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DIODE LASERS: The Soft Tissue Handpiece.

Fay Goldstep DDS, FACD, FADFE, George Freedman DDS, FAACD, FACD

goldstep@epdot.com

While dental lasers have been commercially available for several decades, and their popularity among patients is unparalleled, the dental profession has taken to this treatment modality rather slowly. Lasers have been thoroughly documented in the dental literature. They are an exciting technology, widely used in medicine, kind to tissues, and excellent for healing. So why have they not been more widely embraced by the practicing dentist? There is a wide perception in the profession that somehow the dental laser is not useful, too complicated, and too expensive. These param- eters have change forever with the arrival of the diode laser onto the dental scene. There is now a convergence of documented scientific evidence, ease of use and greater affordability that makes the diode laser a "must have" for every dental practice.

Diode Lasers: The Science in Brief

L A S E R is an acronym for Light Amplification by Stimulated Emission of Radiation. Lasers are commonly named for the sub- stance which is stimulated to produce the coherent light beam. In the diode laser, this substance is a semiconductor (a class of materials which are the foundation of modern electronics including computers, telephones and radios). This innovative technology has produced a laser that is compact, and far lower in cost than earlier versions. Much of the research has focused on the 810nm diode laser. This wavelength is ideally suited for soft tissue pro- cedures since it is highly absorbed by haemoglobin and melanin. This gives the diode laser the ability to precisely cut, coagulate, ablate or vaporize the target soft tissue.1 Treatment with the 810nm diode laser Fig 1(Picasso Diode Laser, AMD Lasers) has been shown to have a significant long- term bactericidal effect in periodontal pockets. A. actinomycetem- comitans, an invasive pathogen associated with the development of periodontal disease and generally quite difficult to eliminate, responds well to laser treatment.2, 3 Scaling and root planing out- comes are enhanced when diode laser therapy is added to the dental armamentarium. The patient is typically more comfortable during and after treatment, and gingival healing is faster and more stable.4, 5

Diode Laser: Ease of Use

Early adopter dentists thrive on new technologies. They enjoy the challenges that come with being the first to use a product. Most dentists, however, are not early adopters. Over the past two decades lasers have intimidated mainstream dentists with their large footprint, lack of portability, their high maintenance profile, confusion of operating tips, and complex procedural set- tings. Common questions: When do I use which tip? What setting works for which procedure? Why do I need a laser when I have been managing well without one?

Enter the diode laser. It is compact. It can easily be moved from one treatment room to another. It is self-contained, and does not have to be hooked up to water or air lines. It has one simple fiberoptic cable which is can be utilized as a reusable operating tip. The units come with several presets, although after a very short time, the operator becomes so comfortable that they are rarely needed. The power and pulse settings are quickly adjusted to suit the particular patient and procedure.

One of the authors is a dentist who does not thrive on the challenge of brand new high-tech, high-stress technology. In fact, having tried many lasers in the past that promised to be user-friendly, they were found to be anything but. The 810nm diode laser was a totally different experience; after a brief in-office demonstration, the laser handpiece felt comfortable enough to perform some simple clinical procedures. Further online training and lecture courses enhanced both clinical comfort level and competency.

Diode laser: Affordability

Laser technology has always come with a high price tag. Manu- facturing costs are high and cutting edge technology commands steep pricing. Diode lasers are less expensive to produce. Break- through pricing for this technology has now reached under $5,000. At this level the diode laser becomes eminently affordable for the average practicing dentist.

Diode laser: Why do I need this technology?

The 810nm diode laser is specifically a soft tissue laser. This wavelength is ideally suited for soft tissue procedures since hae- moglobin and melanin, both prevalent in dental soft tissues, are excellent absorbers. This provides the diode laser with broad clin- ical utility: it cuts precisely, coagulates, ablates or vaporizes the target tissue with less trauma, improved post-operative healing, and faster recovery times.6, 7, 8 Given the incredible ease of use and its versatility in treating soft tissue, the diode laser becomes the "soft tissue handpiece" in the dentist's armamentarium. The dentist can use the diode laser soft tissue handpiece to remove, refine and adjust soft tissues in the same way that the traditional dental handpiece is used on enamel and dentin. This extends the scope of practice of the general dentist to include many soft tissue procedures.

The following procedures are easy entry points for the new laser user:

1. Gingivectomy

Haemostasis

Gingival troughing for impressions

The diode laser makes restorative dentistry a breeze (Picasso, AMD Lasers Inc.). Any gingival tissue that covers a tooth during preparation can be easily removed as haemostasis is simultaneously achieved. Figs 2-6 The restoration is no longer compromised due to poor gingival conditions. There is no more battling with unruly soft tissue and blood. Excess gingival tissue can be readily managed (Fig 7-8) for improved restorative access to Class V preparation (ezlase, Biolase Technology Inc.)

Gingival toughing prior to taking impression Fig 6-7 (Picasso, AMD Lasers Inc.) ensures an accurate impression (particularly at the all-important margins) and an improved restorative outcome. Packing cord is no longer necessary.

Diode lasers make restorative dentistry less stressful, more pre- dictable and more enjoyable for the dental team and the patient.

2. Operculectomy

Excision and/or recontouring of gingival hyperplasia Frenectomy

These procedures are not commonly offered or performed by the general dentist. They are examples of the expanded range of ser- vices readily added to the general practice. The dentist becomes more proactive in dealing with hyperplasic tissues that can increase risk of caries and periodontal disease. Figs 9-11

A frenectomy is now a simple and straightforward procedure (ezlase). Fig 12

3. Laser Assisted Periodontal Treatment

The use of the diode laser in conjunction with routine scaling and root planing is more effective than scaling and root planning alone. It enhances the speed and extent of the patient's gingival healing and post-operative comfort. (Ref 4,5). This is accom- plished through laser bacterial reduction (Picasso, AMD Lasers Inc), debridement and biostimulation. Fig 13-14 A. actinomycetemcomitans which has been implicated in aggres- sive periodontal may also be implicated in systemic disease. It has been found in atherosclerotic plaque (Ref 9) and there has been recent data suggesting that it may be related to coronary heart disease.10 The diode laser is effective in decreasing A. actinomy- cetemcomitans2, 4 and thereby indirectly improving the patients' heart health.

Laser Education

Most diode laser manufacturers provide some education to get the new user started quickly and effectively. The most compre- hensive online diode laser introductory course with certification (which includes the science, safety and clinical procedures) can be found at the International Center for Laser Education, www.dentallaseredu.com tel: +1 877 522 6863. This course provides everything necessary to get started with soft tissue diode laser therapy. Advanced courses are available for more complex procedures.

The soft tissue diode laser has become a "must have" main- stream technology for every general practice. The science, ease of use, and affordability make it simple to incorporate. The laser is now the essential "soft tissue handpiece" for the practice. In fact, there is a case for having a diode laser in each restorative and each hygiene treatment room. Restorative dentistry becomes easier, more predictable and less stressful. Laser therapy expands the clinical scope of practice to include new soft tissue procedures that keep patients in the office. The patient's gingival health is improved in a minimally invasive, gentler manner. Every time the dentist picks up the diode laser the question is: where have you been all my life?

REFERENCES

1. Pirnat S, Versatility of an 810 nm Diode Laser in Dentistry: An Overview, Journal of Laser and Health Academy Vol. 2007 No. 4 1 -8

2. Moritz A, Schoop U, Goharkhay K, Schauer P, Doertbudak O, Wernisch J, Sperr W, Treatment of periodontal pockets with a diode laser, Lasers Surg Med, 1998; 22(5): 302-11

3. Moritz A, Schoop U, Goharkhay K, Schauer P, Doertbudak O, Wernisch J, Sperr W, bacterial reduction in periodontal pockets through irradiation with a diode laser: a pilot study, J Clin Laser Med Surg. 1997 Feb; 15(1): 33-7

4. Ciancio SG, Kazimerczak M, Zambon JJ, Baumbartner S, Bessinger MA, Ho A, clinical Effects of diode laser treatment of wound healing, AADR, 2006, abs 2183

5. Haraszthy VI, Zambon MM, Ciancio SG, Zambon JJ, Microbiological Effects of 810 nm Diode Laser Treatment of Periodontal Pockets, AADR 2006, abs 1163

6. Goharkhay K, Mortiz A, Wilder-Smith P, Schoop U, Kluger W, Jakolitsch S, Sperr W, Effects on oral soft tissue produced by a diode laser in vitro, Lasers Surg Med, 1999; 25(5): 401-6

7. Walinski CJ, Irritation Fibroma Removal: A Comparison of Two Laser Wave- lengths, Gen Dent 2004, May - June; 52(3): 236-8

8. Adams TC, Pang PK, Lasers in Aesthetic Dentistry, Dent Clin North Am, 2004 Oct; 48(4): 833-60, vi

9. Haraszthy VI, Zambon JJ, Trevisan M, et al, Identification of Periodontal Patho- gens in Atheromatous Plaques, J Periodontol 2000, 71:1554-1560

10. Spahr A, Klein E, Khuseyinova N, et al, Periodontal Infections and Coronary Heart Disease: Role of periodontal bacteria and importance of total pathogen burden in the Coronary Event and Periodontal Disease (CORODONT) study, Arch Intern Med, 2006 166:554-559

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Date:Mar 29, 2012
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