Do lasers deserve the flash in the pan stigma? It depends on how diverse a practice is.

Aug. 1, 1998
You are performing a Class Five restoration on tooth No. 6 when you suddenly realize that the decay is deeper than expected and extends subgingivally. You need to do a gingivectomy in order to complete the restoration. Two choices exist.

Harvey Passes, DDS

You are performing a Class Five restoration on tooth No. 6 when you suddenly realize that the decay is deeper than expected and extends subgingivally. You need to do a gingivectomy in order to complete the restoration. Two choices exist.

Take a blade and mechanically cut away the tissue. You must then deal with the problem of hemostasis. This prevents you from having a dry, decontaminated field. There also is the unexpected issue of time needed to stop this bleeding.

Your other choice is to simply take your laser and aim it while you sculpt the tissue, at the same time causing hemostasis. The patient`s postoperative condition is uneventful. This is accomplished in a matter of about a minute.

This is just one of the features, advantages, and benefits of using a laser in dentistry. Given this choice, which one would you choose? (For those who use radiosurgery, see the end of this article.)

Today, the public and the profession treat lasers as something new to dentistry. The fact is that lasers are not new to the dental world. The literature mentions laser research in dentistry during the 1960s. The clinical practice of lasers in dentistry was not seen on a more routine basis until the 1980s.

When used to produce a desired effect in an ethical manner, lasers are exceptional models of treatment for many clinical conditions that dentists treat on a daily basis. One of the greatest advantages of laser use in dentistry is the high rate of patient acceptance. Today`s informed patient is aware of the laser and its advantages over traditional forms of therapy. Lasers have opened the door to a high-tech, rewarding, and potentially profitable arena that is beneficial to the patient.

Simply described, the laser is a device that produces light from a specific wavelength. IT can then be absorbed by tissue to produce a desired therapeutic result. The scope of this article will not include a review of the physics of each laser. For this information, I refer you to Lasers in Dentistry, edited by Miserendino and Pick, published by Quintessence.

This article will provide information about the clinical applications of the various lasers presently available in the United States. It will explore some price tags, offer opinions from some of the early pioneers, describe how the ethical use of lasers is being instructed and policed by the profession, and examine the laser`s future for the dentist and patient. Is this truly a technology that has a lasting place in our profession or a momentary "flash in the pan"?

Various lasers are used in dentistry today. Lasers vary in wavelength and application. The Argon laser is used primarily for curing composite restorations and one-visit tooth-whitening. It also is used for soft-tissue surgical procedures. The Diode laser is one of the newer technologies. Its main function is soft-tissue surgical procedures. It quickly is becoming one of the lasers of choice due to its reasonable price tag, physical size, and precision.

The Nd:YAG (neodymium:yttrium aluminum garnet) has been one of two early workhorse lasers for the general practitioner. Its range of applications seems to have no bounds. The other workhorse laser is the CO2. This wavelength offers special advantages for gross soft- tissue surgery not found in the other lasers.

The Holmium dental laser (for which I have a special affection) is used for soft-tissue procedures requiring more muscle thanthe Nd:YAG can provide, but less than that offered by the CO2. Holmium also has the ability to be used in hard tissue. However, at this time the Food and Drug Administration has not given clearance for hard-tissue use with this laser except in TMJ cartilage surgery.

Lastly, the Erbium laser is approved for both hard-and soft-tissue uses in the United States. It can vaporize decay and shape enamel and dentin for restorative procedures.

The lasers used in dentistry are manufactured by a handful of companies. Each company that develops a laser must have the product approved by the FDA. The FDA has strict guidelines so that companies do not market lasers for procedures other than those for which they were approved. Therefore, even if a company manufactures a laser that already has been manufactured and approved for a specific procedure by another company, it still must have its laser approved by the FDA.

Some of the companies that currently manufacture or distribute lasers within the United States, in no particular order, include: American Dental Technologies, which produces an Nd:YAG laser; Biolase, an Erbium laser; Premier, Diode, Erbium, and Argon lasers; Lares Research, an Nd:YAG laser; ILT, CO2 and Argon lasers; LaserMed, an Argon laser; Sharplan, a CO2 laser; Excel, the Holmium and Nd:YAG lasers; Luxar, a CO2 laser; Kreativ, a CO2 laser; and Millenium Technologies, a perio laser.

As stated earlier, in the United States, the predominant use of lasers is for soft-tissue and bonding procedures. For about $6,000 to $39,900, the following lasers can be purchased: CO2, Erbium, Argon, Diode, Nd:YAG, and Holmium.

"The laser is now an affordable tool for the dentist to keep in his tool box," said Dr. Donald Coluzzi, practicing dentist, professor of dentistry at the University of California at San Francisco, and president of the Academy of Laser Dentistry. "Previously, with the first few lasers running in the six-figure range, dentists often shied away from purchasing a laser for fear of not being able to recoup the money invested. That is no longer a concern."

As a soft-tissue instrument, the laser is used in various surgical and cosmetic procedures. While the FDA governs what procedures are approved in the United States, there is no such body to govern the use of lasers overseas. Therefore, applications currently being used in the European market are not practiced in the United States.

Here is a brief description of some of the applications of the laser that have been FDA-approved. For periodontal disease, the laser can be used to precisely remove layers of gum tissue one at a time. Often, a person may have a fibroma in the mouth, typically from biting one`s cheek. These fibromas can be removed easily and virtually pain-free in a matter of seconds.

For individuals who have undergone an organ transplant or have a seizure disorder, cyclosporin or Dilantin may be prescribed. These medications can produce gingival hyperplasia. In this case, the excess gum tissue can lead to periodontal disease. In a preventive measure, the dentist can use the laser to remove or sculpt the excess tissue prior to the onset of the disease. Lasers are used if a wisdom tooth needs to be removed in a procedure that incises the gum.

The patient, while in the office, may comment that he or she has a canker sore. The dentist can use the laser to excise the canker sore. This could reduce symptoms while healing occurs. If an individual is diagnosed with ankyloglossia, a condition where the lingual frenum is uncharacteristically large or connected to the tongue in a manner that impairs speech, the muscle can be sculpted with the laser. The benefit to the patient is a virtually bloodless surgical site with minimal discomfort.

For crown and bridge procedures, tissue retraction also can be performed with the laser. This minimizes the need for placement of the retraction cord. This list of applications seems endless. And as hard tissue applications begin to become commonplace, as they are in Europe, the list will grow.

Lasers also can be used for hard-tissue or tooth repair. Currently, the only laser cleared for marketing for hard tissue is Erbium. This laser can vaporize caries and composite material. It can be useful in preparing a tooth for a restoration. Presently, the Erbium laser cannot remove amalgam or gold restorations. The laser`s interaction with metal is such that it cannot be used on an existing filling unless it is a composite.

A very popular application of the Argon laser is to whiten the teeth. Argon reacts with specially prepared dental bleaches to actually whiten the teeth multiple shades in just one visit. The whitening process usually continues for a few days after the in-office treatment is completed.

John Sulewski, director of education and training for The Institute of Advanced Dental Technologies, explained that while all of these procedures have been approved in the United States, the FDA does not regulate techniques and equipment used in the worldwide dental community. Therefore, many of the procedures of the future in the United States currently are being applied in the European community.

Some of these procedures include: desensitization of hypersensitive dentin, induction of temporary pulpal analgesia, and modification of the surface of dental enamel for bonding.

Mr. Sulewski continued to explain that one particularly intriguing procedure, using a frequency times two alexandrite laser, would selectively remove tartar from the tooth while leaving the underlying tooth intact. According to U.S. dentists, this procedure, while very appealing, is not very practical at this time based on the high price of the laser. It`s difficult to maintain and is a complex procedure.

Another procedure involves using low-frequency lasers to produce certain effects such as pain relief, wound-healing, and collagen growth. The results of these European studies have not been duplicated and cleared by the FDA for use in the United States at this time.

According to Dr. Steven Glassman, a private-practice, cosmetic dentist in New York City,"The laser affords the general dentist the ability to perform procedures that were once sent out to specialists. This is a benefit to both the patient and the dentist. From the dentist`s point of view, the laser allows him or her to perform complicated procedures in-house. There also is no time lost in sending the patient out to the specialist. The dentist is able to increase his fees substantially, based on the extra service being provided.

"The laser often increases the precision of the service they now can provide. The practitioners benefit from the ability to be more efficient in their procedures. No packing is necessary during surgical procedures, and healing is more predictable. Hemostasis can be more effectively controlled. There is less stress on the practitioner as a result of working in a dry, clean environment. The procedures are fast, quick, and easy. Most dentists feel that the laser is definitely worth its price tag, as it allows them to provide advanced treatment and increased services, which, in turn, allows them to increase fees."

Dr. Glassman wnmt on to explain that while the dentist reaps the financial reward of laser applications, the patient rarely feels the effects in this cost difference. This is because the fees of the procedure may be less than the cost associated with sending the patient to a specialist, where the cost to the patient most definitely would be higher.

An even greater delight for patients is the fact that cavity preparation for operative dentistry has traditionally relied upon mechanical hard-tissue surgery with low- and high-speed air turbine handpieces. These mechanical devices are associated with irritating noise levels and, oftentimes, uncomfortable vibrations transmitted throughout the jaws and craniofacial tissues. In most cases, local anesthesia is required in most cases since mechanical cutting into dentinal tubules is painful.

Various alternative methods of cavity preparation have been searched for, in the hope of finding a more acceptable instrument without the same negative aspects regarding the bur. The Erbium dental laser may fill this need.

Dr. Glassman concluded by stating that dentists generally feel that the laser gives them a tool that allows them to have more "fun" practicing dentistry than they have with traditional instruments.

In their 1993 article in Dental Clinics of North America, Dr. Robert Pick and Dr. Lynn Powell said that laser systems are a prime alternative and now are utilized widely in soft-tissue surgery.

Mr. Sulewski said lasers have a very bright future in dentistry. "There is more science being reported now than ever, with some 3,000 laser citations since 1963. The dental application of the laser is expanding to other medical disciplines as well."

Mr. Sulewski points to recent findings by the American Academy for the Advancement of Science, which proposed a direct correlation between periodontal disease and the onset of heart attacks.

"The link between systemic disease and periodontal disease is becoming clearer. The dental laser, as it is applied to the treatment of periodontal disease, may be used soon by the dental practitioner as a weapon against conditions such as heart disease and osteoporosis," he said.

While many dentists would have reason to concur with Mr. Sulewski`s optimistic outlook for the dental laser, there are those, while satisfied with the current development of the laser, who continue to look for newer, cheaper, and more practical ways of doing things.

Dr. Kim Kutsch, a private-practice dentist from Albany, Ore., notes, "About 3 percent of the dental community utilizes the benefits of laser technology. Those who do not typically feel as if they have not been properly trained or feel that the laser is not worth the cost. The remainder are comfortable with the procedures as they have been performed over the years or are resistant to change."

Dr. Kutsch feels that there may be more practical applications that produce equally effective, if not better, results. "In my efforts to develop the most cost-effective, patient-friendly procedures, I have come to the conclusion that the laser may be replaced by other means in the future."

Dr. Kutsch cites examples of nonlaser bleaching and bonding lights, as well as air abrasive technology.

Over the past decade, laser technology has prompted many clinicians to take note of the wonderful opportunities this bright light offers. The Academy of Laser Dentistry was the offspring of this interest. The ALD serves as a clearinghouse for new laser technology, its education, and ethical use.

Dentists interested in learning more about this advanced technology and courses that are given throughout the world are urged to call the ADL executive director at (248) 548-7171.

For those of you who enjoy radiosurgery, I feel the laser is a worthwhile and effective instrument. I also feel that the dental laser offers more diversity in treatment therapies.

Is the laser a valuable instrument in the dental office or just a "flash in the pan"? To be a truly effective dentist, one must have in his or her practice a large and varied inventory of services. There is no one instrument or service that will ever be a panacea. The dental laser, however, does offer the greatest diversity of services for our patients. As Dr. Coluzzi noted, the laser is merely one tool in the dental arsenal, and he would not recommend throwing away the textbook just yet.

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