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ePaper created 2018-04-25, 08:59:39 | version 1.38.0
Dental Tribune Middle East & Africa Edition | 2/2018 mCME 15 The diode laser as an electrosurgery replacement mCME articles in Dental Tribune have been approved by: HAAD as having educational content for 1 CME Credit Hour DHA awarded this program for 1 CPD Credit Point CAPP designates this activity for 1 CE Credit By Glenn A. van As, Canada In 2008, Dr Gordon Christensen wrote an article in JADA comparing the soft tissue cutting abilities of di- ode lasers to those of electrosurgery (radiosurgery) units.1 In comparing these two technologies against each other, he found that both dental la- sers and the less expensive electro- surgery units have advantages and disadvantages, and he summarized with several key points: 1. Although there was considerable overlap in their uses and both tech- nologies were effective, Christensen found that diode lasers were able to be used around metal (amalgam and gold) as well as with dental implants. 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 anes- thetic, and fi nally he mentioned that lasers were antimicrobial (antibacte- rial). 3. The acceptance and use of lasers, especially the diode laser, was in- creasing in dentistry, and that lasers attract patients because of their rec- ognized and accepted role within the fi eld of medicine (LASIK eye surgery). 4. Electrosurgery units were “far less expensive than the least expensive diode lasers” and he questioned whether “the advantages of the di- ode laser were signifi cant enough to compensate for the additional cost.” There are two basic types of electro- surgical units that can be purchased Table 1: Comparison of diode laser versus monopolar electrosur- gery units. Fig. 1: Absorption curve of various tissue components shows di- ode lasers to be well absorbed in melanin (pigment), hemoglobin and to some degree water. (Images/Provided by Glenn A. van As, BSc, DMD) in dentistry: • Monopolar, in which a single elec- trode exists and the current travels from the unit down a single wire to the surgical site. The patient must be grounded with a pad placed be- hind the patient’s back (a part of the procedure that many patients may question). Heat is produced when the electrode contacts the tissue, and due to pain that is produced, anes- thetic must be used. • Bipolar, in which two electrodes are placed in very close proximity to each other. Bipolar units are more expensive than diode lasers and the electrical current fl ows from one electrode to the other, thus eliminat- ing the need for a grounding pad. Bi- polar units, because of the two wires, create less of a precise cut than the monopolar or diode laser. Although electrosurgical units are inexpensive, require no safety glass- es and can remove large amounts of tissue quickly, diode lasers have become much more common in dental operatories in the four years since Christensen’s article was pub- lished. The primary reasons for their increased popularity are that diode lasers have a small footprint, are reli- able and durable lasers, and are port- able. Where a few short years ago, diode lasers could cost in the range of $10,000 to $15,000, they are now cost effective and can be purchased for less than $2,500. Advantages of the diode laser over electrosurgery Ability to work around metals intraorally Diode lasers in the range of 810– 1,064 nm are well absorbed in hemo- globin, melanin (pigment) and to some degree water (Fig. 1). These mid infrared dental wavelengths in the absorption spectrum offer the den- tal clinician the ability to ablate soft tissues precisely while controlling hemostasis, providing the clinician with an excellent view of the surgical site with a reduced reliance on su- tures. Diode lasers have features that make them attractive as mentioned earlier, but they also have several ad- vantages in function over electrosur- gical units2 (Table 1). Perhaps the greatest benefi t of these lasers is that they allow the clinician to work safely around metals. The lit- erature has shown that monopolar electrosurge units can accidentally create catastrophic results when touching metal intraorally. Pub- lished reports have shown that con- tact for very short periods of time with the electrode of a monopolar electrosurgical unit can cause both pulpal and periodontal problems,3 bone loss,4 severe intraoral burns,5 arcing, and that within three seconds of exposure to a dental implant elec- trosurgical units can cause failure of osseointegration and loss of an im- plant.6,7 In clinical practice, with today’s emphasis on the more esthetically pleasing composite resins and new- er porcelains, there are still many metallic materials used intraorally, including cast partial denture frame- works, gold, amalgam, orthodontic brackets and semi-precious alloys. Diode lasers, unlike their electrosur- gical counterparts, show little inter- action with metallic objects used intraorally. It is important to remem- ber that due to the laser’s ability to refl ect off mirrored surfaces and po- tentially cause eye damage, that all members of the dental team as well as the patient must wear laser safety glasses for eye protection if they are within the nominal ocular hazard zone (NOHZ) during laser operation. ÿPage 16 Fig. 2: Gingival hyperplasia around orthodontic ap- pliances. Fig. 3: Immediate post-op after diode laser gingivec- tomy completed. Fig. 4: Eight-day healing of soft tissue around brack- ets. Fig. 5: Diode laser for second-stage implant uncovery in edentulous maxilla Fig. 6: Four healing cuffs in place in maxilla immedi- ately after uncovery with the diode laser. Fig. 7: Replace select implant fi xtures for upper right premolars. Fig. 8: Abutments in place for both teeth. Fig. 9: Soft tissue on margins preventing full seating of crowns. Fig. 10: Picasso Lite diode laser removing tissue on abutment margins. Fig. 11: Note tissue off the margins of abutments af- ter diode use. Fig. 12: Final crowns cemented onto abutments with- out soft-tissue impingement. Fig. 13: Partially exposed canine requires orthodontic bracket.