The Clinical Application of Soft Tissue Lasers

Part 1 - Lasers and the evolution

Instructors:

Dr. Michael Miyasaki, DDS

Dr. Michael Miyasaki, DDS

Dr. Michael A. Miyasaki is a 1987 graduate of the University of the Southern California School of Dentistry, and has been involved in dental education for over 21 years, 12 of which he was involved in live-patient treatment programs internationally giving him a unique perspective on the global challenges of the dental professional.

Dr. Miyasaki reviews lasers and a brief history of how they have evolved.

Hi, I'm Dr. Michael Miyasaki. In today's program, I'd to discuss the clinical application of soft tissue lasers in principle based patient care. Some of you viewing this program have been considering lasers and are not quite sure if it's right for you in your practice. Some of you that are doing this program already have lasers and would like to be able to the laser a little bit more and more efficiently. So what I like to do is just provide some information in this program to help either make a decision if laser is right for you practice or again to help those of you that have laser use them effectively. Disclosure real quickly is neither I nor members of my immediate family has any financial relationships with the commercial entities that may be relevant to this presentation. So one of the things I asked audiences, clinicians what comes to mind when you think about lasers. And in today's society I think laser has conjured up a lot of positive images. We use lasers for vision corrections such as Lasix. We use laser to rid our bodies of fat, to correct wrinkles and other skin blemishes. So overall I think the layman population thinks that lasers have a very positive use. And surveys have shown that patients think that the use of lasers in their dental treatment will actually make their visits easier. Another question that I get from a lot of clinicians is when can I use the laser. And actually there are 24 clear procedures for the use of soft tissue diode laser that the FDA has listed in this slide. Things like frenectomy, gingivectomy, vestibuloplasty. A lot of different procedures that maybe you haven't consider using a laser for in the past. I think what happens is as a clinician as you learned the indications and the proper use of the dental laser you will use it more and more. Everyday I can use the laser. Almost every patient I can benefit using a dental laser. As you begin to see the indication and the uses for that laser, you then will be able to get a return on that investment both in the equipment, the laser, and in taking the time to learn the education side. I think overall the reason why we like to use the laser isn't for the financial return but I think the big thing is clinically the patient wins. We're able to provide different services for our patients and provide those services in a way that's quicker, faster, and more comfortable for our patients. Laser in itself stands for light amplification by a stimulated emission of radiation and these days we all use different lasers. We have laser pointers. We have lasers on our DVD players, our CD players. And so they're kind of common. But what makes all the lasers different. The lasers are defined by the wavelength. A laser is a light that's coherent of one wavelength of one color. And in that wavelength if we're to look at the wave of light if we measure from peak to peak or trough to trough that is the defining wavelength. Now there are different types of laser and that's defined by the medium that creates that wavelength and then the effect that wavelength has on the tissue that we're trying to treat. So we've got soft tissue. We have hard tissue laser. What I'm going to cover in this program is the soft tissue laser category specifically those of the diodes. So the diode has gallium, aluminum, and arsenic. And that combined gives us a light of the wavelengths that interact with the soft tissues. The lasers that I used are 810 nm wavelength lasers. And why do I choose 810 nm wavelength lasers? Well if you look at this chart, melanin and hemoglobin absorb that wavelength of laser energy very well. There are other soft tissue diode lasers. Those in the 940-980 wavelength of light and those are actually absorbed more by the water. The reason why I like the 810 nm wavelength laser is I can effectively cut tissue, ablate tissue, disinfect tissue, and be able to do that in a dry feel environment. Cause as you've seen in this chart, this wavelength of light isn't absorbed very well by moisture. If I was using a different wavelength soft tissue diode laser such as a 940 or 980, I'd actually appreciate the moisture of that environment because the water would absorb that energy. So one of the key points I think is that we need to know what wavelength or laser we're using. In this case 810 nm wavelength. The evolution of diode laser has been pretty dramatic. When I first started using diode laser back in 1996, I bought two of the premier lasers back then and each one weighed 45 lbs. We had a cart and that cart we had to wheel from operatory to operatory. Over the years they've gotten smaller and smaller. Today, the laser that I use weighs 1.9 oz. and basically allows me to do all the clinical procedures that the laser that weighed 45 lbs. some 15-16 years ago allowed me to do. So we come in a long way and what that's allowed is more portability and the portability has allowed me to use the laser in many more procedures. In our operatory, we have a lot of different types of equipment and very little footprint space. So if I had a laser that was 45 lbs., I'd probably have to have it on a cart somewhere outside of my treatment operatory. If I got in a situation where I thought well you know the use of the soft tissue diode laser would help me, I'd have to ask my assistant to go grab that laser probably outside of the operatory, wheel it into the operatory, then we have to prepare the fiber which is something we'll talk about I just a second, and it will take too long. Even if it took 2-5 minutes that time to us as clinicians feels like an eternity. So today's laser being 1.9 oz. is always with me on my bracket table. So if I am in a situation where I had not planned to have to use a soft tissue diode laser I can just reach over, grab it, and set it up and it's ready to go within a few seconds. Some of the old lasers that we use had a desktop delivery unit and a fiber that run from the desktop unit to the handpiece. In between every patient what we have to do is we've had to prepare that fiber, kind of clip it off. So the fiber much like an electrical wire has a conductive core and insulation on the outside. So between every patient what we have to is we have to strip some of the insulation off and then scribe the glass fiber and snap it to cleave it. That again is time. And for us in our clinical practice, time is a precious commodity. So watch this video. Here we're preparing fiber. We're wrapping the fiber around our hand. We're stripping off some of that insulation. Once we expose some of the clean fiber, we have to scribe that, clip that off then we have to feed that to the handpiece just to prepare it for the very next patient. So not only did we have to go to a different room to bring this unit into our operatory we had to prepare the fiber and again for most of us it's just going to take too long. One of the things that we're going to talk about is most of my crown preparations I don't pack cord anymore. I use a laser to do my gingival troughing. Well if it was going to take 5-10 minutes to prepare the laser what I'd probably like to do is pack the cord. So what we're going to do now is we're going to look at the more current lasers where you no longer have to do the stripping and the cleaving. What we have is pre-prepared tips. So now in order to get the laser ready to use I pick up the laser, I slide that tip on, and we're set and ready to go. So again within seconds now instead of minutes we're ready to use our laser. The small laser is very convenient. But I know a lot of clinicians worry about how to keep it clean. So what I do with a small laser I slip it into a handpiece bag so I never have to touch the body of the laser itself. Extending through the tip is a single use disposable tip. So the first few inches of that laser the tip we're going to discard after we treat our patients. Now as we begin to deliver this laser energy, there are four different things that can happen to that energy. One, we can shine the laser as a light onto a surface and it can reflect off often not even affecting the surface it's reflecting off of. The other thing that can happen is the light can actually transmit through that surface without interacting with it. Another thing is that can happen is we can shine the light and it can be shattered such as if we have a lot of moisture in that environment. When we shine the light into the water, the water is going to scatter that laser energy. What we're going to concentrate on is the fourth interaction that can occur and that's when that laser energy is actually absorbed and begins to have some sort of effect. So, one of the things that differentiate a laser from steel blade or electrosurge unit is that it can be more tissue selective. Meaning it reacts with pigmentation and tissue that has more pigmentation is going to absorb more of the laser energy. So therefore the laser can actually discern healthy tissue from diseased tissue. Diseased tissues are predominantly going to have more blood in it. It's going to be darker. It's going to be more highly pigmented. It's going to absorb more of that laser energy. So another key point is that a laser can be tissue selective. If I take a blade and cut tissue, I'm removing both healthy and diseased tissue. A laser can be more selective cause it reacts to that pigmentation. So those are two more key points I want you to remember. Now when we use the laser our eyeballs have a lot of blood in them. So one of the things we have to do is we have to make sure that we protect our eyes and also the eyes of our assistant and our patient. So the lasers that we use have three pairs of safety goggles. And one of the good things to do is remember put the goggles on your patient first and remove them from your patient's eyes last. So when you sit down preparing to do your clinical procedure put the safety goggles on your patient's first then done yours and let your assistant put his or her safety goggles on. After doing the procedure, take yours off and then as the last step we remove the glasses from your patient. Now some client will say well the safety goggles are difficult to use because they have loops and loops have the long extended lenses. In that case, there are other parties where you can order filters from. They'll insert inside of your loops, the frames of your loops. In that case, what you need to know is you need to know the style of your loops and you also need to know the wavelength of your laser. So those filters are typically going to be wavelength specific. There's two ways that we deliver that laser energy. One is a continuous and the other is a pulse mode. So continuous means if I have my laser and it's at 2 watts of power and I activate my laser, I have 2 watts of power going out. What the pulse mode means that the laser will actually fire, shut off, fire, shut off and fire. And it's a 50% duty cycle with the laser that I use. Which means it's firing half the time and it's off half the time. That short period where the laser is off actually allows for the tissue to cool sometimes making the procedure more comfortable for the patient. But because it's only on half the time and it's off half the time the average power output is kept by half. So I have a laser set a 2 watts of power, the average power output is half of that or one 1 watt of power. If I had my laser set 1 watt of power and we're in the pulse mode, the average power output would be half of that or 0.5 watts. Now one of the things that clinicians will ask is how much power do I need? I'll tell you with the laser that I use my go to power setting is 0.6 watts. I'm typically working in that 0.6 watt area sometimes I'll go down to maybe 0.3, 0.4, but 0.6 is kind of my starting point. When I need more I'll actually titrate it up sometimes going at 1 watt, maybe 1.2 watts but rarely do I ever need more than 1.4-1.5. Other lasers you'll see have more power. The units will say 5 watts and 7 watts of power. To me what all that doing is creating more collateral thermal damage. So I'll stay on the lower side of that. It's going to provide you more predictable healing and will be much more comfortable for your patient. Why do some units have more power. Some of it has to wavelength. If you're working 940-980 nm wavelength laser in a moist environment when you fire that laser you may get some scattering of the laser energy which will dissipate the energy so you need to bump it up. Some unit has to do with the efficiency of the fiber delivery from the base unit through the fiber through the tip. Some units lose a lot of that laser energy. So I've used units where I had to set unit to 2.0-2.5 watts of power to get that same effect that I get from my unit set at 0.6 watts. And then there's also the thought that if the unit says it has more power then the clinician will think more is always better. And again, I'll tell you that 0.6-1.0 watt is really where I want to do most of my work as it gives me that predictability and the patient comfort. So what we're trying to do is we're trying to use a power setting that will maximize the tissue health of our patient. So my go to power setting with the laser is 0.6 watts.