13721c03.

PGS 7/2/04 12:22 PM Page 177

Photomedicine and Laser Surgery

Volume 22, Number 3, 2004
© Mary Ann Liebert, Inc.
Pp. 177–183

Removal of Epithelium in Periodontal Pockets following

Diode (980 nm) Laser Application in the Animal Model:
An in Vitro Study

GEORGE E. ROMANOS, D.M.D., D.D.S., Ph.D., MARCO HENZE, D.M.D.,

SARAH BANIHASHEMI, D.M.D., HAMID R. PARSANEJAD, D.M.D.,
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JÜRGE WINCKLER, M.D., Ph.D., and GEORGE-HUBERTUS NENTWIG, D.M.D., Ph.D.

ABSTRACT

Objective: The purpose of this study was to examine the removal of the epithelium in the periodontal pocket
using a diode (980 nm) laser in comparison with the conventional techniques in an animal experimental
model. Background Data: The goal of periodontal therapy is to reduce the bacterial deposits in the pockets
and to enhance the clinical attachment. Different surgical techniques have been used in the past, which con-
trol the epithelial migration and promote the connective tissue formation. Materials and Methods: The buccal
pockets of the posterior teeth in 10 freshly sacrificed adult pigs were scaled by three different examiners (with
different levels of experience in periodontal surgery) using conventional curettes. The lingual pockets were
treated using a diode (980 nm) laser. The laser was used in a continuous wave (c.w.) mode with two different
power settings (2 and 4 Watts) with a 300-µm-thick glass fiber. The instrumentation period revealed 15 sec in
all of the sites. Soft tissue biopsies of the instrumented sites were removed and examined histologically. Re-
sults: In all of the lased sections, no epithelial remnants were found. The laser with a low power was able to re-
move the thin pocket epithelium in the same way regardless of the level of surgical experience of the examiner.
A high-power setting presented significant damage to the underlying connective tissues. The sites, which were
instrumented with the conventional curettes, demonstrated significant epithelial remnants in all of the tissues
regardless of the level of periodontal surgical experience. Conclusion: The histological findings presented in
this study showed that instrumentation of the soft periodontal tissues with a diode laser (980 nm) leads to a
complete epithelial removal in comparison to conventional treatment methods with hand instruments (inde-
pendent of the clinician’s experience).

INTRODUCTION lowing healing, a new formation of a long junctional epithe-

lium. This is a “reparation” of the periodontal sulcus, where a

T HE GOAL OF PERIODONTAL THERAPY is to eliminate bacteria

in the pockets, to remove the hard and soft tissue deposits,
to remove the granulation tissue and pocket epithelium in the
periodontal lesions, to make root planing, and later, to enhance
the attachment gain. Various instruments are used on the root
surface for the reduction of bacteria, and removal of soft and
hard tissue deposits as well as granulation tissue. Moreover,
there is a biological reaction to any mechanical intervention
that results in partial removal of the pocket epithelium and, fol-
reduction of the probing pocket depth and a relative gain of
clinical attachment may be observed. Regenerative surgical
procedures have been established, which enhance connective
tissue regeneration, followed by new bone formation as the
treated lesion has higher stability, when connective tissue at-
taches to the root surfaces and periodontal apparatus can be
firmly established. Using the guided tissue regeneration (GTR)
technique, special barriers (resorbable and non-resorbable)
may be used in order to control epithelial migration. The

Department of Oral Surgery and Implantology, Dental School (Carolinum), Frankfurt, Germany.

177
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178 Romanos et al.

epithelium covers the wounds relatively fast and restricts new
connective tissue formation, which is of great significance in
the periodontal wound to establish effective regeneration. The
concept of the GTR technique is broadly accepted by clinicians
and scientists from the biological point of view; however, sur-
gical complications, high costs, specialized dental training, im-
plantation of additional materials, and occasional poor clinical
outcomes are associated with this surgical approach.1
For these reasons, there is significant interest and focus on
other regenerative techniques in the periodontium using
enamel matrix proteins (Emdogain®),2 local drug delivery sys-
tems,3 bone grafting materials,4 and polypeptide growth fac-
tors.5 The main goal of these techniques is to regenerate
damaged periodontal tissues.
Lasers have been used in the last decades in periodontology
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Nd:YAG laser use. Another laser wavelength (980 nm) may
also be used in the soft tissue surgery without complications
presenting additional benefits for patients and clinicians.23
This laser wavelength may also be used in the periimplant tis-
sues without damage to the implant surfaces.24,25
The aim of this study was to examine the use of a diode
(980 nm) laser for the removal of epithelium (subgingival
curettage) in comparison to conventional methods in an animal
experimental model.
MATERIALS AND METHODS
Ten lower jaws of freshly sacrificed, periodontally diseased
adult pigs with all periodontal soft tissues intact were used in

to reduce periodontopathogenic bacteria,6,7 remove pocket ep-

this study. All the pigs had periodontal inflammation and
ithelium, and retard epithelial migration into the pocket. If the
pocket formation caused by bacterial accumulation. The buc-
wavelength is appropriate, it is possible to remove the hard
cal pockets of the posterior teeth (P2-P4, M1-M3) were
deposits (i.e., calculus) and to make a root planing.8 In the
treated (scaled) by three different examiners using conven-
past, it was believed, erroneously, that lasers alone should be
tional curettes (control group; Fig. 1). The lingual pockets
applied in periodontology, without the adjunctive and comple-
were treated (subgingival curettage) using a diode (980 nm)
mentary use of mechanical instrumentation. The application
laser (Biolitec, Jena, Germany; test group; Fig. 2). Two teeth
of laser systems has received criticism when used only in as-
were treated from each examiner in each jaw (total numer:
sociation with conventional instruments, although there are
20 teeth for each examiner). All teeth treated by the three ex-
benefits to this approach. A significant reduction of periodon-
aminers had a similar anatomy in the crown and the surround-
topathogenic bacteria has been demonstrated, regardless of
ing periodontal tissues. The laser was used in a continuous
laser wavelength.9–14
wave (c.w.) mode with two different power settings (2 and
Many laser systems have demonstrated the ability to signifi-
4 Watts) with a 300-µm-thick glass fiber (power density:
cantly reduce (though not eliminate) bacterial species, leading
1.96–3.93  105 W/cm2). All of the test and control sites were
to possible reduction of the probing pocket depth but not a
treated for a period of 15 sec for each site. This period has
pocket elimination. Furthermore, it has been shown in different
been selected as a sufficient treatment period according to our
in vitro and in vivo studies.15 that calculus can be removed
clinical experience. No instrumentation with curettes has been
using the Er:YAG laser and special handpiece tips.
performed in the test group. The three examiners who scaled
A comparison of curette use alone (scaling) with Nd:YAG
the teeth had three different levels of surgical experience in
laser application alone (subgingival curettage) in periodontal
the field of periodontal surgery, as follows:
pockets, followed by immediate histological examination
(biopsies taken) after the procedure, showed removal of the Level 1: A postgraduate student in the field of oral surgery
epithelium in the lased group biopsies without inducing (S.B.)
damage to the underlying connective tissue when using the Level 2: A specialist in the field of oral surgery (H.P.)
laser at relatively low-power settings. The pocket epithelium Level 3: A dentist specializing in the field of oral surgery
was shown not to be completely removed after the use of and periodontology (G.R.)
hand instruments.16 Additional benefits are seen when re-
moving the pocket epithelium, leading to retardation of
epithelial migration, which enhances connective tissue at-
tachment. A specific treatment protocol has been developed
following mucoperiosteal flap elevation involving elimina-
tion of the granulation tissue and finally removal of the ep-
ithelium of the flap once every 10 days with the CO2 laser
for the first 4–6 weeks of healing. This surgical procedure
demonstrated histologically a higher connective tissue at-
tachment and new cementum formation, without epithelial
migration in the lased pockets when compared with the con-
trol group, where only hand instruments were used to re-
move the inflamed tissues.17–21
Furthermore, diode lasers (810 nm) have been used in the
treatment of periodontal disease as well as periimplant therapy
because of the characteristic antibacterial effects 7,14,22 without
inducing dramatic changes in the underlying tissues (connec- FIG. 1. Instrumentation in the control group for periodontal
tive tissue, pulp, and bone), as discussed previously following pockets.
13721c03.PGS 7/2/04 12:22 PM Page 179
Removal of Epithelium in Periodontal Pockets
FIG. 2. Laser application in the periodontal pocket using a
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glass fiber and 980-nm laser wavelength.
Immediately following surgery, full-thickness soft tissue
biopsies of the buccal and lingual sites, excluding the sur-
rounding papillae, were removed with a scalpel, fixed in 4%
formalin solution, and, following sectioning, stained with
hematoxylin-eosin and examined histologically by the same
independent examiner (M.H.; Fig. 3). The magnification used
for evaluation was 6.3, 10, and 25 under a conventional
light microscope.
RESULTS
Test group
In all of the examined sections, no epithelial remnants in the
lased areas were found. The laser with a low-power setting
(2 Watts) was able to remove the thin pocket epithelium in the
FIG. 3. Schematic drawing of the experimental design.
179
same way in all of the tissues scaled by all three examiners re-
gardless of the level of surgical experience (Fig. 4).
Using a higher power setting (4 Watts), significant damage
to the underlying connective tissues was seen, with coagula-
tion similar to necrosis caused by increased thermal tissue
damage induced by the laser (Fig. 5).
Control group
Regardless of the level of periodontal surgical experience
of the surgeon who scaled the tissue, epithelial remnants were
found in the areas of pocket epithelium presenting a linear ep-
ithelium opposite of the tooth surface. The epithelium thick-
ness decreased in the tissues of the level 3 examiner as well
as the level 1 examiner, when compared to the control, non-
treated tissues. The collagen fibers and the extracellular ma-
trix showed normal distribution without any tissue damage
(Fig. 6).
DISCUSSION
The histological findings presented in this in vitro study
using the pig model showed that instrumentation of the soft
periodontal tissues (no flap surgery) with a diode laser
(980 nm) leads to a complete epithelial removal in compari-
son to conventional treatment methods with hand instruments
in the pocket. Independent of the level of surgical experience
in periodontal treatment, each dentist treating the lesion was
able to remove efficiently the epithelium using the diode
laser. It is of clinical significance that the laser had character-
istically easy handling in comparison to soft tissue curettage
using conventional methods. The power setting used in the
laser unit must be relatively low in order to eliminate the risk
of collateral damage to the healthy underlying tissues. The
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A B

FIG. 4. Histological demonstration of the periodontal pocket

immediately after the application of a diode (980 nm) laser
(test group) and 2 Watts power setting (c.w.). The epithelium
has been completely removed. No significant damage on the
underlying tissues has been observed. (A) Examiner level 1.
(B) Examiner level 2. (C) Examiner level 3. Original magnifi-
C cation, 6.3.
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A B

FIG. 5. Histological demonstration of the periodontal pocket immediately after the application of a diode (980 nm) laser (test
group) and 4 Watts power setting (c.w.). The epithelium has been completely removed. A significant coagulation with thermal
damage on the underlying tissues similar to necrosis and on the top of the marginal gingival has been observed. (A) Examiner
level 2. (B) Examiner level 3. Original magnification, 6.3.

additional antibacterial effects of the diode laser7 have a sig-
nificant benefit in order to regenerate the destroyed periodon-
tal tissues.
One of the most important goals of the periodontal surgery
is to eliminate or to remove the epithelium of the pocket
using special surgical techniques, which allow a better con-
nective tissue formation. Enamel matrix proteins,26 bone
grafting materials,27 and membranes1 have been clinically
used with different success rates as presented in different pa-
pers. From the biological point of view, the periodontal barri-
ers of the epithelium are able to enhance the connective tissue
attachment.
In the periodontal wound, special macromolecules of the fi-
brin clot may initiate these mechanisms for further periodon-
tal regeneration.28 Growth factors and cytokines present in the
fibrin clot signal the start of the wound repair process. Instru-
mentation of the root surface as well as the removal of the in-
flamed connective tissue and pocket epithelium, using differ-
ent surgical techniques it is possible which allows a matura-
tion of the healthy tissue matrix and contraction or soft tissue
scarring.
In conclusion, epithelial removal using the diode (980nm)
laser (with the additional instrumentation of the root surface
using conventional techniques) may be of significant clinical
importance. The laser allows for adequate coagulation,29
which does not damage the surrounding healthy tissues and
may stimulate new bone formation if applied in the correct
way. This has been observed in a number of previous
studies.30,31 Further animal and clinical studies are required
before this treatment is introduced into daily practice. Spe-
cialized training in laser surgery will be of great importance,
as well, in order to give the clinician the knowledge required
for appropriate clinical use and help to eliminate possible
complications.
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A B

FIG. 6. Histological demonstration of the periodontal pocket

immediately after the application of a curette (control group)
shows epithelial remnants in the pocket. The epithelium thick-
ness was significantly decreased, but no complete removal has
been observed, regardless of the clinical experience. (A) Ex-
aminer level 1. (B) Examiner level 2. (C) Examiner level 3.
C Original magnification, 6.3.
13721c03.PGS 7/2/04 12:22 PM Page 183
Removal of Epithelium in Periodontal Pockets
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Address reprint requests to:
G.E. Romanos, D.D.S., Ph.D.
Dental School (Carolinum)
Department of Oral Surgery and Implantology
Theodor Stern Kai 7
D-60590 Frankfurt, Germany
E-mail: Dr.G.E.Romanos@t-online.de
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