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9Dental Tribune Middle East & Africa Edition | July - August 2014 mCME < Page 8 crown troughing for tissue man- agement around endodontically treated teeth, exposure of par- tially erupted canines for orth- odontic brackets and gingivec- tomies around moderately sized Class V lesions in geriatric pa- tients are all situations where the author has been able to routinely andconsistentlycompletesofttis- sue ablation with only a stronger topical anesthetic. In fact, the lit- erature has shown that a variety of soft-tissue procedures (even frenectomies) can be completed 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 pro- cedure done with diode lasers,19 andwhencombinedwithesthetic porcelainrestorations,thesimple recontouring of tissue can take a goodcaseandmakeitgreat.20–24 A key difference from electro- surgery ablation of soft tissue is that alterations to the symmetry of the soft-tissue contours in the maxillary anterior teeth can be safelyandpreciselycompletedon the same day as the preparation and impressions of these teeth. The risk of recession and expo- sure of margins can be far less withadiodelaserthanwithother techniques,particularlywhenad- equate magnification (e.g., 4.0X loupes) and cautious settings (0.6–0.9 w continuous wave) are usedfortherecontouring. When biologic width is re- spected, and adequate attached andkeratinizedtissueexists,then judiciousrecontouringofthegin- givaonthesamedayastheprepa- rations can yield stunning results (Figs.17–19). The diode laser has become a populartechnologyasanalterna- tive for tissue management com- paredtothetraditionalmethodol- ogy of placing a single or double retraction cord in the sulcus. The diode laser can be used in almost all instances to produce gingi- val retraction as an alternative to cord with excellent results both intermsofgingivalretractionand margindelineationforthelabora- tory. Unlike electrosurgical units where recession can be an issue, as can postoperative pain, diode lasersofferthecliniciantheability topreciselyremoveoverhanging, inflamed tissue while creating a gingival trough that is not likely tocausedamagetobone,cemen- tumorpulptissuelikeelectrosur- gical units can. In addition, there is research that suggests that the lateralthermaldamagedonewith lasers is significantly lower than thatwithelectrosurgery.25 Ability to photocoagulate vas- cular lesions and treat oral le- sions One of the advantages of a di- odelaseristheabilitytotreatoral lesions,including:recurrentaph- thous ulcers (RAU), venous lake lesions of the lips and herpetic lesions. Research has shown that lasers can be safely used to treat these lesions,26–28 and in addition it is possible that if caught early during the prodromal stage that herpetic lesions can be aborted or significantly reduced in terms of length of time they are pres- ent.29 In addition, it has been the author’s experience that, once treated with the laser, the lesions are often less likely to reappear in the same area. In fact some evidence suggests that herpetic lesions 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 longbeforeitreoccurs.30,31 Vascularlesionscalledvenous lakes or hemangiomas can occur on soft tissue-areas including the upper and lower lips, buccal mu- cosaandpalate.Theselesionscan bedifficulttotreatwithtraditional methodswheresignificantbleed- ing may occur. The diode wave- lengths are rapidly absorbed by hemoglobinandthereforecanbe used to coagulate and eradicate these esthetically undesirable purplish lesions often with only topical anesthetic. Literature has shown that the diode can be used in almost 100 percent of cases to eliminate these lesions, most of- teninonlyasinglesessionlasting onlyacoupleofminutes32–35 (Figs. 20–22). Anti-bacterial capabilities of lasers Many articles in the literature have demonstrated the tremen- dous ability of all lasers with re- spect to the reduction of bacterial and even fungal infections.36–43 The excellent antibacterial capa- bilities make lasers effective and desirableinmanyareasintheoral cavity where the risk of postop- erativeinfectionmaybereduced. Electrosurgical units do not typi- cally possess the same ability to provide bacterial reduction as la- sers do. Particular interest is now occurringwiththeroleoflasersin endodontic,periodonticandperi- implantitis cases where there is need to reduce bacterial loads without such a great reliance on antibiotics. Although more research is needed on how the bactericidal capabilities of the diode laser might be beneficial in these ar- eas, there is no debating that all lasers can help healing through decreasing the risk of infection through laser light alone (Figs. 23–25). In addition, growing re- searchhasdemonstratedthatthe riskofhighbacterialloadsinperi- odontal pockets and in particular in endodontic situations may be reducedbylasers. This latest research has impli- cations for improving traditional methodologies locally where used,andinhelpingtoreducethe potential greater systemic health risks generally. The role of lasers continuestoberesearchedtoday, but present research has shown that diode lasers can be used safely within root canals with minimal fear of developing iat- rogeniccomplicationswhencon- servativesettingsareused.44–48 Conclusion The diode laser has become the “soft-tissue handpiece” in many dental offices. The advan- tagesofbeingabletoworkaround metalsincludingdentalimplants, a reduced need for anesthetic, a reduced risk of recession post- operatively, 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 ben- efits in that they do not require a padtobeplacedunderthepatient for grounding, and they can be used safely with pacemakers. Di- ode lasers have found their place in dentistry. Once considered an applicationlookingforapurpose, thesesmall,cost-effectiveandre- liablelasershavediscoveredtheir nicheasthenewgotosolutionfor many soft tissue problems in our dailydentalpractices. References 1. Christensen GJ. Soft-tissue cutting with laser versus electrosurgery. J Am Dent Assoc. 2008 Jul;139(7);981– 984. 2. van As G, The Diode Laser as an Electrosurgery Replacement. Dentaltown. June2010.pgs.56–64. Fulllistofreferencesisavailable fromthepublisher. mCME SELF INSTRUCTION PROGRAM CAPP together with Dental Tribune provides the opportunity with its mCME- Self Instruction Program a quick and simple way to meet your continuing education needs. mCME offers you the flexibility to work at your own pace through the material from any location at any time. 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The answers and critiques published herein have been checked carefully and represent authoritative opinions about the questions concerned. Articles are available on www.cappmea.com after the publication. For more information please contact events@cappmea.com or +971 4 3616174 FOR INTERACTION WITH THE WRITERS FIND THE CONTACT DETAILS AT THE END OF EACH ARTICLE. Figure 12: Final crowns cemented onto abutments without soft-tissue impinge- ment. Figure 18: After recontour- ing of lateral incisors and laser crown troughing for tissue management prior to impressions. Figure 22: Two-week healing of lesion on lip is complete. Figure 23: Diode direct pulp cap to lower bacteria count on MO cavity preparation. Figure 25: Diode laser used to reduce bacterial counts inside a DB canal of upper right second molar after completion of instrumenta- tion and prior to obturation of the canals. Figure 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 hu- man eye). Figure 19: Immediate post- operative result for four Emax veneers. Figure 20: Pre-op view of ve- nous lake on lower lip. Figure 21: Immediate post- op appearance. Figure 13: Partially ex- posed canine requires orth- odontic bracket. Figure 14: Topical gel placed on soft tissue prior to gingivectomy to uncover soft tissue. Figure 15: Pulsed mode at 1.4 w shows removal of at- tached tissue to expose ca- nine. Figure 16: Brackets in place on both canines — immedi- ate post-op view. Figure 17: Pre-op prior to maxillary incisor veneers. For more information you can contact Dr. Glenn A. van As on: glennvanas@me.com. Contact Information