The benefits of a better laser

March 15, 2017

Two laser-dentistry experts share their insight as to how diode lasers can be used for more and with better results.

Dr. Kenneth Magid, DDS, FICD helped develop the Epic Pro and was involved in lasers since they first came to dentistry in the 1980s. Dr. Magid has not only lectured extensively on lasers around the world, but he’s also written articles and textbooks on them. He’s director of laser dentistry at NYU College of Dentistry.

Dr. Sam Low, DDS, MS, MEd, is the chief dental officer and vice president of clinical and dental affairs for BIOLASE. He has 30 years of private practice experience as a periodontist and 20 years’ experience as an associate faculty member of the L.D. Pankey Institute. He’s also professor emeritus at University of Florida, College of Dentistry. He lectures and teaches dental professionals nationwide.

DPR spoke to them about the BIOLASE Epic Pro Diode Laser and what makes it different than the other diode lasers available.  

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How is the Epic Pro different or unique from the other diode lasers available today?

Dr. Low: The Epic X is an excellent laser, but with most everything in life, there’s always something called the starter and then there’s the next level. The Epic X is an excellent all-around laser for hygienists and for dentists who want to do a frenectomy biopsy and things of this nature. That’s not just about the Epic X, but diodes in general.

Dr. Magid: The most common soft-tissue laser in dentistry is the diode laser. It is the most commonly used and least understood laser that exists today.

Dr. Low: Some clinicians use diodes as electro surgery devices. In other words, they’re primarily using them as a heat stick. Most diodes work off thermal reaction. For the most part, diodes are slow. They tend to drag through tissue. Debris builds up on the tips as a coagulum and must be wiped off, and that somewhat undermines the continuous nature of a procedure. So, diodes are effective; they’re more effective than electro surge, but they still have limitations to them.

Dr. Magid: Unlike an Erbium laser and a CO2 laser, which cut with laser energy, the diode laser cuts with a hot tip. The first question then becomes, if it cuts with a hot tip, how hot? With other diode lasers, the dentist has no idea and no way of controlling how hot the tip is. Second, the question is how consistent is that heat? In other words, if I could set it at a certain temperature, does it stay at that temperature? The answer with any other laser is no. It varies all over the place, creating some unique, untoward problems.

Dr. Low: The Epic Pro performs all procedures that a diode does, but quicker with no buildup of tissue debris on the tip.

Dr. Magid: With the Epic Pro laser, you not only can control the heat and control the heat consistently but you can add to that what’s called Super Pulse where you have tremendous energy, tremendous heat in a cutting mode for 100 microseconds and then it’s off, very much like the Nd:YAG laser.

Dr. Low: Power is measured in watts, and the peak power on a high-level diode can elevate up to 10 watts. The Epic Pro goes up to 150 watts. And then you might ask, well, my goodness, that would be so much, wouldn’t that be dangerous? Well, the fact is that even though it may go up there, it only lasts for a very short time, much shorter than any other diode out there.

How does this help with clinical practice?

Dr. Low: Since one does not get overheating of the tissue, the wound healing is quicker and renders a more positive patient response, which is what you want any time you do any procedure in dentistry. By having such great energy for a short period, the Epic Pro almost acts like a blade. In other words, it’s fast, it’s clean and tissue doesn’t collect around it.

Dr.  Magid: With other diode lasers, the dentist spends an enormous amount of time and effort compensating for the deficiencies in the device.

For example, if you are doing a gingivoplasty with a standard diode laser, you get lots of charring and tissue tags. If you’re troughing the tooth and you use a standard diode laser, what you’ll get again is charring and tissue tagging, which makes it difficult if you’re going to use a standard impression material. If you’re using CAD/CAM scans, you can’t have tissue tags or charring because the scan won’t allow you then to do a restoration.

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Dr. Low: Restorative dentistry is rapidly moving toward digital impression. But the unfortunate aspect is that when you do digital, your impression must be so much more accurate than when you use impression material. When you use impression material, the tray assists in moving the tissue away from your restorative margin. When you use digital, there’s no physical moving the tissue away from the margin, so one must use significant retraction cord.

When you use an Epic Pro for retraction, the margin is exposed via troughing and you don’t see those tissue tags and this coagulum sticking to the area that you’ve been working on. Not only just the tip, but also in the physical area that you’re working on. It’s much cleaner. It’s just such an improvement over current diodes.

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What other ways is the Epic Pro different than the typical diode laser?

Dr. Low: A significant limitation to most diodes is inconsistency, and my pet peeve is initiation of the tip. I knew from the beginning as a periodontist and someone who’s been in lasers for 14 years that when folks initiated a tip, the quality of that initiation had everything to do with the energy consistently concentrating on the initiation. And people just do it haphazardly! They find any way they can to get black on there, whether it be a Sharpie or a cork or occlusal paper with inconsistent results.

Dr. Magid: With the Epic Pro, they’ve developed an entirely new kind of tip that deposits titanium and carbon onto the tip permanently. You can cut for three to five minutes, continuous cutting, and nothing wipes off that carbonization. From the beginning where you touch the tissue, it’s a different animal.

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You mentioned that the Epic Pro allows clinicians to control the heat, too. How does that work?

Dr. Magid: When the Epic Pro is on either what’s called APC mode-automatic power control-or the Super Pulse mode, I set the temperature I want. The laser then varies the energy to the tip based on maintaining that temperature. When I’m cutting in thick tissue and it takes more energy, the laser reads that instant feedback from the tip, varies the energy to the tip and maintains that temperature. If I then go into some thin tissue, the laser reads it instantly and then lowers the power automatically.

Dr. Low: That’s why the cut is so clean. The tip is staying at the exact same temperature as it moves through the tissue. With a normal diode, naturally it either cools or overheats, thus a significant decrease in effectiveness.

Do you have any specific treatment examples to share?

Dr. Magid: Sure. Doing a frenectomy with a standard diode laser, especially if it’s a thick frenum, is tedious. Dentists wind up cutting the soft tissue and using the glass tip of their laser to pluck the fibrous tissue in the frenum because the lasers are not capable of maintaining the temperature to cut it. With the Epic Pro, you cut.

The standard for cutting soft tissue has always been a CO2 laser, a very aggressive laser. The CO2 is a non-contact laser and more difficult to control. The Epic Pro being a contact laser cuts as aggressively as the CO2 when you want it to, but with a contact means. You can use a standard diode laser to cut fibrous tissue like an operculectomy where it’s very fibrous tissue or uncovering a buried tooth, but boy, it’s just hard, tedious and essentially more damaging that it should be. With the Epic Pro, it’s just like the CO2, but it’s safe on the tooth.

Also, when you uncover an implant with the standard diode laser, you can put an enormous, damaging amount of heat into the tissue surrounding that implant. That can contribute to loss of tissue around the implant and expose the neck of the implant, which is unhygienic and can be damaging to the surface of the implant. The Epic Pro can uncover an implant without putting the kind of heat into the peri-implant tissue that would cause damage.

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How does the Epic Pro benefit the patient experience?  

Dr. Low: All the clinical research associated with BIOLASE now has patient-related outcomes as part of the measure to determine effectiveness. Our clinical observations demonstrate that patients heal exceptionally well. Because of the tip temperature being so consistent and the cut being so clean and the decreased time that you’re with the patient performing the procedure, my experience is that patients have no wound healing complications.

Dr. Magid: It’s much more comfortable for patients. I can do a soft tissue procedure without anesthetic. If I’m doing a laser trough and I’m going around the palliative side, it is not anesthetized because a palliative injection can be painful. I can do it with the Epic Pro. I’m controlling the heat and it’s much more comfortable than the uncontrolled heat of a standard diode laser. If I’m doing a thin frenulum, I would need a topical anesthetic because I’m using it with the control that the Epic Pro provides.

Are there any benefits to the practice that you’re aware of once people start using the Epic Pro?

Dr. Magid: You can do things that you couldn’t do otherwise or not as easily, like biopsies, operculectomies, frenectomies, all the things for which one should use a laser. For the person just getting into it, there are tremendous benefits to the practice, in using it for troughing and CAD/CAM. In implant uncovering with the Epic Pro, your results are so much better. So, as far as controlling your cases, getting the crown back without tissue tagging, uncovering the implant, and taking the impression and the scan at the same time, the Epic Pro gives the practice the ability to control the patient experience and the resulting restorative dentistry.

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Dr. Low: The other thing is when you have a faulty tip, you don’t know it except with an observable loss of cutting efficiency. The Epic Pro can determine the effectiveness of the tip and then put an icon on the screen immediately that says ‘change the tip.’ Everything with this laser is not only just allowing the clinician to be more effective, but also creating a better tissue response for the patient, which is why we perform these procedures.

What advice would you have for a clinician considering getting into lasers?

Dr. Magid: The first thing I would say is don’t buy the cheapest product. That’s short-term thinking. The cheaper products will cost you more in the long run because they’re not going to do what you want. The second thing is get educated. Make sure that the laser that you buy provides either online education or training by some means so that you know what you’re doing with the laser.

Dr. Low: The first consideration is to determine what laser procedures are desirable in your respective practice after reviewing all the potential indications of a dental laser. Then match a particular laser to your particular indications. And seek as much objective information as possible into the effective utilization of today’s dental lasers. An excellent resource is the Academy of Laser Dentistry.

Dr. Magid: The Epic Pro is going to cost more than other lasers. You can buy a standard laser cheaper. The problem is that once you get it, you will spend the rest of the time compensating for the deficiencies of the device. The easier it is to use, the less you must compensate for the deficiencies in the device, and the more likely you are to use it. A dentist who wants a laser would be much better served starting out with one that’s extremely simple to use. You just pick the procedure and go ahead and the device does all the work.