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Dental Tribune Middle East & Africa Edition | 6/2016 12 mcme Er:YAG & Nd:YAG dual wavelength laser From everyday dentistry to advanced photoacoustic endodontic applications (PIPS) mCMEarticlesinDentalTribunehavebeenapprovedby: Haadashavingeducationalcontentfor2cmecreditHours dHaawardedthisprogramfor2cpdcreditpoints CAPP designates this activity for 2 CE Credits ByDrLawrenceKotlow,DrEnricoDi- Vito,USA,&DrGiovanniOlivi,Italy Introduction Lasers provide an exciting new tech- nology 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 extremelysafeandeffective. Using lasers for caries removal, perio treatment, endodontic treatment, bone management, cutting and shaping, and soft tissue procedures can reduce postoperative discom- fort, infection and provide safe, sim- ple in-office treatment. As a result, we can improve our efficiency, ex- pand what we can do, achieve better resultsandincreaseproduction. Lasers represent a real quantum leap forward in the treatment of our patients, including the paediatric patient. The US Food and Drug Ad- ministration(FDA)gaveapprovalfor the use of the Er: YAG laser in 1997 for both hard- and soft-tissue pro- cedures. The erbium doped (erbium particles placed within the YAG crys- tal) crystal of Yttrium-Aluminum- Garnet’s (Er:YAG) development and success has made the treatment of childrensaferandquicker. Plainly stated, a laser is a piece of equipment that creates a concen- trated monochromatic beam of visible or infrared light that can be absorbed by a specific target. Since then, laser-assisted dental care has changedforeverthewaydentistscan prepare diseased teeth, ablate bone and treat soft tissue abnormalities and disease. An entire new standard ofcareisbecomingareality. Lasers and paediatric 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, especially, chil- dren. Many of these procedures may be treatments dentists historically refer out to other specialists; howev- er,ifyouunderstandanduseyourla- ser efficiently, you will discover that many of these are procedures that everydentistcaneasilycomplete. The question that is often the ma- jor concern and barrier to investing in lasers is the how this investment will pay for itself, more recently described as return on your invest- ment (ROI). Will it pay for itself? We prefer to speak of this as the second- ary effect. If you understand your laser, it will easily pay premiums on your investment, and the cost factor becomesanon-issue. The purchasing of lasers is an invest- ment, not an expense, for any dental practice. Lasers represent a fundamental change in the entire way dentistry hasbeentaught.Wecannowrethink and often modify G.V. Black’s princi- ple of extension for prevention with the concept of minimally invasive micro-dentistry. We need to under- stand that laser dentistry is one por- tion of an entire new way of practic- ingconservative,pain-freedentistry. The laser that we call the “all-pur- pose” laser is the Lightwalker Er:YAG & Nd:YAG laser, manufactured by Fotona and distributed in the United States by Technology4Medicine. The Er:YAG produces its effect at 2,940 nm and has as its primary tissue tar- get 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 comfort- able for the patient, significantly reducing the need for local anaes- thesia. The use of the new generation er- bium lasers for repair of incipient hard-tissuediseaseallowsthedentist to provide a stress-free means of re- storingteethinaminimallyinvasive manor, most often with no shot and no numb lip, without the need for anylocalanaesthetics. The erbium laser can be used for restoring primary and permanent teeth, eliminating or reducing the amount of local anaesthetics. In most cases, the patient will not re- quire numbing for Class1, 2 (some- times),3, 4, 5, 6 restorative procedures using bonded restorative materials. Using the concept of minimally in- vasive restorative procedures, the Er:YAG laser allows the operator to removeonlydis- eased tissue and thus preserves much more of the healthy un- affectedtooth. In cases where alloy is pre- ferred,thelaser’s analgesia effect may also allow the dentist to create a restora- tive preparation using a conven- tional hand- piece that is not meant for bonding. The erbium laser is effective because ofitseffectonitstarget,waterwithin the tooth structure. This effect oc- curs when the laser heats up water within the target tissue, causing it to create small microscopic explosions (photothermal followed by photoa- custicaleffects).Whenappliedtosoft tissue, bone or teeth and cavities, the explosionsthencausetheareastobe vaporized. Er:YAGlaser2,940nm: Soft-tissueprocedures There is a wide array of soft-tissue procedures that are able to be com- pleted using the all-purpose laser: maxillary and mandibular frenum revisions, lingual frenum revisions, treatment of pericoronal pain or infection, removal of hyperplasic tissue because of drugs or poor oral care in orthodontic patients, biop- sies, treatment of aphthous ulcers and herpes labialis, pulpotomies, removal of impacted teeth and in adults apicoectomies and bone re- contouring. Pulpotomies Parents often express concern about theneedtotakeradiographsbecause ofthenatureofX-raysand their pos- siblesideeffectsontheirchild’sover- all health. They question the use of alloysbecauseofthechemicalmake- upofthealloy.Whethertheseshould be a real concern in today’s dental care is open to debate, depending on your individual beliefs. There are alsoconcernsbymany,althoughnot as loudly, about the effect of various pulpotomyproceduremedicaments used in pulpotomy procedures such asformocreosol. Lasers provide a safe, non-chemical effective alternative treatment for pulpotomies. During eight years, post-treatmentresultsonmorethan 4,000 pulpotomies using the erbi- um (2,940 nm) laser provides ample evidencethatthis methodis bothef- fective and safe for children without the need for introducing chemicals orusingelectrosurgerymethods. When the final result of orthodon- tic positioning of the front teeth results in gingival hypertrophy, the laser can be a useful tool to increase crown length and give the patient a moreaestheticsmile.Thismayoften be accomplished without the need for local anaesthesia. Patients who have medically induced hyperpla- sic tissue, such as patients requiring dilantoin, can also have their tissue reduced and reshaped with the er- bium. In addition to the many examples described in this article, lasers can be used for additional procedures not usually required in paediatric dentistry, such as revisions of the abnormal mandibular frenum, of- ten avoiding the need for soft-tissue grafts, crown-lengthening proce- dures where bone requires recon- touring, apicoectomies, removal of boney exostoses, removal of third molar impactions, removal of root remnants, incising and draining soft-tissue infections, advanced peri- odontal treatments and the latest in advanced endodontic treatment Figs.1&2:Representativesampleimagesofroot canaldentinalwallsirrigatedwith17percent EDTAandPIPSfor20seconds. (PhotoscourtesyofTechnology4Medicine) Fig. 3: Representative sample image of root canal dentinal walls irrigatedwith17percent EDTAandPIPSfor20seconds. Fig.5:New tapered tipdesignfor this technique. Fig.4:SEMimageofcleanlateralcanal. via photoninduced photoacoustic streaming. Photoacoustic endodontics usingPIPS The goal of endodontic treatment is to obtain effective cleaning and de- contamination of the smear layer, bacteria and their byproducts in the root canal system. Clinically, tradi- tional endodontic techniques use mechanical instruments, as well as ultrasonic and chemical irrigation, in an attempt to shape, clean and completely decontaminate the en- dodontic system but still fall short of successfully removing all of the infective microorganisms and de- bris. This is because the complex root canal anatomy and the inability for common irrigants to penetrate into the lateral canals and the apical ramifications.Itseems,therefore,ap- propriate to search for new materi- als,techniquesandtechnologiesthat can improve the cleaning and the decontamination of these anatomi- calareas. Among the new technologies, the laser has been studied in endodon- tics 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 bacteria in the infected canals, and important studies have confirmed these results in vitro.7 Studies reported that near infrared ÿPage 13