Nov/Dec 2014
Volume 35, Issue 10

Advances in Laser Dentistry: Expanding Beyond Periodontal Care

Enrico E. DiVito, DDS; Scott D. Benjamin, DDS; and Jan LeBeau, RDH, BS

How is the use of laser technology expanding in dentistry, and how can clinicians determine the proper instrumentation?

Dr. DiVito

Although lasers in dentistry have existed for decades, the earlier versions were viewed as luxury items used only by specialists or researchers. Due mainly to the size and high cost of those early devices and the fact that the reaction to the surrounding soft and hard tissues was primarily thermal and difficult to control, the use and popularity of lasers was limited. With recent advances in technology and refinement in parameters and delivery systems, however, clinicians are now considering lasers more seriously.

For example, a recent advance of a laser application in dentistry is root canal therapy. An application called PIPS® (Photon Induced Photoacoustic Streaming) creates laser-activated irrigation using an Erbium:YAG laser. (Note: PIPS® was developed by the author, along with a research team at Medical Dental Advanced Technologies Group, LLC.) This application is performed at very low energy levels (sub-ablative or less thermal effects) and creates powerful shockwaves that stream cleaning and disinfecting irrigants three-dimensionally throughout the entire root canal system. Unlike conventional instrumentation and irrigation techniques, PIPS can efficiently deliver irrigants to the more complex and morphologically delicate apical third without the need to over-instrument during the shaping process. This results in a conservative, tooth-sparing, biomimetic outcome, in little time with minimal postoperative sensitivity. Photoacoustic streaming coupled with shockwaves at sub-ablative levels results in measurably cleaner root surfaces with no thermal damage.1-3 Considered simple and safe when the proper protocol is used, this new application is altering the way dentists are performing endodontics and is deemed to be a significant change in root canal therapy.

The delivery of dental laser technology will continue to become more user-friendly and ergonomic, and less costly. In the author’s view, the dental profession is in a wonderful era and the benefits of lasers will continue to evolve. Expect laser dentistry to soon become mainstream as dental schools and educational facilities worldwide discover the possibilities.

Dr. Benjamin

One of most commonly performed dental laser procedures today is assisting in reattaching or reuniting the periodontal attachment apparatus to the tooth. This, however, is just the tip of the iceberg of the value laser technology brings to dental practitioners. With the proper education and use of the correct laser and light-based technologies clinicians can accomplish a goal that has been virtually a foreign concept in dentistry: healing the patient versus surgically treating a condition.

When evaluating lasers, clinicians need to determine what they want to use the laser for, both today and in the future. They should understand the composition of the target (anatomical structure) at which they are aiming the energy, and what type of response they desire. Lasers perform only two functions: they vaporize the target by elevating its temperate to the vaporization (boiling) point, or they stimulate a response. In soft tissue, water is the primary chromophore absorbing the light energy. The more the wavelength of the laser is absorbed in water, the more efficiently it will cause this increase in temperature. The laser’s wavelength is a major consideration regarding what procedure the laser can perform and what outcomes are obtainable.

Erbium-class lasers with wavelengths of 2780 nanometers (nm) and 2940 nm have been used routinely by forward-thinking practitioners since the late 1990s for restorative preparations and osseous recontouring. This technology enables dentists to perform extremely conservative preparations, preserving natural tooth structure and achieving excellent bond strengths. Recently, a carbon-dioxide laser with a wavelength of 9250 nm has also received FDA marketing clearance for tooth preparations and has been introduced into the dental market. This wavelength has the potential for melting enamel and possibly making it more resistant to carious breakdown.

The ability of quality lasers to control and titrate the amount of energy and its delivery greatly increases the types of procedures that can be performed. It also reduces the need for anesthesia. Many, but not all, properly performed soft-tissue laser procedures can be accomplished with just a topical anesthetic; many tooth preparations can be performed with no anesthetic at all. This enables tooth preparations and various other procedures in multiple quadrants to be performed during the same visit, significantly enhancing efficiency and productivity.

Additionally, the use of a properly controlled Er:YAG (2940 nm) to thoroughly disinfect and clean the entire root canal system of a tooth being endodontically treated is increasing the success rate and predictability of root canal therapy.4 When using the correct laser system and protocol, accessory canals and anastomoses between canals are being cleaned and disinfected, enabling these regions to be properly obturated.

There are also protocols today being used with the Er:YAG lasers to tighten intraoral soft tissues to help reduce snoring and to reduce facial lines and wrinkles without pain or discomfort.

Possibly the most significant quality-of-life enhancement being performed today with laser technologies is in the management of oral mucositis, the extremely debilitating side effect of chemotherapy and radiation therapy for cancer. With low-level light (laser) therapy (LLLT), more appropriately referred to as photobiomodulation, light energy of various wavelengths, intensity, and time is administered to the affected regions and related lymphatic system to stimulate or inhibit the metabolic processes at a cellular level. With photobiomodulation, like all forms of therapy, the dosage (ie, location, type, and amount of light energy) delivered to the biological structures is critical, and clinicians should understand the real treatment objective, the metabolic processes desired, and the tissue and cellular composition.

Surgical lasers and light-based technologies are maturing as a clinical treatment modality, and photobiomodulation procedures are growing in their clinical applications. Clinicians should learn and understand the true science of light technology along with the benefits—and limitations—it brings to patient care.

Ms. LeBeau

From a dental hygienist’s perspective, perhaps the most common procedure performed with a laser in today’s modern dental practice is the decontamination of the periodontal pocket. This is most often performed as an adjunct therapy to scaling and root planing and is effective in the initial nonsurgical management of early to moderate periodontal disease. Also, within the scope of practice for the dental hygienist is the treatment for recurrent apthous ulcers or herpetic lesions using a laser. Treatment for these lesions is typically performed in a non-contact mode using no anesthesia. Relative to the recurrent apthous ulcer, the light energy from the laser is absorbed into the ulcer, creating a temperature rise within the lesion, which is thought to occlude the exposed terminal nerve endings at the surface of the lesion. This, in turn, reduces or eliminates the patient’s discomfort caused by the ulceration. Additionally, management of the herpetic lesion can be performed using the same protocol. It is best to treat the herpetic lesion in the prodromal stage, creating a temperature rise within the lesion that disrupts or kills the virus. It is important to note, compliant with some state regulations, dental hygienists may not be able to treat herpetic lesions if they are outside the vermillion zone of the lip. Management of these lesions can be a tremendous benefit for patients suffering pain and discomfort with little hope for relief other than topical treatments and time.

Although beyond the scope of practice for the dental hygienist, laser technology plays a key role in relation to minor surgical procedures. The dental hygienist should understand the benefit laser technology brings for procedures such as gingivoplasty or gingivectomy, fibroma removal, frenectomies, and operculectomies. Working in collaboration with the dentist, the hygienist can assist in recognizing the need for these surgical procedures and bring it to the doctor’s attention for evaluation, diagnosis, and treatment planning. In turn, the hygienist should be able to support the doctor’s diagnosis and treatment plan by helping the patient understand the procedure and the benefits of using the laser.

Contrary to popular belief not all lasers are created equal. Selecting a wavelength or specific laser is dependent upon what the clinician hopes to accomplish and possibly who will be using the laser. Different wavelengths are absorbed into various target tissues differently. Although similar in design and function, diode laser wavelengths range from 805 nm to 1064 nm. This variable in wavelengths has an effect on absorption within water and, ultimately, the depth of penetration of light energy within soft tissue. Wavelengths such as the 980-nm class diodes are more readily absorbed into water, thereby penetrating less deeply and potentially creating less thermal collateral damage. This is an important consideration when purchasing a laser to perform bacterial decontamination as an adjunct to scaling and root planing or periodontal maintenance.

Although light-based technologies have been used in dental practices since the mid 1980s, their value for procedures beyond incising and excising tissue is just now coming into focus. From the management of periodontal infections to the treatment of oral mucositis, lasers are proving to be efficient and effective, inspiring clinicians and researchers to consider the value of this amazing instrumentation.

References

1. Olivi G, DiVito E, Peters O, et al. Disinfection efficacy of photon-induced photoacoustic streaming on root canals infected with Enterococcus faecalis: an ex vivo study. J Am Dent Assoc. 2014;145(8):843-848.

2. Lloyd A, Uhles JP, Clement DJ, Garcia-Godoy F. Elimination of intracanal tissue and debris through a novel laser-activated system assessed using high-resolution micro-computed tomography: a pilot study. J Endod. 2014;40(4):584-587.

3. Jaramillo DE, Aprecio RM Sr., Angelov N, et al. Efficacy of photon induced photoacoustic streaming (PIPS) on root canals infected with Enterococcus faecalis: A pilot study. Endodontic Practice. 2012;5(3):
28-32.

4. Peters OA, Bardsley S, Fong J, et al. Disinfection of root canals with photon-initiated photoacoustic streaming. J Endod. 2011;37(7):1008-1012.

About the Authors

Enrico E. DiVito, DDS
Founder, Director, Arizona School of Dental Assisting, Phoenix, Arizona
Clinical Instructor, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona
Private Practice, Scottsdale, Arizona

Scott D. Benjamin DDS
President, Academy of Laser Dentistry; Private Practice, Sidney, New York

Jan LeBeau, RDH, BS
Director of Dental Hygiene, Pacific Dental Services, Inc., Irvine, California

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