Laser applications in hygiene

by Lynne H. Slim RDH, BSDH, MSDH
[email protected]

Some topics are more difficult than others to write about, and this one is a whopper of a doozy. It is a tough assignment to conduct an exhaustive literature search and finding time to discuss laser dentistry with a variety of clinicians. Much misinformation exists about laser applications in dentistry, making it hard to make wise clinical decisions.

Since the mid–1960s, ophthalmologists have been tremendously successful with a variety of laser applications that have revolutionized ophthalmic treatment.1 Also, during the 1960s, research into laser applications for dentistry began, and lasers were cleared by the FDA for soft tissue procedures.

In 1997, the FDA cleared the Er:YAG laser, which is capable of ablating both hard and soft tissues in the oral cavity. In treating soft tissues, the diode, CO₂, Nd:YAG, and Er:YAG lasers are used in today's general dental and specialty practices. The most popular soft tissue procedures carried out using lasers are the gingivectomy, gingivoplasty, and frenectomy.1 Dental Products Report published a survey in May 2005 that described how laser dentists use their devices; 87% of laser dentists use their lasers for cosmetic gingival contouring, including around crown and laminate margins, and 81% use their lasers for gingival retraction/troughing.

In reviewing the literature on nonsurgical pocket therapy and laser applications, I read four literature reviews, two of which are systematic reviews.1–4 Many dental hygienists around the United States are now using lasers adjunctively with conventional, mechanical periodontal debridement. Researchers are still collecting evidence which supports/refutes adjunctive laser therapy on issues such as:

• Hemostatic effects
• Calculus ablation
• Bactericidal effects against periodontal pathogens and gingival inflammatory response
• Undesirable thermal side effects
• Root surface alterations
• Financial cost of laser equipment.

CO₂, Nd:YAG, and diode lasers are ineffective in removing mineralized deposits from root surfaces.1,2 The Er:YAG laser has been shown to remove subgingival calculus without a major thermal change (in vitro), and it has been proposed that the Er:YAG laser may perform similarly to that provided by conventional scaling and root planing.1 In addition, the Er:YAG and CO₂ laser hold promise as an alternative treatment for peri–implantitis.1 The CO₂ laser, in particular, possesses an ability to enhance bone regeneration when used for decontamination of implants in experimentally induced peri–implantitis.1 More clinical studies are needed to determine whether or not the Er:YAG laser can be substituted for conventional scaling and root planing.

Biofilms have been dislodged during in vitro (laboratory) testing with an Nd:YAG laser from hard surfaces.5 Photodynamic therapy, too, has demonstrated a high bactericidal effect, but like other laser application technologies, there is insufficient evidence of superior results when compared to conventional mechanical therapy.1

Cobb, in a classic American Academy of Periodontology review (2006), stresses the need for an evidence–based approach to the use of lasers for the treatment of chronic periodontitis.4 In two more recent reviews, the effect of different lasers in nonsurgical periodontal therapy didn't seem to offer any advantages when used adjunctively to conventional debridement, and it was emphasized that more randomized controlled clinical trials are needed.3,6

What adjunctive results are our dental hygiene colleagues discovering when using lasers during nonsurgical periodontal therapy? Laurie King, RDH, from Palm Springs, Calif., uses an UltraSpeed CO₂ laser and she finds it to be kind to the soft tissues. Although she admits there's not enough research to support the results she's seeing, she's getting great long–term results for her patients.

Laurie is frustrated by the trend to use inexpensive diode lasers adjunctively and describes them as high–end electrosurgery tools. She does concede, however, that inexpensive diodes could be a gateway to a better laser and is excited about future laser applications in periodontal therapy. Laurie, like other hygienists I have written about, is a maverick. She describes laser energy as cascading, meaning that pockets continue to heal over time due to a dynamic system of changes in the pocket's microbial ecosystem.

“Calculus is not the enemy in a pocket's ecosystem; rather, it's the accomplice,” Laurie says, and she also wants dental hygienists to know that self–care compliance is the monkey wrench in anything we do. In other words, we can suppress periodontal pathogens over and over again using equipment at our disposal, but long–term results depend upon patient compliance.

Laurie referred me to another laser aficionado in New York, who is sometimes referred to as “Laser Bob.” Dr. Bob Convissar practices laser cosmetic and restorative dentistry. He is a recognized Academy of Laser Dentistry course provider and has authored several textbooks on laser applications in clinical dentistry. Dr. Convissar uses a variety of laser wavelengths and told me there's plenty of research to support laser pocket decontamination/disinfection and biofilm disruption. When a dental professional is first introduced to lasers in a clinical practice, Bob insists that these three steps are critical: 1. training, 2. training, and 3. training.

It upsets Dr. Convissar greatly when some of the less expensive diode lasers come with a DVD and webinar and don't include at least 12 hours of hands–on training. If you would like to chat about lasers or explore certification courses for dental hygienists, you can reach Laser Bob at [email protected] or Laurie King at [email protected].

Let's continue to follow the science objectively, learning from laser experts such as Laurie and Laser Bob and see where it leads. More randomized, controlled clinical trials are needed to better understand the effects of lasers on adults with chronic periodontitis.

References

1. Ishikawa I et al. Application of lasers in periodontics: true innovation or myth? Periodontol 2000; 50, 2009: 90–126.
2. Schwarz F, Aoki A, Becker J, Sculean A. Laser application in non–surgical periodontal therapy; a systematic review. J Clin Periodontol 2008; 35 (Suppl 8): 29–44.
3. Karlsson MR, Diogo Löfgren Cl, Jansson HM. The effect of laser therapy as an adjunct to non–surgical periodontal treatment in subjects with chronic periodontitis: a systematic review. J Periodontol 2008; 79(11): 2021–2028.
4. Cobb C. Lasers in periodontics: a review of the literature. J Periodontol 2006; 77: 545–564.
5. Krespi YP, Stoodley P, Hall–Stoodley L. Laser disruption of biofilm. Laryngoscope 2008; 118(7): 1168–1173.
6. Slot DE, Kranendonk AA, Paraskevas S, Van der Weijden F. The effect of a pulsed Nd:YAG laser in non–surgical periodontal therapy. J Periodontol 2009; 80(7): 1041–1056.

Lynne Slim, RDH, BSDH, MSDH, is an award–winning writer who has published extensively in dental and dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene–related topics.