March 1, 2014
by Michael A. Miyasaki, DDS
oft tissue diode lasers have been used for decades, but now their affordability and portability make them truly a piece of equipment every practitioner should consider. In this article we will discuss how they work and how to work with them with the intent that if you have a laser already you’ll pick up tips to use them more efficiently, and if you don’t have one you’ll gain information to assist you in making the decision on whether a laser will fit well into your practice and which features may be important for you to consider.
I began using lasers 17 years ago. Then they cost tens of thousands and weighed in at a hefty 45 pounds making them portable only if you had them on a rolling stand of some sort. Today the laser I use cost less than a quarter of the price of my first laser and weighs in at 1.9 ounces (Fig. 1) meaning it’s portable because it fits in my pocket. Being so portable means you will find it hard not to use. You will find your clinical work easier and improved, and the revenue generated will pay for this investment quickly.
Today many lasers are much like DenMat’s SL3 (Fig. 2) with a slightly larger footprint, a touch screen and audible confirmation preferred by some clinicians. Both the NV and SL3 have batteries so they don’t have to be plugged in when moved from operatory to operatory and they are activated using wireless foot pedals maximizing ergonomics and leaving your hands relaxed while operating.
Years ago we would have to prepare the laser fiber in-between patients much like an electrical wire removing a section of the cladding or insulation, and then scoring and cleaving the conductive fiber core. Many lasers today come with prepared tips (Fig. 3) so when you are ready to use the lasers you no longer have to use precious clinic time to prepare the fiber. Now we open a sterilization pouch containing the laser tip in front of the patient, slide the prepared tip on and it is ready to go.
Laser energy for these lasers is developed by a diode which produces a monochromatic light of a single wavelength. The DenMat lasers have a wavelength of 810nm. This light is absorbed by pigmentation (Fig. 4), and this energy can be used to disinfect tissue or ablate it. The fact that the energy has to be absorbed to render its effect makes it much more tissue selective. When using a scalpel or electrosurgery unit both healthy and diseased tissue is removed, whereas, when using a laser the tissue that is more pigmented, for example, dark necrotic tissue selectively absorbs more of the energy and is affected more. A safety note here is that our eyes contain a lot of hemoglobin that could absorb the laser energy so when we use the laser it is important that we protect all the eyes in the operatory and make note of this in the patient’s chart.
An important factor to using a laser properly is using the proper power. Using the minimum amount of power to accomplish the task is key to patient comfort during and after the procedure, and more predictable results. With the NV laser, that has up to 2 Watts of power, I find I can do most of what I need to do with a power setting of 0.6 Watts or less.
When we put the new tip on the laser it is what we call a non-initiated tip (Fig. 5). The fiber is basically used to aim the energy. The uses for this type of tip are to disinfect the sulcus or treat an aphthous ulcer.
To treat an aphthous ulcer the laser is brought in above the ulcerated area at a power setting of 0.6 W with a non-initiated tip (Fig. 6) and no anesthetic. Circling right over the ulceration for two minutes disinfects the sore and seals the nerve endings so the pain is gone and the disinfected sore heals much more quickly.
In cases of periodontal pockets we can use a laser as an adjunct to our standard periodontal therapy to both disinfect the sulcus and lining tissues with a non-initiated tip, and then remove necrotic diseased tissue with an initiated tip. Low power settings of 0.4 Watts are used and anesthetic is typically not needed (Figs. 7 & 8).
When we take the same tip and apply some pigmentation to it, also called initiated (Fig. 5), we convert the light energy to photothermal energy or heat to ablate tissue. With the laser tip initiated we are able to seal the blood vessels, nerve endings and lymphatics. We use the initiated tip when we want to ablate the tissue, such as, for gingival troughing, a frenectomy or removing necrotic sulcular tissue.
Instead of packing a cord to gain space between the hard tooth margin and the soft tissue, and using a hemostatic agent for coagulation, we use the laser
at 0.3-0.6 Watts with an initiated tip to ablate the tissue to create a cord-like space and achieve coagulation saving us time and impression material when we can get our impression the first time very predictably (Figs. 9 and 10).
FIGURES 9. & 10. Gingival troughing replaces the need to pack retraction cord.
A concern I often hear from clinicians is about the predictability of the laser as the tissue heals. In this example we did a Durathin no-prep veneer case doing a laser gingivectomy, at 0.4 Watts and using just topical anesthetic, the same day the impressions were taken knowing that there would be a minimal zone of necrosis from the procedure and predictable healing (Figs. 11 & 12). These photos show the predictable healing and no injectable anesthetic was required for the case. The patient is in broadcasting so a very white shade was selected, and the patient when interviewed shared that he preferred this treatment over orthodontics and traditionally prepared veneers because of its conservative nature and rapid results.
When cases such as this seen here (Figs. 13-16) are treated we are able to use the laser to trough the tissue to help restore subgingival decay with direct composite restorations, correct tissue heights by doing a bloodless gingivectomy and place the final crowns all in the same visit as seen here. A power setting of 0.4 Watts was used and the patient was anesthetized not because of the lasering, but for patient comfort during the extensive caries removal.
FIGURES 13. – 16. Use of the laser helping to restore deep areas of decay.
This pedodontic case (Figs. 17-20) shows the use of the laser at 0.4 Watts to trough the gingival tissue and, disinfect and coagulate the area of the carious pulp exposure. All was done in a single visit with excellent results and a very comfortable anesthetized patient who fell asleep during the procedure.
This patient (Figs. 21 & 22) came in complaining that his lingual frenum was restricting his tongue’s movement, and, therefore, affecting his life. We were able to use the laser with an initiated tip and a power setting of 0.6-1.0 Watt to do a lingual frenectomy incising the frenum while simultaneously coagulating the tissue so no sutures were required. Some injectable anesthetic (0.3 cc 2% lidocaine 1:100,000 epinephrine) was injected at the base of the tongue before the procedure.
Figures 21. & 22. Before and immediately after the frenectomy procedure.
This patient (Figs. 23-25) presented with facial swelling and a draining fistula due to an apical endodontic lesion as seen in the radiograph. Some injectable anesthetic was placed in the area of the fistula (0.5 cc 2% lidocaine with 1:100,000 epinephrine), and the laser at 0.4 Watts was used to open the fistula so we could milk it and drain the lesion without any bleeding as seen in the final photo showing how the patient departed.
Five points that clinicians should keep in mind when purchasing or using a laser are:
1. Look for portability and convenience in a laser so you use it.
2. Know the wavelength of your laser, and protect the eyes.
3. Realize that the laser energy must be absorbed to be effective.
4. Use a non-initiated tip when you want to disinfect tissue, and initiate the tip when you want to remove tissue.
5. Use the minimum power needed to accomplish the task for comfort and predictability.
Soft tissue lasers have a very short learning curve so you will be able to use the lasers safely very quickly. Many companies, like DenMat, offer online and live-education as part of the purchase of the laser. To implement the laser successfully into the practice time should be taken for all in the practice to understand the advantages of the laser so this can be communicated to the patients who often perceive the use of lasers in a very positive light.
Another point that practices often have to be reminded of is to bill for the procedures. When we use a scalpel, place sutures, manage the bleeding and post-op discomfort we charge for our services. When we use a laser which improves the clinical outcome and the patient’s experience we need to remember to do the same, after all, there is an investment we make in the equipment and the training.
Finally, it is hoped that this article increases your interest in the use of lasers or is a reminder to use your laser more. There are many more clinical situations beyond the examples shown here where a simple diode soft tissue laser can be used effectively, and with its use we can truly improve the quality of our services for our patients making their lives better and our clinical life easier. OH
Dr. Michael A. Miyasaki has been involved in dental education for over 23 years, 12 of which he was involved in live-patient treatment programs internationally giving him a unique perspective on the global challenges of the dental professional. He maintains a practice focusing on comprehensive, minimally-invasive aesthetic restorative dentistry and function in Sacramento, CA, USA.OH
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