How have lasers advanced dentistry as we know it?

Dr. John H. Jameson speaks with Dr. Christopher Owens about laser technologies, which he describes as "a fantastic fit" in the general practice.

by John H. Jameson
Featuring Dr. Christopher Owens

Dr. John H. Jameson speaks with Dr. Christopher Owens about laser technologies, which he describes as "a fantastic fit" in the general practice. They enable practitioners to perform procedures that have traditionally been ignored or referred out, thus creating a new profit center for the practice.

Dr. Jameson: As we think about changes we have seen in dentistry and look at the ways doctors continually improve their practices to give the image of being a state-of-the-art care facility, we find more and more practices bringing in lasers. For years lasers have been used for many things from tooth bleaching to now actually preparing for restorations. As we look at these advancements in dentistry, Dr. Owens, what do you see in the future of laser dentistry?

Dr. Owens: There are a lot of things going on in the field of laser dentistry. The FDA has already given the Waterlase approval to do hard tissue, soft tissue, osseous, perio, and endo procedures and just about anything else you would want to do with a laser in the mouth. We will continue to see more FDA approvals but of less and less significance because they have already approved 98 percent of the procedures for which we can use a laser in the mouth. The change you will see in the future of laser dentistry is more dentists using lasers in everyday procedures. Approximately 2 percent of dentists have a laser in their offices, leaving 98 percent of practices that could benefit from Waterlase dentistry or laser dentistry. In the next three to five years we will see a significant increase in acceptance of laser dentistry in general dental practices as well as specialty practices.

Dr. Jameson: I have found, predominantly, the people buying these units are general dentists looking to elevate their practices to that next level. If you are a general dentist determining whether a laser would be beneficial in your practice, what are some of the daily procedures for which you could use the laser and make it a profit center for the practice?

Dr. Owens: For a general dental practice, the laser is great for bread-and-butter procedures — operative dentistry, soft-tissue procedures such as frenectomies, crown lengthening involving soft tissue or bony structures. You can use the laser to desensitize teeth and remove fibromas and hemangiomas. A lot of surgeries we were reluctant to do because of the blood, sutures, and postoperative discomfort have become very easy to do with a laser. As for general dentistry, hard-tissue and soft-tissue procedures are where you would be using the laser the most. The Waterlase is used for Class 1 to Class 6 cavity preps, endodontics, periodontics, and osseous procedures. A lot of frenectomies are overlooked because we learned just enough about them in most dental schools to know that we did not want to do them after graduation. The old technique involved using a scalpel to remove the attachment which, of course, led to bleeding and the need to suture the area. With the laser, we can perform almost all soft-tissue procedures in a clean, bloodless, and relatively painless procedure without the need for sutures. Because of this capability, laser owners will be properly diagnosing and treating more soft-tissue procedures. Dentists can perform frenectomies with a laser in 60 seconds to 90 seconds, on average, with very little postoperative discomfort. This is a great service for patients, in stopping recession before a connective-tissue graft may be necessary, and allows dentists to perform procedures that were being ignored or referred out.

Dr. Jameson: As we look at areas aside from the daily routine of a general dentist, we see a lot of continuing education in cosmetic, aesthetic, and implant dentistry. Are there ways that lasers can be used in those expanding treatment areas where doctors can add them to their treatment mix and make their practices more profitable by using this technology? How can we better implement lasers in these areas?

Dr. Owens: Biolase has recently acquired the PAClive program on aesthetic and cosmetic dentistry. Lasers are a fantastic fit in cosmetic and aesthetic dentistry. The great thing about the Waterlase is not only can it do soft-tissue crown lengthening, but it can perform bony crown lengthening as well. If we see that our restoration is invading biological width and getting closer than 3 millimeters from the edge of the bone, we have the option of either laying a flap or using the Waterlase in a closed technique to remove bone to appropriate levels. In an anterior case, many times we will lay a flap and raise the bone up to where we have 3-4 millimeters of bone above our restoration margins. If it is a posterior case where aesthetics are not as critical, we have the option to do closed crown lengthening without laying a flap. Lasers also can be used for receptor sites for pontics. We can remove soft tissue so that we can recess the pontic into the tissue and, if necessary, we can remove bone as well to give a nice, natural appearance of the pontic "growing" directly out of the gingival architecture instead of hanging in midair. Also, in cosmetic dentistry, the laser can be used to do soft-tissue sculpting prior to seating veneers. The LaserSmile system also is used for soft-tissue recontouring and for bleaching as well. The laser can be used to bleach cases before doing crowns and veneer restorations. For tetracycline or fluorosis patients needing a full-mouth veneer case, many times we will use the Laser Smile and lighten the teeth as much as possible. In some cases, they lighten enough that patients will not need to go through with veneers. If they still need veneers, we do not have to make them as opaque as we might have otherwise.

We can use the laser for scar resurfacing or revisions. For individuals who have pigmented lesions such as freckled gums or ethnic pigmentation, we can take the top 0.5 mm to 1 mm of tissue away. When that tissue granulates back, it will granulate in the same color as surrounding tissues. We also use the laser to treat herpetic lesions and recurrent aphthous ulcers. If a patient will come in during the prodromal stage of a herpetic lesion, we can treat it and stop the outbreak before it becomes visible. If the lesion has already manifested, the laser will stop its growth and start the healing process right away. Cosmetic dentistry and lasers are a perfect fit to allow us to do a lot of site-receptor procedures that we have recently learned to do instead of just filling holes in the mouth with objects resembling teeth.

Dr. Jameson: Lasers are being used more by hygienists as well. Can you expand on the development of the field of periodontics and the general practice with the use of lasers in the hygienist's hands?

Dr. Owens: Most states now allow hygienists to use lasers as a part of their periodontal or hygiene program. Most hygienists are using Laser Smiles or diode-type lasers and doing two basic procedures. These procedures are called Laser Assisted Periodontal Therapy, or LAPT, and Laser Bacterial Reduction, or LBR. LAPT involves the hygienist scaling and root-planing the patient, then addressing the tissues lining the periodontal sulcus. A diode laser allows clinicians to selectively target granulation tissue or necrotic tissue and remove it while leaving healthy tissue alone. This is a self-limiting process as opposed to using a curette or a blade. The laser is able to do that because of the differential in pigmentation between necrotic tissue and healthy tissue. Studies have shown that the deeper-pigmented a tissue is, the more laser energy it absorbs and the faster it absorbs it. With low power settings, hygienists can selectively target and remove diseased tissue while preserving healthy tissue.

The second procedure hygienists are doing with the laser is LBR, a procedure that takes advantage of the lasers' ability to kill bacteria within the pocket.

The third thing we can accomplish with LAPT is called Bio-Stimulation. This refers to a diode laser's ability to increase circulation and collagen formation in periodontal tissues. Many studies have been completed on Bio-Stimulation or low-level laser therapy which show low-level laser power applied to soft tissue increases circulation and collagen formation, promoting healing. This is the only tool we have found that can rejuvenate or revitalize the bottom of a periodontal pocket.

The final advantage to LAPT is in guided tissue regeneration. Many hygienists find that if they go into a pocket and treat it one time with scaling and root-planing, sometimes the tissue will laterally reposition itself against the tooth and attach coronally to the bottom of the pocket, leaving a dead space below the attachment that can erupt into a periodontal abscess. One of the great things we can do is that every time we treat a new quadrant, we go into previously treated areas and go around the teeth very quickly with the laser to re-kill the bacteria and bio-stimulate the bottom of the pocket once again. The laser fiber's movement around the tooth mechanically interrupts lateral attachments while encouraging attachment from the bottom up as well as resolution of inflammation from the top down.

Dr. Jameson: With the hundreds of doctors you have worked with and mentored in developing the laser portion of their practices, what kinds of changes have you seen in practice growth and development? Have lasers become a true profit center? Can you give percentage-increase examples?

Dr. Owens: Some of the doctors we have worked with have started calling their LaserSmile the "ATM machine" in their hygiene rooms. It is a device that the dentists themselves can use, but the hygienists also use as a very profitable tool for their offices. Laser periodontal treatment takes their hygiene practices to the next level.

With the Waterlase's capabilities, most dentists find themselves using it on most patients for the majority of the day. They're doing procedures they were previously ignoring and being more efficient with others. Its capability to do most procedures without the need for anesthesia allows treatment in multiple quadrants at one sitting. Most dentists tell me they feel the instrument has paid for itself very quickly.

Dr. Christopher Owens has lectured both nationally and internationally on subjects ranging from cosmetic and implant dentistry to high-tech laser dentistry. He is a founding member of the WCLI (World Clinical Laser Institute) where he has received his Mastership status as a certified laser educator. Dr. Owens is a member of the Academy of Laser Dentistry where he plays an active role on the executive board and on numerous committees. His accomplishments include writing articles for publication on laser dentistry, and helping to develop educational tools for doctors and patients to better understand the roles of lasers in dentistry.

Dr. John Jameson is Chairman of the Board for Jameson Management, Inc., an international dental consulting firm. Representing JMI, he writes for numerous dental publications and provides research for manufacturers and marketing companies, as well as lecturing worldwide on the integration of technology into the dental practice, and leadership. He also manages the technology phase of the consulting program carried out by JMI consultants in the United States, Canada, and Europe. He may be reached at (877) 369-5558 or by visiting www.jamesonmanagement.com.

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