Policy on the Use of Lasers for Pediatric Dental Patients

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes 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. This policy is intended to inform and educate dental professionals on the fundamentals, types, diagnostic and clinical applications, benefits, and limitations of laser use in pediatric dentistry.

Methods

This policy was developed by the Council on Clinical Affairs and adopted in 2013. It is based on a review of current dental and medical literature related to the use of lasers. This document included database searches using the terms: laser dentistry, dental lasers, laser pediatric dentistry, laser soft tissue treatments, and laser restorative dentistry. Articles were evaluated by title and/or abstract and relevance to pediatric dental care. Expert and/or consensus opinion by experienced researchers and clinicians also was considered. 

Background

Medicine began integrating lasers in the mid 1970s for soft tissue procedures. Oral and maxillofacial surgeons incorporated the carbon dioxide (CO2) laser into practice for removal of oral lesions in the 1980s.1,2 The first laser specifically for dental use was a neodymium-yttrium-aluminum-garnet (Nd:YAG) laser, developed in 1987 and approved by the Food and Drug Administration in 1990.3 Since then, laser technology has advanced significantly. The use of lasers is contributing to many areas of dentistry including periodontics, pediatrics, endodontics, oral surgery, restorative dentistry and dental hygiene, cosmetic dental whitening, and management of temporomandibular joint pain to name a few. 

Laser basics
While a detailed description of how lasers work is beyond the scope of this document, it is important to understand the basics of laser physics prior to selecting a laser for dental treatment. The term laser is an acronym for light amplification by stimulated emission of radiation. Lasers are classified by the active medium that is used to create the laser energy. Within a laser, an active medium is stimulated to produce photons of energy that are delivered in a beam of unique wavelength that is measured in nanometers.4 The wavelength of a dental laser is the determining factor of the level to which the laser energy is absorbed by the intended tissue. Target tissues differ in their affinity for specific wavelengths of laser energy depending on the presence of the chromophore or the laserabsorbing elements of the tissue.4-6 Oral hard and soft tissues have a distinct affinity for absorbing laser energy of a specific wavelength. For this reason, selecting a specific laser unit depends on the target tissue the practitioner wishes to treat.

The primary effect of a laser within target tissues is photothermal.7 When the temperature of the target tissue containing water is raised above 100 degrees centrigade, vaporization of the water occurs, resulting in soft tissue ablation.1 Since soft tissue is made up of a high percentage of water, excision of soft tissue initiates at this temperature. Hard tissue composed of hydroxyapatite crystals and minerals are not ablated at this temperature, but the water component is vaporized and the resulting steam expands and then disperses the encompassing material into small particles.6 Laser operating parameters such as power, frequency, emission mode, thermal relaxation time, and air and water coolant used affect the clinical abilities of a laser. Additionally, the delivery system of laser unit as well as the tissue concentration of the chromophore greatly influence the laser tissue interactions.

Various types of lasers have been used in dentistry. Clinical applications of the lasers commonly used in pediatric dentistry are listed in the Table (see PDF).

Laser safety
Laser plume, a mixture of gases as well as debris, is generated during the use of lasers. When using dental lasers, it is imperative that the doctor and auxiliaries adhere to infection control protocol and utilize high-speed suction as the vaporized aerosol may contain infective tissue particles.2,8 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.9,10 To prevent viral transmission, palliative pharmacological therapies may be more acceptable and appropriate in this group of patients. Reflected or scattered laser beams may be hazardous to unprotected skin or eyes. Wavelength-specific protective eyewear should be provided and consistently worn at all times by the dental team, patient, and other observers in attendance during laser use.2 Many states have well defined laser safety regulations and practitioners should contact their specific state boards to obtain this information.

Lasers in pediatric dentistry
One of the benefits of laser use in pediatric dentistry is the selective and precise interaction with diseased tissues.2 Less thermal necrosis of adjacent tissues is produced with lasers than with electrosurgical instruments.11 During soft tissue procedures, hemostasis can be obtained without the need for sutures in most cases.2,12 With the benefit of hemostasis during soft tissue treatments, wound healing can occur more rapidly with less post-operative discomfort and a reduced need for analgesics.6,11-13 Little to no local anesthesia is required for most soft-tissue treatments.6,12-14 Reduced operator chair time has been observed when soft tissue procedures have been completed using lasers.12,13 Lasers demonstrate decontaminating and bacteriocidal properties on tissues, requiring less prescribing of antibiotics post-operatively.6,12,13 Lasers can provide relief from the pain and inflammation associated with aphthous ulcers and herpetic lesions without pharmacological intervention.5,12,13

Lasers can remove caries effectively with minimal involvement of surrounding tooth structure because caries-affected tissue has a higher water content than healthy tissue.11 The noise and vibration of the conventional high-speed dental handpiece has been postulated as stimulating discomfort, pain, and anxiety for the pediatric patient during restorative procedures.6,15-17 The non-contact of erbium lasers with hard tissue eliminates the vibratory effects of the conventional high-speed handpiece allowing tooth preparations to be comfortable and less anxiety provoking for children and adolescents.6,15,17 Nd:YAG and erbium lasers have been shown to have an analgesic effect on hard tissues, eliminating injections and the use of local anesthesia during tooth preparations.6,15,18-20

Limitations of lasers in pediatric dentistry
There are some disadvantages of laser use in pediatric dentistry. Since different wavelengths are necessary for various soft and hard tissue procedures, the practitioner may need more than one laser.2 Laser use requires additional training and education for the various clinical applications and types of lasers.2,13,15,18 High start up costs are required to purchase the equipment, implement the technology, and invest in the required education and training.2,13 Most dental instruments are both side and end-cutting. When using lasers, modifications in clinical technique along with additional preparation with high-speed dental handpieces may be required to finish tooth preparations.2,15 There are a variety of resources, such as the Academy of Laser Dentistry, available to assist dentists in the training and education for safe and effective use of lasers.

Policy Statement

The AAPD:

  • Recognizes the use of lasers as an alternative and complementary method of providing soft and hard tissue dental procedures for infants, children, adolescents, and persons with special health care needs.
  • Advocates the dental professional receive additional didactic and experiential education and training on the use of lasers before applying this technology on pediatric dental patients.
  • Encourages dental professionals to research, implement, and utilize the appropriate laser specific and optimal for the indicated procedure.
  • Endorses use of protective eyewear specific for laser wavelengths during treatment for the dental team, patient, and observers.

References

  1. Frame JW. Carbon dioxide laser surgery for benign oral lesions. Br Dent J 1985;158(4):125-8. 
  2. Coluzzi DJ. Lasers in dentistry. Compend Contin Educ Dent 2005;26(6A Suppl):429-35. 
  3. Myers TD, Myers ED, Stone RM. First soft tissue study utilizing a pulsed Nd:YAG dental laser. Northwest Dent 1989;68(2):14-7.
  4. Fasbinder DJ. Dental laser technology. Compend Contin Educ Dent 2008;29(8):452-9. 
  5. Green J, Weiss A, Stern A. Lasers and radiofrequency devices in dentistry. Dent Clin North Am 2011;55(3):585-97.
  6. Martens LC. Laser physics and review of laser applications in dentistry for children. Eur Arch Paediatr Dent 2011;12(2):61-7.
  7. White JM, Goodis HE, Kudler JJ, Tran KT. Thermal laser effects on intraoral soft tissue, teeth and bone in vitro. Third International Congress on Lasers in Dentistry. Salt Lake City, Utah: University of Utah Printing Services; 1992:189-90.
  8. Piccone PJ. Dental laser safety. Dent Clin North Am 2004;48(4):795-807.
  9. Parker S. Laser regulation and safety in general dental practice. Br Dent J 2007;202(9):523-32.
  10. Garden JM, O’Bannon MK, Bakus AD, Olson C. Viral disease transmitted by laser-generated plume (aerosol). Arch Dermatol 2002;138(10):1303-7.
  11. Coluzzi DJ. Fundamentals of lasers in dentistry: Basic science, tissue interaction and instrumentation. J Laser Dent 2008;16(Spec Issue):4-10. 
  12. Boj JR, Poirer C, Hernandez M, et al. Review: Laser soft tissue treatments for paediatric dental patients. Eur Arch Paediatr Dent 2011;12(2):100-5.
  13. 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.
  14.  Convissar RA, Goldstein EE. An overview of lasers in dentistry. Gen Dent 2003;51(5):436-40.
  15. Olivi G, Genovese MD. Laser restorative dentistry in children and adolescents. Eur Arch Paediatr Dent 2011;12(2):68-78.
  16. Takamori K, Furukama H, Morikawa Y, et al. Basic study on vibrations during tooth preparations caused by highspeed drilling and Er:YAG laser irradiation. Lasers Surg Med 2003;32(1):25-31.
  17. Tanboga I, Eren F, Altinok B, et al. 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.
  18. van As G. Erbium lasers in dentistry. Dent Clin North Am 2004;48(4):1017-59.
  19. Matsumoto K, Hossain M, Hossain MM, et al. Clinical assessment of Er,Cr:YSGG laser applications for caries removal and cavity preparation in children. Med Laser Appl 2002;20(1):17-21.
  20. Den Besten PK, White JM, Pelino JEP, et al. The safety and effectiveness of an Er:YAG laser for caries removal and cavity preparation in children. Med Laser Appl 2001;16(3):215-22.