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Robert Gregg DDSSpectatorHi Everyone,
I want to extend a WARM welcome (cuz he’s getting the snow storm of two centuries right now in Arnold, Maryland) to Jeff Cranska–aka “Benchwmer”.
Far from being a lurker, Jeff is an active FR Nd:YAG user who has posted several excellent case presentations on Dental Town. In fact, he has a soft tissue crown lengthening case that is posted on the front page of both the on-line and hard cover Dental Town magazine in the February 2003 issue.
I think we can expect to enjoy his case presentation postings here as well. I for one, look forward to some company in this “Nd:YAG” world of mine. :cheesy:
Jeff is a very smart clinician who has applied the basic principles of laser physics and laser tissue interaction to new, innovative and otherwise unheard of applications.
For example, Jeff developed a technique using the FR Nd:YAG to fill-in/close a Black triangle on an anterior tooth. WOW! He showed me how to do it, and it was easier than I thought. (Having the right laser wavelength and configuration helped 😉 ) I hope he posts that case here and many more!
Jeff will also be attending the Academy of Laser Dentistry (ALD) meeting this year in Destin, Florida, March 6,7,8. So Bryan Pope, if you need another reason to come, there it is.
Welcome aboard Jeff!
Bob
(Edited by Robert Gregg DDS at 11:02 am on Feb. 18, 2003)
PatricioSpectatorMark,
If you have time I think it would be good to list here the steps you recommended at Dana Point for catching these handpiece and trunk problems before the trunk becomes totaled. I know we are now more careful about flushing the water tube completely before we change burs using 100% air and checking each handpiece as the pictures above suggest before we use them. Examining the tips for chips and cracks more carefully to reduce backflash. What else? You da man!
Pat
PatricioSpectatorDavid,
Travell, great lady. What a teacher. I have used that material since 1988 and regularly recieve physician referrals for pain management. Just finished a case this morning. It is special to see someone get their life back so to speak. I do not own a diode so have not even thought of this idea but it is pause to reflect. I would like to know if the LLLT group has any experience. If you get any information on this please post it. Thanks,
Pat
BenchwmerSpectatorThe OpusDuo was released in. Oct 2002.
I ordered one with just the Erbium, no CO2 (I’m already a PerioLase/Nd:YAG user) at the ADA meeting in New Orleans. It arrived 2 weeks ago. You were getting no responses in January because the lasers were just being released.
The OpusDuo Erbium has computer, touchscreen technolgy, plus a foot control to vary power to the contact tip during use. The ability to change power for enamel/dentin/ carious dentin without leaving the tooth is the largest jump in technology.
So far no problems in use. I’m only using it for hard tissue and minor tissue removal in Class V restos,so far. No need for anethetic. Patients like it. My Nd:YAG is still my soft tissue laser of choice.
I’m here to learn more about hard tissue laser procedures.
PatricioSpectatorMark,
It is just getting through to me that you are available for training for basic laser certification. It might be good if we provided on the Board a listing of options for education as this is a regular request. What is it that you do(format) and when? One dentist at a time or groups? Purpose or expectations from the training? Etc.
I just finished a restoration on a molar which I had previously treated using the laser and found it necessary to anesthetized the patient the first time. This time I used 5.5w for two full minutes and was able to work without any discomfort. Thanks for you guidance.
Pat
jetsfanSpectatorThere is another product that I like to use. It is called cariosolv. A set of small spoons, which are shaped much like small slow speed round burs, are sold along with the cariosolv. Basically the cariosolv will softened up the carious dentin so that is can be gently removed with the spoons. I agree that it is often difficult to differentiate between carious and normal dentin. After using this I am often amazed at how much decay was present.
JETSFAN
PatricioSpectatorI was watching Emeril Live the other night and he was talk about the difference between a receipt and a formula in cooking. I began to wonder if the difference between those who get 90% plus teeth adaquately numb with the laser and those more into the 50% area has to do with moving from a recipe(watts and settings) to a formula(ingredients and getting the right mix at the right time).
I thinking about what we do here to establish confidence and trust in our patients. The way we get to know most of our patients on a personal level and work to create a mind set in all we do for them of a comfortable pain free environment. We have worked hard to develop a reputation over the years of being gentle.
Chairside body language and staff interaction along with getting in step with the patients mannerisms and the rate at which they can be challenged with any given procedure and then working within that rate.
I do not expect it to hurt the patient in fact I tell the patient I am not allowed to hurt them. Most are confident in this and work with me tolerating some reasonable discomfort knowing they can stop me at any time as we work together. We proceed in a manner which monitors any discomfort and adjusts for it early.
The whole formula in an office taken together, the ambience, the reputation, the approach and the mechanics of care all create a success mode which delivers in our particular case over 90% success for routine restorative and periodontal treatment. Some are better than 90%.
Point is I think the sensitivity problems are most often formula problems and not watts and settings. I am wondering if this is why it seems to me I get good anesthesia at 1.5w for most teeth and the reason why there doesn’t seem to be a recipe for success which works for every one expecially newbies trying for 100% laser anesthesia. It is not what you have it is the way you present it that makes for the greatest success.
OK! let me have it guys.
PatI c
SwpmnSpectatorIn my opinion, this thread and subsequent replies are some of the most significant yet posted on the Forum. This thread and photos should be printed and saved by anyone using or considering purchase of a “hard tissue” Erbium laser.
Use of the Erbium around metals and old metal-containing bases/restorations damages the laser “tips”. In the case of some Erbiums it also damages the reflective mirror in the “head” of the “handpiece”. Damage to the mirror results in eventual failure of the trunk fiber delivery system – my technician explained this to me after my last trunk fiber failure. I’ve suspected this for over a year but finally have some official confirmation.
And it’s not just as simple as avoiding usage of the laser around amalgam or PFM crown margins. I notice “sparking” on removal of old composites and old bases/liners. Until you begin removal, there is no way to predict whether the old composite/base/liner will cause sparking. With mirrored handpiece systems, if you see sparking, you can be assured you are causing damage to the tip, mirror and eventually the trunk fiber delivery system.
Dr. Colonna has done us a great service by providing the first photos I have seen which document damage to a mirrored handpiece delivery system. Those who use or are considering purchase of such systems would be wise to print these photos and check your handpieces on a regular basis.
Al
PatricioSpectatorI am beginning to use the waterlaser for reverse bevel gingivectomy. I have reviewed Rons concerns above and want to investigate his concerns. So far if there is root damage is seems to be of little consequence but am wanting the voices of experience to weigh in. It is true some areas are hard to reach but most pockets are accessable so far. I am looking forward to comparing notes with the group.
Pat
smileagainSpectatorGreetings Pat
Great letter- my feelings exactly re: patient comfort. Patients are told in my office that they will “feel nothing.” I am not sure that I am able to accomplish this w/ the laser. I have a Waterlase and wonder if I was taken in by the marketing!? You say that you can get anesthesia at 1.5W – what do you mean exactly by this? Do you feel confident that you can do a preperation without the patient feeling anything?
With thanks, Jerry Rosenfeld, DDS
greg holmSpectatorNuno. You did this without an injection of anesthetic?
Did the pt feel anything or was the laser able to anes the tooth enough?
Are you saying you basically did most of the work with niti’s and then did a cleaning of the chamber/canals with the laser?
Greg
dkimmelSpectatorPat , So far I have found only this http://www.karna-ddscomfordent.com/LLLT-2.htm on the net.
I have a few Facial Pain Pt that this mighthelp with.
David
SwpmnSpectatorGreg:
Although I don’t have any carefully controlled scientific studies, I’ve had great clinical success for 9 months using an Erbium laser for caries removal, supposedly smear layer removal and also “etching” or beveling of enamel margins(I bevel anteriors but not posteriors). Actually let me rephrase that, I bevel Classes III, IV and V but not Classes I or II.
We use Clearfil SE Bond after the laser prep but I apply primer twice and longer than the manufacturer recommends due to my communications with Raymond Bertolotti. Flowable composite is placed over dentin and our feedback on sensitivity is extremely low. Phosphoric acid is no longer used but our enamel margins on the patients now cycling through recalls look good.
Al
Robert GreggParticipantHi David,
QUOTEIn cases like this would it be of any benefit to have the patient back and do a biostimulation tx ?Thanks, Glenn, but I don’t know how much of an LLLT expert I am compared to someone like Paul F. Bradley, BDS, MD, FDS, FR (no kidding).
To some degree, yes. It sould help with any symptoms and inflammation. And I don’t think it can hurt anything.
I think this may be a little too open for a full recovery, but that depends on things like the age of the patient, whether there is root apexification, etc.
Give it a try and let us know!
Bob
Robert GreggParticipantHi Ron and Pat,
I LIKE Ron’s reasoning!!!
Good News
The forward firing aspect of the FR pulsed Er, CR:YSGG means that unless you are pointing the fiber directly at the root (or greater than 30 degrees), it’s unlikely there will be much absorbtion on the root surface. That seems to be born out by hisology I saw a few months ago (I can’t remember the reference). So keep your fiber oriented to the long axis of the root surface.
Bad News
But the histology showed that the forward penetration into the bone and PDL transceptal and crestal fibers couldn’t be determined/controlled, and the laser pulse cut a nice chunk of healthy attachment and underlying bone–oops.
Thirdly, since the 2.8 wavelength “sees” water, collagen, and hydroxapatite equally, there is no differentiation between the epithelial lining and the connective tissue Rete pegs. That means there is no selective removal of the ulcerated lining from the connective tissue that ideally we want to leave behind and intact in laser curettage. That is better accomplished with near infrared lasers (810-980 nm diodes; 1,064nm pulsed Nd:YAGs)
There are also access problems, fiber stiffness and LENGTH issues, hemostasis challenges– all limitations that reduce the expectations and predictability of results.
This is not to say it is dangerous or “bad” to use Er. Cr,:YSGG in the perio pocket. It’s just that there are better devices and configurations to perform “laser curettage” that are safer, more predictable, more reproducible.
It can be used at lower powers and settings as a “decontamination” device. Sweep back and forth until you get “fresh bleeding” as you visual end-point, I would say.
Great News
There is another larger unappreciated distinction between near-infrared lasers (810-980nm and 1,064nm) and mid-infrared lasers (2,800-2,900nm).
Mid-infrared laser beams are stopped or absorbed by all tissues of the body that contain water, collagen, and hydroxapatite. That means the killings of pathogens is a surface phenomenon–no tissues can be between the laser beam and the bacteria.
Near-infrared lasers, on the other hand, transmitt through water in tissues (you too Biolitec) with NO attenuation of the beam intensity until the beam hits a pigment the wavelength is highly absorbed into–like black pigmented anaerobes embedded out into the tissues (i.e. a papillary cellulitis, or bony invasion).
These near-infrared beams of light will transmitt through tissues without biologic effect (to varying degrees and %) until the beam comes in contact with a black bug, and…..Instant Death! Pretty cool huh?
Even Better News
FR pulsed Nd:YAGs (1,064nm) because they have high peak powers in each pulse, keep the beams intensity deeper, longer, and SAFER than a continuous wave or “gated pulsed” 810-980nm diode. More Bad Bugs DIE at greater distances from the pocket wall, therefore, than with any other laser wavelength or configuration.
The Er, CR: YSGG is best employed as a scalpel replacement, that is, a reverse gingivectomy. But that is getting closer to the incident angle of 30 degrees that needs paying close attention to.
Hope that helps a little.
Bob
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