Laser Dentistry in 2020: Technology Excels While Training Has Flaws

In the field of periodontology, lasers have shown the ability to obtain clinical new attachment with bone fill, with significantly better results than those obtained through conventional osseous grafting alone.² Lasers have been shown to generate new connective tissue and repair cementum.³ They have exhibited the ability to increase fibroblast attachment to root surfaces⁴ and can de-epithelialize flaps more simply and quickly than traditional techniques.⁵

In the field of implantology, the use of laser irradiation results in significantly more bone formation than conventional decontamination of implants affected by peri-implantitis.⁶ Although the American Dental Association Clinical Practice Guidelines,⁷ which have been endorsed by the American Academy of Periodontology,⁸ state that lasers should not be placed in periodontal pockets for nonsurgical treatment of chronic periodontitis, new and exciting research in photodynamic therapy holds promise for bacterial reduction and possibly pocket shrinkage when specific wavelengths are used with certain photosensitizers.^9-11 Of course, not every currently available laser can perform all of these procedures.

For hard-tissue laser dentistry, clinicians presently have a variety of laser wavelengths from which to choose, including two erbium wavelengths (Er,Cr:YSGG and Er:YAG) and a relative newcomer, the 9300-nm carbon dioxide (CO₂) laser. This new wavelength seems to be significantly faster in hard-tissue ablation than the erbium lasers.¹² Soon, another wavelength will join these three hard-tissue lasers, as a 9600-nm CO₂ laser is expected to be available in the United States in the second quarter of this year that is projected to be faster, smaller, and less expensive than the 9300-nm CO₂ laser (according to a personal communication between the author and the Israeli-based manufacturer).

As of this writing, nine different laser wavelengths are available in the United States: four diode wavelengths, two CO₂ wavelengths (10,600-nm and 9300-nm, with the third, the aforementioned new 9600-nm, to be on the market soon), two erbium wavelengths, and one neodymium-doped yttrium aluminum garnet (Nd:YAG) wavelength. Even more wavelengths and devices are available in other countries but are not yet cleared by the US Food and Drug Administration for use in the United States.

Lasers can be purchased in a wide range of prices, from less than $5,000 to well above $100,000, according to various dental supply company catalogs. Laser education programs are also available for a variety of costs, from online webinars that may be accessed for less than $300, to manufacturer certification courses that may or may not be backed by a laser organization, to manufacturer-independent certification courses with certification conferred by medical laser certifying boards at costs of upwards of $700. A number of dental laser organizations worldwide promote their own certifications (which are sometimes funded primarily by one specific laser company or focus on one type of laser). Thus, the array of obtainable certifications can certainly be confusing. Moreover, clinicians should research laser organizations to ensure their leadership and education curriculum is independent of laser manufacturers, so they can be sure they are receiving impartial, unbiased instruction.

With such a dizzying assortment of lasers to choose from, along with the various certifications available, clinicians have a lot to consider when deciding the best laser option for their practice. Investing in dental laser technology should be done similar to how a clinician might purchase other equipment in a typical dental operatory. Take a cone-beam computed tomography (CBCT) machine, for example. Dentists don't just buy one and start taking images; instead, they usually obtain an extensive amount of education in how to use the device, position the patient, choose the settings, and interpret the images. Another example is a digital x-ray system. Before it gets installed, the dentist and staff typically will receive training about acquiring images, using the software correctly, sterilizing the sensors and positioning them for maximum comfort, and so on. The same could be said about a digital impression scanner. Again, before a dentist purchases it and starts scanning, a great deal of training is acquired prior to its use on a patient. Even when administering products like Botox^® and Restylane^® dentists typically take many hours of courses before purchasing vials of product and injecting patients.

As exhilarating as laser dentistry can be with all of the advanced procedures these devices can perform, unless the clinician receives the proper training the device may wind up sitting on a counter and collecting dust. It is important that the dental profession provide some guidance regarding the training of clinicians in laser usage. As implied earlier, certification programs presented by manufacturers often are inherently biased toward their device. Programs presented by various academies may often be supported primarily by one specific type of device and can also be partial. Training programs should be manufacturer-independent and offer multiple wavelengths to clinicians for use during the critically important hands-on portion of the course. Clearly, a course where several wavelengths from various manufacturers are available for use, rather than only one wavelength from just one manufacturer, will provide more comprehensive training. In the author's experience, it is also more likely to be a course where education and not sales is the primary agenda.

A good training program allows dentists to compare multiple wavelengths in one course, "apples to apples," so to speak. In addition to hard-tissue and soft-tissue lasers, the training should also include discussion of photobiomodulation (PBM) lasers, used for the application of red or near infrared light over injuries or lesions to improve wound and soft-tissue healing, reduce inflammation, and provide pain relief.^13,14 Alternatives to lasers, such as the use of air abrasion and piezoelectric devices in comparison to hard-tissue lasers, for example, should also be included in the training. Training exercises during hands-on segments should include instruction on performing many different procedures-at least a dozen, in the author's opinion. The lecture portion of a training program needs to include slides/videos of nonsurgical, surgical, and regenerative periodontics; fixed, removable, and implant prosthetics; oral surgery/oral pathology/oral medicine; pediatrics, including the new field of neonatal dentistry; orthodontics; removable prosthetics; cosmetics; practice management; and, critically important, laser physics and laser-tissue interaction.

To effectively use a dental laser, it is crucial that clinicians understand the basics of laser physics and laser-tissue interaction. Yet this appears to be a shortcoming in the profession. Clinicians must realize, for example, that initiated diodes do not work like CO₂ and erbium lasers. For practitioners to believe that they do, which seems to be all too common, is a failure of the educational programs in laser dentistry. Clinicians who complete programs in laser dentistry should have an understanding that true lasers (CO₂ and erbium lasers, for example) work optically, out of contact, by letting the photons do the work, and that diode lasers when initiated are simply hot glass tips that work purely thermally, at temperatures between 700°C and 1200°C.¹⁵

Education must be the first priority when high-tech dental devices are offered for sale; this is so with virtually every technology-driven device, including a laser, that dentists use on a daily basis. Without proper education, the dentist-and ultimately the patient sitting in the chair-will be sorely disappointed. Lasers are capable of producing excellent clinical results that cannot be delivered through more conventional means but only when the proper wavelength/device is selected for that specific procedure and the clinician is properly trained in using the device.

Robert A. Convissar, DDS
Director of Laser Dentistry, New York Presbyterian Hospital Queens, New York, New York; Diplomate, American Board of Laser Surgery; Fellow, Academy of General Dentistry; Private Practice in Cosmetic, Restorative, Neonatal, and Laser Dentistry, New York, New York