by Terry D. Myers, DDS, and John G. Sulewski, MA
Let’s say you have been thinking about a dental laser. You have seen the buyers’ guides, read some articles in the dental publications, maybe attended a laser lecture or two at a dental convention. What you have learned so far has impressed you, and you are beginning to get serious about acquiring a laser device for your office.
Yet you think you need more information to ensure your decision is adequately informed and the right one for your patients and practice. Want to learn more? Here are some guidelines to help you.
Practice considerations
Inevitably, the first step most successful laser dentists take is time to reflect on the practice. They consider its focus and direction, and then determine how this advanced technology might fit. Thus, any discussion involving “things to know” should initially focus on the practice.
It is quite normal (and healthy) for practitioners to periodically reassess operations. They look for meaningful ways to reinvigorate what might have become routine, or to differentiate what might be perceived as an “average” practice. Many times, dentists use technological advances to help define and lead future direction, providing the technology is appropriate for the practice and a match to their professional outlook.
From a laser standpoint, the device’s clinical capabilities, acceptance by the established dental infrastructure, perceptions and expectations of patients and staff, and return on investment are important considerations. Also important is how the laser will be optimally integrated in the practice to provide adequate and ongoing dental laser education for office staff. This can be a critical success factor.
Continue to read the dental literature and attend dental laser conferences. Collect as many different and reliable views as possible to help form your opinion. Give more credence to those sources that are transparent and willingly disclose any conflicts of interest.
The Academy of Laser Dentistry (www.laserdentistry.org) is a long-established and objective source of reliable information. Ask for checklists from other dentists, then develop a checklist of important do’s and don’ts for your practice.
In other words, do your homework and be prepared to make a strong professional commitment. Begin by reflecting on what your practice is and what you would like it to become. A laser can be a useful tool to realize your vision. The vast majority of laser dentists are happy to share the patient benefits, clinical advantages, economic gains, and practice-rejuvenating qualities they have experienced. Most would be quick to tell you they could not practice dentistry without a laser.
Device considerations
Concurrent with your practice self-evaluation, an examination of the various laser instrument types is timely and appropriate. Do you intend to focus on maintaining a general dental practice and concentrate on restorative dentistry for a broad client base? Maybe you want to enhance diagnostic capabilities. Perhaps you wish to expand services to include early intervention of periodontal disease or perform a myriad of intraoral soft tissue surgical procedures. Are you inclined to offer prosthodontic, endodontic, or implantology services? Perhaps you wish to expand your esthetic offerings. Answers to these questions will help determine which devices to consider since no single laser - despite its versatility - can perform all procedures optimally well.
Once you have developed a prioritized list of clinical needs, investigate which of the various laser types best fit your requirements. Understand that a laser produces light, either visible or invisible, of a very specific wavelength. Different wavelengths are absorbed by, and interact with, different biological tissues or chemical substances.
For example, many lasers operate by precisely heating the water content of cells. This so-called photothermal effect is the basis of targeted and localized coagulation or vaporization. Some lasers are well-absorbed by pigment (such as melanin), others by hydroxyapatite (which accounts for their ability to vaporize tooth structure and bone). Another wavelength stimulates certain chemical reactions, the basis of composite polymerization. Other wavelengths lend themselves well to a phenomenon called “laser-induced fluorescence,” which is useful in caries detection. Still others are used for biostimulatory effects such as pain relief and accelerated wound healing.
In simple terms, dental lasers are named after the source of their specific wavelength. This source may be an enclosed tube of gas (such as carbon dioxide or argon), a solid rod of specific chemical elements (such as Nd:YAG or erbium), or an array of semiconductors (a diode).
Broadly speaking, carbon dioxide, Nd:YAG, and diode lasers are optimally used for intraoral soft tissue surgery. Erbium lasers are best suited for cavity preparation and bone removal. Argon lasers have been used for rapidly curing certain composite restorative materials. Some diode lasers provide a diagnostic aid for detecting decay. Within these and other categories, variations exist. So a clear understanding of laser-tissue interaction is fundamental to choosing the best laser type for your clinical needs. Consult reliable textbooks and attend in-depth training courses to appreciate this critical aspect of laser operation.
Once you have narrowed your range of laser choices based on clinical applications, examine device-specific characteristics important for your practice. Size, portability, and maneuverability are some of the more obvious considerations. Does the device require special electrical or water hookups? Evaluate the ergonomics. Is the control panel easy to use? Are the displays easy to see and differentiate? How much control does the practitioner have over such variables as power and pulse rate? Is the range of control panel settings sufficient and appropriate for your primary dental procedures? Are time-efficient “presets” easily accessible for the more common procedures?
A key consideration is delivering the laser light intraorally. Different types of delivery systems exist, and generally are governed by the laser’s wavelength. Which systems are the most flexible and easy to use? Which require separate handpiece tips? What is the useful life of a given delivery system and tip, and what is the repair cost or replacement? How easily and quickly can the tips be replaced in the operatory? Which parts are autoclavable, and which are disposable?
All lasers are mandated by the U.S. Food and Drug Administration, the regulatory agency overseeing the manufacture and marketing of lasers in the U.S., to have various built-in safety features and accessories that are designed to ensure proper and safe operation by trained, authorized personnel. One of the most critical accessories is eye protection, specific for the wavelength and power of a laser, to be worn by the patient, practitioner, and attending personnel. Learn about these features and accessories, and become comfortable with when and how they should be used.
While “adverse events” (such as a serious injury) are rare in laser dentistry, you need to know how to recognize them and what your reporting obligations are. Private dental practices are encouraged to voluntarily report adverse events to the FDA, and are strongly recommended to report them to the manufacturer who - in turn - is obligated to report them to the FDA.
Device reliability should contribute to your informed decision. Supplement the data provided by the manufacturer and salesperson with reports from clinicians who have had experience with the instrument you are considering.
Of course, cost is one of the primary issues that practitioners contemplate. Be sure to include in your computation not only the initial cost of purchase or lease, but also the cost of maintenance and replacement parts. Balance this total with a realistic expectation of return on investment. Talk to colleagues who have been using lasers for some time (preferably owners of the specific devices you are considering) about their experiences regarding investment return and practice integration.
For those who choose to lease a laser, the amount of additional revenue generated per day can make the daily cost of the lease relatively insignificant. Reasons for added revenue are varied. Laser clinicians report the ability to (1) attract new patients because of new state-of-the-art technology, (2) perform additional procedures in-house vs. having to refer, (3) reduce chair-time because of the reduced need to administer anesthesia, and (4) deliver multiple treatments in a single visit vs. having to reappoint. One of the keys to assuring a comfortable and pleasing return on investment is education and training, both before and after the laser acquisition.
Ask about the warranty. What does the warranty cover (parts and labor and shipping), and for how long? Inquire about the service policy. Can service be performed in-office, or must the instrument be shipped to the factory? How difficult is it to repackage the instrument for shipment? How far is the nearest authorized service center? What is the typical turnaround time? Under such circumstances, is a loaner instrument available to keep your laser practice operational?
With the emphasis placed on evidence-based dentistry, it makes sense to investigate the available published research and reports, not only for the laser wavelength under consideration, but also the specific device, if possible. The report’s scientific rigor and applicability to your situation are important. So, is disclosure of the authors’ relationship (if any) to the manufacturer, and whether or not the article has undergone peer review.
Clinical capabilities and limitations
As you seek an informed decision, you have probably learned the capabilities and limitations of laser dentistry, in general, and those of the devices at the top of your list. Be realistic in your assessments and expectations, and look for opportunities for hands-on comparisons and trials.
The most realistic way to approach a laser instrument is to regard it as an addition to an existing armamentarium. While it may be true that a given laser may improve, add to, or even replace some of your current procedures, it would be imprudent to think you could discard your assortment of instruments in favor of a laser. Rather, see the laser as a valuable assistant, supplementing and expanding your capabilities.
Ideally, before committing to a particular instrument, you should compare the clinical capabilities of a number of laser instruments from different manufacturers - side-by-side - in an unbiased setting. Perhaps this can be done as part of a laser course. Often such venues enable clinicians to use the lasers in an in vitro laboratory set-up under the watchful eyes of experienced and trained workstation supervisors. Sometimes such programs are supplemented by recorded or live patient demonstrations conducted by qualified practitioners. Take advantage of these opportunities. Ask the instructing clinicians about the learning curve, limitations of use, nuances of clinical technique, and what specifics to look for and expect both during the procedure and postoperatively.
Another good question to ask is what should the clinician do to educate and prepare the patient for a laser procedure? Laser procedures tend to be “patient-friendly” because they often can be performed without the need for anesthesia. Their postoperative course is usually more pleasant than when conventional techniques are used.
Considerations of capabilities and limitations can also be approached from a regulatory standpoint. The manufacturer must demonstrate to the FDA the safety and efficacy of a device for specific clinical indications before placing it in the marketplace. Such “marketing clearances” are device-specific (not wavelength-specific).
It is important for the clinician to differentiate which procedures have been cleared by the FDA from ones that are considered “investigational.” For ethical, medical, and legal reasons, it is wise for clinicians to confine their laser services to procedures that have received marketing clearance. This information should be clearly spelled out in the operational manuals provided by the manufacturer.
Manufacturer considerations
Besides becoming familiar with the owner’s manual and clinical indications for use, you should spend time assessing the manufacturer’s qualifications relative to laser dentistry.
Investigate the maker’s track record, including years of experience in the dental marketplace. Ensure that the laser instrument is designed specifically for dentistry, and is not just a medical device with a dental label applied. Ask about the number of installations and how long the laser has been available. Has the company ever filed any adverse effects reports with the FDA?
Determine what sort of “return forgiveness policy,” if any, the manufacturer offers during the first weeks after a sale. This will accommodate the customer who, for one reason or another, elects not to pursue a laser-incorporated practice. Does the company have a money-back guarantee?
Does the manufacturer ever provide upgrades for its instruments as advancements in technology become available, or is there a tendency for instruments to become obsolete - with little availability of replacement parts once a successor enters the marketplace? How pricey are the consumables? Will substitution of factory-authorized accessories with aftermarket offerings nullify the original warranty?
What sort of customer support does the manufacturer offer after the sale? How quickly does the firm address service inquiries, fulfill orders for parts and accessories, and answer clinical questions? Is more than one call necessary to achieve satisfaction? Does the company offer in-office product demonstrations? Does it provide training for clinicians and staff? How extensive is training beyond just referring to the operator’s manual? How detailed and easy to follow are the procedural guidelines for use? Is training included in the purchase price? Are refresher courses available? Does the firm sponsor educational user group meetings? Does the firm provide access to the vast resources of available laser dentistry information, or concentrate mainly on its products?
Talk to several of the company’s customers regarding their experiences. How satisfied are they? Do the customers have any complaints? Listen to testimonials, but determine whether the referred clinician has any financial or other interests in the firm that may be a conflict of interest.
Ask the representative for published device-specific research. How active is the company’s involvement in the established academic world? How much of its annual budget is allotted to laser research and development?
Resources
If you are satisfied with the answers you have received, you are well on the way to making an informed decision of which laser for your practice. However, your well-considered research is not complete until you have examined at least some of the many resources available to laser dentists.
One of the most valuable is meetings dedicated to laser dentistry. These include the annual conference of the Academy of Laser Dentistry, as well as user group meetings. Participation in such sessions will greatly accelerate learning and provide nearly limitless opportunities for networking. Fortunately, much valuable information is also available online, which can be pursued at one’s leisure and according to one’s own schedule.
Be cautious, though, and bring some skepticism as you explore the World Wide Web. Just because something is on the Internet does not necessarily mean it is true. Checking online credentials is just as important as verifying “live” qualifications. A selected list of online resources follows.
Organizations
- Academy of Laser Dentistry (ALD) and the Journal of Laser Dentistry (www.laserdentistry.org)
- American Society for Laser Medicine and Surgery, Inc. (ASLMS) (www.aslms.org)
- Laser Institute of America (www.laserinstitute.org)
- SPIE - The International Society for Optical Engineering (www.spie.org)
- World Association for Laser Therapy (www.walt.nu)
Terry D. Myers, DDS, is an adjunct professor at the University of Detroit Mercy School of Dentistry; co-founder and president of Incisive, LLC, a manufacturer of dental lasers; and executive director of the Institute for Advanced Dental Technologies. Having researched the use of lasers in dentistry since 1983, he co-developed the Nd:YAG dental laser, the first laser designed specifically for general clinical dentistry. Contact Dr. Myers at [email protected].
Mr. John Sulewski serves as the director of education and training for The Institute for Advanced Dental Technologies and as a senior technical writer for Westin Engineering, Inc. He is a consulting editor for the Journal of Laser Dentistry, the official journal of the Academy of Laser Dentistry, and has been involved in the laser dentistry field since 1989. Sulewski can be reached at [email protected].
