December 2012, Volume 8, Issue 12
Published by AEGIS Communications
Question:Why are lasers still a controversial addition to the dental armamentarium?
There is no doubt that lasers are ideal to treat periodontal disease, and to perform many procedures on soft and hard tissues with less bleeding, less discomfort, better results, and, in many cases, without local anesthetics. Based upon the available literature and clinical practice today, lasers definitely have a place in everyday dentistry.
So, why the controversy? Many dentists prefer to continue using old tools instead of adding innovative tools into their armamentarium. They do that because they resist change or because they don’t want to spend the money even though new and better modalities of treatment are available. Consequently, dental lasers have not fully penetrated the dental community. As a result some might think they are controversial, but surely they are mistaken.
There are enough scientific articles that speak to the reliability of dental laser treatment. The technology itself stands on its own merit for what lasers are intended to do. There are plenty of avid dental laser users, dentists who have been certified and have pursued dental laser education to make their patients’ visits more comfortable and effective with less complication. There are more programs every year to expand laser dentistry education sponsored by all dental organizations. This year the Academy of General Dentistry (AGD) Annual Meeting, once again, offered more programs to educate dentists in the safe use of dental lasers. The American Dental Association (ADA), in conjunction with the Academy of Laser Dentistry (ALD), held its fourth Dental Laser Pavilion at this year’s Annual Session, as well as several other laser dentistry educational programs. The ALD is working with manufacturers, distributors, regulatory agencies, dental organizations, academicians, professors, deans, and administrators in dental schools to expand dental laser education and penetrate the dental community in the United States and internationally.
And yet, only a few US dental schools have any laser dentistry education at all. UCSF School of Dentistry and the Arizona School for Dentistry and Oral Health include dental laser education as an integral part of their dental education curriculum. Currently the American Dental Education Association includes a Special Interest Group on Lasers in Dentistry to begin to address the need for curriculum design. Laser dentistry still has a long way to go to penetrate dental education at large, but we are headed in the right direction. It will take teaching laser dentistry as part of the required dental school curriculum in all or most dental schools for dental lasers to penetrate the dental community and become mainstream. When dental lasers are used in dental schools, new dentists will leave school requiring dental lasers in their practices. They will not know how to be a dentist without them.
Early in 1991, I was part of a handful of general dentists who embraced dental laser technology, eager to integrate it into my practice. However, as lasers gain in popularity, the question posed now is very relevant and has a multi-part answer.
The first involves evidence. Before looking into purchasing a laser, I know some colleagues who performed a search of scientific literature looking for studies that unequivocally showed the superiority of the instrument. In fact, there are several manuscripts that show the laser’s effectiveness, for example, in achieving hemostasis for soft-tissue and pathogen reduction on both soft and hard tissue. However, there are other articles that demonstrate either no benefit or actual damage from laser use. In more than a few cases, I’ve personally discovered that the articles have flawed materials and methods, but are published anyway. One must remember that evidence-based dentistry encompasses our own clinical expertise and the patient’s needs and preferences along with the science. Healthy skepticism can soon turn into frustration and confusion, and a potentially useful modality will be ignored.
The second is education. A clinician who does purchase a laser must be properly trained and must understand not only fundamental laser operation and safety, but also how his/her device can properly interact with dental tissue. This sort of education may or may not be included in the selling price, and it also may or may not be complete. Hands-on or over-the-shoulder teaching is a preferred adjunct to written or downloadable didactic material. Another aspect is the laser use by other members of the clinical team, interpreting their scope of practice, and supervising their procedures. A recent article supposedly showed a catastrophic result of improper laser use by a dental hygienist. Inadequate knowledge can only lead to poor clinical results and temerity in using the laser.
The third is marketing “hype.” I’ve heard claims of absolutely pain-free dentistry, or never performing “surgery.” Others tout a “cure” for periodontal disease or “simply” performing osseous crown lengthening. The facts are that laser procedures can be more comfortable, and can offer beneficial therapy for periodontal infections. However, the principles of biologic width consideration should not be ignored, and soft-tissue incisions still must be performed with good surgical technique. Unrealistic expectations can only lead to disappointment.
The summary answer might be that lasers can be used safely and effectively, and that the practitioner should determine how a laser could be added to his/her practice. That would eliminate the controversy.
There is no doubt that both our profession and the public find lasers to be fascinating. Having a dental laser can create an image of being at the leading edge of technology. While this can be useful for attracting new patients, it can also create a bias in favor of the laser when assessing its actual clinical utility. From a scientific perspective, actual clinical utility is confirmed by well-designed and independent clinical trials and subsequent systematic reviews and critical summaries of those systematic reviews. In fact, the ADA has issued a Technical Report to the Profession (No. 110) entitled “Standard Procedures for the Assessment of Laser-Induced Effects on Oral Hard and Soft Tissue” that details the required evidence for claims to be made about laser-tissue effects. Even though the standards of evidence are clear, there seems to be little interest in some parts of the dental laser industry to meet these standards. Claims of clinical utility are often made on the basis of anecdotal data or from histological evidence incorrectly extrapolated to the clinical environment. While the FDA does clear lasers for marketing, the scientific bar for this clearance is relatively low, requiring only relative similarity in result to predicate technologies. Lasers cleared only for soft tissue use are often used intrasulcularly, also exposing hard tissue (cementum, dentin, and bone) to the laser energy. In periodontics, the absence of clinical evidence that directly compares such laser use against traditional therapy is striking. One is left to compare overall tooth loss data from the plethora of studies on traditional therapy with the few studies utilizing lasers (some of which are subject to significant bias as they were performed by the owners and proponents of the laser company). In doing so, we find mixed results. One Nd:YAG laser protocol for the treatment of periodontal disease appears to produce similar tooth loss data as traditional methods, suggesting the contribution of the Nd:YAG laser to the outcome was minimal to nonexistent. Only the erbium family of lasers shows improved clinical indices in some studies while showing no difference in others.
To conclude, the controversy seems to persist because of the gap between the claims being made by laser proponents and the available evidence. Because the use of the more penetrating laser wavelengths carries with it the risk of deep thermal damage, this gap of evidence seems relevant for anyone wishing to know the risk/benefit ratio of laser therapy.
About the Authors
Ana Maria Triliouris, DDS | Dr. Triliouris is a general dentist in private practice in Merrick, New York, and is a charter member and a fellow of the Academy of Laser Dentistry. She currently serves as the Academy of Laser Dentistry’s Immediate Past President.
Donald J. Coluzzi, DDS | Dr. Coluzzi is a clinical professor at the University of California San Francisco School of Dentistry and a charter member, past president, and has Mastership from the Academy of Laser Dentistry.
Douglas N. Dederich BSEE, DDS, MSc, PhD, Cert. Perio. | Dr. Dederich is a professor of periodontics at the Faculty of Medicine and Dentistry, University of Alberta in Edmonton, Alberta, Canada. He also has a private practice in Edmonton, Alberta, Canada, specializing in periodontics.