Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-03-23, 14:16:40 | version 1.38.0
8 Dental Tribune Middle East & Africa Edition | May-June 2015mCME > Page 9 From everyday dentistry to advanced photoacoustic endodontic applications (PIPS): Er:YAG & Nd:YAG dual wavelength laser 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 CAPPmea designates this activity for2continuingeducationcredits. By Lawrence Kotlow DDS, Enrico DiVito DDS and Giovanni Olivi MD I ntroduction Lasers provide an exciting new technology that allows the dentist the ability to give patients optimal care without many of the “fear factors” found in conventional dental tech- niques. Used with proper under- standing of laser physics, lasers are extremely safe and effective. Using lasers for caries removal, perio treatment, endodontic treatment, bone management, cutting and shaping, and soft- tissue procedures can reduce postoperative discomfort and in- fection, and provide safe, simple in-office treatment. As a result, we can improve our efficiency, expand what we can do, achieve better results and increase pro- duction. 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 equipment that creates a con- centrated monochromatic beam of visible or infrared light that can be absorbed by a specific target. Since then, laser-assisted dental care has changed forever the way dentists can prepare diseased teeth, ablate bone and treat soft-tissue abnormali- ties and disease. An entire new standard of care is becoming a reality. Lasers and pediatric dentistry are a perfect fit. There are a wide range of hard and soft dental procedures that may be completed using lasers as an alternative to conventional dental care on adults and, espe- cially, children. Many of these procedures may be treatments dentists historically refer out to other specialists; however, if you understand and use your laser efficiently, you will discover that many of these are procedures that every dentist can easily complete. The question that is often the major concern and barrier to in- vesting in lasers is the how this investment will pay for itself, more recently described as re- turn on investment (ROI). Will it pay for itself? We prefer to speak of this as the secondary effect. If you understand your laser, it will easily pay premiums on your in- vestment, and the cost factor be- comes a non-issue. The purchasing of lasers is an investment, not an expense, for any dental practice. Lasers represent a fundamental change in the entire way den- tistry has been taught. We can now rethink and often modify G.V. Black’s principle of exten- sion for prevention with the concept of minimally invasive micro-dentistry. We need to understand that laser dentistry is one portion of an entire new way of practicing conservative, pain-free dentistry. The laser that we call the “all- purpose” laser is the Light- walker Er:YAG & Nd:YAG laser, manufactured by Fotona and distributed in the United States by Technology4Medicine. The Er:YAG produces its effect at 2940 nm and has as its pri- mary tissue target water and hydroxyapatite. It is very safe, 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 local anesthesia. The use of the new generation erbium lasers for repair of incip- ient hard-tissue disease allows the dentist to provide a stress- free means of restoring teeth in a minimally invasive manner, most often with no shot and no numb lip, without the need for any local anesthetics. The erbium laser can be used for restoring primary and per- manent teeth, eliminating or reducing the 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 restorative materials. Using the concept of minimally invasive restorative procedures, the Er:YAG laser allows the op- erator to remove only diseased tissue and thus preserves much more of the healthy, unaffected tooth. In cases where alloy is pre- ferred, the laser’s analgesia ef- fect may also allow the dentist to create a restorative preparation using a conventional handpiece that is not meant for bonding. The erbium laser is effective be- cause of its effect on its target, water within the tooth structure. This effect occurs when the la- ser heats up water within the target tissue, causing it to create small microscopic explosions (photothermal followed by pho- toacoustical effects). When ap- plied to soft tissue, bone or teeth and cavities, the explosions then cause the areas to be vaporized. Er:YAG laser 2940 nm: Soft- tissue procedures There is a wide array of soft- tissue procedures that can be completed using the all-purpose laser: maxillary and mandibu- lar frenum revisions, lingual frenum revisions, treatment of pericoronal pain or infection, re- moval of hyperplasic tissue be- cause of drugs or poor oral care in orthodontic patients, biopsies, treatment of aphthous ulcers and herpes labialis, pulpoto- mies, removal of impacted teeth and, in adults, apicoectomies and bone recontouring. Pulpotomies Parents often express concern about the need to take radio- graphs because of the nature of X-rays and their possible side ef- fects on a child’s overall health. They question the use of al- loys because of the chemical makeup of the alloy. Whether these should be a real concern in today’s dental care is open to debate, depending on your in- dividual beliefs. There are also concerns by many, although not as loudly, about the effect of vari- ous pulpotomy procedure me- dicaments used in pulpotomy procedures, such as formocreo- sol. Lasers provide a safe, non- chemical, effective and alterna- tive treatment for pulpotomies. During the span of eight years, post-treatment results on more than 4,000 pulpotomies using the erbium (2940 nm) laser pro- vide ample evidence that this method is both effective and safe for children without the need for introducing chemicals or using electrosurgery methods. When the final result of ortho- dontic positioning of the front teeth results in gingival hyper- trophy, the laser can be a useful tool to increase crown length and give the patient a more es- thetic smile. This may often be accomplished without the need for local anesthesia. Patients who have medically induced hyperplastic tissue, such as pa- tients requiring dilantin, can also have their tissue reduced and reshaped with the erbium. In addition to the many exam- ples described in this article, lasers can be used for additional procedures not usually required in pediatric dentistry, such as revisions of the abnormal man- dibular frenum, often avoiding the need for soft-tissue grafts, crown-lengthening procedures where bone requires recontour- ing, apicoectomies, removal of bony exostoses, removal of third molar impactions, removal of root remnants, incising and draining soft-tissue infections, advanced periodontal treat- ments and the latest in advanced endodontic treatment via photo- ninduced photoacoustic stream- ing. Photoacoustic endodontics us- ing PIPS 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 system. Clinically, traditional endodontic techniques use me- chanical instruments, as well as ultrasonic and chemical ir- rigation, in an attempt to shape, clean and completely decon- taminate the endodontic system but still fall short of successfully removing all of the infective mi- croorganisms and debris. This is because of the complex root ca- nal anatomy and the inability for common irrigants to penetrate into the lateral canals and the apical ramifications. It seems, therefore, appropriate to search for new materials, techniques and technologies that can im- prove the cleaning and the de- contamination of these anatomi- cal areas. Among the new technologies, the laser has been studied in en- dodontics since the early 1970s1- 3 and has become more widely used since the ’90s.4-6 Different wavelengths have been shown to be effective in significantly reducing the bac- teria in the infected canals, and important studies have con- firmed these results in vitro.7 Studies reported that near in- frared laser are highly efficient in disinfecting the root canal surfaces and the dentinal walls (up to 750 microns for the diode 810 nm and up to 1 mm for the 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 character- istic morphological alterations of the dentinal wall. The smear layer was only partially removed and the dentinal tubules primar- ily closed as a result of melting of the inorganic dentinal struc- tures.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 ir- radiation demonstrated high on the dentin surfaces but low in depth of penetration because of the high absorption of laser en- ergy on the dentin surface.7 Also the laser activation of commonly 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)