Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-03-23, 14:32:14 | version 1.38.0
8 Dental Tribune Middle East & Africa Edition | July- August 2014mCME > Page 9 The diode laser as an electrosurgery replacement By Glenn A. van As, BSc, DMD I n 2008, Dr. Gordon Chris- tensen wrote an article in JADA comparing the soft tis- sue cutting abilities of diode la- sers to those of electrosurgery (radiosurgery) units.1 In com- paring these two technologies against each other, he found that both dental lasers and the less expensive electrosurgery units have advantages and disadvan- tages, and he summarized with several key points: 1. Although there was consid- erable overlap in their uses and both technologies were effective, Christensen found that diode la- sers were able to be used around metal(amalgamandgold)aswell aswithdentalimplants. 2. He stated that lasers did not harm dental hard tissues (bone) or soft tissues (pulp), and that the clinician could use the laser with less anesthetic, and finally he mentioned that lasers were antimicrobial(antibacterial). 3. The acceptance and use of lasers, especially the diode la- ser, was increasing in dentistry, and that lasers attract patients because of their recognized and accepted role within the field of medicine(LASIKeyesurgery). 4. Electrosurgery units were “far less expensive than the least expensive diode lasers” and he questioned whether “the advan- tages of the diode laser were sig- nificant enough to compensate fortheadditionalcost.” There are two basic types of electrosurgical units that can be purchasedindentistry: •Monopolar,inwhichasingle electrode exists and the current travels from the unit down a sin- gle wire to the surgical site. The patient must be grounded with a pad placed behind the patient’s back (a part of the procedure thatmanypatientsmayquestion). Heat is produced when the elec- trode contacts the tissue, and due to pain that is produced, anes- theticmustbeused. • Bipolar, in which two elec- trodes are placed in very close proximity to each other. Bipolar units are more expensive than diode lasers and the electrical current flows from one electrode to the other, thus eliminating the needforagroundingpad.Bipolar units, because of the two wires, createlessofaprecisecutthanthe monopolarordiodelaser. Althoughelectrosurgicalunits areinexpensive,requirenosafety glasses and can remove large amounts of tissue quickly, diode lasers have become much more common in dental operatories in thefouryearssinceChristensen’s article was published. The pri- mary reasons for their increased popularity are that diode lasers have a small footprint, are reli- able and durable lasers, and are portable.Whereafewshortyears ago,diodelaserscouldcostinthe range of $10,000 to $15,000, they are now cost effective and can be purchasedforlessthan $2,500. Advantagesofthediodelaserover electrosurgery Ability to work around metals intraorally Diode lasers in the range of 810–1,064 nm are well absorbed in hemoglobin, melanin (pig- ment) and to some degree water (Fig. 1). These mid infrared den- tal wavelengths in the absorption spectrum offer the dental clini- cian the ability to ablate soft tis- sues precisely while controlling hemostasis, providing the clini- cian with an excellent view of the surgical site with a reduced reliance on sutures. Diode lasers have features that make them at- tractive as mentioned earlier, but theyalsohaveseveraladvantages in function over electrosurgical units2 (Table1). Perhaps the greatest ben- efit of these lasers is that they allow the clinician to work safely around metals. The literature has shown that monopolar elec- trosurge units can accidentally create catastrophic results when touching metal intraorally. Pub- lished reports have shown that contact for very short periods of time with the electrode of a mo- nopolar electrosurgical unit can cause both pulpal and periodon- tal problems,3 bone loss,4 severe intraoral burns,5 arcing, and that within three seconds of exposure to a dental implant electrosur- gical units can cause failure of osseointegration and loss of an implant.6,7 In clinical practice, with to- day’s emphasis on the more es- theticallypleasingcompositeres- ins and newer porcelains, there are still many metallic materials used intraorally, including cast partialdentureframeworks,gold, amalgam, orthodontic brackets andsemi-preciousalloys. Diodelasers,unliketheirelec- trosurgical counterparts, show little interaction with metallic objects used intraorally. It is im- portant to remember that due to the laser’s ability to reflect off mirroredsurfacesandpotentially cause eye damage, that all mem- bers of the dental team as well as thepatientmustwearlasersafety glasses for eye protection if they are within the nominal ocular hazardzone(NOHZ)duringlaser operation.Thiszoneismostoften between 3 and 7 feet, but some diodes can have extended NOHZ rangesof40feet. Orthodontic patients will of- ten exhibit gingival hyperplasia when in brackets that can make it difficult to work on them. This overgrowthoftissuecanbedueto poor oral hygiene, space-closing mechanics, excess cement or a combinationoffactors.Thediode laser can be used for gingivecto- mies to safely remove and recon- tourtheexcesstissueandhealing canberemarkableinaveryshort periodoftime(Figs.2–4). Ability to work around dental implantssafely Variouslaserwavelengthsthat are available today can offer the clinician who needs to expose an implant during second stage surgery an alternative to tradi- tional methodologies. The ability of the diode laser to ablate tissue, attimeswithouttheneedforlocal anesthetic, while controlling he- mostasis, provides the clinician a greatviewofthesurgicalsite. In addition, the diode wave- length,likealllaserwavelengths, provides for decontamination of the implant site through its anti- bacterialactions.Bacterialreduc- tion with the diode laser can lead toanalmoststerileoperativefield (98 percent reduction of patho- genic bacteria). Finally, there is a growing body of evidence that suggeststhatlasersusedatlower energy settings can have a bios- timulatory effect on tissue, which in turn can reduce postoperative discomfort, improve healing and shortenhealingtimeswhileeven improving early osseointegra- tion.8–12 As an aside, there have been clinicians who routinely use mo- nopolar electrosurgery units to expose implants. It is imperative to realize that although more ex- pensive bipolar (two electrodes) electrosurgery units can be used safely around implants, that the more commonly purchased sin- gle electrode (monopolar) units may damage the implant surface andcancausecompletelossofos- seointegration with resulting im- plantfailurewithcontacttimesas shortasthreeseconds.13,14 Lasers, incontrast,canbeusedsafelywith tremendouscoagulationandare- duction in pain postoperatively forthepatient15 (Figs.5,6) Diode lasers are also useful when it comes time to seat the final abutment and restoration. Tissuemanagementaroundden- tal implant restorations can be difficult, be it for the initial ce- mentation or, even worse, if an implant-restored crown comes loose.Tissuequicklyslumpsonto the abutment, and subgingival margins can be almost impos- sible to retrieve with traditional methodologies. The laser can truly be a “life-saver” for these situations where soft tissue must be safely and quickly removed to allowforidealcementationofthe implantretainedcrownsontothe abutments(Figs.7–12). Reducedneedforanesthetic Monopolar electrosurgery units do not have the ability to be used routinely without local anesthetic. In contrast, diode la- serscanoftenbeusedeitherwith low wattages or in pulsed modes to remove minor to moderate amounts of soft tissue with only topical anesthetics. Although at times this may not seem signifi- cant to the clinician, there are many instances where soft tis- sue acts as a barrier to ideal re- storative treatment, and if local anesthetic can be eliminated it becomes a big selling point to patients. Many patients are looking for alternatives to local anesthetic, andwhentheoccasionallowsfor the procedure to be completed without the patient being numb, the overwhelming majority of patients are grateful for this. Situations such as laser gingival mCME articles in Dental Tribune have been approved by: HAAD as having educational content for 2 CME Credit Hours DHA awarded this program for 2 CPD Credit Points Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. CAPP designates this activity for 2 CE credits. Figure 1: Absorption curve of various tissue com- ponents shows diode lasers to be well absorbed in melanin (pigment), hemoglobin and to some de- gree water. (Images/Provided by Glenn A. van As, BSc, DMD) Figure 2: Gingival hyperpla- sia around orthodontic ap- pliances. Figure 6: Four healing cuffs in place in maxilla immedi- ately after uncovery with the diode laser. Figure 7: Replace select im- plant fixtures for upper right premolars. Figure 8: Abutments in place for both teeth. Figure 9: Soft tissue on mar- gins preventing full seating of crowns. Figure 10: Picasso Lite di- ode laser removing tissue on abutment margins. Figure 11: Note tissue off the margins of abutments after diode use. Figure 3: Immediate post-op after diode laser gingivec- tomy completed. Figure 4: Eight-day healing of soft tissue around brack- ets. Table1:Comparisonofdiodelaserversusmonopo- lar electrosurgery units. Figure 5: Diode laser for sec- ond-stage implant uncovery in edentulous maxilla.