Laser Dentistry’s Expansion Reveals Need for Stronger Education
Inside Dentistry interviews Praveen R. Arany, DDS, PhD, an assistant professor in the Department of Oral Biology and Biomedical Engineering at The State University of New York at Buffalo’s School of Dental Medicine
Inside Dentistry (ID): How is the role of lasers continuing to expand in dentistry and what has the impact been on restorative procedures?
Praveen R. Arany, DDS, PhD (PA): I think that when we say "restorative," we're usually talking about hard-tissue lasers. But soft-tissue lasers have been around for a longer time in terms of clinical acceptance. Regarding the soft-tissue lasers, we don't think of them as being used for restoration per se, but the surgical procedures that we perform with them can offer added advantages to ongoing restorative procedures (eg, troughing around a crown margin). When you cut with a soft-tissue laser, you're also photocoagulating concurrently. This not only improves clinical efficiency because you're not going back and forth again and again with a blade in a pool of blood, but also actually reduces the amount of inadvertent damage to the tissue and results in a better surgical procedure in many ways. We can ablate or remove very precise layers of cells to recontour dental tissues, and that's a really fantastic advantage that we don't currently have with any other blade, bur, or curette. Regarding restorative hard-tissue lasers, I think the major advantages are precision and clinical efficiency. You can ablate a layer of tissue that is less than a micron in thickness, and you can also use them for finishing. Ongoing research is demonstrating that hard-tissue lasers can selectively remove carious tooth structure and preserve intact, normal tissues. In addition, the post-laser dental tissues need minimal preparation prior to restorations. I believe that, in many ways, the concept of using hard-tissue lasers for restorations is still in its infancy, but there's been tremendous progress, and clinicians are excited about the additional capabilities that these lasers will have for restorations in the future.
(ID): With manufacturers' continued progress and also, hopefully, more training for clinicians, do you think that restoring with lasers will be more viable in the future?
(PA): Absolutely. There are new units on the market, but I think the missing part is that as dentists, we are rarely properly educated about light and lasers, let alone the biological response when light interacts with the tissues. The current training programs that are available are all largely focused on specific laser devices, how they are made, and how they work. There is very little emphasis placed on the biological aspect, which is a major factor in determining clinical outcomes. As an analogy, we don't teach dentists or dental students about bur design or how a handpiece works, but that's what we're currently doing with lasers. We should be emphasizing light-tissue interactions. So, I think that the education for lasers needs to be shored up and more structured regarding the biological and clinical aspects of what the light is capable of doing in different situations.
(ID): Do you believe that the claims regarding anesthesia-free laser dentistry are exaggerated?
(PA): No. Er,Cr:YSGGs, Er:YAGs, and CO2 lasers all emphasize the fast rate of tissue removal, which logically, supports the notion that the patient would experience less pain as a result. There is a growing amount of published literature that unequivocally demonstrates that low amounts of light are capable of directly modulating the natural pain pathways. I am confident that lasers will make a significant impact in this area (it already has begun in pediatric dentistry and oral mucositis post-cancer treatments) when the protocols and techniques improve.
(ID): Do you envision a day when lasers will have obviated the need for handpieces for most procedures?
(PA): I don't think so. A laser is not a magic wand; it's not going to cure all of the world's maladies and diseases. It's a tool, and just like every other tool in our clinical armamentarium, we need to understand how to use it. There will be a time and a place for each laser, but I don't think that a single laser will ever be developed to accomplish everything. There are light devices that can do certain common things, such as light curing and fluorescence-based caries and cancer detection. But at the moment, there are also things that a laser can do that other clinical devices cannot. It is completely feasible that in the near future, practices will have some kind of light device that can perform multiple functions, including therapy and diagnosis, built right into the dental chair.
(ID): The literature is divided as to the efficacy of lasers in scaling and root planing procedures. What are the major ways in which a laser can help with hygiene?
(PA): Currently, laser therapy cannot replace scaling and root planing. However, there have been some exciting research developments with both dye-assisted and high-power lasers for calculus removal. There are lasers in development that aim to remove calculus and debride in a very precise manner, but at the moment, a laser remains an adjunctive tool for curettage and disinfection. So, unless you know that it is able to do what you want, it will not work. If you're trying to do a surgical debridement or curettage, high-power lasers will work. Depending on your laser, you can very effectively paint the microbes that selectively absorb the light and destroy them. This is called antimicrobial photodynamic therapy. Simply shining light on colored (ie, pigmented) microbes can also destroy them, but this process is nonselective. Another approach is photobiomodulation therapy, which can improve the host's immune and healing response. When we debride and curette, we are creating an environment for the tissues to heal. However, we can do it much more effectively with photobiomodulation therapy, which results in more rigorous and reproducible clinical outcomes.
(ID): What is your advice for anyone looking to integrate lasers into his or her practice, and what are the biggest pitfalls or hurdles from your experience?
(PA): Well, as I said before, I think the most important thing to remember is that a laser is not a universal solution. An appreciation of that comes with appropriate training. Unless we fully understand what this tool is capable of doing and what we want it to do, we will not get reproducible, safe, and effective clinical outcomes. It is also important to appreciate the unique safety features these devices employ. In addition, there are some new skills that you have to get comfortable with, so training is important. Although I think that each laser manufacturer is doing a great job educating dentists about their particular device, the training is limited to that device. So, if we really want to utilize lasers in dentistry and learn all of their possible comprehensive applications, we need to make laser education routine in dental curricula and training as well as in continuing dental education programs.
(ID): Is there anything else on the subject of lasers that you think is important to the dental industry?
(PA): There is growing emphasis on the nonsurgical use of lasers, specifically for photobiomodulation therapy, that I believe is going to revolutionize clinical dentistry, moving the focus from restoration to regeneration. I was fortunate to be a part of a global team of experts that outlined clinical guidelines for managing oral mucositis in head and neck cancer patients using photobiomodulation therapy that were just recently published. The remarkable efficacy of photobiomodulation therapy in reducing pain and ulcers in these patients without any adverse side effects was striking. The use of this non-pharmacological, non-invasive, simple, and sustainable technology is going to have a significant impact on cancer care in the near future. We hope it will also help showcase the central role of oral-dental care in general health.
About the Author
Praveen R. Arany, DDS, PhD
Department of Oral Biology
The State University of New York at Buffalo
School of Dental Medicine
Buffalo, New York