Who do you want to be for your patients

Part 3 - Lasers

Instructors:

Ms. Rachel Smith, RDH

Ms. Rachel Smith, RDH

Rachel Smith has been a peridontal therapist and passionate dental hygienist for over 20 years.  She currently works in Plano, TX with Dr. Marcus Whitmore. Rachel was one of the first hygienists in the state of TX to incorporate diode lasers in her practice.

Rachel will review the use of lasers in every day practice.

Now I do want to introduce you to lasers, okay. I actually use a diode laser in my practice and I will say that I champion for Zyla and I used to champion for Diskus Dental when they owned the NV laser. So I will give that shout out to Zyla. So I want to let you know that the type of laser there's different types of soft tissue lasers that we use in the practice. One that's great and very economical to use in the general practice is a diode laser. Diode lasers actually work very, very well for what we need for them in dental hygiene and also for your doctor. Your doctor you know, certainly some throughing that they can do as far as crowns and crown lengthening and those kind of things. Certainly they can in touch with Zyla and they will be more than happy to get them going on that level. Also biolase has a nice handheld diode laser as well. NDAG lasers are also a great soft tissue laser. They're a lot more expensive. The periodontist that we work with actually does the lanat procedure with an NDAG and is very, very successful with that.

So when we have laser tissue interaction, four things can happen to laser energy. It's either reflected, transmitted, scattered or absorbed.

We want to actually use the absorbed type laser. We want to focus on what's being absorbed. Lasers and tissue, lasers are tissue selective. The diodes go to melanin and hemoglobin. I'm going to start this over and you can ñokay.
There's laser tissue interaction. Four things can happen to laser energy. It's either reflected, transmitted, scattered or absorbed. We want to focus on what is absorbed. Lasers are tissue selective and they are diodes are actually melanin and hemoglobin that's what they are absorbed by and that's what they are targeted to and that is pigmented. In bacterial cells, in the mouth and actually in the sulcus are actually have high pigments.

I want to make sure that you are wearing protective eyewear and also we can work there and since I wear loops of course I have to have protective eyewear for my loops. Surgitel has some and then also Innovative Optics, they make protective eyewear that is specific for your diode. You can't just take an NDAG eyewear and wear it for a diode. You have to have exactly what you need and your laser will have what it has on it and then also on your eyewear it will say specifically which laser it is specific for.

Laser energy can be focused or defocused so noninitiated or initiated and I just want to let you know that when we have non-initiated, we can treat, we can disinfect and that's actually most dental hygienists when we do laser bacterial reduction especially here in the state of Texas, we are not allowed to initiate the tip or do any kind of cutting or any kind of curettage at all. But there are states and I'm sure there's some states that are going to be watching this video, so please make sure that you know from your state exactly how you can use your diode laser. So here in the State of Texas, we use the non-initiated tip and that actually more ñ it doesn't focus the energy so much so it cuts the tissue. It basically scatters the energy so it attracts the bacteria it needs to but it doesn't cut the tissue. So that's going to be absorbed at 50 to 60 degrees Celsius and it disinfects and the focused energy actually recarbonize the tip and that's what you see here is the film on there. You can use just articulating film, not necessarily the articulating hard paper but the film and you can initiate your tip that way. That actually has photothermal energy to vaporize the tissue.

Now I will say in those states that are allowed to do laser assisted periodontal therapy that is really where you're going to see the most great results as far as when they've done studies on periodontal therapy with the laser. We have great reduction in pocket depth for a longer amount of time and also lesser bleeding points. You're basically able to go in there and curettage. So after you go in and do scaling and root planning, you can take that initiated tip and go and scoop out all that diseased tissue and all that granulation tissue. So you create a clean bleed and completely sterilized pocket which of course creates an amazing heal. So anyway if you're lucky enough to use that in your state, I would encourage you to please do that. You're going to be doing your patients a great service.
We talked about the laser during our presentation the slide show and I wanted to show you a live demonstration on laser bacterial reduction. Here in the state of Texas, this is the greatest thing that hygienists can do for their patients and what it really does is it reduces the amount of bacteria in the mouth, you know, we do a lot of prerinsing with chlrohexedine and that's to reduce biofilm and aerosol for us. Doing laser bacterial reduction reduces the bacteria in the mouth significantly. When we do that, I really like to use a light handheld laser and this is actually the NV laser from Zyla. Biolase also has a hands-free laser. This just happens to be the one that we have in our practice.
There is a lot of presets on this laser. There is not one for laser bacterial reduction but the quickest way to get to it is to get to the aphthous ulcer and go down a bit. When we do laser bacterial reduction, we use it an uninitiated tip and that means we have scattered energy. We also do it at a pulsed and not a continuous wave. Anywhere from 1.5 watts to 1.8 watts and we start actually ñ I use the same method as I do when I'm doing perioprobing. I start at one side, go all the way around and then go on the inside and so on. Most periocharts are set that way so anyway.
When you go in here, you want to use like an explore motion. You don't want to go in and probe. We have a tendency with this fiber to want to go in and probe the teeth like we do with the periodontal probe. Actually what we need to be doing is doing a sweeping motion. So you're taking this energy and you're really focusing it into where those places where the anaerobic bacteria is going to live. So you're going to obviously spend a little more time inner proximally or in the sulcus than you are like say on the facial. If you have a clean tight, pink 2 mm, you're not going to spend a lot of time there. This whole system once you get it under your belt and you feel more comfortable with it, it should take about three to four minutes which really isn't going to take a whole lot of downtime from your time that you're with the patient.

So as we get started, like I said I start in the back and sweep around this way. As I get to the front you may be able to see this a little bit better. As you're going in between the teeth and the molars, especially you know, really take your time. If you see that you're interrupting some biofilm or bacteria even food debris, you know, take some time to really make sure that you're getting in there and you're sweeping that area. A good way to understand that is like a flashlight. You know the end of this laser is like a flashlight. You want that flashlight energy to be able to penetrate and reach that bacteria. So I really want to give it more time in between the teeth than we do say on the facial. So you can understand like right here the gum tissue is very healthy. Not a lot of bacteria living there and this is why of course we explain to our patients it's so important to clean in between their teeth.
The other great thing about this is that you know, we are a little challenged as far as what we should be using around implants and this is such a great tool around implants because bacteria as we know will grow around those implants and we are safe to use the laser around any kind of metal.

And the clinical laser advantages are it vaporizes the tissue with very shallow zone of necrosis. When we use any kind of other material, if we use electrosurge, or we use a scalpel, we go anywhere from three to 500 cell layers deep. When we use a laser it is so specific it goes three to five cell layers deep. So have less inflammation and less healing for the patient. It cauterizes blood vessels so it decreases bleeding. It seals the lymphatics to decrease the swelling and it seals nerve endings so decreased postoperative discomfort. Now those last three right there I'm going to stop for a second because what I'm going to show you us as hygienists even in the state of Texas can use a diode laser to actually get rid of canker sores or aphthous ulcer and also to reduce on the prodromal state fever blisters. So that is a great profit center and a wonderful advantage we can do for our patients.

Also it has biostimulation so it inhibits the histamine released from the mast cells. So already as you go in there you're actually kind of giving a little boost to the healthy cells that are there while you're breaking down the bacteria. So you're going to help that patient to heal faster. Here's the list of all the FDA cleared procedures that can be done so certainly, you know, share this with your doctor if you're getting excited about using a diode laser. Certainly let them know he's got lots of things that he can use the laser for. For those practices that have gone into champion for, a lot of times within six months they're buying a second laser because the hygienist and the doctor are fighting over who gets to use it when. So the ones we're going to be focusing on are laser bacterial reduction, laser assisted periodontal therapy if your labs do that in your state, aphthous ulcer reduction and also prodromal fever blister or herpetic lesion.

You want to prepare your fiber properly which is really easy if you have ñyou'll see this when I use this later, when I show you how to use the NV laser. It actually has a premade tip. You just click it on and you're ready to go. If you have an older diode laser in your practice and you want to start using it great, they'll probably have a fiber on it and you need to take the [0:41:45] [Indiscernible] fiber, get ready to go, put the tip on it and we can certainly go over that. You can get your laser manufacturer and ask them, ask you how to do that. You want to use a light brush stroke. You want to use a low power so you don't want to char anything. So certainly you know, those hygienists who work in states where you can do some curettage, you can be setting that kind of low like a 0.6 initiated. Because you don't want to go in and do a gingivectomy. You don't want be removing any healthy tissue. You're basically just really want to be pulling out all that diseased tissue.

Certainly if you do have a patient where you want to ask your doctor to come in and do some curettage you just want to go ahead and clean that area with some hydrogen peroxide to remove some charring or blackness that can happen at the area. And then just put some vitamin E oil on there or actually you can use some perioscience. I personally like perioscience, it tastes better and does a great job.

One way that we can use this or your doctor is a biopsy or fibroma. I really like this visual in here so I wanted to share it with you and just use some topical anesthetic. You don't even have to use any local. There's little to no discomfort. There's bloodless and there's no scarring. So I want to show you exactly you know, this is right after this procedure was done and you can see this patient is not in any discomfort at all. This was a 1.6 watt, continuous within it. It was initiated tip so it just like pretty much took that right off but didn't involve any of the tissue around it so very low healing. So you can see that this was one week post op and you can see that she's completely healed.

Canker sores, aphthous ulcers, this you want to be your patient's best friend. Let them know or even if they're in the practice to say hey you want me to get rid of those for you, oh that would be great, okay. So there's no discomfort, pain relieving, the faster healing, biostimulation because it inhibits the histamine release. There's no anesthetic and you just need to wear a mask when you do this because canker sores do have some bacteria on them. So what you're going to do is you're going to take that tip. You can see a nice visual right there and you're going to use it like a bull's eye. So you're going to start on the outside room of that. You're never going to touch the ulcer itself. So you're going to start on the outside room and you're going to work your way in kind of like a bull's eye as you start out there. Ask your patient you know, if they feel ñdo you feel anything. If they feel them back of a little bit. As you're working on that aphthous ulcer that pain will go away. So after you work for about 60 to 90 seconds, ask them to touch it with their tongue, ask them if they're having any kind ofÖ And most patients will say oh my gosh it feels so much better or I can still feel it some. You can work on it more. You're not going to overwork this area so don't feel like if you keep working on it, you're going to cause this patient any kind of problem.

There is an ADA code for that. It's you know, destruction of a benign lesion. So you can let your front desk know that there is a CDT code for that so you can build that out. If patients come into my practice, and they only want me to treat this for them, they're taking up chair time, we usually charge about $75 for that. So therefore again you know, and they will share that with their friends. Hey you have a canker sore? My dentist actually can help you out with that so. This is ñyou know, certainly after about a week after from this patient or actually two days after this is one this last photo was taken, and you can see you know, it's completely gone. Your patients will love you even if you minimize their healing time to two to three days as opposed to seven to ten or 14 days.
Now laser bacterial reduction, LBR or circular decontamination. You're going to put the laser on a 1.5 watt to 1.8 watt. It's going to be a pulsed mode. So you don't want continuous energy coming out of that tip and you want a noninitiated tip. When we have a pulsed tip, it actually is firing and cooling and firing and cooling which actually keeps the tip at a cool rate so that your patients don't feel it. You want to keep that away from exposed root surfaces because they will feel a little bit of that photothermal energy. The benefits is definitely reduces the bacteria in the pocket significantly. It reduces the risk of bacteria entering the blood stream and no anesthetic is required. Yay. And improves effectiveness of laser assisted periodontal therapy.

Why should your patients have laser bacterial reduction? Because they're going to ask you that. Your average periopocket has 109 of gram-negative anaerobic bacterial colony forming units. That's billions basically. After five minutes of nonpainful laser bacterial reduction 102 gram-negative anaerobic bacteria will just basically reduces it down to the hundreds.

Plus they get five to six weeks of lasting disinfection. So if you have a patient who's going through periodontal therapy and even if you want to introduce this just with your periodontal patients your patients that are going to go through periodontal therapy or scaling root planning, then do that. Because you're really going to set them up for success for long term healing and that's really what we want for them is from them to reduce those pockets and have a better chance of staying healthy.

Plus we're going to reduce or eliminate cross contamination. When you have a 7 mm pocket in the back of the mouth say at the medial buccal 2, and you have a 2 mm pocket on the medial buccal #7, you don't want to spread that 7 mm pus up to that front tooth at all. Because you're going to basically spread that infection through the mouth. So by doing a chlorhexedine rinse before they come and also using the laser to reduce the bacteria in the mouth, you're really really helping your patient. More so you're reducing less bacteria that's going to go into their blood stream.

The biostimulation thing I think is huge. Everyone is really trying and everyone's immune system is trying very hard every day to stay healthy. So if we're able to stimulate those healthy cells to stay healthy then we're really helping our patients to set themselves up for a better healing too and release histamine to stimulate circulating collagen and osteoblasts and fibroblasts so basically biostimulation.

And profit center for laser bacterial reduction at $30 a patient, 75% of your patients that accept that could translate to $30 x 6 patients a day for a year, $43,000 in increased revenue. Laser assisted periotherapy a lot of hygienists you can do this in their states. Add more if they use their laser like $140 per quad to generate up to $500 or more per patient.
When you do laser curettage or circular debridement for those hygienists who work in those states, you actually want to use your power level at 0.4 to 0.8 watts. You want to continuous mode so you want to continuous energy coming out of your tip. You want to initiate your tip so you want to carbonize it so that it has direct energy. I'll just as a disclaimer definitely in my state doctor has to perform here in our state, and certainly Dr. Whitmore has done that for me many times and I've had great results with my patients with that. Much better than just traditional scaling root planning alone.
I have a couple of works cited. Everything that I've done, everyone that's helped me with this so I just want to give some shout out to that. Also some professional references, ergonomics and instrumentation with Tabitha Tavoc and you can reach her right there. Dr. Mac Lee, one of my definite heroes as far as helping me with lots of easy, easy communication with my patients and then also wonderful Anna Pattison who ran basically the RDH Magazine and also Dimensions for Dental Hygiene just she has a great instrumentation technique and you can find her on the PattisonNewsInstitute.com.
Here's some product references if you need to get in touch with some products. I thank you so much for spending this hour with me today. I certainly hope that you get reengergized for who you want to be in your practice and what you want to be and I certainly wish you many, many years of wonderful being a dental hygienist and touching people's lives.