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The Clinical Application of Soft Tissue Lasers

Part 2 - Initiatiated and non-initiated laser tip

Dr. Michael Miyasaki, DDS
Dr. Miyasaki reviews when to use an initiated and non-initiated laser tip

Now there’s two ways that we can deliver that power and that has to do with the tip. If I take a tip and it’s a fresh tip and I open it from the bag and I place it on my laser, and I’ll demonstrate that to you in just a second. That laser energy can just pass straight through that tip. It’s not going to create a lot of heat. It can be absorbed by the tissue and we often use that when we’re trying to disinfect an area. If I transfer some pigmentation through the tip such as taking a Sharpie marker and painting some ink on there or melting a little bit of articulating paper the ink from that paper onto the tip. Now as the laser energy passes that fiber it’s concentrated at the tip where the pigmentation is and we actually create photothermal energy or heat. And I actually do that whenever I want to vaporize or ablate tissue. So here’s an example where we’re putting the tip on the laser and I’ve taken the piece of articulating paper. Now what I do is I fire the laser and actually physically touch the tip of the laser to that paper and in doing that we’re transferring ink or the pigmentation to that tip. So now that tip is now initiated. Now there are two different way to use this laser. One is in its non-initiated form where you’re trying just to do bacterial disinfection. And the other is where we initiate the tip to get that vaporization or we’re going to ablate the tissue. And then if we combine both that would be for some of our periodontal procedure where we use the tip first in a non-initiated mode to disinfect the tissue and then we go back with initiated tip to remove the diseased tissue. So whether or not you have the same laser that I use or any other laser what I want you to understand is we need to control the temperature. So are we going to initiate the tip or not. We’re going to use a low power setting and then titrate that power setting up as needed. Again what I do is I start 0.6 watts and then titrate it up as I find that I need to. I typically will use my laser in a continuous mode but at low power. Some of you prefer to use your laser on a pulse mode maybe a higher power cause remember again going in that pulse mode decreases your average power output. One of the critical things I always try to do is keep the tissue cool. So as I’m doing my lasering my assistant is blowing air in that area and holding the high-volume evacuation tip right in that area to draw out the heat. And a lot of times as we’re doing the lasering there will be a little bit of a smell to it so that high-volume evacuator is pulling that off. With some of your laser wavelengths that you may be using you may want to use a little bit of water. Again at 810 nm wavelength that I’m using I prefer to work in a dry environment. The other way that we keep the tissue cool is by moving the tip quickly kind of light brush strokes versus moving it very slowly. If you move it more slowly, you’re allowing that heat to concentrate in one area for a longer period of time. So I just use light brush strokes. So basically with laser what I’m doing is I’m just kind of peeling away a cell layer at a time and I’m just kind of working my way down deeper into that tissue. And then as we’ll talk about we can either use the tip in a contact or a non-contact. So let’s start with a non-initiated tip in a non-contact mode, how might you use that. Well we would use that to photo modulate our laser energy to treat things like aphthous ulcers and periodontal disease. So what we’re going to do is we’re going to take the brand new tip. We’re not going to put any type of pigmentation on the tip and we’re going to allow the laser energy to flow out to affect the tissue. So in this case, we’re treating canker sores. The patient may call you up and say I woke up and I have this sore area. I get a lot of cold sores and I got them today so I can’t make my dental visit. Well your front desk would say you’re lucky that we have a laser. Come on in. We’ll treat those canker sores with our laser. We’ll be able to take away that discomfort and those canker sores will actually heal faster because we’re going to disinfect the bacterial cause. So what we do is we bring the patient in. We have a brand new tip. Put our laser. We wave the tip of the laser over those canker sores not even making contact of the canker sore. Just energizing that. Sealing up that nerve endings and disinfecting the bacteria that causes canker sores for about 2 minutes. What you’ll see is that white shiny canker sores will then become kind of a white crusty area. We can then touch that area and the patient will feel relief from the discomfort and then those canker sores will heal up in about half the time. So again just diagrammatically what I do is I come in with the tip. I circle over the surface area of that lesion because again our fiber is a 400 micron fiber. The lesions themselves are typically a centimeter or more in diameter so we have to move that tip to apply the energy to the entire surface area of that lesion. We start a couple of millimeters above. I watch the patient’s eyes. While I’m applying that energy the patient looks comfortable, I just bring the tip closer and closer to that canker sore until right above it maybe about a millimeter above and I just circle over it for about 2 minutes. After that 2-minute period we can lightly touch that lesion if the patient feels any discomfort at all, I’ll hit that area for maybe another 20 seconds until I can touch it and the patient says you know what I feel the relief from the pain. So the cookbook approach I use the 0.6 watts. I use continuous power. But the key points are we go in a non-initiated mode with the tip. There’s no pigmentation in that tip in a non-contact way. So we’re just waving it over that abscess. The average fee for that if I’m doing another procedure like a crown prep I might not even charge the patient for it. But if the patient called up because they wanted to be treated with the laser for the canker sores, we might charge them out for emergency palliative fee which could be $75 or $100. Now let’s move in to using a laser with initiated tip. And now with the initiate tip we’re going to go into a contact mode of use. So what we’re going to do is we’re going to transfer some of the ink or pigmentation to the tip. That pigmentation is going concentrate the laser energy and allows to vaporize the tissue and remove it. Now if we look at different ways to remove soft tissue we got the scalpel. But when I use scalpel one thing I’m not going to get is very good hemostasis. I’m going to get more bleeding. And then I’m going to have to manage that bleeding with postop healing and possible discomfort. The other way I can treat the soft tissue and remove it is with electrosurge unit. But with electrosurge unit I can remove I can remove the soft tissue. I will get cauterization but it may be more difficult for me to work around metal restorations. Taking an electrosurge tip and touching the gold crown or amalgam sometimes can cause sparks. So if I’m going to remove soft tissue, the advantage of using a soft tissue diode laser is that I can remove that soft tissue and get good hemostasis and I can even work around metal. So if I need to uncover an implant I can work that tip around the implant, take away the soft tissue covering it and if I inadvertently touch the metal dental implant we’re not going to see any sparks. It’s so also very safe because this is soft tissue laser. So if I take the laser tip and I touch the tooth cement and dentin, enamel or the bone we’re not going to remove any of the hard tissues because again there’s not a lot of pigmentation there. So it’s not going to absorb that laser energy. So the clinical advantages that we can vaporize the tissue with a very shallow necrosis collateral thermal damage. As we remove that soft tissue, we cauterize the blood vessel so we have less bleeding. We also seal up the lymphatics which bring the fluids to that area where the surgery is done so we have less postop swelling. We also seal up the nerve ending so there’s less postop discomfort. And laser energy has been shown to actually cause bio-stimulation of the area for better healing. In my practice, the advantages have been that the use of the laser is very precisely predictable. I know that where that tissue is going to heal up after I’ve removed it. The patient’s acceptance has been great. If I tell a patient we’re going to use a laser to vaporize the tissue they won’t feel it. They won’t have any bleeding. They’ll have very little or any postop discomfort. Again, they view the use of a laser very positively. Now I’m trying to differentiate how my practice is different from others and if I’m using a lot of the high tech equipment such as laser again it creates more positive perception of my practice. It helps to save me time. I no longer have to pack cord, wait for hemostat agent to work. I can just around the crown prep. I could create the separation between my hard tissue margin and my soft tissue margin and dry that clavicular fluid and the blood up and pop my impression almost immediately. I can work around metals so I no longer have to worry about uncovering implants. I don’t have to worry about using a blade to uncover implant and worry about the bleeding that would be associated with that. Typically, I can work with less anesthetic. Many times if I do gingivectomy, I’ll just place topical anesthetic over the gum tissue, wipe it off after a couple of minutes, and do my gingivectomy procedure without having to use injectable anesthetic. Because we sealed up the nerve ending, we have less postoperative pain. We have good fast healing. We can use the laser to treat periodontal disease and it’s very simple to implement as far as its use into our everyday practice. Some of the tips I’ll give you because many of you have different types of laser but when it comes down to the soft tissue diode lasers one of the things that you have to be aware of is to prepare you tip properly. If you have the type of laser where you have to cleave off the tip if you don’t get a nice clean separation after you scribe it, you can actually get some glass shards. They’re almost microscopic. You have to use high magnification to see those. But when you take that tip into a sulcus and try to get to good coagulation sometimes what you’ll see is you’ll get more bleeding. And the reason why that is because there’s this little shard of glass sticking out. The way that you could detect that is if you take your laser tip and you shine it just maybe half an inch away from a white piece of paper you should see a nice concentric clearly defined circle typically red from an [aiming beaming] laser. If you see that red circle have what we called a [comet still] meaning that the light has been diffused off to the side that means we didn’t get a good cleave. So what you need to do is take that tip again, scratch it with your cleaver and try to pop out that end for a cleaner cut. Use light brushstrokes. The light brush strokes just help to diffuse again that energy to keep the tissue cooler. We try to use the lowest power possible. So even if you had a laser that had 5 watts of power and you want to use 5 watts of power continuously, it would cut the tissue very quickly. But you’re going to create a lot of collateral thermal damage which means you could get a recession in that tissue, the patient can have more discomfort. One of the things again we’ll try to do is we try to use the lowest power possible so that we have less discomfort and that’s why we can get away without having to use injectable anesthetics often times so it saves you times and saves your patients from having to get shot and we get better healing. After we do lasering often times that tissue will be slight discolor. It could be tan, orange or if you’ve actually used too high a power it can be black. And if you’re working in anterior you don’t want the patient leaving with black lines on their gum. So what we do is we take over the counter hydrogen peroxide and just scrub that area and it removes that discoloration. And within 5 or 10 minutes by the time the patient typically leaves your operatory, the tissue looks healthy again. If we do a large area of gingivectomy we expose a lot of tissue just like having sunburn. We advice our patients get some vitamin E oil. Apply that vitamin E oil to that area where we’ve done the gingivectomy in this case for 3-4 times a day for 3 or 4 days just to keep the tissue moist to help it heal up.