Diode lasers have gained in popularity over the last few years in dental offices because of their low cost, portability, reliability and simplicity of use. Diode lasers range in wavelength from 810nm-1064nm, and they are well absorbed in hemoglobin, pigments, and melanin, making these lasers excellent soft tissue “handpieces” that can ablate tissues while maintaining hemostasis.1
Many clinicians now see the diode laser as their replacement for electrosurgery, appreciating that the diode laser can work around metals (amalgam, gold, braces and dental implants) without fear of creating iatrogenic damage.1-4
Moreover, diode lasers can be used within endodontic canals5-9 and periodontal pockets10-12 to reduce bacteria counts, whereas the electrosurgery unit cannot do this. In addition, two unique features of lasers (as compared to monopolar electrosurgical units) are that they require less-anesthetic for small amounts of tissue are removed13-14 and can be used for patients with pacemakers.15-16
When a clinician first purchases a diode laser, it is easy to be confused by representatives who claim that one diode will cut faster than another, or may be superior for certain procedures. The author has used many different diode lasers and different diode laser wavelengths, and has found that they are remarkably similar in their ability to cut soft tissue, and that the differences between brands and lasers is more focused on differences in size, features, accessories, educational support, service and warrantee than on their clinical capabilities. A “diode is a diode is a diode” so the purchaser of a soft tissue laser should focus on these features when considering which brand and wavelength to purchase!17
Zolar Photon diode lasers (http://zolartek.com) are available in two wavelengths: a 3-watt 810nm wavelength and a 10-watt 980 nm wavelength (Fig. 1). These lasers both are manufactured in Canada. They are battery charged, available with single use tips or the more economical strippable fiber. These lasers come with 21 presets on a touchscreen LCD panel, and a cordless foot pedal. The clinician who wishes to cut only soft tissue with the laser can complete almost all ablative procedures with the 3-watt laser. For laser power bleaching, the more powerful 10-watt laser with a specialized laser bleaching hand piece is required.
FIGURE 1. The Zolar Photon Diode Lasers: 3w (810 nm) on Left and 10w (980nm) on Right.)/201407031026290mdjoe1ntoicwic55zek5xxzd.jpg)
Many dentists use their lasers progressively in their practices. At first, laser technology has the ability to make the clinician’s life easier (gingivectomy and laser troughing for crown impressions). Subsequently, the clinician integrates new clinical procedures into the practice with the increased ability to handle soft tissue problems that were not routinely treated previously (frenectomy, fibroma removal, photo-coagulation of venous lakes).17
At times, soft tissue must be removed to accomplish restorative procedures, and thus the gingivectomy is a very common laser procedure. Soft tissue gingivectomies and gingivoplasty are important in regular restorative dentistry (subgingival class V carious restorations), orthodontics (removal of excess interproximal gingival due to poor oral hygiene or for space closure), esthetic dentistry (smile makeover cases to enhance pink esthetics), and with dental implants (soft tissue encroachment on the margins of abutments). In fact, the gingivectomy is the most common procedure that most laser dentists will encounter (Fig. 2).18
FIGURE 2. Soft tissue inflammation and carious Class V lesions (left), after diode gingivectomy (1.0w CW) and final direct restorations (Center) and eight days postoperative healing (right)./201407031026291mdjoe1ntoicwic55zek5xxzd.jpg)
Laser crown troughing can replace retraction cord for the management of tissue for indirect restorations. The diode laser can ablate soft tissue around a deep sub gingival margin allowing for either polyvinyl/polyether or digital impressions to be taken with greater ease. Hemostasis is exceptional and with time, the clinician will use the laser in both the anterior and posterior regions as the sole means of tissue retraction for all indirect restorations. Gherlone et al showed that lasers can be used to trough with minimal soft tissue damage to the periodontal tissues (Figs. 3a & b).19
FIGURE 3A. Preoperative discolored restorations (L), Diode troughing for tissue management for impressions (Center), PVS impression (right)./201407031026302mdjoe1ntoicwic55zek5xxzd.jpg)
FIGURE 3B. Final image of veneers (laterals) and crowns (centrals)./201407031026303mdjoe1ntoicwic55zek5xxzd.jpg)
Soft tissue procedures such as frenectomies, lingual tongue-tie releases (Fig. 4) and fibroma removals (Fig. 5) are not commonly done in many dental offices. The diode lasers is used routinely to remove tissue in situations where an aberrant frenum is causing recession, diastemas or other problems. Higher energies (1.5w Continuous Wave) may be needed as the tissue is often not pigmented and therefore more difficult to ablate. The ablations are typically completed within 60-90 seconds with just a few drops of local anesthetic.
FIGURE 4. Ankyloglossia on six year old (L), immediate postop (Center) and two weeks healing (R)./201407031026304mdjoe1ntoicwic55zek5xxzd.jpg)
FIGURE 5. Fibroma Pre-op (L), immediate postop (Center) and two weeks healing (R)./201407031026305mdjoe1ntoicwic55zek5xxzd.jpg)
Research has shown that patients exhibited less stress during the frenectomy procedure when treated with the diode laser (as compared to electrosurgery), and had less postoperative complications after surgery.20
Many practitioners are finding that patients now wish to have quicker “in-office” tooth whitening solutions that ”
jumpstart” their bleaching treatment. The more powerful 7-10 watt diode laser, when equipped with a bleaching handpiece and specialized bleaching gels that are activated by the laser (Heydent Power Laser Bleaching Gel), can provide rapid in-office bleaching without sensitivity, particularly in patients who present with darker shaded teeth (Figs. 6-7). The mixture of the two bleaching gel components provides a 35% hydrogen peroxide which is applied to the teeth and laser-activated for 30 seconds per sextant. The activated gel is left on the teeth for four to five minutes prior to being suctioned away. A series of 4-5 laser-activation cycles can improve the overall color of the dentition by 4-8 shades.22 In addition, it has been shown that diode laser bleaching results in less tooth and gingival sensitivity and is the preferred in-office bleaching system.23 Take home bleaching trays help to stabilize the improved whitening and provide patients with the ease of a future “touch-up”.
FIGURE 6. Pre-op (L), Laser handpiece (center), Barrier on soft tissue with laser-specific bleaching gel (R)./201407031026306mdjoe1ntoicwic55zek5xxzd.jpg)
FIGURE 7. Before and After images of Power Laser Bleaching./201407031026317mdjoe1ntoicwic55zek5xxzd.jpg)
The diode laser is an excellent introductory soft tissue handpiece for general dental practices. It offers clinicians a cost-effective method to become a “laser” practitioner by purchasing a small unit, that is reliable, portable and efficient. The diode laser makes life easier in many routine aspects of regular restorative dentistry (gingivectomy, crown troughing), as well as providing an opportunity to integrate new soft tissue procedures into the office (frenectomies, fibroma removal, photocoagulation of venous lakes). If the practitioner opts to purchase a slightly more expensive, yet significantly more powerful, 7-10 watt laser with laser bleaching hand pieces and specialized laser gels, then power laser in-office bleaching is also possible. Check out the soft tissue lasers like the Zolar Photon diode lasers – you may find that they can offer you an exciting introduction to providing laser dentistry in your clinic. OH
Dr. Glen van As, BSc, DMD, graduated from the University of British Columbia in 1987 and served as assistant clinical professor there from 1989-1999. He has presented over 200 lectures internationally and published several articles on the value of multiple wavelengths of lasers and the use of the dental operating microscope in practice. Glenn maintains a private practice in North Vancouver, BC.
Oral Health welcomes this original article.
REFERENCES
1. Goldstep, F, Soft Tissue Diode Laser: Where Have You Been All My Life? Oral Health, July 2009, pgs 34-38.
2. van As G, The Diode Laser as an Electrosurgery Replacement. Dentaltown. June 2010. pgs. 56-64.
3. Robertson PB ,Luscher B, Spangberg LS, Levy BM. Pulpal and periodontal effects of electrosurgery involving cervical metallic restorations. Oral Surg Oral Med Oral Pathol. 1978 Nov; 46 (5); 702-20.
4. Skaria AM. Electrocoagulation and hazardous damage to a dental prosthesis. J ! ! AmAcadDermatol. 2006;54(3): 543-4.
5. Wilcox CW, Wilwerding TM, Watson P, Morris JT. Use of electrosurgery and lasers in the presence of dental implants. Int J Oral Maxillofac Implants 2001;16(4): 578-82.
6. Hmud R, Kahler WA, George R, Walsh LJ. Cavitational effects in aqueous endodontic irrigants generated by near-near infrared lasers. J Endo. 2010 Feb;36 (2):275-8. Epub 2009 Dec.4.
7. Alfredo E, Marchesan MA, Sousa-Neto MD, Brugnera-Junior A, Silva-Sousa YT. Temperature variation at the external root surface during 980-nm diode laser irradiation in the root canal. J Dent. 2008 Jul;36(7):529-34. Epub 2008 May 6.
8. Gutneckt N, Franzen R, Meister J, Vanweersch L. Mir M. Temperature evolution on human teeth root surface after diode laser assisted endodontic treatment. Laser Med Sci.2005 Sep;20(2):99-103. Epub 2005 Jul 9.
9. Theodoro LH, Haypek P, Bachmann L, Garcia VG, Sampaio JE, Zezell DM, Eduardo Cde P. Effect of ER:YAG and Diode laser irradiation on the root surface: morphological and thermal analysis. J Periodontol. 2003 Jun;74(6): 838-43.
10. da Costa Ribeiro A, Nogueira GE, Antoniazzi JH, Moritz A, Zezell DM. Effects of diode laser (810 nm) irradiation on root canal walls: thermographic and morphological studies. J Endod. 2007 Mar;33(3):252-5. Epub 2006 Dec 13.
11. Moritz A, Schoop U, Goharkay K, Schauer P, Doertbudak O, Wernisch J, Sperr W. Treatment of periodontal pockets with a diode laser. Lasers in Surgery and Medicine Vol 22, (5), pages 302–311, 1998.
12. Gutierrez T. Diode Laser for Bacterial Reduction and Coagulation: An Adjunctive Treatment for Periodontal Disease. Cont Oral Hyg Dec 2005; Vol. 5, No. 12: 20-2
13. A. Moritz, et al. Bacterial Reduction in periodontal pockets through irradiation with a diode laser: a pilot study. Lasers Surg Med 1999: Vol 22: 302-311
14. Kafas P, Stavrianos C, Jerjes W, Upile T, Vourvachis M, Theodoridis M, Stavrianou I. Upper-lip laser frenectomy without infiltrated anaesthesia in a paediatric patient: a case report. Cases J. 2009; 2: 7138. Published online 2009 May 20. doi: 10.1186/1757-1626-2-7138.
15. Kalas P, Upile T, Stavrianos C, Angouridakis N, Jerjes W. Mucogingival overgrowth in a geriatric patient. Derm Online Journ. 16 (8):7. 2010.
16. Miller CS, Leonelli FM, Latham E. Selective interference with pacemaker activity. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998 Jan;85(1):33-36.
17. Moon MR, Camillo CJ, Gleva MJ. Laser-assist during extraction of chronically implanted pacemaker and defibrillator leads. Annals of Thoracic Surgery. Vol. 73. Issue 6. Pgs 1893-1896, June 2002.
18. van As G. Lasers in dentistry: an application that found its purpose. Oral Health J. 2011 Mar:30-8.
19. White JM, Swift EJ. Lasers for Use in Dentistry. Journal of Esthetic and Restorative Dentistry. Vol 17, Issue 1, page 60, January 2005.
20. Gherlone EF, Maiorana C, Grassi RF, Ciacaglini R, Cattoni F. The use of 980- nm Diode and 1064-nm Nd:YAG Laser for Gingival Retraction in Fixed Prostheses. J Oral Laser Appllications. 2004; 4:183-190.
21. Rai D. Comparison between labial frenectomy done with radio surgery and diode (810nm) laser using visual analogue scale for patients perception of pre-operative distress and post-operative pain. Asian Pacific Orthodontic Society. 2012. Vol 2 Issue 3. Page 2.
22. Goharkhay K1, Schoop U, Wernisch J, Hartl S, De Moor R, Moritz A. Frequency doubled
neodymium:yttrium-aluminum-garnet and diode laser-activated power bleaching—pH, environmental scanning electron microscopy, and colorimetric in vitro evaluations. Lasers Med Sci. 2009 May;24(3):339-46. doi: 10.1007/s10103-008-0567-x. Epub 2008 May 27.
23. Gurgan S1, Cakir FY, Yazici E. Different light-activated in-office bleaching systems: a clinical evaluation. Lasers Med Sci. 2010 Nov;25(6):817-22. doi: 10.1007/ s10103-009-0688-x. Epub 2009 Jul 9.
