Episode 788: Making the Laser Leap: Implant Care That Pays Off

What I would do is I would start off with a nice, good quality CO2, get proficient with it,
do everything you can possibly do with it, and then if you decide you want to do airway, you can
add the accessories, add the hand pieces to the laser. You don't have to junk it and buy a whole
new laser.
Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. So what can a dental laser
really do when it comes to treating peri-implant mucositis and peri-implantitis? What type of
laser works best? Can your hygienist play a role in laser-assisted care? And how might this all
impact your bottom line? And what kind of training are we looking at as far as becoming competent
in using a dental laser? And what's the return on investment after purchasing a laser? To answer
these questions is our guest, Dr. Bob Convissar. a gp with over 40 years of clinical experience
based in new york city dr conversar maintains a private practice and lectures globally on laser
surgery biopsy techniques and infant tongue-tie release He's also the author of more than a half a
dozen textbooks, including the highly respected Principles and Practices of Laser Dentistry,
now in its third edition. Before we bring in our guest, I do want to say that if you're enjoying
these episodes and want to support the show, please follow us on Apple Podcasts or Spotify.
You'll be the first to know about our new releases, and our entire production team will really
appreciate it. Dr. Convissar, welcome to the show. My pleasure. Great to be here. So before we get
into the details of using a dental laser for periimplantitis and periimplant mucositis,
tell us the difference between those two conditions. Most of our listeners know it already, but as
a review. I'll give you an analogy very, very roughly. What's the difference between gingivitis and
periodontitis? Gingivitis is mostly a soft tissue problem. periodontitis is a soft tissue and a
hard tissue problem where you have bone loss. Same thing with perimucositis versus perimplantitis.
Perimucositis is an inflammation of the soft tissue, whereas perimplantitis is an inflammation or
infection of the soft tissue and the hard tissue where you have some bone loss as a result of the
infection. So two different diseases, two different treatment modalities, and we need to discuss.
when you do what for which disease. Right. And one of the most important things between the two is
that periimplantitis, when it does get that far, progresses at a much more rapid rate than
periodontitis because we don't have any Sharpies fibers there defending ourselves to some extent,
right? Correct. There's no connective tissue between the implant and the bone. Right. It's a
complete adhesion between the... titanium oxide in the bone. And that's lost.
And when it's lost, it's lost. Back in the day, we didn't see a lot of peri-implantitis because we
didn't see a lot of implants. But we've been installing three to five million implants a year now.
So just by large numbers, we're going to see... these kinds of cases routinely in our practice,
right? The hygiene bay is going to be seeing patients that have redness around their implant.
They're going to be doing some gentle probing around the implant and they're going to see some
pocket depth, which doesn't have to be as deep as... periodontitis right some of the peri
implantitis can be pretty aggressive in the early stages but not show six millimeter pockets right
they could be four millimeter pockets so these are the kind of things you have to be aware of so
you're an expert on lasers you've written a book on it now in its third edition hats off to you and
i know gordon christensen wrote the uh forward forward yeah which is really impressive so Tell us
how lasers can be instrumental in the treatment of, let's start with peri-implant mucositis first.
Well, the first thing is to figure out what the problem is before we even pick up the laser. Why is
there perimucositis there? What's the etiologic factor? And I've spoken to more periodontists and
oral surgeons and implantologists than you can shake a stick at. And what do they say are the
biggest problems? Number one, improper occlusal loading. Very,
very often, that's a huge part of the problem, occlusal prematurities. Number two, the contour of
the implant crown. When lab technicians make implant crowns, they will make a point contact or a
relatively short contact gingival occlusally when you need a much,
much longer contact gingival occlusally. One of the things that we didn't discuss as an etiologic
factor is a loose abutment, a loose screw. And when that happens and the crown itself starts to
move around a little bit, that can cause tremendous, tremendous problems. So once again, before you
take out the laser, before you take out your scalpel, before you take out anything, find the
etiologic factor. If the screw is tight, there's no movement of the abutment. There's no movement
of the crown. The contours are perfect. You have good contacts.
You have nice small embrasures. You've got all that stuff. Home care is number one.
Home care is number two. Home care is number three. And then if there's no significant improvement,
you use the laser once again as a last resort, as an adjunct to rather than a replacement.
And you try and treat it that way. Lasers are wonderful devices for bacterial eradication.
But if the etiologic factor isn't necessarily bacterial. it's the loose abutment or whatever,
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We've discussed at length, Dr. Convissar, that the dental laser is a great adjunct, but you have to
have SRP first. And after SRP is done, then you can proceed to using the laser to decontaminate the
pocket, which promotes healing and is clinically beneficial that way. Tell us exactly on the tissue
level what the laser is doing as an adjunct to SRP. Well, one of the things that a laser,
particularly a CO2 or an erbium, can do is they're absorbed by water in the soft tissue.
And when you have perimucositis, the tissue is red, the tissue is inflamed, the tissue is
edematous, the tissue is hyperemic. So that is something that is going to be treated absolutely
perfectly by the laser. The laser will draw out the water, will decrease the swelling, will
decrease the hyperemia. decrease all of those things and bring the mucosa back to a state of health
only under two conditions. Number one, the patient can keep the area clean.
And number two, you've checked the occlusion and virtually any period. or peri-implant protocol,
occlusal equilibration is one of the most critical things. But assuming the occlusion is perfect,
the patient's home care... Has to be perfect, has to be spot on. And then you use a CO2 or an
erbium, they both work well, to decrease the swelling in the tissue, decrease the bulk of the
tissue, and make the area more self-cleansable so the patient can use their toothbrush,
their floss, their proxy brushes, their whatever you want to give them. And I do want to reiterate
that scaling and replaning is a prerequisite to using a laser to decontaminate the soft tissue.
Without question, the laser is always used in addition to rather than in place of.
And I'll say that again, because that's critically important. And it's a huge mistake that novice
laser users make. Use the laser in addition to rather than in place of.
Assuming you don't have the laser, how are you going to attack the problem? You're going to attack
the problem with scaling, with replanting, with occlusal equilibration, with giving the patient
whatever ammunition they need to keep the area cleansable. If you have a laser, you do all of those
things. And then use the laser as an additional, as an adjunct to everything else you've used.
The laser is not a magic wand. It can't work in a vacuum. You've got to use it along with more
conventional modalities. And I think it should be pointed out, Dr. Convissar, that patients can
come in with redness around the implant, mucositis, and the rest of the perinatal health is
excellent. Yeah, that can happen from time to time where it's just an... problem with the implant,
not with the rest of the teeth. And then once again, you have to look at the etiologic factors.
Why is it that the patient has peri-implant disease, but not periodontal disease?
It could be the placement of the implant, the angle of the implant. It could be cement. It could be
cement, absolutely. It could be occlusal overload. It could be over-contouring of the crown.
It could be any of a whole bunch. of things and once again all of those things need to be addressed
in addition to using the laser because the laser is wonderful in treating the pathology but you've
got to understand what's causing the pathology first and get to a treatment of that as well so what
do you say to a dentist who claims their hygienists are fantastic which they probably are and the
srp is getting fantastic results the gingiva is healthy they're getting good responses patients are
complying at home You know, is the juice worth the squeeze when it comes to purchasing a laser for
post-SRP procedures? In other words, what actually is the laser doing that SRP cannot do?
What the laser is going to do much more effectively and efficiently is it will be better at
removing the disease tissue than a cure-at. That's been shown in dozens of studies. And once that
disease tissue... is removed, you then have the body's own immune system being able to start to
heal that. The other question, of course, as to what a laser can do is lasers are bactericidal
instruments. So it's going to logarithmically decrease the bacterial content.
And if you remember your old microbiology, you're decreasing significantly the number of CFUs,
the number of colony forming units in the pocket. So once you have a tremendous decrease in the
number of bacteria in the area, which the laser will do without question, and you have a more
complete eradication of the diseased tissue, meaning that the diseased tissue is gone and the
bacteria within the diseased tissue is gone, you'll have a superior therapeutic result. And from
knowing you for a number of years, Dr. Convissar, I know you're a big proponent of dental
hygienists utilizing laser therapy in their dental hygiene appointments. Without question.
I have no problem whatsoever with a skilled, trained, trained, trained hygienist using the correct
laser the correct way. Yeah. And I know we talked about this on other episodes, but I think it's
important to reiterate it. Talk to us about the CO2 laser. It seems to me that that laser is the
safest. It operates at a cooler level, right? It doesn't raise the temperature of the tissue up
like a 980 nanometer. laser, a diode. Tell us about that because a diode is much cheaper.
It costs a whole lot less. And if a dentist wants to buy one laser after talking with you about
this, it seems like CO2 is the way to go. Without question. In my office, I have about 15 lasers.
I have diodes, NDX, erbiums, CO2s, PBMs. I've got plenty of lasers. My go-to without question is
the CO2. The reasons for that would take up a whole podcast by itself.
One of the biggest reasons, is that the average tip temperature of a diode, according to the peer
-reviewed literature, not according to me, according to the peer-reviewed literature, is the
average tip temperature of a diode is 750 to 1500 degrees Celsius. The average tip temperature of a
CO2 or an erbium is 100 degrees Celsius. So what you're doing with the CO2 is you're vaporizing
tissue at a relatively low temperature compared to a diode at 750 to 1500 degrees.
a remote possibility but the possibility is not zero of exacerbating the problem by depositing so
much heat not necessarily on the implant but on the surrounding soft tissue because what's going to
happen to that heat when you heat up the soft tissue that heat is going to convect over to the
implant and it will heat up the implant without question. So on a previous podcast, Dr.
Convissar, we talked about an additional revenue stream using a CO2 laser for non-surgical
periotherapy following SRP. And I think it's a great clinical benefit as the literature shows,
but to get patients to agree on a full mouth treatment like that is challenging to some extent
because the insurance companies don't pay for it. But in this case, when you're using a CO2 laser,
for instance, to treat mucositis after SRP, it seems like patients would be more willing to do that
and pay for that treatment out of their own pocket since they've already invested in that implant.
So they want to protect their investment. Is that what you're finding? We'll be getting right back
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If somebody has gone through it, especially take a look at a maxillary posterior implant,
they may have had a sinus lift and they've had the implant placement and they've had a bone graft
and they've had all of those procedures to get the site ready and then the implant is placed and
then they've had a custom abutment and then they've had a crown. That's a considerable amount of
money. And if it is in danger of being lost, the patient looking at.
A second bone graft, a second abutment, a second crown,
a second everything. And that's going to make it prohibitively expensive for some people. And if I
can take my trusty laser in addition to, rather than in place of, in addition to my conventional
bag of trip. tricks, scaling, root planning, home care, maybe arrestin, maybe chlorhexidine chips,
definitely occlusal equilibration, and I can get success in treating that, then the patient is
going to be much, much more likely to accept that treatment plan rather than, okay, let's take out
the implant and start from the beginning and maybe be without a tooth for six months to a year or
more because we have to let the bone graft heal. Yeah. And then in most cases, I would assume that
patient would accept laser. post-SRP laser treatment for the entire mouth,
not just where the implants are. So you're looking at a $5,000 and upward fee for that, which is
cash, right? You don't have to worry about getting it from the insurance company. Correct.
Absolutely. So based on the fact that there are so many implants out there, and peri-implantitis
is becoming much more prevalent now because of that, just on the law of large numbers, it seems to
me it would make sense for every GP to have a laser, especially a CO2 laser. Absolutely,
without question. It's just not a matter of buying a laser. It's a matter of getting trained to use
the laser, getting trained the right way to understand all the things that the laser can do.
Also understand the limitations of the laser. and then take it from there. I couldn't practice
without my lasers. If my lasers were not working, I would just close up shop for the day.
They are as vital to me, even more so than my handpiece. So let's talk about the ROI for a minute.
What's the best way to get started with a laser? Should we lease it? Should we buy it? The best way
to pay for a laser is the way your accountant tells you to do it. That's not my area of expertise.
Most dentists will just take a five-year lease with a dollar buyback. So after the five years the
lease is up, they pay a dollar and the laser is there. Other dentists that are a little older that
have a nice amount of money in their pension plan or IRA or whatever, they can take a loan against
their pension plan, pay for the laser that way, and then pay themselves. back into the pension
plan. That's another way. Some people may decide they just want to do it in one lump sum.
So typically, what is a good CO2 laser cost these days? Depends on what you want to do with it.
A basic plain vanilla CO2 is going to be somewhere, and don't quote me because I don't sell lasers,
somewhere in the range of about $40,000, give or take. $40,000.
$40,000, give or take. And then, of course, if you want to start doing snoring and sleep apnea,
you want to start doing facial aesthetics, you want to do a whole bunch of other things like that,
then you need different accessories and different hand pieces, and that can bring the price up. But
for a plain vanilla average GP that doesn't want to get involved with airway dentistry, snoring,
sleep apnea, stuff like that, somewhere in the range of about $40,000 should be more than adequate
to get a perfect quality, an excellent quality CO2. And there are some very... very good ones out
there. So let's talk about the claims that different laser companies market.
How accurate are these claims and how much attention should the dentist as the buyer pay to the
claims that are being promulgated by these laser companies? That's a great question. And that's
going to get me in trouble with the laser companies, but I don't care because they don't pay me.
You're a free man. You're a free man, Dr. I'm a free man. I don't take a... from laser companies to
promote anything i've been doing this since 1989 and if i have to start to take money from laser
companies to promote their uh their products i might as well just shoot myself so that's that's not
happening um most laser companies are run by um how do i say this gently liars and thieves um yeah
that's that's worse than i thought yeah Yeah, that's a little extreme. They're not.
They're very nice people, but they want to sell a product. So are they going to overhype and
underdeliver? Yeah, probably. Are they going to talk about how great their laser is and how lousy
other lasers are compared to theirs? Yeah, probably. That's why.
Once again, when you take a course, it's got to be a course with multiple laser wavelengths or
multiple laser companies there. A good way to start is the textbook principles and practice of
laser dentistry that I'm very, very proud of. There's a whole chapter on laser physics,
laser tissue interaction, how these things work. And once you understand how these things work,
it'll help you decide. on what you want to do and how you want to do it and then you go chapter by
chapter if you want to do perio if you want to do endo if you want to do fixed if you want to do
removable you just read the book chapter by chapter and figure out what you want to do how you want
to do it how difficult and boring is the reading is it tolerable because you say textbook when
people say textbook a lot of dentists don't want to read it Well, I've been practicing dentistry
for a very long time, and the thing I have to tell you about the book is that there are over 1,200
pictures. That helps. That makes it very, very easy. If you don't want to read the book,
just take a look at all the pictures and take a look at the captions of the pictures, and that'll
give you a pretty good idea of what to do and how to do it. The way things are now, and I know
we're a little bit older than the generation that... were born with a phone in their hand.
That's insulting, but true. Yeah, it's true. But we're still at it. Listen, you're busy. I'm
running a company here. I got Viva Learning behind me. My son is doing a lot of stuff here. But
what is very interesting is that a lot of dentists, even though they're dentists, they're still
part of the younger generation, they go to YouTube and they want to see a video on it. And listen,
whenever my son needs to fix something or replace something, there's always a video, the most
esoteric, ridiculously far-out procedure that he needs to do around the house,
he could find a video on it. Some guy posted a video on it. It's crazy. Some of it's good,
and it's buyer beware. But my suggestion is to some of these dentists that are interested in
exploring the opportunity of a dental laser, which I hear so much about, is to take a course by you
or someone like you and maybe have the textbook as a reference.
And then as they get more into it and understand where they are, they can use that textbook and
they'll have it handy. Or if they're really gung-ho and they're nerds, they can read it before
they see you. But the point is, everyone needs a mentor because you have so many decades of
experience, Dr. Convissar. You've made your mistakes. You know which patients benefit from what.
There's nothing more valuable than decades of clinical experience. The lasers came out,
what, in 1964? The first lasers were invented in 64. They didn't come into general dentistry until
1989. When did you start using it? 1989. What got you involved with lasers so early?
I had always tutored kids in high school. I tutored kids for the SATs in college.
I tutored kids for the DATs in dental school. I tutored kids for the National Dental Boards Part 1
and 2. I enjoy teaching. And when the first laser came out in 1989,
I said, you know what, this would give me an opportunity to get back to my roots,
to teaching people. And I bought the first laser, got in on the ground floor.
And it was the best thing I ever did. Amazing, amazing. Yeah, you've done so many things with
lasers. Besides the teaching and the writing, you've influenced so many people. And it's really an
honor to have you on the show. I really hope that some of the dentists that are listening to this
program email you, ask you where your course is. And again, we don't have any financial interest in
whether you take a course by Dr. Convissar or not. None, zero, zilch. As far as I could tell,
based on my knowledge of Dr. Convissar over a long time now, he's so excited and passionate about
lasers that... infectious, and I can't imagine that anybody that takes a course with him will not
come out of there with the same excitement. So it is worth looking into. And again, one of the most
important things, correct me if I'm wrong, Dr. Convissar, is that lasers open up the doors to other
services in your practice. Like we said, airway. Infant tongue tie. You said that the ROI on infant
tongue tie, if you do what, one a month? One a month. It covers the lease payment. easily easily
and that one of the other things i want to talk about the courses is i don't get paid per person so
if there are 10 people in the course or 100 people in the course it doesn't matter that doesn't
affect me in any manner shape or form i get paid by the venue um And the venue pays me no matter
how many people are there. So I'm not promoting the courses to put more money in my pocket. The
courses are always there. The courses always sell out. And I'd love to have anyone and everyone
come and learn. And even people that have lasers and the lasers are sitting in the corner and the
lasers are being used once or twice or three times a week, please come to the course and you'll
learn how to use that laser. Whatever wavelength it is, you'll learn how to get so much more out of
it. much happier with it. Yeah. And besides helping the patient, it's a great revenue stream.
It's an additional... Without question. Yeah. It's an additional revenue stream. So as we wrap it
up, Dr. Convissar, I know you're very open to answering questions via email. So if you would tell
our audience what your email is, and I'm sure you'll get some email questions from our listeners.
laserbobdds at gmail. L-A-S-E-R-B-O-B-D-D-S, laserbobdds at gmail.
So please email me any question. There's no such thing as a dumb question. Any questions, I spend
about an hour a day, virtually every single day, answering questions from people all over the world
that have taken my courses, that want to know more information. I've lectured in about 30
countries, hundreds of cities. So I've got people following me from the world over.
So please email me and I will give you the facts and I will not be selling you anything.
Thank you very much, Dr. Convissar. Have a great evening. We appreciate your insight. Thank you.
Great to be here.