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Michael Swick, DMD
It is well known that lasers have made terrific inroads into dentistry. Though the percentage of laser usage remains lower than the use of the high-speed handpiece, lasers have dramatically gained in popularity. The three major categories of lasers available are soft-tissue lasers, hard-tissue lasers, and lasers for photobiomodulation. Massive improvements have been made to these instruments since their inception.
In the soft-tissue laser category, changes in creature comforts and portability are evident in both solid-state diode lasers and lasers with flashlamps and resonators. Creature comforts make the dentist’s life a bit simpler and include preset settings, disposable tips, wireless foot controls, and battery-powered units. The ultimate in portability is found in totally contained handheld units, which can now be found with maximum peak power as high as 5 W and average power as high as 3 W. The significance of this is that higher power and pulsing can reduce thermal damage and speed up cutting.
Soft-tissue lasers can be found in visible light wavelengths ranging from argon at 488 nm, argon at 515 nm, to KTP at 535 nm. Next on the electromagnetic spectrum are the near infrared wavelengths, which consist of 810 nm, 940 nm, 980 nm, and 1064 nm. The 1064-nm wavelength has been recently introduced in a diode platform. This was designed to compete in the periodontal market with the larger, more powerful, free-running pulsed lasers at 1064 nm. Research on this new unit’s effectiveness is ongoing.
The trend over the past several years has been toward smaller, low-power diode lasers. Recently, however, higher-powered and micropulsed lasers with pulses as short as 10 microseconds in the 15 W to 30 W range have been introduced. These lasers are designed to provide thermal relaxation time, much like a free-running pulsed laser. Another soft-tissue laser at 1340 nm is making a resurgence. This wavelength has relatively high water absorption compared to the other near-infrared lasers. It can make endodontic retreatment easier due to its ability to vaporize endodontic files that have been broken off in the canal. This laser also can perform all other soft-tissue laser procedures.
Carbon-dioxide lasers at 10,600 nm are gaining favor. Due to digital pulsing, these lasers can be pulsed in super-pulsed and micropulsed modes. This virtually eliminates thermal damage to root surfaces, enabling these lasers to be used for periodontal therapy.
In the area of erbium hard/all-tissue tissue lasers, wavelengths of 2780 nm and 2940 nm have had significant improvements. With the advent of higher powers and significantly more efficient delivery systems, much faster cutting speeds have been achieved. Increased Hertz rates also have improved hemostasis. Digital pulsing is available, providing square pulses rather than bell-curved analog pulses. This results in quicker ablation with less pain. In addition, FDA clearance has been obtained for cementum-mediated periodontal ligament new attachment procedures with the absence of long junctional epithelium. Another recent breakthrough is the utilization of the photoaccoustic effect of an erbium laser to create photoaccoustic shock waves that maximize debridement of endodontic canals. The area of photobiomodulation also is garnering more interest.
Proper laser education is needed for optimizing the technological experience with lasers. For most dentists, their first involvement with dental lasers begins with a manufacturer’s sales presentation. Many of these presentations are informative and convey valuable information about dental lasers. Naturally, most are designed to steer the dentist in a direction that encourages the purchase of the sponsoring company’s laser. Totally neutral introductory presentations for the dentist to attend are those found at several national meetings sponsored by the Academy of Laser Dentistry (ALD). When available, these courses present an unbiased look at all of the lasers on the market today. In other words, these presentations are “how to buy a laser” courses that better enable the practitioner to choose a laser that will conform to his/her practice goals.
Once the laser is purchased, the next step is to attend a live, manufacturer’s device-specific training course. Some manufacturers provide these, but some do not. The quality of training should be considered when choosing a laser. For beginning laser users, a live interactive presentation, including hands-on training, is best. While online, CD-ROM, and DVD learning materials are great adjuncts to a live course, they do not provide the thoroughness found when colleagues are allowed to interact. A question-and-answer session with adequate clarification should be part of the training course. A quality training course also should include a clinical simulation exercise utilizing hog jaws or a reasonable substitute. This hands-on experience should result in the dentist feeling comfortable and confident using his or her new laser.
This course also should facilitate seamless integration of lasers into the dental practice. It is extremely important for the dentist to understand not only how to use the laser, but how to easily add it to the practice. A good practice integration course should include an explanation of which procedures may be accomplished with a laser, as well as how to diagnose and bill for those procedures. Invaluable in the promotion and acceptance of lasers in the dental practice, the hygienist should be included in the training, as well.
The next step in laser training also is very important—a standard proficiency course given by an ALD-recognized course provider, or a very close facsimile of that course. It is possible that another group or individuals may provide this level of education, which defines the standard of care for using lasers in dentistry. This type of course follows the curriculum guidelines and standards for dental laser education set by the ALD, which have been approved both nationally and internationally. It is a rigorous course that includes a didactic section, hands-on section, written testing, and a clinical simulation examination in which the practitioner must demonstrate competency.
Once practitioners have passed a standard proficiency certification and are practicing within the standard of care, they may elect to take advanced studies. An advanced proficiency certification is available through the ALD. Advanced credentials also may be obtained through other groups.
A truly ambitious practitioner also may elect to sit for diplomat status with the American Board of Laser Surgery (ABLS). This test is not for the faint of heart. It requires an extremely high level of knowledge of both medical and dental lasers. Currently, there exist only around 500 ABLS diplomates. The knowledge gained and the sense of accomplishment is worth the effort to pass this examination.
Because laser articles for years have discussed the benefits for the patient as well as the dentist, only a simple overview is provided here. For patients, lasers can eliminate or greatly reduce the need for injectable anesthetics during both hard- and soft-tissue procedures. Because of a laser’s ability to simultaneously cut and coagulate, a number of procedures, such as gingivectomies, can be readily performed at the same appointment as the restoration. This eliminates the need for a second appointment, saving a patient’s time. An additional patient benefit of laser use is the ability to accomplish many procedures without the need for sutures. For many cases, periodontal packing has become a thing of the past. Elimination of the sound and vibration of the high-speed drill is welcomed by all patients, which is a big advantage of the hard-tissue laser. Other benefits that are very important to most patients include virtually no bleeding, greatly reduced postoperative discomfort, and less stress, anxiety, and fear.
Benefits to the dentist are equally important. Foremost, the ability to perform better dentistry that is more comfortable for patients is particularly gratifying for all dentists. Having the availability of a clean, dry, bloodless field in all cases reduces stress, making the dentist’s day much more rewarding. The ability to perform multiple procedures in one appointment increases practice efficiency and decreases overhead expenses. In addition, most dentists appreciate the added revenue that laser procedures can bring to the dental practice.
This is an exciting time for laser dentistry. The many improvements, innovations, and new devices on the market have made the addition of lasers to the dental practice an even more desirable and profitable venture. It is the author’s passionate opinion that all dentists should be practicing with dental lasers, not only for the benefits to themselves and their patients, but to catapult modern dentistry into today’s technological age.