Lasers in Periodontics: The Good, the Bad and the Ugly
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Wide publicity about the use of lasers in dentistry has generated considerable interest among dental professionals and lay consumers. This newsletter will provide a research-based insight into the potential applications and contraindications of laser technology to dental practice.
Lasers have become widely used in medicine since 1960s. Lasers designed for surgery deliver concentrated and controllable energy to tissue which is absorbed in order to deliver biological effect of laser treatment. The degree of absorption in tissue depends upon the wavelength of the laser unit and optical characteristics of the target tissue. Wavelength affects both the clinical applications and design of the laser. The wavelengths of lasers used in medicine and dentistry generally range from 193 to 10,600 nm. The lasers most commonly used in dentistry are CO2, ND:YAG and Diode, which have respective wavelength of 10,600nm (far infrared), 1,064nm (near infrared) and 819nm. Since the beams for these lasers are in the infrared range, they are not visible and therefore they use a quartz fiber incorporating a 630nm (red) laser into the device to act as an aiming beam.
Both ND:YAG and Diode lasers can be transmitted through an optical fiber allowing the laser delivery intraorally via a handpiece. This gives an operator a familiar tactile sensation while using the laser in the contact mode. CO2 laser, on the other hand, does not have a fiber optic delivery with the handpiece, making its use for intraoral procedures rather difficult. CO2 laser was the first laser to receive FDA clearance for oral use in 1976.
Let's review the characteristics of 3 most popular dental lasers:
What makes a laser so attractive to dental professionals?
THE GOOD: dental lasers are a tremendous asset in soft tissue surgeries, including gingivectomy/gingivoplasty, frenectomy, soft tissue biopsies, gingival sculpting associated with periodontal plastic surgical procedures because of their proven hemostatic effect. Additionally, they have been used successfully in treatment of drug-induced gingival overgrowth either alone or in conjunction with conventional surgery.
THE QUESTIONABLE: there is preliminary evidence that lasers may be useful for treatment of dentinal hypersensitivity, but this requires further investigation.
THE BAD: lasers have been claimed to be more efficient than conventional scaling and root planning.
Many manufacturers of dental lasers and practice consultants try to push their products by claiming that laser curettage will produce a sterile field thereby eliminating periodontal pockets and that the procedure is virtually painless. To this day there are NO RESEARCH STUDIES, not anecdotal reports, or FDA STATEMENTS that have permitted anyone to state that dental lasers can sterilize the field or that laser treatment is painless.
Lasers have been demonstrated to have an ablative effect on dental hard tissues. However, there is little evidence that lasers have any value in root debridement in actual clinical setting. In July 1990 FDA reviewed the submitted data for ND:YAG laser regarding its use on hard tissues. It was concluded that to this day there was no sufficient data to substantiate the claims of its efficacy on ANY hard tissues.
Myth: laser curettage produces sterile periodontal pocket by eradicating pathogenic bacteria.
Fact: no laser device was ever effective in removing calculus from the diseased root surfaces or producing a sterile field. Laser curettage, therefore, IS NOT AN ALTERNATIVE to mechanical therapy, consisting of scaling and root planning and conventional surgical treatment where necessary.
Myth: laser application has no significant adverse affects. It removes diseased soft tissue to promote healthy new connective tissue attachment to the root surface.
Fact: both ND:YAG and Diode lasers induce irreversible damage on root surfaces and prevent the ability of fibroblasts to form new connective attachment to the root surface in-vitro. These negative effects also include thermal damage when used directly on bone or root surfaces and delayed wound healing. Damage to cementum occurred with and without the use of a water coolant (available with WaterLase).
Some reports suggested that laser-created wounds heal more quickly and produce less scar tissue than conventional scalpel surgery. Several studies actually showed that activity of fibroblasts, cells that are responsible for producing new connective tissue attachment in wound healing, was significantly delayed after exposure to ND:YAG laser. Other in-vitro studies evaluated the potential use of lasers for stage II implant uncovering. They showed that laser radiation produced irreversible damage to titanium surfaces, which could translate into loss of osseointegration.
THE UGLY: practice consultants and some dental practitioners have been advocating incorporating dental laser into daily practice of general dentists to "boost the revenue" and offer patients a painless alternative to surgical treatment of periodontal disease. Their suggestions are primarily based on manufacturers' claims of laser efficacy, and not on actual research data. Laser is not a "magic pill" against periodontitis. Laser selection and use requires adequate knowledge and proper training, which is hardly acquired in short seminars.
Fact 1: Several control studies have assessed the use of laser therapy as an adjunct to conventional scaling and root planning. These investigations demonstrated no clinical benefit of using the laser versus scaling and root planning alone.
Fact 2: No long-term clinical studies have shown that laser therapy alone can be effectively used to treat adult chronic periodontitis. Just because lasers received FDA clearance for soft tissue removal (as done in gingivectomy/gingivoplasty), it does not apply to the treatment of bacterially induced chronic periodontal diseases.
Fact 3: Gingival curettage, with or without a dental laser, was originally designed to promote new connective tissue attachment to the root by the removal of diseased pocket lining. It has been often performed in conjunction with scaling and root planning (SRP), therefore making it a close procedure, which does not allow improved access for debridement and visibility that is needed to achieve complete mechanical removal of plaque, calculus and bacterial biofilm. After comparing SRP alone to curettage plus SRP, it was concluded that regardless of the method (ND:YAG and Diode lasers, ultrasonics, curettes) curettage had no additional benefit to SRP alone and had no justifiable application during active therapy for chronic periodontitis.
Laser treatment did not produce statistically significant bacterial reduction as claimed. ADA has deleted the code for gingival curettage from its current CDT-4 edition. The American Academy of Periodontology does not recognize curettage as a method of treatment. This indicates that the dental community as a whole regards gingival curettage as a procedure of no clinical value.
We hope this review will give you a perspective on lasers, their applications and future in dentistry. Please do not hesitate to contact Dr. Carrie Berkovich regarding any issues discusses in this newsletter.
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