by Kristine A. Hodsdon, RDH, BS
There's never been a more exciting time to be a practicing hygienist than right now. To begin with, clients are more knowledgeable and are seeking professionals who are at the top of their game. Plus, hygienists are developing and mastering services in the roles of health-care providers, preventive specialists, periodontal co-therapists, esthetic hygienists, and business partners. As preventive specialists, hygienists are also re-defining and centering their treatment on the whole client, but specifically in the areas of disease prevention, health promotion, and guiding and supporting clients in the restorative care they need and the cosmetic care they desire. Hygienists are becoming better at understanding and contributing to the overall success of the practice, educating clients about the highest attainable periodontal health, as well as restorative and esthetic possibilities. Then add technology to the mix. Laser advancements, as discussed in this article, elevate hygienists' therapeutic armamentarium and their capability to grow a profitable hygiene department that provides quality care.
Master hygienists focus on clinical protocols that complement clients' busy lifestyles, as well as the latest information. This type of treatment can be called "future pacing." Future-paced hygiene assessments and treatment plans consider the following major research findings and investigations while developing periodontal and esthetic therapies:
- Oral disease and disorders affect health and well-being throughout life (oral lesions, birth defects, chronic facial pain, oral cancers, etc.)
- Safe and effective measures for preventing caries and periodontal disease include lifestyle behaviors that affect general health, as well as oral and craniofacial health (tobacco, excessive alcohol use, diet, etc.)
- The mouth reflects the general health and well-being of the body (as a portal of entry). Oral disease and conditions are associated with other health problems (diabetes, cardiovascular disease, stroke, pregnancy outcomes, etc.).
Overview of periodontal debridement
With therapeutic periodontal debridement, the goals of dental hygiene care are to arrest infection, remove plaque and calculus, reduce the amount of bioburden within the pocket, and provide an environment in which the tissue can return to health. After assessing the client's health, a hygienist can develop treatment modalities and select appropriate instruments for achieving the best clinical outcome.
Traditionally, hand instrumentation was the main means of mechanical root-planing. The primary objective was to remove the endotoxins that embedded themselves into the cementum of teeth. It was believed that, to achieve acceptable results, all diseased cementum needed to be removed or an attempt needed to be made to remove all contaminated tooth structure.
More recent research, though, revealed that complete cementum removal was not necessary for achieving a positive result. The objective of debridement shifted to investigating the reduction of bioburden /microfilm within the periodontal pocket. The instrument of choice for debridement became power - sonic and ultrasonic scalers. The scalers create a cavitation action when water or a chemotherapeutic agent hits the tips. This lavage helps reduce bioburden within the pockets and facilitates healing. The "power" therapy - or a combination of hand and powered instrumentation - gained in clinical use.
Hygienists are now developing an even clearer understanding about pathogenesis and wound healing. Currently, periodontal debridement is based on research that bacterial plaque produces a bioburden that can be located supragingivally and subgingivally. The subgingival plaque falls into two categories - adherent and nonadherent.
Adherent subgingival and supragingival plaque are primarily comprised of gram-positive rods and cocci. However, the more virulent, nonadherent plaque or tissue-associated plaque make up both gram-positive and gram-negative bacteria.
When the nonadherent plaque infiltrates the periodontal tissue, a cascade of events and host-immune responses occurs. If not properly managed and treated, breakdown and destruction of the gingival junctional epithelium and bone may occur. While acknowledging that plaque is not the only cause of periodontal pathogenesis, debridement procedures must focus on this factor.
Advances in nonsurgical periodontal therapy are again shifting to the risks of recolonization of already treated pockets and the effects on long-term periodontal stability. The recontamination studies reveal that bacteria are transferred from one site to another, from one tooth to another tooth, or can spread from one person to another.
Therapeutic methods that eliminate or drastically reduce the bioburden count in individualized pockets have become the basis of future debridement treatment strategies. Soft-tissue therapy with lasers is an emerging strategy for achieving the bioburden decontamination of the periodontium (noncontact procedure) and laser curettage (contact procedure).
Laser-assisted, nonsurgical periodontal therapy
LASER is an acronym for light amplification by simulated emission of radiation. Simulated emission is the process by which the photonic energy of a laser is produced. Each laser device is named for the active material/medium (solid, liquid, or gas) within it that causes the simulated emission or the laser energy, which is amplified light. This amplified light is then turned into very precisely focused laser energy. The different laser wavelengths and mediums determine what task may be completed and are distinctly absorbed by specific tissue characteristics.
The lasers that are appropriately used in dental hygiene today are the carbon dioxide (CO2), the neodymium: yttrium-aluminum-garnet (Nd:YAG), the erbium (Er:YAG), argon, and diode [see chart]. These wavelengths have received FDA clearance for sulcular debridement and decontamination.
Laser-assisted periodontal treatment can follow two separate or complementary paths. Preprocedural rinsing with antimicrobial agents is employed by many dental practices. This pre-rinse is administered prior to delivering hygiene services in order to eliminate, reduce, or alter microorganisms and to assist in preventing host bacterium and clinician airborne exposure. Many rinses, however, do not reach the subgingival flora. As a result, therapy has expanded to include subgingival irrigation and a search for the best antimicrobial agent (ultrasonic lavage, rinses, drug-delivery systems, etc.).
Laser decontamination should be added to the quest. Aiming the laser beam into the pocket without contacting the tissue has been reported to achieve decontamination of pathogenic bioburden. In addition, sulcular debridement - otherwise known as soft tissue curettage (the removal of the diseased epithelial lining in the sulcus, which harbors the powerful bioburden) - is recognized as a therapeutic soft-tissue treatment.
Traditionally, curettage therapy is delivered with the blade of a hand instrument positioned in reverse, so the blade is adjacent to the soft-tissue lining. Inadvertent curettage procedures occur in many clinical settings where, legally, hygienists are not allowed to perform this function. However, they "inadvertently" do.
Laser energy, when used at the proper setting and within the proper parameters, can very easily and quickly be used as an armamentarium of choice to vaporize diseased tissue/sulcular lining (contact procedure).
According to the Academy of Laser Dentistry (ALD) (www.laserdentistry.org), the soft-tissue laser (contact therapy) is legal for use by dental hygienists in 18 states in the United States. As when learning any new technology, hygienists should attend (and, in many states, are legally required to attend) formal training and education. This is followed by a commitment to credentialed certification through the ALD or ALD-recognized course providers, such as Pac~Live (www.pac live.com). The appropriate education and understanding of operating guidelines for lasers solidifies the treatment approach of dental hygiene professionals who are practicing at the top of their game.
If a hygienist understands the benefits of bacterial control - whether by ultrasonics, chemotherapeutic agents, antimicrobial agents, drug-delivery systems, and/or lasers - then why not incorporate decontamination services into all hygiene stages, especially traditional 1110 prophy appointments? If decreasing the microorganisms subgingivally and supragingivally is beneficial for nonsurgical periodontal appointments, then take the lead and forge ahead for your client's oral health, using decontamination management for every therapeutic hygiene service.
As with any developing clinical model, considerable research is still necessary for periodontal treatment with lasers. Future-paced professionals will review all studies when determining the risks and benefits. The American Academy of Periodontology developed a position statement in 1999 on the use of lasers for periodontal treatment. It is available online at www.perio.org.
Laser-assisted tooth whitening
A few laser manufacturers have also received FDA clearance for using laser energy to whiten teeth. The laser is easily switched from a periodontal therapy instrument to a laser smile-whitening instrument by simply removing the soft-tissue handpiece and replacing it with the whitening wand. A definition of laser whitening for this article is: A professionally controlled, in-office service using a high concentration of hydrogen peroxide and an added energy source to expedite the process of tooth whitening.
Laser whitening is believed to accelerate the hydrogen particles to enhance whitening results. Laser whitening falls under the Class III laser certification, so it also requires additional training and certification. The whitening products for this category usually contain a 35 to 50 percent hydrogen peroxide bleaching gel or paste (Ultradent Xtra, www.ultradent.com; Illumine, www.dentsply.com; and Virtuoso Lightening Gel, www.denmat.com). These products are usually pre-mixed and are dispensed directly from their syringes onto the teeth. Due to the high concentrations, these whitening agents must be handled with caution.
The caustic nature of the hydrogen peroxide assumes that the soft-tissue has suitable protection. A properly placed rubber dam or a protective light-cured resin on the soft tissue provides appropriate barriers. A few additional safety concerns for both the practitioner and client include:
- Eye safety protection for everyone in the operatory
- First aid kit containing vitamin E, aloe vera, zinc oxide and/or propylene glycol
There is a need for increased research in the area of laser whitening. Areas for the clinician to research include the efficacy of each laser and its wavelength when choosing a suitable laser source, thermal effect of lasers and pulpal response and, without compromise, follow the proper clinical protocol for the safety of the client and user.
Laser-assisted caries detection
An added future-paced hygiene technology is based on improved assessment and diagnosis of early carious lesions. An emerging adjunct in caries detection involves another Class 2 laser that measures fluorescence within the tooth structure. Simply stated, if a hygienist shines a light on an occlusal pit and fissure, then identification of initial (not recurrent) carious lesions can be determined. Conscientious oral care specialists realize that technology only helps our diagnostic interpretation, and some innovations may prove to be less than desirable or valid. But since many clinicians are no longer solely relying on their explorer as "the" instrument to detect cavities, this laser-assisted tool can be implemented when identifying and assessing caries with traditional protocols, such as the clinical exam, salivary flow rate, radiographs, diet analysis, and the measurement of risk indicators.
As the promising evidence supporting laser diagnostic methods becomes available, caries detection and, ultimately, prevention, treatment, and management of caries will move toward improved and more accurate clinical standards.
Future-paced modalities are embracing lasers as the emerging multi-tasking instrument. It can be implemented into any hygiene wellness program, successfully and safely supporting gingival healing and health. In addition, laser-assisted whitening enhancements can be delivered to improve aesthetics. Lasers also have been identified as an aid to caries detection. Dental hygienists often seek out opportunities for professional growth. The many uses of lasers in hygiene are strategies worth adding.
The primary goal of laser technology is to melt or vaporize tissue without inducing irreversible damage to adjacent tissue.
Sequence of treatment:
- Client may be anesthetized.
- Conventional bacterial decontamination and antimicrobial irrigation - before and after laser therapy.
- Each pocket is lased for microbial decontamination (approximately 30 seconds per site).
- Ultrasonic instrumentation and hand instrumentation (scaling and root-planing).
- The inflamed tissue/epithelial lining is removed with the laser by measuring fiber tip to base of pocket and using a sweeping motion away from the tooth and towards tissue pocket wall.
- Constant movement of the tip for 30 seconds to one minute achieves laser bacterial decontamination.
- Postoperative written and oral self-care instructions.
(Reprinted by permission from Demystifying Smiles; Strategies for the Dental Team, PennWell. All rights reserved.)