Lasers Med Sci (2010) 25:345353

DOI 10.1007/s10103-009-0643-x

ORIGINAL ARTICLE

Effects of root planing procedures with hand instrument

or erbium, chromium:yttriumscandiumgalliumgarnet
laser irradiation on the root surfaces: a comparative
scanning electron microscopy study
Sema S. Hakki & Gizem Berk & Niyazi Dundar &
Mehmet Saglam & Nukhet Berk

Received: 6 August 2008 / Accepted: 7 January 2009 / Published online: 14 February 2009
# Springer-Verlag London Limited 2009

Abstract The purpose of this study was to investigate the

efficiency of hand instrumentation and laser irradiation on
calculus removal from the root surfaces, in vitro. Thirty-two
human teeth, extracted for periodontal reasons, were used in
this study. Root surfaces of single-rooted teeth were treated by
different methods including (1) conventional hand instruments; (2) hand instruments and tetracycline-hydrochloride
(Tet-HCl); (3) erbium, chromium:yttriumscandiumgallium
garnet (Er,Cr:YSGG) laser irradiation, setting I (short pulse);
(4) Er,Cr:YSGG laser irradiation, setting II (long pulse). Three
premolar teeth, extracted for orthodontic reasons, served as
control. The morphology of the root surfaces was evaluated by
light and scanning electron microscopy. Energy dispersive
X-ray (EDX) analysis was performed to compare the mineral
content of root surfaces treated with hand instrumentation and
lasing procedures. The results of this study demonstrated that
all treatments were efficient in calculus removal from the root
surfaces. Thermal changes, including melting and carbonization, were not observed in either lasing procedure. The surface
was rougher in the laser groups than in the groups treated with

S. S. Hakki (*) : M. Saglam

Department of Periodontology, Faculty of Dentistry,
Seluk University, Konya 42079, Turkey
e-mail: sshakki@yahoo.com
G. Berk : N. Berk
Dentaform Health Center,
Ankara, Turkey
N. Dundar
Faculty of Dentistry Research Center,
Seluk University,
Konya, Turkey

hand instruments. Moreover, roughness was greater in the

long-pulse laser setting than in the short-pulse setting. While
increased calcium (Ca) and decreased phosphate (P) (weight
concentration percent) were observed in all treatments when
compared with the control, laser procedures resulted in a more
similar mineral content than in the groups treated with hand
instruments. Based on these findings, laser procedures, when
used in appropriate settings, are capable of performing scaling
and root planing in the treatment of periodontitis. It may be
concluded that short pulse laser may be more suitable for the
micro-morphology of the root surface. However, additional in
vitro and clinical studies are necessary to clarify the success of
laser in periodontal therapy.
Keywords Er,Cr:YSGG laser . Root surfaces .
Scanning electron microscopy . Mineral content

Introduction
The major goal of periodontal treatment is to remove bacterial
deposits and calculus and halt disease progression. Hence,
complete removal of organized plaque matrix, calculus and
diseased cementum is vital to success. Scaling and root
planing is an important procedure for the treatment of
periodontal diseases [1]. Several instruments, including
curettes, ultrasonic scalers, and various types of lasers, have
been used for this purpose in periodontology. Satisfactory
results for laser therapies have been shown in the removal of
subgingival calculus and affected cementum in teeth [2].
Some studies demonstrated that appropriate laser applications
increased the efficiency of root debridement and detoxification, whereas some other studies reported that, when laser

DO00643; No of Pages

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applications were compared with hand instrumentation,

deeper craters were observed on the root surfaces [38].
However, the laser-assisted periodontal treatment approach has been extensively investigated; there are some
contradictory results in the periodontology field. In the
1990s the neodymium:yttriumaluminumgarnet (Nd:YAG)
laser was introduced for periodontal treatment, including
removal of subgingival calculus and pocket curettage, but it
was not promising due to profound thermal effects on hard
tissues, including cementum and alveolar bone. Later
researchers reported that Er:YAG laser, which is absorbed by
water and hydroxyapatite, can be used effectively in hard
periodontal tissues. In the late 1990s, erbium, chromium:
yttriumscandiumgalliumgarnet (Er,Cr:YSGG) laser was
introduced as a safe and efficient wavelength to be used on
hard and soft periodontal tissues, supported by several
published studies regarding its beneficial effect in periodontal
treatment. Er,Cr:YSGG laser has the ability to ablate dental
calculus [2]. Ting et al. performed a study to determine the
appropriate power output for Er,Cr:YSGG laser. They
suggested that 1.0 W power output was appropriate to use
for root scaling [9]. Moghare Abed and colleagues used Er.
YAG laser (160 mJ and long pulse mode) for scaling and
root planing. They concluded that lower frequency and long
pulse duration might be more suitable for the micromorphology of root surface [10].
There is great need for us to develop an evidence-based
approach to the use of lasers for the treatment of periodontitis. There are not enough data to suggest that laser
application is superior to the conventional periodontal
treatment. Current knowledge suggests that Er:YAG or Er,
Cr:YSGG lasers for the treatment of chronic periodontitis
may be similar to scaling and root planing regarding
probing depth reduction and subgingival bacterial flora
[1114]. To improve the clinical success of laser-assisted
periodontal treatment, several laser energy settings, pulses/
second (hertz) and pulse duration should be investigated
with respect to efficiency of root debridement. Hence, laser
systems may provide a more comfortable experience for
Fig. 1 Diagram of the in vitro
design of this study

Lasers Med Sci (2010) 25:345353

patients, with less trauma, fewer post-operative complications, and a decreased healing time. To obtain more
efficient, less time-consuming, and less difficult instrumentation, researchers have investigated lasers as alternatives or
adjuncts for scaling and root planing. The purpose of this
study was to investigate the efficiency of hand instrumentation and laser irradiation on calculus removal from the root
surfaces and to compare root surfaces micro-topography and
the mineral content of root surfaces in vitro.

Materials and methods

This study was designed as a comparative in vitro study.
Thirty-two human teeth with calculus on their root surface
and which had been extracted for periodontal reasons were
used in this study. None of the samples had caries, filling,
fracture or endodontic treatment. The samples were kept in
sodium azide solution (0.2%, pH 7.05) until the time of
treatment. The buccal side of the root surface was divided
into two parts with a thin separate burr. A superficial
groove was formed on the buccal side of the root surfaces
of the teeth. The right side of the root surface was prepared
for Er,Cr:YSGG laser (Biolase, Waterlase, USA) and the
left side for hand instrumentation (Hu Friedy, USA) and
chemical (tetracycline; 100 mg/ml) modification. Other
untreated sites were used as their own control (Fig. 1).
The root surfaces of single-rooted teeth were treated by
different methods, including:
(1) hand instruments [Gracey curettes (G), n=8]
(2) hand instruments + tetracycline-hydrochloride Tet-HCI
(100 mg/ml) (G+TetHCl, n=8)
(3) Er,Cr:YSGG laser irradiation, setting I (10 Hz, 1.5 W
(150 mJ), 65% air, 55% water with H mode, 140 s
pulse length) (Laser I, n=8) with 14 mm Z6 tip
(600 m fiberoptic tip, suitable for periodontal use)
(4) Er,Cr:YSGG laser irradiation, setting II (10 Hz, 1.5 W
(150 mJ), 65% air, 55% water with S mode, 400 s

Lasers Med Sci (2010) 25:345353

pulse length) (Laser II, n=8) with 14 mm Z6 tip

(600 m fiberoptic tip, suitable for periodontal use)

347

instrumentation, the surfaces were handled ten times with the

Gracey curettes in the appropriate position, as used in clinics.
Laser scaling and root planing

Hand instrument scaling and root planing

Scaling and root planing were performed by one examiner.
New Gracey curettes ( Hu Friedy 1/2, Chicago, IL, USA) were
used for each group. In the groups treated by hand
Fig. 2 Light microcopy images
of the root surfaces (C control,
G Gracey curette, Tet-HCl
tetracycline-hydrochloride,
Laser I laser irradiation,
setting I, Laser II
laser irradiation, setting II)

An Er,Cr:YSGG dental laser (Biolase) was used in this

study. The lasing procedure was conducted in non-contact
mode, 1.5 mm away from the root surface, with 30
angulations. In the literature, it was reported that the laser

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optical fiber tip was used apicocoronally, with an 2030

inclination angle with respect to the root surface [7, 9, 10,
12]. The procedure was performed with horizontal movements from the apex towards the cemento-enamel junction.
Three premolar teeth extracted for orthodontic reasons
served as control.

Lasers Med Sci (2010) 25:345353

SEM examination

The morphology of the root surfaces was evaluated by light

and scanning electron microscopy.

The images of the SEM examinations (Figs. 3, 4, 5, 6 and 7)

demonstrated that all treatments were efficient in the
removal of calculus from the root surfaces. Thermal
changes, including melting and carbonization, were not
observed in either lasing procedure. The surface in the laser
groups was rougher than that in the groups treated with
hand instruments. Moreover, the roughness was greater in
the long-pulse laser setting (Laser II) than in the short-pulse
setting(Laser I).

Light microscopic evaluation

Results of EDX analysis

Images of the surfaces were taken with a microscope

(Olympus-stereo, SZ40, Japan) at magnifications of 20
and 40. In total, 35 teeth were pictured, and the root
surfaces for each group were evaluated.

The results of the EDX analysis are shown in Figs. 8, 9, 10

and 11.
In our study statistically significant differences were
detected in all treatment groups when they were compared
with the healthy control group (P<0.05). Decreased P and
increased Ca levels (weight concentration percent) were
noted in all groups vs. healthy controls.
The Ca/P ratios of Laser I group was closer to the
control group, which had healthy teeth. The group that
underwent hand instrumentation was almost similar to the
group that was treated with hand instrumentation+HCl, and
the ratios of the hand instrumentation group were higher
than those of the control and laser groups as well.

Root surface evaluation

Evaluation by scanning electron microscopy

The teeth were dried and sputter-coated with gold. The
scanning electron microscopy (SEM) study was conducted
with a JSM-6400 electron microscope (JEOL), equipped
with the NORAN 6 X-ray Microanalysis System and
Semafore Digitizer. SEM pictures were taken at two
magnifications, 50 and 100 for all teeth from the treated
groups and three teeth from the control group.
Analysis by energy dispersive X-ray

Discussion

We used energy dispersive X-ray (EDX) analysis to

compare the mineral content of the root surfaces treated
with hand instrumentation and laser. Calcium (Ca) and
phosphate (P) minerals were determined in the root surface,
and Ca/P ratios were calculated.
SEM and EDX analysis were performed at the Middle
East Technical University, Ankara, Turkey.

Several laser devices have been suggested as alternatives to

conventional hand instruments. It was reported that the Er:
YAG and Er,Cr:YSGG lasers could provide sufficient
removal of subgingival calculus without thermal side
effects at levels similar to those provided by ultrasonic
scaler and hand instruments [1518]. In our study we

Statistical analysis
Difference between the groups with respect to EDX results
were statistically analyzed by KruskalWallis and Mann
Whitney tests. The significance for statistical tests was
predetermined at P<0.05.

Results
Light microscopy examination
Light microscopy images (Fig. 2) showed that all treatment
could remove dental calculus efficiently.

Fig. 3 SEM image of root surfaces of healthy control

Lasers Med Sci (2010) 25:345353

349

Fig. 4 SEM images of the

group treated by hand
instrumentation

planned to compare the efficiency of different treatments of

calculus removal, including hand instruments, hand instruments+Tet-HCl as root surface modifier, and an Er,Cr:
YSGG laser with two different settings.
Fig. 5 SEM images of
group treated by hand
instrumentation+TetHCl

Schwarz et al demonstrated that usage of Er:YAG laser

resulted in a smooth surface, even at higher energy settings
[19]. Although we did not perform roughness analysis to
calculate root roughness values in our study, laser applica-

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Lasers Med Sci (2010) 25:345353

Fig. 6 SEM images at Laser I

setting

tion led to rougher surfaces, morphologically, than did hand

instrumentation. However, surface irregularities and smear
layer were observed in the hand instrumentation group.
Surface irregularities and smear layer may be disadvantaFig. 7 SEM images at Laser II
setting

geous in providing a good root structure to form periodontal attachment.

Folwaczny et al. demonstrated that the surface roughness
does not depend on the radiation energy and the angulation of

Lasers Med Sci (2010) 25:345353

351

Fig. 8 Results of EDX analysis of the root surfaces after different treatments

the working tip [20]. In our study it was observed that there
was a difference between laser groups regarding roughness
of the root surfaces. It may be speculated that the reason for
this different roughness could be related to pulse duration.
Ting et al. compared different power outputs (0.5 W, 1 W,
1.5 W and 2 W) of Er,Cr:YSGG laser by examining the

morphological alterations of root surfaces and the efficiency

of calculus removal. They reported that a 1 W power output
was appropriate for root scaling and that a 2 W power output
was much more efficient in calculus removal but resulted in
significant morphologic alteration to the root surface. Their
study suggested that Er,Cr:YSGG laser had acceptable

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Lasers Med Sci (2010) 25:345353

Fig. 11 Ca/P ratios of the different groups

Fig. 9 P mineral values after the different treatments. For P mineral

values, P<0.05: control > Laser I> G, G+TetHCl, Laser II

efficiency for root scaling without morphologic alterations

and to remove calculus [9]. In our study we used 1.5 W
power and a different pulse setup. While efficient calculus
removal was observed, rougher surfaces with low depth were
observed in the laser groups. The Laser I setting seemed to
be more appropriate for the removal of calculus and with
respect to root surface alterations.
Kimura et al. evaluated the morphological (SEM),
atomic (EDX analysis) and temperature changes in canine
mandibular bone in vitro following irradiation with Er,Cr:
YSGG laser at a power setting of 5 W and 8 Hz pulse
repetition of 10 s or 30 s durations with concomitant air/
water surface spray. The maximum temperature increase of
12.6 C was achieved only during 30 s exposure. EDX
analysis showed no change in the calcium/phosphate ratio,
and the SEM examination revealed cleanly cut bone with
no evidence of charring or melting [21]. In our study
statistically significant differences were detected in all
treatment groups when compared with the healthy control
group. Decreased P and increased Ca levels were noted in

Fig. 10 Ca mineral values after the different treatment. For Ca

mineral values, P<0.05; control < G, G+Tet-HCl, Laser I, Laser II

all groups vs healthy controls. Moreover, increased Ca/P

ratio was observed in all groups. The Ca/P ratios of the
Laser I group was closer to that of the control group, which
had healthy teeth. The groups that had undergone treatment
by hand instrumentations were almost similar, and the
ratios of these groups were higher than those of the control
and laser groups as well. In previous studies inductively
coupled plasma atomic emission spectrometry (ICP-AES)
was used to determine the levels of the mineral content.
However, ICP-AES has some advantages regarding sensitivity, and multiple elements can be measured [22]. Analysis by
EDX was an appropriate method, due to our study design, to
detect the minerals which are important for root structure and
to provide a proper surface for the repair of the periodontal
attachment.
Several clinical studies have reported that non-surgical
periodontal therapy using Er;Cr:YSGG laser + scaling root
planing (SRP), SRP alone, or laser alone, led to significant
improvements in clinical parameters, including gingival
index, probing depth and clinical attachment level. The
combined treatment using laser as an adjunct to SRP
seemed to be advantageous when compared to SRP alone,
due to more efficient attachment level restoration. In our
study design we did not study a combined group, i.e., Er,
Cr:YSGG+ hand instrumentation. However, based on the
findings in this study, laser procedures alone, when used in
appropriate settings, are capable of scaling and root planing
in the treatment of periodontitis. It may be concluded that
short-pulse laser (Laser I) may be more suitable for the
micro-morphology of the root surface. However, additional
in vitro and clinical studies are necessary to clarify the
potential application of lasers in periodontal therapy.
Further studies are required if we are to understand the
various effects of Er, Cr:YSGG laser irradiation on
biological tissues for its safe and effective application
during periodontal therapy. Randomized controlled clinical
trials and more basic studies have to be encouraged and
performed so that the status of Er,Cr:YSGG laser treatment
as an adjunct or alternative to conventional mechanical
periodontal therapy can be confirmed.

Lasers Med Sci (2010) 25:345353

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