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The Use of Diode Lasers in Everyday Practice Ron Kaminer, DDS

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by Ron Kaminer, DDS

Return on investment (ROI) is an important question when incorporating new technology into practice. ROI can be interpreted in a number of ways: making daily life easier, improving the quality of patient care and increasing profit via technology. Diode lasers fit to improve all three categories, yet for years dentists have been reluctant to "pull the trigger." Within the past year there has been a large price drop in this family of lasers, and accordingly, diode laser sales have risen.

Diode lasers are soft tissue lasers; the energy of which is primarily absorbed by pigment and hemoglobin. They range in wavelength from 810nm to 1,064nm, with each company claiming various unique features. Some have fibers which need to be stripped and cleaved. Others have disposable tips in an assortment of shapes and sizes. One even has both of these features (see AMD LASERS). I have used many diodes over the years and have found they all do one thing well – cut soft tissue. They vary in design, price point and warranty, but all seem to get the job done. A diode is a diode is a diode.

Diodes can be used in three fashions: 1) As a 21st-century laser knife; 2) Using laser energy as transmitted heat to kill bacteria; and 3) Using laser energy as a biostimulation tool to alter cellular behavior. When diodes are used as a cutting tool, the energy needs to be concentrated at the tip. To do this, the diode fiber is initiated with a dark piece of carbon paper or a cork. This makes the diode fiber like a sharp pencil. Tissue will be easy to cut if the practitioner uses a light touch and properly set parameters. Using too much power can result in collateral tissue damage resulting in excess pain, inflammation or recession.

There are many practical, everyday uses for diode lasers. Orthodontists use them every day for exposing teeth for placement of brackets and removing tissue from brackets. Periodontists use them for soft tissue crown lengthening. I find the most common use for general dentistry, and my practice, is laser troughing for crown and bridge. With the proper eradication of tissue width (not tissue height), clear impressions can be achieved without any thermal damage (Figs. 1, 2 & 3). This ability alone makes the investment in purchasing a soft tissue diode laser worthwhile. Laser troughing is done quickly and efficiently. Gone are the archaic days of time-consuming cord packing. Multiple units are a breeze and tissue response is predictable. I would recommend starting in the anterior for practice before moving to the posterior. Use as little power as required to get the job done.

In addition to troughing, diodes are commonly used to excise unwanted tissue or lesions from the oral cavity. Soft tissue smile enhancements are easily performed with minimal anesthesia. Diode use for these procedures offer precision, minimal post operative discomfort and rapid healing (Figs. 4, 5, 6 & 7). During soft tissue smile enhancements, care must be taken not to encroach on biologic width in order to achieve optimal results. Excisional biopsies and frenectomies are also common procedures that the practitioner will perform with a diode (Figs. 8 & 9). The diode's ability to coagulate blood vessels makes these procedures easier to perform than traditional scalpel surgery, especially for the inexperienced practitioner.

When looking to use the diode as a heat source to kill bacteria, the diode tip does not need to be initiated. The use of diodes in perio has come under scrutiny from many despite literature to support otherwise. Many articles have been published showing that following diode use, bacteria that cause periodontal disease are eliminated. Tooth mobility and oral malodor are also decreased after using a diode in conjunction with scaling and root planing.1-6 Lack of education and improper training has sometimes resulted in misuse of the laser. Ill-informed practitioners will initiate the diode fiber and place it into a pocket looking to eradicate all the granulation tissue. They will continue into the same pocket until little or no granulation tissue comes out on the fiber. They will continue this pocket by pocket until every pocket in the entire mouth is "laser debrided." Other improper techniques include not initiating a tip and using the diode fiber to disinfect pockets. Total pocket interaction times vary between 15 and 45 seconds. Accordingly, expectations and results have varied as well. Using a diode to treat the type I or II periodontal patient in order to decrease bleeding in a particular pocket or to help decrease oral malodor, seems to be effective. I personally have seen it to be more effective than using Arestin or Atridox, shifting our treatment philosophy from chemistry (drugs) to biology (natural healing). However, long-term periodontal stability after treating the type III and IV periodontal patient is questionable.

The area of biostimulation via diode lasers is underutilized, yet offers great promise. Diodes have the ability, when used in a defocused manner, to create alterations at the cellular level. Increased mitochondrial function, an increase of ATP, positive lymphatic changes and improved blood flow have been seen following the use of diode laser in biostimulation. Jan Turner and Lars Hode have devoted a textbook to low-level laser therapy (LLLT) or biostimulation. LLLT can be used in dentistry to help treat a variety of ailments. Many practitioners have used diodes in the treatment of acute TMJ pain. Those who use it report outstanding results with increased range of movement and decreased pain. Many dentists use diodes to improve healing and decrease pain and inflammation after surgical procedures. Finally, many have used diodes successfully in reversing or partially reversing existing parasthesias or in the treatment of Bell's palsy. Results in this modality of treatment can amaze both dentists and patients alike. LLLT appears to have no side effects and is deemed a very safe treatment modality.

It must be understood that while the diode may be the safest of all dental lasers, proper education and training need to be completed before using a diode intra- or extra-orally. DVDs, online courses and Webinar or video conferencing have substantially accelerated the learning process and implementation of this technology, while hands-on courses by certified laser experts can increase proficiency from basic to advanced procedures. Proper safety measures need to be taken in the office, as well as the operatory.

It should be clear that with proper education and training, diodes fit the bill as a clear return of investment piece of technology in any size practice. With the recent substantial drop in the price of diodes, you can incorporate laser technology into your practice for as little as $2,500. This low price allows the dentist to have multiple lasers in one office. With the variety of procedures that can be performed with this little powerhouse, incorporating a diode into the office poses very little financial risk and tremendous potential. So what are you waiting for?

References
  1. Cobb CM, Low SB, Coluzzi DJ. "Lasers and the treatment of chronic periodontitis." Dent Clin North Am. 2010 Jan;54(1):35- 53. Review.
  2. Caruso U, Nastri L, Piccolomini R, d'Ercole S, Mazza C, Guida L. "Use of diode laser 980 nm as adjunctive therapy in the treatment of chronic periodontitis. A randomized controlled clinical trial." New Microbiol. 2008 Oct;31(4):513-8.
  3. Ribeiro IW, Sbrana MC, Esper LA, Almeida AL. "Evaluation of the effect of the GaAlAs laser on subgingival scaling and root planing." Photomed Laser Surg. 2008 Aug;26(4):387-91.
  4. Genovese MD, Olivi G. "Use of laser technology in orthodontics: hard and soft tissue laser treatments." Eur J Paediatr Dent. 2010 Mar;11(1):44-8.
  5. Angelov N, Pesevska S, Nakova M, Gjorgoski I, Ivanovski K, Angelova D, Hoffmann O, Andreana S. Department of Periodontics, Loma Linda University School of Dentistry, Loma Linda, CA, USA. Periodontal treatment with a low-level diode laser: clinical findings. Gen Dent. 2009 Sep-Oct;57(5):510-3.
  6. Moritz, Andreas MD, DDS, Ulrich Schoop, MD, Kawe Goharkhay, MD, Petra Schauer, MD , Orhun Doertbudak, MD, Johann Wernisch, DTSc, Wolfgang Sperr, MD, DDS, PhD. "Treatment of periodontal pockets with a diode laser" Lasers in Surgery and Medicine. 1998. Vol 22, No. 5: 302-11.
Author’s Bio
Dr. Ron Kaminer maintains two practices in Hewlett and Oceanside, New York. His 20- year span of laser use includes the use of diodes, CO2, Erbium Yag, ND Yag, and ErCrYSGG. He is the founder of the Masters of Laser Dentistry Total Immersion Laser training course (training new Powerlase owners) and holds standard certification from the Academy of Laser Dentistry in multiple wavelengths. Kaminer was also one of the first few dentists to receive the Mastership from the World Clinical Laser Institute and is a former clinical trainer for Biolase. He has lectured nationally and internationally on topics related to minimally invasive dentistry and consults for numerous dental companies. He can be reached for questions or comments at whitertth@aol.com.
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