September 5, 2018
by Marina Polonsky, DDS, MSc Lasers in Dentistry
We all remember graduating dental school and thinking to ourselves: “What’s next?” The future is full of possibilities; we must make decisions which will ultimately affect the rest of our careers and lives. Some of us knew right away that general practice was not for them, whereas specialties like surgery, periodontics or endodontics presented opportunities to maximize one’s talents in a narrow area of expertise. The rest of us, myself including, who did not hear a particular calling towards any specialty and actually enjoyed a great variety of procedures general dentistry has to offer, left dental school and entered into the reality of private practice. We all thought that our newly acquired knowledge of the most recent concepts, products and technologies, which we learned in university, would compensate for the lack of clinical experience.
WERE WE IN FOR A SURPRISE! The real world offers many valuable learning opportunities, and it’s up to us to grab them and pursue the never-ending thirst for knowledge and discovery. Every year we take continuing education courses in order to learn about new materials and technologies which promise to make our lives easier, our procedures better and our patients happier. Laser technology is no different. Depending on the university, students receive little or no education in laser applications in dentistry, which is likely due to the fact that schools pride themselves on teaching only well-proven techniques and concepts supported by decades of double-blind, controlled, and randomized clinical trials published only in reputable peer-reviewed publications. And it is a good philosophy to follow. However, as we put more emphasis on higher levels of evidence, this higher level is becoming more and more difﬁcult to achieve due to the requirement of compliance with ethical standards described in the Helsinki declaration, of 1975. There exists a multitude of in-vitro studies supporting different laser applications in all clinical aspects of dental practice, however very few are well designed double-blind randomized clinical trials. A number of peer-reviewed scientiﬁc journals focus exclusively on laser research: Lasers in Medical Science; Lasers in Dental Science; Photo-medicine and Laser Surgery; and Lasers in Surgery and Medicine, to name a few. Sometimes clinical case reports are the only evidence which we have available to prove the validity or efﬁcacy of a new treatment. Does that mean we should reject this treatment modality, or should we wait another 30 years for higher levels of evidence to become available? Who, but the patient stands to lose in this scenario?
My ﬁrst eye-opening experience with lasers happened in 2006, when I saw a cavity preparation performed with a Waterlase MD laser. The carious lesion was selectively evaporated from the tooth using nothing but the water spray and invisible laser light. No contact. No vibration. Minimally invasive and supposedly painless and not requiring anesthesia. My second eye-opener was when I found out how much this technology costs! And so, I set out on my road to discovery about lasers and their applications in dentistry. Not having the courage to spend close to $100,000 on my ﬁrst laser, I initially purchased a much more reasonably priced diode laser. It was cute, portable, had disposable tips which sounded much better than having to cleave the ﬁber, and most importantly- it didn’t break the bank at a price tag of under $9,000. After all, a laser is a laser, right? WRONG! I quickly realized that I can’t prepare cavities with it, must still use anesthetic, and that it is much slower than cutting with a scalpel. So, what’s the beneﬁt? Moreover, the only training offered to me was from the company representative, who arrived at my ofﬁce with -literally- a package of hot dogs to teach me the set-up and buttonology, after which I was on my own. I started with some simple surgical procedures including gingivoplasty, ﬁbroma removal and frenectomy. Later on, the need for packing a retraction cord became a thing of the past, as I mastered the troughing for impressions technique to help with subgingival margins and hemostasis. Finally, adding sulcular decontamination and periodontal pocket bacterial reduction to my hygiene program, enabled me to use this small laser device to its fullest potential. What amazed me was the patient response: faster healing; no stitches; no antibiotics; and better control of chronic conditions (like periodontal disease) with minimally invasive, non-surgical methods. The word “laser” itself was magic for easier treatment plan acceptance.
Patients are educated by both the media and advertisements on laser technology within other ﬁelds of medicine: laser eye surgery; laser hair removal; laser skin re-surfacing and many other applications (Fig. 1). In fact, lasers are utilized in every major branch of medicine with better clinical patient-reported outcomes, so why not dentistry?
It took close to three years of practice and continuing education courses to become familiar with and fully comfortable with my diode laser, with respect to its applications, advantages and limitations. Who could predict that such a small devise would open such an enormous world of possibilities. One must open the window to let the light in, and this light will change your world. Clear bloodless surgical ﬁeld, disinfection without antibiotics, hemostasis without chemicals or electro-surgery and healing without scar formation is just the beginning…then add pain control, faster healing and anesthesia without the use of pharmaceuticals, through photo-bio-modulation (PBM), and minimally invasive cancer treatment using photodynamic therapy (PDT)!
In our everyday practice, we encounter many conditions for which modern medicine lacks any deﬁnitive treatment. We are trained to treat the symptoms when we cannot offer a cure. We prescribe analgesics, steroids and anti-depressants to our patients which often provides the greatest beneﬁt to the drug companies and leaves us dealing with the side-effects. Neuralgias, xerostomia, Bell’s Pulse, Lichen Planus and other muco-cutaneous diseases, bisphosphonate-related-osteo-necrosis of the jaw (BRONJ), oral mucositis in cancer patients, are just a select few of the medical conditions where low-level-laser-therapy (LLLT) offers us a new and better way to address not just the symptoms, but rather to provide healing modalities for our patients. The uninformed, the sceptics, might call this voodoo, but the patients whom we help heal call us miracle workers and become ever grateful and loyal.
The scientiﬁc evidence and support for the concept of Bio-Stimulation goes back to 1964 in Hungary and Prof. Endre Mester, the father of PBM (photo-bio-modulation). He experimented with carcinogenic effects of low-power ruby and HeNe lasers on rats and found that instead of cancer, there was faster hair growth and wound healing. His paper “Effects of laser rays on wound healing” was published in 1971, in The American Journal of Surgery. In 1985, he reported an 85% success rate in healing wounds resistant to conventional treatment in 875 patients. “The biomedical effects of laser application” was published in Lasers in Surgery and Medicine Journal.
Since the invention of the ﬁrst working ruby laser by Theodore Maiman in 1960, based on the concept by Gordon Gould in 1959, many different types of lasers have been created and utilized for various applications, from underwater welding with Argon lasers to calculating distances between planetary bodies. Our medical counterparts have embraced CO2 lasers as scalpels and excimer lasers in eye surgery, aesthetic medicine is relying on diode lasers for hair removal, and Nd:YAG and pulsed dye lasers for the treatment of vascular malformations and tattoo removals. Fractional technology with erbium lasers is evolving to address skin resurfacing and recontouring applications. So why is dentistry so resistant to accepting lasers into the scope of practice?
This edition of Oral Health will showcase many different uses of laser technology in an attempt to open you to the world of possibilities, and all you have to do is keep an open mind. I’d like to ﬁnish by quoting Arthur Schopenhauer, “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” OH
About the Editor
Dr. Marina Polonsky DDS, MSc is a gold medal University of Toronto ’99 graduate, she maintains private general practice in Ottawa, Ontario with focus on multi-disciplinary treatment utilizing lasers of different wavelengths. She holds a Mastership from World Clinical Laser Institute (WCLI), Master of Science in Lasers in Dentistry from RWTH University in Aachen, Germany and Advanced Proficiency Fellowship from ALD (Academy of Laser Dentistry). She is the founder of the Canadian Dental Laser Institute (CDLI), study club affiliated with the Academy of Laser Dentistry. She serves on the Executive Committee for Oral Health and is the editor of the Laser Dentistry issue.