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Dental Tribune Middle East & African Edition Jan.-Feb. 2015

6 DENTAL TRIBUNE Middle East & Africa Edition | January-February 2015mCME From everyday dentistry to advanced photoacoustic endodontic applications (PIPS): Er:YAG & Nd:YAG dual wavelength laser By Lawrence Kotlow, DDS, Enrico DiVito, DDS, and Gio- vanni Olivi, MD, DDS L asers provide an exciting new technology that al- lows the dentist the abil- ity to give patients optimal care without many of the “fear fac- tors” found in conventional den- tal techniques. Used with proper understanding of laser physics, lasers are extremely safe and ef- fective. Using lasers for caries removal, periotreatment,endodontictreat- ment,bonemanagement,cutting and shaping, and soft-tissue pro- cedurescanreducepostoperative discomfortandinfection,andpro- vide safe, simple in-office treat- ment.Asaresult,wecanimprove our efficiency, expand what we cando,achievebetterresultsand increaseproduction. Lasers represent a real quantum leap forward in the treatment of our patients, including the pedi- atric patient. The U.S. Food and Drug Administration (FDA) gave approval for the use of the Er: YAG laser in 1997 for both hard- and soft-tissue procedures. The erbium doped (erbium particles placed within the YAG crystal) crystal of Yttrium-Aluminum- Garnet’s (Er:YAG) develop- ment and success has made the treatment of children safer and quicker. Plainly stated, a laser is a piece of equipmentthatcreatesaconcen- trated monochromatic beam of visible or infrared light that can be absorbed by a specific target. Since then, laser-assisted dental carehaschangedforevertheway dentists can prepare diseased teeth, ablate bone and treat soft- tissue abnormalities and disease. An entire new standard of care is becomingareality. Lasersandpediatricdentistryare a perfect fit. There are a wide rangeofhardandsoftdentalpro- cedures that may be completed using lasers as an alternative to conventional dental care on adults and, especially, children. Many of these procedures may be treatments dentists histori- callyreferouttootherspecialists; however, if you understand and useyourlaserefficiently,youwill discover that many of these are- proceduresthateverydentistcan easilycomplete. The question that is often the major concern and barrier to in- vestinginlasersisthehowthisin- vestment will pay for itself, more recently described as return on investment (ROI). Will it pay for itself?Weprefertospeakofthisas thesecondaryeffect.Ifyouunder- stand your laser, it will easily pay premiums on your investment, and the cost factor becomes a non-issue. The purchasing of lasers is an in- vestment,notanexpense,forany dentalpractice. Lasers represent a fundamental change in the entire way den- tistry has been taught. We can nowrethinkandoftenmodifyG.V. Black’s principle of extension for prevention with the concept of minimally invasive micro-den- tistry.Weneedtounderstandthat laser dentistry is one portion of an entire new way of practicing conservative,pain-freedentistry. The laser that we call the “all- purpose”laseristheLightwalker Er:YAG&Nd:YAGlaser,manufac- turedbyFotonaanddistributedin the United States by Technology- 4Medicine.TheEr:YAGproduces its effect at 2940 nm and has as its primary tissue target water andhydroxyapatite.Itisverysafe, relatively quiet, eliminates the smells and vibrations associated with the dental handpiece and, most importantly, is much more comfortable for the patient, sig- nificantly reducing the need for localanesthesia. The use of the new generation erbium lasers for repair of in- cipienthard-tissuediseaseallows the dentist to provide a stress- free means of restoring teeth in a minimallyinvasivemanner,most often with no shot and no numb lip, without the need for any local anesthetics. The erbium laser can be used for restoringprimaryandpermanent teeth,eliminatingorreducingthe amount of local anesthetics. In most cases, the patient will not require numbing for Class 1, 2 (sometimes), 3, 4, 5, 6 restorative procedures using bonded restor- ativematerials.Usingtheconcept of minimally invasive restorative procedures, the Er:YAG laser allows the operator to remove onlydiseasedtissueandthuspre- servesmuchmoreofthehealthy, unaffectedtooth. In cases where alloy is preferred, the laser’s analgesia effect may also allow the dentist to create a restorative preparation using a conventional handpiece that is not meant for bonding. The er- bium laser is effective because of its effect on its target, water within the tooth structure. This effectoccurswhenthelaserheats up water within the target tissue, causing it to create small micro- scopic explosions (photothermal followed by photoacoustical ef- fects).Whenappliedtosofttissue, bone or teeth and cavities, the explosions then cause the areas tobevaporized. Er:YAGlaser2940nm:Soft- tissueprocedures Thereisawidearrayofsoft-tissue proceduresthatcanbecompleted using the all-purpose laser: max- illaryandmandibularfrenumre- visions,lingualfrenumrevisions, treatment of pericoronal pain or infection, removal of hyperplasic tissue because of drugs or poor oral care in orthodontic patients, biopsies, treatment of aphthous ulcersandherpeslabialis,pulpot- omies,removalofimpactedteeth and,inadults,apicoectomiesand bonerecontouring. Pulpotomies Parents often express concern about the need to take radio- graphsbecauseofthenatureofX- raysandtheirpossiblesideeffects on a child’s overall health. They questiontheuseofalloysbecause of the chemical makeup of the alloy. Whether these should be a realconcernintoday’sdentalcare is open to debate, depending on yourindividualbeliefs.Thereare also concerns by many, although not as loudly, about the effect of various pulpotomy procedure medicaments used in pulpotomy procedures, such as formocreo- sol. Lasersprovideasafe,non-chemi- cal,effectiveandalternativetreat- mentforpulpotomies.Duringthe span of eight years, post-treat- ment results on more than 4,000 pulpotomies using the erbium (2940 nm) laser provide ample evidence that this method is both effective and safe for children without the need for introducing chemicals or using electrosur- gerymethods. Whenthefinalresultoforthodon- tic positioning of the front teeth results in gingival hypertrophy, thelasercanbeausefultooltoin- crease crown length and give the patientamoreestheticsmile.This may often be accomplished with- out the need for local anesthesia. Patients who have medically in- duced hyperplastic tissue, such aspatientsrequiringdilantin,can alsohavetheirtissuereducedand reshapedwiththeerbium. Inadditiontothemanyexamples describedinthisarticle,laserscan beusedforadditionalprocedures not usually required in pediatric dentistry, such as revisions of the abnormal mandibular frenum, often avoiding the need for soft- tissue grafts, crown-lengthening procedures where bone requires recontouring, apicoectomies, removal of bony exostoses, re- moval of third molar impactions, removal of root remnants, incis- ing and draining soft-tissue in- fections, advanced periodontal treatments and the latest in ad- vanced endodontic treatment via photoninduced photoacoustic streaming. Photoacousticendodonticsus- ingPIPS The goal of endodontic treat- ment is to obtain effective clean- ing and decontamination of the smear layer, bacteria and their byproducts in the root canal sys- tem. Clinically, traditional end- odontictechniquesusemechani- cal instruments, as well as ultra- sonic and chemical irrigation, in an attempt to shape, clean and completely decontaminate the endodontic system but still fall shortofsuccessfullyremovingall of the infective microorganisms and debris. This is because of the complex root canal anatomy and theinabilityforcommonirrigants topenetrateintothelateralcanals and the apical ramifications. It seems, therefore, appropriate to search for new materials, tech- niques and technologies that can improve the cleaning and the de- contamination of these anatomi- calareas. Amongthenewtechnologies,the laser has been studied in end- odontics since the early 1970s1-3 and has become more widely usedsincethe’90s.4-6 Different wavelengths have been shown to be effective in signifi- cantly reducing the bacteria in the infected canals, and impor- tantstudieshaveconfirmedthese results in vitro.7 Studies reported thatnearinfraredlaserarehighly efficient in disinfecting the root canal surfaces and the dentinal walls(upto750micronsforthedi- ode810nmandupto1mmforthe Nd:YAG 1064 nm). On the other hand, these wavelengths did not show effective results in debrid- ing and cleansing the root canal surfaces and caused characteris- tic morphological alterations of thedentinalwall.Thesmearlayer was only partially removed and the dentinal tubules primarily closedasaresultofmeltingofthe inorganicdentinalstructures.5,8 Other studies reported the abil- ity of the medium infrared laser in debriding and cleaning root canal walls.9,10 The bacterial load reduction after erbium laser irra- diationdemonstratedhighonthe dentin surfaces but low in depth ofpenetrationbecauseofthehigh absorption of laser energy on the dentin surface.7 Also the laser activation of commonly used ir- rigants (LAI) resulted in statisti- cally more effective removal of debris and smear layer in root canals compared with traditional techniques (CI) and ultrasound (PUI).11,12 Additionally, the laser activation method resulted in a strongmodulationinreactionrate > Page 7 Figs. 1-2. Representative sample images of root canal dentinal walls irrigated with 17 percent EDTA and PIPS for 20 seconds. (Photos/Provided by Technology4Medicine) 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.

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