by Michael Miyasaki, DDS
Soft-tissue lasers are fast and predictable, but can you justify owning one? Even if you think not, keep an open mind and read on. First, what are the advantages of a soft-tissue laser? Clinically, they allow us to work much more efficiently. In many laser applications, you perform the laser procedure and continue on with the needed restorative work during the same visit. That's right, the same visit! Can you see the advantages for you and your patient clinically and economically?
Secondly, a laser allows you to do a wider range of procedures than an electrosurgery unit or scalpel, ranging from treating an apthous ulcer to releasing a frenum — all with little or no patient discomfort or post-operative bleeding. A final reason for looking at soft-tissue lasers now is cost and your return on investment. Currently, the cost of a diode laser is about $10,000, which is less than half of what it was five years ago. It still sounds like a lot, but we'll analyze this later and show how a laser can provide a positive cash flow to your practice.
First, let me disclose both my experience and bias. I have owned and used several diode soft-tissue lasers over the past five years and now I couldn't work without one. At the Las Vegas Institute for Advanced Dental Studies, we use the laser in virtually every case, doing a variety of procedures from soft-tissue recontouring to frenectomies. The laser is critical to the success of the cases we do.
Finally, a laser in the office projects a high-tech image to your patients. Today, everyone is familiar with lasers used in vision correction. So much of the connotation of a laser being a scary instrument is fading away. Patients now realize the benefits of using lasers in many medical applications. Clinical studies have indicated that 86 percent of patients surveyed after treatment with a dental laser considered it to be faster than traditional instrumentation.
A laser is symbolic of the fact that your office and your training is modern, advanced, and up-to-date. It becomes a reason patients seek out your services. We have had patients come to us because we had a soft-tissue laser, and many were referred by general dentists who did not use lasers, but who understood the advantages the treatment provided.
Characteristics of the laser
How does a diode laser work? I'll boil down the actual laser science down to the basics. The laser creates an intense beam of light energy, which travels down a thin fiber optic cord. This energy is converted to heat within the target tissue because of its pigmentation. There is a photothermal interaction that creates a highly localized thermal effect for tissue vaporization with very minimal collateral tissue damage.
An important rule is to always use the least amount of power needed to accomplish the necessary treatment. This reduces the collateral tissue damage, speeds healing, and decreases the possibility of post-operative discomfort.
The tactile feel when using a laser is very light and differs depending on its application. When tissue is to be removed, the tip is held in light contact with the tissue and the procedure is done with light "brush strokes." The tissue should appear slightly brown and not charred black. There is rarely any bleeding or discomfort since the blood vessels and nerve endings are sealed while the tissue is removed — hence, minimal edema and post-operative discomfort. Applying over-the-counter 2 percent hydrogen peroxide removes the slight discoloration of the tissue, and, within minutes, the tissue appears close to normal.
For treatment of apthous ulcers or hemostatic procedures, the laser tip is held 2 mm over the tissue without making actual contact and is gently waved over the affected area for a few minutes. What you then see is a decrease in the tissue edema and size of the vesicles.
The laser I use weighs 11 pounds and is, therefore, extremely portable. The laser unit is turned on by engaging a key lock; it warms up quickly and is ready to use. The laser handpiece, which itself is lightweight with a slightly offset tip, is attached to the main laser unit by a thin, flexible fiber delivery system. Between patients, the lasing fiber is disinfected, the sheath around the fiber is removed (exposing fresh fiber), and the tip is cleaved. Both the patient and staff wear eye protection to guard against potential eye damage from direct or indirect radiation emitted from the laser. The selected power setting is entered and, with a foot pedal, the laser is activated. While lasing, the assistant holds the high-volume suction unit near the tissue and blows air on the area being lased to keep the tissue cool. That's it.
Do you have any equipment in your office that you bought, but never used? It's happened to all of us. Why? Because the equipment was difficult to use, did not deliver the benefits for which we bought it, or we could not master its use to the point where we felt comfortable using it on our patients.
The laser is different because it is very easy to use, has a very short learning curve, and delivers results. My transition from an electrosurgery unit to the laser was very quick. One of the nice benefits is that you no longer need to use a grounding pad or wire as you do with an electrosurgery unit.
I would highly recommend taking an approved laser course offered by the Academy of Laser Dentistry. In the course, you are given the physics, safety procedures, and treatment protocols of laser use. After a few procedures, you will feel very comfortable with the laser's light feel and its application on your patients.
Examples of everyday laser use
A patient walks in with an apthous ulcer or herpetic sore. In the past, these patients suffered through the pain of using topical ointments while the lesion ran its course for seven to 10 days. For these patients, I now offer laser treatment of the ulcer, which usually takes no more than a few minutes and provides immediate relief. Without even anesthetizing the tissue, you can lase the sore for a few minutes. This seals the nerve endings, decreases inflammation, and disinfects the sore. After treatment, the patient normally will report the ability to touch the sore without discomfort, and they will notice more rapid healing. Think about how that will impress patients and what a great service you will have provided!
Some other examples include:
Frenectomy: In cases where the frenum needs to be released, the laser can be used to perform this procedure in just minutes. The great part about using the laser is the ease of the procedure and the absence of bleeding and post-operative discomfort.
Aesthetic gingival recontouring: In almost every aesthetic case I do, I need to recontour the gingiva to better frame the aesthetic restorations. The patient is anesthetized for the tooth preparations, so it takes just a few minutes to laser the tissue. The great thing is that the tissue will heal after lasing. So I will do my final preparations and take impressions during the same visit.
In the past, if I performed an aesthetic gingivectomy with an electrosurgery unit or scalpel, I allowed the area to heal for weeks or months before preparing the teeth because of my fear of gingival recession from its immediate post-operative position. Following the proper protocol with a laser means there will be less collateral thermal damage and, therefore, less tissue shrinkage. This means an improved result for our patients, less discomfort, and fewer appointments.
Tissue retraction: Tired of packing cord? What if a laser meant you could throw the retraction cord away? Not only is using a laser in this case easy to do, but it is kinder to the tissue. Look what happens when you force retraction cord into a tight, shallow sulcus. The tissue usually bleeds and resembles hamburger after you're done. And this assumes you are able to put up with the frustration often experienced when you push the cord down in one area only to see it pop up in another. While biting your lip under the cover of your mask, you are now dealing with the combination of bleeding and frayed tissue that often makes it hard to tell if you'll get that great impression you had hoped for. And you know that ultimately the final fit of the restoration is going to depend on this procedure.
In my office, the laser has replaced retraction cord, and I don't miss packing the cord. Instead, we trough around the preparation by running the laser fiber between the tissue and tooth surface in the gingival sulcus. In seconds, you have a tissue-free, bloodless margin. The laser stops the bleeding by sealing the blood vessels. Now you can clearly see your margins before taking the impression, creating a more predictable situation. Laser troughing improves the quality of your impression, reduces the number of retakes and remakes, and lowers your stress.
Many times, it is possible to work without anesthetic when doing minor soft-tissue treatment, as long as adequate air is blown over the treatment area so that the patient doesn't feel the heat. For gingivectomies where I haven't injected any anesthetic, I'll apply a topical anesthetic over the area to be treated for a few minutes then proceed.
Periodontal disease: Using a laser is a fantastic adjunct in treating periodontal disease in your practice. The American Academy of Periodontology has estimated that approximately 80 percent of adults are affected by periodontitis.
Diagnosed periodontal disease is treated with the laser following root-planing and scaling. The laser is used to remove the diseased epithelial lining, as well as the bacterial contamination of the sulcus. Studies have shown that laser treatment can kill most of the sulcular bacteria. It enhances the effect of altering the subgingival microflora beyond that provided by conventional treatment, potentially arresting the progression of periodontal disease.
In many states, the application of laser therapy can be done by a registered dental hygienist. Clinically, after root planing and scaling, the laser fiber is placed in the sulcus and low levels of energy are applied to the tissue to kill the bacteria. This use of a laser to treat the periodontal pocket is again easy to do, painless, and very effective.
Metal: When working with a laser around implants or metal restorations, I don't have to worry about inadvertently touching the metal and seeing sparks fly. I can trough around an implant to further expose it, which is another great application.
Other uses of the laser include eradication of lichen planus lesions, excisional biopsy (such as mucocele or fibromas), extension or modification of the vestibule, incision for drainage of abscesses, nonbony crown lengthening, lasing a surgical site to control bacterial overgrowth, control of chronic granulation tissue, and root desensitization.
In summary, soft-tissue lasers are easy to use and effective, and their versatility allows you to offer your patients a wide range of treatment options for all types of soft-tissue treatments. Your patients will appreciate this treatment because it is both quick and comfortable with little or no post-op sensitivity. I definitely see it as a piece of equipment you should evaluate for yourself. Once you use a laser, you won't be able to practice without one.
How affordable is it?
A question asked by every astute dentist is, "Can I afford a laser?" I believe the answer is, "You can't afford not to have a laser."
Here are some numbers you could possibly generate in a month of laser use:
- If 25 percent of your average 16 crowns a month required gingivectomies, you could produce an additional $500 at $125 per gingivectomy.
- One frenectomy per month would produce an additional $250.
- Saving 1.5 hours per month by not packing cord would allow you to produce another $375 (assuming you earn $250 per hour).
- The analysis of periodontal treatment (produced by the hygienist, if allowed in your state) calculates the treatment of one to two pockets during a hygiene appointment. Three patients per day during 16 days a month would mean 48 periodontal procedures a month, each taking about three minutes to accomplish. If the fee is $89 in addition to the hygiene visit, this could generate an additional $4,272 per month.
The total potential cash flow per month is $5,397. When you subtract the $300 lease payment, the net profit is $5,007.
These projections make it easy to see how a laser might make economic sense for your practice without even taking into account the priceless value of increased patient referrals and job satisfaction it will generate.
