“The Advantages and Applications of Lasers for Pediatric ... · 5 DR. JAJU By Rishita Jaju, DMD...

DR. JAJU5

By Rishita Jaju, DMD

If you are a pediatric dentist, or a general dentist that treats pediatric patients, you may be hearing more and more about the personal, professional, and practice-wide benefits of adding laser technology to your practice. In 2013, the American Academy of Pediatric Dentistry recognized the judicious use of lasers as a beneficial instrument in providing dental restorative and soft-tissue procedures for infants, children, and adolescents — including those with special health care needs.1 Looking at the landscape, laser technology seems to be on its way to being the gold standard in pediatric dentistry.2

Pediatric DentistryThe Advantages and Applications of Lasers for

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18. Chi D, Kanellis M, Himadi E, Asselin M-E. Lip biting in pediatric dental patients following dental local anesthesia: a case report. Journal of pediatric nursing. 2008;23(6):490-493. doi:10.1016/j.pedn.2008.02.035.

19. American Academy of Periodontology; www.perio.org; Gum Disease in Children https://www.perio.org/consumer/children.htm

20. Christopher H, Blackburn P. It’s not rocket science!, RDH volume-31, issue 7

21. A Sivriver. In vitro analysis of RFPT5 tip durability throughout a standard periodontal treatment. Journal of Laser-Assisted Dentistry 2014; volume 1, pg 12

22. American Academy of Periodontology; www.perio.org; Laser Therapy https://www.perio.org/consumer/laser-therapy.htm

23. Chen W. The clinical applications for the Er,Cr:YSGG laser system, an atlas; oral surgery procedures pg 250; 2009 ISBN:978-09822073-0-7

24. Academy of Laser Dentistry. Advantages and Limitations of Lasers. https://www.laserdentistry.org/uploads/files/education/LaserEdu_Laser_Advantages_Limitation.pdf

25. Huth, K.C., Hajek-Al-Khatar, N., Wolf, P. et al. Long-term effectiveness of four pulpotomy techniques: 3-year randomized controlled trial. Clin Oral Invest (2012) 16: 1243. doi:10.1007/s00784-011-0602-3

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...there are added advantages to laser use – especially in the realm of providing a calm, anxiety-free dental visit.

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IntroductionDental lasers have been used for more than 25 years. Since then laser technology has ad-vanced significantly and the advantages of laser technology in performing procedures is well established. Advantages attributed to lasers include: targeted ablation, hemostasis, analgesia, decontamination, and photobiomodulation. The use of lasers is contributing to enhancing and evolving care in many areas of dentistry including periodontics, pediatrics, endodontics, oral surgery, restorative dentistry and dental hygiene; lasers also have a role in whitening and management of TMJ pain.

For the pediatric dentist, there are added advantages to laser use – especially in the realm of providing a calm, anxiety-free dental visit. Lasers diminish the need for an injection of local anesthesia or the use of a handpiece for most Class I – VI fillings and dental restorations. Thus, the dental visit becomes a lot easier for everyone: patient, parents, and practice team. Children are more cooperative during restorative, pulpal and surgical treatments using lasers, which significantly promotes the quality of care and enhances the process of treatment.

Laser BasicsThe term ‘laser’ is an acronym for Light Amplification by Stimulated Emission of Radiation. Within a laser, an active medium is stimulated to produce photons of energy that are delivered in a beam of monochromatic light of a specific wavelength. Wavelengths in the range of 193 – 10,600 nanometers (nm) are applicable in medicine and dentistry.

Oral hard- and soft-tissues have a distinct affinity for absorbing laser energy of a specific wavelength. For example, the Er,Cr:YSGG laser contains erbium and chromium ions, and a crystal of yttrium, scandium, gallium, and garnet and produces a specific wavelength of 2780 nm when pumped with electricity. In diode lasers, the stimulated substance is a semicon-ductor that operates at 810 nm - 980 nm. There are pros and cons to each wavelength.

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Reference:

1. AAPD Council on Clinical Affairs. Policy on the Use of Laser for Pediatric Dental Patients. Pediatric Dentistry, Oct 2013 Reference Manual, Vol. 35 Issue 6, p75 Oct. 2013.

2. Ramazani N. Poureslami H, Ahmadi R, Ramazani M. Early childhood caries and the role of pediatricians in its prevention. Iran J Pediatric Soc. 2010; 22:11-25.

3. Dye B, Thornton-Evans G, Li X, Iafolla T. Dental Caries and Sealant Prevalence in Children and Adolescents in the United States, 2011-2012. NCHS Data Brief No.191, March 2015.

4. Coluzzi D. Fundamentals of dental lasers: Science and instruments. Dent Clin North Am 2004;48(4);751-70.

5. Coluzzi DJ. Lasers in dentistry. Compend contin educ Dent 2005;26(6A Suppl):429-35.

6. Kotlow LA. Lasers in pediatric dentistry. Dent Clin North Am 2004;48(4)889-922.

7. Van As G. Erbium lasers in dentistry. Dent Clin North Am 2004;48(4)1017-59.

8. Olivi G, Genovese MD. Laser restorative dentistry in children and adolescents. Eur Arch Paediatr Dent 2011;12(2):68-78.

9. Olivi G, Genovese MD, Caprioglio C. Evidence-based dentistry on laser paediatric dentistry: Review and outlook. Eur J Paediatr Dent 2009;10(1);29-40.

10. Takamori K, Furukama H, Morikawa Y, Katayama T, Watanabe S. Basic study on vibrations during tooth preparations caused by high-speed drilling and Er:YAG laser irradiation. Laser Surg Med 2003;32(1):25-31.

11. Tanboga I, Eren F, Altinok B, Peker S, Ertugal F. The effect of low level laser therapy on pain during cavity preparation with laser in children. Eur Arch Paediatr Dent 2011;12(2):93-5.

12. Martens LC. Laser physics and review of laser applications in dentistry for children. Eur Arch Paediatr Dent 2011:12(2):61-7.

13. Whitters CJ, Hall A, Creanor SL, et al. A clinical study of pulsed Nd: YAG laser induced pulpal analgesia. J dent 1995;23(3);145-50.

14. Matsumoto K, Hossain M, Hossain MM, Kawano H, Kimura Y. Clinical assessment of Er, Cr: YSGG laser applications for cavity preparation. Med Laser Appl 2002;20(1):17-21.

15. DenBesten PK, White JM, Pelino JEP, Furnish G, Silveira A, Parkins FM. The safety and effectiveness of an Er: YAG laser for cares removal and cavity preparation in children. Med Laser Appl 2001;16(3)215-22.

16. Soares F, Varella CH, Pileggi R, Adewumi A, Guelmann M. Impact of Er, Cr:YSGG laser therapy on the cleanliness of the root canal walls of primary teeth. J Endod. 2008;34(4):474-477. doi:10.1016/j.joen.2008.02.006.

17. Boj JR, Poirer C, Hernandez M, Espassa E, Espanya A. Review: Laser soft tissue treatments for paediatric dental patients. Eur Arch Paediatr Dent 2011;12(2);100-5.

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Many parameters also affect the clinical abilities of lasers (e.g. – power, operating mode, delivery system, etc.). The most commonly used lasers in pediatric dentistry are listed below (Figure 1).

While providing a detailed description of how lasers work is beyond the scope of this paper, it is important to understand the basics of laser physics prior to selecting a laser for your dental practice. Understanding the basic principles will enable you to make an educated decision about the type of laser that will provide the most benefits to you and your patients. The Academy of Laser Dentistry (www.laserdentistry.org) and the World Clinical Laser Institute (www.wcli.org, sponsored by BIOLASE, Inc.) provide a variety of resources to assist dentists in the education and use of lasers, and offer a number of continuing education courses for pediatric use of lasers.

LASER TYPE WAVELENGTH APPLICATION

CO²

10600 nm

1. Soft-tissue ablation - gingival contouring for esthetic purposes, frenectomy and gingivectomy

2. Treatment of oral ulcerative lesions

3. Elimination of necrotic epithelial tissue during regenerative periodontal surgeries

CO²

9300 nm

1. Hard-tissue procedures - caries removal and cavity preparation

2. Soft-tissue procedures - incision, excision, vaporization, coagulation and hemostasis

3. Osseous tissue procedures

Er:YAG 2940 nm1. Caries removal and cavity preparation in enamel and dentin

2. Root canal preparation

Er,Cr:YSGG 2780 nm

1. Hard-tissue procedures - enamel etching, caries removal and cavity preparation in enamel and dentin

2. Osseous tissue procedures - bone ablation without over-heating, melting or changing the calcium and phosphorus ratios

3. Soft-tissue ablation - gingival contouring for esthetic purposes, frenectomy and gingivectomy, operculectomy

4. Endodontic Therapy – pulp cap, pulpotomy, pulpectomy and root canal preparation

5. Elimination of necrotic epithelial tissue during regenerative periodontal surgeries

6. Treatment of oral ulcerative lesions

Diode 810 - 1064 nm

1. Proliferation of fibroblasts and enhancing the healing of oral lesions or surgical wounds (photo biomodulation).

2. Soft-tissue ablation - gingival contouring for esthetic purposes, frenectomy and gingivectomy, operculectomy

3. Whitening

Laser Fluorescence (LF) 450 - 655 nm1. Detection of occlusal caries

2. Detecting calculus concrements in periodontal pockets

Figure 1. Table: Commonly used lasers in pediatric dentistry

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Lasers have advanced significantly since they were first introduced 25 years ago.

ConclusionThe introduction of any new technology requires a commitment of time and money for the training, implementation, and continuing education. Effective use of lasers is no different. Lasers have advanced significantly since they were first introduced 25 years ago. The use of lasers is contributing to many areas of dentistry including periodontics, pediatrics, endodontics, oral surgery, restorative dentistry, and dental hygiene. Advantages attributed to lasers compared to traditional instrumentation include: targeted ablation, hemostasis, analgesia, decontamination, and photobiomodulation. For the pediatric dentist, there are added advantages to laser use especially in its ability to provide anxiety-free dental visits and a gentler, less invasive dental experience. There is broad clinical application for lasers in pediatric dentistry and lasers have proven effective across both hard-tissue and soft-tissue procedures. Lasers can contribute to personal, professional, and financial satisfaction for the dentist and the practice when integrated appropriately. There are limitations to the use of lasers, most notably is that additional studying and training is required to become proficient in its use.

The American Academy of Pediatric Dentistry (www.aapd.org) has recognized the judicious use of lasers as a beneficial instrument in providing dental restorative and soft-tissue pro-cedures for infants, children, and adolescents – including those with special health care needs. The Academy of Laser Dentistry (www.laserdentistry.org) and the World Clinical Laser Institute (www.wcli .org, sponsored by BIOLASE, Inc.) provide a variety of resources to assist dentists in the education and use of lasers, and both organizations offer a number of continuing education courses for pediatric use of lasers.

About the AuthorDr. Rishita Jaju is a Board Certified Pediatric Dentist in Reston, VA. She completed her dental education at Harvard School of Dental Medicine. She received her specialty training in Pediatric Dentistry at Children’s National Medical Center in Washington, DC where she continues to remain as a clinical faculty.

Dr. Jaju is well published in many areas of pediatric dentistry including care for patients with special health care needs, behavior guidance, esthetic dentistry, pain management, and laser dentistry. She has provided numerous seminars and trainings for introducing and promoting the benefits of lasers applications in dentistry to area general dentists, pediatricians, lactation consultants and speech pathologists.

She has achieved Mastership Status and Advanced Proficiency Certification from the Academy of Laser Dentistry.

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Clinical Applications of Lasers for Pediatric Dentistry

TREATMENT OF CARIES

CDC data from 2011-2012 National Health and Nutrition Examination Survey reveals that prevalence of dental caries in primary teeth remains at 22.7% among children 2-5 years of age and rises to 55.7% among children 6-8 years of age. On the same note, close to 50% of caries go untreated either due to lack of cooperation of the children or parental resources.3 All-tissue lasers can remove caries effectively with minimal involvement of surrounding tooth structure because caries-affected tissue has a higher water content than healthy tissue.1,4,5 Lasers are capable of removing caries and preparing teeth for restorative procedures in children and adolescents.6-9 The non-contact mode of lasers with hard-tissue eliminates the vibratory ef-fects of the conventional high-speed handpiece, allowing tooth preparations to be comfortable and less anxiety-provoking for children and adolescents.8,10,11 Of particular benefit to pediatric patients is the fact that lasers have been shown to have an analgesic effect on hard-tissues, reducing the need for local anesthesia needed for tooth preparations.6-8, 12-15 No need for local anesthetic allows for a better post-op experience for patients without numbness in lip/tongue. A prospective study found that 13% of children ages 2 to 18 experienced soft-tissue trauma following unilateral or bilateral mandibular nerve block anesthesia. The incidence of soft-tissue trauma was highest in the youngest patients – 18% among children less than 4 years of age, 16% in children ages 4 to 7, 13% in 8 to 11-year-old children, and 7% in children 12 years of age and older18 (Figure 2).


2-18 years 2- 4 years 4-7 years 8-11 years 12+ years

18%

13%

16%

13%

7%

Incidence of soft-tissue trauma following unilateral or bilateral manndibular nerve block anesthesia19

Figure 2.

utilizing the laser, the clinician has the ability to provide care for multiple quadrants in fewer visits as there are no local anesthetic dosing restrictions.

In addition to providing practices with the ability to complete more treatment in a single visit, laser technology provides the pediatric practice the ability to add new procedures that were previously referred out – such as frenectomies and other soft-tissue surgeries or endodontic therapies.

Limitations of Lasers in Pediatric DentistryThere are limitations in the use of lasers for pediatric dentistry. When using lasers, mod-ifications in clinical technique are required that need to be learned during laser education courses. Wavelength-specific protective eyewear must be provided and worn at all times by the dental team, patient, and other observers in attendance during laser use. There are times when a dental handpiece may still be required for cavity preparation. In this case, proper laser analgesia protocol allows for the use of the handpiece without the need for anesthesia. When using dental lasers, it is imperative that the doctor and auxiliaries adhere to infection control protocol and utilize high-speed evacuation to protect against vaporized aerosols (also known as plume). The practitioner should exercise good clinical judgment when providing soft-tissue treatment of viral lesions in immunocompromised patients; as the potential risk of disease transmission from laser-generated aerosol exists similar to the use of ultrasonic instruments.¹

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Lasers can boost practice productivity as well.


...a positive dental experience with reduced fear and anxiety...


36-month Clinical Sucess Rate

Figure 3. Long-term effectiveness of four pulpotomy techniques: 3-year randomized controlled trial. 25

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ENDODONTIC THERAPY

Hard-tissue lasers have demonstrated effectiveness for indirect and direct pulp capping treatments and endodontic procedures including primary tooth pulpotomies and root canal disinfection.1,4,5 Success rates of laser pulpotomies have been comparable to those of formo-cresol pulpotomies – with the significant advantage that with laser treatment, no formocresol is needed for disinfection thereby eliminating any concerns of safety related to carcinogenic or mutagenic properties (Figure 3). Recently, there is also increased concern of internal resorption among primary teeth treated with ferric sulphate, which can be avoided by use of laser for decontamination and coagulation within the pulp chamber.

Efficient use of laser technology in cleaning the root canal system has also been demonstrated. For instance, the Er,Cr:YSGG laser demonstrates cleaning and shaping efficacy similar to that of rotary instruments and superior to that of hand instruments.16 This is especially advanta-geous for treatment of young permanent teeth affected by trauma or pre-eruptive caries due to enamel hypoplasia.

SOFT-TISSUE PROCEDURES

The combination of the analgesic properties of laser and its hemostatic capability allows most soft-tissue procedures to be completed with little or no local anesthesia and without the need for sutures in the vast majority cases. Thus, wound healing can occur more rapidly with less post-operative discomfort and reduced need for post-operative analgesics. Additionally, because lasers demonstrate decontaminating and bactericidal properties, there is reduced need for post-operative use of antibiotics.

Clinical applications of soft-tissue lasers in pediatric dentistry include frenectomies, operculec-tomies, prevention and treatment of pre-eruptive caries and exposure of teeth for orthodontic

ALL-TISSUE LASER DENTISTRY PATIENT BENEFITS

� Reduces pain and discomfort

� Eliminates or reduces injections of local anesthesia for dental fillings

� Removes tooth decay with minimal involvement of surrounding tooth structure

� Eliminates the noise and vibrations of dental handpiece

� Less anxiety-provoking for children and adolescents

SOFT-TISSUE LASER DENTISTRY PATIENT BENEFITS

� Reduces pain and discomfort

� Eliminates or reduces injections of local anesthesia

� Reduces bleeding

� Eliminates need for sutures in most cases

� Reduced inflammation and faster initiation of healing response

� Reduces post-operative discomfort

� Reduces need for antibiotics post-operatively

Advantages of Lasers for the Pediatric Dental Practice Team Pediatric dentists take great pride and personal satisfaction in the delivery of care to their patients. For many, dentistry is more than a career, it is also a vocation which is personally gratifying for a host of reasons. To become a certified laser dentist requires specific education and training that often ignites a renewed passion for the technical aspects of dentistry and brings about a higher level of skill and knowledge. Any time a dentist and the practice team can use their skills and technology to improve the patient experience, it provides a sense of accomplishment and personal satisfaction. Lasers can boost practice productivity as well. By



purposes, gingival contouring, gingivectomies, removal of mucosal lesions, biopsies, and treatment of aphthous ulcers and herpetic lesions.7,12,17

Laser assisted frenectomy to release restricted maxillary labial frenum (lip-tie) or ankyloglossia (tongue tie) have been possible in an office setting for infants, toddlers and children. The pos-itive impact of on growth and development of the pediatric patient when it comes to improving their feeding and swallowing abilities, speech development and caries prevention have also been widely recognized.

LASER BACTERIAL REDUCTION

Chronic gingivitis, aggressive periodontitis and generalized aggressive periodontitis are types of gum disease in children.19 For mild, moderate and severe periodontal issues, laser bacterial reduction (LBR) can be performed to promote the return of the periodontium to a state of health. LBR is most commonly provided by diode laser and it is accomplished by inserting the fiber tip into the free space of the periodontal pocket and moving it in a sweeping motion to achieve a thorough bacterial kill. Various studies reveal many positive effects of LBR, including, but not limited to, a 21-to-58-day reduction in planktonic bacterial migration, elevation of ATP synthesis and reduction in anaerobes introduced into the bloodstream.²0


...wound healing can occur more rapidly with less post-operative discomfort and reduced need for post-operative analgesics.


For more severe periodontal conditions, Er,Cr:YSGG, C0², and Nd:YAG lasers are indicated for

elimination of necrotic epithelial tissue. Surgical periodontal procedures are performed either on single sites or multiple sites as determined by the clinician and the patient’s condition. A radial firing periodontal tapered tip (RFPT) has been developed for the Er,Cr:YSGG laser which is designed to deliver laser energy to the periodontal pocket walls and to the bottom of the periodontal pocket, treating both diseased soft-tissue, root surface and infected bone simultaneously.²¹ Current controlled studies have shown that similar results have been found with laser compared to specific other treatment options.²²

Laser Benefits for the Pediatric PatientUse of laser for pediatric dentistry contributes to providing a positive dental experience with reduced fear and anxiety for the pediatric patient. Children are often more cooperative when laser is used for dental treatments due to its minimally invasive nature. Laser instrumentation is a stark contrast compared to traditional anesthesia and high-speed drill for restorative dentistry, or, use of scalpel and sutures or electro-surgery for soft-tissue procedures. This results in an overall better experience for the patient and translates to higher satisfaction and loyalty from parents.

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...laser bacterial reduction (LBR) can be performed to promote the return of the periodontium to a state of health.


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