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The Clinical Application of Soft Tissue Lasers

Part 4 - Patient treatment with a laser contiued and incorporating a laser into your practice

Dr. Michael Miyasaki, DDS
Dr. Miyasaki discusses lasers in the treatment of periodontal therapy and how to successfully incorporate lasers into your practice.

Then another area of interest for many practitioners today is use of lasers in the periodontal therapy. Lasers in periodontal therapy are just an adjunct, not a replacement for all the different things that you do today. So how do we use it in periodontal therapy? In two different modes; first with non-initiated tip and secondly with initiated tip. So how does it work? Well there are two steps. The first step with a non-initiated tip is where we are just trying to disinfect the sulcus, try to eliminate the bacteria that’s in the sulcus and we called that laser bacterial reduction or LBR. The second step in the use of a laser in treating periodontal disease is what we called sulcular debridement and that is now with an initiated tip. We place that initiated tip in an area of disease to actually remove the necrotic tissue the disease tissue. So in general the way this is going to be applied is we’ll do LBR. We’ll take the bacteria in the sulcus down and we do this around every tooth in the mouth. And then we’ll do scaling and root planing to remove the hard tissue deposits and the last thing we’ll do is we’ll go back and do our sulcular debridement where we take our initiated tip and we remove the epithelial lining of that diseased sulcus. Now I’m looking at how this can be done in different states. Here’s a little diagram. The states that are colored in blue, those states are the ones that allow a hygienist to use a laser in the periodontal therapy. Those that are in red, don’t. So what you need to do is just check. This change all of the time. Just check the local regulations in your state and see if the hygienist in your office can actually use a laser for the periodontal therapy. In those states where the hygienist cannot, many times the doctor work with the hygienist. Sometimes the hygienist will do the LBR cause they are not removing any soft tissue and the dentist will come in and do the sulcular debridement. So again going back to lasers in general what you want to do is try to use the lowest power possibly to accomplish what it is you’re trying to do with the wavelength and the unit that you’re using. So again if we’re just trying to do bacterial reduction, we don’t have to initiate the tip. We’re going to use very little powers. We’re just trying to raise the temperature in that tissue 50-60 degrees to inactive the bacteria. If we’re trying to do tissue ablation, we need to raise the temperature of that tissue up to about 100-150 degrees. As we do that we can vaporize the tissues kind of melt it away. If you’re using your laser and when you’re done again you see black charring. It’s like coal. That power setting is way too high. So the tissue color should be more tan when you’re done not burn and black. Remember patient comfort. The lower the power, the more comfortable your patients will be. Again if you want to use a pulse mode where the power fires, shuts off, fire, shuts off some will say that makes it more comfortable for your patients. Most of the procedures I do I do in a continuous setting but again I use a very lower power. I keep my tip moving very quickly so we don’t concentrate the heat in any one area for prolong period of time. And then my assistant is helping me by keeping that tissue cool with high-volume evacuator and blowing air in the area where we’re doing our laser procedure. And then anesthetic. I’ve had some doctor say well if I’m using a laser does that mean I don’t need anesthetic. And I tell the doctors I go again that’s very patient specific. Some patients will do very well. You just get in there, do your gingivectomy even a frenectomy with no topical or a little bit of topical and they do fine. Other patients that you’re trying to do a simple gingivectomy you just know they’re a little bit more nervous so you might provide them with an injectable anesthetic. What I’m trying to share here is that just because we’re using a laser doesn’t mean that we don’t have to provide anesthetic for our patients to keep them comfortable. Do what you think is right for that patient. So again the way our laser flow works is we can use the laser with a non-initiated tip to disinfect tissue areas. We can initiate the tip to actually ablate tissue, remove and recontour tissue. And in the case of treating periodontal diseased, we’ll actually use it both ways the non-initiated and in the initiated modes. Again for your laser unit know the wavelength. There are different wavelengths 810, 940, 980 are some of the most popular but know the wavelength of your laser. Make sure that your safety goggles are specific to protect your eyes and those of your patients and your assistants from that wavelength of laser. Remember that a laser likes pigmentation so it is more tissue selective. It is attractive to melanin and the hemoglobin and will leave the healthier tissue behind. And try to use the lower power, try to control the temperature, suction, air and a quick moving tip. One of the questions, one of the areas that we started of with is do you think a laser can generate revenue in your practice. So think about how many crowns you do today. How many times do you have pack cord? How long does that take? How many retakes of impressions do you have to do and how much do those retakes, how much is that impression material costing you? Again today what I do is I just take the laser quickly around the tooth. As we do that we create the physical separation as if we have packed a cord and immediately because we get hemostasis at the same time I can pop my impression. So it saves me chair time, and because I more often get the impression the very first time, I’m saving on material cost also. So the procedures again you have to remember to charge out. Things like operculectomy, frenectomy you need to remember to charge. Here are some examples of codes and examples of fees. Gingivectomy on a single tooth you can charge $150. One of the things that I find with doctors is when we use a blade and we see a lot of blood and we have to place sutures and we have to manage that postop discomfort I think we feel we deserve our fee of $200. When we use a laser, it almost seems too easy. And so our tendency is to tell the patient there’ll be no charge for that. And then it becomes harder and harder for us to justify the investment in both the equipment of the laser and in training. What you have to remember is you’re using a laser you’re actually providing a better service to your patients. So, you’re providing a service that keep them more comfortable and you can do to your office instead of having to refer them out which would take more time out of their day. What we’re able to do is provide that service and I want you to feel good about charging a fee for that service. So remember if you’re doing a gingivectomy currently and you’re using a blade and you’re charging $200 when you use a laser it may good quicker but still charge that same amount. You’re investing in the equipment and you’re investing in the training. You’re even watching this program today. We’ll look at the hygiene side. What our practice will do with the LBR, the laser bacterial reduction, is it will add an additional $25 charge may or may not be covered by the patient’s insurance. They’ll have to pay that possibly out of pocket. But the sulcular debridement when you go back into the pockets and treat the diseased areas and remove the necrotic tissue what a lot of office are doing is they’ll just add an additional fee to their current scaling and root planing fees. So just an example, if we do some LBR, some sulcular debridement procedure as we do gingivectomy over the entire month, your laser can actually generate a significant amount of revenue maybe $5,000-$10,000 even. I had a doctor who we did a course with had never use a laser before. I saw that same doctor a month later and she said even in that first month that she was trying to get comfortable with using a laser she had already billed out for over $3600 of procedures. When it comes down to the integration of a laser into your practice, a soft tissue laser will integrate almost immediately into your practice. They’ll make everything that you currently do faster and easier. So if you decide to get laser one of the most important things you do is to get trained either go to an online course or alive course. HDiQ now has some online training for the soft of tissue diode laser. The other thing to do is make sure that your team understands the advantages of a laser so when you’re talking to your patients, your patients appreciate that you know have a laser and know how to use it properly. Designate somebody in your office to be the laser safety officer to make sure that they put up the signs in your office to say laser in use in our office. Make sure that the safety glasses are right, to make sure that lasers are well maintained. Set fees. If you haven’t done a frenectomy in the last few years you may not even have a fee in your fee schedule, so make sure that you set the fees for the procedures you can now do with the laser: frenectomies, operculectomies, gingivectomies. And then in the morning huddles figure out where that lasers is going to be. As you learned more and more uses for that laser and let’s say you start with laser in your practice well there could be another clinician in the dentistry practice that needs to use it, your hygienist may now want to use. So when you have your morning huddles figure out where that laser needs to be. Not only will that help you to all share this laser but then your front desk will know which procedures need to be billed out. So in the past you may have not done gingivectomies or you maybe you did gingivectomies and nobody ever billed out for them. Well now what you’re going to do is you’re going to make sure that your front office knows that our patient at 8 o’clock we’re going to do onsite procedure and gingivectomy is going to be involved. Let’s make sure that we billed out of that. So again it’s going to give you a better return on your investment. The other step you need to do is educate your patients. Hey our practice now has a laser. Cause remember patients perceive the use of a laser as being more advance and they’ll look more positively at both you and your practice. So put that fact in your website, business cards, and your newsletters. And the last point is if you invest in a laser, if you already have laser make sure that you use it. Many times we run into doctors that will say I have a laser, I purchased the laser a year ago but I just haven’t used it enough. What you can do is join HDiQ, view their soft tissue laser program; just a couple hours of investment in your time will help you again generate the revenues I’d showed to you in the previous example. So I think it would be a good investment in your time and you’ll see that a laser will be a very good investment as far as the piece of equipment in your office. So with that I’d like to thank you for your time. I hope we’ve covered some topics. I hope we’re showing you why you might want to purchase a laser if you don’t already have one. And hopefully we’ve given you some kind of recipe and some thoughts so those of you that already have a laser will be using it more when you return to your practice soon.