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AnonymousSpectatorJust read NADC articles on perio procedures and understand the following to be important;
1.healing from bottom up
2. pulsed application
As a newbie to the erbium and diode I’d appreciate if someone was willing to share their technique (laser used,setting,application,results)
Thanks
Glenn van AsSpectatorRon, I really like the new setup and the way the forums look. Bravo.
As for the LAPT (laser assisted periodontal therapy), Dr. Robert Gregg is one of the leaders in this area. Mind you most of his work comes from the ND:Yag but it is applicable to the diode.
Many hygienists in California are using it and Don Coluzzis staff is using them alot in his practice and I have heard Nora Rafaetto (sp) and his former hygienist Terri Guttierez speak on the topic.
I can post values for the diode if you want me to.
I will forward to Robert Gregg your concerns.
Glenn
AnonymousSpectatorGlenn,
It would be great to see what settings you are using with the diode (and how that compares to what others are doing). I can’t wait until my diode arrives. I’m in a small town and the patients I refer for perio either;
a. don’t want to travel 20 miles for Tx
b. can’t afford Tx (periodontists don’t offer finance options)
or
c. all end up with extremely sensitive teeth – all have a nice perio result but they can’t touch their teeth with anything but luke warm h20Thanks for participating on the board and your past incites and help.
AnonymousSpectatorMy TwiLite just arrived and soon Biolase will be coming to do the presets. Can you share what you have found to be most useful to have the presets programmed at?
Thanks
Robert GreggParticipanttest
Robert GreggParticipantRon,
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
AnonymousSpectatorBob, thanks for the post! My response in italics ( including dumb questions:) )
QUOTEQuote: from Robert Gregg on 9:39 pm on Sep. 11, 2002
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.
Plan on visiting Bill Chen’s office soonI 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? 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?
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. Guess I’m back to the book to review gated pulse and true pulsed :confused:
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. Others have suggested a sweeping motion.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?Were these settings arrived at thru experience or how are they determined?
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
Welcome to the Board!
RonRG
Robert GreggParticipantThanks 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 迀 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)
Robert GreggParticipantCan’t insert a picture. All photos are 400KB or greater
(Edited by Robert Gregg at 3:57 pm on Sep. 12, 2002)
PatricioSpectatorI have noticed lately especially on molars I am getting white dings in the tooth surface next to my prep due my movement or the patient’s Some of these are visible after I restore the tooth. Will they disapear after hydration? What can I do to improve this appearance when I score the tooth surface?
Glenn van AsSpectatorAll I know is that I just learned one heck of alot from listening to the master.
THanks Rob…..great read.
Glenn
2thdocSpectatorI’ve noticed these also. I kind of like them on the border of the prep-an etched mini bevel perhaps. These disappear after application of etch and BA. In my experience the remaining ones that don’t disappear immediately upon contact with moisture have been gone a couple days later when the patient has returned for other work. Sure am less worried about these than the microfractures a bur causes. Anybody else find this to be true?
How about a little dab of topical fluoride gel on the etched ding?
lasersmiledrSpectatorOver the last couple of years it has come to my attention the significant number of new laser doctors who do not have standard proficiency certification. Equally disturbing is the lack of interest in providing that education by a significant number of the major players in the laser arena. The ALD has taken a gate keeper stand on laser education by creating an Educator status which is above and beyond the Advanced Proficiency status. As of the last few years, this gate has been closed still to the limited few of us who have completed the Advanced Proficiency Level of certification. I feel if we can regurgitate this information well enough to pass an Advanced Proficiency certification with a panel of our peers, we are capable to again diseminating this information to those who need to know safety, protocols, uses and physics of laser dentistry (not necessarily in that order). Question: do we wait until 60 minutes or dateline rips us apart and instills fear in the minds of the general public before we open the gate to laser education for the dental masses and if so what impact will that have on it’s use by the rest of us in dentistry? What authority does the ALD have on regulating laser education anyway? Are there some other motives to controlling access to laser education by this group? Who takes responsibility if a uncertified laser doc gets him or herself into trouble? I pose these questions in hopes of generating further discussion on the matter and hopefully to point out the need for a wider scope of laser education that the ALD may or may not be able to meet. Where should we go from here? :confused:
PatricioSpectator2thdoc,
Thanks, I have been trying to profect a bevel to blur the margin and find this is working well in many cases especially the anterior where careful control is more easily achieved. When I see the prep which looks a little like the moon surface l have great confidence in the bonding process. that extra 50% retention is great.
Pat
Robert GreggParticipantHi Todd,
Welcome to Ron’s new laser forum.
When the first 12 laser users to have ADL’s dlase 300 pulsed Nd:YAG (now ADT), even before it received FDA clearance, they formed a study club of users. Eventually that study club became the North American Academy of Laser Dentistry (NAALD) and the International Academy of Laser Dentistry (IALD). I was involved in the formation of both academies.
Eventually the IALD was merged with the American Academy of Laser Dentistry into one group called the Academy of Laser Dentistry (ALD), and the NAALD was dissolved.
What started out as a study club to share clinical techniques between clinical users and invite researchers to attend meetings and go away with research ideas, has turned into another entity altogether with a different agenda as you pointed out.
I started out with the NAALD as it’s first Vice-President, and we ran the meetings like a study club with d-lase 300 laser dentists presenting their cases, and then a Q&A session after each presenter where a robust discussion took place–as well as lots of learning and note taking by the audience (including the researchers present).
Later on, dentists who used different lasers (carbon dioxide, surgical Argon, CW Nd:YAG) were invited to present. But with the new folks that assumed board positions, a new format was instituted and the “off-label” uses were discouraged. ALD became less of a clinical study and innovations club and more of a presentation society….but I digress.
In the interest of legitimizing the clinical use of lasers that had very few FDA cleared procedures–like “laser curettage” and caries removal, but that many were performing (before erbium was around)–a few clinicians and manufactuer reps got together with Joel White at USCF and developed the Curriculum Guidelines and Standards for Dental Laser Education (CGSDLE). It was a good idea, a huge effort by Dr. White and Arlen Lackey, DDS, and I’m glad we did it. I think it impressed a lot of folks in and out of organized dentistry that we in the IALD and NAALD were serious about being taken seriously. But as to impressing the people who were most critical of our “off-label” uses of our lasers? They could care less. Even today, there is one periodontist professor who openly ridicules the CGSDLE during his lectures that he gives around the country.
So the CGSDLE gave laser dentistry some guidelines on laser education. There were 4 levels:
1. Category I was an introductory class, an overview of lasers that manufacturers might give.
2. Category II–now called “Standard Proficiency”–is a device specific lecture and with a written and participation exan where the attendees show that they have a basic understanding of how to use the laser that they own. The idea was that SP would provide a level of protection should a peer review or malpractice action be filed against a laser user for non-FDA cleared procedures, or just laser use in general where a bad outcome took place.
3. Category III-Mastership–now “Advanced Proficiency”–Provided a laser dentist the chance to demonstrate his/her clinical use of a specific laser device(s) by presenting clinical case presentations under a specific format to their laser peers in the ALD–and earn a certificate from the ALD. It has been a real challenge to standardize this category and there have been different criteria for different presenters.
4. Category T–for trainer (now “E” for Educator)
Was the “natural” progression of the implementation of the CGSDLE and for those who had achieved their Category III. I participated in the first E training session, and felt we all fell short of the mark. The purpose was to provide a standardized teaching baseline for which to teach Category II. We all received a CD-ROM with clinical and reasearch images and was left to us to then modify or replace “slides” with our own material. I suggested that everyone who received their E meet once a year or every other year to re-certify their material, but that idea was set aside for some reason. So much for standardization…….The only authority the ALD has on regulating dental laser education is that they (we) assumed it. No one has conferred it upon them–not the FDA, the ADA, nor the Regents of UC California.
Unfortunately, the individual dentist assumes the responsibility if they get into trouble. That is why it is CRITICAL for dentists to become familiar with the term “Due Diligence”, take their time, and research all aspects of laser dentistry before they make a purchasing decision.
My biggest disappointment is that the emphasis on education and training of dentists by manufacturers is a recommendation or a referral to someone who might train them–or to the ALD that can “certify” them, but not train them. No manufacturer (well, except one) builds the cost of clinical training into the purchase price of their systems. They are all trying to sell a “box” on cost and dentists are all comparing lasers devices based on price for a box. Only later do densits ask, “how do I use this thing?”
Who really is at fault is the deans and the board of trustees and chancellors at the dental schools and universities that after 15 years since lasers were cleared for use in dentistry (carbon dioxide), there are no standardized CLINICAL training programs in any dental school except for maybe post-graduate maxillo-facial or perio residency programs. But who are those people but “gray hairs” who have to die off before new technology can become part of the stardard curriculum? The only other way is if manufactures buy a wing at the dental school….like Visx did at UCLA’s Jules Stein Eye clinic for teaching LASIK. Look how far that procedure has come since 1995!
And I think if 60 Minutes does an unfavorable dental laser story, those who have tried to implement serious laser education and training standards will fair better in the public opinion than the dental schools, who should be harshly criticized for their abdication of their responsibilities to the public trust to train dentists in this established technology. I mean, this isn’t Cerac 3 where the consequences to the patient for poor usage isn’t a severe injury.
Bob
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