Hey Ron,

I’m gonna let some diode/PerioLase/erbium owners describe the difference between the clinical results they have seen.

But here’s my general take on it.

For example, Diodes:

1.  Are “hot” lasers and tend to create a dry versus a moist wound at higher settings.

2.  Kill some bugs.  Mostly on the tissue surface and not a depth of 2-4mm.  Not all or most, but enough to allow the body to recover and heal.

3.  At lower settings, there is less dryness and more moisture in the tissue, germ lethality is much less.

So there is a trade off with a CW/gated diode in controlling the desired effects.

Alternatively, the Free Running Pulsed Nd:YAG (Periolase):

1.  Has intensity in each pulse of 100 millionths of a second (and 2000 watts per pulse) for substantial germ lethality at depths of 2-4mm and through “priviledged sites” that anaerobes hide in  (Harris, Loomer AADR 2003).  PS are endothelial cells, macrophages, calculus, dential tubules (Koch).

2.  That intensity (brightness) is offset by pulse “off” times that are about 500 times longer than the on time.  At 20 hz that would be 100 usec on and 49,900 usec off.  That allows the tissue to cool down a bit and not burn or get too hot.  

3.  Long pulse durations are user selectable (150 to 650 usec).   Because the tissue and most importantly, the blood is not boiled (vaporized) away at long PDs we can “slow cook-it” or poach it (blood) if you will.  This allows the blood to form of heat thrombus that sticks to the connective tissue and root surface, which seals the pocket from the oral environment and epithelial migration.  Thrombi have nutrient cells in that zone of thermal injury called the “stasis” zone (as in “hemostasis”–NOT coagulation, which is cell death).  Thrombi later converts to fibrin, the elixer of regeneration!

For comparison, erbiums:

1.  have no selectivity within tissue.

2.  so bone, PDL, cementum all get to absorb the wavelength along with any bacteria.  But again, the bacterial kill will be on the tissue surface, not at any depth into tissue as Harris describes:

http://iadr.confex.com/iadr/2003SanAnton/techprogram/abstract_27983.htm

3.  No hemostasis means no thrombus, no fibrin, no regeneration.

So the healing that we do see when we get some results with diodes or even erbbiums is “repair” not regeneration.

Repair = Long junctional epithelium.  Long JE is still health and is clinically acceptable, but it may not be as stable as true regeneration.  It is certainly not our end goal we want.

We strive at all time to achieve:

Regeneration = New Attachment.  NA = new cementum on the root, new PDL, new alveolar bone.

http://iadr.confex.com/iadr/2004Hawaii/techprogram/abstract_47642.htm

The first and only human histology (the highest form of evidence) showed 6 of 6 teeth treated with LANAP and FRP Nd:YAG had 100% cementum-mediated new attachment with new bone at 3 months post op.  These were the first 6 teeth ever subjected to this protocol and then removed en bloc and sectioned for microscopic evaluation.

Okay Ron Schalter, your turn!

Bob

Hi Bob,

Great encapsulation of the 3 different wavelengths on periodontal treatment.

You are forever the teacher. Your words and explanations are poetic in nature. Concise and precise.

Andrew

Hi Ron,

In the time I used my diode (~9 months) to treat perio the cases that relapsed did so because of 3 factors which added together overcame what the patients body could handle.
1. less than great OH
2. systemic factors (diabetes was significant in 2 relapses)
3. occlusion/ bruxing
I believe like Bob, that the diode tx is really just getting Long JE and will not hold up as well to the insults our patients throw at it , as the new attachment/new bone will.

Here’s a case I just saw recently (this will look familiar DAvid K) about 9 months after FRVP nd:YAG tx.

The frvp nd:yag

69 YOWF Severe crossbite. Bilateral distal extention RPD.
Furcation involvement 10 + mm distal pocket mobility

9 months post Tx – 6mm distal pocket/ no mobility . Appears to be bone fill in furcation and some distal. Pt OH not as good as it should be. Will reevaluate for return nd:YAG Tx at 3 month recall.

Maybe Mark C. can get Bob Barr to post some cases. I just haven’t seen any with bone fill.

Checked the chart -negative to percussion, normal limits hot, slight sensitivity cold that didn’t linger.

OK here we go.

First image is pre op:

10-03 Pre Op x-ray. There is no evidence of much bone on the distal and the apical area looks to be involved.

5-04 (9months) Post Op. Distal area is clearly corticated and very dense. Apical area is much improved. Mesial area did not respond as well. There is a soft tissue defect suggesting granulation tissue was pulled out. Also, occlusion was still hitting hard today and was adjusted on the buccal incline planes and the MESIAL marginal ridge!!

Again, the tooth tests “vital” at 33 on the EPT, and “ache” with FRP Nd:YAG at 4.00 watts 150 usec, 20 Hz in contact with facial enamel for 15 seconds that immediately went away with its removal…..

Bob

Bob,
A little more info- patient at time of FRVP nd:YAG tx had just been placed in a U/CD and L/RPD by prosthodontist. I’m inclined to think it may be torquing by the distal extention RPD (which has a metal base), although I couldn’t seem to get much movement out of it. In your experience does that sound reasonable as opposed to traumatic occlusion from u/CD? I did get bleeding on probing on the distal so we’re going the try to improve OH for the next 3 months, then reevaluate.

Ron,

Yes, that makes more sense.  In my experience PDs can torque teeth unfavorable to regeneration.

Look, for example, at the PDL space on the bicuspid.  The mesial is thicker towards the apex, and the distal is thicker towards the crown.  There is an occlusal trauma hitting the tooth to cause that tooth to fulcrum in that way.

I suspct there is a heavy distal marginal contact.

Similar with the molar.  In my experience, there is a heavy mesial marginal contact on the molar driving the tooth (orthodontically) down into the alveolus, together with a distal marginal ridge trauma on the proximal bicuspid.  See if you can find it.  Look very closely for them.  You may need green articulating wax.

Bob