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What to know about lasers before you buy

Feb. 1, 2008
LASER DENTISTRY has been a hot topic professionally for more than a decade. Its inclusion in general practice is reaching past the innovator phase and well into early adopters of this technology, which has changed the face of how I clinically perform everyday dentistry.

LASER DENTISTRY has been a hot topic professionally for more than a decade. Its inclusion in general practice is reaching past the innovator phase and well into early adopters of this technology, which has changed the face of how I clinically perform everyday dentistry. While there are many more criteria – more than this column will allow – I’ve created the most compelling and practical factors to consider from the perspective of a general dentist with a focus on esthetics.

Before making any equipment purchase, I evaluate four primary criteria to assess its value to the practice. It must meet one or more of these criteria to be deemed worthy of consideration.

  1. Will it provide a better result than the method or technique I’m currently using?
  2. Will it enhance my patient’s experience (i.e., less discomfort, less time in the chair, fewer appointments, reduce stress)?
  3. Will it increase efficiency or add additional revenue?
  4. Can I utilize it in my marketing efforts?

The information that follows will help you develop your own rationale for whether or not lasers will benefit your practice.

Criteria No. 1 – Will it provide a better result than the method or technique I am currently using?

Let’s first look at the diode laser in soft-tissue applications. Just a decade ago, gingival recontouring or gingivectomies were procedures that required the use of a scalpel or electrosurge. This treatment required several weeks of healing time, and the final result could be somewhat unpredictable in certain cases because of the tissues’ tendency to rebound.

The diode laser has provided a means to very predictably reshape and recontour gingival tissue to optimize symmetry and maximize esthetics. The hemostatic nature of the laser eliminates the need for a retraction cord during restorative procedures, and the minimal zone of necrosis of the actual laser “cut” provides a very stable final contour that will not change after the definite restoration is placed. There are simply very few esthetic cases that don’t benefit from tissue recontouring. At the Hornbrook Group, we estimate 80 percent of all esthetic cases that are treated in our clinic require some level of tissue contouring for ideal results.

Other routine soft-tissue procedures include labial and lingual frenectomies, particularly common in a high pedodontic or adolescent patient base. This can be done chairside, without the bleeding and sutures required with traditional surgical interventions.

The use of the diode in periodontal treatment has been well documented for more than 10 years. When used in deep periodontal pockets at a very low wattage with associated bony defects, the laser not only removes the diseased granulation tissue and associated bacteria, but also promotes osteoclast and osteoblast activity, often resulting in bone regrowth.

Whether or not your hygienist will be able to incorporate it into his or her periodontal therapy and management program is largely dictated by your state board. But, it is an additional option for your patients to assist them in managing their periodontal condition. In states that do not allow laser use by the hygienist, many clinicians opt to incorporate site-specific laser therapy. This is done when warranted during the visual exam after the hygienist has scaled those areas to promote health and pocket sterilization, further aiding reattachment.

With the erbium laser, the most significant procedure allows me to perform osseous recontouring and crown-lengthening at the patient’s preparation appointment. Previously, a clinician was limited in the removal of soft tissue by the patient’s biological width (distance from free gingival margin to osseous crest). When this measurement was less than 3 mm, surgical methods were required to increase the tooth length from a gingival perspective. This involved laying a flap and removing osseous structure using a diamond bur.

Most leading periodontists recommend a 12-week to 16-week healing time to ensure osseous and soft-tissue stability. The healing time alone was often reason enough for the patient to decline treatment. With the erbium laser, the gingival tissue is removed to the desired level, regardless of biological width (assuming there is adequate attached tissue). Using a 400-micron tip, with a setting specific to osseous tissue, the laser is then placed parallel to the root tip of the tooth surface and under the gingiva, in effect repositioning the natural osseous crest and establishing a “new” biological width. Although long-term clinical studies are certainly indicated, anecdotal and short-term (four-plus years) clinical experience indicates that the osseous levels remain at the newly contoured level.

Another use of the erbium laser is to remove defective enamel and dentin in assorted restorative procedures, many times without anesthetic. This fulfills more of Criteria Nos. 2 and 4 for me, more so than No. 1. While I can prepare teeth with a hard-tissue laser, it hasn’t yet replaced my high-speed handpiece in most tooth preparations. In most cases, the most significant improvement over a traditional preparation is the elimination of anesthesia.

Criteria No. 2 – Will it enhance my patient’s experience (i.e., less discomfort, less time in the chair, fewer appointments, reduce stress)?

This is by far one of the most compelling motives for incorporating lasers into a general practice. The accelerated healing time and noticeable lack of postoperative discomfort in a variety of cases are primary reasons for considering what a laser could do in your practice. In the case of soft-tissue procedures, the elimination of sutures alone reduces your patient’s discomfort and stress dramatically. In every case, the hemostatic nature of the laser eliminates or considerably reduces bleeding. Treatment acceptance dramatically increases for procedures that save your patients’ time, reduce the need for additional visits, and result in minimal post-operative sensitivity.

Criteria No. 3 – Will it increase efficiency or add additional revenue, contributing to profitability?

With every manufacturer and new technology claiming to increase profits, I had to take a realistic look at the claim that incorporating either or both lasers would increase revenue. The first place I noticed increased revenue was in my periodontal treatment. As an adjunct to traditional scaling and root planing procedures, there is an additional fee for laser therapies as an augmentation to improve results. Because of the nature of the technology, I also became more aware and confident in performing procedures I did not incorporate routinely in my practice. Before incorporating the diode laser in my practice, I rarely considered including frenectomies as a treatment option in either esthetic or periodontal cases. Surprisingly, after communicating with our referring orthodontists and periodontists, we currently average two to three frenectomies a month in an all-adult practice. Additional treatment includes treating aphthous ulcers, indirect pulp caps, cementum hypersensitivity, fibroma removals, crown lengthening, and gingival and osseous recontouring.

Criteria No. 4 – Can I use it in my marketing efforts?

Lasers are associated from a consumer level with high-end technology. They are used and marketed for banishing wrinkles, permanent hair removal, vision correction, tattoo removal, and even inanimate uses such as engraving, customization of metal products, or laser DVD/CD/Blue Ray technology. The consumer market has a drive that includes technology and gadgetry that make inclusion of “laser dentistry” a highly marketable concept.

For the most part, patients have very little knowledge of what a dental laser actually does or how it works. The advertising is already being done for me by a multitude of consumer companies highlighting “lasers.” If I can attract new patients to technology, coupled with my experience, utilizing lasers as a marketing vehicle is a natural fit. Developing new patients through “no drilling, no anesthetic” dentistry in many cases gets them through the door and eliminates their fear. I may not be able to use the diode or erbium exclusively in every patient’s treatment, but the responsibility is on me to create trust and credibility that allows me to use all the tools at my disposal to ensure the best result.

Laser dentistry is one of only two technologies and equipment integrations that actually meets all four criteria in my opinion (the other being digital radiography). In my experience, both the diode (DioDent Micro 980, Odyssey, Navigator) and the erbium (VersaWave) lasers answer a resounding “yes” to all of these questions, which is why both are tools that I use daily in my practice ... and frankly, I would not practice without them!

I concede that there are many ways to calculate return on investment, but the four criteria described above are the most important to me as a busy general practitioner. Lasers are not for every practice, but after developing a solid rationale, you may find that you are indeed in the market to buy.

I find after a clinician evaluates these criteria and buys a laser, it is imperative that they obtain as much training as possible in laser usage to ensure success, both clinically and in the return on their investment. Many laser companies will have a variety of options, including “hands-on” training with swine or bovine jaw procedures to help perfect your technique. You may also find options that include an expert laser user coming into your practice to assist you with patient treatments.

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David Hornbrook, DDS, FAACD, is the executive director of The Hornbrook Group Center for Advanced Clinical Education. Recognized as a leader in esthetic dentistry, Dr. Hornbrook has lectured internationally, been published extensively, and has been a pioneer in live patient treatment programs. An Accredited member and Fellow of the American Academy of Cosmetic Dentistry, he maintains a practice in San Diego.

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