By Dr. Timothy Kosinski and Stephanie Pajot, RDH, BS
DIGITAL DENTISTRY
Diode lasers are an efficient and productive tool easily added to your practice. Achieving hemostasis, creating clean incisions, excisions, ablations and vaporization are just a few of the intended uses. These soft tissue lasers are implemented for use in periodontal, restorative, orthodontic and minor surgical treatments.1
The NV PRO3 microlaser demonstrated here is a portable soft tissue laser. Weighing only 1.9 ounces is it easily transported from operatory to operatory. It’s cordless design and excellent shape make it my favorite to use. It is really not much bigger than a Sharpie. The class IV laser device has a lithium ion battery with over and undercharge protection and delivers thirty minutes of continuous operation at 1.2 watts or power. The twelve preset procedural settings are used for all periodontal, restorative and orthodontic treatments. There is a wireless foot pedal, audible notifications to make the patient aware of its active use. The fiber tips are disposable. The soft tissue laser can deliver between 0.1 and 2.0 watts of power in continuous wave or pulse mode. The wavelength of this tool is 808nm (+/- 5nm)
This microlaser allows the dentist and hygienist to perform different procedures with less chair time with predictable results as compared to more traditional methods. Discomfort is reduced or eliminated and procedures are often completed without local anesthetic. A positive patient experience is the best marketing tool, as patients who undergo non-invasive procedures are more likely to continue treatment and tell their family and friends. Preventive and restorative dental procedures become minimally invasive.
Laser Bacterial Reduction is a simple, effective procedure that does not require local anesthesia and reduces pocket depth.
An equally relevant, practical use of the NVPRO3 microlaser is for periodontal treatment performed by the dental hygienist. Bacterial reduction is accomplished in areas of bleeding on probing and significant pocket depth.2 As an adjunct to traditional scaling and root planing, laser assisted periodontal therapy is designed to selectively target dark, necrotic tissue while preserving healthy tissue and promoting healing. To perform periodontal therapy, the laser can be set to the pulse mode at 1.5W and configured with a non- initiated tip. Initiating a laser tip using blue marking occlusal paper creates a “cutting tip,” which is not necessary for bacterial reduction. The soft tissue laser tip is effective in reducing the bacterial count in the pocket area, which reduces the risk of bacteria entering the patient’s bloodstream. No anesthetic is needed. In a short 2-3 weeks, re-evaluation indicates reduced pocket depth and no bleeding on probing.
We do recommend that you wait three months before continuing probing depth to achieve the full effect of healing after laser therapy.
Most lasers operate off a selection of continuous wave or pulsed output. Continuous means it is giving off the same power output constantly. This would be used for all procedures that require cutting with an initiated tip. This is also where you can heat the tissue and start to see charring which is not desirable.
This means the area is overheating and the power supply should be reduced to allow cooling. Pulsed operation of lasers refers to any laser not classified as continuous wave, meaning the power appears in pulses of some duration at some repetition rate.
Understanding how laser energy works is important for safety. Reflected energy can be harmful to our eyes, and this is why we wear safety glasses during the procedures. Transmitted energy could excessively heat up the underlying tissue, which is not desirable. Scattered energy can be effective for things like biostimulation of canker sores and herpetic lesions.3 Absorbed energy is used for cutting. The diode laser energy is absorbed by hemoglobin, melanin, water and pigmentation. The darker the pigmentation, the more attraction the laser energy has. This is how the laser works and why it only cuts soft tissue and not bone. The 810 nm laser like the NV3PRO microlaser are better absorbed by melanin and hemoglobin and has a lower affinity to water.4
This work well in a dry field. The diode laser works in heating the tissue to the 100 to 150 degree Celcius range. Blood coagulation is seen early in the process while heating tissue. When the laser tip contacts soft tissue, the tip must be initiated to concentrate the energy. The laser light is turned into heat, creating the photo-thermal reaction. There is localized vaporization around the zone of carbonization. This tool has reduced my use of a scalpel. In providing same day dentistry, there is minimal bleeding, minimal postoperative discomfort, faster healing, little or no gingival recession and more precise treatment with no tissue scarring. It can be used around metal, dental implants and crown and bridge work.
The use of the diode laser in periodontal and hygiene applications is significant. Laser assisted periodontal therapy is an adjunct to traditional scaling and root planing. Other indications include bacterial reduction, sulcular debridement and desensitization of exposed root structure.
Patients often present with herpetic lesions, which are embarrassing and painful. When the lesion presents to us early in the process, the laser provides an excellent tool to expedite healing and minimize the discomfort experienced. Our hygienists have found this diode laser to be an effective tool to reduce pocket depth and eliminate bleeding on probing. This is a non-initiated procedure with the laser set at 1.5 watts in pulsed mode, using a non-initiated tip.
Naturally when you consider adding a piece of equipment to your practice you need to ask yourself if it’s applicable to your patient’s needs, and can it boost production? From the Hygiene Department standpoint, the answer is an easy, “yes”. Or better yet, “YES!” When you decide to invest in a laser, you can do as many or as few laser therapy applications as you wish.
Laser Bacterial Removal (LBR) is a method to decrease bacterial counts prior to a prophy, periodontal maintenance or initial periodontal therapy. Time does not typically need to be added to the appointment since it only takes an average of 8 minutes to treat the whole mouth. Your protocol for recommending LBR can be as simple as noting an increase in pocket depth or bleeding upon probing during a periodontal charting . Maybe you choose to treat every adult once per year with LBR as a preventative measure, or just those with a systemic or periodontal history. These are just options, and a fee for a procedure can vary from $15-$50 per visit. Because the laser helps with coagulation and post-op healing, it can be used just to help those patients who complain of soreness following a hygiene procedure. That, alone, will earn your patient’s trust and loyalty if he/she can leave your office smiling and not reaching for the Ibuprofen!
Sulcular debridement is similar to LBR but is utilized at the end of an initial therapy appointment. You use the same laser, the same tip, but maybe the tip is initiated and necrotic tissue is being removed from the diseased pocket. Some practices choose to keep the fee per session the same as LBR, or increase this to $60-$200 per quadrant. It can also be incorporated into your SRP fee if you so choose.
Aside from periodontal uses, laser-assisted hygiene can include treating hypersensitive tooth surfaces, as well as reduction of healing time for oral lesions including apthous ulcers, herpetic lesions and even painful tongue bites. The fee range for these procedures can be in the $30-50 range and it would be at your discretion if multiple sites are included for this cost. In my experience, treating a brand new herpetic lesion is especially magical, because the lesion won’t continue on its path to an unsightly crusty lesion, and your patient will love you for it!
The bottom line for office production is that these hygiene procedures only cost you, the provider, about $6 per tip, not much in additional chair time, and patients are thrilled you have a pain-free method of improving the result of virtually any dental hygiene appointment you can offer.
Conclusion
The NVPRO3 microlaser is an excellent investment that can be used for many dental procedures. Uncovering buried dental implants, without the need for local anesthetic infiltration, troughing around a crown preparation, thus eliminating the need for retraction cord, for outstanding traditional polyvinyl siloxane impressions, creating hemostasis around subgingival class V restoration preparations, allowing for immediate composite placement are just a few of the daily clinical applications. Bacterial reduction and laser assisted periodontal therapy are used to manage challenging intraoral issues. Finally, painful herpetic lesions and apthous ulcerations are reduced and eliminated is quick time. The responses from our patients is positive and certainly reinforces our other treatment plans. Workflow is maximized, patient satisfaction is increased, the procedures become minimally invasive and production increases.
REFERENCES:
1 Yeh, S, Jain, K, Andreana S. Using a Diode Laser to Uncover Dental Implants in Second Stage Surgery. Gen.Dent. 2005, Nov-Dec; 53(6). 414-417.
2 Andreana, S. The Use of Diode Lasers in Periodontal Therapy: Literature Review and Suggested Technique. Dent.Today. 2005, Nov;24(11). 132-135.
3 Eduardo, C. et al. Laser Treatment of Recurrent Herpes Labialis: A Literature Review. Lasers in Medical Science. 2013, 29(4).
4 Stomatol, A. Effectiveness of a Diode Laser in Addition to Non-Surgical Periodontal Therapy: Study of Intervention. Annali Di Stomatologia. 2015, Jan-Mar; 6(1). 15-20.
Timothy Kosinski, DDS
Dr. Timothy Kosinski is an Affiliated Adjunct Clinical Professor at the University of Detroit Mercy School of Dentistry and serves as the Associate Editor of the national AGD journals. He is a past president and editor of the Michigan AGD. Dr. Kosinski has placed over 14,000 dental implants and published over 190 articles on the clinical and prosthetic phases of implant dentistry. He received the Academy of Dentistry International’s Humanitarian Award “in recognition of significant contributions to the enhancement of the quality of life and the human condition.” Dr. Kosinski can be reached at 248-646-8651, drkosin@aol.com or www.smilecreator.net.
Stephanie Pajot, RDH
Stephanie Pajot, RDH, BS has been practicing dental hygiene for 17 years with 7 years of clinical experience in soft tissue lasers. She has assisted in numerous continuing education courses involving periodontics, laser and implant dentistry. Stephanie currently works in an elite general practice in Bingham Farms, Michigan. She was an Adjunct Clinical Instructor for the University of Detroit Mercy School of Dentistry. Pajot is a 2002 graduate of UDM. She can be contacted at stephaniepajot_rdh@yahoo.com.
