lasers and soft tissue treatments for the pediatric dental ...lasers and soft tissue treatments for...

Lawrence Kotlow

SCIENTIFIC ARTICLE

Lasers and Soft Tissue Treatmentsfor the Pediatric Dental PatientLawrence Kotlow, DDS

Lawrence Kotlow, DDS

Lawrence Kotlow graduated from SUNYBuffalo Dental School and did specialtytraining at the Children’s Hospital, Cincin-nati, OH. He is a board-certified pediatricdentist, practicing since 1974. He has re-ceived Advanced Proficiency certificationfrom the Academy of Laser Dentistry andis also a Recognized Standard ProficiencyCourse Provider by the Academy. He haswrittenmore than 30articles describing la-ser use in a pediatric practice, and lecturesnationally and internationally on the sub-ject. He can be contacted at [email protected], and his website is www.kiddsteeth.com

Historically, oral soft tissue surgery on infants and young children wascompleted in the operating room under a general anesthetic agent.Many children were referred to an oral surgeon and required a phy-

sician’s physical examination and medical clearance for a hospital admission.This potentially placed a child at risk during the use of a general anesthetic foran elective procedure, which may not have insurance benefits. Traditionalmethods of oral surgery using scalpels or electrosurgery may produce signif-icant postoperative discomfort and require sutures and prolonged healing.Lasers provide a simple and safe in-office alternative for children while atthe same time reducing the chances of infection, swelling, discomfort, andscaring.

In a pediatric practice, there area variety of surgical and restorative la-ser wavelengths, such as diode andthe Erbium family, and other photo-biostimulation or therapeutic laserswhich are effective at powers well be-low those of the surgical lasers.

PHOTOBIOSTIMULATION LASER

TREATMENTS

Laser treatments in this article areperformed with the Q1000 photo-biostimulation unit or the Accu-point laser. Photobiostimulation3

(also known as therapeutic lasertherapy and low level laser therapy)has had limited use in the UnitedStates in dental care. The 2 primarydiodes used for this therapy are theInGaAIP (indium/gallium/alumin-ium/phosphide; 660 nm, creatingenergy of 50 mW) and the GaAlAs(gallium, aluminium, arsenides;808 nm up to 500 mW).

Pulpal Analgesia

In selected patients, using the660-nm laser probe can achieve ad-equate pulpal analgesia4,5. Success-ful analgesia may allow a dentist touse a high speed drill to prepare

a class II restoration without theneed for any local anesthesia. Suc-cess in primary molars varies from50% to 75%. Success in bicuspidsvaries but is greater than that foundin permanent molars. Analgesia ef-fect may be effected by things suchas pigmentation of the patient’s gin-gival tissue, because the diode mayreact with the pigment in the tissuerather than be absorbed by thepulpal tissue. Treatment consists ofplacing the laser probe on the occlu-sal surface of a primary molar for1 to 2 minutes. In permanent teeth,placing the probe for 1 minute nextto gingival tissue over the roots ofthe treated tooth also contributesto successful analgesia. Using the808-nm probe may achieve highersuccess in permanent teeth. Figures1 through 4 show the laser placedon permanent and primary teeth;shortly thereafter, the carious lesioncan be treated (Figure 5).

Maintaining Pulpal Vitality After

Trauma

In young patients where an ante-rior primary central or lateral incisor

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mailto:[email protected]

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http://www.kiddsteeth.com

Figure 4. Placing the 66nm probe ona primary molar to achieve laser analge-sia.

Figure 1. Placing the laser tip on thebuccal surface of a lower bicuspid for 1minute to achieve laser analgesia usingthe 660 nm photobiostimulating laser.

LASERS AND SOFT TISSUE TREATMENTS FOR THE PEDIATRIC DENTAL PATIENT

has received a traumatic injury, plac-ing the 808-nm probe over the rootmay prevent the tooth from devital-izing. Trauma to a primary anterior

Figure 2. Placing the laser tip on the lin-gual surface of the lower bicuspid.

Figure 3. Placing the laser tip on the oc-clusal surface of a lower bicuspid.

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tooth may compromise the tooth’svitality and result in requiring eithera pulpotomy or extraction in a 4- to6-week period. A tooth or teeth

Figure 5. Using a high-speed hand pieceon a tooth having laser analgesia.

Figure 6. Traumatically displaced lower ante

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which have been significantly dis-placed may respond positively iftreatment is begun within a fewhours of trauma. Treatment consistsof placing the laser over the injuredtooth for a period of 1 minute on thefacial root area and 1 minute on thelingual or palatal root area. Anteriorpermanent teeth which have beendisplaced or traumatized may alsobe treated successfully with similarparameters. An additional treatmentin 24 to 36 hours may improve thechance of successfully healing thetooth. Figure 6 shows a partiallyavulsed primary anterior tooth,and laser therapy was used. Figure 7is 3 days posttreatment, and Figure 8is 9 months posttreatment.

Healing of Soft Tissue Trauma

Patients who fall and receive faciallacerations6,7,14 and swelling benefitfrom placing the laser/light-emittingdiode (LED) unit over the area forapproximately 3 minutes and plac-ing the 660- or 808-nm probe overthe most injured area for 1 to 2 min-utes, helping to heal the lesionsmore quickly and with less post-trauma discomfort. Additional treat-ment 24 to 36 hours later may beneeded to reduce the discomfortand improve healing. Figure 9

rior primary teeth.

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Figure 7. Three days after laser treat-ment using the 808 nm laser probe.

Figure 10. Two and a half days after trauma and use of a 660 nm probe and cluster ofdiodes and LCDs.


depicts a traumatic injury in whichthe child fell and hit the upper teethand soft tissue. The treatment con-sisted of removing the teeth and su-turing the gingival tissue (Figure 10)and a 660-nm laser was then used.Six days later, the tissue is healingwell (Figure 11).

Figure 8. Nine months after treatmentof lower anterior teeth, the teeth remainvital.

Figure 9. Facial trauma to child aftertreatment of wound and suturing to-gether soft tissue.

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Controlling Gag Reflex

During the taking of intraoralradiographs or during an intraoralexamination, some patients may gagand in extreme cases vomit. Using

Figure 11. Six days post laser treatment.

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the 3 J to 4 J of energy with the660-nm probe placed over the P-6acupuncture point on each wristmay prevent the gag8,9 from occur-ring. This point is located

Omegan � Volume 101 � Number 3

Figure 12. Location and placement of660nm probe on the p6 acupuncturepoint on the wrist to prevent gagging.


approximately 1 inch above thewrist crease. The probe is placedon each wrist for 1 to 2 minutes(Figure 12).

Treatment of Herpetic Type Lesions

One of the most painful and de-bilitating intraoral lesions a childcan develop is primary herpes10,11

or a similar herpetic-like stomatitis.

Figure 13. Placement of laser cluster on patiorally.


Placing the laser/LED unit in mode3 for 3 minutes and the 880-nmprobe for 1 minute over large lesionsreduces the discomfort and reducesthe disease outbreak period in manychildren (Figure 13). More than onetreatment over a 24- to 48-hour pe-riod may be needed to treat the le-sions. Figure 14 shows that thechild is pain free 48 hours afterthis laser therapy.

Orthodontic and

Temporomandibular Joint

Discomfort

Patients having orthodontic ad-justments or having temporoman-dibular joint discomfort mayexperience relief using the laser/LED unit12,13 over the area for 3minutes using mode 3. More than1 treatment over a 24- to 48-hourperiod may be needed to reducethe discomfort.

Pretreatment of Surgical Sites

Pretreating a surgical site may re-duce postoperative hemorrhageand discomfort. Treatment involvesplacing the 660-nm laser over thesurgical area for 1 minute before las-ing the soft tissue.

ent diagnosed with primary herpes intra

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PHOTOTHERMAL LASER

TREATMENTS (ERBIUM:YAG,

ERBIUM:CR; YSGG, AND DIODE)

Treatment of soft tissue proce-dures27 are completed using theVersaWave Erbium:YAG laser (2940nm) or the Power Lase AT Spa Er:YAG laser (distributed by Lares Re-search Chico, CA), or the Diodent(810 nm) diode laser (both fromHoya Dental Lasers, Fremont, CA),but are equally able to be completedby the other manufacturers of laserswithin diode and the Erbium familyof lasers. The Erbium:YAG and Er-bium:Cr; YSGG at 2780 nm are use-ful in treating most soft tissuelesions where absolute hemostasisin not required. Diodes in the 810-to 980-nm range are excellent lasersfor treatment where hemostasis is anabsolute necessity. There is one ma-jor difference in these 2 groups ofwavelengths: first, the Erbium fam-ily of lasers is relatively shallow inlaser energy penetration; therefore,what you see is exactly what youare doing. Second, when using adiode, the result of treatment mayinitially be unobserved because ofdeeper penetration of the laserenergy. This may result in more col-lateral damage and more postopera-tive discomfort. For all soft tissuetreatments, it is very important toremember that when using theErbium laser you can observe the di-rect effect of the laser on the tissue;however, when using the diode,the tissue must heat up first andthe laser penetrates deeper into thetissue. If you increase the laser en-ergy to increase the speed of thetreatment, more collateral damageand postoperative discomfort mayresult.

Lingual Frenum Revisions

Revision of an abnormal lingualfrenum attachment is one of the

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Figure 14. Forty-eight hours post treatment without pain or discomfort.

Figure 17. Class III classification of lin-gual frenum 4-8mm.


most undertreated developmentalanomalies of the oral cavity.15–

18,22,24,26 A short lingual frenummay result in newborns failing tobe able adequately nurse and result

Figure 16. Class II classification of lin-gual frenum 8-12 mm.

Figure 15. Class 1 classification of lin-gual frenum 12-16 mm.

Figure 18. Class IV classification of lin-gual frenum 0-4 mm.

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in failure to thrive. Mothers attempt-ing to nurse may find nursing toopainful and difficult to continue.Gagging may occur when infantsare beginning to eat solid foods be-cause of the inability of the re-stricted tongue to clear food fromthe palate. A short frenum mayalso contribute to speech or peri-odontal problems as children ma-ture. Traditional methods ofcorrecting this anomaly consist ofusing scalpels or electrosurgeryand often result in extended periodsof patient discomfort and usually re-quire suturing of the surgical site. Adiode laser or the Erbium family oflasers significantly reduces postop-erative discomfort, and suturesmay not be required in some cases,especially in infants and toddlers.

In order to assist in the diagnosisand treatment of the frenum, I cre-ated a classification system basedon the distance from the tip of thetongue and the insertion of the fre-num to the base of the tongue. Nor-mal frenum attachment wasdetermined to be more than 16mm of distance from the tip of thetongue to the insertion of the fre-num.19,20 The classification is as fol-

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lows: class I, 12 to 16 mm(Figure 15); class II, 8 to 12 mm(Figure 16); class III, 4 to 8 mm(Figure 17), and class IV 0 to 4mm (Figure 18). When the frenuminsertion is less than 8 mm, I willusually recommend that the frenumbe revised. Whether the patient isa few days old or in his or her teens,the revision of the lingual frenum isa simple procedure easily completedusing lasers.

Revision consists of initially plac-ing a topical anesthetic on the tissue.The frenum is then stretched usingan instrument known as a groovedtongue positioner (Miltex, York,PA; Figure 19). When the frenumtissue is primarily a thin fibrous at-tachment, no local anesthesia is nor-mally required. Place the laser 2 to 3mm away from the tissue and allow


Figure 19. Grooved tongue positioneravailable through Miltex.

Figure 21. Er:YAG laser treating class IVlingual frenum attachment.

Figure 23. Er:YAG laser treating an ab-normal lingual frenum attachment witha local anesthetic and being held usinga hemostat to control tongue move-ment.


the laser energy to ablate the frenum(Figure 20). If the tissue is thick andfibrous, the use of local anesthesiamay be required, and it may be nec-essary to place a single gut suture atthe end of the lased area to preventfrenum reattachment. The recom-mended settings for an Er:YAG laserfor a new or inexperienced user are30 Hz and 55 mJ. As the dentist ac-quires more experience, the hertzcan be increased to 45 Hz and 55mJ. No water is required for thistreatment. Figure 21 shows a preop-erative view of complete anklyoglos-

Figure 20. Er:YAG laser treating an ab-normal lingual frenum attachment with-out a local anesthetic.


sia; Figure 22 shows the immediatepostoperative successful revision.

When the frenum is dense ormuscular, after the tissue is anesthe-tized, grasp the frenum using a he-mostat (Figure 23). The hemostatis placed as close to the base of thetongue as possible. The laser is

Figure 22. Er:YAG laser treatment im-mediately after using the laser.

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used on the exposed side of the he-mostat using the chisel tip, not onthe surface of the hemostat touchingthe tongue. It is prudent to stayaway from the floor of the mouthand avoid any treatment lingual tothe lower incisors. The proceduretakes approximately 15 to 30 sec-onds to complete (Figure 24). A su-ture can be placed to preventreattachment (Figure 25). Postoper-ative care involves the use of overthe counter pain medications if dis-comfort occurs. To prevent reattach-ment, the parent is instructed tohave the child exercise the tongueand to stretch the area daily. Follow-up observations are scheduled in6 to 7 days. Figure 26 is a 6-daypostoperative view.

When using the diode 810-nm la-ser, the laser tip is first initiated us-ing a piece of articulating paper to

Figure 24. Er:YAG laser treatment im-mediately after frenum revision.

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Figure 25. Placing suture to prevent fre-num reattachment.

Figure 27. Class IV maxillary frenum oninfant.


prevent it from becoming a hot tip,which would heat the tissue abovethe desired temperature. Unlikethe Erbium laser, the diode tip isused in direct contact with tissue ata power of 1.0W CW using a 400u fiber. The procedure usually takesmore time and requires the use ofa local anesthetic.

Maxillary Frenectomy Revisions

Many oral conditions can be inter-cepted or prevented by examiningchildren by 1 year of age or approx-imately 6 months after the first teetherupting to the oral cavity.21,23 Dur-ing an examination, it may appearthat there is an extension of the max-illary frenum into the palatal area orinserting into the interproximal areabetween the upper central incisors.This degree of frenum attachmentmay contribute to nursing difficul-ties, mother discomfort duringnursing, the development of facialcaries on the upper anterior teeth,

Figure 26. Patient six days after surgicalrevision.

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bleeding gingival tissue betweenthe incisors, preventing healing oftrauma to the frenum area, andcausing a diastema to form betweenthe 2 central incisors. Interceptingor preventing these problems asso-ciated with the abnormal placementof frenum may require revision ofthis abnormal attachment at an earlyage.

Treatment in infants and in theprimary dentition involves placinga topical anesthetic over the area,and then lasing the area to get thedesired detachment and reposition-ing of the frenum. Figure 27 showsan abnormal frenum, lasing is be-ginning in Figure 28, and Figure 29is the immediate postoperative view.The recommended settings whenusing the Erbium laser are 30 to 45Hz and 55 mJ and the chisel tip. Wa-ter is not required unless the processincludes cutting away interproximalbone. In permanent dentition, ifbone removal is required interprox-

Figure 28. Frenum being revised usingEr:YAG with local anesthetic.

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imally, water should be turned onwhen lasing the bone. Settings re-main the same. Bleeding is usuallycontrolled; however, occasionallya small area in this highly vasculararea continues to seep blood.When this occurs, pressure for 1 to2 minutes usually resolves the prob-lem. If bleeding remains uncon-trolled, placing a small moistteabag over the area for 2 minuteswill create good hemostasis.

The diode laser will usually pre-vent any bleeding, because it is a bet-ter laser for hemostasis. When usinga diode, the settings are 1.0W, CWusing a 400 u fiber. Healing usingthe diode usually takes longer withthe potential of more post perativediscomfort than when using theErbium laser. More care is requiredto prevent photothermal collateraldamage of adjacent tissue.

When the frenum is not correctedin children before 3 years of age, thenext best time to revise the frenumoccurs when the maxillary perma-nent central incisors begin to erupt.Revising the frenum when a largegap appears or when the central in-cisors appear to be erupting distallycan prevent diastema formation orperiodontal problems in the frenumarea. A diastema as wide as 4 to 5mm may close without orthodonticintervention. No scar tissue hasbeen observed interproximallywhen the frenum is revised. The fre-num should be revised before thebeginning of any orthodontic care.

Biopsies

Fibrotic lesions, gingival growths,mucoceles, and other nonheman-gioma type lesions can be quicklyand safely removed using the Er-bium laser. Lesions usually requirea local anesthetic, but in some in-stances, a topical anesthetic may beadequate. Each child and lesion


Figure 29. Area immediately after lasing.


must be treated on its own charac-teristics. Erbium settings rangefrom 15 to 45 Hz and 55 mJ eitherwith or without water. Tips may in-clude the chisel tip or any one of thehard tissue tips. Diode settings using

Figure 30. Mucocele requiring removal.

Figure 31. Removal of lesion using Er:-YAG laser.


the 400 u fiber are 1.0 to 1.5W CW.The diode is especially useful if thelesion contains a vascular area

Figure 32. Surgical site immediately af-ter lesion removal.

Figure 33. Surgical site one week post surge

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which could result in posttreatmenthemorrhaging. Fibrotic lesions orlesions which do not contain anypigment may be more effectively re-moved using the Erbium laser. Thisis because of the target tissue charac-teristics of Erbium and diode lasers.Figure 30 shows a preoperative viewof a mucocele, which is excised byfirst outlining the lesion with the Er-bium laser (Figure 31) The immedi-ate postoperative view showscomplete removal (Figure 32) andhealing is progressing at 1 week(Figure 33).

Herpes Labialis and Recurrent

Aphthous Ulcers

Two of the most debilitating orallesions children may experienceare recurrent herpes labialis or aph-thous ulcers. The Er:YAG or the Di-ode laser can bring instant relieve tothe aphthous ulcer lesion and oftenabort or shorten the duration ofthe herpes labialis lesion. Treatmentof the aphthous ulcer using the Er:YAG laser involves settings of 15 Hzand 35 mJ in a noncontact mode.Extend the treatment area about1 mm beyond the lesion’s boundaries.Water is not required. Place the lasertip above the lesion until small white

ry healing.

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Figure 34. Child with Herpes Labialis. Figure 36. Forty-eight hours after lasertreatment.

Figure 38. Removal of hyperplastic tis-sue using Er:YAG laser without a localanesthetic.


areas are seen on the tissue. Allowthe laser to remain over the lesionfor 15 seconds, moving the tip ina circular area over the entire lesion.Repeat the process 2 to 3 times untilthe child indicates that the lesion nolonger feels uncomfortable. Large le-sions may need a second treatmentin 24 hours.

Herpes labialis is treated similarly;however, the tip should slowly bepassed over the entire portion ofthe lip that is affected just short ofobserving the white change in tissuecolor. This usually involves treatingthe entire half of the lip involved.The process takes 1 to 2 minutes.The diode settings are 0.500 mw,400 u fiber for approximately 1 min-ute for aphthous ulcers and 2 min-utes for herpes labialis lesions. Thediode fiber does not need to be initi-ated and is kept defocused 2 to 3mm above the lesion. Because ofthe photothermal reaction of the di-ode, there will be no visual indica-

Figure 35. Lasing the area using diodelaser.

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tion that the lesion is being treated.The nature of the diode laser allowsfor deeper penetration of the laserenergy and may be more effectivethan the Er:YAG laser when treatingherpes labialis lesions. No local an-esthesia is required for either laserduring treatment. Figure 34 showsthe lesion, and the 810-nm diodeis used for treatment in Figure 35.Forty-eight hours later, the patientis comfortable, and the lesion is re-solving (Figure 36).

Pulpotomies

Lasers eliminate placing chemicals(such as pulpotomies formocresol)into the tooth chamber to completethe pulpotomy. The Erbium laser isthe laser of choice for this treatment.Treatment consists placing the lasertip into the coronal portion of thetooth at settings of 30 HZ, 55 mJwith water or without water for ap-proximately 15 seconds or until ade-quate hemostasis is achieved, this

Figure 37. Cleft palate patient requiringremoval of soft tissue followed by cariesremoval and tooth restoration.

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may require 2 to 3 treatment inter-vals. The pulpotomy is completedby placing zinc oxide and eugenol(ZOE b & T cement) into the cham-ber. In teeth where the dentist antic-ipates that a pulpotomy is needed,local anesthesia is recommended;however, there are instances whentreating a tooth—when the nerve isexposed unexpectedly during cariesremoval—that a local anesthesiamay not be required. This is becauseof the analgesic effect of using thelaser on the tooth.

Gingival Recontouring

Children undergoing orthodontictreatment or taking medicationssuch as Dilantin (Pfizer US, NewYork, NY) may develop gingival hy-perplasia. This may be a contribut-ing cause for facial or buccal dentalcaries formation or enamel decalcifi-cation within the deep gingivalpocket. This overgrowth of tissuecan be reshaped or removed using

Figure 39. One week post treatmenthealing.


Figure 40. Exposure of permanent toothunder soft tissue using Er:YAG laserwithout local anesthetic.

Figure 42. Immediate post surgeryready for band placement.

Figure 44. Immediately after surgerywithout any medical intervention forbleeding.


either the Erbium or diode laser.Post-orthodontic treatment may re-sult in the desire to improve aes-thetics by exposing more availabletooth enamel to eliminate the shorttooth appearance of anterior teeth.This gingival recontouring is pain-less in most instances. Using eitherthe Erbium or the diode laser, thetissue can often be reshaped withoutthe need for local anesthesia. TheErbium laser settings are 30 to 45Hz and 55 mJ. No water is usuallyneeded. Using a 400 u initiated fi-ber, a diode laser would be used at1 to 1.5W CW, depending on thedensity and amount of pigment inthe tissue. In some patients, a localanesthetic may be required. The Er-bium laser was used for the follow-ing excision: Figure 37 shows thepreoperative excessive tissue; the la-ser excision is shown in Figure 38;and the 1-week postoperative viewdepicts good healing (Figure 39).

Figure 41. Lasing and exposing tooth.


Removal of Soft Tissue

To expose permanent teeth underjust gingival tissue or in pericoronaldiscomfort over erupting molars, ei-ther laser can be used with settingssimilar to those used in gingival re-contouring. Care must always betaken when using the Erbium laserto stay parallel to the tooth’s surfaceto prevent enamel etching, and us-ing the diode may require using lo-cal anesthesia. Figure 40 shows theErbium laser in position, andFigure 41 shows layer by layer tissueremoval. The completed exposure ofthe cuspid is shown in Figure 42.

Surgical Treatment of Patients with

Bleeding Disorders

Patients who have bleeding disor-ders where hemostasis is a vital re-quirement for soft tissue surgeryshould be treated primarily usingthe diode laser. Those wavelengthstarget blood and pigment to provideexcellent hemostasis, whereas theErbium laser is not always success-

Figure 43. Maxillary frenectomy on pa-tient with von Willibrauns disease usingdiode laser.

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ful in controlling bleeding. Patientswith hemophilia or von Wille-brand’s diseases can often be treatedwithout medical intervention. Thissaves the patient from complicationsand the cost of medications to con-trol bleeding. Patients on bloodthinners for reasons such as organtransplants or cardiac valve replace-ments can also be effectively treatedwith the diode and not have to havetheir blood thinner medications al-tered. Figure 43 shows the diode la-ser beginning to incise the frenum ofa patient with von Willebrand’s dis-ease, and Figures 44 and 45 showthe excellent hemostasis immedi-ately following the laser surgery.

Venous Lake Lesions

A venous lake or pool often ap-pears at the site of an injury to thelower lip. A venous lake or poolpresents as a bluish soft, discrete,painless nodule beneath the epithe-lium of the lower lip. Although it isusually seen after 40 years of age,this case shown is an 8-year-old

Figure 45. One week healing of surgicalsite.

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Figure 46. Venous lake lesion on lowerlip. Figure 49. One week post surgery lesion

not longer present.


patient (Figure 46). The source of le-sion is a feeder vessel that has ex-tended an appendage into theepithelium of the lip. The diodecan ablate and seal the extension ofthe feeder vessel without damagingthe lip, collateral damage, or scar-ring at the area of the lesion. Topicalanesthetic was placed, and the 810-

Figure 47. Lasing of the lesion using theDiode.

Figure 48. Immediately after surgery.

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nm diode with a 400 u noninitiatedfiber at 0.6W CW was used for 60seconds (Figure 47) and then outof contact for an additional 30 sec-onds. The immediate postoperativeresult is shown in Figure 48, andcomplete healing is shown in Fig-ure 49.

DISCUSSION

The settings suggested above havebeen developed after years of suc-cessful laser treatments, and areboth a safe and effective and a con-tinuously evolving part of lasercare. Other wavelengths, such asNd:YAG and carbon dioxide, mayalso be used. Lasers are an excitingnew technology which provides pe-diatric patients with optimal carewithout many of the ‘‘fear factors’’found in conventional dental care.

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