Yeah, that’s about it………..Things happen quickly at 650, both good and bad if one isn’t careful and trained.

Or the operator can turn the PD down to say 350 and not have to move the tip quite as fast.

Bob

Hey Ron,

Q&A format:

We know with the diode we stay 1mm from the base of the pocket totally away from the attachment…. Clinically we see very often great results in pocket shrinkage  yet the belief is that is long junctional epithelium not attachment….  

Resolving inflammation (regardless of the technology)will get pocket reduction and long JE–even some bone that will push up against the long JE.  We saw that in Yukna’s study with the S/RP control group, but it was “repair” not regeneration.

If that is correct..and we can repeat the diode procedure when that breakdows since it is isnt as stable as attachemnt…is that acceptable and if not why?  

Sure, it is acceptable because it is “health” (the absence of disease).  But who wants to keep retreating pockets, any more than retreating endo or restorative?  And what a chair time and practice management nightmare it was 14 years ago when I used to do it that way.  I mean, how do you charge for a service that requires repeated re-entries and later on retreatent?  What do you say to the growing # of patients that start asking why the need for re-treatments?  

I guess I could keep putting IRM into a cavity prep, or I could take the time and use the right materials to bond a long lasting restoration and charge a comensurate fee for that service…….;)

I see too many perio patients to try to manage such a population of patients that will eventually be breaking down. I’ve been doing about 2 quads of LPT at &#361,000 per quad for the past 2 weeks–some days 4 quads.  I want to minimize the # of patients I need to re-treat and revisit by creating a stable new attachment.

One of our doctors in Texas recently did 48 quads in 6 weeks at &#36850 a quad after some media exposure.  If he isn’t doing single treatment LPT–one visit per quad, and one quad per hour–he’s not going to address that sort of volume with repeat entries and eventual breakdown…….

Are there studies and I’m sure there must be of the stabilty of Long junctional epithelium…  

I would have to check.

With the periolase are u going throught attachment partly because reattchemnt definitetly occurs so it is predictable and safe?

Yep.  And well established in the perio literature.

Hi Ken,

1) For LPT, I thought the first pass with the Periolase was to de-epithelialise the pocket as well as remove  debris. At least that was my assumption from the diagrammatic LPT protocal.

Yes.  Also to:

1.  to trough the tissue open, thereby creating a “funneling” of the coronal/crestal tissue at the gingival margin.  

2. create a blood free environment

3.  establish access and visibility by relaxing the tissue tension on the gingival crestal tissue.

2) Diode decontamination was to carry out after SRP in a non-activated mode. Does this not penetrate into tissue to remove bacteria? (or not as effective since the intensity is much weaker than Nd:YAG.)

Diode decontamination from my experience and Harris’ study is a surface effect.  FRVP Nd:YAG is a surface AND sub-surface effect 2-4mm.  That, and Harris’ study showed Nd:YAG has a 16 fold increase in lethality of PG than 810nm diode w/o effecting the blood agar.

Good questions!

Thanks for starting the thread Ron!

Bob

I have actively used the diode to tx periodontal ds for close to a year. Taking the patient through RPC’s decontaminating the pocket then de-epithelialise the pockets. 3 mo. later I was seeing relapses. Since I like to spend money I bought the perioscope. In every case there was still calculus present.
Then I tried using the perioscope at the RPC appt. . This did not work because it takes 1 hour to do one root surface if your lucky. Finally settled on doing the RPC using the laser then waiting 3 mo. reeval for relapse and then treat with the perioscope. After which you start all over again with the laser.
This procedure will work. Is it Long junctional epi attachment? Do I get any bone regeneration? In some case it is just LJE attachment. In some of them I did get bone regeneration.
The problems:
1. Not predictable.
2. Labor intensive.
3. The laser if used only by the dentist becomes costly.
4. Patient compliance is a real big problem. They have to be seen every 7-10 dqays.
5. A scheduling nightmare. Imagine having a bunch of patients you have to stick into your day just for a couple of min.

This is what I do until I can come up with enough money for Bob and Rusty.
1. I’ll do RPCs as usual only using the diode to decontaminate the sulcus.
2. Reeval at 3mo.
3. Unresolved sites are then treated with the perioscope.After which we start with the deepi. sequence and see them as needed. Unless there is a restorative component and then they go to sx.

David

Hi Ken,

I’m pretty sure no one is bored by the questions.  If they are, they can lurk or log-out, right Ron?;)

OK, let’s go through your questions:

1) For Nd:YAG,when the fiber enter the pocket un-initiated, the laser removes bacteria / debris (Does the laser de-epithelialise without initiation? How?).

Yes the FRP Nd:YAG de-epithelialises w/o any “initiation” whatsoever.  In fact, if it is unitentionally done or the Hot Goop (protein accumulation) Effect starts in, or the fiber end is scuffed or damaged, we cleave to get as clear and clean a bare fiber as we can.

The “how” of it is just a matter of physics.

CW diodes, even in gated diode mode, can only reach mathematical “peak powers” of 10’s of watts.  And that’s with an un-initiated fiber.

Free-running pulsed Nd:YAGs (or erbium YAGs or Er, Cr, YSGG for that matter) have peak powers in the 1,000’s of watts, but they are only “on” for 100 millionths of a second (if the pulse duration is 100 microseconds(usec).  At 20 Hertz that means there are 50,000 pulses at 100 microseconds in a second.  So that would mean for every 100 usec at 20 Hz, there is 49,900 usec “off” time.  That’s what gives high intensity (heat), but for a very short time, AND with nearly a 500 fold time period for the tissue to cool down.

So at 4.00 watts (average power), 20 Hz, 100 usec = 2000 watts per pulse (peak pulse power), but for only 100 usec.  Then because the laser is “off” for he next 49,900, the average power calculates out to be 4.00 Watts.

So it is the high intensity, for very short periods of time, that cause the vaporization, denaturation thresholds to be rapidly reached and accomplished, and then a relatively long period to cool down before the next 2000 watt blast comes along to do it again.

It is because of this pulsing that result in rapid heating followed by cool down, that requires the operator to move a lot slower than someone who has used a diode.  You have to allow the pulses to do the work, NOT the edge of the fiber.

It is very much non-tactile in the beginning like with the Er; YAG and the Er, CR, YSGG

Then the fiber periphery gets clogged up with these proteins helping to remove more tissue and debris but there is a temp increase ( not as much as a hot glass effect ).

That’s right.

Think about what an 800 degree C object does when submerged into something that in 48 degrees C.  I call it “quenching”.  It is an immediate and constant transfer of heat from the fiber to the tip o the tissues that have little chance to cool down.

2) An un-initiated diode can only do biostimulation , coagulation ; and surface decontamination ( no sub-surface decontamination as the intensity is low.
High enough power produce heat stacking effect causing bacterial decontamination BUT collateral tissue damage.

Yes, that’s about it…….

Bob

(Edited by Robert Gregg DDS at 4:16 pm on July 3, 2004)

For Danny:

I finally got around to opening up this case to inspect the mesial as to why there was not radiographic and clinical fill as there was on the distal–AND to give Danny the physical and photographic evidence he wanted that the radiographic appearance of bone was indeed bone.

Pre-Op x-ray

9 month post op x-ray.  Bone fill on distal seems evident

Pre-op photo before raising an envelope flap

Probe in place.  Cortical bone is rock hard and very pronounced

Bone to the buccal had a “peak” of bone pushing up.

Hi Res of distal area

I have many more pictures of this case both of the mesial and the distal, but this addresses the question of photo-documentation of bone fill.

Thanks for your patience.

Bob

Bob,
Pretty cool. You do have to tell the rest of the story about what happened on the mesial.

David

Bob,
This comes as no surprise to me! We discussed this case awhile back and I knew what you were going to get.
Al, early on I thought Bob would have a problem with #5 mesial because of the concavity as you said. That is why I like to reshape these areas.
Back to Bob! Way to go and keep going. In your case a picture tells a million words!
Thanks for your incredible contributions to Dentistry!
Danny