Ron,

Welcome to laser dentistry!

You will be doing yourself and your patients a great service if you dedicate yourself to becoming educated and trained in the language of photons and laser tissue interactions. From that understanding, all clinical applications are based.

I have seen a lot of developments since I began studying dental lasers in the early 1980’s, both good and bad. The worst one is lack of standardized laser education and training…the ALD notwithstanding.

Anyway, if you understand how your own particular laser device works (wavelength, emission mode), then you can begin to understand laser tissue interactions.

Your Er:Cr(YSGG) is highly absorbed in collagen, water, and hydroxyapitite, regardless of the water spray. So be very careful in/around the perio pocket, Yes, erbium will disinfect and kill bugs, but what other tissues are nearby that are also absorbing the radiation?

Your Twilite diode is a near infrared 810 nanometer continuous wave (CW) emission mode with millsecond “gated pulse” EM capability. Since it is not a “true” pulsed laser like a free-running Nd:YAG, it will not be as forgiving a pulsed Nd:YAG. But it will get some shallow pockets 4-6mm to resolve as long as you do not linger in anyone place too long.

Laser Curettage 810 nm Diode Settings: 320 micron fiber for anteriors, 400 micron fiber for posteriors; gated pulse @ .01 seconds; 1.2 to 1.4 Watts and steady continuous movement. I would not “condition” the fiber for pocket therapy–only for fibrous tissue removal. Your movements would be “up and down” in the pocket, then cross-hatching horizontally, repeat. Your end point is when bright red blood flows from the pocket. DO NOT over heat and dry out the pocket. You will get recession, exposed roots, and an open pocket. If you can “see” the results of your laser altering the soft tissue (e.g. blanching, charring,drying), you have spent too much time and/or energy in the pocket.

Good luck!

RG

Thanks Ron,

“Plan on visiting Bill Chen’s office soon”.

Visiting Dr, Chen’s office is one good place to start.  But don’t stop there.  Get some good instruction for your diode at a dedicated training class.  ALD has a list of providers who offer classes.  I would recommend Bob Barr, DDS in San Jose @ 408-247-9683.

We also offer courses for other wavelengths from time to time through the Institute for Advanced Laser Dentistry (IALD).  We are ADA-CERP and AGD-PACE recognized.  562-860-2908.

“The more I learn , the less likely I think I’ll use this for perio -my understanding is that if I do- 1. make sure no overheating of tissue and 2. use an up and down motion since the tip isn’t side firing-correct?”

Probably not the best device for perio, but not for the reasons you stated.  It isn’t because of overheating with the 2.8 micron wavelength delivered in a “free-running” emission mode–it is the tissues that tend to absorb that “color” of light are predominately water, collagen, and hydroxyapatite so roots, PDL, bone are going to have a high affinity for the erbium light (as well as bugs of all sorts).  When what you want to do is kill the bugs, remove the epithelium, treat the “goop” in the pocket (e.g. the pathologic proteins–cytokines, prostogladins, etc) without needlessly risking damage to the root, PDL cementum, and bone.  810 +/- 30 nm is near-infrared and will be absorbing in hemoglobin and pigmented tissues, not PDL, bone, or cementum/dentin.  “Sweeping” motion best employed with the erbium if attempted.

“Guess I’m back to the book to review gated pulse and true pulsed”

Gated pulse simply means that a shutter interputs a continuous beam (like sunshine through a fan).  Free-running (FR) means that the pulses are delivered in the 10-6 seconds per pulse (millionths of a second) and are generated electronically within the laser cavity (that’s why free-running lasers are more expensive than diodes).  So 3.0 watts (average power) in a diode in a gated pulse might give you some “peak powers” in the 10’s of watts….a free-running would give you peak powers of around 1500 watts per pulse for the same 3 watts of average power (see Jeff Manni’s book).  FR peak powers allow for the rapid heating and ablation of the target tissue (that absorbs the specific color of light), without heating up collateral tissues since the “off” time is around 500 times longer than the “on” time before the next pulse fires.  That’s how the erbium lasers work.  Water acts to cool the tooth, hydrate the tooth surface for continuous ablation, and exclude oxygen to prevent carbonization.

“Others have suggested a sweeping motion.”

There are several motions depending on what you are trying to achieve, what technique you are employing, and what laser device you are using.  For “laser curettage” only, using a diode, I would employ the technique as I detailed it above.

Now, if I also want to reduce the height of hyperplastic marginal tissues, in other words, perform a “reverse gingivoplasty/gingivectomy, then I would start at the crestal tissues and work my way down in a sweeping motion.  But my settings would be different.

And here are some critical issues:

1.  Invest &#36800 in a power meter from Moletron 800-366-4340 and tell Burt Mooney I referred you.

2.  Calibrate your power for patient treatments AT THE FIBER TIP, not on the console of the laser.  Lasers can vary from laser to laser, and from day to day depending on a lot of variables (heat, humidity, etc).  Unless everyone is speaking about CALIBRATED power settings, no standardization exists, and then you hear all sorts of different settings for similar procedures and with identical laser devices.

“Does it matter if you start at the top of the pocket and work down or it seems to me it would be beneficial to find the base of the pocket ,and work up?”

This is a key point, but is is not related to the power or technique for laser curettage.

It is critical in treating inflammatory periodontal disease to find the true base of the pocket.  That’s why initial pocket therapy cannot be accomplished with any predictability or certainty without profound anesthesia to measure the full depth and 3-D contour of the bony defect.  Periodontists agree that the true pocket depth is AT LEAST 2mm greater than what you can probe without anesthesia.

“Were these settings arrived at  thru experience or how are they determined?”

Experience.  1.4 watts with a 810nm diode will do the job, whereas 1.4 with a 980nm diode won’t cut it (literally).  Yet that’s only 170nm difference.  So wavelength matters, emission mode matters, power matters, pulse duration matters, “conditioning” the fiber matters.

OK, right, Conditioning the fiber.  New term:

It is the blocking of the transmission of laser light and “trapping” the energy in the tip of the fiber, in order to heat the tip, or glass, or material to some high temperature (say 500 degrees C) and tissue interaction is MELTING, not anything else.  Inks, paper, tongue blades are use to create this effect on the fiber.

When to employ:

Fibrous or connective tissues, and in some instances of pocket therapy and tissue contouring (ovate ponitc sites)…..and that’s a whole ‘nother topic…….

“Thanks for your suggestions-I’m not trying to be lazy,(actually it’s pretty uncomfortable showing my ignorance in a public forum).I just would like to gain from others experience,shorten my learning curve, and provide my patients a better result ,quicker”

And that’s what it should be about…..the PATIENT!

Don’t be uncomfortable about not knowing it all.  It tooks me YEARS to learn what I know, and YEARS to make mistakes and learn why it was WRONG so I could correct it!–OK, not all of it was wrong.  

But all of the problems that I know about from improper laser use stems from dentists who are too proud to admitt maybe they don’t know it all, or they will WING-IT on their own.  Guess who gets hurt when pride comes before patient care?

I know some doctors are trying to perform our form of laser perio therapy, without being trained, and patients are getting injured because they didn’t get trained by us.   How do I know?  They’ve told me…..

Bob

(Edited by Robert Gregg at 3:28 pm on Sep. 12, 2002)

(Edited by Robert Gregg at 3:32 pm on Sep. 12, 2002)

Bob, was just cruising around the forum and came across your statement…Experience.  1.4 watts with a 810nm diode will do the job, whereas 1.4 with a 980nm diode won’t cut it (literally).  Yet that’s only 170nm difference.  So wavelength matters, emission mode matters, power matters, pulse duration matters, “conditioning” the fiber matters.
I’ve always had great respect for your opinion, could you clarify what you mean with regard to the 980nm?  Mike Swick