It's NOTyour dad's dental laser

By Robert Gregg, DDS

Dental lasers no more resemble lasers of 15 years ago than today's desktop computers resemble computer technology, performance, and utility of 15 years ago. Can anyone seriously suggest that computers have not had mind-boggling advancements in performance and capabilities in the past 15 years? OK, so when a dentist says in 2004 that his or her last look at lasers in 1994 did not reveal enough science, performance, reliability, capability, clinical procedures, FDA clearances, or return on investment, it is probably time to take a new, conscientious look at what dental lasers are all about today — if for no other reason than 81 percent of people surveyed by the American Dental Association think it is somewhat to very important that their dentists use laser technology.

The electronics that have improved desktop computer performance have been incorporated into laser device designs during the past decade. New dental lasers are more reliable, efficient, clinician-friendly, and clinically capable than those of 10 to 15 years ago.

Clinical uses have exploded

Where limited soft-tissue "incision and excision" procedures were once the limitation, today's clinicians use the latest generation of lasers for sophisticated soft-tissue manipulation such as aesthetic recontouring, ovate pontic site creation, flap design, and closed periodontal debridement for pocket reduction.

Use of dental lasers for hard tissue of all types has best defined the expansion of dental laser utility in the 21st century. Where once there were no FDA "indications for use" on any hard tissue 10 years ago, today we see dental lasers used on diseased and healthy enamel, dentin, bone, and even in the endodontic canal to cut, ablate, shape, shave, and modify these structures. Four years into the new millennium, dental lasers offer an extensive range of FDA indications and clinical applications that render tissue "sealed" and antiseptic, treatments with minimal or no pain, greatly reduced morbidity, rapid wound healing, improved clinical outcomes over traditional treatments, and patients who are much more satisfied with their dental experiences.

Ten years ago, the engineering-design focus was on "the box," but today's manufacturers are adapting to clinicians' needs for different handpiece angles and configurations, tip lengths, shapes, and flexibility. Now laser handpieces are shaped like traditional high- and low-speed handpieces, as well as specially designed shapes and cannulas for specific intended purposes.

Lasers are still not cheap

The idea that lasers will eventually drop in price assumes there is a large consumer marketplace (like for cell phones) that "quantities of scale" will push the prices down.

Here's a news alert — there are only 140,000 dentists in the U.S. marketplace. To get the sort of price reductions we see in computers or cell phones, we would need a marketplace of perhaps a few million. Today and for the foreseeable future, lasers will not be mass-produced on an assembly line. They will remain handmade, custom-built works that require great attention to detail during assembly to align the optics and calibrate the electronics.

You get what you pay for

Unless and until there are astonishing technological breakthroughs in laser optics and physics, we will not see price reductions in dental laser devices of the sort suggested 10 years ago of $1,000 per watt of laser output power (i.e. a 5-watt laser equals $5,000 retail price).

We likely will see prices remain where they are — or even higher — but we will see continued device improvements in size, technology, software, electronics, optics, performance, and reliability.

Cost vs. value

Most dentists do not have MBAs. As such, the cost of products and devices such as lasers are the first and last consideration. Dental chairs and operatory equipment are purchased as the "cost of doing business" — necessary to practice.

Not so with dental lasers. I've heard dentists say that if they were ever required to use lasers, they would quit dentistry. That's a pretty dramatic response to something that may offer patients something better than cold steel and sunshine.

The value proposition

The value proposition to the dentist for dental lasers is the same today as it was 15 years ago, and will likely be the same in 10 years. Consider:

1) What do you want or expect to accomplish with a laser? It's OK not to know, but this is the question to start with.

2) What laser devices have the best overall operating parameters for the uses you might consider? Not all lasers do all things equally.

3) How does the price relate to intended use and ROI?

Some other thoughts:

1) What is your practice's biggest clinical challenge?
2) Do you want to improve the methods and manner you leave your patients at the end of the appointment? And how do you envision that?
3) Do you need to improve your high-tech image with your existing patients, staff, or yourself?
4) Do you need a way to rejuvenate your practice and production?
5) Do you want to get more patients through internal and/or external marketing? They are not the same question.
6) Are you willing to invest time to research the technology and become fluent in laser lingo before you buy?
7) Does your business need an IRS Section 179 equipment deduction for tax savings?

Buy or lease?

Dental practices have many options for purchasing dental lasers.

Through a loan, the payments on a $50,000 loan can be as low as $1,000 a month. Creative lease programs can make zero monthly payments for three to six months with increasing monthly payments as the practice integrates the laser to greater uses.

ROI multitasking procedures

Dental lasers' ROIs may be realized from performing procedures and treatments not previously performed easily with scalpels and sutures. These include fibroma removal, frenectomies, gingivectomies, crown lengthening, and others.

Increased efficiencies

Other advantages come from increases in intra-operatory utility and performances to accomplish difficult results, they but do not add directly to profitability. Instead, indirect savings are realized from not re-appointing patients or rapid start to finish of certain procedures due to the lack of anesthetic requirement.

These increased efficiencies include the ability to take crown impressions in hemorrhagic tissues without re-appointing, and the ability to perform multiple cavity preps and restorations without anesthesia and without the need to wait for anesthesia to take effect.

Stand-alone procedures

Lasers are designed to maximize their performances for single dedicated procedures such as caries and calculus detection, bleaching, photopolymerization, and laser periodontal therapy.

In these instances, the lasers are designed to offer value from the implementation of one procedure that offers a return on the laser investment. Some of these lasers are capable of performing other procedures in addition to their initial dedicated functions that offer significant revenue enhancements over initial purchase cost.

Marketing

Nothing screams "high-tech" to patients louder than lasers. Internal marketing to an existing patient database is just one way to rejuvenate a practice. External marketing is a more potent practice and profit builder.

While the various ways to market a dental laser are beyond the scope of this article, few new patients per month combined with the added procedure capabilities are required to pay back the monthly lease payment.

Laser resource and reference guide

A tremendous number of laser companies have received FDA clearance for their surgical lasers. Not all that have received FDA clearance for dental indications are actively marketing in the United States — Cao Laser, Fotona, Sciton, and Lokki, just to name a few. Here is a short way to check on FDA-cleared laser features and parameters:

Wavelength: the "color" of light that is absorbed into target tissue. But wavelength alone does not determine the entire tissue interactions that can take place. It is a critical element, but not the only key parameter.

Temporal Emission Mode (TEM): how a laser delivers its energy over time. This is a key component of tissue interactions. For example, is the energy being delivered like a garden hose of photons, "soaking" the tissue with light of one wavelength and or color without means to control overflow? This would be a continuous wave, or CW TEM. Or is the laser delivering pulsed laser light to the tissue, which better controls how the stream of photons enter into and interact with the target tissue? There are two main types of pulsed lasers in dentistry: gated pulsed, where a shutter interrupts a continuous beam of light (such as light shining through the blades of a fan); and free-running pulsed, or FR, where the electronics inside the laser cavity allow light out in intense bursts of approximately 100 millionths of a second (10-6 sec), much greater than the average power displayed on the console of the laser device, but with long "off" times to give low "average" powers, and a lot of control of tissue interactions.

Diodes (808 to 980 +30nm): near-infrared CW lasers that for many soft-tissue surgical procedures require the "conditioning" of the tip to trap photons in the tip, thus heating the tip to 500 to 800 degrees C, and cut by melting the tissue. Some diodes can be used in a "high fluence" mode with water lavage with a cleaved bare fiber (SmilePro980). Tissue conditioning would not be used for treatment of aphthous ulcers or biostimulation. If they have a pulse mode, it would be a gated pulse. The devices are too small and inexpensive to have the necessary elements to generate an FR pulse. Soft tissue and biostimulation only.

Don't forget to check out the features and parameters in each diode device. While similar in tissue response, not all diodes are created equal. For example, the SmilePro980 from Biolitec has a timer and fluence display that tells the operator how much energy has been delivered to tissue ($25L). Continuum's DioDent has a separate/remote power supply that should help with some of the overheating issues diodes can have. Zap Laser's SoftLase is small and inexpensive, and isn't "over-stacked" with unneeded wattage — that should help keep it cooler, too. LaserSmile has lots of nifty features too, including a bleaching wand. So, check them out for features and performance that fit your needs.

Nd:YAG (1.064 micron wavelength): an-FR pulsed, near-infrared, soft-tissue selective ablation device, dedicated soft-tissue laser with some hard-tissue applications (enamel caries removal) and biostimulation as well. Nd:YAG wavelength represents the first to go to digital electronics vs. analog (PerioLase MVP-7).