By Samuel B. Low, DDS, MS, MEd
Studies now validate the incorporation of lasers in procedures to assist in managing periodontal disease. Laser wavelength activity is positioned to assist in a positive effect on hard-tissue and soft-tissue components contributing to periodontal pathology. Several states allow delegation of duties consisting of laser procedures to the dental hygienist. With a significant amount of nonsurgical periodontal care already being rendered by the dental hygienist, the addition of laser to the periodontal armamentarium provides a synergistic approach to the patient.
Why a laser?
Periodontal disease is a multifactorial risk condition that has not only a microbial etiology but also a host inflammation component. The bacterial aspect is in the nature of biofilms comprised of a gram- negative anaerobic flora. The response to local factors such as biofilm, calculus, and endotoxins results in a hyperactive inflammatory response that destroys connective tissue and eventual loss of teeth. There also exists an oral-systemic connection.
The nonsurgical periodontal procedure of choice is periodontal debridement (scaling and root planing) generally performed by a dental hygienist. The objective is to remove local irritants from the root surfaces of teeth and thus decrease the inflammatory response. An additional procedure noted as curettage can be adjunctive but is controversial in the literature. Lasers can contribute to health by having the following effects in the oral cavity:
- Antimicrobial: Most gram-negative anaerobes are vulnerable to heat, and lasers can provide thermal conduction. In addition, some laser wavelengths are attracted to pigment and specific organisms found in the sulcus are of a black-pigmented variety. Studies using photodynamic therapy of placing a dye into the sulcus and using laser therapy to seek out the dye and destroy organisms are in the literature. Areas of present and future studies consider the photo-acoustic nature of lasers to destroy bacteria by shock waves as an additional antimicrobial property of dental lasers.
- Debridement of the root surface: Depending on the respective laser wavelength, lasers can have a positive or detrimental effect on roots. All will provide some level of access either by displacing the pocket wall or actually removing sulcular epithelium via a "troughing" process. The tissue-positioning procedure creates an environment to negotiate the root surface more effectively with power-driven ultrasonic devices and respective microthin tips. Several lasers have an affinity for hemoglobin and assist in hemostasis to enhance visualization of the root surface. Removing necrotic surfaces on roots decreases inflammation, and also provides a more receptive surface for reattachment.
- Biostimulation: Low-level laser therapy has caught the interest in medicine for wound healing with significant studies and the associated availability of commercial devices. While there are limited studies in LLLT for periodontal procedures in dentistry, the rationale appears sound in increasing energy at the ATP level, decreasing inflammation and having a positive effect on tissue repair in wound healing.
What laser to acquire?
There are several laser devices on the commercial market. They are classified according to their wavelengths. Each wavelength has a respective attraction to a target, providing a choice of lasers being based primarily on the target tissue. Erbium and CO2 lasers are used for hard and soft oral tissues, and the diode and Nd:YAG are appropriate for soft tissue. Other factors also come into play in choice such as cost, ease of use, size, and effectiveness of the respective procedures.
While the erbium or CO2 may be the laser of choice in nonsurgical periodontics by having an effect on both hard tissue (roots) and soft tissue (sulcular epithelium and connective tissue), they are generally cost prohibitive for the dental hygienist. Cost is also an issue for the Nd:YAG. Therefore, the most common laser in the dental hygiene operatory is the diode laser.
Several criteria should be considered in purchasing a diode laser. Tip size should be thin in diameter (0.4 millimeters) in order to negotiate the sulcus. The clinician may choose a disposable tip to overcome the inconvenience of cleaving a new tip with each use.
The device should be user-friendly with graphic presets for the respective procedure, along with the ability to have continuous and pulsed settings and wattage in the 7 to 10 range for peak power. Physical characteristics include a small footprint and low weight with battery power and cordless foot switches. The primary rationale for these properties is to ensure portability in moving to various operatories as the need arises.
Where to use a laser in nonsurgical periodontal care?
There are varying opinions of what procedures to perform for various periodontal conditions; however, removing or decreasing the microbial etiology and enhancing wound healing/repair are the cardinal principles of periodontal management. The clinician is wise to use appropriate data collection, including risk assessment to make decisions regarding the choice of treatment.
A general rule is to base a choice of surgical versus nonsurgical periodontal care on pocket depth, existence of local factors, furcation involvement, nature of bone loss, and compliance. Nonsurgical periodontal care with pocket depths less than 6 mm, calculus on roots, few concavities, edematous tissue, and horizontal bone loss is effective with periodontal debridement (scaling and root planing) augmented with local laser therapy.
The diode laser can enhance the scaling and root planing effect by its antimicrobial properties, distending the sulcular wall for ultrasonic access, decreasing hemorrhage for improved visualization, and possibly enhancing wound healing by biostimulation. But the reattachment may be the "long junctional epithelium attachment" characteristic of periodontal debridement, and depending on the level of soft tissue debridement, possibly a reduction in inflammatory mediators.
Indications for using the laser could include new-patient periodontal debridement. Also, individual progressive periodontal sites on the periodontal maintenance appointment could be managed via laser procedures possibly with topical anesthesia.
Can a dental hygienist use a laser?
While the majority of states allow a dental hygienist to use a dental laser, the dentist and hygienist should be aware of the respective statutes and regulations. Areas to note should be level of supervision, necessary training/certification, and the circumstances under which a particular kind of laser can be used and how it can be used in those circumstances.
Quality training is essential through groups such as the Academy of Laser Dentistry. As an example, some states allow the hygienist to only perform laser bacterial reduction with an uninitiated tip and less than 0.5 watts while others are more liberal and include use of the device in soft-tissue curettage.
In states that do not allow hygiene laser use, it is suggested that the laser be placed in the hygiene operatory with the appropriate settings and attention to safety protocols. After the hygienist prepares the patient, including anesthesia, the dentist performs laser sulcular debridement on respective periodontal sites to gain access. The dental hygienist completes the procedure with ultrasonic instrumentation.
And, is there a return on investment?
The acquisition of a diode dental laser is not cost-prohibitive when one considers the enhancement to periodontal procedures and use in other dental procedures, including laser whitening and soft-tissue procedures. While there are no reimbursement third-party codes specific to laser management, practices do increase the fee for nonsurgical periodontal procedures by as much as 50%. Developing the appropriate script to deliver a laser treatment plan is key for patient education and acceptance.
As with many areas of effective delegation to our dental hygienists, adding laser technology to periodontal debridement adds value by the antimicrobial effect, access, and overall tissue response, including postoperative patient comfort through biostimulation.
Samuel B. Low, DDS, MS, MEd, is professor emeritus, the University of Florida, and associate faculty of the Pankey Institute with 30 years of practice in periodontics and implants. He is past president of the American Academy of Periodontology and Florida Dental Association and Dentist of the Year by the FDA. Selected Distinguished Alumnus by the University of Texas, Dr. Low received the Gordon Christensen Lecturer Recognition Award. Currently, he is the 17th District ADA Trustee. Contact him via email at email@example.com.
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