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Laser Treatment for Improvement of Oral Health in Elderly

Laser Treatment for Improvement of Oral Health in
Elderly
Meri Shapurik1 and Fimka Tozija2,
1PHI “Prodent – Idadia” – Skopje, Macedonia, 2Institute of Public health of R. Macedonia
sapurik_meri@yahoo.com, ftozija@t-home.mk
Abstract. The negative impact of poor oral health on the quality of life in the
elderly is an important public health problem, which must be addressed by the
policy makers. This paper addresses a cross-sectional study which analyzed the
condition in oral health in patients aged 60 years and older, in the Republic of
Macedonia. The clinical protocol was conducted in 100 subjects who completed
the questionnaire. We used the clinical protocol to evaluate the actual condition
in oral health through a dentist clinical examination. The clinical examination
of our subjects showed findings of dental plaque, dental calculus and
periodontal pockets. Dental plaque seen only by sound on the marginal gingiva
was found in 45% of subjects; dental calculus of the upper molars was present
in 51% of subjects, and more than half of the subjects had dental calculus on
the lower incisors located supra and/or sublingually (56%). The results
obtained in our research provide important basic data on various aspects of oral
health of people aged 60 years and older. To improve dental and periodontal
status among elderly, the using a laser in a dental treatment would be of a great
benefit. Plaque and calculus removal, coagulation, faster tissue ablation and
healing, no or minimal pain, no or few sutures, instant sterilization, little tissue
shrinkage and depigmentation are main factors favoring laser application in
periodontics. Our findings have indicated a very low level of oral health
behavior of this population in R. Macedonia leading to a very poor oral health.
Laser dentistry can be a precise and effective way to perform many dental
procedures. Some dental laser technology has been developed that can be used
to generate both hard and soft tissue laser energy, depending upon the patient’s
needs.
Keywords: Oral health ⸱ Elderly ⸱ Prevention ⸱ Dental and periodontal status ⸱
Laser dentistry.
1 Introduction
Negative influence of the poor dental oral health on quality of life in the elderly is an
important public health problem, which has to be addressed and resolved by the
health policy creators. Many tools and instruments are available for enhancing the
implementation and conveying the program of dental health care, and hence it is a
huge challenge to apply the knowledge in action programs for oral health in the
elderly. Recommendations of the World Health Organization are that a large number
of countries have to accept strategies for improvement of oral health in the elderly.
National health authorities should develop policies and measurable goals for oral
health. National public health programs should be included in the promotion of oral
health and prevention of diseases that share common risk factors [1].
1.1 Dental and periodontal state in population older than 60 years
A well preserved gum/teeth is a precondition for good quality of life. In spite of the
improvements made in preventive dentistry, edentulousness is still a huge health
problem worldwide. For example, in the USA, the number of edentulous people older
than 60 years is 9,000.000 or 25% of the total population. According to some studies,
teeth loss may influence the general health condition in a few ways:
Smaller consumption/intake of fruit and vegetables, fibers and carotene, due
to mastication problems results in increased cholesterol and triglyceride
levels, which increases the risk of cardiovascular diseases and
gastrointestinal disorders (onset of peptic or duodenal ulcer);
Increased risk of type 2 diabetes;
Increased risk of electrocardiographic abnormalities, hypertension, heart
failure, ischemic heart disease, coronary heart disease;
Increased risk of chronic kidney diseases;
There is association between toothlessness and sleep and breathing
impairment, including obstructive sleep apnea.
Toothloss has a negative effect not only on the oral function, but on the social life
and everyday activities of the individual, as well. Affected oral function is also
associated with reduced self-confidence and reduced psychosocial well-being [2].
The state of the periodontium is of substantial importance for the oral health of every
human being. The most common and most serious disease in the field of dentistry
nowadays is periodontal disease. It is a progressive and degenerative disease of the
supportive apparatus of the teeth, including the gums, jaw bone and periodontal fibers
that are a link/connection between the teeth and jaw bones. It usually starts without
pains and insidiously, but it is a long-term disease and appears mainly after the age of
35 years. Pain is felt if secondary gum infection develops.
The main cause for onset of periodontal disease is the appearance of dental
plaque, which is formed due to consumption of squashy and soft food, which along
with the poor and inadequate hygiene of the mouth and teeth result in formation of
sticky, colorless film of bacteria and microorganisms. With mineralization, or
precipitation of saliva minerals, dental plaque is transformed into dental calculi and
dental concrements, which can be removed only with ultrasound or hand-held
instruments for removal of dental calculi in a dental office. Therefore, regular dental
controls, at least twice a year, are very important in order to recognize this disease in
its initial phase by a dental practitioner and to prevent development of eventual
periodontal disease.
General factors that diminish the immunity/resistance of the organism and
periodontium thus alleviating and hastening the action of the dental plaque are: some
blood dyscrasia (leukosis, agranulocytosis, hemorrhagic syndrome), endocrine
disorders (diabetes), presence of toxic materials (lead, bismuth, mercury, arsenic),
inherited predisposition (periodontal disease is not an inherited disease, but the
anomalies regarding the position and shape of the teeth are inherited) and the older
age.
During aging atherosclerotic changes in the blood vessels appear. All tissues are
affected by atrophy. Similar changes happen in the periodontium. In the elderly
population the ability for regeneration and reparation of periodontal tissue is reduced,
and hence the effect of all harmful agents is stronger, including those from the dental
plaque. The appearance of periodontal disease in adults and older persons is the most
common form of parodontopathy [3].
The research in the area of dental public health among elderly in the Republic of
Macedonia has been addressed in several papers. Some of them assessed the oral
health and the impact it has on the quality of life in the elderly [4], as well as the
knowledge and attitudes to preserve oral health among older people aged 60+ [5].
Others refer to the oral health strategy for elderly over 65 years, which is recognized
as one of the public health priorities in the Republic of Macedonia [6]. The
association between the level of education and the oral health status among elderly
over the age of 60 is addressed in [7].
1.2 Lasers as tools in oral health
Dentistry increasingly uses new technologies including material science, engineering
and Information and Communication Technology (ICT). This affects the dental
practice, education of people that work in the field of dentistry and oral health, the
research in oral health and dental care in general.
Addressing the problem in focus, recent research has indicated that application of
lasers in dentistry is of great help in treatment of periodontal diseases.
Lasers have made their way in dental treatment since 1994. The term “LASER”
stands for “Light Amplification by Stimulating Emission of Radiation”. Modern
techniques using lasers can control the spread of harmful bacteria and limit tooth loss
compared to standard periodontal treatment options. Some benefits of laser treatment
for gum disease include: elimination of cutting and bleeding, soreness and discomfort
of the gums, isolation of deep periodontal pockets, reduction in tooth loss, and
regeneration of bone and ligament tissues.
Optical properties of a tissue decide the interactions with lasers. When radiant
energy is absorbed by tissue, four basic types of interactions occur:
1. Photochemical interaction
2. Photothermal interaction
3. Photomechanical interaction
4. Photoelectrical interaction
Photochemical interaction includes bio-stimulation, which describes the stimulatory
effects of laser light on biochemical and molecular processes that normally occur in
tissues such as healing and repair.
Photothermal interactions include photoablation, or the removal of tissue by
vaporization and superheating of tissue fluids, coagulation and hemostasis.
Photomechanical interaction includes photo-disruption or photo-disassociation,
which is the breaking apart of structures by laser light.
Photoelectrical interactions include photoplasmolysis, which describes how tissue is
removed through the formation of electrically charged ions and particles that exist in
a semi-gasseous high energy state [8].
2 Methodology of the research
This is a transversal, cross-sectional study, which presents the clinical aspects of oral
health in subjects older than 60 years. The clinical protocol was conducted in 100
surveyed patients, who were treated at the University Clinical Dental Center in
Skopje, Clinic of Mouth and Periodontal Diseases, and in the Health Center – Skopje.
This research was conveyed during 2015. The clinical examination was made in order
to assess the current condition of oral health by a dental practitioner. The examination
referred to assessment of dental and periodontal condition in the mouth.
Clinical protocol for objective assessment of the condition of the teeth and
periodontium was used in this study. The protocol helped us to assess the current state
of the oral health with clinical examination done by a dental practitioner, which
comprised dental and periodontal condition in the mouth (according to the protocol
annex 2). The clinical protocol consisted of two segments: the first one was based on
the standard questionnaire created by WHO (1997); the second segment included
findings of clinical examinations of almost half of the subjects that filled in the
questionnaire, based on the modified version of Silness-Löe index.
The clinical examination was done by using standard light, mirror and dental and
periodontal probe in line with the WHO recommendations. Prior to the clinical
examination, no previous cleaning of the teeth is necessary/required.
The measurement of the state of oral hygiene, according to Silness-Löe plaque
index, is based on recording soft debris and mineralized deposits on targeted teeth.
The plaque index system shows moderate accumulation of soft deposit on the teeth
and gingival margin or within gingival pockets that can be seen with naked eye. Each
of the four surfaces of the teeth (buccal, lingual, mesial and distal) is given a score
from 0-3. The results of the four surfaces of the tooth are added and divided by four in
order to give the plaque index for one tooth. The indices for the following six teeth
may be grouped to designate the index for the adequate group of teeth: 16, 12, 24, 36,
32, 44. The index for the patient is obtained by summing the indices for all six teeth
and dividing by six.
In addition, a patient questionnaire was developed, which contained questions
about the oral health behavior in the elderly, as well as the sources of information
concerning the individual oral health care and treatment. This questionnaire was used
to obtain corelations between oral health behavior and results from clinical
examinations.
3 Results
Based on the analyses obtained upon the clinical examination of the teeth and
parodontium, results are obtained by which the situation of the oral health in persons
aged above 60 in the Republic of Macedonia can be seen.
Of the subjects, 59.1% were females, and 40.9% were males. Regarding age,
subjects aged 60-69 years of age were predominant (54.9%), and the rest (45.1%)
were subjects older than 70. In terms of educational status, the majority of subjects
had completed secondary education (46.6%), followed by subjects with high
education (24%) and primary education (22.3%). Of the entire cohort, most of the
subjects had between 1 and 15 teeth (49%), whereas 13% of the subjects had between
16 and 20, as well as more than 21 teeth, respectively. The percentage of female
subjects who had more than 21 teeth (16.7%) was almost twice higher in comparison
with the male subjects (7.6%). There was a statistically significant difference in the
number of teeth according to age 2=15.357, df=3, p=0.002); the larger percentage
were subjects with 1-15 teeth in the age group of 60-69 years, in comparison to 43.7%
of the elderly who had 1-5 teeth. In the following subsections some of the important
findings of this study will be addressed.
3.1 Dental plaque – upper molars
More than half the subjects (68%) had a clean finding for a dental plaque of the upper
molars; 29% had plaque when checked only using a probe on a marginal gingiva, and
only 3% had a dental plaque which was visible on the marginal gingiva (Fig. 1).
Fig. 1. Number and percentage of subjects with clinical findings for dental plaque (n=100).
Table 1 shows the correlation between the clinical finding for the dental plaque of the
upper molars and the results generated from the answers obtained from the
questionnaire, which concern subject oral health and behavior.
Table 1. Correlation of the clinical finding for dental plaque of the upper molars and the
subject oral health and behavior.
Toothbrushing
frequency
Fluoride
toothpaste use
Toothbrushing in
the morning
Toothbrushing in
the evening
Interdental areas
cleansing
Spearman -,052) -,075) -,053) -,215) -,023)
P ,601 ,651 ,456 ,312 ,534
N 100 100 100 100 100
0% 50% 100%
clean
only with a probe on a
marginal gingiva
visible on a marginal gingiva
3.2 Dental plaque of lower molars
45% of the subjects had dental plaque on their lower molars, upon clinical
examination visible with a probe on the marginal gingiva, 20% had dental plaque
which is visible on the marginal gingiva, and in somewhat more than a third (35%)
the finding was a pure surface (Fig. 2).
Fig. 2. Percentage of subjects with a dental plaque on the lower molars upon clinical
examination.
Table 2 shows the correlation between the clinical finding for the dental plaque of the
lower molars and the results generated from the answers obtained from the
questionnaire, which concern subject oral health and behavior.
Table 2. Correlation of the clinical finding for dental plaque of the lower molars and the
subject oral health and behavior.
Toothbrushing
frequency
Fluoride
toothpaste use
Toothbrushing in
the morning
Toothbrushing in
the evening
Interdental areas
cleansing
Spearman -,071) -,055) -,053) -,145) -,041)
P ,821 ,275 ,456 ,125 ,254
N 100 100 100 100 100
0% 20% 40% 60%
clean
only with a probe on a
marginal gingiva
visible on a marginal gingiva
3.3 Dental calculus – lower incisives
More than half of the subjects in the research had calculus on their lower incisives
which is found supra and subgingival (56%). In 40% of the subjects, calculus was
detected supragingivally, and in only 4% no calculus was detected on lower incisives
(Fig. 3).
Fig. 3. Percent of subjects with clinical findings for dental calculus on lower incisives.
Table 3 shows the correlation between the clinical finding for the dental calculus of
the lower incisives and the results generated from the answers obtained from the
questionnaire, which concern subject oral health and behavior.
Table 3. Correlation of the clinical finding for dental calculus of the lower incisives and the
subject oral health and behavior.
Toothbrushing
frequency
Fluoride
toothpaste use
Toothbrushing in
the morning
Toothbrushing in
the evening
Interdental areas
cleansing
Spearman -,358) ,245 ,134 -,044) -,682)
P ,089 ,655 ,121 ,147 ,492
N 100 100 100 100 100
3.4 Periodontal pockets on the upper molars
Periodontal pockets on the upper molars was not present in only 19% of the subjects.
In subject that had periodontal pockets upon the clinical check, mostly they were
found supragingival (46%), and somewhat less supra and subgingival (35%) (Fig. 4).
Fig. 4. Distribution of the findings for existence of periodontal pockets in upper molars upon
clinical examination.
0% 20% 40% 60%
supragingival
supra and subgingival
none
0% 20% 40% 60%
supragingival
supra and subgingival
none
Table 4 shows the correlation between the clinical finding for the periodontal pockets
of the upper molars and the results generated from the answers obtained from the
questionnaire, which concern subject oral health and behavior.
Table 4. Correlation of the clinical finding for periodontal pockets of the upper molars and the
subject oral health and behavior.
Toothbrushing
equency
Fluoride
toothpaste use
Toothbrushing in
the morning
Toothbrushing in
the evening
Interdental areas
cleansing
Spearman -,134 -,011 -,111 -,014 -,006
P ,176 ,911 ,263 ,889 ,955
N 100 100 100 100 100
3.5 Periodontal pockets – lower molars
Periodontal pockets on the lower molars were present in 69% of the subjects upon
clinical examination, in 40% the pockets were located supragingivally, and in 29%
supra and subgingival (Fig. 5).
Fig. 5. Distribution of the findings for existence of periodontal pockets on the lower molars
upon clinical examination.
Table 5 shows the correlation between the clinical finding for the periodontal pockets
of the lower molars and the results generated from the answers obtained from the
questionnaire, which concern subject oral health and behavior.
Table 5. Correlation of the clinical finding for periodontal pockets of the lower molars and the
subject oral health and behavior.
Toothbrushing
frequency
Fluoride
toothpaste use
Toothbrushing in
the morning
Toothbrushing in
the evening
Interdental areas
cleansing
Spearman -,277** -,023) ,013 -,213* -,169)
P ,005 ,818 ,901 ,031 ,089
N 100 100 100 100 100
0% 20% 40%
supragingival
supra and subgingival
none
4 Discussion: motive for introduction of lasers in dental
practice
Assessment of oral health in the elderly population, people older than 60 years, has
shown that demographic characteristics of the subjects contribute to differences in the
oral-health state determined during the clinical examination of our patients.
Although dental plaque is a primary etiological agent responsible for the
development of periodontal diseases, there is a significant difference in the grade and
severity of tissue damage among individuals, teeth and their location. The clinical
finding for presence of periodontal pockets in the upper molars showed that only 17%
of patients had no periodontal pockets, indicating the existence of periodontal disease
in the larger number of our patients. Introduction of lasers in dentistry would
significantly improve the treatment of teeth and soft tissues.
The results differ from those obtained from the clinical examination in the study in
Lithuania [9], where only 1% of the subjects did not have periodontal pockets, while
60% of the subjects had periodontal pockets with depths of 4-5 mm, and in 70% of
the examinees the depth of the pockets was 6 mm and more. In the Lithuanian study,
dental plaque, calculus and periodontal pockets were present in all clinically
examined subjects, and in 70% of them periodontal pockets were recorded, with a
depth of 6 mm and more.
The results of the research in Lithuania show that only 13% of the subjects did not
detect the presence of dental plaque, 35% were present in the marginal gingiva, and
52% was visible only with a probe of the marginal gingiva.18 Compared with the
results of our research leads us to conclude that the condition of periodontal and teeth
in elderly patients is at a very low level both in Lithuania and in the Republic of
Macedonia.
A survey done in the UK for the presence of dental plaque at different ages of the
examined groups [10] suggests that the prevalence of dental plaque and periodontal
disease was 33% in adult patients over 60 years of age who had natural teeth in the
mouth, while in 54% of adults the periodontal pockets were deeper than 3.5 mm.
Although a severe form of periodontal disease was relatively rare in the findings, 31%
of people aged 65 years and more noted the existence of deep periodontal pockets,
with a depth of 6 mm or more. It has been found that if more teeth are preserved in
old age, there is a possibility of improving oral hygiene among a large number of
older people in the United Kingdom.
The results in our study also differ from the results of a recent cross-section study
in Denmark [11], which was conducted on a random sample of 1,115 adult
respondents grouped in age groups 35-44 and 65-74 years old. A large percentage of
older respondents found a serious disorder of the periodontal condition, i.e., more
than 82% had pockets with depths of 4-5 mm or deeper, while in the younger group,
this percentage was twice lower (42%). In both age groups, the average number of
teeth that had periodontal pockets deeper than 4-5 mm was higher for people with low
levels of education. Analyzes of the results of the clinical trial showed that
respondents with low or middle level education had significantly more teeth with
shallow and deep periodontal pockets than those with higher education.
Laser dentistry can be a precise and effective way to perform many dental
procedures. As the applications for dental lasers expand, greater number of dentists
will use the technology to provide patients with precision treatment that may
minimize pain and recovery time.
4.1 Benefits
Procedures performed using soft tissue dental lasers may not require sutures
(stitches).
Certain procedures do not require anesthesia.
Minimizes bleeding because the high-energy light beam aids in the clotting
(coagulation) of exposed blood vessels, thus inhibiting blood loss.
Bacterial infections are minimized because the high-energy beam sterilizes
the area being worked on.
Damage to surrounding tissue is minimized.
Wounds heal faster and tissues can be regenerated [12].
4.2 Types of Dental Lasers
The Food and Drug Administration (FDA) has approved of a variety of hard and soft
tissue lasers for use in the dental treatment of adults and children. Because dental
lasers boast unique absorption characteristics, they are used to perform specific dental
procedures.
Hard Tissue Lasers: Hard tissue lasers have a wavelength that is highly
absorbable by hydroxyapatite (calcium phosphate salt found in bone and teeth) and
water, making them more effective for cutting through tooth structure. Hard tissue
lasers include the Erbium YAG and the Erbium chromium YSGG. The primary use of
hard tissue lasers is to cut into bone and teeth with extreme precision. Hard tissue
lasers are often used in the “prepping” or “shaping” of teeth for composite bonding,
the removal of small amounts of tooth structure and the repair of certain worn down
dental fillings.
Soft Tissue Lasers: Soft tissue lasers boast a wavelength that is highly absorbable
by water and hemoglobin (oxygenating protein in red blood cells), making them more
effective for soft tissue management. Commonly used soft tissue lasers include
Neodymium YAG (Nd:YAG) and diode lasers, which may be used as a component of
periodontal treatment and have the ability to kill bacteria and activate the re-growth of
tissues. The carbon-dioxide laser minimizes damage to surrounding tissue and
removes tissue faster than the fiber optic method. Soft tissue lasers penetrate soft
tissue while sealing blood vessels and nerve endings. This is the primary reason why
many people experience virtually no postoperative pain following the use of a laser.
Also, soft tissue lasers allow tissues to heal faster. It is for this reason that a growing
number of cosmetic dental practices are incorporating the use of soft tissue lasers for
gingival sculpting procedures [13].
A very common phenomenon discovered in the elderly is fibrous hyperplasia,
which appears as a result of long-term wearing of uncomfortable prosthesis that leads
to irregular oral functioning. Fibrous hyperplasia is treated by surgical incision using
a scalpel, together with removal of the source of chronic trauma. However, scalpel
techniques do not provide the hemostasis that is necessary when dealing with highly
vascular tissues.
The results presented in the study of M.B.F. Amaral et al. demonstrated that
diode laser surgery can be used in the management of oral tissues due to its high
absorption by water and hemoglobin, and has provided good results in both
periodontal surgery and oral lesions. They compared the effects of diode laser surgery
to those of the conventional technique in patients with fibrous hyperplasia. A
randomized clinical trial was performed in which surgical and postoperative
evaluations were analyzed. On comparison of the laser-treated (study group) patients
to those treated with a scalpel (control group), significant differences were observed
in the duration of surgery and the use of analgesic medications. Over a 3-week period,
clinical healing of the postoperative wound was significantly faster in the control
group as compared to the study group. They concluded that diode laser surgery
proved to be more effective and less invasive when compared to scalpel surgery in the
management of fibrous hyperplasia [14].
Laser Assisted New Attachment Procedure (LANAP) is a relatively new treatment
option that helps remove plaque and calculus, while limiting bacterial infection to
help fight periodontitis by regenerating rather than resecting tissues. LANAP helps to
remove infection causing bacteria in a safe and painless procedure that promotes
epithelial and periodontal fiber attachments in the affected area. The use of the laser is
guided by a microscope offering a less invasive, highly precise approach. Modern
techniques using lasers can control the spread of harmful bacteria and limit tooth loss
compared to standard periodontal treatment options. Some benefits of laser treatment
for gum disease include: elimination of cutting and bleeding, soreness and discomfort
of the gums. Isolation of deep periodontal pockets. Reduction in tooth loss.
Regeneration of bone and ligament tissues [15].
The study published by Marteli et al. revealed that the application of PERIOdontal
Bio Laser Assisted therapy might “eradicate” the periodontal disease. This study, the
world's largest to date with the longest recorded microbiological follow-up period of
24 months, demonstrated that the PERIOBLAST treatment successfully eradicated
periodontal disease in 100% of 2,683 patients. Treating periodontal disease with
antibiotics and invasive surgery or tooth extraction is ineffective in eradicating the
disease, as the periodontal pathogens live below the gum line and colonise in poorly
or non-vascularised areas. The antibiotics can reduce the presence of pathogens in the
pockets but they cannot penetrate the biofilm to reach the dentine where further
bacteria live. PERIOBLAST involves microbiologically-guided Nd:YAG laser
irradiation of periodontal pockets, in conjunction with scaling and root planning. The
use of the laser is guided by a microscope offering a less invasive, highly precise
approach [16].
The results obtained in other studies, which demonstrate the benefits of lasers in
treatment of oral diseases, have motivated us to conduct an investigation for
application of laser therapy in the elderly population. We expect to get interesting and
significant results in the future.
5 Conclusions
This paper presents a cross-sectional study which analyzed the condition in oral
health in patients aged 60 years and older, in the Republic of Macedonia.
The results obtained in our research provide important basic data on various
aspects of oral health and oral health behavior of people aged 60 years and older, with
a special accent on knowledge, attitudes and oral health habits of these subjects.
Education is a significant factor in oral health behavior, but, for improving oral health
habits, continual education is necessary, as well as broadening the knowledge for
better oral health in this population in R. Macedonia. Our results have pointed out that
there are many areas in the dental education that are to be resolved within the
framework of the programs for the elderly: programs aimed at overcoming the lack of
knowledge related to oral health in the elderly, periodontal diseases and oral cancer,
by which those who seek dental care would greatly benefit. Subjects with higher level
of education had better knowledge about the oral health and better oral health
behavior.
The clinical finding of dental plaque is in a positive correlation with sex and age
of patients, and in a negative correlation with the degree of education. Clinical
examination of our subjects showed findings of dental plaque, dental calculus and
periodontal pockets. More than a half of our patients had dental plaque on the lower
incisors, and only 19% of the patients had no periodontal pockets at the time of the
clinical examination. In the time when engineering and ICT are becoming integral
part of dentistry, and thus oral health, the introduction of laser dentistry would
significantly improve the treatment of teeth and soft tissues in this age-category of
adults. Soft tissue lasers are particularly important since they may be used as a
component of periodontal treatment as well as after tooth extraction for faster tissue
healing. Also, presently there are no studies comparing laser treatment methods and
traditional methods. Additional research is necessary in order to determine this, as
well as the broader effect of laser therapy in dental practice.
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... Various types of lasers are used in the surgery of the soft oral tissues such as CO2 laser, ER : YAG laser, ND : YAG laser, diode laser, argon laser, and KTP laser [2,[18][19][20]. ...
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Oral health behavior and dental health care for elderly in the Republic of Macedoniapreventive aspects Doctoral thesis. Skopje: Faculty of Medicine
  • M Sapurik
Sapurik M. Oral health behavior and dental health care for elderly in the Republic of Macedoniapreventive aspects Doctoral thesis. Skopje: Faculty of Medicine; 2015.