Laser treatment for inflammatory disease: mainstream or unconventional?
Dr. Rosen
Laser periodontal therapy for inflammatory diseases has become a hot-button topic in dentistry. While the use of dental lasers can be traced back several decades, their involvement in patient care has become more front and center of late. The mere mention of dental lasers invokes strong sentiments both for and against them, with very few clinicians having neutral feelings on the subject. What is clear is that laser therapy in dentistry appears to be gaining more traction, which may be due in part to the widespread use of lasers in medical specialties such as ophthalmology, dermatology, and otolaryngology, to name just a few.
There appear to be several reasons for the heightened interest in laser use in the dental profession. Part of it is patient generated, as this method of treatment is seen as cutting-edge, effective, and less invasive. It is also perhaps being driven by the profession itself, as clinicians seek alternatives that will be more widely accepted and possibly equal in efficacy to meet the needs of an aging population that is demonstrating more inflammatory diseases. And, this heightened interest also may be partly due to marketing efforts by the corporations that manufacture these devices. Whatever the reason(s), dental laser treatment is making significant inroads, and many clinicians and their patients are benefiting from it.
I began my training and incorporated the Nd:YAG laser protocol into practice more than 4 years ago. I had been well aware of the use of lasers in dentistry, and my shift in this direction was largely driven by anecdotal evidence from my peers for whom I held great respect. However, it was also due to emerging scientific evidence in the form of human histology, which gave this mode of therapy increased validity.1
I respected that the laser company with which I trained was committed not only to educating me about laser use as a whole but also in how to properly employ the device to maintain patient safety and treatment efficacy around both teeth and dental implants. The results that I have seen for teeth with periodontitis have been quite good. Pocket depth reductions, gain in attachment levels, and bone gain have been clinically meaningful. In general, patients also have embraced the treatment readily and have been happy with their experiences. In a number of instances, I have been able to achieve outcomes that can be maintained by both the patient and hygienist, and in some situations teeth that were poor-hopeless have been significantly improved in their prognoses. This is not always the case, as molars with furcation invasion and dental implants with peri-implantitis have not always responded so well, necessitating surgical approaches to care to achieve better long-term outlooks for these situations.
When reflecting on my own successful experiences and the current scientific evidence available to support my observations, the question exists, “What needs to be done to move the use of lasers forward and to a larger number of adopters?” There appears to be a lack of high-level literature evidence that supports the excellent results I often see. Furthermore, most periodontitis studies focus on single-rooted teeth, and there seems to be a lack of randomized controlled trials comparing different lasers to regenerative surgical approaches for class II furcations. With regard to peri-implant diseases, case reports do demonstrate the virtues of minimally invasive laser approaches to care. However, few randomized controlled studies exist that assess how well different lasers and their varying algorithms can render an affected implant surface compatible for cellular attachment and proliferation (with the exception of the Er:YAG laser) and how effective lasers may treat peri-implant mucositis or peri-implantitis compared to currently used methods. Moreover, such studies should examine patient preferences/perceptions.
I, along with Drs. Salcetti and Low, have seen laser-associated therapy provide tremendous value for patients on a daily basis and expect it to be a mainstay in the treatment of inflammatory diseases. Our hope is that more research will be done to better understand how these devices enhance patient care. As disclosed, two of us have some affiliation with dental laser companies. While some readers may perceive this as bias, we feel that if one was to evaluate the results that we routinely obtain in our practices, one would better understand why we see a bright and prolific future for laser-assisted care.
Dr. Low
With a background as a graduate director, clinical researcher, and practitioner, I was not an “early adopter” of laser technology. However, for several years leading up to my introduction to laser engagement, I was curious to continually search for minimally invasive techniques that would provide positive patient outcomes. That quest brought me to the dental laser. For access, the laser tips had the familiar dimensions of the time-honored periodontal probe in both length and width. The activity taken on the periodontium and, now today, the implant surface was optical energy versus mechanical, and it demonstrated positive effects on the target tissue. The action was aligned with my core periodontal beliefs: suppress epithelial down-growth, have antimicrobial capabilities, provide degranulation/curettage, remove smear layer, perform decortication, and provide “attachment.” As I continued my investigation, a review of physics and wavelengths directed me to erbium lasers, because the periodontium includes not only soft tissue but also root morphology and bone. These components are the respective targets for the erbium laser.
Today, after 14 years, my use of dental laser therapy has expanded with all-tissue lasers being utilized for such applications as esthetic crown lengthening, extraction, lateral sinus lift, ridge splitting, implant uncover, and, now, management of peri-implantitis. Not all wavelengths are created equal as to their true targets/chromophores. Using an inappropriate wavelength on an implant surface can create a thermal adverse event. The discerning practitioner must be careful with certain laser wavelengths in the antimicrobial process as to settings, time, and proximity to the implant surface. Erbium lasers can be antimicrobial and decontaminate titanium surfaces with minimal heat production. Recently, laser tips have been developed whereby in early to moderate cases of peri-implantitis an effective energy can be guided deep into the implant threads for decontamination without flap reflection.
No laser product is ideal for all practitioners. The choice of laser must be based on the needs of the practice and the practitioner's beliefs. While systematic studies lend themselves to the laser controversy, dental laser applications to periodontal and implantitis management can demonstrate at least equal clinical outcomes to traditional modalities.2 However, clinical metrics are not the only factor in today's practice; patient-related outcomes as to wound healing, decreased discomfort, and reduced anxiety are also considerations in end points of therapy. Irrespective of one's choice of dental laser, these results can be very positive and rewarding with regard to case acceptance and marketing, not to mention positive outcome.
We cannot, however, undermine science for personal views on lasers, and, therefore, quality randomized controlled trials are needed—either to substantiate or unnerve many anecdotal observations. Such trials must be calibrated with trained clinicians using consistent settings, as wavelengths and their respective settings can be like comparing “apples and oranges” and are partly why inconsistent results have been noted. Moreover, dental research must determine etiologies of implantitis and surface effects as different wavelengths are applied to the respective surfaces. Much of this research regarding thermal effects and surface alterations can be done in vitro.
Much like it has for me, the addition of the dental laser in managing periodontics and implantitis provides clinicians with a technological achievement to satisfy their therapeutic need to enhance patient care in the areas of comfort, function, and esthetics.
Dr. Salcetti
My decision to investigate incorporating a laser into my periodontal practice was initiated from vigorous discussion I had with well-respected fellow periodontists who strongly encouraged me to provide this surgical treatment alternative to my patients. Initially, I was a “naysayer,” not seeing enough evidence to support the claims and justify the expense. However, my colleagues assured me that this would be a wise decision and that their clinical results were undeniable. After 6 years of using a variable-pulsed Nd:YAG dental laser featuring digital technology (on mostly maxillary second molars), I can indeed confirm they were absolutely right.
The laser that I chose was based on the manufacturer's strong belief in the academic and clinical rigors of understanding and applying laser therapy. This training was instrumental in my clinical success and in ensuring safety for my patients upon incorporating the technology into my practice. I also have noticed a significant transformation in my patients' willingness to accept laser therapy as the use of lasers becomes more prevalent in other medical fields. This seems especially so for those patients who have previously undergone a more traditional “scalpel” approach to treating moderate to advanced periodontal disease. Showing patients the documented “before” and many years “after” probing depths as well as radiographic changes helps them to see the benefits of and embrace this technology themselves.
I have witnessed the enormous impact on patients who have undergone full-mouth LANAP® laser treatment that not only arrested their disease but is continually used by my hygienist to maintain these patients in a complete state of health and wellness. Teeth that I have diagnosed with a guarded or poor prognosis have continued to be retained, while those that were hopeless (mostly second molars with advanced furcation involvement and horizontal bone loss) were often removed. My patients also enjoy the relatively minimal pain or discomfort and lack of swelling after laser surgery. Following strict protocol afterwards, my patients recognize and have complete understanding of their role to perform the necessary oral hygiene practices on a daily basis. At the same time, they are made aware that if they fail to maintain their due diligence, they may succumb to diseased sites returning.
For patients with peri-implant mucositis or peri-implantitis, I have seen better outcomes using my laser in the anterior esthetic zone compared to conventional treatments, as I believe access to treat the infection around the implant is easier, and virtually no recession of the gingival tissues occurs after the surgery. For posterior implants, if I am able to remove the crown and gain direct access to the implant, laser treatment is preferred. However, if the crown cannot be removed, I typically approach the ailing implant with a traditional open-flap surgery. With all my laser surgeries, controlling the occlusal forces is paramount to long-term success.
I have seen clinically what appears to be true regeneration of soft and hard tissues around previously diseased teeth. Certainly, I recognize the value in having research to corroborate my clinical findings, and while some evidence-based papers with histology have been published,1,3 I believe there could be more. For clinicians to forge into this realm of laser technology and take on the expenses of the necessary equipment and training, they must be assured that their return on investment will be better than that of their established methods, and continued research will help bring this to light. The challenge, of course, is obtaining the financial support to pursue these randomized clinical trials. Because my personal challenge is with treating implants, I would like to see further research with an emphasis on the treatment of peri-implantitis and a comparison of those results to traditional approaches to surgical management of such defects.
A dear colleague of mine once said, “Incorporating the right laser technology in clinical practice is not only the most sensible decision, it is the right thing for my patients. We owe this to them.” I wholeheartedly agree.
Disclosure
Dr. Rosen has received honoraria from Millennium Dental Technologies, Inc. in the past for lecturing engagements. Dr. Low is Vice President, Dental and Clinical Affairs and Chief Dental Officer for BIOLASE, Inc.
About the Authors
Paul S. Rosen, DMD, MS
Clinical Professor of Periodontics, University of Maryland Dental School, Baltimore, Maryland; Clinical Professor of Periodontics and Oral Implantology, Temple University Dental School, Philadelphia, Pennsylvania; Private Practice, Yardley, Pennsylvania
Samuel B. Low, DDS, MS, MEd
Professor Emeritus, University of Florida College of Dentistry, Gainesville, Florida; Associate Faculty Member, The Pankey Institute, Key Biscayne, Florida; Vice President, Dental and Clinical Affairs and Chief Dental Officer, BIOLASE, Inc., Irvine, California
Jeanne M. Salcetti, DDS, MS, MS
Former Chair, American Academy of Periodontology Oversight Committee in Continuing Education; Adjunct Assistant Professor, Department of Periodontology, University ofNorth Carolina School of Dentistry, Chapel Hill,North Carolina; Private Practice,
Colorado Springs, Colorado
References
1. Nevins ML, Camelo M, Schüpbach P, et al. Human clinical and histologic evaluation of laser-assisted new attachment procedure. Int J Periodontics Restorative Dent. 2012;32(5):497-507.
2. Gupta M, Lamba AK, Verma M, et al. Comparison of periodontal open flap debridement versus closed debridement with Er,Cr:YSGG laser. Aust Dent J. 2013;58(1):41-49.
3. Yukna RA, Carr RL, Evans GH. Histologic evaluation of an Nd:YAG laser-assisted new attachment procedure in humans. Int J Periodontics Restorative Dent. 2007;27(6):577-587.
