The opportunity is there; simple research to using lasers routinely
by Patti DiGangi, RDH, BS
Anita just interviewed for a new office and is excited because the practice respects dental hygienists and gives them nearly free reign to create an optimal hygiene department. She is thrilled to get this interview because she just moved from another state. At her last office, the practice was integrating a CAMBRA/minimal intervention (MI) philosophy for caries management. This new office seems to be forward thinking also. The hygienists routinely use lasers as part of their periodontal protocol.
The challenge is that Anita knows very little about lasers. This new practice sounds very supportive of Anita’s learning, yet she is not sure where to start. What classes does she need? What is the evidence for using lasers? How do lasers fit into the MI paradigm of care? Is it just fear of the new and unknown that gives her these thoughts? Anita has been out of school for 12 years, and she feels she practices a high-quality of care with all she has already learned.
Most hygienists are faced, or will face, this kind of dilemma in our ever-changing profession with new and evolving technologies and changing practice laws. Tracing Anita’s journey can be informative to every hygienist.
Bethany and Sally
Anita decides the best place to start is talking with her new co-workers, Bethany and Sally. Bethany has been working with lasers since 2008. Sally more recently began to incorporate lasers into the care of her patients. Bethany told Anita about the continuing education programs offered on the science of laser physics, clinical applications, and practice implementation. Anita could find programs through manufacturers, qualified consultants, clinical trainers, and national and international organizations such as the American Academy of Laser Dentistry (ALD), World Clinical Laser Institute (WCLI), and European Society of Oral Laser Application (ESOLA.)
Bethany and Sally had discovered there are multiple ways to incorporate lasers. Both hygienists have been using lasers for bacterial decontamination with periodontal cases. They also use a laser for selected patients of record and periodontal maintenance patients who have sporadic areas of pocketing and inflammation. Primarily, dental hygienists use lasers for decontamination, disinfection, and biostimulation through the absorption of light energy into the periodontal tissues. It is the healing benefit of lasers through the reduction of inflammation, disinfection, and the elimination of bleeding that speaks to the true value of laser implementation into the hygiene model of care.
This sounded straightforward and simple to Anita. Bethany and Sally explained they continue to take courses and find opportunities to learn more about lasers. Anita was happy to know the professionals at this new office obviously valued learning.
Like everything we do in dental hygiene, developing new skill sets requires practice, educational interest, and expansion. Several national and international organizations offer ongoing education to members and nonmembers interested in expanding their knowledge base and shared laser experiences with their colleagues.
Anita now realizes the world of lasers is extensive and was excited to embark on an investigative journey into this new world of patient care. Anita decided to focus on learning about the science and evidence; to find the thoughts of other professionals, both dentists and hygienists outside of this new practice; and gain information from laser manufacturers, as well as the opinions of educators and other key opinion leaders. This exciting journey led to as many new questions as it did answers.
Destruction of biofilms
The initial journey into the science of lasers takes a review of current understanding of biofilms. Many of us completed our education at a time when bacteria were studied in a free-floating planktonic state. This led to the thinking that certain pathogens were the reason for breakdown. It was thought that thorough removal of supra- and subgingival deposits by professionals at the office and the patient at home would equate to health.
Biofilms are medically/dentally important since what we now understand is few diseases are caused by microbes living in a planktonic state, that is, nonadherent and free-floating. An oral biofilm environment is an accumulation of a mixed population of bacteria, fungi, or protozoa that produce large amounts of slime or matrix material around themselves.
Periodontal disease is a type of wound. Mealey and Rose talk about the periodontium as a unique ecological niche in the human body. Prior to the eruption of teeth, the tissue is intact yet inhabited by bacterial communities that don’t much challenge the individual’s health, similar to the way skin protects the rest of the body. When the teeth erupt, this intact surface can have as many as 32 objects poking through this formerly intact mucosa. This creates the potential for biofilm and promoters of inflammation to reach the bloodstream. Through the work of Costerton, we know that the complex makeup of the biofilm community and its ability for self-preservation is amazing. Only 20% of the biofilm are pathogens, with 80% a difficult-to-penetrate slime layer composed of self-secreted glycoproteins and polysaccharides.
This short review of current thinking on biofilms has great significance on the discussion of laser research. Hygiene care is no longer only about removing supra- and subgingival deposits that can be seen, touched, and felt — and not only around the mouth. This new information sparked Anita’s interest even further. She started to understand that the changing face of periodontics and the role of the hygienists in treating patients to this new level of patient health and wellness would be her inspiration to become more knowledgeable and skilled in incorporating a laser during treatment.
How lasers work
Anita decided to google dental lasers. She found many articles from researchers and professionals using lasers worldwide and companies that sell lasers. These articles are helpful in the understanding of how lasers work and the types of lasers available.
A variety of lasers are currently used routinely in practice for hard tissue and soft tissue procedures, as well as technologies that help identify caries. Anita used a DIAGNOdent (www.kavo.com) at her last practice. Enamel infections can be identified, quantified, and treated without damaging the outer covering of enamel. Quantitative fluorescence assesses the enamel in a more comprehensive way and enables the understanding of the pathologic changes to provide a wider range of therapeutic alternatives. Anita was somewhat surprised because she didn’t know she had already been using a type of laser.
Anita found the information on hard tissue laser wavelengths for surgical procedures interesting, but they had no application for her as a dental hygienist. She decided to narrow her search to the soft tissue laser wavelengths which apply to the scope of practice in hygiene. The Food and Drug Administration (FDA) has approved the diode and Nd:Yag laser wavelength/device for sulcular debridement, decontamination, and surgical removal of soft tissue. These wavelengths fit well into the world of hygiene when dealing with the bacteriologic and host immunologic side of the periodontal infections as well as the surgical side of periodontics for the dentist.
The American Dental Association’s (ADA) Center for Evidence-Based Dentistry website (www.ebd.ada.org) defines evidence-based dentistry (EBD) as being “based on three important domains: the best available scientific evidence, a dentist’s clinical skill and judgment, and each individual patient’s needs and preferences.”
The ADA developed clinical recommendations that can be used by practitioners in conjunction with their clinical judgment and their patients’ needs and preferences to make evidence-based treatment decisions. There are recommendations on fluoride, sealants, reconstituting infant formula, and more.
EBD is not about research, only as can be seen with the ADA definition. As Anita read article after article, she began to think about the clinical parameters. She decided it was time to talk to more people. Anita has learned the real value of EBD in clinical practice is to close the gap between what is known in research and what is practiced with the goal of improving patient care based on informed decision-making. What she also knows is a practitioner’s need to have chairside access to be able to find the answers when needed.
View from a manufacturer
Dental industry/manufacturers provide research regarding products. Anita took the time to connect with a variety of companies selling lasers. The representatives were very helpful in sharing information as well as putting her in touch with the scientific leaders at their companies.
Anita checked in with her microbiologist friend Bill Landers, who is the president of OraTec (www.oratec.net), a company that sells microscopes and other anti-infective products. Bill said he wasn’t impressed with the initial data on lasers, though later studies were more persuasive. A number of his customers using microscopes began using lasers and lauded the results. He became more impressed with those results than the data because these users were seeing actual microbiological improvements. In theory, there should be a benefit. Anything that kills or disrupts biofilms should be beneficial.
Talking to a dentist
Anita thought it was time to talk to some dentists. One dentist friend had been working with lasers for a number of years and had personally seen some amazing results. He has definitely realized a tremendous return on investment, both in patient good-will and financially. His office chooses not to charge a separate fee. Instead, they chose to increase the fee of the D1110 prophylaxis and D4910 periodontal maintenance procedure codes.
He works with a periodontist who supports the office’s philosophy. What Anita found really interesting is that they do not alternate recall maintenance. The periodontist feels the patients have been experiencing a higher level of care and better health, and co-management is not needed. The periodontist prefers performing the surgical and implant work and is more productive.
Anita was surprised because her experience with the perio/general office relationships were often strained to the point of being nonexistent. Communication on recall visits goes only one way. The perio office sends a brief, nearly useless note and the general office sends nothing beyond the initial referral.
That’s the thing about learning; even when on a journey with a clear destination, other opportunities to learn and grow arise.
View of CAMBRA/MI dentists
Anita decided to talk with a CAMBRA dentist about lasers. Sometimes CAMBRA/MI is thought of only with caries management. Anita’s experience had already taught her that the MI philosophy is to diagnose caries, oral cancer, and periodontal disease and treat their infections before they cause damage. The model of dental and medical care in the United States has long been about disease; waiting for disease, measuring disease, and treating disease, often with amputation. The first response from this CAMBRA dentist was that he knew he was biased. He immediately followed that by saying we all have biases. As much as EBD attempts to reduce and eliminate bias, as human beings we have biases.
As an early adopter, he has been using several different lasers since 1990. His opinion is that we should focus less on the technology and more on the patient outcomes. Lasers are an instrument in our armentarium — nothing more, nothing less. The question practitioners should ask is if the laser will provide results for a particular patient that is as good as or better than the traditional care.
What he questions are the baselines we use. Periodontal pocket depth, bleeding on probing (BOP), clinical attachment loss, and bacterial activity are usually the parameters used in research, although most studies do not identify how they measuring bacterial activity. In clinical practice, often it is only pocket depth and BOP. He questions the accuracy of these measures in every setting.
From the MI point of view, most of the clinical parameters currently used are about disease manifestations. The metaphorical horse is already out of the barn. MI is concerned with the first occurrence, earliest detection, and earliest possible treatment on micro-molecular levels, followed by the most minimally invasive and patient-friendly options to repair irreversible damages caused by disease. MI aims to empower patients through information, skills, and motivation to be in charge of their own oral health, so that they require only minimum intervention from the dental profession. MI provides general guidance into new ways of dental diagnosis and treatment, following principles of EBD. Laser readily fits this model.
Anita completed PennWell’s Soft-Tissue Lasers and Procedures by Dr. Ray Voller (www.ineedce.com) and had an ah-ha moment when she read “the absorption of the light results in the production of heat, and depending on the temperature change and tissue, the end result may be superficial or deeper, such as vaporization with soft tissue wavelengths or the meltdown of enamel and subsequent re-crystallization with hard tissue wavelengths, which can also increase acid resistance.”
Lasers are amazing and definitely fit the MI model of care.
What dental hygiene trainers have to say
Anita’s final interviews were with several hygienists who have incorporated lasers into their clinical practice as well as offering laser training courses. Each had very informative thoughts.
Rebecca has been using lasers in clinical practice for several years for decontamination on routine visits, as part of a periodontal protocol and also for treating canker sores and herpes simplex outbreaks. Rebecca has embraced the thought of biofilms and using lasers for wound healing. She worked with a dentist providing LANAP periodontal therapy. LANAP protocol was developed by the founders of Millennium Dental Technologies, Inc. (www.lanap.com). LANAP is an acronym that stands for laser-assisted new attachment procedure and is a surgical procedure performed by dentists. LANAP is the only laser patented protocol to treat periodontal disease using the ND:YAG laser.
Mary, a member of the ALD Education Committee, recommends looking to the ALD website (www.laserdentistry.org) to find resources and textbooks on lasers. She particularly recommends a book published in August 2010, Principles and Practice of Laser Dentistry, by Dr. Robert A. Convissar because it brings a concise, evidence-based approach to using lasers.
Linda was, like many dental hygiene professionals, very proficient for 30 years in the usual ways of practicing dental hygiene. She was very proud of all she gave to patients. Yet more than 10 years ago, a new opportunity arose. She began working with a dentist who told her he wanted her to find a way to make patients healthy and would provide what she needed. Sounds simple, right? Many of us wish that was the description of where we work yet, with those challenges also come responsibilities.
Recidivism is the term used when criminals keep going in and out of prison. It is defined by Webster’s as “the tendency to relapse into the previous condition or modes of behavior.”
Most dental hygienists, as well as dentists, believe periodontal disease is something to be managed rather than cured. There is an expectation of recidivism; in other words, we expect bleeding and continued inflammation.
Again, we wait for and expect disease. Linda has turned these thoughts upside down. With the goal of health, Linda began to see the way hygiene has been traditionally practiced is a form of insanity. We do the same things over and over and expect a different result. In 1998, she began using a diode laser — first just for periodontal patients — with great results. So she thought, “Why not use it on everyone?” For the following six to seven years, she used the laser routinely on every patient. Her goal is to prepay for tomorrow, which means she wants to see patients before there is disease. Her approach includes the use of lasers, micro-ultrasonics, and more recently, ozone therapy. Yet all of those modalities are only a means to an end.
Linda said there are three important steps in her care plans:
- Thinking/knowing and applying her philosophy of care
- Communication, truly listening to what the patient wants
- Her clinical habits.
She knows her protocol and applies her clinical skills, seeking a healthy result. She doesn’t expect the patient to come back with inflammation or disease. She knows the goal is not complete removal of biofilm because that is impossible, nor is it to only disrupt the biofilm; rather it is to create a healthy biofilm. The majority of her patients have no calculus to remove.
Linda’s protocol does not start with treatment; it starts with five specific life-saving screenings. Life-saving may seem like a strong language, yet it is exactly what Linda believes. It is this belief that fuels her work. One specific diagnostic test she uses is CariScreen (www.CariFree.com) to determine the health of the biofilm. CariScreen is a quick, painless, chairside test using ATP bioluminescence for the quantification and activity of oral bacterial load. Her work centers on managing pH. Though often thought of only in caries control, biofilm health and pH are key to periodontal health.
Talking with Linda was the capstone of a very interesting journey for Anita. Linda helped Anita to see that lasers are definitely another arrow in her quiver, another option supporting an MI model of care. Anita wants to use them like Linda does as part of a method to help patients attain and keep health.
Anita is thrilled that she has such a wonderful opportunity to work with a practice using lasers. She knows that she must learn as much as possible about lasers and the office philosophy. She is going to seek out a variety of ways to learn. Anita plans to use lasers in clinical practice but not as a stand-alone or be-all process. Anita no longer wants to practice management of disease; she is ready for a new career path — one with a goal of health. She is sure Sally and Bethany will join her on this journey. She can’t wait to get going.
Author note: A special thanks to hygienists Bethany Culbert, Sally Solcum, Pat Pine, Jeanne Godette, Cris Duvall, Cindy Quinn, and Lynne Slim for sharing their time and expertise to make this article possible. An extra measure of special thanks goes to Janet Press for her knowledge, assistance, and generosity.
Patti DiGangi, RDH, BS, is a vision-driven person finding strength and direction from her inner convictions. Like most true visionaries, she views obstacles as learning experiences that can be used for self-development. As a lifelong learner, her energetic, thought-provoking, and successful program development and mind-bending view of what can be shine a bright light for others to preview the future and find their place in it. She can be contacted through her website at www.pdigangi.com.
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