Sample Selection

The American Association of Orthodontists (AAO), the American Academy of Periodontology (AAP), and the American Dental Association (ADA) all granted permission to conduct the study. They each provided the names and addresses of 1000 randomly selected and actively practicing clinicians (for a total of 3000). All 50 US states were represented in each of the three groups in the sample.

Surveys were sent by mail and included an addressed, postage-paid envelope. Envelopes were numerically coded to identify nonrespondents. A follow-up survey was sent to those who did not return the questionnaire.

Analogous surveys were designed to gather information about the attitudes of orthodontists, periodontists, and general dentists toward the use of soft tissue lasers by orthodontists during the course of orthodontic treatment (Table 1). Prior to the study proper, the survey design was tested for ease of use by surveying and consulting full- and part-time faculty members at the Department of Orthodontics, Periodontics and General Practice at Virginia Commonwealth University.

Table 1 The Survey

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The front page of each survey contained the title of the study and explained its purpose. At the beginning of the survey respondents were asked whether they were an orthodontist, periodontist, or general dentist in order to allow group comparisons of the results. The first section of the survey gathered demographic information, such as gender, age, and the calendar year of graduation from dental school. Respondents were then asked if they felt that it was appropriate for a soft tissue laser to be used by an orthodontist (Table 1).

The second section included eight questions on how appropriate respondents felt it was for an orthodontist to perform various soft tissue laser procedures reported in the orthodontic literature.3–7 Respondents were asked to make a vertical mark on a 100-mm visual analog scale (VAS) labeled at one end with the word “inappropriate” and at the other end with “appropriate.” The higher the score the more appropriate the respondent felt the procedure was (Table 1).

Subjects were then asked how they thought the use of soft tissue lasers by orthodontists would affect referrals and whether or not they had used soft tissue lasers in their respective practices. If the answer to the latter question was “yes,” subjects were prompted to continue to the final section of the survey.

The final section was for those actively using a soft tissue laser and included questions about the procedures performed, the type and amount of training received, the frequency of use, and whether fees were charged for these services. A section allowing additional comments was also included at the end of the survey.

Statistical Analyses

Data were entered into an Excel spreadsheet (Microsoft, Redmond, Wash), and the three groups were compared using a chi-square test or analysis of variance, as indicated by the outcome variable, with significance set at P < .05. All analyses were performed using SAS software (JMP version 8.0.2, SAS Institute Inc, Cary, NC).

Perceived Appropriateness of Soft Tissue Laser Use

Eighty-four percent of the total sample felt that it was appropriate for an orthodontist to use a soft tissue laser in their practice. On an individual group basis, 93% of orthodontists, 88% of general dentists, and 59% of periodontists regarded soft tissue laser use by orthodontists as appropriate. Significantly fewer periodontists regarded soft tissue laser use as appropriate, compared to orthodontists and general dentists (P < .001).

Table 3 illustrates the responses of the clinicians with regard to the appropriateness of soft tissue laser use by orthodontists for eight specific procedures. A higher mean VAS score indicates that the procedure was more appropriate for use. “Uncovering TADs” was given the highest mean VAS score by all three groups of clinicians (Table 3). The second highest VAS score recorded by orthodontists and periodontists was for “gingivectomy to improve hygiene around brackets,” whereas “removal of keratinized gingival to expose unerupted teeth” was scored second by general dentists (Table 3). Both orthodontists and general dentists allocated mean VAS scores greater than 50 for all eight procedures, whereas mean periodontist scores were all below 50, with the exception of the “uncovering TADs” score (Table 3).

Table 3 Perceived Appropriateness of Soft Tissue Laser Use by Orthodontists for Eight Specific Procedures^a

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Further statistical analyses of the data showed significant differences among the three groups of clinicians for each of the eight soft tissue laser procedures (P < .001; Table 3). Periodontists recorded lower scores than both orthodontists and general dentists for all eight procedures (P < .001). Orthodontists allocated higher scores for “gingivectomy to enhance esthetics” and “operculectomy” compared to periodontists and general dentists, respectively (P < .001). None of the differences found in responses could be attributed to gender (P  =  .56), differences in age (P  =  .61), or year of graduation (P  =  .98).

Effect of Soft Tissue Laser Use on Referral Patterns

Figure 1 illustrates the perceived effect of soft tissue laser use by an orthodontist on referrals to their practice. Seventy-eight percent of the total sample believed that there would be no effect on referrals, while the rest of the sample was split equally between an expectation of an increase and a decrease in referrals (Figure 1). Similarly, on an individual group basis the majority of clinicians thought that referrals would not be affected (Figure 1). Significantly more orthodontists perceived an increase rather than a decrease in referrals (11% and 7%, respectively; P < .01). Conversely, significantly more periodontists perceived a decrease rather than an increase in referrals (21% and 10%, respectively; P < .01). Equal proportions of general dentists felt that referrals would increase or decrease as a result of soft tissue laser use (13%, respectively; P > .05).

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Use of Soft Tissue Laser by Respondents

The prevalence of laser use within the three practitioner groups is shown in Figure 2. Overall, 28% of orthodontists, periodontists, and general dentists surveyed said they used a soft tissue laser, and this percentage did not differ significantly among groups (P > .05).

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Further analysis of the data was carried out to assess whether respondents' personal use of soft tissue lasers affected perceived appropriateness of use by orthodontists. Results showed that 71% of orthodontists who used a soft tissue laser regarded its use as appropriate, whereas all of the orthodontists who did not use a soft tissue laser regarded its use as inappropriate (P < .05). Similarly, 76% of periodontists that used a laser regarded its use as appropriate by orthodontists (Figure 3; P < .05). However, periodontists that did not use a laser were equally divided in their opinion as to the appropriateness of its use by orthodontists (Figure 3). Personal use of soft tissue lasers did not seem to influence general dentists' decisions regarding the appropriateness of its use by orthodontists (P > .05).

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Procedures Performed with a Soft Tissue Laser

Table 4 illustrates the percentage of respondents performing adjunctive orthodontic procedures using a soft tissue laser. The most common procedures performed by orthodontists were “removal of keratinized gingiva to expose unerupted teeth” and to allow “proper bracket positioning” and “gingivectomy to improve hygiene.” The most common procedures performed by periodontists were “frenectomy” and “gingivectomy to enhance esthetics.” A similar percentage of general dentists carried out a wide range of procedures, including gingivectomy to “improve hygiene” and “enhance esthetics,” “operculectomy,” “frenectomy,” and “ablation of aphthous ulcers.” Statistical analyses among groups are illustrated in Table 4.

Table 4 Percentage of Respondents Performing Adjunctive Orthodontic Procedures Using a Soft Tissue Laser

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Training

Table 5 shows the data for different types of soft tissue laser training reported by the practitioner groups. Periodontists were more likely than either general dentists or orthodontists to have been trained to use a soft tissue laser in a formal educational setting (P < .001). There was no difference among the three practitioner groups regarding training obtained from continuing education (CE) classes, self-taught training, training provided by sales staff, or company-sponsored training.

Table 5 Forms of Soft Tissue Laser Training Acquired by Each Practitioner Group

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There was a significant difference among the three practitioner groups in the number of hours of soft tissue laser–related CE credits reportedly earned in the last 5 years, as shown in Table 6 (P < .001). Periodontists reported more CE credit hours, with 44% reporting more than 24 hours of CE and over 50% reporting at least 17 hours.

Table 6 Soft Tissue Laser Continuing Education (CE) Credit Hours Earned in Last 5 Years

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There was no significant difference among the three groups with regard to how often the soft tissue laser was used, with most practitioners using it weekly (P > .05). Ninety-five percent of periodontists and 80% of general dentists said they charge a fee (“yes” or “sometimes”), compared to only 52% of orthodontists (P < .001).

Perceived Appropriateness of Soft Tissue Laser Use

The use of a soft tissue laser by orthodontists was considered appropriate by the majority (84%) of respondents. However, periodontists' approval (59%) was significantly less than that of orthodontists (93%) and general dentists (88%), respectively (P < .001). Periodontists generate revenue by performing surgical and nonsurgical procedures aimed at improving the health and esthetics of the oral soft tissues. It could have been that the lower rate of approval by periodontists was a result of economic implications associated with orthodontists performing such procedures. Alternatively, some periodontists may have felt that the use soft tissue lasers should be limited to specialists trained in their use and better aware of the possible clinical and biological consequences.

The highest mean VAS score allocated by all three groups of clinicians was for “uncovering TADs” (Table 3). This finding was not surprising, since TADs are now commonly placed by orthodontists, and their maintenance and follow-up may be regarded as the responsibility of the orthodontist. There were fewer instances of consensus among groups on the appropriateness of the other seven soft tissue laser procedures. Five of the eight clinical procedures investigated involved possible violation of biologic width, which may result in rebound of the tissues, thus negating the procedure altogether or resulting in chronic inflammation.12 Even though the survey instructed respondents to assume that the procedures were done correctly, and despite the fact that it specified that this included no violation of biologic width, the biggest differences of opinion between orthodontists and periodontists were seen in those procedures (Table 3).

Effect of Soft Tissue Laser Use on Referral Patterns

Over 75% of all practitioners surveyed believed laser use by an orthodontist would not affect referrals to the orthodontist's practice. However, there were differences among groups (Figure 1). More orthodontists felt that laser use would increase rather than decrease referrals to their practice (11% vs 7%, respectively). These orthodontists may have felt that laser use would portray a positive image to their patients and referring dentists by showing that they used the latest technology. Furthermore, this service may have been viewed as a practice builder. Conversely, periodontists felt that referrals were more likely to decrease than increase (21% and 10%, respectively). This may have been because periodontists themselves would be less likely to refer to an orthodontist who was performing periodontal surgery with a laser. The possibility of negative sequelae resulting from laser procedures carried out by an inexperienced practitioner may have further supported this view.

Use of Soft Tissue Laser by Respondents

The prevalence of laser use among the three groups surveyed was not significantly different (Figure 2). The advances in laser technology have made it possible to use lasers to perform gingival procedures that were traditionally achieved using a scalpel blade. Although the advantage of laser use over scalpels with regard to tissue healing is questionable,13 several advantages were summarized by Rossman and Cobb.14 These included ease of use, more precise cutting, cleaner surgical field as a result of the laser's ability to cauterize blood vessels, and a sterile surgical field, resulting in less postoperative infection, less scarring, and less damage to adjacent tissues.14 Perhaps orthodontists and general dentists found that laser use for minor gingival surgeries made such services more convenient and affordable for their patients by avoiding referral to other dental specialists.

Procedures Performed with a Soft Tissue Laser

All laser procedures considered in this investigation were offered to some extent by orthodontists, periodontists, and general dentists (Table 4). The most common procedures performed by orthodontists were “removal of keratinized gingiva to expose unerupted teeth” and to allow “proper bracket positioning” and “gingivectomy to improve hygiene” (Table 4). These findings were not surprising, since the above-mentioned procedures are all closely related to the core of orthodontic treatment, and orthodontists could potentially carry out these procedures as part of their day-to-day practice.

The present study has several limitations. Being based on the self-reported and subjective perceptions of the respondents, the results are subject to the inherent personal biases of each respondent. Hence, respondents were more likely to be performing the procedures investigated and more interested in this topic than those not using a laser, regardless of the group from which they originated. Furthermore, some of the reported data, such as the amount of CE credits and the reported frequency of laser use, required those surveyed to recall past events, which may or may not have been accurate.