All aboard the laser train!
Michael D. Swick, DMD
Many dentists are "technophobes" when it comes to the rapid influx of technology in dentistry. The pace of change is incredible! In this dentist`s opinion, these changes are inevitable. Until recently, we`ve performed restorative dentistry with techniques largely unchanged since the 1890s - the only profession in medicine to do so. On one hand, this is a tribute to the teachings of Dr. G.V. Black. However, this resistance to change is a smudge on our profession.
One way many dentists resist change is by using the excuse of "waiting for the technology to be perfected." The basic nature of technology today is that it will never be perfected; it just evolves. The train is leaving the station. For those of you perusing the travel itinerary with thoughts of taking the trip, take the ride - you won`t be disappointed! Those of you refusing to board the train just might miss the trip completely.
Both doctor and patient can benefit from four major areas where lasers can be used in the general dental practice. The patient benefits from precise treatment in which the discomfort normally associated with dentistry is greatly reduced or eliminated. An added benefit is that the high-tech quality of laser dentistry frequently instills within the patient a perception of better treatment. The dentist benefits by simplifying often difficult treatment options, which can reduce the acute stress often associated with treatment and enhances the practice`s income potential.
The first area where lasers can be utilized is in the diagnostic arena. The long-awaited approval of KaVo`s Diagnodent Laser by the FDA gives microdentistry practitioners some real indication of the severity of the decay located in the occlusal fissures of teeth. For those of you who have not followed the evolution of microdentistry, it is a relatively young arm of our profession. It began in the little town of Refugio, Texas, in the office and intellect of Dr. J. Tim Rainey (see Dr. John Jameson`s article, "Q & A With Dr. Tim Rainey, Father of Air-Abrasion Dentistry," in the March issue of Dental Economics). The principles of microdentistry advocate minimally invasive preparations to conserve tooth structure. KaVo`s Diagnodent Laser is the perfect tool for aiding the diagnosis of carious lesions, which lend themselves to minimally invasive dentistry. The explorer, the method of choice in the 1890s, has been rendered virtually useless in the 1990s due to successful fluoridation.
The Diagnodent Laser works on the principle of quantitative fluorescent iridescence. A laser beam of 655 nm wavelength is projected into the tooth. The natural fluorescence of the tooth enamel is calibrated out, so that the decayed tooth structure then fluoresces. This fluorescence is reflected back to the probe and is read as a measurement. This measurement reflects the amount of caries that is present in the affected fissure.
This instrument is a valuable addition to the microdentist`s armamentarium. It aids with the decision about when to treat, a difficult one to make, at best. Prior to the Diagnodent, caries-detection dye was used to locate affected fissures, but we could not assess the extent of the decay without opening the fissure with air abrasion. On occasion, a fissure would be opened prematurely, and a sealant would be placed rather than a restoration. Now, the dentist has a quantitative instrument, which can accurately monitor the spreading of caries in a way that does not bring with it the possibility of unnecessary treatment.
The accuracy of this instrument provides a win/win situation for the dentist and the patient. The patient is provided with the most accurate diagnosis available. When the Diagnodent is used properly with the other diagnostic modalities at the modern dentist`s disposal, carious lesions cannot progress unnoticed, nor are they treated prematurely. This saves the patient (and third-party payers that reimbursement them) from unnecessary treatment in its earliest stages and from more extensive treatment in the disease`s later stages because the diagnosis was made too late.
The dentist benefits by using his or her time more appropriately. No longer is the doctor scheduling time for major restorative treatment, only to find a sealant is all that is needed. The dentist also benefits from heightened patient opinion by using a technologically advanced, scientific method of diagnosis. Because this instrument is so new, third-party reimbursement is not available. If current trends hold true, it most likely will be lumped into the exam category, rather than being reimbursed as a unique entity, the way it should be. However, the good news is that this laser is available at a nominal cost, compared to the cost of other lasers.
My friend and colleague, Dr. Jon Karna, also reminded me that the argon laser, at 488 nm, has a distinct place in laser diagnosis. It is superb for the diagnosis of cracks in teeth and in transillumination for the location of carious areas interproximally.
Curing composite resins
The second area in dentistry where lasers are valuable is in the curing of composite resins. The most popular manufacturer of curing lasers in the market today is LaserMed. Its Accucure Elite is a workhorse that just keeps curing and curing. Argon lasers were the first instruments to make inroads into the rapid-curing market. Many others exist today. Curing with lasers is more rapid than with conventional lights. Camphorquinone initiators are a must for laser-curing, because the argon-curing laser produces photons at only 488 nm. All but a few composites and bonding agents cure at this wavelength.
The major advantage here is that there are no excess photons giving off excessive heat to the pulpal tissues. All of the photons are used in the curing process; therefore, curing occurs at lower milliwatts of power. The highest diametral tensile strength in the 200-300 MW range was produced with the argon laser (Kelsey W.P. et al, J. of Clinical LaserMed & Surgery. Vol 10 No. 4, 1992). The laser also has the advantage of being able to be titrated to produce the optimum power for the specific resin being cured. LaserMed has actually performed tests on various composites and can give you the proper parameters for curing. A little known fact is that Ostler, Ostler, and Kaufman of LaserMed are the inventors of the method for modulated curing and hold a patent on it. (US patent 6,008,264 for those who are interested and have interesting information on composite-curing for the production of the best characteristics in the composite.)
The argon laser also does a great job in the arena of vital bleaching. The fast-food generation of today is not always patient enough to wait for take-home bleaching to gain the desired effect.
A little-known area where the argon laser can be used is in increasing caries resistance. Research done by Hicks et al has shown significant increases in caries resistance in enamel and also on root surfaces.
The LaserMed argon laser is again a win/win situation for the dentist and the patient. The patient benefits from a better quality of composite-curing, less heat to the pulpal tissues, and quicker treatment times without sacrificing quality. The dentist benefits from decreased individual treatment time, fewer postoperative complaints, and the patient`s perception of a high-quality, up-to-date practice because of the investment in new technology.
The third area in dentistry where lasers are coming of age is in hard-tissue removal. The Continuum Biomedical Er:Yag is a superb addition to the technologically-advanced dentist`s arsenal. This dental laser definitely excels in the preparation of small to moderate and occasionally large carious lesions for composite restorations. My feeling is that it does not replace air-abrasion in the restorative dentist`s arsenal, but it is a valuable adjunct to it. Some dentists, though, prefer this laser to air-abrasion because it eliminates the dust.
The erbium laser`s biggest advantage is that it is a superb caries-removal tool. Other advantages of the erbium laser are significantly improved patient comfort, no waiting for anesthesia, the ability to practice more conservative dentistry, the ability to treat multiple quadrants in one sitting, exceptional qualities for pedodontics, less rise in pulpal temperature than that found with the dental drill, the bacteriocidal nature of laser energy, the laser`s ability to prioritize the cut of carious dentin, greater patient satisfaction, and more referrals due to an enhanced practice image.
These factors again generate a win/win situation for the dentist and the patient. The patient benefits by receiving more conservative treatment, not needing anesthesia, and improved comfort during the procedure as a result of less heat to the pulp. The dentist benefits by being able to perform multiple restorations without anesthesia, and from the elevated practice esteem which comes with the presence of this high-tech device. The practice also is likely to see an influx of new patients who are referred to you because they are afraid of the drill. These are patients who have not seen a dentist in a long time and who don`t particularly care if you participate with their insurance plan. What they want is "drill-free" dentistry.
The fourth area of laser usage in dentistry is the oldest. In my opinion, it is the most important area - soft-tissue surgery. Lasers can be used to perform a myriad of soft-tissue procedures. The 10,600 nm wavelength of CO2 and the 1064 nm wavelength of Nd:Yag were the original wavelengths used in dentistry. More recently, the solid-state diodes were introduced. These small, very portable, maintenance-free lasers are destined to become the workhorses of the dental industry.
The CeramOptec 980 nm diode has surfaced as a unique laser for intraoral use. The physics of this wavelength makes it extremely suitable intraorally. The laser`s wavelength exists at a harmonic absorption peak in water, which gives it the capability of tissue ablation by vaporizing water. (Tissue is 97 percent water; therefore, water absorption in a tissue-cutting laser is desirable. However, excessive water absorption can limit penetration to a less-than-desirable degree.) This feature - in conjunction with the wavelength`s absorption in hemoglobin and oxyhemoglobin - makes it a very desirable intraoral wavelength. The wavelengths of CO2, Er:YSGG, and Er:Yag are much more highly absorbed in water than the 980 nm wavelength. As a result, their effects are much more superficial with extremely friable hemostasis in hyperemic tissues, even when excessive heat is applied.
I routinely use the 980 nm diode laser to make incisions through the periosteum to the bone. I also use it to remove granulation tissue to the bone in healthy patients, and I have never experienced an adverse bony effect. Other wavelengths cannot be used in this manner.
Periodontics is another area where the general dentist can benefit from this diode laser. Procedures such as free gingival grafts with Alloderm, guided-tissue regeneration, and bone grafts are just a few of the standard periodontal procedures that can be accomplished in a blood-free field. This technique results in less postoperative pain than using a blade. An important benefit of laser-cutting is the sterilization of the wound, as well as the only postulated, but not yet elucidated, biostimulation effects that are present.
Periodontists are skeptical about the ability of lasers to adequately treat periodontal disease. However, Drs. Robert Gregg and Delwin McCarthy have submitted a study for publication which shows not only substantial gains in osseous height, but also substantial gains in bone density from their ENAP [Excisional New Attachment Procedure]. They substantiate this through the use of digital subtraction radiography.
The Ceralas D15 can be used for Dr. Jorge Pinero`s PPSP [Pinero pre-cardiac surgery protocol] procedure. Dr. Pinero is involved in treating cardiac patients prior to surgery with laser energy. He has shown no transient bacteremias, elimination of streptococcus A from the gingival sulcus, and a significant decrease in the failure of valve- replacement surgery.
Laser gingivectomy and crown- lengthening are two valuable procedures that are available to the dentist. Gingivectomy can be accomplished at the crown-preparation appointment with very predictable gingival response and a bloodless field for impression-taking. The advantage to the dentist is that a separate appointment is unnecessary and usually no additional time needs to be scheduled to perform the additional procedure.
Crown-lengthening can be accomplished in a similar manner with a few changes in incision technique. The operator can make a micro flap and remove bone with either an end-cutting diamond burr or, better yet, an erbium laser. Adequate attached tissue is paramount for the single-appointment technique. If it is not available, a more conventional laser- assisted periodontal procedure should be selected.
Cosmetic recontouring of the upper anterior teeth, a specialized type of gingivectomy, also can be easily accomplished at the laminate- preparation appointment with superb results. Tissue-removal for gaining access to subgingival decay is another area where the CeramOptec laser excels. This laser will provide the general dentist with a bloodless field, which is free of the lymphatic oozing when bonding composite restorations. The CeramOptec Ceralas D15 is even approved for bleaching.
The good and the bad
Now comes the good news and the bad news. Dental lasers are expensive - that`s the bad news. Paying for your laser and generating income is the concern of most dentists. Unfortunately or fortunately - depending on how you view it - insurance companies do not recognize lasers as something they should pay more for.
Starting with the diagnostic laser, the Diagnodent, the cost is minimal compared to other dental lasers. Insurance should pay a separate fee for the superior diagnosis, but it does not. On the plus side, though, the laser aids the restorative dentist in more adequately scheduling his or her time and, as a result, it pays for itself easily. Build the cost into your exam fee and educate patients about the benefits.
The curing laser, the LaserMed, also has no insurance codes to help with reimbursement. The plus here is that it helps the dentist speed up procedures, particularly in a composite-only practice. We`ve all seen the figures on how much time can be saved by curing in 5-10 seconds versus the extended time needed with conventional lights. The LaserMed also can help generate substantial income if your practice markets in-office bleaching as part of its cosmetic services.
The hard-tissue laser, the Continuum Biomedical Delite, will speed up treatment time by frequently eliminating the need for anesthesia. Multiple small and moderate restorations can be completed at one appointment, with the patent in total comfort. Insurance will not pay any additional funds for restorative procedures. I raised my composite fees across the board and generated enough additional income to pay for the laser and make a reasonable profit from its use. The laser is used on every preparation to remove decay, even if the drill is used to remove amalgam.
The soft-tissue laser, the CeramOptec Ceralas D15, can generate a tremendous amount of income in short periods of time. Paying for it is easy. Without adding additional time, laser gingivectomy during composite placement, and laser gingivectomy during crown-lengthening procedures, can be done in minutes during the course of normal restorative and crown-preparation appointments. Complete cosmetic recontouring to improve a smile can be done in as little as 20 minutes, generating fees in the $1,500 range and up. The Ceralas D15 can easily generate fees in the $3,000/hour range if used effectively. Insurance will cover laser-assisted periodontics in the same way that conventional periodontal treatment is covered.
Patients are in love with technology. They will gladly pay for it even if their insurance won`t reimburse them. In fact, they will seek you out, they will refer to you ... and they might even start to like you. Take the ride!