Al, yesterday I did 2 class III’s (8, 9 -1 moderately deep, the other close to the pulp ~ 1/3 of the tooth gone, pt scared and had stayed away from dentist long enough that she needs 7 surgical ext) Prepped and restored both in 30 minutes.Patient reported nothing uncomfortable. Used a small round bur slow speed to move things along. Small diameter round burrs kept off the DEJ seem to work well, less vibration, and you don’t have to apply alot of pressure which can be misinterpeted by the patient  I think you will spend longer prepping than with a high speed but you make up the time not having to wait for anesthesia. I never suggest to my patients they might feel pain but rather that if they feel anything uncomfortable to let me know.I often tell them before beginning that if it gets too ‘cold’ let me know so I can adjust the settings-if they do ,I drop the W a bit. I also tell them the laser will ‘tap’ on their tooth and I tap on the back of their hand to show them. If they ask if I can do this w/o them feeling anything ,I tell them no because even if we did it w/ anesthesia and the highspeed they would still feel vibration, pressure,etc.  Be careful not to precondition the patient to the idea of possible pain, I think your confidence in the procedure will make a big difference in how they perceive it.
I’ve been amazed at how aggessively you can use the round bur and the pt will not have any discomfort if you’ve properly ‘conditioned’ the tooth.
I guess I never had the idea that my laser will do everthing a high speed and anesthesia does.
Best Wishes,

Howdy Mike!

Welcome to Ron’s forum.

Thanks for the kind words.

I meant that as a relative comparison between the two wavelengths and in stressing the importance of other device parameters.

As an expert in 980 diode, you know how make the 980 laser wavelength cut and finesse tissue, even at relatively low settings like 1.4 watts on certain tissues.

My experience with the two wavelengths is that 810 is hotter in the tissues than 980, and therefore 980 requires less energy than 810.  Sometimes, some users can’t get any tissue interaction at the lower watts, and when they turn up the power–it’s too hot and too much tissue is effected.

My main point is that other parameters besides Watts need to be appreciated, like wavelength, emission mode, etc. when considering tissue effects–not to suggest a 980 couldn’t cut anything at 1.4 watts.

I mean, how many times have you heard people talk about “The Diode”?  I’ve hear too many “experts” say that all diodes devices are “the same”, indeed, all lasers are “the same” and can be used for the “same” procedures, with the same results.  That’s just not accurate in my opinion.

Bob

Hi Pat and gang: I agree with what Ron and Pat are saying. When you go to the dental meetings and you see the lasers work you think ……….wow can I cut faster than a drill, no anesthetic. Oh boy , more patients, more money………….then reality sets in.

You have to often on anxious first time users of the laser use low settings and build up.

I had a patient today where I could use 5 watts on her class Vs to get the composite resins out and it was much faster than usual but this is the exception not the rule.

Most of my patients feel something but 80 % rate the discomfort or sensation as being between 1-15 on a scale of 100. 10 % rate it as 15-50 and for them laser dentistry is ok but not unbelievable.

the other 10 % need anesthetic in my practice.

I do know that some people here seem to have more sensitivity than I have when working.

Here are a few tips…….for what it is worth and my opinions come from 3 years of doing this under the microscope….

1. Use lots of water and air.
2. Start low and build up, Rons settings are a good starting point.
3. Dont put the high volume suction to close, the water gets sucked out and doesnt cool the tooth.
4. Dont cut such a narrow trough that the water cant get into the tooth to cool it down.
5. On enamel go across the groove to flatten out the cuspal slopes coming up from the groove.
6. In large open lesions if you use enamel settings , scatter will cause sensitivity on the dentin. You must lower the settings.
7. If the decay tracks laterally, you must either open up the prep wider with a high speed (diamond for instance) or really have a tough time doing it with the end cutting laser. I use round burs sometimes here.
8 In big mushy decay cases I always check the dentinal caries with a small round slowspeed bur. Caries Detector messses up the enamel etching.
9 Soft tissue without water , if you want water, double the energy settings to cut soft tissue.
10. Use silk cord on your class Vs to protect the deeper tissues and serve as a visual marker when you remove the gingival tissue. I will post a case of this in the next couple of days.

Dont be afraid to use drills, I do and many people using the laser do.

I try to do anesthetic free dentistry and limit the amount i use the drill.

Those are some tips, hopefully some are new.

Glenn

Yeah,

Pat’s got it right.  You need to use a “light” touch (pardon the pun) in the beginning when you are trying to avoid using local anaesthetic on hard tissue.

Very nice post Glenn.  Great info and good tips!  Welcome back from training.

Before I get to my hard-tisse “Tips”, I hope Y’all will appreciate a little perspective on this subject.  It’s one I have dealt with for well over a decade using several laser wavlengths and device configurations, including neodymium (1.064 micron), erbium (2.8 and 2.9 microns) and holmium (2.1).  I may need Glenn’s flame retartant suit for the following politically incorrect opinions.

Few folks remember, these days, that HARD tissue was the FIRST use of pulsed 1.064 micron Nd:YAGs, by Dr. Bill and Terry Myers in the mid-1980’s and later the rest of us starting in 1989 and to date.  And it was (big surprise) the manufacturer (then ADL) that advertised, promoted and HYPED using those Nd:YAG lasers for hard and soft tissue WITHOUT anesthetics.  Current advertising practices and clinical advocations are nearly identical to 12 years ago…….Hmmmmmm.

While it was possible to use our lasers without anesthetic to cut nice, clean preps into dentin and diseased enamel with pulsed Nd:YAGs–and could /can VAPORIZE AMALGAM and COMPOSITE–we had many of the discussions and MIXED success that Erbium users mention today–we learned it was not all that predictable, that patients were trying hard to cooperate, but that they were often more uncomfortable than they were letting on.  

We eventually learned which teeth and situations were most likely to succeed w/o anesthesia.  Generally speaking, it turns out the teeth we were sucessful prepping without anesthesia using pulsed laser anything, were the teeth that we could prep w/o anesthesia using a HS or SP handpiece.

Having said that, I am NOT saying that there are no special advantages or ways to use lasers to prep teeth using “hard” tissue lasers without anesthesia, or as alternative to the drill.  It’s just not as easy as the hype makes it sound.  There are too many variables between “identical” devices, as I tried to demonstrate in the Peak Power example above, for this to be “Buy laser, turn on Pre-sets, Fire, and Fill”.  “Oops!  It didn’t work for you doctor?”  “Wow, it works for Dr. Guru.  Maybe you need some training, some over-the-shoulder demos”…..Same stuff, different companies.  Sometimes, it’s still the same Gurus though!  Interesting……

I don’t think this is fair to the new laser clinican to be given incomplete info and training.  I don’t think it is fair to subject the patients to the new laser dentist with incomplete info and training.  And ULTIMATELY, I fear greatly for this wonderful field of laser dentistry to subject the profession to the disappointments of disillusioned dentists who were given incomplete info and instruction.

It takes time, study, skill, patience, some advice, tips, and training.  I learned by watching the master, Dr. McCarthy, who can make lasers rotate teeth!  OK, I’m kidding.  But he would spend HOURS working on a phobic and/or patient “allergic” to anesthesia, use the 1.064 to create anesthesia in a tooth or teeth, remove the decay, prep the teeth with laser and bur and restore.  I won’t do that…..I refer them to Del!!!  Now, he doesn’t takes hours to prep teeth w/o anesthesia much anymore, but we both take our time.  If it starts to take too much time, we numb and prep.

Us “old” laser users eventually came to the conclusion that we bought our lasers to be provide a better service to our patients, and not to hurt them, or titrate our learning curve on them, or experiment on them unnecessarily.

Tip:  Using a “3-pulse” on the tooth at first rarely can be felt by the patient.  Since some devices have fixed Rep Rates like 20 Hz, you have to develop a “foot-tap” that delivers only 3 pulses.  Tap and repeat the 3-pulse at about 1 second intervals.  Use your water and air as best the patient can tolerate them.

Yours in Laser Dentistry,

Bob

(Edited by Robert Gregg DDS at 4:10 pm on Oct. 11, 2002)

(Edited by Robert Gregg DDS at 4:18 pm on Oct. 11, 2002)

Jacques:

Good post, venting is allowed on a Laser Forum. Not everyone is achieving the phenomenal results advertised by the hard tissue laser companies. Dissenting or negative views should be welcome here – we are here to discuss, learn and improve upon our clinical experiences.

We use the Erbium for Class III, IV and V preparations and it works great. Some patients can tolerate the procedure without anesthetic. On the Class I and II lesions we find it is best to anesthetize the patient, rapidly remove enamel with the Bien-Aire electric handpiece, then use our Erbium to remove caries and prepare dentin. We have virtually eliminated use of the old slow speed air driven handpiece and our patients love that!

I guess everyone has to find their “niche” with the hard tissue laser. The Erbium is a useful tool but it’s not a panacea like the laser companies want dentists to believe.

Al

Hi Bob: I will say that I am surprised and at times disappointed with the reactions that come out of the professionals that visit various forums.

I dont ever post pictures or cases to show my work in a holier than thou attitude. I realize that I have a gift in being able to show magnfied images of lasers through the scope and think it is fun to see what lasers can and cant do.

I have taken alot of flak for the microscope and lasers and most of it is taken and forgotten but sometimes it gets a little disheartening to see how close minded some people are.

I like this forum for laser dentistry because those here have a genuine interest in learning.

I know that lasers are not a panacea for all and not a replacement for the handpiece but with training, some basic knowledge of laser physics, some clinical experience and perhaps a few tips from gurus like yourself and others , many can incorporate lasers successfully in a practice generating more income, and having alot of fun practicing.

I do hope that people here realize that I challenge myself to post the cases I do, because I know that the constructive criticism offered will make me a better practitioner and in turn help my patients towards better end results.

I really appreciated Janet Century’s comments from the Continuum laser symposium that I attended and spoke at. She appreciated my honesty in saying how I use the lasers and not someone standing up and saying that it could do everything. I need to be honest because in the future I will run into some of you and I want you to say I walked the walk and talked the talk.

Your kind words and some of the posts by others like Janet, make a big difference.

Thanks again………

Glenn

2thdoc–

I really depends on what procedure you are actually performing, not the device. If you are performing a “curettage” procedure and regardless of whether you are using steel or laser, the you would bill for that.

Remember that there are ADA/CDT “procedure” codes, and the various carriers and their individual “payment” codes. They are often, but not always the same.

For example, many carriers do NOT have a payment code for 4240–Mucogingival Surgery per quadrant, so if you bill that out, you will get a DENIAL not an explanation.

The best way to answer the question is to better understand what procedure(s) you are performing?

Bob

Hi Newbie,
  I just returned from France and the World Clinical Laser Institute meeting, and I chatted with Bill Chen about our differing ways of “anesthetizing” teeth. I have not tried his way before, and am going to, but the way I use my Waterlase, it works. From the crown/veneer preps to the regular ole class I-V’s. The only time I start lower is usually on an abfraction area, that is already sensitive. I also have heard that Bill Grieder in Florida always uses 6W as well. It would be a good study to see what is more or less effective. Like I said, I have had very good, no, great success using this method. I haven’t used anesthetic on any patient I have used the Laser on in the last 8 months. So far so good.
Regards,
Mark