Everyday Laser Treatments for Everyday Dentistry
Abstract
This article will focus on five laser treatments that can be easily incorporated into any dental practice. Many times we, as women dentists, read articles or attend lectures and think “I could never do that,” but in reality it is dealing with these negatives thoughts that is the obstacle. I believe, because I have seen it happen over and over, that once the female practitioner can visualize what lasers can do specifically…they can move forward and take that big step toward purchasing a laser. With the insight gained from “seeing” in the mind's eye the possibilities, confidence will follow. I’m not saying that all worries will go away but this article should help allay fears and open doors.
Dr. Rice’s Top Five Laser Treatments
1. Subgingival Curettage
2. Sulcular Development for Crown & Bridge
3. Retread of Anterior Incisal Edges
4. Class V Abfractions/Abrasions
5. Removing Existing Anterior Composites
Let’s assume you have been reading my laser articles and have been thinking of purchasing an erbium laser for hard tissue removal and a diode for soft tissue. But you still can’t visualize the procedures you could do every day in order to pay for your lasers, make you a happier and more productive dentist. Let me share my secret to laser success, the top five laser procedures I employ EVERY DAY and how to implement them. I like to schedule crown and bridge at 9:00 and 1:00, my most productive time of the day, all other treatment falls into 11:00 and 4:00. In between all this, there are hygiene patients to check. Secret #1 for implementing new laser treatments, start with treatment planning in hygiene. During new or periodic exams, you have the opportunity to “plant seeds” as my Dad would say. In other words, you present treatment options, educate patients and discuss where the patient is and more important where they are going with their oral health. During these hygiene appointments I look for decay, broken teeth, failing fillings and pathology. Then I look at occlusal wear, abrasion and periodontal disease. Lastly, I review cosmetic needs and wants. I will treatment plan all of my findings into a sequential plan that, over time, will preserve the patient’s teeth.
Periodontal disease should be addressed first. That is why I have listed laser subgingival curettage at the top of my top five procedures. Diode and Nd:YAG have been cleared by the FDA for sulcular debridement. Pockets from 4-6mm that have not responded to traditional scaling and root planning will respond to laser curettage. It is a great service to patients to help them avoid surgery. However, 7mm pockets and above should be flapped and surgical periodontal treatment employed if other methods such as balancing of occlusal forces, endodontic therapy and treatment of systematic problems (uncontrolled diabetes) have been exhausted. The laser is only another tool in the dental armamentarium. Remember a laser is not a magic wand that eliminates disease and grows bone. It will kill bacteria, excise the diseased pocket lining and provide hemostasis. Do you still need curettes? Yes, you have to thoroughly remove subgingival calculus. Start with the laser to kill bacteria in the pocket then move to a series of curettes and then back to the laser for pocket reduction and hemostasis. I could write this whole article on periodontal treatments with the laser, but you must find a good ALD approved course and take it!
The next step in our treatment planning is restoring broken, missing or mal-aligned teeth. During any crown preparation, I utilize the diode laser after I have completed the diamond reduction into subgingival areas; this is called laser sulcular development. The Diode laser seals the blood vessels to produce a drier field to inspect subgingival margins. This makes temporaries easier to fabricate and impressions cleaner. It also allows hemostatic cord to be placed not packed. At the same time I am developing a new sulcus for my crowns and bridgework to emerge out of the tissue in a compatible, esthetic and cleansable fashion. You can manipulate the gingival tissues around crowns to achieve a new and healthy biologic width. Also during sulcular development, the Erbium laser can be used for crown lengthening. I’ll call it a “semi-closed flap” crown lengthening. This procedure removes bone when encountered during the crown prep to about 2-3 mm past the crown margin. Once this is accomplished, healing to the correct biologic width is possible.
Third, on the list of top five is the classic “retread” which restores worn anterior incisal edges without numbing or drilling. This interesting procedure utilizes Erbium wavelength lasers ( Er:YAG or Er,Cr:YSGG) to remove the dentin that has been exposed due to wear and then bond to dentin and enamel to restore teeth to their original height and function. This is at the heart of your laser advantage in helping restore your patients’ teeth. Use a total etch technique here. This is a procedure that I can guarantee that you will never need to use anesthesia and the patient will never be uncomfortable. Some bicuspid and molar cusp tips that have been severely eroded due to bruxism and are cold sensitive will need some anesthesia but never in the anterior. Next, number four on the list of my top five and my favorite is Class V abfractions. The occlusion must be evaluated and corrected before this procedure. Use the erbium laser starting on the enamel surface and develop a traditional buccal prep undercutting just mesial and distal to the notch. Slowly and with lower laser energy, ablate the dentin to remove the smear layer and roughen the surface. Then use the 7th generation etch less conditioner with a dental adhesive and place a micro hybrid composite. Polish with soft flex discs and enhance cups. The micro hybrid has a better modulus of elasticity and will bend with the tooth. But still adjust the occlusion. I would say that about 75-80% of abfractions can be restored without anesthesia and you can do multiple quadrants. This is a wonderful procedure that goes undiagnosed and treated. This can pay for your laser and you can provide a great service to your patients.
Last but not least, look at your cosmetic enhancement procedures. There are several possibilities to enhance the cosmetic appeal of teeth but none better than to remove discolored anterior composite. Number five on my list is removal of existing composites. With the erbium laser this can be accomplished without anesthesia in almost every case, I’d say 98%, and with greater control than a high speed hand piece.
Nothing can boost your patient’s confidence in you than to replace a yellow composite and match their new bleached teeth.
Summary
There are dozens of other procedures I enjoy doing with the laser but not every day. I have tried to highlight the procedures I use every day.