Forums › Erbium Lasers › General Erbium Discussion › How to laser anaesthesize
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Edwin KwokSpectatorI have used the Opus Er:YAG for 2-3 years now, still can’t see the laser anesthetic effect. Can some one tell me how is that achieved?
AnonymousGuestEdwin, here are a couple good places to start. You might also want to contact Jeff Cranska a.k.a.- Benchwmer from the board as he is an Opus user. <a href="http://www.cranska.com/
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SwpmnSpectatorQUOTEI have used the Opus Er:YAG for 2-3 years now, still can’t see the laser anesthetic effect. Can some one tell me how is that achieved?Dr. Kwok:
When you speak of “laser anesthetic effect” are you referring to:
1) Ability to operatively prepare teeth with carious lesions and not use pharmaceutical anesthetic?
2) Ability to “anesthetize” teeth with the Er:YAG so that you can, e.g., remove amalgam restorations without pharmaceutical anesthesia?
What Opus system are you using, the older model Er:YAG or the new Opus Duo E Er:YAG?
The Opus concept of erbium ablation is radically different from that taught to us Waterlase Er,Cr:YSGG and DELight Er:YAG users. Waterlase and DELight users generally cannot achieve millijoule energy settings above 300 whereas current Opus erbiums routinely produce 1000mJoules. Waterlase Hz rate is set at 20 and DELight users generally prepare teeth at 10-30 Hz. Opus users are advised to use energy settings of 800-1000 mJoules and very low rep rates of 7-12 Hz and this is done with tips in contact whereas Waterlase and DELight users use tips defocused at 0.5 to 1.5 mm. Most Waterlase and DELight users apply the erbium beam with a 600 micron tip whereas Opus provides large 1 mm tips.
Many Waterlase and some DELight users report excellent “anesthetic” affect by applying the erbium beam at 300 mJoule 20-30 Hz setting defocused at perhaps 10 mm and applied for 90-120 seconds all over the tooth. I personally have had mixed success with this technique. To me it’s difficult to imagine how the erbium beam which should be immediately absorbed by water and hydroxyapatite in enamel could ever penetrate far enough to “anesthetize” dentin and certainly not the pulp. However, there are many reports that this technique works very well.
Personally, my greatest success with “no anesthesia” erbium operative dentistry has been by using the Waterlase and DELight at low millijoule settings. My favorite setting on my Waterlase is 20 Hz 135 mJoules. This morning I placed a very deep MO restoration with my DELight set at 10 Hz 180 mJoules on an unanesthestized patient that felt nothing. In fact, this week I report a 100% no pharmaceutical anesthesia rate on several composites!!!!! Well, it’s Tuesday and tomorrow I’m out of town for Thanksgiving – don’t want to mess up my numbers!!!!!!
Al
Edwin KwokSpectatorI had the older opus20 first and then now have the newer opus Duo.
When we “laser anesthesize”, do we use high energy level and high frequency and then in defocus mode for 1-2 minutes all over the tooth?
AnonymousGuestQUOTEQuote: from Swpmn on 11:22 pm on Nov. 25, 2003Quote:To me it’s difficult to imagine how the erbium beam which should be immediately absorbed by water and hydroxyapatite in enamel could ever penetrate far enough to “anesthetize” dentin and certainly not the pulp.Al
Al,
I had the same questions but recently stumbled across something that talked about the optical properties of enamel and dentin. Evidently the set up of the rods in enamel and the tubes in the dentin can cause them to act as ‘hollow waveguides'(Lasers in Dentistry-Modern Optics and Dentistry chapter) that are lined up close to being parallel and thus enable the beam to travel further than expected.
drnewittSpectatorPretty interesting and logical theory with regards to the dentinal tubules acting as hollow waveguides Ron. Where did you read this?
And Al, Using youre DELight set at 10 Hz 180 mJoules on an unanesthestized patient. Where you cutting through a virgin tooth? What tooth and how long did it take at such a low setting? I am finding some teeth, even at 25Hz 240mJ are tough to get through.
I did have a case a few days back where I tried Mark’s 90sec technique with the Enamal setting on my Delight. I removed two amalgams from two 2nd molars and was amazed that the patient felt nothing but I must admit I was feeling a little stressed!
SwpmnSpectatorQUOTEWhen we “laser anesthesize”, do we use high energy level and high frequency and then in defocus mode for 1-2 minutes all over the tooth?Dr. Kwok:
Yes, you are absolutely correct. The erbium laser anesthesia technique (as I understand it) used by Dr. Colonna and others involves a defocused(perhaps 7-10 mm) application of the erbium wavelength with air/water spray for 90-120 seconds facially, occlusally/incisally and lingually/palatally at what would be considered a high wattage setting for a Waterlase or DELight user: 20 Hz/300 mJoules.
Others having greater experience with the technique such as Mark, Ron(Schalter/Kaminer), Glenn, Al(Boholst) and Dave Kimmel chime in here and help me out.
Al
SwpmnSpectatorQUOTEAl,
I had the same questions but recently stumbled across something that talked about the optical properties of enamel and dentin. Evidently the set up of the rods in enamel and the tubes in the dentin can cause them to act as ‘hollow waveguides'(Lasers in Dentistry-Modern Optics and Dentistry chapter) that are lined up close to being parallel and thus enable the beam to travel further than expected.Ron:
That’s an excellent point! What is the exact reference or can you post the discussion in the reference section so that we may all read? Perhaps this could explain the mechanism of action of erbium laser anesthesia.
May very well explain erbium anesthesia on virgin teeth but what about teeth with existing amalgams, old bases and underlying caries? Seems like the erbium wavelength would be attenuated prior to reaching the pulp, particularly from the occlusal. Perhaps facial/lingual application would allow the erbium wavelength to reach the pulp via this “hollow waveguide” theory?
I’m not trying to create controversy I just think we need a good scientific explanation for the observed phenomena prior to generally recommending the technique.
Wouldn’t at least a “yeah” or “nay” on the technique be fairly easy to assess? I’m sure studies are already being conducted but all we’d need to do is take a control reading with a pulp tester on a tooth, attenuate the tooth with the erbium and then compare to a second, post-erbium “anesthesia” reading with the pulp tester. We could also test contralateral teeth, for example, quantify number 21 and 28 with pulp tester as control then apply the erbium to number 28 and compare the second reading of 21 and 28.
We could even get together and just do this on one another as a preliminary study. I’m more than willing to volunteer my teeth as still have a few that aren’t restored!!!!!!
Al
AnonymousGuestQUOTEQuote: from Swpmn on 5:30 pm on Nov. 28, 2003QUOTEAl,
I had the same questions but recently stumbled across something that talked about the optical properties of enamel and dentin. Evidently the set up of the rods in enamel and the tubes in the dentin can cause them to act as ‘hollow waveguides'(Lasers in Dentistry-Modern Optics and Dentistry chapter) that are lined up close to being parallel and thus enable the beam to travel further than expected.Ron:
That’s an excellent point! What is the exact reference or can you post the discussion in the reference section so that we may all read? Perhaps this could explain the mechanism of action of erbium laser anesthesia.
May very well explain erbium anesthesia on virgin teeth but what about teeth with existing amalgams, old bases and underlying caries? Seems like the erbium wavelength would be attenuated prior to reaching the pulp, particularly from the occlusal. Perhaps facial/lingual application would allow the erbium wavelength to reach the pulp via this “hollow waveguide” theory?
I’m not trying to create controversy I just think we need a good scientific explanation for the observed phenomena prior to generally recommending the technique.
Wouldn’t at least a “yeah” or “nay” on the technique be fairly easy to assess? I’m sure studies are already being conducted but all we’d need to do is take a control reading with a pulp tester on a tooth, attenuate the tooth with the erbium and then compare to a second, post-erbium “anesthesia” reading with the pulp tester. We could also test contralateral teeth, for example, quantify number 21 and 28 with pulp tester as control then apply the erbium to number 28 and compare the second reading of 21 and 28.
We could even get together and just do this on one another as a preliminary study. I’m more than willing to volunteer my teeth as still have a few that aren’t restored!!!!!!
Al
Reference posted in Literature Section.
Nice of you to volunteer, Al. It could become a very interesting study, especially on your part. Good thing you’ve been nice to everyone here!
SwpmnSpectatorQUOTEAnd Al, Using youre DELight set at 10 Hz 180 mJoules on an unanesthestized patient. Where you cutting through a virgin tooth? What tooth and how long did it take at such a low setting? I am finding some teeth, even at 25Hz 240mJ are tough to get through.Paul:
In the cases I mentioned from early this week they were either virgin or restored with composite and needed repair. You are absolutely normal in your finding that some teeth, particulary molars, are difficult to ablate with the erbium. There are some reports that patients who have benefitted from fluoride may have teeth that are much more difficult to ablate with the erbium. Bear in mind that the majority of my patients are elderly, without the formative benefits of fluoride and may have enamel that is easier to ablate with the erbium.
Al
SwpmnSpectatorQUOTEReference posted in Literature Section.Nice of you to volunteer, Al. It could become a very interesting study, especially on your part. Good thing you’ve been nice to everyone here!
Ron:
Anything to advance the science of laser dentistry. Glenn’s already used me as a “guinea pig”!!!!
Al
2thlaserSpectatorHi guys,
From what I have read here, you guys are on to something. I think Ron has found a possibility to what I see is more laser energy transfered to the pulp…Al, you ask about amalgam removal….remember, our lasers also produce a photoacoustical component, a photothermal component, as well as “cold” water/air, with subsequent “freezing” of the enamel/dentin. I think all of this combined, helps the analgesia effect of our erbiums. Just a thought. I think we forget about the photoacoustical effect the most. If you take an extracted tooth, and prep it, your fingers can get a bit numb…again, you can FEEL the photo acoustical effect that way. It’s cool! Just some thoughts from someone on vactation in Atlanta, late at night!Mark
dkimmelSpectatorAl do you want to do this study before or after Hooters?
Mark if what we are seeing is due to a photoacoustic effect would we not expect to see differences when changing the HZ? Would there not be an optium HZ?
At what level do you think the laser is working? We have all heard about the possible Na pump disruption. What about possible changes to Substance P or other peptides that have a role in nerve transmission. If it is a photoacoustic effect does it have anything to do with different nerve fibers in the pulp ot more with the dentinal tubules. I do not believe that what we see in our restorative work the anaesthesa being related to dentinal tubular flow. I keep going back to something that stuck in my head a while back. Most of the pain we cause is from heat. In the pulp the A delta fibers and the C-fibers respond to heat. These fibers conduct impulses at a slower rate then the A-beta fibers that are also present . There is a greater number of A-delta and C-fibers then A-beta fibers. Does this rate of conduction have anything to do with the photoacoustic effect?
David -
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