This alternative to the periodontist’s scalpel puts orthodontic treatment fully in control of the orthodontist while creating clinical and practice efficiencies and a better patient experience

How often do you refer patients to the local periodontist for canine exposures or TAD placement? Have you thought about incorporating a soft tissue laser to take care of these procedures in-house? For that matter, have you thought about how soft tissue lasers can be a practice differentiator? 

When Robert Miller, DMD, introduced soft tissue lasers into his Culpeper, Va, practice almost 20 years ago, he was filling a void in his community, as no periodontists had offices locally. Rather than refer patients to specialists more than an hour’s drive away for basic procedures he knew his orthodontic training made him more than qualified to handle in-house, he embraced the modality. Orthodontic Products recently spoke to Miller about how he is using soft tissue lasers in his practice today and how this alternative to the periodontist’s scalpel is creating clinical and practice efficiencies. 

Orthodontic Products: How are you using soft tissue lasers in your practice? 

Robert Miller, DMD: There are five procedures we primarily use soft tissue lasers for: canine exposures, TAD placement, gingival recontouring, soft tissue frenectomy (Figure 1), and photobiomodulation for rapid healing of aphthous ulcers. We use it most for canine exposures. At that point, we’re ready to put on the bracket but the soft tissue is still halfway over; basically, we can see them or they’re just starting to erupt. In those cases, we have two options: reschedule the patient or take the laser out, apply a topical anesthetic gel, and expose the tooth ourselves. It takes about 2 or 3 extra minutes and we can put the bracket on where it’s supposed to go (Figure 2). When you bond a tooth, you want to be able to put the bracket on in the accurate position, but if the soft tissue is in the way, you can’t; you will have to re-position at some point. That really doesn’t make sense. It makes more sense to gain the access and put the bracket on where it’s supposed to go at the beginning and save treatment time. This also applies when repositioning brackets in the presence of hypertrophied tissue (Figure 3)

For TAD placement, we always use the laser for pilot hole access. I like that the laser cauterizes as it opens up the tissue—so you don’t have the bleeding, inflammation, and slower healing that you have with a tissue punch. The other thing is, if an oral surgeon places a TAD and it comes loose, the oral surgeon is going to wonder if it was in the wrong location or did the orthodontist put too much force on it. Whereas if an orthodontist puts it in and it comes loose, the orthodontist can just find another location, sterilize the TAD, and put the same one back in. It’s easy for me to make that call. I’m of the opinion that if an orthodontist is placing their own TADs, they should be using a laser. 

And then for gingival recontouring, we’re using the laser to produce ideal micro aesthetics and proper tooth proportion in relation to the soft tissue. With gingival recontouring and aesthetics, you have to be careful because we don’t want to over promise and under deliver. I try to do the opposite: under promise and over deliver. But after 35 years in orthodontics, I also try to weed out those patients that may suffer from some form of body image dysmorphia. They will have higher expectations than I can deliver. I either try to steer them away or I won’t mention it if I think they may fall into that category. There has to be a balance there. 

With soft tissue frenectomy, it’s mostly maxillary. Occasionally, we’ll do a lower lingual frenectomy, but I’m cautious with those. There has to be a compelling reason and a set of criteria. And then for abscess ulcers, we use the cold laser to help promote rapid healing. With cold laser therapy, you’re selecting a wavelength, typically an 810 wavelength, that penetrates deeper and can get into the tissue. The laser takes the damaged cells and activates the mitochondria to produce more adenosine triphosphate (ATP) so they can heal more rapidly. When we treat abscess ulcers with cold laser therapy, we find that patients instantly feel better and heal twice as fast. 

OP: Do you charge for the use of soft tissue laser? 

Miller: For gingival recontouring and frenectomy, we do. Those are purely cosmetic and we have perio coding we use. We generally don’t charge for the canine exposures because we still send some of those out—the deep or high ones we will send to oral surgeons; but for the real superficial ones, we don’t charge. My thought is that we could charge, but we’re building value by being able to put that bracket on—we’re making the appointment more efficient, avoiding additional appointments, and saving the patient treatment time. To me, it’s kind of a wash. We’re benefiting more than the patient because of fewer visits and being more efficient. We also don’t charge for using cold laser therapy to treat abscess ulcers. We tell our patients who are susceptible to a lot of abscess ulcers to just stop by the office and any of our assistants can do that. To me, that’s just value added. Why should you seek treatment in our office? Because we’re going to take good care of you. Not all orthodontists do that. We have tried to charge for that, but insurance does not pay; so, we gave up and just said, you know, it’s a nice service for our patients and I don’t even have to be in the office. 

OP: Are there any additional benefits for the patient when it comes to lasers vs the periodontist’s scalpel? 

Miller: The periodontist in our area doesn’t like lasers for one simple reason: they’re too slow. They want to cut with a knife. Well, guess what, that causes bleeding. It causes inflammation, swelling, the need for stitches, and pain. To me, all of that is crazy. Yes, they can do it faster; but I would rather take the time to go slower, cauterize as I cut, promote rapid healing, and cause the patient less pain. And I would add this: An orthodontist who’s done 100 plus frenectomies with a laser, in my opinion, can probably do as good if not a better job than a periodontist using a scalpel in terms of the patient experience and the outcome. 

OP: What do you look for in a laser? 

Miller: We have three different types of lasers, but I don’t recommend you go out and buy three. I started with the Biolase diode laser, but today I have two Spectralase diode lasers and a Gemini dual wavelength diode laser from Ultradent. My preference is a corded device because a wireless/cordless is not going to be as robust. I do think the portable ones are probably more suited to orthodontics. However, while small pen or pencil type lasers are more portable, I find they just don’t cut as fast and don’t have the power. Plus, they require constant recalibration because they’re moved around so much. Lasers need to be calibrated and tested occasionally, as they are somewhat fragile. 

OP: What role does your staff play? 

Miller: They basically do everything except the cutting. They apply the topical gel, do the setup, initialize the tips, and do the suction. 

OP: How do you prep the patient?  

Miller: Our philosophy is, if we use a laser, we don’t want our patients to feel anything; and so we get them numb, and I don’t hesitate to do so. We start with a gel that we have compounded locally that is stronger than topical. It’s lidocaine, prilocaine, and tetracaine mixed in a cinnamon gel. It’s really important that the patient is monitored while it is on the tissue, because, if they swallow, it will make them sick. We have an assistant sit with them with the suction on and leave it on for about 15 minutes before I start. And then we test them. If they aren’t numb, I have a Madajet needle-less injector and use septocaine. If that doesn’t work, we don’t hesitate to pull the syringe out. You have to be prepared to get the patient numb. And for really anxious patients, I don’t hesitate to give them Valium—anything to make it as easy as possible for the patient. 

OP: What would you say to orthodontists who are on the fence about incorporating lasers into their clinical workflow? 

Miller: You have a percentage of orthodontists who will never place their own TADs; they’ll never do laser. It’s the whole blood and guts thing. They’ll say, “That’s why I went into ortho. I don’t want to be managing pain in my operatory.” But it’s really not a big deal. It’s not like you’re doing major surgery. And as for it being slower than using a scalpel or tissue punch, that’s true; but we’re talking about 20 seconds versus a minute and providing a better patient experience. 

If you think about it, we are the masters of enhancing smiles, of the cosmetic realm. Neither restorative dentists nor periodontists are as aesthetically orientated as an orthodontist. If your mindset is that I’ll never do laser, then I think it’s a missed opportunity. It’s not a big moneymaker, but it does helps us provide more efficient care. OP