Dental Tribune Italian Edition

27SpecialeLaser Tribune Italian Edition - Maggio 2014 << pagina 26 Many patients are looking for alter- natives to local anesthetic, and when the occasion allows for the proce- dure to be completed without the pa- tient being numb, the overwhelming majority of patients are grateful for this. Situations such as laser gingival crown troughing for tissue manage- ment around endodontically treated teeth, exposure of partially erupted canines for orthodontic brackets and gingivectomies around moderately sized Class V lesions in geriatric pa- tients are all situations where the au- thor has been able to routinely and consistently complete soft tissue ablation with only a stronger topical anesthetic. In fact, the literature has shown that a variety of soft tissue procedures (even frenectomies) can be completed on with only topical anesthetic16-18 (Figs. 13-16). Ability to do gingivectomies and crown troughing with less recession White et al have mentioned that laser gingivectomies are the most common soft tissue procedure done with diode lasers,19 and when com- bined with esthetic porcelain resto- rations the simple recontouring of tissue can take a good case and make it great.20-24 A key difference from electrosurgery ablation of soft tissue is that alterations to the symmetry of the soft tissue contours in the maxillary anterior teeth can be safe- ly and precisely completed on the same day as the preparation and im- pressions of these teeth. The risk of recession and exposure of margins can be far less with a diode laser than with other techniques, particularly when adequate magnification (e.g., 4.0X loupes) and cautious settings (0.6-0.9 w continuous wave) are used for the recontouring. When biologic width is respected, and adequate attached and keratinized tissue ex- ists, then judicious recontouring of the gingiva on the same day as the preparations can yield stunning re- sults (Figs. 17-19). The diode laser has become a popu- lar technology as an alternative for tissue management compared to the traditional methodology of placing a single or double retraction cord in the sulcus. The diode laser can be used in almost all instances to produce gingival retraction as an alternative to cord with excellent results both in terms of gingival retraction and margin delineation for the laborato- ry. Unlike electrosurgical units where recession can be an issue, as can post- operative pain, diode lasers offer the clinician the ability to precisely re- move overhanging, inflamed tissue while creating a gingival trough that is not likely to cause damage to bone, cementum or pulp tissue like electro- surgical units can. In addition, there is research that suggests that the lat- eral thermal damage done withlasers is significantly lower than that with electrosurgery.25 Ability to photocoagulate vascular le- sions and treat oral lesions One of the advantages of a diode la- ser is the ability to treat oral lesions, including: recurrent aphthous ulcers (RAU), venous lake lesions of the lips, and herpetic lesions. Research has shown that lasers can be safely used to treat these lesions26-28 , and in addi- tion it is possible that if caught early during the prodromal stage that her- petic lesions can be aborted or signif- icantly reduced in terms of length of time they are present.29 In addition, it has been the author’s experience that, once treated with the laser, the lesions are often less likely to reap- pear in the same area. In fact some evidence suggests that herpetic le- sions treated in the early stages with the diode laser can cut the healing time in half and create a remission period that is twice as long before it reoccurs.30,31 Vascular lesions called venous lakes or hemangiomas can occur on soft tissue areas including the upper and lower lips, buccal mucosa and pal- ate. These lesions can be difficult to treat with traditional methods where significant bleeding may occur. The diode wavelengths are rapidly ab- sorbed by hemoglobin and therefore can be used to coagulate and erad- icate these esthetically undesirable purplish lesions often with only top- ical anesthetic. Literature has shown that the diode can be used in almost 100 percent of cases to eliminate these lesions, most often in only a single session lasting only a couple of minutes32-35 (Figs. 20-22). Anti-bacterial capabilities of lasers Many articles in the literature have demonstrated the tremendous abil- ity of all lasers with respect to the reduction of bacterial and even fun- gal infections.36-43 The excellent antibacterial capabili- ties make lasers effective and desir- able in many areas in the oral cavity where the risk of postoperative in- fection may be reduced. Electrosur- gical units do not typically possess the same ability to provide bacterial reduction as lasers do. Particular in- terest is now occurring with the role of lasers in endodontic, periodontic and peri-implantitis cases where the need to reduce bacterial loads without such a great deal of reliance on antibiotics might be exciting. Al- though more research is needed on how the bactericidal capabilities of the diode laser might be beneficial in these areas, there is no debat- ing that all lasers can help healing through decreasing the risk of infec- tion through laser light alone (Figs. 23-25). In addition, growing research has demonstrated that the risk of high bacterial loads in periodontal pockets and in particular in endo- dontic situations may be reduced by lasers. These newer articles have implications for improving tradi- tional methodologies locally where used, and in helping to reduce the potential greater systemic health risks generally. The role of lasers continues to be researched today, but present research has shown that diode lasers can be used safely with- in root canals with minimal fear of developing iatrogenic complica- tions when conservative settings are used.44-48 Conclusion The diode laser has become the “soft tissue handpiece” in many dental offices. The advantages of be- ing able to work around metals in- cluding dental implants, a reduced need for anesthetic, a reduced risk of recession postoperatively, the ability to reduce bacteria, and to use the diode to photocoagulate vascular lesions have all provided dentists with a new alternative for soft tissue surgery. Lasers have two added benefits in that they do not require a pad to be placed under the patient for grounding, and they can be used safely with pacemakers. Diode la- sers have found their place in den- tistry. Once considered an applica- tion looking for a purpose, these small, cost-effective and reliable lasers have discovered their niche as the new go to solution for many soft tissue problems in our daily dental practices. La bibliografia è disponibile presso l’Editore. Fig. 20 - Pre-op view of venous lake on lower lip. Fig. 22 - Two-week healing of lesion on lip is complete. Fig. 24 - Diode laser in gingival sulcus lowering bacteria count (image of diode pulse captured with video camera on operating microscope – typically the image is not visible to the human eye). Fig. 25 - Diode laser used to reduce bacterial counts inside a DB canal of upper right second molar after completion of instrumentation and prior to obturation of the canals. Fig. 21 - Immediate post-op appearance. Fig. 23 - Diode direct pulp cap to lower bacteria count on MO cavity preparation.