INTRODUCTION
Lasers have been in dentistry now for a good number of years. We have been using lasers in our offices for close to 10 years. What is new in laser dentistry is that now the dental lasers have gotten much better and much less expensive. As a result, it is within the realm of all dentists to now begin to integrate laser technology into their dental practice. This is no different than any other technology that continues to improve and also becomes more efficient and less costly.
From Electrosurgery to Laser Technology
There are essentially 2 kinds of lasers currently available for use in dentistry. There are soft-tissue (only) lasers and hard- soft-tissue lasers. Dental soft-tissue lasers are typically diode lasers, and there are a number of manufacturers who produce them. To me, as a very practical-minded general dentist, a diode laser is pretty much an electrosurge replacement. Electrosurgery has had a positive history in dentistry and there are still many fine electrosurgery units on the market. Like any technology, there are many advantages and disadvantages and most dentists reading this article know the disadvantages of electrosurgery. These include that awful smell that comes with burning tissue, and also having to be extremely careful not to touch bone, tooth, or a metal implant. In addition, electrosurgery is not typically precise, especially when it comes to troughing tissue before crown-and-bridge impression. With electrosurgery, most dentists are never exactly sure where the gingival tissue will end up after you have done a gingivectomy or have troughed the tissue simply because many times too much heat has entered the delicate gingival tissues and healing is just not predictable.
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| Figure 1. Failing restoration in the lower first bicuspid. | Figure 2. Dental laser excavation that was accomplished with no anesthesia. |
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| Figure 3. The final restoration was accomplished in less time than it takes most patients to achieve anesthesia. | Figure 4. Preoperative view of failing restorations. |
Soft-Tissue Diode Lasers
Enter a soft-tissue diode laser—this is a much more precise instrument; it will cauterize the tissue just like the electrosurge, and most of time can be used on soft tissue only with topical anesthetic. There are now simple diode lasers on the market that are anywhere from 1.8 to 4W in power and for a price equal to or slightly more than an electrosurge, you can have all of the advantages of a soft-tissue laser at your fingertips. As many dentists just hate packing cord, the soft-tissue diode laser, when used properly with the right tips, can be a very predictable procedure by troughing the inside collar of the gingival tissue without reducing the its height. You will also be able to perform all of the other soft-tissue procedures that we as general dentists probably don’t do enough of, which includes frenectomy, gingivectomy, soft-tissue biopsies, soft-tissue ridge reduction for pontic placement, and a whole host of other soft-tissue procedures. Anecdotally, there is no question in my mind that soft tissue cut with a laser seems to heal up much more quickly than with an electrosurge and even a scalpel. This most likely has to do with low-level laser biostimulation that also occurs whenever you use a laser, which we are learning more and more about its use in medicine and in dentistry.
Hard- and Soft-Tissue Lasers
Hard- and soft-tissue lasers (such as the LightWalker [Technology4Medicine], Waterlase MD [BIOLASE Technology], and Picasso ATL [AMD LASERS]) are where we have seen the most advancement in technology and reduction in cost, which now makes them affordable for every dental practice. These lasers can treat hard tissue such as teeth and bone. The big advantage here, when you learn how to use this technology, is the ability to do selected tooth preparations without local anesthetic.
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| Figure 5. Old amalgam restorations that were in need of full coverage restorations. | Figure 6. Full-laser excavation with removal of old amalgams (note that a rubber dam was used). |
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| Figure 7. Full-crown preparations that were done with only a dental laser (Picasso ATL [AMD LASERS]). | Figure 8. One-appointment final crowns cemented with no anesthesia. |
What To Look For…
Make sure that you consider a number of things when looking to buy a hard- and soft-tissue laser. While the hard cost of the laser may be below $30,000, there may be additional costs involved that were bundled in the past with your purchase, but now you will be paying extra. This means that the actual cost of the laser may be more than you think when you add up the extras that used to be included in the price. You will need hands-on training—does the laser you are buying include training with the purchase, or will that be an extra cost? What are the continuing costs of the laser tips? What is the reputation of the company you are dealing with? How is their customer service and support? Consider the entire package before you purchase as this will make a difference in both the short-term and long-term cost.
To me, this has always been an interesting observation—those who have had hard- and soft-tissue lasers and have properly learned how to use them find them indispensable and really like the “no anesthesia” practice of dentistry. Those who do not have a hard- and soft-tissue laser still cannot believe that this is possible. Especially now, with the advent of the improvements in dental technology, the ability to perform many dental procedures without the use of local anesthesia is here now more than ever. I certainly would not want to practice any other way.
CASE EXAMPLE 1
Restorative Work With Laser Technology
A 45-year-old female patient came to our office with mild to moderate sensitivity present on tooth No. 28. Figure 1 shows the failing restoration with caries evident on the occlusal surface. At the initial patient interview, she reported, like many other patients, that she always tried to avoid a dental visit at all costs due to fear of dental injections. She was a dental phobic and hated having injections in her mouth. However she was not a needle phobic; this was obvious from the observation of many tattoos all over her body. She was new to town and chose our office based solely on the fact that we were using laser technology.
In this case, being amenable to laser treatment, we used the new Picasso ATL (All-Tissue Laser) system for both patient education and then clinically to excavate the carious lesions without the use of any dental anesthesia. How is that possible? The Picasso ATL has an iPad port where the included iPad is attached. The iPad (with the included iPad Apps) is used for laser diagnostics, doctor, team, and patient education of laser procedures. This represents a high level advancement for hard- and soft-tissue dental lasers.
Total treatment time for this excavation was approximately 2 minutes and is shown in Figure 2. (The white marks, seen in Figure 2, are left by the laser ablation of the enamel and dentin and disappears once the tooth is rehydrated during the restorative procedure.) Compare this to the conventional treatment time with a high-speed handpiece which requires dental anesthesia; counting the time it would take to give and wait for anesthesia to occur, plus the preparation time, the dental clinician easily could have used up 20 minutes of time with nothing to show for it. (This perfectly fits into my concept of “faster, easier and only if it’s better dentistry” for the dentist, but especially for the patient.) After preparation, a sectional composite matrix system was placed (V3 Ring [Triodent]), a self-etching bonding agent was then applied to the teeth (G Bond [GC America]) and a low flow bulk fill composite resin was used to restore these teeth (G-ænial [GC America]) (Figure 3).
CASE EXAMPLE 2
One Visit No-Anesthesia Crowns
With the newer advancements in dental lasers, restorative preparations from simple operative procedures to full-crown preparations can now be accomplished efficiently. This case example showcases a 49-year-old male patient. Figures 4 and 5 show the preoperative condition of failing restorations on teeth Nos. 3 and 4. He is a successful businessman, always in a hurry, wants it done now, is afraid of the dentist, fusses because he has to get numb, knows that he needs some crowns and hates to wear a temporary crown because the last one he had fell off twice and wasted his time. You know this patient, just a joy to work on.
The combined use of dental lasers and CAD/CAM technology can be a marriage made in heaven, for this and all patients. Figure 6 shows the completed excavation of the teeth. While the US Food and Drug Administration has not yet approved the removal of old amalgams with dental lasers, that does not mean they cannot be accomplished directly. Generally, though, I prefer (as in this case) having the laser cut the tooth at the border of the old restorations and let the amalgam just fall out exactly the same way I would do this if using a high-speed handpiece and a carbide bur. The laser (again the Picasso ATL system) was then used to accomplish a full-crown preparation by directing the laser energy at the dentin-enamel junction and literally chunks of enamel started to come off. Figure 7 shows the completed crown preparation with resin-modified glass ionomer (Fuji IX [GC America]) used for the crown buildup material. The completed cemented CAD/CAM crowns are shown cemented in place in Figure 8. The tissue was precisely troughed with the same all-tissue laser prior to the optical impression and with the well-fitting permanent crown in place, will heal within normal limits. Interestingly, this patient (being a type A personality businessman) would not come back for the final postoperative picture. However, on the phone, he stated that he was very thankful for the treatment being accomplished in one visit with no anesthesia and he reported that he was very satisfied with the aesthetics.
CLOSING COMMENTS
From a marketing and practice management perspective, nothing else in dentistry comes close to the state-of-the-art appearance of having a dental laser technology available in your office. It is also enhanced when other up-to-date technologies like Apple’s iPad are worked into the system. I remember years ago when we first integrated lasers into our offices and, for the first couple of months, patients would say, “It’s about time.” I would ask what they meant by that and they would tell me that “every other healthcare professional” they go to has a laser. Their dermatologist, ophthalmologist, and internists all had medical lasers in their offices for a number of different uses. These patients, who were made aware of very current technology, felt that most dental offices were a bit behind the times. Don’t misunderstand me; I use a high-speed handpiece every day, but to patients, it is 50 year old technology, and they are right. At this point in time, with lasers being as inexpensive as they are, I could actually make the practice management argument, as silly as it sounds, to get a laser and let it just sit there…point to it during the patient visit, and tell the patient you are a laser dentist! That action alone would have a tremendous advantage in updating your practice’s image. Of course, you and your patients should benefit clinically by actually implementing the use of modern laser technology whenever indicated. The best way to differentiate yourself in today’s economic climate is by changing the patient experience in your dental office. Dental lasers are the number one way to accomplish this. What a dental laser will also do is change the clinician’s experience as well. The fact that it can really treat patients faster, easier, and better…once you learn how to use it properly…is what makes it enormously productive for a dental practice!
For the past year, as I have lectured to thousands of dental professionals, and my advice was to wait and see where the dental laser market was going to settle in terms of the costs of the lasers and the technology. Wait no longer—in my opinion, the dental lasers on the market have never been better and the entry cost is now within the realm of every general dental practice.
Acknowledgement:
The author would like to thank a master of laser dentistry, Dr. James Jesse, for some of the case photography in this article.
Dr. Malcmacher is a practicing general dentist and an internationally known lecturer, author, and dental consultant known for his comprehensive and entertaining style. An evaluator emeritus for CLINICIANS REPORT, Dr. Malcmacher is president of the American Academy of Facial Esthetics. He can be reached at (440) 892-1810, at drlouis@facialesthetics.org or at commonsensedentistry.com.
Disclosure: Dr. Malcmacher has served as a consultant to BIOLASE Technology, Lares Research, GC America, Triodent, and AMD LASERS.
