dentistry. All rights reserved unless other ownership is indicated. If any omission or infringementof copyright has occurred through oversight, upon notification amendment will be made in a future issue. No part of this publica-tion may be reproduced or transmitted in any fom or by any means, individually or by any means, without permission from thecopyright holder.

The Journal of the Academy of Laser Dentistry ISSN# 1935-2557.

JLD is published quarterly and mailed nonprofit standard mail to all ALD members. Issues are also mailed to new memberprospects and dentists requesting information on lasers in dentistry.

Advertising Information and RatesDisplay rates are available at www.laserdentistry.org/press.cfm and/or supplied upon request. Insertion orders and materials shouldbe sent to Bill Spilman, Innovative Media Solutions, P.O. Box 399, Oneida, IL 61467, 877-878-3260, fax: 309-483-2371, [email protected]. For a copy of JLD Advertising Guidelines go to www.laserdentistry.org/press_advguide_policy.cfm.The cost for a classified ad in one issue is $50 for the first 25 words and $2.00 for each additional word beyond 25. ALD membersreceive a 20% discount. Payment must accompany ad copy and is payable to the Academy of Laser Dentistry in U.S. funds only.Classified advertising is not open to commercial enterprises. Companies are encouraged to contact Bill Spilman for information on dis-play advertising specifications and rates. The Academy reserves the right to edit or refuse ads.

Editors Note on Advertising:TheJournal of Laser Dentistry currently accepts advertisements for different dental laser educational programs. Not all dental laser educationalcourses are recognized by the Academy of Laser Dentistry. ALD as an independent professional dental organization is concerned that coursesmeet the stringent guidelines following professional standards of education. Readers are advised to verify with ALD whether or not specificcourses are recognized by the Academy of Laser Dentistry in their use of the Curriculum Guidelines and Standards for Dental Laser Education.


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ED I TOR S V I EW

Last month we had articles thatdescribed how light, including laser

light, can be used in everyday

dental practice. The article on laser

fluorescence for caries detection

described just one of the novel new

techniques that are becoming avail-

able. This month a review of

several other techniques is

presented. The bottom line is that

we must understand how each of

these instruments works so that we

can make an assessment of what

the results mean for our patients.

There is no step-by-step cookbookwith recipes to work from. The

practitioner must be able to inter-

pret the output to best use the

information.

Many dentists who use lasers in

their practice use them for ablation

of dental hard tissues, for the

removal of decay, and for cavity

preparations. In this issue we have

an applied research article that

helps us understand what the

erbium lasers are doing. Again, a

better understanding of the tools

that we have in our hands isessential for the best treatment

plan and the best outcome for our

patients.

The case studies are presented

as examples of how to put into

practice the understanding that

the authors have of the lasers

that they are using for the

various tasks. Laser dentistry is

not the only way to tackle any ofthese clinical problems. However,

each of the cases presented

demonstrates an elegant use of

laser technology in clinical prac-

tice. These articles cover the use

of Er:YAG, Nd:YAG, and diode

lasers for primarily soft tissue

applications. In every case the

authors have chosen the laser

that they considered, from their

understanding, to be the best one

for the task at hand.

We are all dental professionals,

each with our own skills and expe-rience. The common message that

runs through all of the articles in

this issue is that we must under-

stand what we are doing in clinical

dentistry in order to decide on the

laser, or light source to use, and to

interpret what is happening as we

use it. Our education and experi-

ence together must guide us to do

the very best that we can for the

oral and general health of our

patients.

In conclusion, I looked back on

my editorial from the last issue andI find it worth repeating the ending

statement: We must all be

continual learners and work out

how to apply our learning to what-

ever we do each day.

Please enjoy this issue of the

journal. Feel free to e-mail me with

suggestions, criticisms, or compli-

ments at [email protected].

AUTH OR B IOG R APH Y Dr. John D.B. Featherstone is

Professor of Preventive and

Restorative Dental Sciences and

Interim Dean in the School of

Dentistry at the University of

California, San Francisco (UCSF).

He has a PhD in chemistry from

the University of Wellington (New

Zealand). His research over thepast 33 years has covered several

aspects of cariology (study of tooth

decay) including fluoride mecha-

nisms of action, de- and

remineralization of the teeth,

apatite chemistry, salivary dysfunc-

tion, caries (tooth decay)

prevention, caries risk assessment,

and laser effects on dental hard

tissues with emphasis on caries

prevention and early caries

removal. He has won numerous

national and international awards

including the T.H. Maiman awardfor research in laser dentistry from

the Academy of Laser Dentistry in

2002, and the Norton Ross Award

for Clinical Research from the

American Dental Association in

2007. In 2005 he was honored as

the first lifetime honorary member

of the Academy of Laser Dentistry.

Dr. Featherstone has published over

200 papers. He is the editor-in-chief

of theJournal of Laser Dentistry.

Disclosure:Dr. Featherstone has no

personal financial interest in any

company relevant to the Academy of

Laser Dentistry. He consults for, has

consulted for, or has done research

funded or supported by Arm &

Hammer, Beecham, Cadbury, GSK,

KaVo, NovaMin, Philips Oralcare,

Procter & Gamble, OMNII Oral

Pharmaceuticals, Oral-B,Wrigley, and

the National Institutes of Health.

Featherstone

Understanding Our Laser Toolsto Better Serve Our PatientsJohn D.B. Featherstone, MSc, PhD, San Francisco, CaliforniaJ Laser Dent2008;16(1):5

S YN OPS IS

John Featherstone, editor-in-chief, describes some of the highlights of

this issue of the Journal of Laser Dentistry, illustrating how we must

understand what we are doing to better serve our patients.


8/56

6

JO

URNAL

O

F

LASER

DENTISTRY

|

2008

VO

L

16,

NO

.1

COVER FEATURE

Karlsson and Tranus

Supplementary Methods for Detectionand Quantification of Dental CariesLena Karlsson, RDH; Sofia Tranus, DDS, PhDDepartment of Cariology and Endodontology, Institute of Odontology, Karolinska Institute,

Huddinge, Sweden

J Laser Dent2008;16(1):6-14

IN TR OD UCT IONOur efforts to make the concept of

caries prevention popular, and to

preserve the dentition into old age

are continuously successful.1-5

However, despite the dramatic

decline in dental caries, particu-

larly in industrialized countries

and among children and young

adults, the disease persists, albeit

with highly skewed distribution.6-7The following major changes have

occurred in the pattern of the

disease: progression of enamel

caries is now slower, and allows

preventive intervention before irre-

versible destruction of tooth

substance. There is also a

pronounced reduction in lesion

development on the smooth

surfaces, which are readily acces-

sible to fluoride.8-11 Diagnostic

techniques to support appropriate

clinical decisions about manage-

ment of the individual lesion,whether invasive therapy or a more

conservative, noninvasive approach

is indicated,12 are predominantly

based on subjective interpretation

of visual information: visual inspec-

tion, bitewing radiography, and the

use of a dental explorer.

Longitudinal monitoring of lesions

has been hampered by the lack of

appropriate diagnostic techniques,

i.e., techniques of high sensitivity

and specificity that reflect the slow

lesion progression. The aim is to

arrest or reverse the disease

process, and to intervene before

operative restorative dentistry is

needed.

Objective, reliable quantitative

data on the outcome of this

strategy, i.e., lesion response to

preventive measures, would allowflexibility in selecting intervention

appropriate for the individual

patient, before lesion progression to

a stage requiring expensive inva-

sive therapy. Optimal dental care

and treatment will increasingly

involve a shift of emphasis and a

change of the education and

training of oral health personnel,

and dental providers need to keep

abreast of new approaches and

technological advances for diag-

noses and therapies of dental

caries. In this context, there is aneed for complementary methods

for detection and quantification of

dental caries. There are certain

requirements that should to be met

by the methods; they have to meet

all safety regulations; detect early,

shallow lesions; differentiate

between shallow and deep lesions;

give a low proportion of false posi-

tive readings; present data in a

quantitative form so that activity

can be monitored; be precise so that

measurements can be repeated by

several operators; be cost-effective

and user-friendly. Clinically appli-

cable methods for detection of avery early phase of mineral loss

and quantification of caries lesions

have emerged. In this paper, some

novel and commercially available

supporting caries detection

methods will be summarized; Fiber-

Optic Transillumination, Digital

Imaging Fiber-Optic Transillumin-

ation, Laser Fluorescence,

Quantitative Light-Induced

S YN OPS IS

Thi s ar ticle reviews the modes of action and cl inical appl icat ion of

novel caries detection methods including digital imaging fiber-optic

transillumination, laser fluorescence, quantitative light-induced laser

fluorescence, and alternating current impedance spectroscopy.

A B STR AC TThere is a need for objective instru-mental caries detection methods tosupplement traditional visualassessment by the clinician. Thesemethods should be used as

supplements to aid in makingappropriate decisions about theclinical management of the indi-

vidual lesion, such as whether touse invasive therapy or a moreconservative, noninvasive approach.Objective, reliable, quantitativemeasures for longitudinal moni-toring of lesion response topreventive measures would allowflexibility in selecting interventionappropriate to the individualpatient, before lesion progressionreaches a stage requiring invasivetherapy. This paper reviews somenovel and commercially availablecaries detection methods: Fiber-Optic Transillumination, DigitalImaging Fiber-Optic Transillumina-tion, Laser Fluorescence,Quantitative Light-inducedFluorescence, and Electronic CariesMeasurement.


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COVER FEATURE

Karlsson and Tranus

Fluorescence, and Electronic Caries

Measurement.

TH E ME TH OD SFiber-Optic Transillumination

(FOTI)

FOTI is a technique that uses light

transmission through the tooth13-18

and has been available on the

market for more than 40 years, in

contrast to the other more novel

methods described below that have

only recently been developed. FOTIis based on the theory that

demineralized dental hard tissues

scatter and absorb light more than

sound tissue. White, cold light is

transmitted from a light source

through an optical fiber to a hand-

piece with a thin probe that is

applied to the tooth surface. Figure

1 shows the clinical FOTI setup. It

detects and visualizes the caries

lesions, so demineralized regions

appear darker compared to the

surrounding sound tissue, and the

contrast between sound andcarious tissue is then used for

detection of lesions on occlusal,

approximal, and smooth surfaces,

on enamel as well as dentin. This

technique relies on the human eye

as the detector and is not quantita-

tive. The majority of the FOTI

studies show the same tendency as

the well-performed in vitro study

on occlusal surfaces by Grossman

et al.,19 which showed low sensi-

tivity (0.39) and high specificity

(0.92), i.e., the risk for false positive

observations was low, and the risk

for missed carious lesions was high.

There is a need for training and

calibration of operators, but few

clinical factors influence the read-

ings.Clinical perspective: FOTI is

essentially a refinement of tradi-

tional visual observation that can

enhance caries detection by a

trained and experienced clinician,

but is not quantitative and has the

same limitations as traditional

visual methods for assessing lesion

extent and following lesions overtime.

Digital Imaging Fiber-Optic

Transillumination (DIFOTI)

A recently marketed method based

upon the same principles as FOTI

is the digitized DIFOTI method. In

this method the white light is

delivered through an optical fiber

via a specially designed handpiece

that has a mirror on the opposite

side of the tooth, thereby chan-

nelling the image back to a digital

camera and visualizing the imageon a monitor via a computer

system. An ordinary computer

setup with specially designed soft-

ware creates a real-time image of

the illuminated tooth on the

computer screen. The images can

be stored for later retrieval and

comparative examination. Two

disposable mouthpieces are avail-

able, one for proximal and one for

occlusal surfaces, in an adult as

well as a pediatric size. The

DIFOTI method is still qualitative.

Figure 2 shows a DIFOTI image ofa molar occlusal surface. As can be

seen tooth defects are readily visu-

alized, such as the unusual

morphology in this image. As with

regular FOTI, the users level of

experience is essential. Only

limited research has so far been

performed.20-22

Clinical perspective: The

DIFOTI technique essentially picks

up surface scattering of the visual-

izing light and readily indicates thepresence of very early carious

lesions, cracks, or imperfections in

the tooth surface. From a clinical

perspective, however, this informa-

tion is very limited in its

usefulness. The method gives no

indication of lesion depth, severity,

or progress over time, and cannot

be used in the determination of

how deep the lesion is and whether

surgical intervention is necessary.

This problem was highlighted in

the recent study by Young and

Featherstone.22

Laser Fluorescence (LF)

When a caries lesion in enamel and

dentin is illuminated with red laser

light (= 655 nm), organic mole-cules that have penetrated porous

regions of the tooth, especially

metabolites from oral bacteria, will

create an infrared (IR) fluorescence.

The enamel is essentially trans-

parent to red light. The IR

fluorescence is believed to originate

from porphyrins and related

compounds from oral bacteria.These molecules are chiefly respon-

sible for the absorption of red light.23

The laser instrument,

DIAGNOdent (DD) (KaVo Dental

GmbH, Biberach, Germany), is

based on research by Hibst and

Gall,24 was introduced in the late

1990s, and is today marketed in two

versions.Apart from smooth and

occlusal surfaces, the latest version,

Figure 1: Clinical FOTI setup. There are

several types of probes on the market.

This illustrates a quite thick probe.

Figure 2: An occlusal surface on a molar,

viewed through DIFOTI. The tooth is illu-

minated from the buccal surface. Dark

areas around the fissures indicate caries

lesions.


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the DD-pen, also aims to readily

access approximal surfaces. There is

as yet limited information on the

usefulness of the latter device.

As described in a recent review

by Hibst,23 red light from a 655-nm

diode is transmitted through an

optical fiber to a hand probe. This

light beam is used to irradiate the

tooth, with the red light transmit-

ting readily through sound enamel.

When the light reaches a carious

lesion and interacts with appro-

priate organic molecules that have

been absorbed into the porous

structure, the light is re-emitted as

invisible fluorescence in the near-

infrared region. The emitted lightis channelled through the hand-

piece to a detector and presented to

the operator as a digital number on

a display (0-99). A higher number

indicates more fluorescence and by

inference a more extensive lesion

below the surface.

The first version of the LF

device has shown good performance

and reproducibility for detection

and quantification of occlusal and

smooth surface carious lesions in in

vitro studies,25-27 but with somewhat

more contradictory results in vivo,both in the primary and permanent

dentition.28-34 It has also been tried

for longitudinal monitoring of the

caries process, and for assessing

the outcome of preventive interven-

tions.25,35-37 The DD-pen (Figure 3)

might be a useful additional tool in

detecting approximal caries, but

has so far only been evaluated in

three in vitro studies.38-40 Factors

that may influence the outcome of

the measurements in different

ways are: presence of plaque,

calculus and/or staining on thetooth surface,18,25 and the degree of

dehydration of tooth tissue.26 The

system detects fluorescent organic

molecules that can be present in

any surface deposits, thereby

readily producing false positives.

For measurements on occlusal

surfaces, it is also of great impor-

tance that the tip is tilted over a

range of several different angles to

access all relevant subsurface

regions.Clinical perspective: The LF

device is a useful adjunct to tradi-

tional visual examination,

especially in occlusal surfaces, for

the detection of hidden lesions

below the surface. However, the

device detects organic molecules

that have penetrated into surface

deposits or subsurface porosities,

such as carious lesions. It does notdirectly detect demineralization.

Results must be interpreted with

caution by understanding how the

device works and how false positive

readings can be misleading. The

digital number displayed indicates

the amount of fluorescence, which

is not necessarily a measure of

lesion size or depth.

Quantitative Light-

Induced Fluorescence

(QLF)

The phenomenon of toothauto fluorescence has

long since been suggested

to be useful as a tool for

the detection of dental

caries.41 Fluorescence is a

property of some man-

made and natural

materials that absorb

energy at certain light

wavelengths and emit

light at longer wavelengths. An

increased porosity due to a subsur-

face enamel lesion, occupied by

water, scatters the light either as it

enters the tooth or as the fluores-

cence is emitted, resulting in a loss

of its natural fluorescence.

Consequently the demineralized

area appears opaque. The strong

light scattering in the lesion leads

to shorter light path than in sound

enamel, and the fluorescence

becomes weaker. Bjelkhagen and

Sundstrm42 and later de Josselin

de Jonget al.43 developed a tech-

nique based on this optical

phenomenon, making the difference

in fluorescence radiance betweenthe carious and sound tooth struc-

ture quantitative. This has been

termed quantitative light-induced

fluorescence (QLF).

The QLF method can readily

detect lesions to a depth of approxi-

mately 500 m. on smooth andocclusal enamel surfaces. In the

currently marketed systems

(Inspector Pro, Inspektor Dental

Care, Amsterdam, The

Netherlands) the illumination

system consists of a 50-Watt

microdischarge arc lamp equippedwith an optical bandpass filter with

a peak intensity of 370 nm, trans-

mitted through an optical fiber

from the light source to a handpiece

with a micro CCD video camera. A

high-pass filter in front of the

camera blocks the excitation light

together with the ambient light, so

Figure 3: Approximal measurement with

the DIAGNOdent pen. The red laser light

can be seen through the dental hardtissue.

Figure 4: Principal setup of the Quantitative Light-

Induced Fluorescence method.


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Karlsson and Tranus

that only wavelengths above 520

nm are transmitted to the detector.

Figure 4 shows the principal setup

for the QLF-technique.

The preferred image is captured

and saved by the operator by

pressing a foot switch, and is later

processed. Details about the tooth

and the surface examined are set

in the program, and the position

and orientation of the processed

image is thereafter automatically

stored in a preset pattern so that

when the patient comes back on

recall, a contour guides the oper-

ator to the right position again. The

program offers an automatic repo-

sitioning facility, which can be setat any level, and when correlation

between the reference image and

the real-time image is satisfactory,

it can be saved automatically. The

fluorescence image is first

converted into a black-and-white

image so that thereafter the lesion

site can be reconstructed by inter-

polating the grey level values in

the sound enamel around the

lesion. The difference between

measured and reconstructed values

gives three quantities: F (average

change in fluorescence, %), lesionarea (mm2), and Q (area x F), thelatter giving a measure of the

extent and severity of the lesion.

Figure 5 shows the analytical part

of the QLF method, as calculated

by the specially designed software.

The QLF method has been tested

in several in vitro,44-46 in situ,47 andin vivo43,48-53 studies for smooth

surface caries lesions. The possi-

bility of adapting the QLF method

for occlusal caries diagnosis is under

investigation54-55 as well as modifica-

tion for detection and quantification

of secondary caries,56-58 but has yet to

be tested clinically. Application for

quantification of dental fluorosis

has also been investigated.59

Highamet al.60 concluded QLF

has the potential to detect, diag-

nose, and longitudinally monitor

occlusal caries and provide useful

information to the clinician with

regard to the severity of the lesionand likely treatment. Eggertssonet al.61 reported good reproducibility

of QLF methods clinically with

inter- and intra-examiner relia-

bility greater than 0.95 after

training.

Factors that may influence the

outcome of the measurements are:

presence of plaque, calculus and/or

staining,62 ambient light, daylight

or office light, and the degree of

dehydration of tooth tissue.63 The

newly designed handpieces on the

commercially available deviceshave largely overcome the ambient

light problems. Certain errors in

the capturing stage of the method,

such as differences in x- or y-axis,

or rotation of the image, may be

adjusted during the analytical

stage of the method.

The QLF method can

also measure and quan-

tify the red fluorescence

(RF) from microorgan-

isms in plaque. The RF

observed in plaque can

be of use when moni-toring oral hygiene;

removing infected

dentin; detecting a

leaking sealant or caries

at the margin of a

restoration. Two quanti-

ties are obtained, R(average change in red

fluorescence, %), and

area (mm2). So far there

are a very limited number of

studies performed with this

feature.64

Clinical perspective: The QLF

system that has recently come on

the market (Inspektor Pro) in

several countries can be used as a

quantitative measure of enamel

lesions in smooth surfaces. It is

likely that is will also be useful for

occlusal surfaces but this has yet to

be proven. The sophisticated

computer-driven repositioning

feature enables lesion progression

or arrestment to be followed over

time. This system appears to be a

useful adjunct to traditional visual

examination.

Electronic Caries Measurement

(ECM) and Alternating Current

Impedance Spectroscopy

The ECM technique is based on the

theory that sound dental hard

tissue, especially the enamel, shows

very high electrical resistance or

impedance. Demineralized enamel

becomes porous, and the pores fill

with saliva, water, microorganisms,

etc. The more demineralized the

tissue, the lower the resistance

becomes. In the impedance meas-urement system a circuit of a very

weak alternating current is closed

through the patient. From the

device, a fiber leads to a probe,

which is placed on the site that is

to be measured.

Figure 6: Clinical use of Electronic Caries

Measurement (ECM).

Figure 5: The analytical interface of the QLF method.

The lesion is color-coded so that the operator can get a

quick impression of the area and the depth.


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Figure 6 shows clinical use of an

Electronic Caries Measurement

device. The patient holds a ground-

unit in the hand, and from the

ground-unit, a fiber leads back to

the device. Compressed air that is

led through the probe isolates the

measuring site from the

surrounding saliva. The result of

the measurement is presented on a

display as a number between 1 and

13, and the higher the number, the

deeper the lesion.

Site-specific measurements have

been evaluated in a number ofin

vitro studies65-71 and in vivo

studies.72-73 The reported sensitivity

for ECM in detecting dentinalcaries lesions of permanent

premolar and molar teeth ranges

from 0.93 to 0.95, and the speci-

ficity ranges from 0.53 to 0.70, in

clinical studies, which gives a

moderate risk for false positive

readings, and a low risk of missed

carious lesions. Surface-specific

electrical conductance measure-

ments have been investigated

under in vitro conditions,74 which

showed moderate sensitivity and

specificity. Factors that may influ-

ence the outcome of themeasurements are the degree of

dehydration of tooth tissue,75 the

degree of maturation of the

enamel,76 and temperature varia-

tions.77

Another impedance/conduc-

tance-based method is Alternating

Current Impedance Spectroscopy

(ACIST). It is based on the same

assumptions about electrical

circuits and dental hard tissues as

the ECM instrument. Apart from

the forward conductance (resist-

ance values, representingcontinuous conduction/diffusion

pathways) it also measures trans-

verse conductance (capacitative

conductance pathways). This could

give more information than the

ECM.78-79A commercially manufac-

tured impedance measurement

device has recently come on the

market in the United Kingdom

(CarieScan, IDMoS PLC, Dundee,

United Kingdom) and is likely to

reach the United States in the near

future.Clinical perspective: The elec-

trical conductance or impedance

measurement devices have had

limited success in the past. The

new ACIST system shows consider-

able promise as a method with

good ability to detect lesions with a

low level of false positives.

However, the device gives a

lesion/no lesion answer rather than

an image, extent of the lesion, posi-

tion of the lesion measure. This

technique is likely to be a useful

adjunct to traditional examination

provided the clinician uses theinformation wisely in combination

with other observations to deter-

mine an intervention or restorative

treatment plan.

DISCUSS IONQuantitative dental caries detec-

tion methods may take subjective

interpretations of visual, tactile,

and radiographic methods to

evidence-based clinical practice. A

shift from traditional diagnostic

methods to advanced and more

sensitive methods will improvecaries diagnostic routines and

hence the dental care and treat-

ment for our patients benefit:

minimize the use of unavoidable

hazards of ionizing radiation,

detect caries in an early stage,

obtain a more precise estimation of

lesion depth and severity, reveal a

dentinal lesion obscured by super-

imposed sound tissue, monitoring

de- or remineralization, evaluate

the outcome of different preventive

strategies, and detect and quantify

bacterial activity.The caries detection methods

reviewed in this article meet

general clinical needs and although

significant promise is seen in these

techniques, there is not enough

evidence currently available to

recommend any one of them as a

substitute for conventional

methods. However, each of them

can be valuable in its own way, as

summarized above as a supplement

to traditional methods. Each of the

new methods reviewed brings addi-

tional information about lesions in

a manner specific to the technology

used.

Nevertheless, traditional

methods of caries assessment,

which discriminate lesions at the

cavitation stage, are not always

clinically appropriate, and are obso-

lete for clinical research requiring

detection of a very early phase of

mineral loss, which allow a reduc-

tion in the duration of

experimental periods and the

number of subjects required, saving

both time and money. To developand test a new medical technical

device is a long-term commitment;

it takes time, scientific research,

and evidence from the time of the

first idea to a validated commer-

cially available device, and even

though laboratory findings show

strong results, caution is indicated

when extrapolating these into clin-

ical conditions.

The QLF method is today the

most promising technology of those

currently on the market, due to its

close correlation to the enamelmineral content, but with limita-

tions such as the inability to detect

approximal (and occlusal) caries

lesions, and dentinal caries. One of

the upcoming methods and devices,

based on different physical theories

that is expected to appear on the

market in the future is Optical

Coherence Tomography (OCT)

which can produce two- or three-

dimensional images of

demineralized regions in dental

enamel. When a tooth with a

carious lesion is illuminated withinfrared light at 1310 nm, OCT

technology can produce a quantita-

tive image of the subsurface lesion

to the full depth of the enamel.80-81

The OCT method is, however, still

yet far from a marketed device for

everyday use in the dental office.

All improvements require

change, but not all change is

improvement. Evidence-based care


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Karlsson and Tranus

is by definition the conscientious,

explicit, and judicious use of the

current best evidence in making

decisions about the care of indi-

vidual patients, which includes

integrating individual clinical

expertise with the best available

external clinical evidence.82 It is

therefore important to emphasize

the need for clinical trials to support

critical appraisal and decision

making in using these techniques,

by theory and empirical evidence.

In summary, there are several

devices currently on the market

and more to come that can be used

by the clinician as valuable supple-

ments to the traditional cariesdetection and assessment methods.

All of the new methods require a

basic understanding of how they

work so that the results can be

correctly interpreted for the benefit

of the patient, especially to aid in

the decision as to how to treatment

plan, which lesions can be reversed,

which chemical therapy should be

used, how to assess success or not,

and when to intervene with

restorative work.

AUTH OR B IOG R APH IE SLena Karlsson is a registered

dental hygienist and a PhD student

at Karolinska Institute, Sweden.

She works as a lecturer at the

Institute of Odontology, unit of

Cariology and Endodontics, and is

involved in the dental hygienist

and the dental student educational

programs. In the late 1990s she

began to undertake research in the

field of diagnosis, prevention, and

management of dental caries with

a focus on the interaction between

laser light and dental hard tissues,supervised by Professor Birgit

Angmar-Mnsson. Today she is one

of Dr. Sofia Tranuss doctoral

students and her thesis work

involves studies of different

methods for detection and quantifi-

cation of carious lesions at their

earliest stages. She may be

contacted by e-mail at

[email protected].

Disclosure:Lena Karlsson has

received research funding from inde-

pendent organizations including the

Karolinska Institutet, the Swedish

Patent Revenue Fund for Research in

Preventive Dentistry, and the Swedish

Dental Society. She has also received

research funding or free use of tech-

nical devices from Inspektor Research

Systems BV (The Netherlands), KaVo

Scandinavia AB (Sweden), and KaVo

Dental GmbH (Germany).

Dr. Sofia Tranus is a senior

lecturer in the Department of

Odontology at the Karolinska

Institute in Stockholm, Sweden.

She has spent the past 10 yearsdeveloping and testing new tech-

niques for detection and

quantification of dental caries. Dr.

Tranus completed her PhD in

2002 at the Karolinska Institute,

with her thesis entitled Clinical

application of QLF and

DIAGNOdent Two new methods

for quantification of dental caries.

Currently, she is on a temporary

2-year assignment at SBU The

Swedish Council on Technology

Assessment in Health Care. Dr.

Tranus may be contacted by e-mail at [email protected].

Disclosure:Dr. Tranus has received

research funding from independent

organizations including the

Karolinska Institutet, the Swedish

Patent Revenue Fund for Research in

Preventive Dentistry, and the Swedish

Dental Society. She has also received

unrestricted research funding from

Inspektor Research Systems BV (The

Netherlands), KaVo Scandinavia AB

(Sweden), and KaVo Dental GmbH

(Germany).

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with laser fluorescence. Caries Res

1995;29(1):2-7.

44. Hafstrm-Bjrkman U, Sundstrm

F, de Josselin de Jong E, Oliveby A,

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45. Emami Z, Al-Khateeb S, de Josselin

de Jong E, Sundstrm F, Trollss K,

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methodologic study.Acta Odontol

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Mnsson B, de Josselin de Jong E,

Sundstrm G, Exterkate RAM,

Oliveby A. Quantification of forma-

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47. Al-Khateeb S, Oliveby A, de Josselin

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48. Al-Khateeb S, Forsberg CM, de

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fluorescence study of white spot

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J Orthod Dentofacial Orthop

1998;113(6):595-602.

49. Ferreira Zandon AG, Isaacs RL,

van der Veen M, Stookey GK.

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50. Tranus S, Al-Khateeb S, Bjrkman

S, Twetman S, Angmar-Mnsson B.

Application of quantitative light-

induced fluorescence to monitor

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children. A comparative study of

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and professional cleaning.Eur J

Oral Sci 2001;109(2):71-75.

51. Tranus S, Shi X-Q, Lindgren LE,

Trollss K, Angmar-Mnsson B.In

vivo repeatability and repro-

ducibility of the quantitative

light-induced fluorescence method.

Caries Res 2002;36(1):3-9.

52. Pretty IA, Ellwood RP. Comparison

of paired visual assessment and

software analyses of changes in

caries status over 6 months from

fluorescence images. Caries Res

2007;41(2):115-120.

53. Yin W, Feng Y, Hu D, Ellwood RP,

Pretty IA. Reliability of quantitative

laser fluorescence analysis of

smooth surface lesions adjacent to

the gingival tissues. Caries Res

2007;41(3):186-189.

54. Ferreira Zandon AG, Analoui M,

Beiswanger BB, Isaacs RL, Kafrawy

AH, Eckert GJ, Stookey GK. An in

vitro comparison between laser fluo-

rescence and visual examination for

detection of demineralization in

occlusal pits and fissures. Caries Res

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55. Ando M, Eggertsson H, Isaacs RL,

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Comparative studies of several

methods for the early detection of

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56. Hall AF, DeSchepper E, Ando M,

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tification of mineral loss from dental

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57. Tranus S, de Josselin de Jong E,

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Brettle DS, Whelton H, Ellwood RP.

Quantification of dental fluorosis

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Development of an occlusal caries

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SC I ENT I F I C R EPOR T

Effect of Er,Cr:YSGG Laser on Human DentinCollagen: A Preliminary StudyEleftherios-Terry Farmakis, DDS, MDSc, PhD

1

; Konstantinos Kozyrakis, DDS, PhD2

; Evangelos G.Kontakiotis, DDS, PhD3; Kouvelas Nikolaos DDS, PhD4

1Fellow Researcher, Department of Endodontics, Dental School, University of Athens, Greece; 2Lecturer, Department of Endodontics,

Dental School, University of Athens, Greece; 3Assistant Professor, Department of Endodontics, Dental School, University of Athens,

Greece; 4Associate Professor, Dept of Pediatric Dentistry, Dental School, University of Athens, Greece.

J Laser Dent2008;16(1):15-20

IN TR OD UCT IONSince the discovery of lasers in

1960, much research has been done

in order to investigate the interac-

tion of lasers with the dental

tissues.1-2 The early dental lasers

for use with hard dental tissue

applications often produced a char-

ring effect. A few years ago, a Class

IV Erbium Laser was cleared bythe U.S. Food and Drug

Administration (FDA) for use in

dentistry. This type of laser

(Er,Cr:YSGG) uses a crystal whose

main element is erbium (a rare

earth element), in addition to small

portions of chromium, yttrium,

scandium, gallium, and garnet.

This crystal when irradiated emits

a characteristic wavelength of 2780

nm that falls within the absorption

band of water.3-5

One of the earlier possible expla-

nations, proposed by themanufacturer, for the action of the

Er,Cr:YSGG laser on dental hard

tissues has to do with the interac-

tion of this specific laser

wavelength with the water spray of

the laser handpiece. It has been

suggested that when water droplets

are introduced into the

Er,Cr:YSGG laser beam, that the

water droplets explode violently

outwards, due to the energy

absorption, thus creating a plasma

expansion which drives the water

droplets to supersonic velocity. The

expression of this phenomenon is a

production of a pressure of 400

MPa and velocities up to 1000

m/sec from energized water

droplets.6 When this stream of

water jet is striking the target, itsupposedly has enough power to

dislodge material but with a very

accurate cutting.7 It has been

suggested that water is the cutting

agent; and in addition that hard

dental material that is dislodged,

once incorporated into the stream,

could act as abrasive particles, thus

increasing the efficiency of the

cutting field. This abrasive water

jet (AWJ) is speculated to be

capable of removing hard dental

tissues but without the carboniza-

tion effect associated with othertypes of lasers, due to its indirect

action. Actually, the temperature at

the operating field is reduced,8-9

something that might be expected

due to the cooling effect of water.

However, it has recently been

proposed that the action of the

Er,Cr:YSGG laser is similar to the

Er:YAG, since their wavelengths

are similar (2780 nm for the

Farmakis et al.

AB STR AC TObjective:The objective of this

study was to determine the alter-ations of human dentin proteins(mainly collagen) following theuse of an Er,Cr:YSGG laser.

Materials & Methods:Fifteenhuman dentin sections werestudied in three equal groups. Halfof the surface was irradiated usingan energy density of 88 J/cm2 forgroups A and C, and 150 J/cm2 forgroup B. In addition, group C wasetched for 15 seconds with 37%phosphoric acid. All sections werethen immersed in 5% ninhydrinsolution for 3 hours and thenexamined by light microscopy forcollagen assessment. Results:Ingroups A and B the controluntreated surfaces appeared in ablue-reddish color. In group A, thetreated surfaces showed circular

white areas surrounded by deepblue rings and under magnifica-tion the dentin appearedroughened and smear layer-free.In group B, the treated areasshowed a roughened surface withno coloration. In group C, both theetched-only and the irradiated andetched surfaces showed a lightercoloration compared to control.

Conclusions:From this prelimi-nary study, it is suggested thatthere was a severe change inhuman dentin collagen andcreation of a roughened dentinsurface following the use of thislaser. The higher the energy, thegreater the effect. Fewer changesoccurred after the use of etchantonly.

S YN OPS IS

This ar ticle reports a study that il lustrates how the collagen is

affected during ablation of dentin by an Er,Cr:YSGG laser, at clinically

relevant fluences.


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Er:YAG, 2940 nm for the

Er,Cr:YSSG), both falling within

the water absorption band.

Accordingly they have similar

absorption parameters in the hard

dental tissues.10

The most recent explanation for

its action is the interaction of this

specific laser wavelength with

hydrated dentin. Since this wave-

length is absorbed very well by the

water content of dentin and also by

the hydroxyapatite mineral, the

water is heated and finally vapor-

ized; the vapors remain inside the

dental tissues until the pressure

building up in the dental hard

tissues is enough to disrupt theirintegration, causing micro-explo-

sions, thereby ejecting dentin

particles (water-induced ablation).11

In cavity preparations made by

dental burs, bonding of resin to

enamel is achieved via micro-

mechanical retention on the

roughened surface, whereas the

retention to dentin is based mainly

on the hybrid layer formation and

to a lesser degree to the microme-

chanical retention offered by the

resin tags embedded in dentin.12-13

In cavities prepared byEr,Cr:YSGG lasers, the associated

microroughness on both enamel

and dentin does not require a

change of approach to resin

bonding to the enamel. However,

the resulting alteration of collagen

may lead to the formation of an

inferior hybrid layer zone due to

incomplete penetration of the

collagen fibrils by the hydrophilic

primers and resin monomers.14 In

this case, the resin-dentin bond is

favored by resin tag formation.15

The objective of this work was toinvestigate the possible alterations

of human dentin proteins (mainly

collagen) following irradiation by

an Er,Cr:YSGG laser under

different clinically relevant

settings. These changes in dentin

could affect the hybrid layer forma-

tion and the subsequent dentin

bonding to resin composite restora-

tive materials.

MATERIALS ANDME TH OD SFifteen standardized dentin

sections (each 2 mm thick) were

prepared from sound human

molars that had been stored in

sterile saline, until they were used.

From each tooth, a single disc wasobtained by using a low-speed saw

(IsoMet, Buehler Ltd., Lake Bluff,

Ill., USA) under tap water cooling.

The cutting plane was parallel to

the occlusal surface of the tooth

and in most cases the sections did

not interfere with the pulp horns. A

groove was made on one side of

each section, dividing the surface

into two parts. Finally the sections

were randomly distributed into

three groups.

The Er,Cr:YSGG laser hand-

piece (Millennium, BiolaseTechnol

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