Diode Laser for Hemostasis - Laser Dentistry Forum

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October 18, 2003 at 2:35 am #2987 Reply

Swpmn
Spectator

This is nothing new and I don’t have digital documentation but wanted to report on a situation where my 810 nm diode helped me with a bleeding problem. Removed splinted crowns 27-28 where my diagnosis was interproximal impingement on biologic width(patient smiles and tissue bleeds between 27 and 28):

[img]https://www.laserdentistryforum.com/attachments/upload/williamsa101703-1.JPG[/img]

Cut the crowns off and as you can imagine all I see is red. Used the diode at 1.75W CW with an initiated 200 micron fiber to remove the interproximal tissue and create a mini-flap buccal and lingual. Now begin use of my Er:YAG laser 20 Hz 160 mJoules with copious distilled water irrigation for my planned osseous interproximal crown lengthening procedure.

Guess what’s right below the osseous crest?

A “heatbeat pumper” nutrient canal artery complex. Go ahead and reduce my bone with the erbium and measure my margin to osseous width with probe. Pump area with 1:50K epinephrine, pack and have Maria apply pressure while I go in the lab and have a cup of coffee to contemplate how I’ll ever get a decent provisional. Idea pops in head, try your diode laser.

Come back, same situation, red soaked 2 X 2’s. Re-cleave diode fiber so that it’s now uninitiated, crank diode laser to 3.00 W CW and apply in a non-contact, defocused mode at approximately 1.0 mm. With the 4.5 X loupes observed the area gel as I rapidly moved the diode across the treatment site. Moved the diode rapidly as I was afraid at the high energy setting and deeper penetrating 810 wavelength might cause damage. We obtained not perfect but good hemostasis and were able to place our relined, laboratory frabricated fixed partial denture from #27 to 31.

Questions for those in the know:

1) Are my findings consistent with the observations of others?
2) Are my settings and use of the 810 nm diode here correct?
3) What is the diameter of a nutrient canal artery and should we expect the diode laser to effect hemostasis on what I consider a large blood vessel?

Al

November 20, 2003 at 6:57 pm #7860 Reply

dkimmel
Spectator

Al, Great stuff! I to use 3W CW defocused and uninitiated. Works pretty darn good. Not 100% at first but within a couple min. close enough. As far as time , who knows. I try to keep it to a min as you know at 3W it is cooking.
David

November 20, 2003 at 8:56 pm #7863 Reply

Swpmn
Spectator

Thanks for your feedback Dave!!!!!

Only took a month to get a response!!!

Al

November 20, 2003 at 9:43 pm #7861 Reply

dkimmel
Spectator

Ok, so I am not the fastest or sharpest pencil in the box!

November 24, 2003 at 4:15 pm #7862 Reply

Robert Gregg DDS
Spectator

Hi Allen,

Sorry, but I missed your post too, but I’ve been out-of-the-loop for about a month or so anyway.

You handled this like a pro. Exactly how I wuold have done so using CW diode.

Your insticts and thought processes, and especially your concerns and cautions were right on.

Questions for those in the know:

1) Are my findings consistent with the observations of others?

Yes

2) Are my settings and use of the 810 nm diode here correct?

Yes (or did you slough any bone? )

3) What is the diameter of a nutrient canal artery and should we expect the diode laser to effect hemostasis on what I consider a large blood vessel?

OK, now you are getting into some deep laser-tissue interaction thought here…….excellent, I love it.:cool:

Your ability to get hemostasis is dependent on (not necessarily in this order) the “Zone of Irradiance”, blood flow, wavelength, Temporal Emmission Mode (TEM), power and energy density….and the diameter–or cross sectional area you are trying to “poach” or get stasis.

1. Wavelength–gotta have a near-infrared wavelength (800nm to 1400nm) to get peetration and absorption into deeper structures, i.e surface absorbing wavelengths like Argon at 477 and 517 nm and CO2 at 10,064 nm won’t do it unless the Creme Brulee effect is sufficient to stop blow flow at the surface

2. Continuous Wave–Can be though of as an “infinite long pulse duration” since the TEM is CW.

3. Zone of Irradiance–Very diffuse with CW Near-IR. You can finess it, as you did, being mindfull of excess exposure to surrounding bone………Better to have a high peak power Near-IR and “long pulse” TEM to better define the cross-section (vessel diameter) in the Z of I, and deliver higher energy densities (intensities) with long refractory “off” times (i.e. 650 microseconds) .

4. Blood flow–The ultimate heat sink for Near-IR lasers regardless of PD. By Using 1:50K epi, pressure and time, you gave yourself and the tissue time to slow the blood flow, making it easier to transfer photons (temperature) into the deeper blood vessel bed w/o taking the partially clotting blood away in a sea of flow.

5. Diameter–Hemostasis in vessel diameter of 600 to 1200 microns is probably what you can achieve, dependent on doing what you did–epi, pressure, time, before Near-IR exposure.

Well done!! You have demonstrated excellent deductive thinking. You may now proceed to the next level of sophistication, technology, and tissue mastery!!;) 😉

Bob

November 24, 2003 at 4:44 pm #7859 Reply

Anonymous
Guest

Al, this weekend at Stu’s class we had something similar and while not a ‘pumper’ it was a continuous never slowing flow.

Dentist started doing a little crown lengthening w/ an erbium between 18/19 then had difficulty w/bleeding in the area. He then placed superoxyl , then when that didn’t work -infiltrated, after that I suggested he might place a cord (diode was in a different room).That didn’t work either.

It was time to go get the diode. I used 1.0W CW initiated.The dental assisitant was instructed to keep air flow directed right on the bleeding area allowing for some more precise visualization of the source of the bleeding and to help keep the tissue cool. A couple of light, quick brush stokes were used across the vessel and all bleeding stopped. The sulcus was clear of any clot and an impression could have been taken if needed.

I assume I probably got a little bit of ’tissue weld’ across the openning of the vessel. Superoxyl/infiltration/cord Tx time~25-30 minutes. Diode Tx time <5 seconds- as I've heard before – lazin is amazin!

Just thought I’d share an alternative that seemed to work well.

Bob, I would have used the Periolase w/ a widened pulse width, but it wouldn’t fit in my suitcase 😉

November 25, 2003 at 2:01 am #7864 Reply

Swpmn
Spectator

Bob and Ron:

Thanks so much for the feedback!!! I wonder if my post wasn’t seen because I placed it in the Diode forum?

No Bob, we did not have bone sloughing and this patient actually reported no discomfort at all. Would there have been any benefit to “gating” the application of the diode in this case? Have a “gated” rep range available from 5 to 15 Hz. I think it’s great that we can use near-InfraRed lasers to affect hemostasis on a 600-1200 micron blood vessel.

In my opinion, this is an excellent example of why we need to have proper training prior to utilizing lasers on patients. I was presented with an atypical clinical situation and was able to use the knowledge I’ve gained from you guys on LDF and from the seminars attended this year to get me out of a sticky problem!!!

Al
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