16 Introducing Lasers into the Dental Practice

David M. Roshkind, DMD , Robert A. Convissar, DDS

Dental practitioners who incorporate lasers into their clinical treatment options must still follow the basic tenets of dental practice management, but with several unique additions to their routine procedures. Laser use in dentistry allows the practitioner to balance the science of lasers, the artistry of dentistry, and the business of practice management. Offices where lasers are incorporated into treatment options are considered “cutting edge” and have a unique psychological and promotional advantage over those that do not offer such services. Increased credibility is established as an up-to-date facility, where confidence is more easily attained, needs more readily turned into wants, and trust more easily established and turned into referrals.

Catone and Alling ¹ state that surgeons should possess at least a “fundamental understanding of qualitative laser physics and essential operation” of the lasers most useful in the clinical practice setting. Proper understanding of the science of lasers in dental practice is imperative in affording the clinician the knowledge and ability to deliver optimal treatment to patients. Many laser procedures are technique sensitive, and thus knowledge of the scientific basis of the treatment will enable the practitioner to improve and refine the techniques associated with the clinical practice and artistry of dentistry.

Team Approach

The introduction of lasers into the practice should proceed in an orderly, calculated manner. Proper planning will help ensure successful integration of the new laser and its associated changes into the practice. For the introduction of a laser to be most productive, the entire team must be involved. Every team member should be educated on the uses and capabilities of the specific laser. It is strongly suggested that the entire staff attend a laser introductory course together so that all members can raise questions specific to their function as part of the dental team. The interaction of the team members can produce new ideas to accelerate the acceptance of the laser by both staff and patients.

An introductory course on laser dentistry is designed to be an informative overview of the capabilities of the various lasers currently available. It should include a hands-on segment where the participant tries several different laser wavelengths on a pig jaw. Encourage the entire team to experience the hands-on portion, even members who are not dentists or hygienists, to help them take ownership of the promotion of laser dentistry to their patients.

This type of introduction to laser dentistry allows the participants to experience the type of laser that may be purchased for their office. The practitioner can begin to formulate potential uses for a laser in the practice while considering the other parameters pertinent to the purchase decision.

General Practice

A general practitioner has the choice of a variety of laser wavelengths. If the practice is focused on cosmetic procedures, a diode laser, neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser, or carbon dioxide (CO₂) laser would be sufficient. These lasers are also appropriate if gingival recontouring or tissue retraction would be the primary laser procedure used.

If the practice is oriented to family and pediatric dental care, where performing surgical procedures on virgin teeth is a priority, an erbium laser must be considered. However, their large size, weight, air/water requirements, and many components mean that erbium lasers are often delegated to a specific treatment room; therefore, erbium laser–specific procedures must be scheduled according to this room’s availability to maximize the laser’s use. This may reduce the number of procedures using the laser and thus affect the return on investment of the purchase. In contrast, a small diode laser, although useless for hard tissue procedures, may easily be moved from treatment room to treatment room and can be in constant use by the dentists and hygienists (in states where hygienists are permitted to use lasers).

Once lasers are introduced into a practice, the demand by the clinicians becomes such that more than one laser or more than one type of laser is needed, and a second laser is eventually purchased.

Specialty Practice

The dental professionals in various specialties will approach laser use according to the number and types of procedures they can perform in their practice. For example, oral and maxillofacial surgeons may want an extremely precise yet fast-cutting laser for soft tissue use. Virtually every surgeon who has a laser in the dental office, or who has access to a laser in a hospital, uses a CO₂ laser because of its ability to incise, excise, and remove tissue quickly. Except for a few specific procedures (e.g., TMJ arthroscopy, performed with a holmium laser), the CO₂ is the laser of choice for oral and maxillofacial surgery (OMS). Although these surgeons also work on bone, OMS has not embraced the erbium wavelength for osseous surgery because of its rather slow speed when cutting any significant amount of osseous tissue. Erbium lasers, however, are becoming popular in some OMS practices in states where these surgeons are permitted to perform facial cosmetic surgery, such as skin resurfacing.

An orthodontist may want a laser that is useful for frenectomies, crestal fiberotomies, tooth exposure, and orthodontically induced gingival hyperplasia. An inexpensive diode laser may be sufficient for orthodontic use. Pediatric dentists may find the greatest use for both hard and soft tissue lasers, and thus an erbium or combined erbium/soft tissue laser may be best suited to their needs. Some manufacturers market combined erbium/soft tissue lasers specifically for the dentist who wants the best hard tissue laser and a dedicated soft tissue laser. Similarly, endodontic, periodontic, and prosthodontic practices must weigh the types and number of different procedures planned for the laser in deciding which laser best suits their needs.

The proper selection of a laser for specific practice needs is not the focus of this chapter. The reader is strongly encouraged to attend a laser course in which at least three wavelengths are available for hands-on training and the lecturer owns multiple wavelengths. Attending a lecture where the speaker owns just one wavelength will most likely be skewed toward the purchase of that specific wavelength.

Cost of Acquiring a Laser

Cost is always one of the first considerations in the acquisition of a laser. The term “cost” can be viewed in several ways: “the amount or equivalent paid or charged for something: price; the outlay or expenditure (as of effort or sacrifice) made to achieve an object; [or] loss or penalty incurred esp. in gaining something.”²

Opportunity cost, also referred to as economic cost, is the cost of “passing up the next best choice” when making a decision. Opportunity cost is “the added cost of using resources (as for production or speculative investment) that is the difference between the actual value resulting from such use and that of an alternative (as another use of the same resources or an investment of equal risk but greater return).”² Opportunity cost analysis is an important part of a company’s decision-making processes but is not treated as an actual cost in any financial statement.³ Opportunity cost is an important concept because it implies a choice between desirable but mutually exclusive results. Just as the acquisition of a laser has its cost, the choice not to purchase a laser also has associated costs. Among these opportunity costs are the loss of income that would have been produced by the new procedures that otherwise are referred out or not done at all, as well as the loss of referrals to the practice for those procedures that could be performed with a laser that were not previously done. Because there is a special perception of the “high-tech cutting edge” image that is projected by the use of lasers in the office, the loss of referrals is an additional opportunity cost lost to the practice resulting from the decision not to use lasers.

The first definition of cost mentioned is the price.² The current price of a laser is about $4000 to $85,000 or more, depending on the type of laser and the manufacturer. The use of a laser can be paid for in four ways: purchase, finance, lease, and rent. The outright purchase of a laser may have distinct advantages if the cash flow of the practice or the assets of the owners allow for this option. Favorable tax laws may make the actual price significantly lower than the invoice price.

The option of financing a purchase is usually available from several sources. Often the manufacturer’s relationship with a finance company can facilitate the transaction, although the fees, rates, and terms should be compared to other sources of financing. The practice’s banking or loan institution is another good source of information and perhaps financing. Additionally, many finance companies specialize in capital equipment and may be considered. These same points apply to leasing if considered in the acquisition of a laser. Other finance methods, such as purchase by a family trust, pension plan, or limited partnership, are viable options but are beyond the scope of this discussion. Tax consequences differ, depending on the method of acquisition. The practitioner should discuss all the options with a trusted financial advisor.

A fourth way to acquire a laser for use in the dental practice is to rent the laser. The rental of a laser could be arranged on an “as needed” or on a scheduled basis. Although this method is common in the medical field, it is rare in dentistry because of the “cottage” nature of dental practices, as well as the relatively low prices of dental lasers compared with medical lasers. Dentistry is considered a cottage industry because the vast majority of practices are solo or small groups of five or less clinicians. This smaller number in a dental practice compared with the hospital setting, where many surgeons would have access to expensive capital equipment and could generate a large number of procedures, makes the cost/benefit ratio unfavorable for a company to rent equipment on a per-diem or per-procedure basis to smaller dental offices.

Many other considerations go into the “cost” of acquiring a laser, including the ergonomics. In urban areas where office space is at a premium, most dental treatment rooms are small. When considering a small, tabletop diode laser, size and plumbing requirements are not a factor. With the footprint of an erbium laser, however, the following questions must be considered:

Will the laser fit comfortably into the treatment room?

Will the treatment room need to be remodeled to allow for easy access to the laser?

Will a “water quick connect” be needed? An “air quick connect”?

Will plumbing or carpentry costs be incurred from placing the laser in the treatment room?

Will a refillable easy-access water bottle be needed and available?

Disposables are another factor associated with laser use. Erbium lasers have many disposable items whose price should be compared, as follows:

Does erbium manufacturer A give you 20 sapphire tips when your purchase the laser?

Does manufacturer B give you 10 sapphire tips and 10 quartz tips?

What is the replacement cost of the sapphire tips? The quartz tips?

How many uses can be expected from the tips?

How do I adjust my fees for operative dentistry now that I am using a laser with a cost per “bur” (sapphire or quartz tip) of $10 to $85, rather than 99¢ for a carbide bur?

What is the replacement cost of the fiber? Does the fiber have a full warranty (how long?), or is the fiber warranty pro-rated based on length of service?

What does a service contract cost?

If the laser breaks down, how fast will I receive a loaner or service call?

All these questions must be answered before the true cost of the laser over time can be fully determined.

Laser as Profit Center

There are many ways to evaluate the viability of a laser as a profit center in the dental office. Time is money, and all practices must gross a certain hourly income to flourish, so the ability to perform many procedures more quickly and efficiently means extra income. Procedures that can be performed much more quickly and efficiently with lasers include (but are not limited to) the following:

Laser tissue retraction for impressions

Implant recovery and impression immediately after uncovering

Gingivectomy to improve access for operative dentistry, especially Class V lesions and root caries in geriatric patient

Multiple-quadrant operative dentistry

Soft tissue and hard (osseous) tissue crown lengthening

Smile lift procedures

Apicoectomy

Exposure of unerupted teeth

Frenectomy

Implant placement/sinus lift/periimplantitis treatment

Vestibuloplasty before full-denture fabrication

Procedures not previously done that enhance the results of routine procedures include the following:

Ovate pontic site preparations

Periodontal pocket disinfection

Graft donor site palliation

Graft bed site preparation

Esthetic remodeling of bulky graft sites

Esthetic crown lengthening/gingivoplasty

Melanin depigmentation

Laser tooth whitening

Tooth desensitization

Certain referred procedures now stay in the practice, as follows:

Tuberosity/torus reduction

Biopsy

Orthodontic and drug-induced tissue hypertrophy

Osseous periodontal surgery/de-epithelialization

Lingual frenum removal

Oral medicine procedures, such as treatment of aphthous ulcers, herpetic gingivostomatitis, and lichen planus

Return on Investment

Once the laser has been purchased, good business principles dictate that there should be a fair return on investment (ROI). Just to break even, the income generated by the laser must include covering the price of the laser, maintenance, and supplies, as well as an additional amount to cover the income lost from the money used to purchase the equipment and not otherwise generating its own income. The profit exceeding the break-even point is the actual ROI.

Some of the items that should be included in this ROI would include profits from the following:

1. New procedures performed with the laser.

2. Certain procedures no longer referred, because a laser is now available.

3. Referrals to the practice resulting from acquisition of a laser.

In this way a laser could be considered a profit center.

Table 16-1 demonstrates the significant positive financial impact a laser can have on the bottom line. It also illustrates possible income derived from the use of a laser for just a few procedures per month with very low fees (not using laser to full potential). If the laser’s price is $50,000, the income over this price in the first year is almost $40,000, so the laser would almost pay for itself in 1 year.

Table 16-1 Return on Investment (ROI) Chart for Dental Laser Purchase

If you examine your practice for 1 week and track the number of procedures that could be performed with the laser, you can use Table 16-1 as a worksheet to evaluate the potential profit a laser can bring to your practice. Just plug in the number of procedures you tracked for the week, insert your fees, and do the calculations. Remember that this rough calculation does not include the amount of hours per week saved by using the laser for procedures that save time compared with conventional techniques (e.g., gingival retraction, implant recovery, gingivectomy), which will allow you to see more patients per week, thus generating even more income. This rough calculation also does not take into account the reduced time per week spent tending to postoperative visits for discomfort after surgical procedures, which are greatly reduced when lasers are used. Strauss⁴ emphasizes that “one of the main advantages of using the laser is the lack of postoperative problems and the minimal need for wound care.”