Our case of the month is one which involves our amazing Waterlase i Plus laser. This laser has a multitude of benefits and one of those is removing composite restorations and tooth decay without having to use a drill. For some patients, the dental drill is a dreaded object which fills them with dread and fear. For others, there may a medical issue at hand such as tinnitus which may be made worse by the vibrations of the drill. In these cases, the Waterlase i Plus laser could be the answer.
 

Article written by Beata Knysak for dentists, dental hygienists and therapists.

Periodontal disease is a major public health concern due to its high prevalence. According to the data severe periodontitis is the sixth-most prevalent condition in the world [1]. In the United Kingdom, 62% of adults under 40 years of age are affected by moderate periodontal disease [2] and throughout the Covid-19 pandemic we have seen an immense increase in the number of patients with periodontal tissue breakdown and tooth loss.

While there is an increase in life expectancy and a significant decrease in tooth loss, periodontal disease puts a burden on the national healthcare systems across the globe.

Although bacteria arising from plaque is the main aetiological factor of periodontal disease, the host’s immune inflammatory response is accountable for the majority of the destructive changes seen in periodontal tissues. Even in healthy periodontium, host immune cells are continuously present, supporting the balance between microbial plaque and the host [6]. Any interactions between the host and oral microbiota will either support the homeostasis or results in dysbiosis within the community of pathogenic microorganisms [7].

Periodontal health-associated commensals are vital in protecting this equilibrium by for example inhibiting the growth of periopathogenic microorganisms. However, quantitative and qualitative changes within subgingival plaque biofilm may lead to disturbed homeostasis, which subsequently leads to the onset of the periodontal disease with various degrees of periodontal tissue breakdown.

This is not a continuous process but alternates between a period of inactivity and aggravation and it can be affected by local and systemic factors [3&4]:

• Microbial plaque-biofilm burden
• Patient’s age, ethnicity, genetic predisposition and patient’s immune response
• Systemic diseases i.e., Diabetes Mellitus, Osteoporosis
• Tooth morphological factor: i.e., defective restoration, malocclusion, bulbous crowns and dental bridge that unbales the patient to perform an adequate oral hygiene routine
• Patient’s socio-economic factors i.e., education and access to dental care
• Life-style choices i.e., smoking, obesity, poor diet, stress, sleeping pattern,
• Deficiencies in patient’s oral hygiene routine.

If not treated, periodontal disease leads to connective tissue destruction and alveolar bone resorption that eventually results in tooth loss [5]. It negatively affects patient’s chewing function and aesthetics, it is a source of social inequality, and significantly impairs their quality of life.

The main objectives of non-surgical periodontal therapy (NSPT) are to provide the least invasive treatment that gives the patient the best and most predictable outcomes through the promotion of periodontal tissue regeneration and restoration of tooth function. After successful treatment, periodontal ligament (PDL) cells (fibroblasts) migrate and attach to the microorganism free root surface. They proliferate, differentiate and synthesise extracellular matrix proteins to form collagen fibres. It is crucial to obtain newly formed PDL to prevent apical migration of junctional epithelium and to allow regeneration of PDL, cementum and alveolar bone; therefore, the application of laser irradiation has been proposed to allow for the compatibility of root surfaces with regenerative processes.

An increasing number of studies have demonstrated the benefits of adjunctive laser therapy in conventional NSPT due to its reported ability to significantly reduce pathogens, promote healing and to suppress the inflammatory cytokine cascade through to surgical ablation of diseased tissues [8]. As a result of its deeper penetration, diode laser has not only had bactericidal effects but also bio-stimulatory effects on periodontal ligament stem cells, osteoblasts and fibroblasts [9]. The Erbium Chromium: Yttrium Scandium Gallium Garnet (Er,Cr:YSGG) laser, however, allows selective subgingival biofilm and calculus ablation without causing any thermal side effects (carbonisation) or morphologic changes to the root surface to allow the attachment of these cells [10]. Also, when compared with conventional hand instrumentation, Er,Cr:YSGG laser therapy was not only found to promote PDL fibroblast cell migration and attachment, but it also increased the number of cells that differentiate in periodontal regeneration [11,12,13].

Although in the treatment of periodontal disease, surgical interventions (with the use of osseous graft material, barrier membranes or application of a biologically active material) deem to have more predictable outcomes than conventional NSPT, they may however, possess multiple shortfalls including high cost, painful healing and post-operative complications. Also, with regard to the application of local or systemic antibiotic there are multiple side-effects including antibiotic resistance, gastrointestinal complications or drug interactions.
 

Our case of the month for July 2021 is quite a complex one involving multiple ceramic crowns after an accident during the first lockdown. Our patient, Xavier, had a cycling accident where he cracked 3 of his front teeth. Now with any trauma case, there is a certain way to handle the situation and it is important not to rush into a specific treatment. The reason being is that once the teeth and gums have been damaged, the consequences may not be apparent for several weeks or months. Hence the use of provisional materials such as composite and temporary crowns are vital during this healing phase.

Periodontal or gum health is paramount also and we needed to spend some time stabilising the gum health with conventional and laser treatments. Beata Kynsak did a wonderful job using Waterlase i Plus and the Epic 10 diode laser with a complete transformation from inflamed , swollen gums to a pink, firm attached gum line. Laser dentistry, although not new, is still a rarity across our profession but we are firm believers in the technology and have many years of experience highlighting great results. 

Once the gums were stable, provisional crowns were made using a diagnostic wax up. This is where our laboratory, Ceramic Studios, re create the teeth using digital means to provide us with a prototype of the final teeth. We can use this guide to define our preparations of the teeth, make the temporary teeth and allow our patients to see what the final crowns can look like. Our temporary crown material of choice is Luxatemp; the gold standard. 

After some time in the temporary crowns, we were ready to proceed with the final crowns which were E Max all ceramic crowns, again the gold standard when it comes to aesthetics. There is no better. Ceramic Studios did a great job and just take a look at the before and after results:
 

Fibroepithelial polyps are commonly seen in the mouth on the lip, cheek, gum line and tongue. There are a small mass of tissue that usually form in response to trauma such as lip biting or cheek chewing. Although, in the main, polyps are pain free and benign, they can be irritating especially if you keep catching them whilst eating which could cause ulcers or inflammation. Here is a common appearance of a fibroepithelial polyp on the lip:
 

Our case of the month for May 2017 involves treatment of tooth decay using our incredible Waterlase i Plus laser. This highly sophisticated technology allows us to treat tooth decay without having to drill the tooth and without any anaesthetic in most cases. Just think; dentistry without drilling and without needles! Just take a look at our case:
 

We love our Waterlase i Plus laser. Why? Well, it makes treatment that was difficult, painful, time consuming and costly into an everyday event. A prime example of this is surgical crown lengthening. What is this? Well, if you have broken a tooth and there is not enough tooth left to place a crown, you will need surgical crown lengthening. In the old days, this involved a scapel, stitches, bleeding, pain and a long time to wait before the next step. No longer. Using the Waterlase i Plus, we can perform the surgical crown lengthening at the time of preparing the crown for the tooth. The laser sterilises at the time of application, reduces bleeding, swelling encourages regeneration and has amazing healing capacities. No stitches, minimal pain and no time delay. Just take a look at a recent case:
 

We have invested in the very latest laser dentistry at Progressive Dentistry- the Waterlase i Plus 2.0 and the Epic 10. Both have different wavelengths and hence complement each other or can be used as stand alone lasers. We think that both lasers are magic! Having now used lasers within dentistry for over five years, these two lasers are certainly the most sophisticated and advanced we have seen. 

One application of the Epic 10 is low level laser therapy LLLT. The aim of this is to aid healing, pain relief and regeneration. We have successfully used LLLT to treat incredibly painful jaw problems, ulcers, cold cores, post surgical pain and non healing extraction sockets. This is just the tip of the iceberg. Future studies will provide exact protocols for specific treatments. LLLT can do no harm and hence it should be used in most aspects of dentistry.

Please contact us if you are interested in laser dentistry and low level laser therapy. It could change your life!