by Martha Cortés, DDS
When assessing the dental practice, the dentist's outlook and the type of practice he or she enjoys are major contributing factors to success. Lasers are an expensive investment, but, to my mind, they are an essential part of a modern practice and worth every dollar — as the return in satisfaction for both patient and doctor is priceless.
Lasers attract the community of patients looking for a painless and alternative approach to traditional dentistry. The steps of practice profitability are: enjoying the work, the practice, the patients, and the tools that allow a practice to blossom into a financially satisfying establishment. Patients enjoy knowing that the practitioner is up-to-date with modern dental practices. Lasers sometimes can transform normally noncompliant patients into totally compliant and willing patients that commit to necessary restorative and surgical dentistry. I believe the following three cases will prove my point.
Case one: A twenty-five-year-old female presented with an oral abscess, facial cellulitis, three fractured and carious endodontically treated teeth, a loose temporary acrylic bridge held in place with denture adhesive, edematous soft tissue, foul taste, and bad breath. She was in pain and unhappy about her dental condition. Although an emergency case, this patient also was concerned about the aesthetic portion of her smile, but had obviously avoided the dentist for a long time. Besides pain and emergency management, the patient desired beautiful teeth to enhance her career as a model and actor.
I explained that the condition of her mouth would ultimately effect the aesthetic outcome, and that a good, structurally sound, and functional oral cavity was the first step in creating excellent aesthetics. I also explained to my potential patient that a large portion of my dentistry utilizes the laser as a main or adjunct tool that speeds up the dental process and makes some techniques relatively painless.
Even though she was anxious about the work and noncompliant in the past, she agreed to start with the basics and work toward the aesthetics for the future. Laser dentistry provided her the springboard to compliance and commitment to total restorative work.
Since the molars were so broken down, they were extracted using a modified laser-assisted Widman flap technique. Purulent exudate was drained and the inner portion of the modified flap was lased with the Nd:YAG laser. The necrotic tissue was removed, establishing availability for bone regeneration. Pockets of infection were eliminated with the laser. The laser initiates an acute inflammation response that causes leukocyte activity and biostimulation of the infected area.
The patient also suffered from periodontal disease, with pockets ranging from 4 to 7 mm that required immediate attention and treatment. Laser ENAP (Excisional New Attachment Protocol), as created by Robert Gregg, DDS, and Delwin McCarthy, DDS, was used to eliminate the periodontal disease and promote gingival reattachment; the gingival pockets are not cut or sutured in this method. This technique is used in combination with conventional scaling and root-planing as an alternative to traditional periodontal surgery. The laser minimizes the loss of soft tissue during surgery because only the necrotic tissue is removed — allowing for soft-tissue reattachment and conservation of gingival tissue. In addition, the technique is minimally painful and recovery from surgery is quick, resulting in minimal pain and discomfort. Patients who have had prior nonlaser periodontal surgery find lasers less invasive and aesthetically superior because of the conservative nature of the surgery.
The laser's fiberoptic tip is premeasured to the pocket depth, and then inserted to the root surface and tilted toward the gingiva in contact with the epithelium. The laser is used to debride the necrotic tissue and to eliminate the bacterial infection. Between 97 and 99 percent of the bacteria that causes periodontal disease is eliminated by the thermal and photo action of the laser.
Starting from the gingival margin, the tip is gradually taken to the depth of the pocket as it is moved back and forth, removing epithelial margins and inflamed necrotic connective tissue with a sweeping motion. Plume and debris are removed using a high-volume evacuation device. Each pocket is lased for approximately 30 seconds, using 20 hz (pulse per second), and 2.5 w (watts) cross-sweeps totaling 30 seconds inside each pocket.
Ultrasonic scaling and light root-planing is then performed. All sites are rinsed with povidone-iodine followed by a saline solution, then examined for remaining diseased tissue. A final laser sweep is set at 20 hz (pps) and 3 w for the final seal. Folded wet gauze is placed and compressed for two minutes at the laser site, where the tissue is held in place over the alveolar bone.
The laser-assisted extraction sites are treated in a similar manner to the laser ENAP procedure. This is done to reduce the bacterial load at the extraction site.
Prior to extraction, the gingival tissue is lased and the site is sonically and mechanically scaled and lightly root-planed. Following the extraction, the inner connective tissue is lased for almost 30 seconds at the 20 hz (pps) 2 w setting. The actual extraction site is lased for 30 seconds at 15 hz (pps) and 1.5 w using circular motions inside the socket, and remaining clear of the bone. This initiates blood coagulation and tissue welding. Wet gauze is then placed on the area surrounding the extraction site; the tissue is then placed over the alveolar bone with wet, cold, gauze, compressing it for two minutes.
In this particular patient, a failed root canal needed retreatment. The laser followed the mechanical cleaning and shaping of the canals. When the canal is dry, the laser tip is used with a constant circular sweeping movement up and down at a setting of 15 hz (pps) 1.5 w for 30 seconds, followed by sulcular debridement of the surrounding area at 25 hz (pps) and 2.5 w for 30 seconds. This decontaminates the outer and inner aspects of the tooth and canal.
The patient was delighted by the treatment, and, as a result, decided to go for the restorative treatment as well. The initial aesthetic portion involved a complete laser bleaching in combination with a take-home bleaching kit. In the end, this patient had two PFM noble-gold bridges, one porcelain crown, and seven porcelain veneers. Because of her initial positive experience with the laser, the patient overcame her recalcitrant behavior, completed the necessary basic work, and finished with a beautiful smile.
Case two: A man in his mid-40s with severe periodontal disease and associated tooth mobility presented for a clinical examination. Charting indicated a Class III-IV, generalized, severe periodontal disease with extensive horizontal and vertical bone loss. Charting further indicated Class 2-2.5 mobility of 12 teeth, and periodontal pocket depths in the 10 mm range on both lingual and buccal sides on many of the teeth. He had pus and associated halitosis, accompanied by a low-grade fever. The patient also stated that when he awoke in the morning, his pillow would be blood-stained.
The patient had consulted with numerous nonlaser periodontists and dentists before he consulted with us for laser surgery. He was hoping to avoid having multiple teeth extracted, loss of gingival tissue, and dentures. The patient was not pleased with the nonlaser diagnoses or surgical options, as they required extensive oral surgery and open-flap surgery for the excision of his thoroughly compromised gingival tissue.
The patient wanted an alternative, and thus sought us out for laser surgery. The patient had severe mobility and pain, and needed immediate care. Maintaining tooth and gum integration for as long as possible was his aim; however, he was fully aware that some of his mobile teeth might not be salvageable.
The purpose for the laser in this case was to remove diseased and inflamed soft tissue in periodontal pockets, and to possibly stimulate bone and ligament regeneration. The laser vaporizes bacteria, diseased tissue, and pathologic proteins while conservatively maintaining gingival tissue for future reattachment. Inflamed sulcular and pocket epithelium is excised without substantially removing any connective tissue. The patient was treated in the same manner as the patient in the first case; the only difference was that each pocket was lased for 60 seconds instead of 30 seconds.
Due to the severity of Class III-IV periodontal disease, inclusive of detached gingival tissue, aggressive initial sulcular debridement was followed by laser curettage utilizing 20 hz 3.0 w. The purpose was to provide removal of the necrotic debris, bacterial decontamination, and drainage of purulent exudate.
As stated, the laser mechanically destroys the bacterial load and introduces a local immune response via acute inflammation because of the thermal and photo activity. The photo-thermal effect vaporizes necrotic tissue and microbes, so that proteins, enzymes, and other biological molecules denature and shrink, releasing a cascade of cytokine response boosting the local and general immune response and restoring homeostasis to the site.
Periodontal probing and a full-mouth radiographic series were performed prior to initial laser treatment. Patients are required to return after one week for examination of the laser site. This is followed by a one-month, three-month, and finally, a six-month followup with a periodontal probing and a new FMX to compare with the initial perio chart and radiographs.
Complete healing may occur after a full year has passed, as attachment levels may continue throughout the year with regeneration of new bone and ligaments. (Regeneration is specific to the state of health of each patient, and may vary greatly among individuals.)
The patient was ecstatic with the treatment, because his response was excellent. Part of his treatment also included occlusal equilibration and the use of a Tanner splint. Periodontal pockets were reduced by half — from approximately 10 mm pockets to 6-5 mm pockets. The four lower anterior teeth were periodontally splinted to ensure anchoring of the teeth in the bone and to prevent further mobility. The upper left quadrant also was splinted to prevent supereruption of tooth No. 4, as the tooth was being pushed up and outward from the bony socket. The pus and halitosis were eliminated. The patient also felt physically better and stronger, and the low-grade fever disappeared.
His teeth progressively anchored into the new bone and ligament structure. Overall, he responded splendidly to treatment as the bone filled in nicely. Within a year, his teeth were no longer mobile and pocket depth decreased to 3-5 mm, depending on his home care. The patient was once again able to eat hard foods, such as apples.
The patient has remained stable for the past four years, with pockets depths stabilized between 2-3 mm. He experienced bone regeneration, no more tooth mobility, and no loss of any of his teeth, which was his desired outcome from the beginning.
This patient now comes in every six months for oral hygiene treatment and has introduced his wife and friends into the practice. This individual, who is involved in public relations, has referred many patients with similar periodontal problems for laser treatment.
Case three: A patient referred by a holistic M.D. presented with an infected molar for possible endodontic laser treatment. This tooth was the anchor for a five-unit temporary bridge — the restorative case could not be continued because of the condition of tooth No. 15. The referring holistic practitioner was not in the habit of sending patients for endodontic treatment because the condition is believed to be a focal infection. This type of infection is not considered to be treatable by the holistic medical world. The tooth would, in fact, normally be extracted. This was an important tooth to the patient; without it, there would be no anchor for the future bridge. The holistic practitioner had heard about the use of lasers in endodontic treatment and decided to try it as a possible way of saving his patient's tooth and future bridge.
The patient was a middle-aged man — a patient of an alternative practitioner who had successfully treated his wife for cancer. As a result, he was a convert to alternative medicine. This was an initial infection of tooth No. 15, but it also had an 8 mm mesial defect, a bony defect, and converging roots that made the tooth unstable.
The tooth is initialized with the mechanical removal of the pulp chamber; the canals are shaped and cleaned normally. However, no noxious chemicals are used for bacterial elimination or to destroy remaining tissue. A saline solution and EDTA are used for lubrication and reinstrumentation of the canals. Once the canals are fully shaped and cleaned, the laser is used to debride any remaining tissue and for optimal bacterial elimination.
The canals are dried and the laser tip is inserted with a constant up-and-down circular sweeping motion at a setting of 1.5 w at 15 hz (pps) for 30 seconds, followed by sulcular debridement of the surrounding area at 2.5 w with 25 hz (pps) for 30 seconds. The periodontal aspects were treated in the fashion described earlier (laser ENAP) to help eliminate the mesial defect and help anchor the tooth fully into the bone.
The laser root canal is not a one-visit treatment; it may require multiple treatments to assure an infection-free tooth — a requirement by alternative practitioners who use techniques to test for infection. When it is ready to be completed, the canal is filled with Biocalex instead of gutta percha. Biocalex is a metal-free calcium hydroxide that expands into the canals and dentinal tubules. It is very close in composition to bone matrix. The only possible drawback of Biocalex is that it is not very radiopaque and may only appear as a shadow in radiographs.
As a result of how the laser is viewed by the holistic medical community, many other referrals have come from holistic practitioners as well as from many patients who want alternative dental treatment.
Lasers = Opportunities
Lasers allow dentists to think in new ways. Patients are attracted to the modality of the laser because of its modern technology, versatility, and creativity. Lasers have held a mysterious and compelling sci-fi image to the public since their inception in the mid-twentieth century.
It is definitely a modality that belongs in a twenty-first century dental practice. A twenty-first century practice is very attractive and appealing to a population that normally avoids dentistry because of its association with the drill. The laser allows patients to see beyond their fears — to a healthy and beautiful smile.
