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As lasers become more widely used in dental offices, hygienists are seeking more information on how they can use lasers and, more importantly, if they are allowed to use them in their state.
Depending on state regulations,1 common laser procedures that may be performed by hygienists are bacterial reduction,2 sulcular debridement,3 and bacterial decontamination.4 With the use of lasers, these procedures allow the tissue to heal and new attachments to form, so that the periodontal pocket is easier to maintain. Moreover, laser therapy in general is antimicrobial and decreases virulent red-complex bacteria, which can invade soft tissue and enter blood vessels, affecting overall health.5,6 If the state regulations permit these uses, there are many options for hygiene treatments.
Hygiene Uses for Lasers
Lasers provide superior results for several procedures, including:
Treatment of herpetic lesions or aphthous ulcers. These procedures are great practice builders, as patients are often pleased with the results. As there are few over-the-counter treatments for herpetic lesions, hygienists can use lasers to eliminate the pain from lesions, facilitate significantly faster healing, and decrease the probability of lesions reoccurring in the same area.7,8
Laser Bacterial Reduction (LBR).LBR is the practice of administering low-power laser energy within the sulcus throughout the entire dentition to eliminate bacteria prior to completing hygiene procedures. Preprocedural decontamination with a laser is done before any instrumentation, even probing. The objectives are to affect the bacteria within the sulcus, reducing the risk of bacteremia caused from instrumentation, and to lower the microcount in aerosols created during ultrasonic instrumentation. For some patients, LBR is used at the end of the appointment.
Laser-Assisted Periodontal Therapy (LAPT).Used with active periodontal therapy (SRP with laser decontamination) and in conjunction with traditional "deep scaling" appointments, LAPT is the practice of administering laser energy within the periodontal pocket for profound decontamination. LAPT also results in increased tissue interaction by removing inflammatory factors, significantly reducing bacteria within the pocket, and consequently promoting growth factors for healing, with the goal of tissue rehabilitation.
Desensitizing of tooth structure. Laser energy may be used to eliminate sensitivity on the tooth structure. Depending on the severity, this application may require a few treatments to provide relief, while others may need only one treatment.
Laser whitening. This technology can be used to activate the bleaching solution in a whitening procedure, allowing superior results.
Photobiomodulation (PBM). Low Level Laser Therapy (LLLT) is also employed to activate cells for wound healing, pain management, and biostimulation. For example, this therapy can be used for TMJD issues, as well as desensitization and many other options.
Before commencing any laser procedures, the hygienist must be knowledgeable about what can be performed legally. Begin by becoming familiar with the State Practice Act (SPA).1 It is the hygienist's responsibility to review the appropriate State Practice Act to determine if she or he can utilize a laser to perform these procedures in this state. In addition, if these rules change, the hygienist needs to be aware of the revisions. If hygienists are not permitted to perform specific procedures without a laser, then they will not be allowed to complete them with a laser. For example, hygienists cannot do a gingivectomy because they have a laser, as they cannot without a laser.
Once a hygienist determines which laser to use and for which clinical procedures, the State Practice Act may determine whether laser training or a laser certification course is required. If the state requires a laser course, many programs encompass at least 8 hours of tutorial and 4 hours of hands-on training to build competency and proficiency. Most states require only basic knowledge, but as lasers continue to evolve, it is highly recommended that hygienists take all the available laser classes to remain educated on evolving techniques and applications, and become more efficient with the laser.
State Regulations
Each state has the opportunity to regulate its own State Practice Act (SPA) and Scope of Practice, determining laser use by doctors and hygienists using lasers under their license. The primary concern is that lasers are not used without some knowledge of the tool. For state dental boards that need a better understanding about lasers prior to setting up regulations to ensure public safety, organizations such as the Academy of Laser Dentistry (ALD) are willing to assist with this process,9 as are laser companies and sales representatives.
Each state determines what its Practice Act includes and what is necessary to ensure safety. It is important that practitioners stay apprised of state regulations. This information is also posted on the ALD's website; the ALD is not a regulatory authority, but its regulatory affairs committee, led by the author, has researched the information for each state for educational purposes.
States such as Nevada, Arizona, and Wisconsin have regulations stipulating continuing education (CE) requirements for relicensure.1 Some state regulations do not address the topic of lasers,1 while others may be based on inaccurate information about safe laser use. Fundamentally, education is needed for safe and effective laser use by any dental practitioner.
Certain states allow hygienists to use lasers,1 while other states have written laws that specify a hygienist cannot use lasers.1 The majority of states do not have any written rules and regulations on the use of lasers by dental hygienists.
States currently allowing laser use by dental hygienists (meaning there are rules in place in the Scope of Practice stating dental hygienists can use a laser)1 include Arizona, Arkansas, California, Colorado, Hawaii, Iowa, Kentucky, Nevada, New Mexico, New York, Tennessee, Texas, Utah, Virginia, Wisconsin, Wyoming. States currently prohibiting laser use by dental hygienists (meaning there are rules in place in the Scope of Practice that state dental hygienists cannot use a laser)1 include Florida, Louisiana, Miss-issippi, North Carolina, and West Virginia.
States that currently do not have regulation on laser use by dental hygienists (meaning that they do not address lasers in the SPA, and have no rules in their Scope of Practice) are considered a No Regulation State.1 This includes Alabama, Alaska, Connecticut, District of Columbia, Delaware, Georgia, Idaho, Illinois, Indiana, Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mis-souri, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Vermont, and Washington.
Case Studies: Different State Regulations
Regulation language among states varies, and a review of the wording and requirements reveals how practitioners need to remain updated on the specific rules.
Case Study 1: Wyoming is a "Yes State"1
In Wyoming, hygienists have expanded duties, and a laser certification is required; they may provide soft tissue therapy within the scope of practice. Hygienists cannot use lasers to treat apthous ulcers or herpetic lesions and cannot use laser settings that cut soft tissue.
Case Study 2: Texas is a "Yes State"
Hygienists can use lasers in Texas. The state requires 12 hours of CE at an approved course, including a hands-on CE activity. Dentists are required to have equivalent or higher training/certification than the hygienists that they employ.
Case Study 3: Nevada is a "Yes State"1
Nevada is very specific with its SPA, which states therapeutic periodontal treatment to include scaling, curettage, and also has to meet ALD Standards in Laser Education. Hygienists have to meet the curriculum guidelines for lasers. Note: In Nevada's rule, the CE activity requires review and approval. Not all courses meet the ALD standards for exams and certification. It is the clinician's responsibility to select courses that meet Nevada's guidelines as meeting ALD's standards. Not all courses will satisfy the Nevada ruling.
Case Study 4: West Virginia is a "No State"1
At this time, lasers are limited to dentists only, even low-power lasers.
Case Study 5: Florida is a "No State"1
Florida is actively trying to move forward with regulations on lasers for hygienists. Although the regulations did not pass for 2018, the state is planning to continue to address this in the future.
Case Study 6: Oklahoma is a "No Regulation State"1
Oklahoma currently has nothing listed regarding lasers in its SPA. It does not say yes, but more importantly, it does not prohibit use, allowing hygienists to use their own discretion to use lasers or any tools needed to complete procedures for their patients.
Case Study 7: Washington is a "No Regulation State"1
Washington regulations state that soft tissue "curettage" is acceptable, but no surgical removal of tissue (which of course hygienists cannot perform anyway).
Case Study 8: Maryland is a "No Regulation State"1
Maryland law is not very specific. The regulation states that lasers are not allowed, but nothing is specified in the SPA, therefore it is listed as a no regulation state.
Expanding the Practice
Incorporating lasers into the practice (as allowed by state regulations) aids in practice building and elevated patient experiences. Lasers are becoming easier to use and more common in practice. Many laser manufacturers provide training or videos. However, most of this initial training is only enough to get started. Additional, more detailed training or certification to perfect technique and to incorporate the laser safely into practice is highly recommended.
Once lasers are integrated into the clinical armamentarium, hygienists can use the dental codes that are already available; there are no "extra" codes for lasers and dental hygiene procedures. In other words, fees can be adjusted appropriately for the codes already in use.
Lasers offer a new professional avenue for dental hygienists, enhancing the hygiene appointment and improving patient care.
About the Author
Angie Wallace, RDH
Academy of Laser Dentistry Recognized Educator, Advanced Level Proficiency and Mastership
Owasso, Oklahoma
References
1. Academy of Laser Dentistry State by State Quick Reference Chart on Laser Use by Dental Hygienists* (Draft 4.16.2018). Academy of Laser Dentistry website. https://www.laserdentistry.org/uploads/files/Reg%20Affairs/Regulatory%20Chart%20ALL%204_2018%20-%20ALL%20STATES.pdf. Published April 16, 2018. Accessed May 6, 2020.
2. Moritz A, Schoop U, Goharkhay K, et al. Treatment of periodontal pockets with a diode laser. Lasers Surg Med. 1998;22(5):302-311.
3. Harris DM. Dosimetry for laser sulcular debridement. Lasers Surg Med. 2003;33(4):217-218.
4. Crispino A, Figliuzzi MM, Iovane C , et al. Effectiveness of a diode laser in addition to non-surgical periodontal therapy: study of intervention. Ann Stomatol (Roma). 2015;6(1):15-20.
5. Percival SL, Francolini I, Donelli G. Low-level laser therapy as an antimicrobial and antibiofilm technology and its relevance to wound healing. Future Microbiol. 2105;10(2):255-272.
6. Yaneva B, Firkova E, Karaslavova E, Romanos GE. Bactericidal effects of using a fiber-less Er:YAG laser system for treatment of moderate clinical periodontitis: preliminary results. Quintessence Int. 2014;45(6):489-497.
7. Schindi A, Neumann R. Low-intensity laser therapy is an effective treatment for recurrent herpes simplex infection. Results from a randomized double-blind placebo-controlled study. J Invest Dermatol. 1999;113(2):221-223.
8. Akerzoul N, Chbicheb. Low laser therapy as an effective treatment of recurrent aphtous ulcers: a clinical case reporting two locations. Pan Afr Med J. 2018;30:205.
9. Dental Regulations in the United States. Academy of Laser Dentistry website. https://www.laserdentistry.org/index.cfm/patients/Dental%20Regulations%20in%20US. Accessed May 7, 2020.
